Why a patient panel is an outdated concept in primary care

“How many patients do you have?”

I’m not sure what you mean. How many patients do I see on average each day? About twelve.

“No. How many patients do you have?”

Let’s see: Last week I saw about sixty patients altogether. Five of them were new patients.

“No, no. How many patients do you have on your panel?”

My panel? I don’t know what you mean by that. I don’t work as an employer in a fully prepaid system where patients are specifically assigned to me. I’m down to only two capitated HMOs, insurance plans that pay me a certain amount (not much) each month for each patient on my list. Some people on the list are patients I’ve had for years, while others have never heard of me, since the plan randomly assigns those who don’t choose for themselves. I have about 260 people on one of those lists and about 75 on the other. Is that what you’re asking?

“No. Let me put it this way: How many people out there could potentially call you for an appointment at any given point in time?”

Gee, I don’t really know that either. Given that I accept most insurances and that I’m open to new patients, I don’t think there’s any way I could possibly come up with a number.

“Well, how many patients do you feel you can reasonably take care of?”

About ten to fifteen a day, or about sixty a week. Approximately the number I’m currently seeing. Maybe a little more.

“So how many patients are on your panel?”

Talk about useless conversations.

When you think about it, a patient panel is a meaningless concept in private practice. How many active patients do I have? Depends on precisely what you mean by “active.” Even though it’s usually defined as any patient to whom I’ve provided medical services in the last three years, does it include people who have died? Patients who have asked to have their medical records transferred? What about those people on the insurance capitation lists whom I may not have seen yet but am still getting paid for each month?

Frankly, I wouldn’t even know how to go about figuring out who’s on my panel, much less what the bottom line number may be. More importantly, I have better things to do with my time. Like taking care of patients. However many of them there may be.

There’s a new kind of practice model out there based on the idea of a subscription: In order to see a doctor, you have to sign up ahead of time to be on the panel, a privilege for which you often have to pay. Both the concierge model and the so-called direct primary care model use this principle. The specifics (and the amount of money) vary greatly, but the basic idea is to explicitly define who is on a doctor’s panel. Neither one of those models is right for me at this time, but the idea of managing a panel seems to be way more trouble than it’s worth.

My personal sense of my active patient panel is a group of patients that is continually in flux. I have folks in the middle of an acute illness: pneumonia, a flare of diverticulitis, a kidney stone, with whom I expect to have more frequent contact over the next few days or weeks. I have lots of long-term patients with well-controlled chronic illnesses: the hypertensives and diabetics I can expect to see two to four times a year. I have the super healthy folks who come in once a year or less: the flu shot groupies; the well babies, who start out getting seen a lot, with lots of phone calls if it’s a first child, and with whom contact tapers off after the first two years. Hospice patients whose needs for my attention increase as the end draws near. Broken bones and other injuries; postoperative, post-ER, post-MI followups.

People move in and out of the active circle. The kidney stone passes, the cast comes off, the “OK to return to unrestricted activities” note is written. They’re still considered active patients to the bean counters, just not as active as before.

It’s called primary care, it’s all in a day’s work, and I love it.

I suppose your definition of my panel is the grand total of everyone who is or could rotate into that spotlight of acutely needing me. But what’s the point of keeping count? The phone rings; I’m able to offer an appointment whenever the caller wants. What more could anyone ask?

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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