Journal of Healthcare Management - September/October 2016 - 374

J o u r n al of H ealt H care M anageMent 61:5 S epte Mber /o ctober 2016 as they pursued further nursing education. Some CHCs helped fund the employees' education. DISCUSSION The results of this study add to previous studies of the primary care workforce, which are mostly national or state-level analyses that tend to focus on single health professions (National Association of Community Health Centers, Robert Graham Center, & The George Washington University School of Public Health and Health Services, 2008; Phillips, Bazemore, & Peterson, 2014). Our findings highlight the complexity of CHC leaders' medical staffing decisions (McDaniel, Driebe, & Lanham, 2013). The findings also shed light on some of the local factors that shape demand, as well as the role that perceptions may play as CEOs consider the tradeoffs of various staffing configurations. We found that CEOs did not perceive the decision to hire MAs, NPs, or PAs as a function of physician shortages; they valued NPs and PAs for the different qualities they brought to a practice. This finding contrasts with the dominant portrayals of APPs as substitutes for physicians (Ku, Jones, Shin, Bruen, & Hayes, 2011; U.S. Department of Health and Human Services, 2013) or as "physician extenders" (Rodyskill, 2003). The desire for balance raises the empirical question of whether CHCs that employ a diversity of provider types actually have better outcomes and higher patient satisfaction, as the CEOs in our study believe. CEOs' choices of provider type were constrained by the CHC's history; PCMH accreditation status; the local supply of physicians, NPs, or PAs; state SOP variations (in particular, between NPs and PAs); and, of course, the magnitude of the wage gap between APPs and physicians. Several of these variables may be useful in developing state and local government workforce planning efforts. Wage gaps between physicians and APPS are a local variable that may be important to incorporate into local workforce planning models. How these wage gaps affect the likelihood of NPs' and PAs' practicing in primary care settings is another emerging question relevant to workforce planners. Documenting where SOP regulations vary for NPs and PAs would help planners anticipate a greater demand for one type of APP over another. Our findings regarding CEOs' clinical support staff decisions also raise important questions. The prevalence of nurses with associate degrees and LPNs in CHCs was notable, given the Institute of Medicine (2010) recommendation that, by 2020, 80% of the nursing workforce should have a BSN. While this recommendation appears to be having an impact in hospital and home care settings (Pittman, Bass, Hargraves, Herrera, & Thompson, 2015), CEOs in our sample expressed great interest in nurses with associate degrees and LPNs. Participants appreciated their greater SOP and clinical skills compared with those of MAs, especially in states with a more restricted SOP for MAs. This finding raises the question of whether hiring nurses with associate degrees and LPNs is more cost-effective than hiring MAs. How can return on investment be measured, and how can nurse-heavy 374

Table of Contents for the Digital Edition of Journal of Healthcare Management - September/October 2016