Attributing Patients to Primary Care Physicians in Teaching Practices

Bruce Soloway, M.D.Vice Chair

Department of Family and Social Medicine

NYS HMH Site VisitNovember 12, 2013

What is a “Medical Home”?

The site that provides most of a patient’s primary

care serves as a patient’s first point of care

for most problems is ultimately responsible for a patient’s

chronic and preventive care Principle: Every patient should have

one and only one “medical home”

What is a “Primary Care Provider”?

Within a “medical home”, the provider who is: the first source of care for each

patient ultimately responsible for each

patient’s chronic and preventive care Principle: Every patient should

have one and only one PCP

What is a “Site Panel”? The list of patients for whom each

site serves as the medical home The source of demand for

appointments and other services for the site

The basis for accountability for patient care and

outcomes continuity of care patient satisfaction

What is a “Provider Panel”? Within a “medical home”,

the list of patients for whom each provider serves as PCP

the source of demand for appointments and other services for each provider

The basis for accountability for patient care and

outcomes continuity of care patient satisfaction

Why are provider panels important?

Within a “medical home”, provider panels Allow individual feedback to providers on

aggregate demographics, processes and outcomes for the patients they treat

Help to define and equitably divide the work of the practice, improving access, efficiency and continuity

Allow rational transfer of patients from one PCP to another when a provider enters or leaves a practice

The challenge of teaching practices

Residents as PCPs Residents need continuity panels for their

training Continuity, but what level of accountability? Not recognized by insurers

Multiple part-time providers Frequent cross-coverage

Frequent resident turnover Need for systematic, rational reassignment

Stabilizing teaching practices in Family Medicine

Attending-resident teams 1 Attending (Team Leader) + 3 residents Team Leader supervises and is accountable for

residents’ patient care Basis for cross-coverage and provider transitions

Consistent clinic sessions each week Inpatient rotations built around ongoing outpatient

responsibilities Basis for resident continuity and panel-building

How big should a panel be?

FHC12,780 unique patients / 9.5 FTE= 1345 patients per FTE x 2.77 visits/yr/pt= 3740 visits per yr per FTE

WB8814 unique patients / 6.1 FTE= 1452 patients per FTE x 2.59 visits/yr/pt= 3724 visits per year per FTE

Ideal panel size by provider

Assuming 1400 patients per FTE:FTE Panel Size

PGY-1 0.035 49PGY-2 0.15 210PGY-3 0.23 322

Attendings 0.3 4200.4 5600.5 7000.6 8400.7 980

Based on ACGME (FM) expected visits/year

Defining terms EMR PCP

The provider identified for each patient in the “PCP” field in the EMR

Should be controlled by clinicians based on real primary-care relationships negotiated with patients, but…

Clinical and administrative personnel can change this field

Often inaccurate due to provider turnover, unrecorded patient migration, administrative good intentions…

Defining terms Visit-based PCP

The active provider seen most often by each patient in the last 18 months

Or, if there is a tie, the active provider seen most recently in the last 18 months

Some patients are “orphan patients” No visit-based PCP, no active EMR PCP During the past 18 months, have only seen

providers who have since left the practice

Panel Reports Available on demand for each practice Patient lists for each provider:

Band 1 – Patients for whom the provider is both the EMR PCP and the Visit-Based PCP

Band 2 – Patients for whom the provider is the EMR PCP but not the Visit-Based PCP

Band 3 – Patients for whom the provider is the Visit-Based PCP but not the EMR PCP

Who is really the PCP? The EMR PCP is regarded as the

provider responsible for the care of the patient Clear, unique assignment across the

enterprise Easily queried for generation of reports and

registries Requires frequent updating to remain

meaningful

Patient reassignment algorithm An automated process available to all

practices Reassignments are based on:

Roster of active providers in practice Including FTE, panel status (open vs. closed)

Patient-level data Current EMR PCP

May reflect long-standing relationship (or may not) Recent visit history

Rational reassignment of “orphan” patients

Patient reassignment algorithm For the past four years, the Department of

Family Medicine has updated PCP assignments for its teaching practices on a quarterly basis.

With each update, panel reports are distributed to all providers as Excel files and PDF documents.

Providers have learned to update the EMR PCP themselves when care is transferred and to accept responsibility for the patients on their panel lists.

Outcomes of panel management

0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6

CristalloManners

PeraltaBecker

VillarThill

YoungJohnston-briggs

KishoreBumol

OkiLucan

OkrentBerlusDewittFlores

HowellAguillard

MooreMarrero

SatoDaguilhMckeeKumarPolisar

EkanadhamWilliams

Guilliames

Actual/Expected Panel SizeWB, October 2013

Outcomes of panel management

Outcomes of panel management

Outcomes of panel management

Outcomes of Panel Management

Measuring continuity of care by provider From the patient’s perspective

During a given interval (e.g. 18 months), at what percent of all visits made by members of a provider’s panel did the patient see the PCP (rather than another provider)?

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Continuity Rate by Provider (Patient View)Family Health Center

Outcomes of Panel Management

Measuring continuity of care by provider From the provider’s perspective

During a given interval (e.g. 18 months), what percent of all visits with each provider are with members of that provider’s own panel?

What percent of all visits with each provider are devoted to cross-coverage of other providers’ patients?

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Continuity by Provider (Provider View)Family Health Center

Conclusions Patients can be rationally assigned to unique

PCPs based on past assignments and retrospective visit histories in the hospital database

Patient assignments have many potential applications:

Correction of panel sizes to balance productivity and access

Rational transfer of patients to new providers Characterization and balance of panels Accountability for patient care and outcomes Measurement of continuity of care

Questions?