Model-Based Estimates of Changes in Net Revenue per Full-Time Physician for Primary Care Clinics Delivering PCMH Services Compared With the Net Revenue in the Traditional FFS Clinic Before PCMH Transformation
| Change in Net Revenue ($/FTE physician/year) | Traditional FFS $ (95% CI) | Increased FFS $ (95% CI) | PMPM $ (95% CI) | PMPM plus P4P Bonuses $ (95% CI) | Maximizing Net Revenues Under PCMH Payment Initiatives |
|---|---|---|---|---|---|
| Minimum required changes for PCMH fundinga | N/A | −53,464 (−69,725 to −37,203) | 103,835 (24,462 to 183,208) | 113,343 (28,511 to 198,176) | N/A |
| Service delivery enhancements | |||||
| Optimize staff ratiob | 46,722 (25,737 to 155,577) | −53,464 (−69,725 to −37,203) | 103,835 (24,462 to 183,208) | 113,343 (28,511 to 198,176) | FTEs: 0.23 CC, 0.31 RN, 0.53 LPN, 1.11 MA |
| Extend visit length by 5 minc | −119,092 (−170,874 to −83,002) | −184,925 (−255,049 to −149,057) | −62,771 (−156,974 to −57,134) | −55,390 (−152,320 to −52,719) | Not in optimal result |
| Replace 10% of visits with electronic visitsd | −16,175 (−17,134 to −15,165) | −71,497 (−83,935 to −59,960) | 80,427 (11,394 to 145,836) | 89,610 (15,611 to 159,704) | Not in optimal result |
| Replace 10% of visits with telephone visitsd | −16,151 (−17,107 to −15,144) | −71,473 (−83,915 to −59,931) | 80,451 (11,413 to 145,868) | 89,634 (15,629 to 159,736) | Not in optimal result |
| Extend evening/weekend hourse | 380 (373 to 386) | −52,959 (−69,227 to −36,692) | 104,781 (25,402 to 184,160) | 114,321 (29,482 to 199,159) | 3.0–3.8 h/wk |
| Net revenue-maximizing combinationf | 47,101 (26,110 to 155,963) | −52,959 (−69,227 to −36,692) | 104,781 (25,402 to 184,160) | 11,4321 (29,482 to 199,159) | FTEs: 0.23 CC, 0.31 RN, 0.53 LPN, 1.11 MA + 3.0–3.8 h/wk evening/weekend service |
CC = care coordinator; FFS = fee for service; FTE = full-time equivalent; LPN = licensed practical nurse; MA = medical assistant; P4P = pay for performance; PCMH = patient-centered medical home; PMPM = per member per month; RN = registered nurse.
Note: Revenues include 4 funding scenarios: traditional FFS, increased FFS, PMPM, and PMPM plus P4P bonus. Confidence intervals in parentheses are from probabilistic sensitivity analyses in which the model was rerun 10,000 times while sampling from the probability distributions of all input parameters to generate confidence intervals around model results.
↵a Meets basic criteria of PCMH funding initiatives, cataloged previously,4 incorporating changes in communication, care management, external coordination, patient tracking, test/referral tracking, and quality improvement at an inflation-adjusted cost of $2.51 per patient per month (95% CI, $0.95–$4.57).35 Staffing ratios include a minimum of 0.23 FTE for a CC (0.21–0.25), 0.31 FTE for an RN (0.28–0.34), 0.53 FTE for an LPN (0.50–0.56), and 1.11 FTE for an MA per FTE physician (1.09–1.13).40 Probabilistic sensitivity and uncertainty analyses performed across the listed CIs through repeated sampling from corresponding normal distributions of minimum staffing levels to assess robustness of results. All costs expressed in 2015 US dollars.
↵b Adjusted support staff (CC, RN, LPN, and MA) levels per full-time physician, determined by repeated sampling from observed joint probability distributions linking staffing levels across clinicians and support staff to encounters and empanelment (Supplemental Appendix Figure 1, http://www.annfammed.org/content/14/5/404/suppl/DC1), then detecting which combinations of staffing levels maximized net revenue while still meeting the minimum PCMH funding requirements. Note that maximum net revenue was achieved by minimum staffing in all PCMH funding scenarios.
↵c Increasing visits by 5 minutes each from the baseline length at each simulated clinic.
↵d Simulated as replacing 10% of regular in-person encounters.
↵e Optimization involved finding the number of evening or weekend hours per week that would maximize net revenues for the clinic, calculating medical revenue from each additional business hour of providing service availability during nights and weekends via a midlevel practitioner, and subtracting the costs of compensation and overhead expenditure for those hours.
↵F Includes optimized clinic activities in all above-mentioned domains.