A recent article claimed that some PCP’s had patient panels exceeding 3700. David Williams doesn’t believe it:
I think these numbers are an exaggeration, especially the first. Most primary care physicians have 1500 to 2500 patients and somehow seem to survive. To have even 3750, never mind 5000 would require never seeing most of them or making heavy use of nurse practitioners and other “physician extenders.”If these doctors are struggling under such heavy loads, why don’t they just scale back to a typical number of patients rather than going berserk and dropping to only several hundred?
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{ 18 comments }
It may well be true. I worked for an HMO which had PCP’s carrying somewhere above 3000. The administrator of the clinic considered very low rates of answering phone calls (in the 40% range) a useful way of avoiding utilization (the clinic was capitated). Other than NP’s, etc. the other way to do it is to simply be so inacessible, or to deliver such uninviting care that only the most stubborn, desparate, and devious actually get in to get service.
I believed in capitation and the HMO model 15 years ago. I now believe that I was an inexperienced gullible fool, and for it to be frankly immoral.
30 patients per day for 16 working days per month for 12 months. That is over 5700 patient visits per year. Servicing a panel of 3500 individuals is pushing things, but is do-able.
Sure anon if you have 3500 healthy pt’s. Why don’t you look at a typical internist’s panel. There will be a lot of COPD, CAD, DM, renal failure, etc, etc. 1.5 visits year on these pt’s is crazy. Very simply it is not doable if you want to do a good job.
For the sake of argument:
Ten-minute office visit ( = 6 patients per hour). Eight-hour day. Five days a week. No vacation.
6 x 8 = 48 patients a day
48 x 5 = 240 patients a week
240 x 52 = 12480 patients a year
If you really carried 3700 patients:
12480 / 3700 = 3.37 patient visits a year.
That assumes you take no vacation. That assumes you never get sick. That assumes you do no procedures. That assumes you have no new patients. That assumes no time away for emergencies in the hospital, nursing home, etc. That assumes you never have to spend a lot of time with a patient for a big emotional problem. Mom needs to go to the nursing home. Bad news of a fatal disease. And so on.
I suspect that sort of patient panel reflected the HMO capitation days when you had, or supposedly had, patients nominally under your care, but never needed a doctor.
The majority of your patients are not train wrecks: many will have stable HTN and possibly heart disease, some fewer will have Type 2 DM, and many will have DJD. Fewer will have unstable problems like advanced COPD, ESRD and other disorders that require frequent visits within any given year. A few will be healthy people who will have a routine physical once every two or three years and an occasional acute problem that will not require any followup. Those folks probably don’t make one visit per year, but they belong in the census too.
The fragile patients with multiple advanced and chronic diseases take up the most time, relative to others, have the most followup appointments, the most hospital admissions and demand the most coordination with specialists. Fortunately they are still a small percentage of a typical census, but they figure largely because they demand so much time.
A census of 3500 souls is likely going to be a busy practice. But unless you have skewed the distribution toward the severely and multiply diseased, or serve a socially difficult population as are found in most Medicaid-laden areas, then the number should still be manageable, even without extenders.
What is someone cries in your office or maybe even asks a question? Then you’re behind the rest of the year!
Question anon 12:34: Is this what you do for a living? Are you saying this from experience? I am and you are underestimating the number of pt’s in the panel with multiple medical issue.
an experienced internist.
Anon. 9:59:
No need to be defensive.
You can still spend huge amounts of your time on your sickest patients and still have a “census” of 3500 with your head above water. Remember what makes for a census, it is both more and less than you think. Your census includes your multiply severely chronically ill patients, who you know all about, your not quite ill but regular patients and a whole field of people who are less ill that you don’t see as much at all. Most censuses count each soul seen at least once in the past three years. Included in that is the one-time visit under workmen’s comp. the routine physical for a job application, the healthy patient wanting a physical, the sick but lost to followup either because of relocation, transfer without notice to other doctors or death (in my very real practice full of old folks, deaths are culled from our census by either newspaper obits or community word of mouth, otherwise, they remain “alive” ) and until we cull their charts they are as much a part of the census as any other patient.
