3 pcp visits meaning

5 vital questions you should ask your PCP at your next visit

Posted February 04, 2021 by Charles A. Zonfa, MD, FACOG | Chief Medical Officer

Regular appointments and building a strong relationship with your primary care provider are important steps toward a healthy — and perhaps, longer — life. Think of your primary care provider, or PCP, as your partner in becoming your healthiest self. 

Good communication is one way to build a strong relationship with your PCP. Coming prepared with a list of your top questions and concerns is important to ensure you make the most of your next checkup.

SummaCare offers 5 simple, yet vital questions you should add to your list the next time you meet with your PCP to maximize every minute with him.

Screening tests, such as a mammogram or colonoscopy, are vital to catch cancer or other diseases at an early stage. In most cases, an early diagnosis makes these serious conditions easier to treat.

Your doctor may recommend any number of important preventative tests, based on your age, gender, family history and lifestyle.

In addition, ask about any immunizations or boosters that you need to stay protected against serious diseases. Your age and health can play a role in which vaccines are recommended for you.

If you’ve been prescribed long-term treatments, ask your doctor about the latest trends and developments to make sure you’re still receiving the best treatment available. Improved and sometimes less invasive surgical techniques, medical procedures and drugs are constantly being developed, so it’s a good idea to ask, “What’s new?”

In addition, be sure to bring a list of all your current prescription and over-the-counter medications to discuss with your doctor to assist in determining which are all still necessary.

If your current medications aren’t controlling your symptoms or if you are having side effects, talk to your PCP about changes to your current treatment plan. More importantly, be sure you ask about side effects, risks and benefits before you start any new medication.

If something is bothering you, it’s best to bring it up before it becomes too serious. Your PCP’s job is to focus on your vitals, such as weight, blood pressure and cholesterol numbers, to assess your health, but your visit is the best time to discuss any new concerns you may have.

If you’re experiencing pain, trouble sleeping, stress, or other physical or mental ailments, be sure to share with your PCP. These issues may point to a condition that needs to be addressed. Additionally, your provider can offer solutions to help you feel better.

Your doctor’s office should be a safe place to talk openly and ask questions about how your lifestyle is affecting your health.

Heart disease is the No. 1 cause of death among men and women, yet it’s one of the most preventable conditions. Simply sticking to a healthy diet and exercise program can help improve or even reverse many health issues.

If you’re struggling with weight, high blood pressure or cholesterol, your PCP can offer tips to adjust your lifestyle to bring your numbers down and help you lead a healthier life.

In addition, if you’re considering taking vitamins or supplements, be sure to discuss that with your PCP first. He can offer advice and let you know if the vitamins could interact with any current medications you’re taking.

• What do I need to work on before my next visit?

As your partner in health, your PCP can help you set goals on what you need to be doing in between appointments, including healthier eating, regular exercise, getting more sleep or quitting smoking.

Taking guidance from your PCP on how to be proactive in your health in between appointments can help reduce the number of doctor visits and even prevent certain conditions from developing or getting worse.

There’s no time like the present to begin building a strong and healthy relationship with your PCP. Studies show it can help you live a healthier, happier, and longer life. Remember, good communication with your provider is the key!

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When to see your PCP or use other medical services

It’s important to manage your health with your primary care physician (PCP). But when should you seek more immediate care? Learn when to use other medical services.

As an Aetna Medicare Advantage plan member, it’s good to know when you should see your primary care physician and when you should seek other types of care. That way you can save time and money for minor conditions and, more importantly, access the right care for serious health issues. Following are some general guidelines for deciding when you should use your PCP or other types of medical visits or services.

What is a “PCP” and what does the PCP do for you?

Under your plan coverage, you can select a network or out of network PCP. Your PCP can help you stay healthy, treat illnesses and coordinate your care with other health care providers.

Depending on where you live, the following types of providers may act as a PCP:

• General practitioner
• Family practitioner
• Geriatrician
• Physician assistants (Not available in all states)
• Nurse practitioners (not available in all states)

For a complete listing of PCPs in your area please refer to your Provider & Pharmacy Directory or go to AetnaMedicare.com/en/find-doctors-hospitals/find-provider.html .

When to see your primary care physician

A primary care physician is essential to your health. Your PCP is the first line of care to help you stay healthy and treat illnesses. You can choose your PCP, no referral required, from our strong network of providers. They are your best option for advising, arranging and coordinating all covered services in your plan.

Your PCP is the right choice for:

• Preventive care
• Regular checkups
• Treating illnesses and ongoing conditions
• Getting medical advice
• Coordinating other covered services

For example, if you haven’t done so already, there are two important visits you should schedule with your PCP each year.

*First, an annual wellness visit to develop or update a personalized prevention plan.

*Second, an annual physical exam. An annual physical typically involves an exam by a doctor along with bloodwork or other tests.

Note: The annual wellness visit generally doesn't include a physical exam, except to check routine measurements such as height, weight and blood pressure.

Remember, you always have the option to switch to a new PCP. If you need to switch or would like to sign up for a new PCP, you can search for providers in our network by visiting AetnaMedicare.com/en/find-doctors-hospitals/find-provider.html . Or call us at the number on your member ID card.

Your secure member website is waiting . To check your coverage and benefit costs, go to your personal plan page — it’s listed on your Aetna Member ID card.  Register now .

What is the role of a PCP in coordinating covered services?

Your PCP will provide most of your care, and when you need more specialized services, they will coordinate your care with other providers. They will help you find a specialist and will arrange for covered services you get as a member of our plan. Some of the services that the PCP will coordinate include:

• Laboratory tests
• Treatment from medical professionals like physical therapists
• Care from doctors who are specialists
• Hospital admissions

Call our 24/7 Nurse Line at 1-800-556-1555 (TTY: 711) to speak with a registered nurse, 24 hours a day, 7 days a week. If it’s an emergency, dial 911.

