Abstract
This study characterized adult primary care medical assistant (MA) staffing. National Survey of Healthcare Organizations and Systems (n = 1,252) data were analyzed to examine primary care practice characteristics associated with MA per primary care clinician (PCC) staffing ratios. In 2021, few practices (11.4%) had ratios of 2 or more MAs per PCCs. Compared with system-owned practices, independent (odds ratio [OR] = 1.76, P <0.05) and medical group-owned (OR = 2.09, P <0.05) practices were more likely to have ratios of 2 or more MAs per PCCs, as were practices with organizational cultures oriented to innovation (P <0.05). Most primary care practices do not have adequate MA staffing.
Key words: health workforce, primary health care, organizational culture, health care systems, ownership
INTRODUCTION
Medical assistants (MAs) are among the fastest growing occupations within the US primary care workforce,1 but little is known about organizational factors associated with MA support levels for primary care clinicians (PCCs). Increased accountability for quality of care has led many practices to expand roles for primary care MAs, including health coaching for adults with chronic conditions.2-4 Interprofessional care team approaches rely on robust support from MAs; for example, the teamlet model of primary care recommends 2 MAs per PCC.5
We examine primary care characteristics associated with MA staffing ratios. Past evidence indicates that health care system ownership of primary care practices may impede patient-centered innovation, such as MA role expansion, because they require resources that may not be sufficiently aligned with existing health care system goals or incentives.6
METHODS
Data
We analyzed practice survey responses to the second wave of the National Survey of Healthcare Organizations and Systems (NSHOS II), a 52-question survey of a nationally representative sample of non-federal adult primary care physician practices, as defined by the 2020 IQVIA OneKey database. The NSHOS was developed by Dartmouth College, Harvard University, and University of California, Berkeley researchers, and the data have been analyzed extensively in past research.6-9 Surveys were collected from physician leaders and/or practice managers between May 2021 to March 2022. From 1,540 total responses (response rate = 38%), duplicate surveys (n = 137) and surveys with high item non-response (n = 151) were excluded, resulting in an analytic sample of 1,252 practices. Supplemental Table 1 compares NSHOS II respondent and non-respondent practices. Sampling and non-response weights were used.
Measures
Medical Assistant per PCC Staffing Ratio
Respondents were asked, “What is the current ratio of medical assistants (MAs) to primary care clinicians in your practice?” and selected from the following response options: (1) We do not employ MAs, (2) Less than 1 MA per clinician, (3) One MA per clinician, (4) Two MAs per clinician, and (5) Three or more MAs per clinician. Given the recommended 2 or more MAs per clinician for the teamlet model of primary care,5 we constructed a binary outcome measure of 2 or more MAs per PCC.
Practice Ownership
Practice ownership was a categorical variable that assessed whether a practice is independent, health system owned, hospital owned, medical group owned, designated as a Federally Qualified Health Center (FQHC), or other.
Practice Culture
Practice culture was assessed with a 7-item measure of “innovation culture.” The questions were informed by qualitative research of the complexity of organizational cultures within and between physician groups10 and the Competing Values Framework of organizational culture.11 Organizational cultures more oriented to innovation have been found to be associated with greater practice adoption of patient engagement strategies and chronic care management processes.6,9 Information about item content (Supplemental Table 2), internal consistency reliability (Supplemental Table 3), and distributions (Supplemental Figure) are detailed in the supplemental materials linked here. Other covariates are described in Table 1 footnotes.
Table 1.
