Top

Published in:

01-10-2018

Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices

Authors: David Meyers, MD, Lisa LeRoy, PhD, Michael Bailit, MBA, Judith Schaefer, MPH, Edward Wagner, MD, Chunliu Zhan, PhD

Published in: Journal of General Internal Medicine | Issue 10/2018

Abstract

Background

Broad consensus exists about the value and principles of primary care; however, little is known about the workforce configurations required to deliver it.

Objective

The aim of this study was to explore the team configurations and associated costs required to deliver high-quality, comprehensive primary care.

Methods

We used a mixed-method and consensus-building process to develop staffing models based on data from 73 exemplary practices, findings from 8 site visits, and input from an expert panel. We first defined high-quality, comprehensive primary care and explicated the specific functions needed to deliver it. We translated the functions into full-time-equivalent staffing requirements for a practice serving a panel of 10,000 adults and then revised the models to reflect the divergent needs of practices serving older adults, patients with higher social needs, and a rural community. Finally, we estimated the labor and overhead costs associated with each model.

Results

A primary care practice needs a mix of 37 team members, including 8 primary care providers (PCPs), at a cost of $45 per patient per month (PPPM), to provide comprehensive primary care to a panel of 10,000 actively managed adults. A practice requires a team of 52 staff (including 12 PCPs) at $64 PPPM to care for a panel of 10,000 adults with a high proportion of older patients, and 50 staff (with 10 PCPs) at $56 PPPM for a panel of 10,000 with high social needs. In rural areas, a practice needs 22 team members (with 4 PCPs) at $46 PPPM to serve a panel of 5000 adults.

Conclusions

Our estimates provide health care decision-makers with needed guideposts for considering primary care staffing and financing and inform broader discussions on primary care innovations and the necessary resources to provide high-quality, comprehensive primary care in the USA.

Available only for authorised users

Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press; 1998.

Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166–71.CrossRefPubMedPubMedCentral

Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996.

Ellner AL, Phillips RS. The coming primary care revolution. J Gen Intern Med. 2017; 32(4):380–6.CrossRefPubMedPubMedCentral

World Health Organization. Primary Health Care: Now More Than Ever. Geneva: WHO; 2008.

Patient-Centered Primary Care Collaborative. Shared principles of primary care: moving the United States toward a vibrant future of person-centered, team-based, and community aligned primary care. Available at: https://www.pcpcc.org/about/shared-principles. Accessed May 11, 2018.

Ghorob A, Bodenheimer T. Share the care: building teams in primary care practices. J Am Board Fam Med. 2012;25(2):143–5.CrossRefPubMed

Grumbach K, Olayiwola JN. Patient empanelment: the importance of understanding who is at home in the medical home. J Am Board Fam Med. 2015;28(2):170–2.CrossRefPubMed

Patel MS, Arron MJ, Sinsky TA, Green EH, Baker DW, Bowen JL, et al. Estimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care. 2013;19(6):509–16.PubMed

10.

Friedman A, Hahn KA, Etz R, Rehwinkel-Morfe AM, et al. A typology of primary care workforce innovations in the United States since 2000. Med Care. 2014;52(2):101–11.CrossRefPubMed

11.

Ladden MD, Bodenheimer T, Fishman NW, et al. The emerging primary care workforce: preliminary observations from the primary care team: learning from effective ambulatory practices project. Acad Med. 2013;88(12):1830–4.CrossRefPubMed

12.

Bodenheimer T, Willard-Grace R. Teamlets in primary care: enhancing the patient and clinician experience. J Am Board Fam Med. 2016;29(1):135–8.CrossRefPubMed

13.

Balasa DA. New roles for the certified medical assistant to enhance quality and effectiveness of care. J Med Pract Manage. 2008;23(5):276–8.PubMed

14.

Bodenheimer T, Bauer L. Rethinking the primary care workforce—an expanded role for nurses. N Engl J Med. 2016; 375:1015–7.CrossRefPubMed

15.

Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826–34.CrossRefPubMed

16.

Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272–8.CrossRefPubMedPubMedCentral

17.

Jabbarpour Y, DeMarchis E, Bazemore A, Grundy P. The impact of primary care practice transformation on cost, quality and utilization: a systematic review of research published in 2016. Available at: https://www.milbank.org/news/patient-centered-primary-care-collaborative-publishes-new-evidence-report/. Accessed May 11, 2018.

18.

Bauer MS, Leader D, Un H, Lai Z, Kilbourne AM. Primary care and behavioral health practice size: the challenge for healthcare reform. Med Care. 2012; 50(10): 843–8CrossRefPubMedPubMedCentral

19.

Hing E, Burt CW. Characteristics of office-based physicians and their medical practices: United States, 2005-2006. . National Center for Health Statistics. Vital Health Stat. 13(166). 2008.

20.

Lau DT, McCaig LF, Hing E. Toward a more complete picture of outpatient, office-based health care in the U.S. Am J Prev Med. 2016. 51(3):403–9.CrossRefPubMed

21.

Peikes DN, Reid RJ, Day TJ, et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med. 2014;12(2):142–9.CrossRefPubMedPubMedCentral

22.

Agency for Healthcare Research and Quality. Primary care transformation. Available at: https://www.ahrq.gov/professionals/systems/primary-care/tpc/index.html. Accessed May 11, 2018.

