INTRODUCTION

Provisions of the Affordable Care Act have accelerated primary care redesign and encouraged new reimbursement approaches.1 Redesign initiatives include a focus on multidisciplinary teams caring for primary care populations with increasing use of population-based reimbursement strategies.2 In this context, approaches to measuring patient-level primary care team effort are necessary to account for variation across primary care patient panels among clinicians and care teams.3 , 4

Prior studies have used measures of patient complexity to control for differences in the effort and resources needed to manage a given panel of patients.5 – 8 These predictive models and risk adjustment approaches focus predominately on the measures of medical complexity, including the number and severity of chronic conditions or prior healthcare utilization and cost.9 – 11 However, behavioral health, socioeconomic, and environmental factors that contribute to primary care team effort may not be adequately captured in current measures of patient complexity.12 – 14

An ideal primary care risk adjustment measure would closely approximate the amount of clinician and primary care team effort needed to care for an individual patient or patient panel. Although most compensation models currently use relative value units (RVUs) as proxies for primary care effort,15 RVUs underestimate primary care clinician work.16 , 17 In particular, RVU-based reimbursement approaches capture only the effort related to face-to-face patient encounters.18 Given that a substantial and increasing proportion of primary care work occurs outside of office visits,19 – 21 new measures of effort also need to capture non-visit-based work. Patient-level factors also contribute to primary care team effort, but these factors are often difficult to identify from existing data sources.22 A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches, leading to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians.23 – 28

Primary care physicians (PCPs) have a unique perspective on the relative level of effort required to care for patients in their panel, including both visit-based and non-visit-based work, as well as patients’ psychosocial needs that affect primary care team effort. We previously evaluated a measure of patient complexity using physician qualitative assessments.13 In the current study, we sought to define cohorts of patients by physician-defined effort, characterize high-effort patients by domains of effort, and use electronically available data to identify patient-level factors that are important drivers of primary care team effort.

METHODS

Participants and Setting

We recruited staff PCPs from the Massachusetts General Primary Care Practice-Based Research Network. We linked all patients seen in our network in the previous 3 years to specific PCPs using a validated algorithm.29 We invited PCPs managing a panel of at least 100 patients in 2013 to review a list of 100 randomly selected patients using an electronic survey tool developed in REDCap version 5.9 (Vanderbilt University, Nashville, TN, USA). Participating PCPs received a gift card incentive of up to $250.

Variables

After verifying that the patient was theirs, PCPs were asked, “How much effort does it take you and your team to care for this patient?” PCPs responded on a four-response scale (a lot of effort, moderate amount of effort, little effort, no effort). We categorized patients as high-effort (a lot or moderate amount of effort) or low-effort (little or no effort). For high-effort patients, PCPs indicated which factors from three effort domains influenced their decision (Table 1). We adopted these domains from previously published concepts,13 , 30 and modified them based on feedback from a primary care physician advisory group in our institution. We also asked PCPs, “In your view, do you consider this patient a ‘complex patient’?” Since our goal was to compare physician-defined constructs of effort and complexity, we did not provide PCPs with a predetermined definition of effort or complexity. Based on PCPs’ responses, we divided patients into four groups: 1) low-effort, not complex 2) high-effort, not complex (high-effort only), 3) low-effort, complex (complex only), and 4) high-effort, complex. To evaluate the impact of patient age on effort designation, we created eight age strata and assessed for changes in the prevalence of each effort domain.

Table 1 Effort Domains Associated with Physician-Identified High-Effort Patients
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PCP variables assessed included age, gender, time since graduation from medical school, years in practice at our institution, total outpatient visits in the previous 3 years, panel size, and whether they practiced at a community health center. We derived patient-related variables from data available in an electronic data repository over the preceding 3 years.31 Patient demographic variables included age, gender, self-reported race or ethnicity, language, and insurance status. We used outpatient scheduling data to identify the number of visits to the PCP and other practice providers, missed appointments (“no-show”), and number of different providers seen. We obtained data on admission and emergency department (ED) visits in the prior year, comorbid conditions, medication prescriptions, and laboratory results from the electronic medical record and billing data (using International Classification of Diseases, Ninth Revision [ICD-9] and Current Procedural Terminology [CPT] codes).