Coordinating your services includes consulting with other plan providers about your care and how it is progressing. Since your PCP will provide and coordinate most of your medical care, we recommend that you have your past medical records sent to your PCP’s office.

What is the role of the PCP in making decisions about or obtaining prior authorization?

In some cases, your PCP or other provider or you as the enrollee (member) may need to get approval in advance from our Medical Management Department for certain types of services or tests (this is called getting “prior authorization”). Obtaining prior authorization is the responsibility of the PCP, treating provider or you as the member. For questions or help, please call the Member Services number on your member ID card.

Here are some other health services for you to consider:

PCP telehealth visits*

You can connect with participating PCPs (and other telehealth providers) virtually. Simply connect using with a smartphone using the Aetna telehealth app or over the phone. Learn more at AetnaMedicare.com/Telehealth

Healthy Home Visits*

For help managing your care from the comfort of home, you can choose a Healthy Home Visit. With this option, one of our trusted licensed health care professionals will come to you — at no extra cost. All health care professionals will follow the guidelines and safety measures of the U.S. Centers for Disease Control and Prevention during the visit. In these visits, a licensed health care professional can:

• Review your health needs
• Perform a health assessment
• Review your medicines

When to seek urgent care at a clinic

It’s best to visit a walk-in clinic or urgent care center when you experience sudden health issues that aren’t life threatening or severe. These can include sprains and moderate injuries. These locations tend to have shorter wait times compared to the emergency room.

When to visit an emergency room

You may experience more severe health issues that require immediate care. If you experience sudden health issues, you may require a visit to the ER. If you believe that your symptoms are life threatening, you should call 911.

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Empowering you for a visit with your PCP: What to know

January 24, 2024 | Wellness | Healthy You | Aging Well

PCPs are your health advocate. Partner with yours for better health and well-being.

One of the most important things you can do for your health is to establish a good relationship with your primary care provider (PCP).

A PCP is someone you trust. Having a good relationship with your PCP can make it easier to talk about your health concerns. 

Your PCP's goal is to provide care when you are sick and give you advice on staying healthy in the long run.

If you have a health concern or a chronic condition, a PCP can help coordinate your care. And if you need a specialist, your PCP can give you recommendations, refer you for care and guide you through next steps.

“PCPs are your health advocate,” says Sarah Winslow, MD, a provider with PeaceHealth Medical Group. “We care for the whole person and help our patients foster healthy habits to prevent disease and live their best lives.”

Plan your visit

Prepare in advance for a visit with your PCP to get the most of your time. Here are a few suggestions:

Prepare to answer possible questions from your PCP.

Take now of how you feel physically and mentally. Prepare to answer questions your PCP might ask, such as:

• How long have you had the symptoms? 
• What makes the symptoms better? Worse?
• Do the symptoms affect your daily activities? How?

Prepare questions to ask your PCP.

Your visit with your PCP is a two-way exchange or conversation. Think about questions you might ask your PCP, such as:

• Which wellness tests do I need (at my age)? 
• How does my family history affect my health? 
• Am I at risk of developing heart disease?  

Share lifestyle and habits that may affect health.

To give you the best care, your PCP needs to understand you and how you live. 

Be open and honest about your habits or daily choices. That might include what you eat, where you live, how you sleep, sexual practices, how much exercise you get, your work and your daily activities. 

Share any changes in your appetite, weight, sleep or energy levels. This can help your PCP understand your medical conditions and what you can do about them.

“It may be uncomfortable to talk about some topics, but the more you share, the better we can advise you,” says Dr. Winslow. “Your PCP isn’t here to judge you. We’re here to help, so please be honest. Lying to your PCP may be a disservice to your health.”

If you feel judgment from your PCP and the need to keep information hidden, you may want to find a PCP you feel safe opening up to.

Bring information about your medications.

Bring a list of your medications to your appointment. This should include over-the-counter medicines, herbal remedies and supplements (e.g., eye drops, vitamins and laxatives). 

For everything you take, note the dose strength (e.g., 500 milligrams) as well as how much you take and how often (e.g., 1 capsule twice a day). This gives your PCP the right information to help you avoid drug interactions or potential side effects.

Describe your health goals.

Do you want to lose weight, quit smoking or start an exercise routine? Talk about these goals. Your PCP can help you make a plan that will fit your current conditions, especially if you are recovering from an injury or surgery. It might also help you stick to your plan.

If you have one or more chronic condition (e.g., high blood pressure, arthritis, diabetes, asthma), ask your PCP about Flourish. This care management program can help you learn steps that keep you feeling your best.

“Your PCP can also connect you with the right specialist to treat your condition or make referrals to other providers to support your health goals,” adds Dr. Winslow.

Take notes and review the visit summary.

After your visit, you'll get a summary of your visit on paper and/or in your medical record. You might also jot notes to help you remember next steps or specific details.

If you're a PeaceHealth patient, you can view your record safely and securely online at My PeaceHealth. Once you've signed up, you can look at your PCP's notes and send follow up questions through My PeaceHealth.

Bring a family member or trusted friend.

If you’re not feeling well, bring a family member or trusted friend with you to the appointment. They can help you ask or answer questions during the visit.   Note: healthcare providers may limit the number of people you bring with you. Ask before your appointment if you have questions.

Having a PCP can help you see the whole picture of your physical and emotional health. It can make a big difference.

“Our priority is your health and wellness,” reminds Dr. Winslow. “Partnering with your PCP will pay dividends in the long run.”

