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 modelsAlexander Kolker. All rights reserved 2

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. Alexander Kolker. All rights reserved 9

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 Alexander Kolker. All rights reserved 13

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 flowAlexander 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.Alexander Kolker. All rights reserved 15

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)Alexander Kolker. All rights reserved 16

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

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 coordinationAlexander 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

Primary care clinics-managing physician patient panels

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