Primary care clinics-managing physician patient panels

Session 6

Primary Care Clinics & Managing Physicians’ Patient Panel Size:

Advanced Access and Reducing Delays in

Primary Care Clinics

Alexander Kolker. All rights reserved 1

OUTLINE

• Traditional scheduling and the advanced access at a primary care clinic • Uncertainties that should be considered when patients are scheduled • Decisions that need to be made for designing an appointment system • Practice on using the panel size calculator •Emerging Trends in Primary Care:

•Team Care •Patient-Centered Medical Home • Five main payment models


Primary Care and Advanced Access • For most patients, their primary care physician is their major access point to care • Yet, primary care practices often have long waits for appointments and may have difficulty in accommodating patients with urgent problems

• Some primary care practices have adopted a patient scheduling approach known as advanced access •In a “traditional” system each physician’s daily schedule is booked in advance, and some fixed number of appointment slots are held open for urgent cases •The Institute of Medicine has reported “timeliness” as one of six key “aims for improvement” in its major report of quality of care

“Crossing the Quality Chasm: A New Health System for the 21-st Century”, 2001. IOM, Washington, DC, 2001.


• The advanced access approach offers every patient a same-day appointment, regardless of the urgency of the problem • However, advanced access can only work if patient demand for visits and physician capacity to see patients are “in balance”

Main Points to discuss

• What constitutes an appropriate balance ?

• What is a “manageable” patient panel size ?


Question:

If the demand for appointments is equal on average to the number of available appointment slots, do you expect no backlogs and no wait time for appointments?


•A fundamental feature of patient demand for primary care is its random nature: the actual number of patients requesting care on any particular day will vary around the average daily value, sometimes substantially •It is this inherent randomness that makes it difficult to answer the questions such as: “How large a patient panel size can be served by a given physician practice?”

• Because of this variability, making supply and demand equal on average would create chronic backlogs for care and wait for appointments that would likely get longer and longer

The Need for “Safety” Capacity


Alexander Kolker. All rights reserved

To illustrate, suppose that 10 daily appointments are scheduled in the clinic. Demand for appointments is: about 50% of time 9 appointments are requested (demand is 9), and another 50% of time 11 appointments are requested (demand is 11), i.e. the average demand is 10 appointments

7


(Green, Savin, Murray, 2007. The Joint Commission Journal on Quality & Patient

Safety.)

But …… Isn’t it seems logical to assume that “bad” days with the demand of 11 will be balanced out by “good” days with only 9 patients demand ? So, why doesn’t this balancing out happen?

The answer is: When patient demand is less than the appointment capacity, the extra service capacity cannot be transferred to the next day to serve future patient demand; therefore it is lost. On the other hand, on the “bad” days, when patient demand exceeds service capacity, the un-served demand does not disappear, and it has to be satisfied in the future. Therefore “good” days cannot clear the backlog created by the equal number of “bad” days.


Key points:

• The average daily demand for appointments must be strictly less than the maximum appointment capacity.

• There must be some safety capacity relative to demand. • Safety capacity (the amount of capacity in excess of

average demand) serves as a hedge against demand variability.

• Without safety capacity a practice will be unable to offer

timely access to care.


Finding the Right Balance Between Supply and Demand

Question: How much safety capacity does any specific practice need? Answer: This depends primarily on the desired overflow frequency level—the percentage of days when demand exceeds the number of appointment slots for that day. In the example illustrated above, the overflow frequency is 50%. The lower the overflow frequency level, the easier it will be to offer the same-day appointment


•Decreasing the overflow frequency can only be accomplished by increasing the safety capacity (good for patients – higher chance for the same day appointment). •However, more safety capacity also means more idle physician time (bad for physicians – loss of revenue).


•So, the “right” level of safety capacity for an office must be determined by the trade-off between: (i) the revenue associated with seeing more patients and

(ii) the amount of overtime the practice is willing to undertake to keep patient delays minimal. •To evaluate the possible trade-offs, it is necessary to establish the relationship between: • safety capacity • patient panel size • overflow frequency


Patient panel size is the major determinant of demand and the prime lever for achieving the right balance between supply and demand.

