Productivity in primary care is geared for a revival

Though visits to primary care physicians (PCPs) have slumped compared with previous years, experts say that productivity in the primary care field is ready for resurgence in the next few years. The 85th annual Medical Economics 2013 Physician Profile Study found that the average doctor worked 50 hours a week in 2012, while 27% worked 40 hours or fewer per week.

Median hours per week remained unchanged from 2011 to 2012 for family/general practitioners at 50 hours, though visits per week increased slightly from 98 in 2011 to 99 in 2012.

Internists worked fewer median hours-54 hours per week in 2011 compared with 52 in 2012. They also reported seeing fewer patients, going from 98 per week in 2011  to 93 a week in 2012.

Both groups of primary care professionals have yet to recoup their patient load from 2009, when family/general practitioners reported seeing 102 patients a week while working 51 hours, and internists saw 101 patients while working 54 hours a week.
Enhancing PCP productivity will be important because millions of patients are expected to flood the healthcare system in the next few years due to the Affordable Care Act (ACA), Medicare expansion, and an aging Baby Boomer population, while practitioners continue to feel added practice management pressures such as  more documentation and prior authorization.

Young physicians working hard to keep up
Younger doctors are working more hours per week compared with earlier years. In 2012, doctors younger than 35 reported working 59 hours week, compared with working about 56 hours a week the previous year. Those doctors also report seeing significantly fewer patients. In 2012, doctors under 35 saw 81 patients a week, compared with 83 patients a week in 2011.

“Longer hours and fewer patient encounters in the younger band of physicians might be explained by a couple things.  First, younger physicians haven’t yet mastered the means of efficiency that often come from hard experience,” says Gray Tuttle Jr., CHBC, principal healthcare adviser with The Rehmann Group in Lansing, Michigan and a Medical Economics editorial consultant. “Next, could more of [these physicians] be under hospital employment models? I see fewer encounters in that setting than independent, private practice.”

Though some older doctors aren’t seeing much change in the hours they have worked over the past few years, they too are seeing fewer patients a week. Doctors ages 50 to 54 reported seeing 99 patients a week in 2012, compared with more than 100 patients a week in the three previous years.

Even doctors a little older, ages 55 to 59, reported seeing 96 patients a week in 2012, compared with 101 patients a week in 2011. That trend is reversed in older doctors, as doctors 60 to 64 saw slightly more patients in 2012 (97) compared with 2011 (95). Doctors closest to retirement-ages 65 and older-saw 79 patients a week in 2012, more than they have in the past four years.

“Older doctors shorten their work day or week because they don’t have debt and they do have retirement money, which is exactly what younger doctors need to establish,” Tuttle says.

Patient increases predicted in all communities
Rural, inner city, and suburban physicians are working the same amount of hours, while seeing slightly fewer patients.

Rural physicians reported working 52 hours a week for the past two years, while seeing 96 patients a week in 2012, compared with seeing 99 patients a week in 2011.
Inner-city doctors saw the fewest patients in 2012 (85 patients in 2012 versus 93 patients in 2011). They reported working 50 hours a week in 2011 and 2012.

Urban doctors were the only ones who reported seeing more patients. In 2012, doctors in urban communities reported working 50 hours a week, and saw 89 patients a week in 2012 compared with 87 patients a week in 2011.

In the next few years, doctors from all communities will see an increase in patients, according to Judy Bee, a healthcare consultant in La Jolla, California, and Medical Economics editorial consultant.

“It depends on the socio-economics of the practice, but I think all practices will start seeing people who haven’t had coverage before,” Bee says. “It might be a culture shock. If your practice currently sees a high volume of patients with no insurance, you might see a groundswell. But geography has nothing to do with it.”

Documentation’s drain on productivity
Time management in a physician’s office is more than just patients divided by hours. Other factors, including increased paperwork and integrating technology into practice management, also eat away at a physician’s productivity.

Anita Sabharwal, MD, a 10-year solo practitioner from Peoria, Illinois, says that her hours have remained steady from 2011 to 2012, and her patient volume may have dipped slightly over the past year. However, the biggest drains on her time are the bureaucratic functions of her job-and she thinks it will only get worse.

“The time spent on documentation and prior authorizations has certainly increased this year,” Sabharwal says. “The ACA will certainly increase the work load and need for more documentation. Productivity at the practice was better prior to the electronic health records, as documentation was more relevant and easier.”

Sabharwal says she is worried that the costs and time involved in implementing Meaningful Use 2 (MU2) will also eat away at the time she needs to run an efficient practice.

“MU2 next year will be more demanding and expensive for a solo practitioner. I have been delaying the patient portal purchase for last several months because of the cost,” she says, adding that the increased documentation coupled with lower reimbursements have caused her to expand her business in ways besides adding more patients and hours.

“The reimbursements have not improved for last several years and the only reason I have been able to stay independent is because of the ancillary services I offer,” Sabharwal says.

How productivity will change in the next few years
PCPs should start prepping for an increase in patients, in spite of the current numbers, practice management experts say.

“Some say there will be a rushing demand for primary care physicians. Physicians will have to either learn to be more efficient or work longer hours,” Tuttle says. “The first challenge is to not add more hours in the week. The last resort is extended hours.

One benefit of the ACA, PCPs will be able to see more patients with insurance, so it should be a boon for them.”

Tuttle points to the rise in urgent care and retail clinics as one reason why patient visits have remained constant in primary care. According to RAND Health, Americans made almost 6 million visits to retail clinics in 2009, the same point that patient visits began slumping in primary care.

“Urgent cares are positioned nicely, but they are threats to PCPs. Many practices are happy for patients to go to urgent care, but that’s money they could capture for themselves,” Tuttle says.

Ultimately, Bee says that though no one can predict what the actual growth will be, physicians should start thinking of ways to incorporate non-physician practitioners in their practices and to anticipate and solicit new patients. She says that a shift toward practice models incorporating midlevel providers such as nurse practitioners and physician assistants will be one way that PCPs will be able to accommodate more patients without increasing hours.

“If a doctor wants to grow [by] a finite number of patients, he [or she] has to decide how to use midlevel providers,” Bee says. “There’s a drastic shortage of doctors, and an acute need. It makes all the sense in the world.”

Other 2013 results related to salaries, productivity and malpractice:

Flat, declining salaries inflate physician worries over payments, red tape

Physician practice owners take a 6% pay cut

What primary care physicians earn: A five-year review (chart)

Primary care physician earnings by gender (chart)

Primary care physician earnings by community (chart)

Primary care physician earnings by region (chart)

Malpractice premium trends (chart)

Competition driving malpractice premiums down

Productivity in primary care is geared for a revival