Sarah S. L. Winslow MD

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Preventive Care: What's Free and What's Not

Thanks to the Affordable Care Act , health insurers in the U.S. have to cover certain preventive health care without requiring you to pay a deductible , copayment, or coinsurance . That rule applies to all non- grandfathered major medical plans in both the individual/family and employer-sponsored markets.

This article will explain how the preventive care rules work, what services are covered, and what you need to be aware of in terms of potential costs when you go to the doctor for a check-up.

So, what exactly counts as preventive care? Here’s the list of preventive care services for adults that, if recommended for you by your healthcare provider, must be provided free of cost-sharing .

Children have a different list , and there's also an additional list of fully covered preventive services for women .

As long as your health plan isn't grandfathered (or among the types of coverage that aren't regulated by the Affordable Care Act at all, such as short-term health insurance or fixed indemnity plans ), any services on those lists will be fully covered by your plan, regardless of whether you've met your deductible or how long you've been enrolled.

But keep in mind that you'll need to use an in-network medical provider in order to obtain zero-cost preventive care.

Preventive care is one of the ACA's essential health benefits (EHBs). But it's the only one that has to be covered with no cost-sharing . And it's the only one that has to be covered by large group health plans ; the rest of the EHBs only have to be covered on individual/family and small group health plans (although most large employer plans do tend to include all of the EHBs).

Covered preventive care includes:

Cancer prevention measures:

• Colorectal cancer related : for adults age 50 to 75, including screening colonoscopies, removal of polyps discovered during a screening colonoscopy, and anesthesia services required to perform the screening colonoscopy. Note that people do sometimes report being charged for polyp removal during a regular screening colonoscopy, but that is not allowed under federal rules. However, if the colonoscopy is being done in conjunction with any sort of symptoms, or if it's being done more frequently than the normal schedule, it will be considered diagnostic rather than preventive, which means regular cost-sharing rules would apply. For example, if a colonoscopy is being done as a follow-up to a previous colonoscopy in which a polyp was found; doctors sometimes recommend a follow-up after three years, which would generally not be covered by health insurance, since that's outside the regular screening guidelines of once per decade. It's a good idea to thoroughly discuss colonoscopy coverage with your health insurer in order to make sure you fully understand what is and isn't covered under the screening guidelines.
• Breast cancer related : including screening mammograms every 1-2 years for women over 40, BRCA genetic testing and counseling for women at high risk, and breast cancer chemoprevention counseling for women at high risk. As is the case for colonoscopies, mammograms are only covered with zero cost-sharing if they're done purely as a screening measure. If you find a lump in your breast and your healthcare provider wants a mammogram to check it out, your health plan's regular cost-sharing (deductible, copay, and/or coinsurance) will apply, since this will be a diagnostic mammogram rather than a screening mammogram. This will be true even if you've never had a mammogram before, or even if you're due for your regularly-scheduled screening mammogram.
• Cervical cancer related : screening covered once every three years from ages 21 through 65; human papillomavirus DNA testing can instead be done in conjunction with a pap test once every five years.
• Lung cancer related : screening for smokers or those who’ve quit smoking within the last 15 years and are between the ages of 55 and 80

Infectious disease prevention measures:

• Hepatitis C screening one time for anyone born 1945-1965 and for any adult at high risk.
• Hepatitis B screening for pregnant women at their first prenatal visit, and for any adults considered at high risk.
• HIV screening for anyone between ages 15-65, and for others at high risk.
• Syphilis screening for adults at high risk and all pregnant women.
• Chlamydia screening for young women and women at high risk.
• Gonorrhea screening for women at high risk.
• Sexually transmitted infection prevention counseling for adults at increased risk.
• Routine immunizations as recommended by age for
• COVID-19 ( recommendation was added in December 2020 )
• Hepatitis A
• Hepatitis B
• Herpes Zoster(shingles)
• Human Papillomavirus
• Influenza (flu)
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Tetanus, Diphtheria, Pertussis (lock-jaw and whooping cough)
• Varicella (chickenpox)
• Obesity screening and counseling.
• Diet counseling for adults at high risk for chronic disease.
• Recommended cardiovascular disease-related preventive measures, including cholesterol screening for high-risk adults and adults of certain ages, blood pressure screening, and aspirin use when prescribed for cardiovascular disease prevention (and/or colorectal cancer prevention) in adults ages 50 to 59.
• Diabetes type 2 screening for overweight adults age 40 to 70
• Abdominal Aortic Aneurysm screening one time for men who have ever smoked

Recommended substance abuse and mental health preventive care:

• Alcohol misuse screening and counseling
• Tobacco use screening and cessation intervention for tobacco users
• Depression screening
• Domestic violence and interpersonal violence screening and counseling for all women

Woman-Specific Preventive Care

• Well-woman visits for women under 65 (note that most Americans transition to Medicare at age 65, and Medicare has its own preventive care coverage).
• Osteoporosis screening for women over 60 based on risk factors.
• Contraception for women with reproductive capacity as prescribed by a healthcare provider. This includes all FDA-approved methods of female contraception, including IUDs, implants, and sterilization. The Supreme Court ruled in 2020 that employers with a "religious or moral objection" to contraception can opt out of providing this coverage as part of their group health plan. But the Biden administration has proposed a rule change that would eliminate the moral objection, and that would ensure access to zero-cost contraception for women whose employers have a religious objection. (Note that although male contraception is not a federally-mandated benefit, some states do require state-regulated health plans to cover vasectomies; state-regulated plans do not include self-insured plans , which account for the majority of employer-sponsored coverage. )
• Preventive services for pregnant or nursing women, including:
• Anemia screening
• Breastfeeding support and counseling including supplies
• Folic acid supplements for pregnant women and those who may become pregnant
• Gestational diabetes screening at 24 and 28 weeks gestation and those at high risk
• Hepatitis B screening at first prenatal visit
• Rh incompatibility screening for all pregnant women and follow up screening if at increased risk
• Expanded tobacco counseling
• Urinary tract or other infection screening
• Syphilis screening

Who Determines Which Preventive Care Benefits Are Covered?