Finding the Right Panel Size (Savin, S., In: Patient Flow: Reducing Delay in Healthcare Delivery. Ed. R. Hall, Springer, 2006)

Establishing an appropriate panel size for the existing practice includes the following 6 steps: 1. Identifying the current panel size 2. Estimating the daily visit rate per patient 3. Fixing the number of daily appointment slots 4. Calculating the current overflow frequency 5. Setting the target overflow frequency 6. Computing the panel size based on the target flow Alexander Kolker. All rights reserved 14

1. The panel size N

It will be most accurately estimated by calculating the total number of distinct patients seen by a physician (or requests for appointments) in the last 18 months.

2. The daily visit rate r = A/(N * T) Here, A is the number of patient appointments / requests for T work days (determined from examination of the appointment log). For example, consider a general practice with a current panel size N = 2500 patients and A = 6500 office visits during the last 18 months (T = 315 days). For this practice, r =6500/ (2500*315)= 0.0082 visits/day per patient. This is the average over a long period of time. It can over- or underestimate the actual demand over any short-term period.


3.Establishing the Target Number of Daily Appointment Slots. The average daily supply of appointment slots, C, is determined by the average length of an appointment slot and the average daily number of hours devoted to direct patient care. For example, if a physician spends an average of 6 hours per day in patient care and appointments are scheduled 20 minutes apart, the daily scheduled appointment capacity is C = 6 hours × 3 appointments/hour = 18 appointments.

4. CALCULATING THE OVERFLOW FREQUENCY- Use the online calculator (info on the next slide…. ) Let current and the desired future (recommended) panel size be 2500; 18 appointment slots; 5 days/week; 50 weeks annually (2 weeks off). For this example, the overflow frequency is 10%, and appointment capacity utilization is 74% (for the number of weekly visits 90)


Panel size online calculator link: You will have to register: create you own user name and password

http://www.panelsizer.com/wps/panelsizer.aspx


http://www.panelsizer.com/wps/panelsizer.aspx

Panel Sizes (Capacity Utilizations %) for Different Parameter Values (from Green et al, 2007, page 217)

Overtime Frequency # of overtime days per week

40% 2

20% 1

10% 0.5 (1 in 2 wks)

5% 0.25 (1 in 4 wks)

Overflow frequency

Daily Appointments

slots=24

Daily Appointment

slots=20

5% 2321 (73%) 1879 (70%)

10% 2515 (79%) 2053 (77%)

20% 2765 (86%) 2279 (85%) Alexander Kolker. All rights reserved 18

Key Points

•Ensuring timely access to medical care is an important goal for any physician practice •Advanced access is a way of achieving this goal •The variability inherent in the demand and delivery of care makes it difficult to determine patient panel size or, conversely, physician practice size by using guesswork or intuition. • Quantitative models help to take into account the unavoidable variability of patient demand.


• Traditional scheduling systems:

– Long times until next appointment

– High no-show rates

– Double/triple booking—queues form

• Advanced access:

– Patients seen the same day as requested

– Reduces no-show rate

– Better continuity of care


• PanelSizer™ is a tool that diagnoses the degree of mismatch between the needs of patients and the capacity of physicians • Based on that diagnosis, it then recommends the size of the patient panel consistent with the goal of providing the same-day appointments for most patients • Thus, the environment is created in which patient satisfaction and revenue generation go hand-in-hand



Ozen et al, 2013, 16(2), 101-118. Healthcare Management Science Journal. THE IMPACT OF CASE MIX ON TIMELY ACCESS TO APPOINTMENTS IN A

PRIMARY CARE GROUP PRACTICE

Abstract

At the heart of the practice of primary care is the concept of a physician panel. A panel refers to the set of patients for whose long term, holistic care the physician is responsible. A physician's appointment burden is determined by the size and composition of the panel. The overflow frequency, or the probability that the demand exceeds the capacity, is a measure of access. The problem of minimizing the maximum overflow for a multi-physician practice is formulated as a non-linear integer programming problem. This optimization framework helps a practice: 1) quantify the imbalances across physicians due to the variation in case mix and panel size, and 2) determine how panels can be altered in the Ieast disruptive way to improve access. An important advantage of this approach is that it can be implemented in an Excel Spreadsheet and used for panel management decisions.

