Attributing Patients to Primary
Care Physicians in Teaching
Practices
Bruce Soloway, M.D.
Vice Chair
Department of Family and Social Medicine
NYS HMH Site Visit
November 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




Multiple part-time providers


Residents need continuity panels for their training
Continuity, but what level of accountability?
Not recognized by insurers
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?

FHC
12,780 unique patients / 9.5 FTE
= 1345 patients per FTE x 2.77 visits/yr/pt
= 3740 visits per yr per FTE

WB
8814 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
PGY-1
PGY-2
PGY-3
Attendings
Panel Size
0.035
0.15
0.23
49
210
322
0.3
0.4
0.5
0.6
0.7
420
560
700
840
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:

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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


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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

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Including FTE, panel status (open vs. closed)
Patient-level data

Current EMR PCP


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May reflect long-standing relationship (or may not)
Recent visit history
Rational reassignment of “orphan” patients
Algorithm for PCP Reassignment
E
Band 1
Provider = CareCast PCP
= Visit-Based PCP
No Change
Provider = CareCast PCP
Patients with an active Visit-Based PCP also appear in
that provider's Band 3
Band 2
Visits to
CareCast PCP in past
18
months?
Patient has VisitBased PCP?
No
F
No
Yes
Yes
CareCast PCP
chronically
overpaneled?
Visit-Based PCP
Chronically
Overpaneled?
Yes
No
No
H
No Change
(Patient stays with
CareCast PCP)
No
Continuity (>1 visit
and > half of all visits) with
Visit-Based PCP?
G
Yes
Yes
Reassign to VisitBased PCP
(4)
G
Algorithm for PCP Reassignment
Yes
E
Band 1
Band 3
With an active
CareCast PCP?
Provider = CareCast PCP
= Visit-Based PCP
No Change
Provider = Visit-Based PCP
Patients with an active CareCast PCP also appear in
that provider's Band 2
Continuity (>1 visit
Visit-Based PCP is
Yes
and
> half of all visits) with
overpaneled? Provider = CareCast PCP
Visit-Based
Patients with an active Visit-Based PCP also appear inPCP?
that provider's Band 3
No
Band 2
Yes
No
I
Visits to
Handled PCP
as part
of
CareCast
in past
Band 18
2 (F,G)
months?
Reassign to VisitPatient
hasPCP
VisitBased
Based (5)
PCP?
No
F
No
Yes
Orphans
No Change
(Patient stays with
CareCast PCP)
April 2010
No
Yes
CareCast PCP
Yes
chronically
overpaneled?
Yes
No
No
Reassign
to underpaneled
Visit-Based PCP
providers (by team
Chronically
or at random)
Overpaneled?
(6)
No
Reassign
Patients with no H
active CareCast PCP or
to underpaneled
active Visit-Based PCP
providers (by team
treated patient
Continuity (>1 visit(All providers who have
Reassign
to Visitor at random)
past 18 months
the practice)
and > half of all visits)inwith
Yes have leftBased
PCP
(7)
Visit-Based PCP?
(4)
G
Yes
Patient reassignment algorithm
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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
Actual/Expected Panel Size
WB, October 2013
Cristallo
Manners
Peralta
Becker
Villar
Thill
Young
Johnston-briggs
Kishore
Bumol
Oki
Lucan
Okrent
Berlus
Dewitt
Flores
Howell
Aguillard
Moore
Marrero
Sato
Daguilh
Mckee
Kumar
Polisar
Ekanadham
Williams
Guilliames
0.6
0.7
0.8
0.9
1
1.1
1.2
1.3
1.4
1.5
1.6
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)?
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Continuity (Patient View)
Family Health Center
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Joo , P
Soloway , B
Ritchin , A
Selwyn , P
Baron , L
Bonadonna , S
Gbur , M
Gorski , V
Portnoy , D
Tattelman , E
Anderson , M
Jordan , W
Gross , P
Kumar , B
Brown , C
Duggan , M
Mendez , C
Chambers , S
O'connell , D
Robles , J
Guevara , E
Littleton , A
Flattau , A
Rosenberg , M
Stumbar , S
Liggett , A
Ambrogi , I
Mitsumoto , J
Rasanathan , J
Schiff , E
Gervits , M
Rosenstein , H
Schonberg , D
Brittner , M
Shigeura , A
Craemer , E
Kavanoor , K
Paneth pollak , R
Reed , E
Amico , J
Tschannerl , A
Andalcio , S
Gold , M
Novotny , R
Manchester , L
Harris , R
Andre , J
Continuity Rate by Provider (Patient View)
Family Health Center
100
90
80
70
60
50
40
30
20
10
0
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?
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Continuity (Provider View)
Family Health Center
80%
70%
60%
50%
40%
30%
20%
10%
0%
Joo , P
Duggan , M
O'connell , D
Littleton , A
Tattelman , E
Portnoy , D
Soloway , B
Ritchin , A
Gorski , V
Gross , P
Jordan , W
Baron , L
Mendez , C
Anderson , M
Bonadonna , S
Selwyn , P
Rosenberg , M
Tschannerl , A
Flattau , A
Gbur , M
Robles , J
Mitsumoto , J
Guevara , E
Gervits , M
Schonberg , D
Kumar , B
Liggett , A
Rosenstein , H
Reed , E
Schiff , E
Shigeura , A
Stumbar , S
Craemer , E
Gold , M
Rasanathan , J
Ambrogi , I
Brittner , M
Manchester , L
Amico , J
Kavanoor , K
Andre , J
Harris , R
Andalcio , S
Paneth pollak , R
Novotny , R
Continuity by Provider (Provider View)
Family Health Center
100
90
80
70
60
50
40
30
20
10
0
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?