Statistical Analyses

We examined the relationship between effort and physician and patient panel characteristics using simple linear regression models, with the proportion of high-effort patients as a continuous outcome, and presented the summary statistics by tertiles of proportion of high-effort patients. We used logistic regression models using the general estimating equations approach (PROC GENMOD, SAS version 9.3; SAS Institute Inc., Cary, NC, USA) to compare the characteristics of patients who were 1) high-effort vs. low-effort, 2) high-effort only vs. complex only, and 3) high-effort only and complex only vs. high-effort, complex patients, while accounting for PCP-level clustering. We compared the prevalence of effort domains by age strata using a chi-square trend test. We also conducted multivariable regression analyses to identify predictors of patients being in each of the four groups. The institutional review board of Partners HealthCare approved our study.

RESULTS

Among eligible PCPs, 54 % (99/182), representing 90 % (17/19) of network practices, reviewed their patient lists. There were no statistically significant differences between participating and non-participating PCPs (Online Appendix 1). Of the 9900 patients provided to participating PCPs, PCPs reviewed 9832 patients and designated 238 (2.4 %) as not their patient. Among the remaining 9594 patients, PCPs classified 23.7 % as high-effort (range 3.0–55.8 %, SD 13.0 %) and 27.9 % (range 5.0–64.0 %, SD 13.5 %) as complex (Table 2). Not all high-effort patients were deemed complex, and not all complex patients were deemed high-effort (Fig. 1).

Table 2 PCP-Reported Effort and Complexity
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Figure 1
figure 1

Four different patient groups based on PCP-defined effort and complexity.

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Based on the proportion of patients designated as high-effort, there were no statistically significant differences between PCP characteristics, while differences in patient panel characteristics included mean age, insurance status, and number of clinic and PCP visits (Online Appendix 2). PCPs identified a mean of 1.7 effort domains associated with high-effort patients. Medical/care coordination issues were most prevalent (79.4 %), followed by behavioral health (59.7 %) and socioeconomic issues (31.5 %). PCPs more frequently identified behavioral health issues in younger patients and medical/care coordination issues in older patients, while socioeconomic issues remained stable across age groups (P < 0.01 for trends by decade) (Online Appendix 3).

Unadjusted Analysis Comparing Patient Characteristics in the Different Effort/Complexity Groups

Compared to low-effort patients, high-effort patients were older and were more likely to be female, reside in neighborhoods with lower median household income, be insured by Medicare or Medicaid, have a greater number of clinic/PCP visits, and see a greater number of different providers in their primary care practices. Compared to low-effort patients, high-effort patients were also significantly (P < 0.01) more likely to have medical (e.g. diabetes [23.2 % vs. 6.4 %]), psychiatric (e.g. bipolar disorder [4.5 % vs. 1.0 %]), and behavioral health (e.g. substance use disorder [9.8 % vs. 2.9 %]) comorbidities and have an ED visit (25.8 % vs. 7.7 %) or hospitalization (15.0 % vs. 3.9 %) in the prior year (Table 3).

Table 3 Characteristics of Physician-Defined High-Effort vs. Low-Effort Patients
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Compared to patients designated as complex only, high-effort-only patients had a significantly (P < 0.05) greater number of clinic/PCP visits, saw a greater number of different providers in their primary care practices, and were prescribed fewer medications. The proportion of patients with ED visits was similar (14.7 % vs. 14.8 %, p = 0.61), but high-effort-only patients were less likely to have had a hospitalization (4.9 % vs. 9.3 %, p = 0.03) in the past year (Table 4).