Primary Care Practice Characteristics, by Medical Assistant to Primary Care Clinician Staffing Ratios
| All Practices | 2 or More Medical Assistants per PCC | Fewer Than 2 Medical Assistants per PCC | P Valuea | |
|---|---|---|---|---|
| No., (%) | 1,252 | 142 (11.3) | 1,110 (88.7) | |
| Practice ownership (%) | P <0.01 | |||
| Independent | 19.7 | 34.0 | 17.8 | |
| Medical group | 6.4 | 7.8 | 6.2 | |
| Hospital | 14.5 | 18.4 | 14.0 | |
| Health system | 38.9 | 17.6 | 41.6 | |
| Federally Qualified Health Center | 19.7 | 21.5 | 19.4 | |
| Other | 1.0 | 0.8 | 1.0 | |
| Independent practice association affiliation (%) | 15.8 | 14.9 | 15.9 | |
| Practice size | P <0.01 | |||
| Solo physician | 0.5 | 1.8 | 0.4 | |
| Small (2-9 physicians) | 76.9 | 82.6 | 76.2 | |
| Medium (10-19 physicians) | 13.2 | 11.4 | 13.5 | |
| Large (20+ physicians) | 9.3 | 4.3 | 10.0 | |
| Primary care physicians (mean, SD) | 6.5 (6.9) | 4.9 (3.2) | 6.7 (7.2) | P <0.01 |
| Advanced practice clinicians (mean, SD) | 3.7 (5.7) | 3.9 (6.0) | 3.7 (5.7) | |
| Specialty mix | ||||
| No specialists | 58.9 | 61.3 | 58.6 | |
| Low specialists (1-29%) | 20.9 | 17.5 | 21.3 | |
| High specialists (30% + ) | 20.3 | 21.1 | 20.1 | |
| Rural-urban continuum code (%) | ||||
| Metropolitan | 82.3 | 80.6 | 82.5 | |
| Micropolitan | 10.4 | 10.7 | 10.3 | |
| Small town | 4.9 | 7.6 | 4.5 | |
| Rural | 2.5 | 1.1 | 2.7 | |
| Area deprivation index of practice zip code | 96.5 (19.7) | 99.6 (16.1) | 96.1 (20.0) | P <0.05 |
| Weekend care (% yes) | 31.7 | 43.0 | 30.2 | P <0.05 |
| After-hours weekday care (% yes) | 57.2 | 68.2 | 55.8 | P <0.05 |
| Professional language services (% always/often) | 71.4 | 66.8 | 71.8 | |
| Behavioral health integration (% yes) | 50.7 | 49.9 | 50.9 | |
| Reduced staff hours/layoffs (% yes) | 38.5 | 30.0 | 39.5 | |
| Staffing shortages impacting patient care (%) | P <0.05 | |||
| Not at all | 9.1 | 12.0 | 8.8 | |
| A little | 17.2 | 28.3 | 15.8 | |
| Some | 35.6 | 29.7 | 36.4 | |
| Quite a lot | 38.1 | 30.1 | 39.0 | |
| Complex care management processes (range: 0-3; mean [SD]) | 1.7 (0.8) | 1.8 (1.0) | 1.7 (0.7) | |
| Practice innovation culture (range: 0-3; mean [SD]) | 1.5 (0.7) | 1.7 (0.6) | 1.5 (0.7) | P <0.01 |
| Health information technology functions (range: 0-1; mean [SD]) | 0.7 (0.3) | 0.6 (0.3) | 0.7 (0.3) | P <0.05 |
PCC = primary care clinician.
Values without P values are not statistically significant (P >0.05).
Note: Specialty mix was calculated as specialists divided by total physicians and advanced practice clinician count included include nurse practitioners, physician’s assistants, and clinical nurse specialists. Health information technology functions included questions assessing patient access to their electronic medical records, patient input into medical records, secure messaging, prescription refill notifications, advanced analytics. Complex care management processes included measures of non-physician involvement with patient care coordination, adherence to care plans, supporting risk modification and medication adherence. The Area Deprivation Index of the practice’s zip code from the Neighborhood Atlas was sourced from the Neighborhood Atlas and includes the domains of income, education, employment, and housing quality, where areas with greater socioeconomic disadvantage are ranked higher. The rural-urban continuum code of the practice’s zip code was included. Staffing shortages were assessed using responses to a question that asked, “How much are staff shortages within your practice impacting patient care (do not include shortages related to being ill with COVID)?,” which included the response options of “Not at all,” “A little,” Some,” and “Quite a lot.”
Analyses
Multivariable logistic regression models estimated the association of practice ownership and practice culture with practice use of staffing ratios of 2 or more MAs per PCC, controlling for covariates.