So where did the government come up with the specific list of preventive services that health plans have to cover? The covered preventive care services are things that are:

• Rated “A” or “B” in the current United States Preventive Services Task Force recommendations. (In 2023, a federal judge overturned the requirement that health plans cover preventive services recommended by the USPSTF since 2010. But that ruling has been put on hold while the case is appealed, so health plans must continue to cover these services. )
• Provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA updated its recommendations for women's preventive services in 2019; the updated guidelines are available here ).
• Recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention

All of the services listed above (and on the lists maintained by HealthCare.gov ) meet at least one of those three guidelines for recommended preventive care. But those guidelines change over time, so the list of covered preventive care services can also change over time. For example, COVID vaccines were added to the list of covered preventive care in December 2020.

If there's a specific preventive care treatment that you don't see on the covered list, it's probably not currently recommended by medical experts. That's the case with PSA screening (it's got a "C" or a "D" rating, depending on age, by USPSTF).

Vitamin D screening is another example of a preventive care service that isn't currently recommended (or required to be covered). For now, the USPSTF has determined that there's insufficient evidence to determine whether to recommend Vitamin D screening in asymptomatic adults. But they do note that more research is needed, so it's possible that the recommendation could change in the future.

It's also important to understand that when you go to your healthcare provider for preventive care, they might provide other services that aren't covered under the free preventive care benefit. For example, if your healthcare provider does a cholesterol test and also a complete blood count, the cholesterol test would be covered but the CBC might not be (it would depend on your health plan's rules, as not all of the tests included in the CBC are required to be covered).

And some care can be preventive or diagnostic, depending on the situation. Preventive mammograms are covered, for example, but your insurer can charge you cost-sharing if you have a diagnostic mammogram performed because you or your health provider find a lump or have a specific concern that the mammogram is intended to address.

Or if you need a follow-up screening sooner than the regular recommended screening guidelines (due to an issue that was found on the last screening test, for example), the follow-up may have your plan's regular cost-sharing. If in doubt, talk with your insurer beforehand so that you'll understand how your preventive care benefits work before the bill arrives.

Preventive Care Related to COVID-19

The COVID-19 pandemic gripped the world starting in early 2020. There's normally a lengthy process (which can last nearly two years) involved with adding covered preventive services through the channels described above.

But Congress quickly took action to ensure that most health insurance plans would fully cover the cost of COVID-19 testing, although that only lasted through the end of the COVID public health emergency, which ended in May 2023.

And the legislation that Congress enacted in the spring of 2020—well before COVID-19 vaccines became available—ensured that once the vaccines did become available, non-grandfathered health plans would cover the vaccine nearly immediately , without any cost-sharing.

ACIP voted in December 2020 to add the COVID-19 vaccine to the list of recommended vaccines, and non-grandfathered health plans were required to add the coverage within 15 business days (well before the vaccine actually became available for most Americans).

That continues to be the case, even after the public health emergency has ended. Recommended COVID vaccines continue to be fully covered by non-grandfathered health plans, just like other recommended vaccines.

Obviously, the medical costs related to COVID-19 go well beyond testing. People who need to be hospitalized for the disease can face thousands of dollars in out-of-pocket costs, depending on how their health insurance plan is structured. Many health insurance companies opted to go beyond the basic requirements, temporarily offering to fully cover COVID-19 treatment , as well as testing, for a limited period of time. But those cost-sharing waivers had mostly expired by the end of 2020.

When Your Health Plan Might Not Cover Preventive Care Without Cost-Sharing

If your health insurance is a grandfathered health plan, it’s allowed to charge cost-sharing for preventive care. Since grandfathered health plans lose their grandfathered status if they make substantial changes to the plan, and can no longer be purchased by individuals or businesses, they’re becoming less and less common as time passes.

But there are still a substantial number of people with grandfathered health coverage; among workers who have employer-sponsored health coverage, 14% were enrolled in grandfathered plans as of 2020. Your health plan literature will tell you if your health plan is grandfathered. Alternatively, you can call the customer service number on your health insurance card or check with your employee benefits department.

If you have a managed care health plan that uses a provider network , your health plan is allowed to charge cost-sharing for preventive care you get from an out-of-network provider. If you don’t want to pay for preventive care, use an in-network provider.

Also, if your health plan is considered an "excepted benefit," it's not regulated by the Affordable Care Act and thus not required to cover preventive care without cost-sharing (or at all). This includes coverage such as short-term health plans , fixed indemnity plans , healthcare sharing ministry plans , and Farm Bureau plans in states where they're exempted from insurance rules.

Preventive Care Isn’t Really Free

Although your health plan must pay for preventive health services without charging you a deductible, copay, or coinsurance, this doesn’t really mean those services are free to you. Your insurer takes the cost of preventive care services into account when it sets premium rates each year.

Although you don’t pay cost-sharing charges when you receive preventive care, the cost of those services is wrapped into the cost of your health insurance. This means, whether or not you choose to get the recommended preventive care, you’re paying for it through the cost of your health insurance premiums anyway.

Under the Affordable Care Act, certain preventive care has to be covered in full (ie, without a deductible, copay, or coinsurance) on all non-grandfathered major medical plans. Covered preventive care includes a long list of services that are recommended by medical experts, although it does not include all medical care that's considered preventive. And some services, such as mammograms, pap test, or colonoscopies—can be fully paid for by the health plan or not. Coverage will depend on whether they're done at regular screening intervals without any symptoms, or to diagnose a problem or follow-up after a previous test returned abnormal results.

