February 22, 2019, 03:57 pm Sheri Porter – Patient empanelment and weighting may strike some as topics of little importance to a busy physician in practice. But in reality, understanding these concepts can be a real boost to health care systems and independent practices alike when it comes to assessing staffing needs and providing top-notch care to patients.
Hence the importance of findings from a study published in the October/December 2018 issue of Quality Management in Health Care titled "A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large U.S. Multidisciplinary Group Practice."
Co-author and family physician Sandra Kamnetz, M.D., is vice chair of clinical operations in the department of family medicine and community health at the University of Wisconsin's (UW) School of Medicine and Public Health in Madison.
She spends two days a week in clinical practice and the remainder of her working hours wearing that administrative hat.
In an interview with AAFP News, Kamnetz defined empanelment this way: "It's really about knowing who you are caring for -- those patients with whom you have a continuous relationship and who, in turn, consider you their doctor."
The process of "weighting" the patient panel assesses the level of physician work. "As we move to models of accountable care organizations and population health, we need to recognize that all patients are not created equal," said Kamnetz.
For example, a 40-year-old patient with Medicare coverage likely has psychosocial and medical issues not observed in a healthy 40-year-old employed woman with private health insurance.
The issue then becomes understanding which patient needs more physician attention, staff time and resources.
This work represents a retrospective observational study about how to "right-size" a patient panel by implementing a weighting methodology.
In practical terms, the beauty of weighted panels is that practice decisions are made using data and metrics "rather than relying on your gut," said Kamnetz.
"This process has allowed us to look at our clinics (within the UW system) and decide when panels are getting full and to help make decisions around staffing. Do we need another physician? Another advanced-practice provider? How many medical assistants and registered nurses should we have?"
Kamnetz recalled that in the past, some physicians in the UW system said they felt overworked and then prematurely closed their panels -- an action that didn't address the underlying problem.
Kamnetz and her co-authors pointed out that the number of patients cared for by a primary care physician could vary substantially. "Across primary care disciplines, it is well recognized that the number of patients in a panel is not an accurate marker of work."
Rather, the resources and effort required by a practice to care for patients depend on a number of factors, including demographics, health behaviors, access to care and psychosocial issues.
The recent article covers all the important background information as to why the university health system chose to explore empanelment and weighting, as well as the intricacies involved in accomplishing that work.
The study authors pointed out that in 2006, the system experienced issues around patient access. "Practices had limited access for patients due to physicians' perceptions of being at capacity or unable to accept new patients," they wrote.
To make matters worse, no good metrics were available at that time to identify practices that were at capacity or where additional physicians were most urgently needed.
The authors went on to describe how a utilization-based weighting system that considered patient complexity was developed and applied to primary care patient panels at the academic health system.
The work focused on 27 clinics that serve more than 150,000 patients. Male and female patients ranged in age from birth to older than 75 years and had both public and private health insurance coverage.
The authors compared weighted and unweighted patient panels before and after November 2012, and then they measured the impact on patient access to care by examining responses to a patient experience survey about availability of appointments.
Lastly, they described how health care delivery in the system improved after changes were implemented.
The study's authors focused on 112 primary care physicians working in those clinics during the six-year study period. The cohort breakdown was 55 family physicians, 24 general internists and 33 pediatricians.
Before panel weighting, open panels were available for
But after weighting was initiated, open panels decreased for 14 family physicians (25 percent) and 14 pediatricians (42 percent) but increased for 10 general internists (42 percent).
Overall, the number of active patients increased by 2 percent after panel weighting.
Importantly, in the year after panel weighting, "Patients' perceived access improved in family medicine and general internal medicine clinics despite an increase in the total number of active patients," wrote the authors.
"We hypothesize that this is due to panels becoming 'right-sized,' and thus better able to reflect the amount of actual work required to meet the access needs of a population," they said.
The authors noted that the health system's panel adjustment plan was "clear enough to use in determining compensation, opening and closing panels and making physician hiring decisions."
Additionally, the organization used weighted panel sizes to help make staffing decisions, build registries for chronic diseases such diabetes and create outreach opportunities for patients.
All those features represent "critical components of a high-performing primary care system," wrote the authors.
Furthermore, right-sizing patient panels improved access for existing patients because the health system purposely added new patients to physician panels that showed room for expansion.
If by chance existing patients were unable to schedule appointments when they needed them, they could switch to a primary care physician with more availability.
Kamnetz noted that even though this study focused on physicians and patients in a large health system, the ideas and concepts work for small and independent primary care practices. The same questions need to be asked and answered, she said.
"Who are your patients? How many patients do you you have? Do you have enough clinical staff and physicians to care for them?"
Kamnetz encouraged family physicians to use data to quantify, in a systematic way, who their patients are, "whether it's our model or a model they develop themselves."
"This is critical as you make business decisions around hiring or whatever else you need to serve your patient population," she said.