23.

Agency for Healthcare Research and Quality. Redefining primary care for the 21st century. Available at: https://www.ahrq.gov/professionals/systems/primary-care/workforce-financing/white-paper.html. Accessed May 11, 2018.

24.

Agency for Healthcare Research and Quality. AHRQ new models of primary care workforce and financing. Available at: https://www.ahrq.gov/ncepcr/primary-care-research/workforce-financing/exec-summary.html. Accessed May 11, 2018.

25.

Angstman KB, Horn JL, Bernard ME, et al. Family medicine panel size with care teams: impact on quality. J Am Board Fam Med. 2016;29(4):444–51.CrossRefPubMed

26.

Raffoul M, Moore M, Kamerow D, Bazemore A. A primary care panel size of 2500 is neither accurate nor reasonable. J Am Board Fam Med. 2016;29(4):496–9.CrossRefPubMed

27.

Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States: population estimates and projections, 2014. Available at: https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed May 11, 2018.

28.

Bureau of Labor Statistics. May 2015 national occupational employment and wage estimates. Available at: http://www.bls.gov/oes/current/oes_nat.htm. Accessed May 14, 2018.

29.

Peckham C. Physician compensation report 2015. Available at: http://www.medscape.com/sites/public/physician-comp/2015. Accessed May 11, 2018.

30.

Peckham C. Medscape nurse salary report 2015. Available at: http://www.medscape.com/features/slideshow/public/nurse-salary-report-2015. Accessed May 11, 2016.

31.

Peckham C. Clinical and office staff salary report 2015. Available at: http://www.medscape.com/features/slideshow/public/staff-salary-report-2015#page=1. Accessed May 11, 2018.

32.

Basu S, Phillips RS, Bitton A, Song Z, Landon BE. Medicare chronic care management payments and financial returns to primary care practices: a modeling study. Ann Intern Med. 2015;163:580–8.CrossRefPubMed

33.

Goroll AH, Bwewnson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med. 2007; 22(3):410–5.CrossRefPubMedPubMedCentral

34.

Medical Group Management Association. MGMA Cost Survey for Primary Care Practices: 2014 Report Based on 2013 Data. Glacier Publishing Services, Inc.; 2014.

35.

Muhlestein DB, Smith NJ. Physician consolidation: rapid movement from small to large group practices, 2013-2015. Health Aff. 35(9): 1638–42.CrossRefPubMed

36.

Murray M, Davies M, Boushon B. Panel size: how many patients can one doctor manage? Fam Pract Manag. 2007;14(4):44–51.PubMed

37.

Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Ann Fam Med. 2012;10(5):396–400.CrossRefPubMedPubMedCentral

38.

Oregon Health Authority and the Department of Consumer and Business Services. Primary care spending in Oregon, 2014. Available at: http://www.oregon.gov/oha/HPA/CSI-PCPCH/Documents/2017%20SB231_Primary-Care-Spending-in-Oregon-Report-to-the-Legislature.pdf. Accessed May 11, 2018.

39.

Center for Medicare and Medicaid Services. National health expenditures 2015 highlights. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf. Accessed May11, 2018.

40.

Bailit MH, Friedberg MW, Houy ML. Standardizing the measurement of commercial health plan primary care spending. Available at: https://www.milbank.org/wp-content/uploads/2017/07/MMF-Primary-Care-Spending-Report.pdf. Accessed May11, 2018.

41.

Watkins LD. Aligning payers and practices to transform primary care: a report from the multi-state collaborative. Available at: https://www.milbank.org/publications/aligning-payers-and-practices-to-transform-primary-care-a-report-from-the-multi-state-collaborative/ . Accessed May 11, 2018.

42.

Phillips RL, Green LA, Fryer GE, Dovey SM. Uncoordinated growth of the primary care work force. Am Fam Physician. 2001;64(9):1498.PubMed

43.

Petterson SM, Liaw WR, Phillips RL Jr, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503–9.CrossRefPubMedPubMedCentral

44.

Petterson SM, Phillips RL Jr, Bazemore AW, Koinis GT. Unequal distribution of the U.S. primary care workforce. Am Fam Physician. 2013 1;87(11). Available at: http://www.aafp.org/afp/2013/0601/od1.pdf. Accessed May 11, 2018.

45.

Auerbach DI, Chen PG, Friedberg MW, et al. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff. 2013;32(11):1933–41.CrossRef

46.

Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff. 2013;32(11):1881–6.CrossRef

Title: Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices
Authors: David Meyers, MD
Lisa LeRoy, PhD
Michael Bailit, MBA
Judith Schaefer, MPH
Edward Wagner, MD
Chunliu Zhan, PhD
Publication date: 01-10-2018
Publisher: Springer US
Published in: Journal of General Internal Medicine / Issue 10/2018
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-018-4530-7

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices

Abstract

Background

Objective

Methods

Results

Conclusions

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Objective

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 10/2018

Atypical Pressure Ulcer as Cellulitis Mimic

Multi-level Influences on Breast Cancer Screening in Primary Care

Words Matter

A human touch

Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial

Engagement of Accountable Care Organizations in Acute Care Redesign: Results of a National Survey

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page