A Word From Verywell

Your health plan likely covers a wide range of preventive services at no cost to you, and it's in your best interest to take advantage of these benefits. But to avoid being surprised by an unexpected medical bill, you'll want to be sure you understand the details prior to receiving preventive care. Make sure you use a provider who is in your health plan's network, and make sure you understand exactly what tests or services will be provided during the visit. If you decide to go beyond what your health plan will cover, that's perfectly fine and is a decision you'll make with your medical provider.

U.S. Centers for Medicare & Medicaid Services.  Preventive care benefits for adults .

Centers for Medicare and Medicaid Services. Affordable Care Act Implementation FAQs - Set 12 (See Q5) .

Rovner, Julie. Kaiser Health News. High Court Allows Employers To Opt Out of ACA's Mandate On Birth Control Coverage .

U.S. Center for Medicare and Medicaid Services. Coverage of Certain Preventive Services Under the Affordable Care Act: Proposed Rules . January 30, 2023.

Rakoczy, Christy. lendedu. Does Health Insurance Cover the Cost of a Vasectomy?

Kaiser Family Foundation. 2021 Employer Health Benefits Survey .

American Cancer Society. Patient Groups Applaud Circuit Court Ruling That Largely Stays Remedy in Braidwood Management v. Becerra . June 13, 2023.

Health Resources and Services Administration. Women's Preventive Services Guidelines .

Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) .

U.S. Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening .

U.S. Preventive Services Task Force. Vitamin D Deficiency in Adults: Screening .

Pollitz, Karen. Kaiser Family Foundation. Private Health Coverage of COVID-19: Key Facts and Issues .

America's Health Insurance Plans. Health Insurance Providers Respond to Coronavirus (COVID-19) .

Kaiser Family Foundation. 2020 Employer Health Benefits Survey .

By Elizabeth Davis, RN Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.

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Provider Type and Management of Common Visits in Primary Care

• Lee F. Cromwell, MS
• Michael Robbins, PhD
• Brandi E. Robinson, MPH
• David Auerbach, PhD
• Ateev Mehrotra, MD, MPH

In primary care, nurse practitioners and physician assistants do not necessarily order more ancillary services, or more costly services among alternatives, than physicians.

Objectives: Debate continues on whether nurse practitioners (NPs) and physician assistants (PAs) are more likely to order ancillary services, or order more costly services among alternatives, than primary care physicians (PCPs). We compared prescription medication and diagnostic service orders associated with NP/PA versus PCP visits for management of neck or back (N/B) pain or acute respiratory infection (ARI).

Study Design: Retrospective, observational study of visits from January 2006 through March 2008 in the adult primary care practice of Kaiser Permanente in Atlanta, Georgia.

Methods: Data were obtained from electronic health records. NP/PA and PCP visits for N/B pain or ARI were propensity score matched on patient age, gender, and comorbidities.

Results: On propensity score-matched N/B pain visits (n = 6724), NP/PAs were less likely than PCPs to order a computed tomography (CT)/magnetic resonance image (MRI) scan (2.1% vs 3.3%, respectively) or narcotic analgesic (26.9% vs 28.5%) and more likely to order a nonnarcotic analgesic (13.5% vs 8.5%) or muscle relaxant (45.8% vs 42.5%) (all P ≤.05). On propensity score-matched ARI visits (n = 24,190), NP/PAs were more likely than PCPs to order any antibiotic medication (73.7% vs 65.8%), but less likely to order an x-ray (6.3% vs 8.6%), broad-spectrum antibiotic (41.5% vs 42.5%), or rapid strep test (6.3% vs 9.7%) (all P ≤.05).

Conclusions: In the multidisciplinary primary care practice of this health maintenance organization, NP/PAs attending visits for N/B pain or ARI were less likely than PCPs to order advanced diagnostic radiology imaging services, to prescribe narcotic analgesics, and/or to prescribe broad-spectrum antibiotics.

Am J Manag Care. 2017;23(4):225-231 Takeaway Points

Practice variation by providers, rather than by provider type, may be more important in understanding differences in management of conditions commonly presented in primary care.

Nevertheless, concerns have been expressed that nurse practitioners (NPs) and physician assistants (PAs) might more frequently order ancillary services, or more costly services among alternatives, compared with primary care physicians. In this study of a group model health maintenance organization’s primary care practice, we found NPs and PAs were less likely to order:

• Advanced diagnostic imaging or narcotic analgesics for management of neck or back pain.
• Broad-spectrum antibiotics or rapid strep tests for management of acute respiratory infections.

Increasing the percentage of nurse practitioners (NPs) and physician assistants (PAs) in the primary care provider workforce has been suggested as one strategy for addressing the United States’ national shortage of primary care physicians (PCPs). 1-5 Although NPs/PAs have clinical training and regulated scopes of practice that differ from those of PCPs, they are permitted to manage a range of medical conditions in ambulatory care. 6-11 A recent survey of the US national population indicated broad acceptance of NPs/PAs as primary care providers. 12

Currently, there is interest in how the addition of NPs/PAs to primary care might impact patient outcomes, medical service utilization, and costs. 13-17 Prior studies have been relatively consistent in demonstrating that levels of patient satisfaction with care and quality of care are similar between NPs/PAs and physicians 11,18-23 ; however, it is less clear whether care provided by NPs/PAs or PCPs affects medical services use and cost.

