Thursday, February 20, 2014

How Many Patients Should A Primary Care Physician Care For?

The answer is probably about 1000 or less. But most primary care physicians (PCPs) have a panel of perhaps 2,500 patients and often more.  Why the dichotomy?

As insurers have held the line on physician reimbursement in the current fee-for-service system, PCPs have found that they must increase the number of visits per day in order to meet overheads yet still maintain their personal income of about $175,000 per year.  In order to see more patients, usually 24-25 per day or more, they must no longer visit inpatients in the hospital nor see their patients in the emergency room.  And they have shortened most visits to about 15-20 minutes which means 8-12 minutes of “face time.”  Too little time for someone with multiple chronic illnesses on 5-7 prescription medications and possibly impaired by age with reduced vision, hearing and memory.

Further, there has been a major shift over the years form mostly seeing acute illnesses to a much larger proportion of patient with chronic illness, often complex and often with multiple chronic diseases. These diseases are difficult to manage, last a lifetime (some cancers excepted) and are inherently expensive to treat. These patients often need to be seen, over time, by many specialists. Someone, preferably the PCP, needs to coordinate this team of caregivers to assure quality, safety and in so doing keep expenses down..

Baron published an article on how a primary care physician spends his or her time. He is part of a Philadelphia area internal medicine group practice with an active caseload of 8840 patients divided across the equivalent of four full-time physicians each working 50-60 hours per week. The office has 3.5 full time support staff per physician. Each physician handled 24 telephone calls, 17 emails, reviewed 20 laboratory tests reports, 11 imaging reports and 14 consultation notes and processed 12 prescription refills each day in addition to seeing patients. It is clear from this report that the PCP spends a lot of time in clinically relevant work not directly associated with a patient visit – which is the only activity that generates an insurance reimbursement. Not noted was the very substantial time spent in non-clinical requirements such as insurance forms.

So what is an appropriate number of patients under care or number of visits per day?  The answer, of course, is that “it depends.”  It depends on the type of patient, their reason for the visit, their impairments and their personal needs, to name but a few. 

I have completed multiple in-depth interviews with many PCPs.  Most were in private practice; some were in an academic setting.  Most accepted fee-for-service insurance; some were retainer-based PCPs.  Some had been in practice for decades, others for a few years.  About three-quarters were men, the remainder women.  Of the 21 questions, one asked the ideal size of the PCPs patient panel. Their responses varied but here are some generalizations.  PCPs, they said, should have no more than about 1,000 patients under care, perhaps less if the majority are geriatric with complex chronic illnesses and perhaps up to 1500 if most were basically healthy.  But, in order to meet overheads, most of these same PCPs had closer to the 2,500 panel size.  The exceptions were retainer-based PCPs with about 500 and a salaried PCP in a retirement community with 400 patients in his panel.  These physicians felt they were able to give much better care to these smaller sized panels of patients. The retirement community PCP had strong data to support his contention, e.g., reduced hospitalizations and markedly reduced unplanned 30 day readmissions to the hospital. One of the retainer-based physicians participated with MDVIP, an organization which has developed similar data on substantially reduced admissions.

I asked the same question on a LinkedIn group.  Many responded as did the PCP interviewees.  Here are some specific comments: “Patients are not products on an assembly line that must all fit into specified compartments as business models dictate.”  “Time is what affords the physician the ability to utilize all of his or her experience and medical expertise in the most efficient manner to benefit the patient.”  “Time is the one component necessary to be effective.”  Another response was that PCPs who decline insurance and have the patient pay directly can actually charge less because their overhead declines so dramatically, perhaps by about $58 per patient visit.  A third stated that PCPs need to develop and properly manage an office team and delegate responsibility and authority accordingly.  Data collection and data entry for example can be done by non-clinicians and much preventive care can be handled by nurses and nurse practitioners, thereby freeing up substantial time for the PCP to interact with patients – time to listen and time to think. 

An article in the Annals of Family Medicine by Altshuler and others sought to estimate a reasonable sized patient panel for a PCP with team-based task delegation consistent with the patient centered medical home model.  Using published estimates of the time needed by a PCP to provide preventive, chronic and acute care they modeled how panel sizes would change if some portion of the work in each of the three categories was delegated to team members.  If there was no delegation of work, as has been typical in PCP practices for decades, the data suggest that a patient panel size of about 983 is the maximum, not too far from my own estimate of 1,000 based on the various interviews.  They then assumed varying levels of delegation to the team.  Their model panels with team-based delegation ranged from 1,387 to 1,947 patients.  This analysis suggests that a primary care physician can care for more than 1,000 patients provided he or she practices as part of a well-oiled team-based medical home practice.  It does not address the question of whether the team can practice true “population health” meaning that the PCP and his or her office team reach out proactively to all members of the patient panel to address high quality preventative care rather always being reactive by waiting for the patient to arrive at the office with a problem. 

PCPs (and all doctors) need time with the patient if they are to be effective and to be trusted.

Something needs to change if PCPs are to get back to providing the level of humane, comprehensive care that patients want and doctors wish to offer. The current reimbursement system short changes the patient and frustrates the physician. Insurers should look to new approaches that pay the PCP to actually spend time with the patient – time to listen, time to prevent, time to treat, time to coordinate chronic care, time to think and time to interact with their colleagues, especially regarding more difficult situations. This can be with fee for service, capitation, bundling, etc. or by the PCP no longer accepting insurance and expecting the patient to pay directly by the visit, the month or the year. In whatever manner, the new paradigm must create time for the physician to spend with the patient so as to listen and think about both the patient and his or her condition.


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