The average patient panel size for a U.S. primary care physician is about 2,300 patients, according to a team of California-based primary care physician researchers. Couple that with statistics showing new physicians often choose medical specialties other than primary care, and it leaves primary care medicine in the United States with a big problem -- particularly when even more patients soon will be searching for a primary care physician, thanks to passage of the Patient Protection and Affordable Care Act.
That developing dilemma led researchers at the Center for Excellence in Primary Care in the Department of Family and Community Medicine at the University of California, San Francisco, to explore solutions that could work for some primary care practices based on delegating the work physicians typically do to nonclinician members of a practice's health care team.
- Primary care physicians in the United States are experiencing an increase in the size of their patient panels.
- This is happening at the same time that the country is experiencing a shortage in primary care physicians.
- A new study looks at how delegating varying percentages of tasks associated with patient care to nonclinician team members may help solve the problem.
The results of the study, Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation(annfammed.org), are in the September/October Annals of Family Medicine.
The study uses information compiled by the Department of Community and Family Medicine at Duke University in Durham, N.C., to estimate the time a physician would need to provide the health care required by 2,500 patients in each of three areas: preventive care, chronic care and acute care.
The researchers calculated that it would take one physician
- 1,773 hours per year (0.71 hours per patient) to deliver all the preventive services recommended by the U.S Preventive Services Task Force,
- 2,484 hours per year (0.99 hours per patient) to provide necessary health care to patients with chronic conditions, and
- 888 hours per year (0.36 hours per patient) to provide acute care to the panel of 2,500 patients.
Researchers then postulated various delegation models with size-adjusted patient panels that could correspond directly to the percentage of tasks delegated to nonclinician team members. They based their models on an estimated family physician workload of 43 hours per week for 47.1 weeks per year, for an average of 2,025 hours worked per year.
The study uses four models that have the physician providing varying percentages of care tasks. For example, the first model incorporates no delegation, and the physician takes responsibility for all preventive, chronic and acute patient care. The authors calculate that a physician can realistically provide quality care to a maximum of 983 patients in this model. The physician spends -- per patient, per year -- 0.71 hours on preventive care, 0.99 hours on acute care and 0.36 hours on acute care for total of 2.06 hours per patient.
The first model that incorporates delegation would delegate 77 percent of preventive care and 47 percent of chronic care to nonclinical team members. In this model, a physician cares for a panel of 1,947 patients and spends -- per patient, per year -- 0.16 hours on preventive care, 0.53 hours on chronic care and 0.36 hours on acute care for a total of 1.04 hours.
In the second delegation model, 60 percent of all preventive care time and 30 percent of all chronic care services are delegated to the team. The patient panel size is 1,523 patients. The physician spends -- per patient, per year -- 0.28 hours on preventive care, 0.70 hours on chronic care and 0.36 hours on acute care for a total of 1.33 hours per patient.
The third delegation model delegates 50 percent of preventive care services and 25 percent of chronic care services to the team. In this model, the physician spends -- per patient, per year -- 0.35 hours on preventive care, 0.75 hours on chronic care and 0.36 hours on acute care for a total of 1.46 hours per patient.
The study researchers acknowledge that for practices interested or able to move to a delegated model of care, it requires a significant shift in the delivery of health care services. "Solving the primary care dilemma -- excessive panel sizes in an environment of a primary care physician shortage -- requires the replacement of physician-only care with team-based care," say the researchers. To accomplish what they call an "unprecedented change" in the culture and structure of a primary care practice, physicians must consider whether they can provide all of the necessary hands-on patient care.
In addition, practices considering team-based care need to take other steps, including
- training nonclinical practice team members,
- mapping the office workflow and individual tasks,
- creating standing orders that allow nonclinician staff members to perform patient care previously provided by the physician, and
- educating patients about team-based care.
Reforming payment mechanisms for primary care, an element largely out of physician control, also needs to be considered, note the researchers. "Fortunately, all of these elements are being implemented in many innovative primary care practices around the United States," the study concludes.
"These practices point to a future of high-functioning primary care teams than can ensure health care access and quality for the nation's population with a reasonable work life for physicians and other team members."