An NP/PA visit can be cost saving compared with a PCP visit because salary differentials lower the cost of time for patient evaluation and management. 13,17,24,25 However, this cost advantage may be offset if NPs/PAs order ancillary services (ie, laboratory, radiology, pharmacy) at higher rates than PCPs, or order more costly services among alternatives (eg, computed tomography [CT] scan/magnetic resonance image [MRI] vs x-ray).

Studies show mixed results on use of ancillary services by provider type. One study found NPs/PAs ordered significantly more CTs/MRIs for primary care visits than physicians treating Medicare patients 26 ; another found no difference in office-based care using the National Ambulatory Medical Care Survey (NAMCS). 16 A study of Veterans Affairs patients with lower back pain found no statistically significant difference in clinical appropriateness of lumbar spine MRIs by provider type (physician, PA, or NP). 27 In prescribing medications, rates of prescribing controlled medications 28 and antibiotics 16,29 were similar for NPs, PAs, and physicians.

The primary question of our retrospective observational study was: Do NPs/PAs attending visits for neck or back (N/B) pain or acute respiratory infection (ARI) in primary care order ancillary services at different rates than PCPs? We focused on these 2 medical conditions for several reasons. Musculoskeletal pain and respiratory infections are common reasons that adults present for medical care in the United States, 30 and visits for N/B pain or ARI are frequently accompanied by orders for ancillary services. There are general concerns that, across all providers, certain types of ancillary services are overused and add cost without value—specifically, CTs/MRIs and narcotic analgesics in management of N/B pain, 16,31,32 and antibiotics (particularly broad-spectrum antibiotics) in management of ARI. 33-38

METHODS Study Setting and Period

At the time of this study, Kaiser Permanente Georgia (KPGA) provided comprehensive medical services to approximately 240,000 enrollees per year (59% Caucasian, 33% African American) in the Atlanta area. The study protocol was reviewed, approved, and monitored by the KPGA Institutional Review Board.

During the 27-month study period (January 2006 through March 2008), approximately 180,000 KPGA members were empaneled to a PCP in the Adult Medicine department. The study period is limited to these 27 months because, beginning in 2006, an electronic health record (EHR) system was fully implemented—allowing for measurement of providers’ orders for medical services—and it ends in early 2008 when the multidisciplinary Adult Medicine department became a PCP-only department. 39 More recent comparisons of practice variation are not available.

Sample Definition

The sample used for analysis consisted of patients 18 years or older at the time of presentation for an “incident” N/B pain or ARI visit in the KPGA Adult Medicine department. An “incident” visit was considered to have occurred if the patient who presented for N/B pain or ARI had no visit in adult ambulatory medicine for N/B pain or ARI, respectively, for at least a period of 30 days prior to the visit. Using this definition, a single patient may have had multiple incident visits during the study period.

A visit for N/B pain or ARI was determined from specific International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) diagnosis codes associated with the visit, either designated as a primary or secondary condition ( eAppendix A [eAppendices available at ajmc.com ]). Due to the broad range of ARIs, we selected specific ICD-9-CM diagnosis codes used in previously published studies as indicative of an ARI. 33-38

Research Design

We used propensity score matching of visits to reduce the effect of patient selection on comparisons of practice variation between NPs/PAs and PCPs when attending a visit for N/B pain or ARI. NPs/PAs tend to treat younger, healthier patients than physicians which, in turn, can affect rates and mix of ancillary service orders. 11,16,40 Thus, we propensity score-matched NP/PA visits with PCP visits on preexisting patient characteristics to address potential selection issues.

Separate analyses were conducted for N/B pain and ARI visits. First, within each visit class, the propensity for a visit to be attended by a NP/PA

versus PCP was estimated with logistic regression. 41-43 Second, based on the estimated propensity of NP/PA versus PCP attending a visit, each N/B pain or ARI visit attended by an NP/PA was matched with an N/B pain or ARI visit, respectively, attended by a PCP.

All analyses used computerized administrative and EHR databases. Records were linked by unique identifiers and sequenced by event dates. The EHR databases distinguished services ordered by the provider from services completed by the patient. We used services ordered rather than services delivered because rates of services delivered can be affected by factors such as patient access (eg, limited locations for CT/MRI services) or cost sharing (eg, co-payments for prescription medicines). 44 Thus, services ordered are more representative of practice style than services delivered.

Services ordered at the time of the visit were linked to the incident N/B pain or ARI visit by unique visit numbers. All services ordered were attributed to the provider attending the visit. Thus, there is no attribution of orders by an NP/PA to a PCP providing practice supervision (as might occur in billing of “incidental to” visits).

We were advised by several senior physicians that some orders related to the incident visit might occur up to 3 to 5 days following conveyance to the attending provider of initial tests or consultation results. Thus, we considered a diagnostic service order or prescription order as related to the incident visit if it occurred within 5 days from the visit date and was ordered by a provider in the adult primary care department at the same primary care facility where the incident visit occurred. Follow-up orders occurred in less than 5% of NP/PA visits and/or PCP visits for either N/B pain or ARI (data available on request).

Dependent variables. The outcomes of interest were the percentages of visits associated with an order for a specific service class. The service order classes defined for N/B pain visits were: N/B x-rays, N/B CTs/MRIs, nonnarcotic analgesic prescriptions, narcotic analgesic prescriptions, and prescriptions for skeletal muscle relaxants. The service order classes defined for ARI visits were: ARI x-rays, ARI CTs/MRIs, rapid strep tests, any systemic antibiotic prescription, any broad-spectrum antibiotic prescription, and any prescription for relief of ARI symptoms (eg, decongestants, expectorants, respiratory system anti-inflammatory medications). We combined CTs with MRIs because preliminary review of the data indicated very low rates of MRIs relative to CTs, and availability of one or the other of these advanced diagnostic imaging services at selected facilities preferred by a patient might have affected a provider’s decision to schedule one or the other of these services.

