[smartdoctor] dajte nam vrijeme za pacijenta /How Many Patients Should a Primary Care Physician Care For? /tko je tu lud?

From: "BARI" <bari.sita@xxxxxxxxxxx>
To: <smartdoctor@xxxxxxxxxxxxx>
Date: Wed, 22 Oct 2014 11:12:45 +0200
 

 


How Many Patients Should a Primary Care Physician Care For?


 
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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
<http://www.nejm.org/doi/full/10.1056/NEJMon0910793>  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
<http://www.ajmc.com/publications/issue/2012/2012-12-vol18-n12/Personalized-
Preventive-Care-Leads-to-Significant-Reductions-in-Hospital-Utilization>  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 <http://www.annfammed.org/content/10/5/396.full>  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 timewith 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.

 <http://healthworkscollective.com/users/stephenschimpff>
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Authored by:


Stephen Schimpff <http://healthworkscollective.com/users/stephenschimpff> 


Stephen C. Schimpff, MD is the retired Chief Executive Officer of the
University of Maryland Medical Center and former chief operating officer of
the University Maryland Medical System, today a twelve hospital system.
Board certified in internal medicine, medical oncology and infectious
diseases, he has been an active clinician, researcher and professor of both
medicine and public policy. ...
[smartdoctor] dajte nam vrijeme za pacijenta /How Many Patients Should a Primary Care Physician Care For? /tko je tu lud?

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