RESULTS
Most adult primary care practices (56.6%) had ratios of 1 MA per PCC, while only 11.4% had ratios of 2 or more MAs per PCCs; 27.6% had ratios of less than 1:1, and 4.3% of practices did not employ MAs (Table 1). In adjusted analyses, compared with system-owned practices, independent (odds ratio [OR] = 1.76, P <0.05) and medical group–owned (OR = 2.09, P <0.05) practices had significantly greater odds of having ratios of 2 or more MAs per PCC (Table 2). Practices with organizational cultures oriented to innovation (OR = 1.35, P <0.05) had greater odds of having ratios of 2 or more MAs per PCC.
Table 2.
Adjusted Analyses: Practice Characteristics Associated With Medical Assistant per Primary Care Clinician Staffing Ratios
| Two or More Medical Assistants per PCC Adjusted Odds Ratios (95% CI) | P Valuea | |
|---|---|---|
| Practice ownership | ||
| Independent | 1.76 (1.07, 2.89) | P <0.05 |
| Medical group | 2.09 (1.12, 3.90) | P <0.05 |
| Hospital | 1.47 (0.74, 2.94) | |
| Health care system (reference) | − | |
| Federally Qualified Health Center | 1.46 (0.85, 2.50) | |
| Other ownership | 2.15 (0.54, 8.66) | |
| Practice size | ||
| Solo physician | 8.73 (2.45, 31.1) | P <0.01 |
| Small (2-9 physicians) | 2.63 (1.17, 5.93) | P <0.05 |
| Medium (10-19 physicians) | 1.59 (0.68, 3.76) | |
| Large (20+ physicians) (reference) | − | |
| Independent practice association affiliation | 0.86 (0.57, 1.31) | |
| Advanced practice clinicians (mean, SD) | 1.02 (1.00, 1.05) | |
| Specialty mix | ||
| No specialists (reference) | − | |
| Low specialists (1-29%) | 0.88 (0.54, 1.41) | |
| High specialists (30% + ) | 1.20 (0.73, 1.96) | |
| Rural-urban continuum code | ||
| Metropolitan (reference) | − | |
| Micropolitan | 0.89 (0.52, 1.54) | |
| Small town | 1.08 (0.56, 2.10) | |
| Rural | 0.51 (0.15, 1.74) | |
| Area deprivation index | 1.00 (0.99, 1.01) | |
| Staffing shortages impacting patient care | ||
| Not at all (reference) | ||
| A little | 1.26 (0.71, 2.20) | |
| Some | 0.97 (0.57, 1.65) | |
| Quite a lot | 0.75 (0.44, 1.32) | |
| Complex care management processes | 1.07 (0.86, 1.35) | |
| Practice innovation culture | 1.35 (1.03, 1.78) | P <0.05 |
| Health information technology functions | 0.63 (0.33, 1.18) | |
| Constant | 0.21 (0.01, 0.12) | P <0.001 |
PCC = primary care clinician.
Values without P values are not statistically significant (P >0.05).
DISCUSSION
Approximately 1 in 10 adult primary care practices have ratios of 2 or more MAs per PCC. Independent practices, medical group–owned practices, and FQHC practices were more likely to have ratios of 2 or more MAs per PCC ratios than practices owned by health care systems. Practice ownership may influence managerial control and physician autonomy to determine staffing levels that enable high-quality, patient-centered primary care.12 Practices with cultures oriented to innovation were also more likely to have staffing ratios of 2 or more MAs per PCC, possibly because they were better able to retain MA staff during the COVID-19 pandemic federal emergency period.13
System-owned practices may opt to hire other staff, including nurses and other non-physician clinicians, instead of staffing 2 MAs per PCC.14 The number of advanced practice clinicians and the extent of non-physician clinicians’ involvement in complex care management processes, however, were not significantly associated with MA per PCC staffing ratios. These findings challenge the perception that MAs are substitutes for other care team members like nurses and behavioral health specialists.
Study limitations include a modest response rate, although comparable to large-scale organizational surveys conducted during the pandemic. Clinical and non-clinical efforts were not differentiated, and staffing records were not used to confirm the levels reported. Additional measures of practice culture and burnout could have enriched these analyses and should be examined in future research. Staffing ratios and cultural assessments were both self-reported, so common method bias is another potential limitation.
