Patients turning to nurse practitioners, physician assistants for primary care services, analysis finds

About 3 in 10 people who received medical services between 2016 and 2022 didn’t see a primary care provider, though that portion ranged anywhere from 16% to 43% depending on the state, according to an analysis of private claims data released Wednesday by FAIR Health.

The nonprofit’s new report found broad differences between the ratio of population to primary care providers between certain states or even within a state’s major population areas.

Patients are getting their primary care services elsewhere. The review spotted a larger portion of patients who received primary care services from a non-physician in rural states.

“Healthcare stakeholders, such as patients, providers, payers, policymakers and researchers, can use these data to bring clarity to the use of primary care across the country and to help determine where attention should be directed to improve primary care access and, ultimately, health outcomes,” FAIR Health wrote in the report (PDF).

Massachusetts (16%), New Mexico (20.1%) and Wisconsin (20.3%) came in as the states with the lowest percentage of residents who had not seen a primary care provider during the seven-year study period, while Tennessee (42.6%), Alabama (41%) and Michigan (38.6%) were the highest, according to the report.

When measuring major population centers, or core-based statistical areas (CBSAs), based on population-to-primary-care-provider ratio by practice locations, FAIR found ratios as low as 114.5 (Rochester, Minnesota) and as high as 2,759.6 (Zapata, Texas). Those ratios shifted when looking at where the patient actually received their care, ranging from 56 (Bloomsburg-Berwick, Pennsylvania) to 926.4 (Pecos, Texas).

FAIR noted “substantial variation” within states themselves, as states like Texas and Georgia, home to several CBSAs with the highest population-to-primary-care-provider ratios, also had some on the lower end of the scale. Practice location-based ratios for the former state spanned from 389.2 to 2,759.6, while the latter had a range from 372.7 to 2,331.4.

Nurse practitioners made up the largest share of primary care providers by specialty at 27%, followed by family medicine physicians (20%), internal medicine physicians (18%) and physician assistants (15%).

States in which the largest percentage of primary care patients received their care from a nurse practitioner were those with laws and regulations permitting a broader scope of practice, Fair wrote. These included Mississippi (26.4%), Maryland (17.9%) and Arizona (17.2%).

The inverse was also true for states with the most restrictive practice and licensure laws such as California (1.7%) and Michigan (3%). The exception was Hawaii (1.7%), which has full practice “but has been shown to underutilize nurse practitioners, for reasons that may include low reimbursements, insufficient understanding of their role and lack of team-based care models,” FAIR wrote.

States with the largest portion of patients who received care from family medicine physicians tended to be rural, the group found.

Nationally, reimbursement as measured by the average allowed amount for common procedure codes was higher for physician specialties and non-physicians during the study period.

FAIR saw a sharp spike in primary care telehealth services delivered by physician assistants and nurse practitioners that coincided with pandemic virtual care and licensure waivers, followed by a corresponding decline from 2021 to 2022.

Behavioral health diagnoses treated by primary care increased by 7% from 2016 to 2022 while the percentage of patients with a primary substance use diagnosis dipped by 2.5%. The same period saw non-physician primary care providers more than double the percentage of patients they treated with either mental health or substance use disorder primary diagnosis.

“These latter results are consistent with the passing of the Comprehensive Addiction and Recovery Act in 2016, which allowed nurse practitioners and physician assistants to prescribe buprenorphine for opioid use disorder starting in January 2017,” FAIR wrote in the report. “Potential reasons for the differences between providers include reduced costs and increased availability of non-physicians compared with physicians.”

New information on the changing shape of U.S. primary care delivery and regional supply comes as policy researchers decry the nation’s “chronic lack of adequate support” for these providers.

At the same time, primary care has been a major target for retailers, payers and other disrupters looking to increase their slice of the U.S. healthcare system. CVS, Amazon and Walgreens each have recent deals on the books to bring established primary care players under their umbrellas.