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EPtalk by Dr. Jayne 7/21/16

July 21, 2016 Dr. Jayne No Comments

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I’m always on the lookout for FDA alerts on drug recalls and other issues of interest to my clients. Usually those come as a “Dear Health Care Provider” letter and often involve contaminated biologicals, poorly compounded pharmaceuticals, or counterfeit prescription medications. This notice caught my eye, however, because it notified health care providers of hair loss, itching, and rash caused by a cosmetic product rather than a drug. Sometimes we forget that the FDA does more than approve prescription drugs, so this was a good reminder.

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Although the majority of providers hanging around the typical physician lounge don’t have a working knowledge of MACRA or MIPS, those of us who are knee-deep in the transition to value-based care have some pretty detailed conversations. One of my colleagues has been in a discussion group about how Accountable Care Organizations submit their quality measures. I have to admit that I haven’t been deep into the ACO regulations, so I was surprised to learn that submission using the CMS Web Interface typically uses the first 284 Medicare patient encounters of the year. How do they even come up with a number like that?

The discussion group had been spurred by some kind of advertising piece targeting practices that see a lot of snowbirds, since those patients (who are often more physically and financially healthy than their peers) typically head south after the holidays. This could theoretically skew quality numbers in the less-temperate zones based on the demographics and clinical status of the remaining patients. Of course, depending on the size of the practice and the number of snowbirds, the skew could be negligible. But it makes one wonder about the rationale behind such an arbitrary number as well as taking the sample from the first encounters of the calendar year rather than as a random sampling. I’d be interested to hear opinions from those that know more about ACOs.

I’ve seen a definite shift in the scope of consulting requests that I’ve seen over the last couple of years. Where they used to be strongly flavored with the need to find an EHR, replace an EHR, or optimize an EHR, I’m not getting many of those these days. Most of my potential clients want help transforming their practices, either into a patient-centered medical home model or in helping with general office efficiency. One of the most common discussions I get into during these projects is the idea of panel size, or how many patients a primary care physician should have under their care.

When I first came into practice as a solo primary care physician, the hospital that sponsored me wanted to target a panel of 4,000 patients. That was partly based on the demographic of the area, knowing that many of my patients would be young and healthy and wouldn’t need more than one or two visits a year. However, since I was the only physician within a 10-mile radius taking new Medicaid patients, the ridiculousness of that panel size quickly became apparent as my schedule was loaded with patients who would come in 12 or more times per year. Helping clients determine what the right panel size for their providers is can be tricky, and I try to keep up with articles that address it.

One of the first things I look at the wait for a patient to get an appointment. Regardless of your panel size, if your patients can’t get in, you have too many patients (or not enough appointments – either way something isn’t right). I also look at provider scheduling habits and whether they run on time or double book and how they cope with that. If they’re getting through the day by double booking and praying for cancellations, it’s more likely to lead to burnout, employee dissatisfaction, and patient dissatisfaction. I also look at whether the practice is running using a care team model or whether they’re running as a more traditional physician-run practice.

Unfortunately, income goals tend to drive visit volume more often than other factors such as clinical quality or perceived workplace stress. I was recently wearing my EHR hat in a conversation with a practice management consultant whose opening comments to the physician asked how much she wanted to make per hour because that was going to drive patient volume and panel size. Although income is certainly a factor for most of us, I thought it was insulting to use that as the primary discussion point rather than asking the physician what kind of practice she wanted to have and how she saw herself and her team delivering care. My sense was that if this physician was about the money, she would have chosen something other than family medicine as a specialty, and leading with that aspect of practice management really put a damper on our ability to have a good discussion.

I came across an article this morning that addresses the concept of panel size as an issue in physician workforce planning. It addresses the idea that a panel size of 2,500 patients is often cited with little evidence to back it up. How far that is from my initial 4,000 patient target! The article goes on to look at practices that actively manage panel size (such as Kaiser Permanente and the VA) whose numbers are more in the 1,200 to 1,700 range. It also mentions that physicians in a “concierge or boutique” model care for between 900 and 1,000 patients, but my experience shows these to be even smaller – typically in the 500-600 range in the Midwest.

It’s no surprise that smaller panel sizes lead to reduced wait times and improved quality of care, as mentioned in the article. The trick is ensuring that primary care compensation allows smaller panel sizes so that physicians can truly get off the volume-driven hamster wheel. Compensation also has to allow for utilization of diverse clinical team members such as dieticians, social workers, care coordinators, and more, if that’s what our “value-based” system requires. I guarantee that if primary care physicians were compensated to the same degree that procedural subspecialists are (even if you adjust for years of training), you’d see people flocking to primary care.

We’re not there yet though – and we’re trying to use figures like $10 per member per month to drive change. It will be interesting to see what the next few years hold as we transition to new models of care and new models of payment.

What do you think about the transition to value-based care? Email me.

Email Dr. Jayne.

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