Emerging Trends in Primary Care

Team Care •PCP reimbursement is less than most other specialties •This discourages many physicians from careers in primary care •As a result, many practices are using support staff, such as Physician Assistants (PA) and Nurse Practitioners (NP) to fill the void • Primary care teams start playing a central role



(Team care cont.) •While a patient’s PCP remains a main point of contact and coordinate the care, the patient might be seen by other clinicians in the team •This pooling of the team’s capacity helps to better absorb fluctuations in demand, as well as direct care based on acuity of the case •Patient appointment scheduling in primary care has to consider this team aspect rather than focusing primarily on physicians


Patient-Centered Medical Home (PCMH) •An approach to primary care that facilitates partnership between individual patients, their PCP and the patient’s family •The PCMH attempts to counter the increasing fragmentation and a lack of coordination of care between various providers •Each patient will have a PCP who will also coordinate and will stay informed of the patient’s care across the other parts of the system: subspecialties, hospitals, health agencies and nursing homes •The PCMH model will use extensively IT and EHR to achieve this level of coordination Alexander Kolker. All rights reserved 26

(PCMH cont.)

•Currently, physician reimbursement is based on the number of visits •In PCMH model, ‘face-to-face’ visits will be complemented by visits to other team members, such as LNP and PA •Some exchanges may happen over e-mails and phone calls •The reimbursement will have to account for ‘non-visit’ care time •This creates a number of operational questions since ‘capacity’ of a clinic now assumes a flexible form rather than being centered solely on physician visits


Summary of payment models The goal of payment models is to change the way physicians, hospitals, and other care providers are paid in order to provide higher quality at lower costs, i.e. to improve value.

There are 5 main payment models: 1. Fee-for-Service


•Policymakers and Payers have grown increasingly frustrated with fee-for-service payment system. •Fee-for-service rewards volumes and encourages silos and fragmentation of care. •Several provisions of 2010 healthcare reform legislation seek to shift provider payments to value-based approaches that encourage quality improvement and cost reduction

Fee-for-Service (cont.) Yet, this payment model has some advantages: The types of care that are best suited for fee-for-service payment model: •emergency and trauma care •elective procedures that are not covered by insurance


Summary of payment models (cont.)

2. Pay for coordination

The types of care best suited for pay for coordination are: • primary care management and care coordination for patients with chronic conditions, • and care coordination for healthy patients who are at risk for chronic illness.


The typical example of this model is the medical or health care home model. The medical home receives a monthly payment in exchange for the delivery of care coordination services that are not otherwise provided and reimbursed.


3. Pay for performance This model has actually become Pay for Compliance

The types of care that are best suited for pay for coordination are: •services for which metrics already exist including management of some chronic conditions (e.g. diabetes, asthma, heart failure) •certain surgeries


4. Episode or Bundled Payments

The types of care best-suited for episode or bundled payments are:

• obstetric/maternity care

• transplants

• joint replacement surgery

• other general surgeries

• pacemaker/ICD implantation

• and some other ambulatory diagnostic or therapeutic procedures.



5. Comprehensive Care/Total Cost of Care Payments

• Practice with improved flexibility for providers in terms of care delivery

• Practice with greater potential for innovation in delivery design

• Practice with improved incentive for providers who serve a particular population to collaborate with each other


The types of care best-suited for this model are:


Provides a single risk-adjusted payment for the full range of health care services needed by a specified group of patients for a fixed period of time.


•There is no ‘silver bullet’ among the options •No single payment model is appropriate for all types of care or applicable in all settings, practice types, and geographic locations

Overall take-away for payment models:

Next session 7

‘Fair’ Costs and Payoff Distributions among

cooperating providers.

Introduction into Game Theory and the concept of

the Shapley Value.

Reading Assignments:

Kolker, chapter 6
