To unleash the power of primary care, focus on practice resources—including staffing levels and levels of staff training—rather than patient panel size.

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Health care organizations seeking to adopt population health and value-based care business models are spending a lot of time and energy trying to find the ideal patient panel size for primary care physicians.

Researchers with the Department of Veterans Affairs (VA) in Los Angeles expressed disappointment when their recent systematic review of existing literature not only failed to reveal this number but also highlighted that the body of research on the subject was sorely lacking. The real problem, however, was that they were asking the wrong question, according to a pair of AMA physician researchers.

“Evidence is insufficient to make evidence-based recommendations about the optimal primary care panel size for achieving beneficial health outcomes,” says the article—“What Is the Optimal Primary Care Panel Size?: A Systematic Review”—published in Annals of Internal Medicine. “Our principal finding is that the evidence about the association between panel size and aims of health care is surprisingly thin, given the importance of primary care panel size to all models of population-based care.”

What’s needed for optimal management

Rather than seek some elusive number or try to determine whether 500 patients per physician works better 2,500 patients, Christine Sinsky, MD, the AMA’s vice president for professional satisfaction, and Marie T. Brown, MD, director of practice redesign, responded in an editorial that it would be better to solve the equation for finding the optimal amount of resources needed per patient.

Better questions, they wrote, would be:

  • What are the resources and practice models that facilitate optimal management of a population of patients by primary care physicians and their teams?
  • What resources and models provide access to the highest-quality primary care for the U.S. population?

The systematic review looked at studies that examined physician workload driven by patient characteristics and need.

“It’s important that more research assess how variables within the work environment impact a physician’s capacity to manage a particular size panel rather than just how patient-specific variables impact a manageable panel size,” Dr. Sinsky, an internist, said in an interview. Read more about her in this AMA Moving Medicine Magazine profile, “A quest to never waste a step.”

Dr. Sinsky noted that physicians who do all of the clerical tasks of a practice, take patient vital signs, perform medication reconciliation, and enter every order into the computer by hand will see far fewer patients than a physician who works with two medical assistants or registered nurses and is able to delegate the majority of those tasks.

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Power up primary care

So what’s the answer to the question of ideal patient population size? It depends.

“It depends on the work resources—that is, it depends on the staffing levels, it depends on the level of staff training, and it depends on roles staff members are able to take on,” Dr. Sinsky said.

In their Annals of Internal Medicine editorial entitled “Optimal Panel Size: Are We Asking the Right Question?” Drs. Sinsky and Brown note that the $3 trillion U.S. health care industry is underperforming, in part, because of “underpowered primary care.”

“Primary care physician resources are being squandered,” they wrote, noting that physicians spend a majority of their day on tasks that do not require a medical school education.

To provide high-powered primary care, Dr. Sinsky recommends, at minimum, a core team of a physician working with two nurses or medical assistants. Their work can be bolstered by an extended care team consisting of a pharmacist, social worker, and either a dietitian, physical therapist or behavioral health specialist[MB1] —depending on the nature of the practice’s patient population.

“We have studied the science of medicine—what tests and treatments may be beneficial for a patient—but we've invested far, far less on the science of how we organize our practices and how we actually deliver care,” Dr. Sinsky said. “Imagine the value physicians can provide to their patients, to the community, to the health system, if they were able to work at full power.”

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Help to find the right panel size

Identifying the Optimal Panel Sizes for Primary Care Physicians” is an AMA STEPS Forward™ CME module offering guidance on adjusting panel sizes based on patient and practice variables. Co-written by Dr. Sinsky, this enduring material is designated by the AMA for a maximum of 0.5 AMA PRA Category 1 Credit. 

The module states that an appropriate size patient panel will:

  • Prevent underutilization of physician skills and avoid limitations in access to care for patients of over-empaneled practices.
  • Avoid the stresses placed on physicians and care teams in over-empaneled practices.
  • Facilitate equitable compensation within organizations that are moving away from a production model of payment.
  • Develop sustainable models of primary care to reduce physician burnout.

STEPS Forward is part of the AMA Ed Hub™️, an online platform that brings together all the high-quality CME, maintenance of certification, and educational content you need—in one place—with activities relevant to you, automated credit tracking and reporting for some states and specialty boards.

Learn more about AMA CME accreditation.

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