Abstract
At the heart of the practice of primary care is the concept of a physician panel. A panel refers to the set of patients for whose long term, holistic care the physician is responsible. A physician’s appointment burden is determined by the size and composition of the panel. Size refers to the number of patients in the panel while composition refers to the case-mix, or the type of patients (older versus younger, healthy versus chronic patients), in the panel. In this paper, we quantify the impact of the size and case-mix on the ability of a multi-provider practice to provide adequate access to its empanelled patients. We use overflow frequency, or the probability that the demand exceeds the capacity, as a measure of access. We formulate problem of minimizing the maximum overflow for a multi-physician practice as a non-linear integer programming problem and establish structural insights that enable us to create simple yet near optimal heuristic strategies to change panels. This optimization framework helps a practice: (1) quantify the imbalances across physicians due to the variation in case mix and panel size, and the resulting effect on access; and (2) determine how panels can be altered in the least disruptive way to improve access. We illustrate our methodology using four test practices created using patient level data from the primary care practice at Mayo Clinic, Rochester, Minnesota. An important advantage of our approach is that it can be implemented in an Excel Spreadsheet and used for aggregate level planning and panel management decisions.
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References
Balasubramanian H, Banerjee R, Denton B, Naessens J, Wood D, Stahl J (2010) Improving clinical access and continuity using physician panel redesign. J Gen Intern Med 25(10):1109–1115
Balasubramanian H, Muriel A, Wang L (2011) The impact of flexibility and capacity allocation on the performance of primary care practices. Flex Serv Manuf J. doi:10.1007/s10696-011-9112-5
Balasubramanian H, Muriel A, Ozen A, Wang L, Hippchen J, Gao X (2013) Capacity allocation and flexibility in primary care. In: Denton B (ed) Handbook of healthcare operations management. Springer US
Bodenheimer T, Pham HH (2010) Primary care: current problems and proposed solutions. Health Aff 29(5):799–805
Chakraborty S, Muthuraman K, Lawley M (2010) Sequential clinical scheduling with patient no-shows and general service time distributions. IIE Trans 42(5):354–366
Coleman K, Reid RJ, Johnson E, Hsu C, Ross TR, Fishman P, Larson E (2010) Implications of reassigning patients for the medical home: a case study. Annals of Family Medicine 8(6):493–498
Gill JM, Mainous A (2010) The role of provider continuity in preventing hospitalizations. Arch Fam Med 7:352–357
Green LV, Savin S (2008) Reducing delays for medical appointments: a queueing approach. operations research. Oper Res 56(6):1526–1538
Green LV, Savin S, Murray M (2007) Providing timely access to care: what is the right patient panel size? Joint Comm J Quality Saf 33:211–218
Gupta D, Wang L (2008) Revenue management for a primary-care clinic in the presence of patient choice. Oper Res 56(3):576–592
LaGanga L, Lawrence S (2007) Clinic overbooking to improve patient access and increase provider productivity. Decis Sci 38(2):251–276
Liu N, Ziya S, Kulkarni VG (2010) Dynamic scheduling of outpatient appointments under patient no-shows and cancellations. Manuf Serv Op 12(2):347–364
MDoH (2012) Health care homes payment methodology development. http://www.health.state.mn.us/healthreform/homes/payment/index.html. Accessed 20 Sep 2012
Murray M, Berwick DM (2003) Advanced access: reducing waiting and delays in primary care. J Am Med Assoc 289(8):1035–1040
Murray M, Tantau C (2000) Same-day appointments: exploding the access paradigm. Fam Pract Manag 7(8):45–50
Murray M, Davies M, Boushon B (2007) Panel size: how many patients can one doctor manage? Fam Pract Manag 14(4):44–51
Muthuraman K, Lawley M (2008) Stochastic overbooking model for outpatient clinical scheduling with no shows. IIE Trans 40(9):820–837
Naessens J, Stroebel R, Finnie D, Shah N, Wagie A, Litchy W, Killinger P, O’Byrne T, Wood D, Nesse R (2011) Effect of multiple chronic conditions among working-age adults. American Journal of Managed Care 17(2):118–122
Nutting P, Goodwin M, Flocke S, Zyzanski S, Stange K (2003) Continuity of primary care: to whom does it matter and when? Ann Fam Med 1(3):149–155
Qu X, Rardin R, Williams J, Willis D (2006) Matching daily healthcare provider capacity to demand in advanced access scheduling systems. Eur J Oper Res 183(2):812–826
Reid RJ, Fishman P, Yu O, Ross TR, Tufano JT, Soman M, Larson E (2009) Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. The American Journal of Managed Care 15(9):71–87
Reid RJ, Coleman K, Johnson EA, Fishman P, Hsu C, Soman M, Trescott CE, Erikson M, Larson E (2010) The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff 29(5):835–843
Robinson L, Chen R (2010) A comparison of traditional and open access policies for appointment scheduling. Manuf Serv Oper Manag 12(2):330–347
Savin S (2006) Managing patient appointments in primary care. In: Hall RW (ed) Patient flow: reducing delay in healthcare delivery. Springer US, pp 123–150
Starfield B, Weiner J, Mumford L, Steinwachs D (1991) Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res 26(1):53–74
Wang W, Gupta D (2011) Adaptive appointment systems with patient preferences. Manuf Serv Op 37(1):111–126
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This work was funded by the grant R03 HS 018795 from the Agency of Healthcare Research and Quality (AHRQ). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the AHRQ.
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Ozen, A., Balasubramanian, H. The impact of case mix on timely access to appointments in a primary care group practice. Health Care Manag Sci 16, 101–118 (2013). https://doi.org/10.1007/s10729-012-9214-y
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DOI: https://doi.org/10.1007/s10729-012-9214-y