I have no doubt you are experienced and that your patients are sick and that you are as busy as you say. All that can be true and you can still have a census bigger than you think.
Well…..yeah.
It depends on how you define “census”. There’s a lot of patients coming through my door, who I will never see again. The Japanese tourist, the scientist temporarily here on a research project, etc.
When is that person no longer your patient, for the purpose of counting him/her in the “census”?
12:59:
Generally at three years from the last visit or at the time you transfer total care to another doctor at the patient’s request or when the patient dies.
Three years is the period after which you can count a patient returning as a “new” patient to your practice, and charge their visit as a new patient visit, whether they have been in the care of someone else in that time or not.
Actually, If you terminate your relationship with a patient with written notice, the time period can be as short as the time it takes another doctor to assume total care or at thirty days from notice. And seeing someone once terminated while on compulsory call, in the ED, for instance, does not automatically place that patient back in your census.
These comments relect the weakness of primary care. I am an FP and I was amazed to observe the range of care considered”acceptable” in the outpatient setting. From frequency of visits to treatments of common problems(UTI’s rx over phone, no UA,,, narcotic refills for years, MRI’s ordered without patient visit). And the patients love the doc and are sure he must be great because”he’s so busy’.
There ought to be an answer and infact there is. It’s just we want to do it OUR way. Cowboy up.http://poemd.blogspot.com/2007/02/primarily-careless.html
DDX, just an aside. I am familiar with several recommendations that suggest an uncomplicated UTI with typical symptoms and no fever can be treated empirically.
Given that guideline … why get a UA in an uncomplicated patient with typical symptoms having her first UTI in years?
no point whatsoever in getting a UA in that situation.
However, calling in a prescription without seeing the patient would give the patient the misconception that this non-reimbursable luxury will take place EVERY time in the future she has dysuria. Not to mention that if she has frequent symptoms, she needs a urine culture & perhaps some post-coital education for her & partner, & perhaps eventually a course of prolonged antibiotic prophylaxis and/or urology/urogyn referral.
David Williams has little understanding of modern medical practice, and the forces that impact upon it. I also resent his arrogant, ignorant comments about concierge practices.
I agree with the empirical treatment. I do it over the phone after talking with the patient if the setting seems appropriate. But not three times in three months…Which I have seen.
Primary care shouldn’t be knee jerk anything. But if you want good care it requires some thought, some time, some communication.Some compensation?
(That is another topic…Hard to stay focused typing 10 WPM.)
My point is, that we have not upheld any significant measures of quality and assumed the certification tests with 90+% pass rate were adequate. And the market decides quality on their basis, which, given the nature of most things people seek medical care for in primary care are self limiting, thus they get better no matter what you do. And the ‘value’ of primary care gets diluted, when it should be undeniable.
If performing services over the phone, such as treating UTI’s is an appropriate and routine part of primary care, then the docs can and should find a way to charge for that, whether a per service charge, or monthly charge to be available for that. As a patient, I prefer the first, as I virtually never call my doctor, but it is up to the docs to find what works for them.
One thing is clear, they have a right to charge for and get paid for their services whatever insurance companies and CMS says. Involuntary servitude is unconstitutional.
Anonymous said:
“David Williams has little understanding of modern medical practice, and the forces that impact upon it. I also resent his arrogant, ignorant comments about concierge practices.”
Ouch! (I’m not perfect, but at least I sign my real name to my comments.)
I stand by what I wrote: it’s awfully unlikely for a PCP to have 5000 patients, and it is possible to make a decent living with a more normal number.
Here’s some data I shared with an FP commenter on the Health Business Blog:
According to the Medical Group Management Association’s Physician Compensation and Production Survey (2005 edition), the mean number of ambulatory encounters for a Family Practice Physician (w/o OB) is 4287 per year with a standard deviation of 1,568. The 75th percentile was 5,088 and 90th percentile 6,167. (The # of encounters for FPs who do OB is lower.)
According to the same source, mean compensation for FPs w/o OB was $170,059 with a standard deviation of $64,046. FPs in the 25th percentile made $129,662, those in the 75th made $196,645 and those in the 90th made $250,741. Those who did OB made a little more.
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