Physicians in primary care are inundated with patient demands for services including preventive care, chronic disease management, and acute care. Its been estimated that the average primary care physician spends on average 2.06 hours per patient per year[1]. For an average panel size of 2300, this equates to 4738 hrs or 790 days per year to meet all needs for our patients. Given that the average primary care physician works 2025 hrs per year, the gap between what is needed and what is available is glaring. To meet these needs, the average primary care physician would need to spend 21 hrs per day in their office.
No wonder then that the outcomes of primary care physicians are mediocre at best. For instance, only 55% of Americans receive the needed preventive and chronic services.[2] Fifty percent (50%) of patients with hypertension are uncontrolled[3] and less than 20% of patients with high lipids are in control.[4]
In order to improve these outcomes, one of two options need to be developed. The first option is lowering panel size. As mentioned, the average primary care physician panel size in the United States is 2300. To fully meet preventive, chronic and acute care needs of all its patients, a physician’s panel would need to be reduced to 983, even smaller for a more geriatric panel. The concierge model of medicine has advocated for smaller panels (500-700) who subscribe at rates of $150 per member per month or more for comprehensive services. However this model of care, although better for a select few patients, worsens an already taxed health system struggling to provide access to a growing population. A 2011 national survey indicates that 57% of Americans cannot obtain timely care. Unless Federal support for primary care training programs greatly expands, this option will not meet the needs of all Americans.
The second option is a major shift in delivery model where members of a care team fulfill primary functions in the provision of care.[5], [6]. Team-based care identifies specific functions for nurses, MA, clerks and others as part of the ‘teamlet’ that by protocol and position description provides a range of care services. For instance, 77% of preventive services can be delegated to team members. 47% of chronic care can be delegated (many of the population health functions). This team-based care allows the primary care physician to spend considerably less time per year with a patient, estimated to be 1.04 hrs compared to 2.06 in the non-delegated version. This sharing of care allows excellent care for a panel of patients of over 1900.
To get started in optimizing your care team, consider the following changes (non inclusive). A great resource is the Primary Care Team Guide available at http://www.improvingprimarycare.org/team .
- Define the tasks currently performed in your practice. With your team, list out all the things that happen before, during and after a patient visit
- Have your team estimate how they spend their time. A good resource is the Clinical Microsystem workbook for primary care, worksheet found on page 14 http://clinicalmicrosystem.org/wp-content/uploads/2014/07/outpatient-primary-care-workbook.doc
- Realign tasks to member of the team that best uses their level of training and expertise. For example immunizations and counselling can be done by RNs or MAs
- Develop visit protocols to formalize the above reassignments into specific patient care pathways.
- Identify where training and support needs to be performed or improved.
- Hold huddles, debrief, and more formal team meetings to evaluate team functioning and continual to optimize roles and functions. Look at the Stanford Coordinated Care model developed by Alan Glaseroff https://stanfordhealthcare.org/health-care-professionals/medical-staff/medstaff-update/2014-april/201404-stanford-coordinated-care-reinvents-classic-diease-model.html
So consider examining how you delivery primary care and look for opportunities to share the care, and optimize your team. I am often reminded of an old Japanese proverb that goes “none of us are as smart as all of us”. In our clinical work for our patients, I propose that none of us are as good care providers as all of could be”
[1] Altschuler J; Margolius, D; Bodenheimer, T; Grumbach, K. “Estimating A Reasonable Patient Panel size for Primary Care Physicians with Team-Based Task Delegation”. Annals of Family Medicine 10(5): 396-400, 2012
[2] McGlynn EA et a. “The quality of health care delivered to adults in the United States”, NEJM, 348(26): 2635-2645,2003
[3] Egan BM et al. “US trends in prevalence, awareness, treatment and control of hypertension”. JAMA 303(20):2043-2050, 2010
[4] Ford ES et al. “Trends in hypercholesterolemia, treatment and control among United States adults”. Int J. Cardiology, 140(2): 226-235, 2010
[5] Bodenheimer T; Laing BY. “The teamlet model of primary care”, Annals of Family Medicine 5(5) 457-461
[6] Scherger JE :It’s time to optimize primary care for a healthier population”, Medical Economics. 87(23) 86-88, 2010