Independent variable. The primary independent variable was the type of provider who attended the visit: NP/PA versus PCP.

Patient covariates. Covariates were: age at the time of the visit, gender, years of enrollment with KPGA at the time of the visit, and the presence (vs absence) of several major comorbidities (diabetes, hypertension, hyperlipidemia, cardiovascular disease [coronary artery disease, congestive heart failure, cerebrovascular disease], asthma or chronic obstructive pulmonary disease, or cancer) at the time of the visit.

Statistical Analysis

The initial step in analysis was to compare the distribution of patient characteristics at presentation for a visit for N/B pain or ARI with respect to attending provider type: NP/PA versus PCP. Independence of patient characteristics from attending provider type (ie, NP/PA vs PCP) was assessed using a 2 test.

Propensity of a visit for N/B pain or ARI to have been attended by an NP/PA versus PCP was estimated using logistic regression including the patient covariates. This step resulted in a probability estimate of NP/PA versus PCP selection. Matching of 1 NP/PA visit with 1 PCP visit was done using a caliper of 0.25 times the standard deviation (SD); matching was done without replacement. Distributions of patient covariates before and after propensity score matching were compared using a 2 test. Before and after propensity score matching, the percentages of visits with a related diagnostic test or a medication order on an NP/PA versus PCP visit were compared using a 2 test.

Several sensitivity analyses were conducted. Results might be sensitive to the granularity of matching of NP/PA to PCP visits. Sensitivity of propensity score matching was tested with a finer caliper of 0.025 times the SD. Second, we examined percentages of visits with diagnostic radiology or medication orders by subgroups of visits classified according to the primacy of codes for presenting conditions, assuming that NPs/PAs or PCPs might use the EHR differently and, therefore, code visits differently according to sequence of “presenting” and “diagnosed” conditions. Finally, we estimated a logistic regression of each service order type as a function of NP/PA versus PCP using PROC GENMOD (SAS Institute, Cary, North Carolina) to evaluate whether clustering of service orders by provider might account for statistical significance of likelihood of a service type order by NP/PA or PCP.

All data management and statistical analyses were conducted using SAS version 9.4 (SAS Institute, Cary, North Carolina).

NPs/PAs attended to 16.2% of the visits (6724 of 41,404) with N/B pain as a primary or secondary diagnosis. NPs/PAs attended to 22% of the visits (24,190 of 109,844) with ARI as a primary or secondary diagnosis.

Table 1 displays patient characteristics on visits for N/B pain or ARI. Compared with PCPs, patients on N/B pain or ARI visits attended by NPs/PAs were younger, of shorter enrollment duration, and had lower prevalence of major comorbidities.

Table 2 displays the percent of N/B pain visits with orders for diagnostic radiology services and prescription medications by provider type, both before and after propensity score matching. After propensity score matching, PCPs were more likely to order an N/B-related CT/MRI (3.3% vs 2.1%; P <.01) or a narcotic analgesic (30.1% vs 26.9%; P <.01). On the other hand, NPs/PAs were more likely to order a nonnarcotic analgesic (13.5% vs 8.5%; P <.01) or a musculoskeletal relaxant (45.8% vs 42.5%; P <.01). N/B pain visits with an order for an x-ray did not differ between NPs/PAs or PCPs (21.6% vs 22.1%; P = .53).

Table 3 displays the percent of ARI visits with orders for diagnostic radiology services and prescription medications by provider type, both before and after propensity score matching. After propensity score matching, there were significant differences in practice between NPs/PAs and PCPs in treatment of ARI. Over all visits, PCPs were more likely to order ARI-related x-rays (8.6% vs 6.3%; P <.01), CTs/MRIs (0.5% vs 0.3%; P <.01), a broad-spectrum antibiotic (42.5% vs 41.5%; P = .03), or a rapid strep test (9.7% vs 6.3%; P <.01). NPs/PAs, however, were more likely to order any antibiotic (73.7% vs 65.8%; P <.01). As with N/B pain visits, this difference in practice variation between NPs/PAs and PCPs was the same as that observed before propensity score matching.

In the first sensitivity analysis, matching on a smaller caliper made no difference in the findings. Next, the practice pattern differences between NPs/PAs and PCPs over all visits on which a diagnosis of N/B pain (or ARI) was suggested were basically the same whether the relevant ICD-9-CM code was primary or secondary (Tables 2 and 3). Finally, there was some clustering by provider, and adjusting for this clustering tended to push the statistical significance of the NP/PA versus PCP effect toward the null ( eAppendix B ) in some cases; for example, CT/MRI for back pain pushing significance to nonsignificance (ie, P >.05). For most comparisons by provider type, however, the NP/PA versus PCP effect was significant whether the model did or did not account for clustering of service orders by provider.

The objective of our study was to ascertain whether NPs/PAs differed from PCPs in frequency of orders for diagnostic services or prescription medications when managing adults presenting with N/B pain or ARI in primary care. We used propensity score matching of visits to adjust for the fact that patients attended by NPs/PAs tended to be younger and have a lower prevalence of comorbidities, which could affect diagnostic or therapeutic treatment choice.

After matching, several important differences by type of primary care provider were noted in management of N/B pain: PCPs were more likely to order CTs/MRIs and narcotic analgesics and NPs/PAs were more likely to order nonnarcotic analgesics and muscle relaxants. Similarly, differences were noted in management of ARI: PCPs were more likely to order CTs/MRIs—although the rate of these orders was low&mdash;as well as x-rays, broad spectrum antibiotics, and rapid strep tests; NPs/PAs were more likely to order any antibiotic. Thus, on balance, PCPs tended to be more likely than NPs/PAs to order diagnostic or therapeutic services related to N/B pain and ARI visits and to order more costly services among alternatives (eg, CTs/MRIs vs x-rays for adults with N/B pain, broad spectrum antibiotics vs first-line general antibiotics for adults with ARIs).