Table 4 Characteristics of High-Effort Patients Versus Complex Patients
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Compared to patients designated as high-effort only or complex only, patients who were both high-effort and complex were older and were more likely to reside in neighborhoods with lower median household income, have a higher number of clinic/PCP visits, and be prescribed a higher number of medications. In addition, compared to high-effort only and complex only patients, patients designated as both high-effort and complex were significantly (P < 0.05) more likely to have acute care utilization in the past year (e.g. hospitalizations [4.9 % and 9.3 % vs. 17.2 %]), as well as medical (e.g. diabetes [11.8 % and 19.7 % vs. 25.7 %]), psychiatric (e.g. depression [32.2 % and 31.5 % vs. 48.9 %]), and behavioral health comorbidities (e.g. substance use disorder [4.4 % and 6.0 % vs. 10.9 %]) (Table 4).

Independent Predictors of the Different Effort/Complexity Groups

The high-effort only group was independently associated with being prescribed opiates and having increased primary care utilization, but fewer hospitalizations. The complex only group was independently associated with lower rates of ED and PCP visits despite being associated with measures of medical (e.g. being older and being prescribed more medications) and psychosocial complexity (e.g. being unmarried, and having high no-show rates). Lastly, the high-effort and complex group was associated not only with the aforementioned measures of medical and psychosocial complexity, but also with uncontrolled diabetes (HbA1c >9 %), behavioral health comorbidities (e.g. substance use disorder, and anxiety/depression), as well as higher rates of ED and PCP visits (Table 5).

Table 5 Independent Predictors of Four Different Effort and Complexity Patient Groups
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DISCUSSION

In this study, we presented a new measure of primary care team effort based on PCPs’ qualitative assessment of their patients. We described the characteristics of patients whom PCPs deemed to require a high level of effort to manage, assessed the relationship between PCP-defined primary care team effort and patient complexity, and identified characteristics that were independently associated with high primary care team effort. Our results suggest that PCP-defined effort represents a unique construct that is interrelated with, but distinct from, complexity.

Within a large academic healthcare system, PCPs designated a quarter of their patients as high-effort, and reported medical/care coordination, behavioral health, and social factors as contributors to primary care team effort. Psychosocial factors, which are typically not incorporated into traditional risk adjustment and complexity measurement approaches, appeared to weigh heavily in PCPs’ assessment of primary care team effort, with two- to sixfold higher prevalence of behavioral health problems in high-effort patients.

We previously examined medical, behavioral health, and social factors associated with PCP-defined complexity, and found that it was distinct from traditional comorbidity-based measures of complexity.13 However, measures of complexity, including our measure of PCP-defined complexity,32 do not always correlate with the effort required to care for patients. For example, a medically complex patient who receives extensive support from a caregiver at home or from a multidisciplinary specialty care team may not require a lot of effort from a primary care team. Conversely, a patient with few medical comorbidities might have significant behavioral health or social issues that require extensive attention from the primary care team. In our study, almost one in five (18 %) patients who were considered high-effort were not deemed complex by the same PCPs.

Characterizing our cohort by PCP-defined effort and complexity generated four different patient groups: 1) low-effort, not complex; 2) high-effort, not complex (high-effort only); 3) low-effort, complex (complex only); and 4) high-effort, complex. Although each group likely represents a heterogeneous group of individuals, a conceptual framework developed from PCP-defined effort and complexity (Fig. 1) may be useful for health systems attempting to better allocate resources and redesign primary care to meet the quadruple aim of improving clinical care, patient care experience, provider work satisfaction, and costs.33

From a population perspective, high-effort complex patients represent a group of individuals who have both medical and psychosocial complexity that demands significant effort from primary care teams. These individuals have coexisting chronic medical and behavioral health issues and unmet social needs that drive high rates of acute care utilization and make them harder to manage. They represent an ideal target for care management programs that employ multidisciplinary teams to address not only patients’ medical comorbidities, but also their complex psychosocial needs.34

The high-effort only group represents the “worried well.”35 These individuals have fewer or better-managed chronic medical conditions and a lower rate of hospitalization than complex patients, but present frequently to the clinic and the ED, are more likely to be prescribed opiates, and see many different providers. Involvement from a greater number of providers increases the potential for care fragmentation, which leads to increased primary care team effort in care coordination activities. This highlights the importance of accounting for non-visit-based work (e.g. frequency of electronic communications with patients and other providers) in assessing primary care team effort. Primary care teams may want to ensure same-day or next-day access and focus on improving continuity of care through co-management of patients with a mid-level provider.36 Given the high prevalence of coexisting behavioral health comorbidities among patients receiving opioids for chronic non-cancer pain,37 , 38 approaches that promote close collaboration with mental health and addiction specialists will also be important for this population.39 , 40

