Should primary care physicians consider closing their patient panels?

Do you have too many patients? Primary care physicians with crowded waiting rooms already feel overburdened. Many physicians are thinking of closing their practices to new patients. Experts say that no matter how busy you are, closing your panel may be a mistake.

As the Affordable Care ACT (ACA) kicks in, millions of newly insured patients may soon come knocking at your door. Many physicians are already working long hours yet don’t have enough time to spend with each patient. They need a breather and want to make sure they aren’t spread so thin that they can’t provide appropriate and effective care.

If you think the solution is closing your panel to new patients, you may want to think again. It’s almost always a mistake to close your panel to new patients, say the physician experts and practice management consultants who spoke to Medical Economics on the issue.

“Busy is in the eye of the beholder,” says Rosemarie Nelson, a Medical Group Management Association (MGMA) consultant based in Syracuse, NY. “The average panel for a primary care doctor is about 2,500 patients. Some busy practices are simply inefficient. A practice with 2,200 patients may want to close while another with 3,200 patients has figured out ways to accommodate new patients without sacrificing quality.”

Closing your panel should be a last resort. “Once you turn the faucet off, turning it back on when your situation changes may be a challenge if word gets around the community that you weren’t accepting new patients,” says William T. Manard, MD, director of clinical services in the Department of Family and Community Medicine at St. Louis University School of Medicine in St. Louis, Missouri.

“Even in mature practices, it’s essential to replace patients who leave your care,” says Gray Tuttle Jr., a consultant with the Rehmann Group in Lansing, Michigan. “Closing your panel causes misperceptions by patients and other doctors. They may conclude that the doctor is retiring, leaving or is ill. That can accelerate the contraction of your practice beyond what you wanted.”

Expanding your capacity for more patients

It’s clear there’s a problem when the waiting room is packed, it’s difficult for established patients to get an appointment, and sick patients can’t be seen soon enough, says Judy Bee, a principal of PPG Consulting in La Jolla, California. “Often unknown to the doctor, staff members are suggesting that patients go to an urgent care center because they’re just so jammed.”

Tuttle agrees. “If it takes more than a month for a new patient to get an appointment, the practice is probably pushing the limit on what it can accommodate,” he says.

“Established patients should be able to get in within two weeks. Practices need systems for same-day care or patients will go to urgent care centers instead.”

Here are five ways you can adjust your practice management process to accept more patients without substantially increasing your workload.

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1. Scheduling fixes

How many patients did you see today that didn’t need to be seen right away? “It’s often as much as 40%,” Bee says. “Practices often see patients who are stable but chronically ill every three months. Instead of making an appointment that far in advance, you can send reminder cards. When patients call for an appointment, you’ll have a better idea of your capacity and can adjust the schedule so that there’s room for patients who have more acute needs.”

Physicians should save a few slots for sick patients who need to be seen that day, she says. Bee recommends a scheduling model where physicians determine the average number of work-ins for each day of the week. Then look at the average number of no-shows or last minute cancellations. Monitor the urgent patients or appointments made within one week. Note how many return appointments are made for patients seen as an emergency or urgent. This can help the practice best adjust its schedule.

2. Sharing more responsibility with midlevels

If the practice is still overwhelmed, it’s time to make better use of medical assistants and midlevel providers such as nurse practitioners and physician assistants.

“Medicine is a team effort and physicians need to rely more on their staffs to engage patients with data collection, coaching and even prescribing,” says Manard. “Resistance to change comes from both sides. Doctors have to convince themselves and colleagues that they can let go of some aspects of care and let midlevels handle them.

“Many patients expect to be cared for only by the doctor,” he says. “We need to educate patients that nurses and assistants can handle many parts of care that don’t require our level of training.

“We have also created protocols for preventive tests and common conditions, either by phone or face to face,” he adds. “Nurses can call in prescriptions, etc.”

Adding providers is a key strategy for any practice going forward. “It’s necessary to deal with the anticipated onslaught of demand created by the Affordable Care Act,” Tuttle says. “Properly using a midlevel can be a profit center.”

3. Expanding office hours to meet patient demand

Hiring midlevel providers won’t help much if there aren’t enough exam rooms to handle the patient volume at your practice, Nelson cautions. “If the facility is physically limited, it’s time to expand hours and work in shifts,” Nelson says. “One provider can work early morning to mid-day, another provider comes in and works until evening. Physical expansion should be addressed if necessary.”

Bee agrees. “Expanding hours doesn’t give a doctor any more hours to see patients. But it does provide more space so that midlevels can pick up the slack.”

4. Use more virtual care to connect with patients

Not all measures of “availability” require the doctor’s immediate or personal attention, Manard says. “We can provide more virtual care by telephone, websites, electronic health records (EHRs) and patient portals. I didn’t see any patients today but I answered 10 emails. Technology allows us to monitor chronic conditions and notice trends.”

Patient portals are integrated into many EHR systems. Standalone options also are available. An up-to-date health record can facilitate directed interventions, Manard says. Advice can be “blasted” to groups of patients as a way to educate them in between visits.

“We can leverage data in electronic records to send out mailings for preventive services,” he says. “We can send out reminders for mammograms, etc., with minimal time investment.”

5. Dropping bad insurers

Practices should review their payer lists and determine if there are any they would be better off without. Does a poor paying third party represent more than 10% of the practice? If so, consider dropping it, says Tuttle. “You can’t do that if it represents 25%, though. It would take too long to fill in that capacity.

“You don’t have to take all payers,” he adds. “It’s purely a business decision. The key is to follow the rules and provide adequate notice to the plan and patients.”

Each insurance contract is different. “I’d seek legal advice before dropping a payer,” Manard says. “Most insurers require providers to continue to accept new covered patients, at least to some degree if you want to continue to accept that payer. If you decide to withdraw from participating with an insurer over reimbursement issues or just to help manage panel size, recognize that any patients with that coverage will likely leave your practice as well. Account for this in any objective panel size calculation. Also recognize that it may mean terminating long-term relationships with patients.”

The impact of healthcare reform

It’s still uncertain how the ACA will affect primary care, but most experts believe the demand for care will increase significantly. “There’s no question that doctors need to find ways to accommodate larger panels,” Tuttle says.

“I see it as an opportunity,” he says. “There is big expansion of Medicaid. A provision in the law increases reimbursement rates for primary care doctors to Medicare levels for two years. Medicare is still a good payer.”

An addition of up to 30 million newly insured patients will certainly strain medical practices, says Manard. “These patients are likely to have longstanding significant health needs. Doctors should carefully consider which exchange or Medicaid plans they want to participate with to prevent oversaturation of the practice, especially with lower paying carriers.”