Next in a series.
How many patients can a primary care physician (PCP) reasonably care for? I have been interviewing PCPs: Here are some of their thoughts when asked this question.
Responses were widely divergent ranging from about 300 to 3,000 or even more. Yet many are clearly conflicted. Some say they can manage about 2,000 with little difficulty — but then observe elsewhere in the conversation that they have no time for communicating with the specialist or hospitalist. A general consensus appears to be that 1,500 patients is about the upper limit provided it is a practice in which the PCP has gotten to know most of the patients well over many years. Otherwise a lower number seems appropriate. But even at 1,500, PCPs say they still spend the full day seeing patients plus added time each evening completing their EMR.
Having stated that 1,500 is about right, they then say that 1,000 would mean much better care. But this ideal is not possible; they need to have about 2,500 patients and about 24-25 visits per day to cover overhead and maintain an income of about $175,000 (Per the Medscape report on PCP income.)
All agreed that if the population is largely geriatric, meaning a proxy for those with multiple chronic conditions, then a lower maximum is necessary. One primary care group that only has geriatric patients in a Medicare Advantage program limits the number of patients per physician to about 400. They find that at this number they can give good care, have high patient satisfaction and keep the total cost of care well below the local and national averages for such older patients. Another which caters to those with multiple chronic illnesses and impaired socioeconomics limit the number per doctor to just 300 and uses a team approach. They also generate a much lower total cost of care.
It would appear from my interviews with practicing PCPs, that, in a practice comprised of a wide range of patient ages and problems, that there should be about 1,000 or fewer patients. Fifteen hundred might be acceptable for a practice with many healthy younger patients or one organized along the precepts of a team approach. For a geriatric oriented practice, 400-500 should be the maximum.
I started a discussion on LinkedIn asking the question, “How many patients can a PCP safely care for each day?” This was based on a post by Dr. Luis Collar. There were over 50 responses. The answer, of course, was, “It depends.” It depends on the mix of patients and their needs. But the respondents focused on time and the importance of time to fully and compassionately treat each patient properly. The patent needs “faith in the doctor, which when present slashes the illness in half.” Developing faith takes time.
An article in the Annals of Family Medicine sought to estimate a reasonable sized patient panel for a PCP with team-based task delegation consistent with the patient centered medical home model. Using published estimates of the time needed by a PCP to provide preventive, chronic and acute care they modeled how panel sizes would change if some portion of the work in each of the three categories was delegated to team members. If there was no delegation of work, as has been typical in PCP practices for decades, their data suggest that a patient panel size of about 983 is the maximum, not too far from my own estimate above of 1,000. They then assumed varying levels of delegation to the team. Their model panels with team-based delegation ranged from 1,387 to 1,947 patients. This analysis suggests that a primary care physician can care for more than 1,000 patients provided he or she practices as part of a well-oiled team-based practice. It does not address the question of whether the team can practice true “population health” meaning that the PCP and his or her office team reach out proactively to all members of the patient panel to address high quality preventative care rather always being reactive by waiting for the patient to arrive at the office with a problem.
A practice with reduced numbers of patients could be paid for with regular fee-for-service insurance if the insurer agreed to a higher fee per visit (I know I’m dreaming, but some actually do it) or with a capitated model provided the per member per month fee was sufficient to keep the patient numbers down (same comment).
Alternatively the PCP could refuse any insurance, limit the patient number and go the direct primary care approach and either expect the patient to pay directly per visit or monthly/annually as part of a membership/retainer based approach. Whatever model is followed, when the patient number comes down, the care gets better, the frustrations go down for doctor and patient alike and the total costs of care drop substantially. That’s good for everybody.
Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.