The National Academy of Sciences, Engineering, and Medicine’s Committee on Implementing High-Quality Primary Care recommended greater investment in primary care as a key step toward improving population health.15 Most primary care practices do not have adequate MA support. Ensuring that PCCs have sufficient MA support is a concrete step that payers and organizations can take to support primary care practices.
Acknowledgments
We thank Wendy Yang and Karen Schifferdecker for contributions to survey development, data collection, and research data management.
Footnotes
Conflicts of interest: authors report none.
Funding support: The research study was funded by the Robert Wood Johnson Foundation (#78479).
References
- 1.Bureau of Labor Statistics, U.S. Department of Labor . Occupational Outlook Handbook, Medical Assistants. Updated Sep 6, 2023. Accessed Jul 19, 2023. www.bls.gov/ooh/healthcare/medical-assistants.htm
- 2.Kwan BM, Hamer MK, Bailey A, Cebuhar K, Conry C, Smith PC.. Implementation and qualitative evaluation of a primary care redesign model with expanded scope of work for medical assistants. J Gen Intern Med. 2022;37(5): 1129-1137. 10.1007/s11606-021-07246-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Willard-Grace R, Chen EH, Hessler D, et al. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Ann Fam Med. 2015;13(2): 130-138. 10.1370/afm.1768 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Shaw JG, Winget M, Brown-Johnson C, et al. Primary care 2.0: a prospective evaluation of a novel model of advanced team care with expanded medical assistant support. Ann Fam Med. 2021;19(5):411-418. 10.1370/afm.2714 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Bodenheimer T, Laing BY.. The teamlet model of primary care. Ann Fam Med. 2007;5(5):457-461. 10.1370/afm.731 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Miller-Rosales C, Lewis VA, Shortell SM, Rodriguez HP.. Adoption of patient engagement strategies by physician practices in the United States. Med Care. 2022;60(9):691-699. 10.1097/MLR.0000000000001748 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Brewster AL, Fraze TK, Gottlieb LM, Frehn J, Murray GF, Lewis VA.. The role of value-based payment in promoting innovation to address social risks: a cross-sectional study of social risk screening by US physicians. Milbank Q. 2020; 98(4):1114-1133. 10.1111/1468-0009.12480 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Fisher ES, Shortell SM, O’Malley AJ, et al. Financial integration’s impact on care delivery and payment reforms: a survey of hospitals and physician practices. Health Aff (Millwood). 2020;39(8):1302-1311. 10.1377/hlthaff.2019.01813 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Miller-Rosales C, Brewster AL, Shortell SM, Rodriguez HP.. Multilevel influences on patient engagement and chronic care management. Am J Manag Care. 2023;29(4):196-202. 10.37765/ajmc.2023.89348 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Nembhard IM, Singer SJ, Shortell SM, Rittenhouse D, Casalino LP.. The cultural complexity of medical groups. Health Care Manage Rev. 2012;37(3):200-213. 10.1097/HMR.0b013e31822f54cd [DOI] [PubMed] [Google Scholar]
- 11.Helfrich CD, Li YF, Mohr DC, Meterko M, Sales AE.. Assessing an organizational culture instrument based on the competing values framework: exploratory and confirmatory factor analyses. Implement Sci. 2007;2(1):13. 10.1186/1748-5908-2-13 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Poon BY, Shortell S, Rodriguez HP.. Physician practice transitions to system ownership do not result in diminished practice responsiveness to patients. Health Serv Res. 2018;53(4):2268-2284. 10.1111/1475-6773.12804 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Lai AY, Fleuren BPI, Larkin J, Gruenewald-Schmitz L, Yuan CT.. Being “low on the totem pole”: what makes work worthwhile for medical assistants in an era of primary care transformation. Health Care Manage Rev. 2022;47(4):340-349. 10.1097/HMR.0000000000000342 [DOI] [PubMed] [Google Scholar]
- 14.Peikes DN, Reid RJ, Day TJ, et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med. 2014;12(2):142-149. 10.1370/afm.1626 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Committee on Implementing High-Quality Primary Care, Board on Health Care Services, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine . Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. National Academies Press; 2021. 10.17226/25983 [DOI] [PubMed] [Google Scholar]