Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation

"Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation" provides a path to solving in part the impending shortage of primary care providers. Although there has been progress in expansion of the primary care clinician workforce, it appears this will be insufficient in meeting future needs. Allowing members of the clinical team to work to the "top of their license" through appropriate division of labor and delegation is a critical part of the solution package to meet the primary care needs of the nation. This includes includes physician assistants and nurse practitioners in the mix.

In order to achieve the goal of effective team-based task delegation, we must begin to train our future providers in primary care teams. Recently the Society of Teachers of Family Medicine (STFM) and the Physician Assistant Education Association released a joint statement on educating primary care teams for the future. The Statement also clearly articulates the mechanisms by which PAEA and STFM will collaborate to develop innovative models of inter professional health care education (see Brenneman & Kruse, The Journal of Physician Assistant Education Vol 23(3) 2012).

Finally, we all must recognize that no matter which models prove to be the most efficient and effective from a workforce perspective, we need to continue to focus on patient outcomes to determine which models best improve the health and welfare of our patients.

Competing interests:   None declared

Competing interests:   None declared

I have disagreed with some of the claims of the Bodenheimer, et al. articles in the past regarding the panacea of team-based primary care. However, this one, assuming that the models that form the basis of this study are a reasonable facsimile to reality, struck me as both reasonable and thoughtful. Clearly, we must evaluate innovative models for the delivery of primary when faced with the conundrum of high demand and scarce resources. And this article does a very good job at assessing the quantitative aspects of the delivery of care. What is ultimately most important, however, is the quality of care delivered. What happens when parcels of care--preventative, chronic or acute--are parceled out among different team members? Who is responsible for integration? Will everything then become template based? And who takes responsibility for toggling between the various domains of care to highlight the important interrelationships between health, disease and acute, chronic and preventative episodes of care? And how will providers, relegated to meeting out specific tasks day after day, feel about their jobs? How will that affect retention and burn out rates? These are the tougher, more important questions that need answering. Otherwise, we risk presiding over a profession that slips ever more dangerously toward a corporate model of efficiency and outcome.

Competing interests:   None declared

I frequently comment in presentations that there is no science behind primary care panel size. The historic 2000-2500 patients comes from a time in general practice when most patient care was common acute problems. Since then, comprehensive prevention and the management of chronic illness has come to dominate our work. We seek to practice the biopsychosocial model. Therapists with active panel sizes of 20-30 patients wonder how we take care of over 1000.

This article provides an excellent framework for a modern primary care team, and suggests numbers that are very workable. Some PCPs claim they have 3000-5000 patients, but with patients coming in for primary care 2.5 times a year under age 65 and 5-6 times a year as seniors, the visit numbers do not add up to such a panel.

My thanks to these authors for providing some science behind the primary care panel size.

Competing interests:   None declared

I read through this article eagerly to see if it contained any models for the use of PAs or NPs. It seems as though they were considered as equivalent to physicians and no differences or allowances for collaboration, supervisory time or consultation were provided. I agree that these have not been well studied but would like to present another model.

I agree that PAs/NPs with their own panels would assume similar patterns of delegation. I do still feel that optimal utilization of the primary care workforce could over the long run actually lessen the number of required primary care physicians, increase the numbers and roles of PAs and NPs, and maintain or increase delegation to other health care workers as stated here.

There are slightly under 100,000 active PAs in practice and slightly over 100,000 NPs. Very roughly half of these two cohorts combined are involved in primary care, so this is equivalent to 100,000 primary care clinicians. Studies find that PAs in primary care see close to the number of patients as seen by physicians, and NPs slightly less, probably due to training models and the cultures of the two professions. Collaborative teams involving one physician for every two or three PAs/NPs and adequate numbers of support staff have the potential to leverage patient care per physician to levels three or four times that currently experienced, and still maintain the ideal of a "physician led" team. Given the demands of the ACA, it is likely time to realize that the era of the "physician only" primary care practice is actually wasteful of scarce workforce and reimbursement resources and should be actively discouraged and certainly not incentivized. Physician primary care clinicians should be freed to spend all of their attention, time and energies on complicated and sicker patients with acute needs or complex chronic conditions. Administrative matters should be handled by administrators (not mentioned here). Routine acute care and almost all chronic and preventive care should be handled by PA/NP clinicians, supported by teams of allied health professionals.

Competing interests:   None declared