Evidence from this health maintenance organization (HMO), therefore, differs from the results of other studies, suggesting that NPs/PAs might more frequently order diagnostic or therapeutic services for common conditions treated in primary care; or, among alternatives, order more costly services. 27 Our study’s findings are, however, consistent with another recent study using data from the National Ambulatory Medical Care Survey (NAMCS), which found no significant differences between NPs/PAs and physicians in office-based practice when ordering “low-value” ancillary services. 16 In our study, the pattern of ancillary services use suggests that NPs/PAs might have been more judicious in use of “low-value” ancillary services than PCPs. For management of back pain, overuse of CTs/MRIs and narcotic analgesics is a current concern. 32 We found NPs/PAs had lower rates of use of CTs/MRIs and narcotic analgesics in management of N/B pain. In management of an ARI, overuse of antibiotics—particularly broad-spectrum antibiotics&mdash;is a long-standing concern. 33-36,38 Overuse of rapid strep tests is another concern in management of ARIs, 37 and we found NPs/PAs were less likely to order broad-spectrum antibiotics and rapid strep tests.

What factors might have contributed to this NPs/PA practice pattern? Training of NPs/PAs typically emphasizes patient education and self-management over other interventional strategies. Thus, NPs/PAs may be more comfortable in initially managing N/B pain or ARI with fewer ancillary services. It is also possible that NPs/PAs are more compliant than PCPs with clinical practice guidelines in management of N/B pain or ARI in primary care.

Sensitivity analyses suggest this study’s findings are robust. Matching a narrower caliper —one a tenth of that used for the findings discussed in this paper&mdash;yielded similar results. Frequencies of orders by NPs/PAs versus PCPs for visits related to N/B pain (or ARI) did not generally differ by whether N/B pain (or ARI) was indicated as a primary or secondary diagnosis. The clustering analyses do indicate some proportion in outcomes by provider type is due to practice variation among individual providers; however, the persistence of significance of the NP/PA effect after adjusting for provider clustering strongly suggests that practice variation by provider type is important.

Limitations

Our study was conducted within the context of a single, group-model HMO in the southeastern United States. Because this HMO had a strong tradition encouraging multidisciplinary, collaborative primary care, study findings might not be generalizable to other settings with a different delivery model. NPs/PAs work under supervision of PCPs; however, we had no measure of how supervision practices might have influenced NP/PA ordering patterns. During the study period, NPs/PAs were relatively established in this HMO; their practice patterns might not represent practice patterns of newly hired NPs/PAs. This HMO had relatively well-defined practice guidelines for management of N/B pain and ARI. Rates of orders for medications reflect only orders for prescriptions and not over-the-counter medications. We did not investigate specific quality measures, so we cannot conclude that over- or underuse of specific diagnostic services or prescribed medications was beneficial or detrimental to patient health. The propensity score matching relied on a limited number of patient covariates, and does not necessarily account for illness acuity within the selected comorbidities. Other factors that varied across clinics where NPs/PAs practiced (eg, use of care managers in some clinics but not others) might also influence practice variation by provider type.

Other factors that we did not consider in our analyses could offset the potential savings in medical care delivery costs due to lower ancillary services rates on visits attended by NPs/PAs. Length of visit was not available, so we could not assess if longer NP/PA visits decreased visit productivity (in terms of visits per day) and attenuated labor cost savings due to lower NP/PA salaries. 13,45 We did not examine variation by provider type in other utilization measures such as referrals or potentially avoidable hospital admissions. Other studies that have examined postvisit utilization generally find equal or lower rates of these classes of services following NP/PA visits compared with physician visits. 15,22 Similarly, we show elsewhere that the extent of NP/PA integration into this HMO’s primary care delivery system did not increase levels of these broad classes of utilization across all medical conditions. 39

CONCLUSIONS

In this group model HMO, NPs/PAs who attended visits related to N/B pain or ARI in adult primary care typically had lower rates of associated orders for diagnostic services or prescription medications than PCPs when treating patients of comparable age, gender, and comorbidities.&ensp; Author Affiliations: School of Public Health, Georgia State University (DWR), Atlanta, GA; Center for Clinical and Outcomes Research, Kaiser Permanente (DWR, LFC, BER), Atlanta, GA; RAND Corporation (HL, MR, AM), Santa Monica, CA; Harvard University (HL, AM), Cambridge, MA; Massachusetts Health Policy Commission (DA), Boston, MA.

Source of Funding: Funds to conduct this study were provided by a grant from the American Academy of Family Physicians. The funding source had no role in the study design, data collection, interpretation of the results, and decision to submit the manuscript. Analyses and interpretations presented in this manuscript are solely those of the authors and do not represent the views of the sponsor or the authors’ employers.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DWR, HL, MR, DA, AM); acquisition of data (DWR, LFC, DA); analysis and interpretation of data (DWR, HL, LFC, MR); drafting of the manuscript (DWR, MR); critical revision of the manuscript for important intellectual content (DWR, HL, MR, BER, AM); statistical analysis (DWR, LFC, MR); provision of patients or study materials (BER); obtaining funding (DWR, DA); administrative, technical, or logistic support (BER, AM); and supervision (DWR).

Address Correspondence to: Douglas W. Roblin, PhD, School of Public Health, Georgia State University, 1 Park Pl, Rm 662C, Atlanta, GA 30303. E-mail: [email protected].

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