Controlling your panel: Are physician shortages creating more patients per doctor?

The Medical Group Management Association’s most recent MGMA Stat poll asked healthcare leaders, “Has your patient panel per doctor increased in the past year?” A majority (70%) responded “yes,” and 30% reported “no,”.

This poll was conducted on December 17, 2019, with 802 applicable responses.

Measuring panel size

When it comes to patient panels for primary care practices, size absolutely matters. To maintain reasonable access for patients, a medical practice administrator should know the number of unique patients for which his or her care team is ultimately responsible.

For primary care and cardiology practices that participate in the MGMA Cost and Revenue Survey each year, provider panel size is largely determined by the set of individual, unique patients seen by a provider within the practice over the past 18 months. The per-physician panel size is set using the following methodologies:

• If a patient has only seen one physician in the practice, assign the patient to that physician.
• If a patient has seen more than one physician in the practice, assign the patient to the physician seen most frequently.
• If a patient has seen more than one physician in the practice the same number of times, assign the patient to the physician who did the patient’s last physical.
• If a patient has not had a physical, assign him/her to the physician seen most recently.

The patient access challenge

Care models such as the patient-centered medical home (PCMH) shift the mentality of panel management away from episodic care to a proactive, relationship-focused model in which the full panel’s care is considered. [More information on panel management is available from the Agency for Healthcare Research and Quality (AHRQ) Practice Facilitation Handbook.]

While the patient panel may not directly translate into a specific workload of patients in many medical groups, it does contribute to the challenge of managing patient access, which has increased in recent years. An Oct. 13 MGMA Stat poll found that consumerism is one of the biggest disruptors in healthcare in 2019, and ensuring short patient wait times for appointments is one piece of patient access that remains crucial for practice leaders to manage. As MGMA Chief Operating Officer Ron W. Holder Jr., MHA, FACMPE, FACHE, wrote:

Patient access … used to boil down to having enough providers to meet patient demand. Now, due in part to the changing demographics of the patient population, access means providing telehealth, as well as offering evening and weekend appointments and more convenient hours.

As with most elements of a practice’s operations management, the ability to appropriately staff for various models of care delivery is being impacted by a rising trend of physician shortages across the country in multiple specialties. The Association of American Medical Colleges (AAMC) projects a shortfall of between 46,900 and 121,900 physicians by 2032 for both primary and specialty care, driven largely by increased need for care and increased complexity of care as the population grows and ages.

For the existing physician workforce, the number of patients from the panel who can be seen depends greatly on the number of hours worked and time dedicated to clinical work. Numerous reports on physician burnout point to non-clinical aspects of practice operations encroaching upon clinical time; the 2018 Survey of America’s Physicians: Practice Patterns & Perspectives by The Physicians Foundation finds that about one-quarter of a physician’s time is spent on non-clinical paperwork, resulting in fewer clinical hours worked and fewer patients seen.

These factors can influence quality of care outcomes. A 2016 study of primary care physician (PCP) panel size and quality of care found that the likelihood of hospitalization related to ambulatory-care-sensitive conditions was higher for patients in larger panels. A separate study from 2016 of family medicine panel size found that patient diabetes control and a practice’s time-to-third (the average number of days from an appointment request to the third-next-available appointment per clinician) were negatively impacted with higher panel size.

Improving access and managing panels

To see patients as quickly and conveniently as possible, there are several initiatives that can help improve patient access without hiring more providers, according to Nate Moore, CPA, MBA, CMPE, president, Moore Solutions Inc. These include reducing no-shows to lower the number of unfilled appointment slots; implementing effective portals and online scheduling; and reducing errors in scheduling with specialists.

The AHRQ recommends that practices monitor key metrics for empanelment, including but not limited to:

• Percentage of patient visits to designated clinicians
• Percentage of patient visits to non-designated clinicians
• Size of panel by clinician compared to the practice’s target panel size
• Number of overbooked appointments per week
• Time-to-third
• Patient satisfaction survey data pertaining to access.

 A 2017 report from the University of California Health’s Center for Health Quality and Innovation (CHQI) proposes three methods for determining the “right-sized” panel for a provider group:

1. A visit-based method based solely on office visit supply, which calculates panel size by multiplying PCP scheduled visits per day by PCP work days per year, divided by average visits per patient per year. This method, however, does not account for time spent on non-face-to-face clinic activities, such as patient emails and other activities required for value-based payment arrangements.
2. A time-based method can be used to establish a right-sized panel by examining how various types of care — preventive, chronic and acute — are delegated between physicians and nonphysician team members. Panel size varies based on time delegated to each set of the care team based on hours per patient per year in those three types of care.
3. Using normative benchmarks of existing panel sizes in varying healthcare settings, since definitions of panel metrics are not standardized across specialties. This is particularly important for primary care practices with a greater share of geriatric patients in the panel, which likely leads to a more complex case mix in the patient population.

Additional resources

• “Make room: Optimizing patient access and accelerating practice growth via a space utilization plan” (MGMA Connection article)
• “How do you improve patient access for your organization?” (MGMA Stat data story)
• Patient Access: Tools and Strategies for the Medical Practice (Book)
• “Largest disruptors in healthcare from the past year” (MGMA Stat data story)
• “Manage panel size and scope of the practice” (Institute for Healthcare Improvement)
• “Panel size: How many patients can one doctor manage?” (FPM)

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