Conversely, the complex only group comprises patients with increased medical complexity as evidenced by older age, higher number of prescribed medications, and multiple behavioral health and social issues. However, these complex issues do not drive frequent acute care utilization or primary care team effort in the ways the data might predict. One potential explanation for this discrepancy is that, unlike the high-effort complex group, where medical and psychosocial comorbidities coexist, this group is composed of two distinct subgroups: medically complex older individuals with multiple well-controlled chronic conditions, and psychosocially complex younger, healthier individuals who are uninsured and have high no-show rates.

Improved risk stratification models are needed to identify high-effort patients,41 because traditional diagnosis-based measures do not fully account for patient complexity or the level of primary care effort required to manage patients.42 The fact that PCPs in our study did not consider all medically complex patients, such as those with a greater burden of chronic diseases and higher rates of hospitalization, as high-effort patients supports the idea that primary care risk adjustment models must take into account demographic and psychosocial factors as well as an assessment of available practice resources. PCPs’ unique knowledge of their patients, their teams, and their practice assets allows them to account for some of these factors. However, it is time-consuming and impractical for PCPs to review their entire panel of patients, and incorporating PCP review into a risk adjustment approach would introduce the possibility of gaming the system. A better understanding of physician-reported primary care team effort will help strengthen risk adjustment approaches and allow us to better use quantitative data sets to distinguish between high- and low-effort patients. This will become increasingly important as we move towards risk-adjusted population-based reimbursement strategies.

Our results show that factors contributing to primary care team effort changed with a patient’s age. Older patients were more likely to be considered high-effort due to medical or care coordination issues, while younger patients posed challenges related to behavioral health issues. For PCPs who have closed and aging patient panels, investment in and use of an intensive care management team that can perform care coordination activities and help patients manage multiple chronic conditions will likely be most valuable.43 For PCPs with mostly younger patients, better integration of primary care and behavioral health teams may be more effective.44 , 45

For this study, we primarily used electronically available patient data, which allowed us to construct a conceptual framework for effort and complexity in primary care at the population level, but did not provide enough granularity to further segment patients into clinically actionable subgroups. Although our network includes a variety of practice types, including community health centers, findings from a single health system may not be generalizable to other primary care networks. PCPs’ assessments were cross-sectional in nature, while domains that drive primary care team effort and patient complexity are likely to fluctuate over time. Utilizing new data sources to monitor not only patients’ clinical status, but also changes in patients’ social and behavioral determinants of health, will be important.46 Although PCPs incorporate knowledge of their practice and team assets in their assessments of primary care team effort, their assessment may be incomplete. Therefore, repeat surveys and in-depth qualitative work with PCPs in other practice settings may help broaden our understanding of PCPs’ perception of patient complexity and effort. At this time, there are no standardized or validated methods of defining primary care effort. Further research is needed to identify important determinants of primary care team effort (e.g. specific combinations of chronic diseases and medications) and to develop new approaches for measuring primary care team effort that encompass non-visit-based work, primary care team and practice assets, and relevant patient characteristics.

In summary, our study demonstrates that PCP’s unique perspective on primary care team effort not only reflects the medical complexity of patients, but also accounts for behavioral health and socioeconomic factors impacting the level of effort required to care for patients. Current chronic disease-focused risk adjustment approaches often do not account for these unmeasured components of physician effort, increasing the potential for the unintended consequence that providers caring for patients with a greater number of psychosocial issues will not have sufficient resources to address patients’ needs or receive adequate compensation for their work.47 Future studies should aim to improve understanding of primary care team effort and to develop approaches to better assess it. These will have important implications for 1) efficient resource allocation, 2) healthcare redesign that improves care and reduces physician burnout by providing the necessary support to PCPs in both visit-based and non-visit-based aspects of care, and 3) equitable physician compensation through improved risk adjustment approaches.