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Health centers are a critical source of primary care, especially for individuals living in underserved communities. In 2023, over 110 million visits were managed by over 300 000 full-time equivalent (FTE) clinical and nonclinical support staff.¹ The study by Sun and colleagues² identified 5 distinct FTE staffing patterns across a subset of health centers with publicly available health workforce data and found notable differences in care quality across these staffing models. Limited studies to date have been able to inform employers, policymakers, and other workforce planners on how health center staffing models affect health care delivery to underserved communities.³ The findings of the study by Sun et al² consider how different team configurations, rather than specific professions as examined in previous studies,^4,5 contribute to variations in primary care delivery and outcomes.

At first glance, health centers in the study by Sun et al² appeared to have an equivalent distribution of FTEs across physicians, advanced practice registered nurses (APRNs; including certified nurse midwives), and physician associates (PAs) based on data from the Uniform Data System (UDS), an administrative reporting system managed by the Health Resources and Services Administration (HRSA) to which health centers submit annual data. The reality was more complex, with only 19% of health centers having a balance of physician, APRN, and PA FTEs based on the authors’ cluster analysis of 2022 UDS data for the 791 of 1370 health centers that consented to the release of their workforce information. In the other staffing models, certain clinical staff were predominant, such that 33% of health centers had a high mean FTE of both APRNs and physicians yet fewer PA FTEs, 22% had a high mean APRN FTE, 20% had a high mean physician FTE, and 5% had substantially large FTEs for each of physicians, APRNs, and PAs compared with the other models (these were referred to as large-scale health centers). Not surprisingly, large-scale health centers primarily served urban populations, while over half of the health centers with high-APRN FTEs served rural communities that also had the highest percentage of uninsured patients; this finding is consistent with literature showing that APRN supply is higher in rural and underserved areas.⁵

Using clinician FTEs adjusted for number of visits as well as the ratio between each specific clinician type’s FTE relative to all clinician FTEs, Sun et al² found significant variation between staffing configurations and health center performance on half of the 14 quality metrics measures assessed, controlling for other facility and patient characteristics. Specifically, the authors found that at certain thresholds, there were positive associations between physician FTE and rates of breast and cervical cancer screening, infant vaccination, HIV testing, and depression in remission, while APRN FTE was positively associated with rates of adult body mass index (BMI) assessment and counseling and PA FTE was positively associated with infant vaccination rates. The study by Sun et al² differs from prior studies by examining how health outcomes are associated with different team configurations, which is more aligned with how health care is being practiced, instead of focusing on how 1 clinician type contributes to health outcomes. The findings of the study raise important questions about what may be driving the care processes and workflows within these different health center staffing models that lead to different health outcomes. Also, questions arise as to how training and education differences of physicians, APRNs, and PAs contribute to each clinician’s approach to patient care and how to maximize each specialty’s strengths to provide optimal care.

Interestingly, Sun et al² did not find staffing configurations to have a significant association with depression screening and chronic disease management outcomes. This null finding may be encouraging in that health centers may be able to provide similar care regardless of staffing, possibly by optimizing the clinicians available to them. Additional attention is needed on the presence of other types of health care professionals, such as counselors and social workers, who are often in short supply in underserved and rural communities, and their role in influencing these outcomes.

The findings of the study by Sun et al² suggest that patients currently face variable care based on the health center available to them due in part to the staffing configuration. The availability of funding to recruit and retain a health workforce that is prepared to provide a high quality of care is an ongoing challenge. Health centers have long faced tight margins, if any, and are currently grappling with funding challenges due to declines in Medicaid enrollment and the end of emergency funding from the COVID-19 pandemic.⁶ The National Health Service Corps can help recruit health care professionals such as physicians and APRNs to help health centers but is limited in scope. While a one-size-fits-all staffing model is not likely to exist given that multiple factors affect recruitment and retention of clinicians to health centers, a broad-based federal investment strategy is necessary for health centers to optimize the available health workforce to ensure high-quality care for patients.

Published: October 22, 2024. doi:10.1001/jamanetworkopen.2024.40083

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Frogner BK. ÌÇÐÄvlog Open.

Corresponding Author: Bianca K. Frogner, PhD, Center for Health Workforce Studies, University of Washington School of Medicine, 4311 11th Ave NE, Ste 210, Box 354982, Seattle, WA 98195 (bfrogner@uw.edu).

Conflict of Interest Disclosures: Prof Frogner reported receiving grants from the Health Resources and Services Administration outside the submitted work.