Health system leaders need to generate nuanced estimates of panel size based on the interplay of patient needs and physician capacity when adding PCPs to their networks. Two analyses will help organizations develop a more confident assessment of physician needs: A high workload makes delivering consistent, high-quality, and comprehensive care challenging.

Risk-adjusted panel size

A risk-adjusted approach to panel size accounts for the complexity of care and coordination needed by the population served. Instead of prescribing a general clinician-to-patient ratio, a risk index recalibrates the PCP’s panel based on patient characteristics. This accounts for factors that influence the demand for health services of the patient population, such as payer class, patient demographics, and disease type and prevalence of the population. As a result, panel sizes reflect a more specific understanding of patients’ health demands and clinician capacity.

For example, a PCP who primarily treats commercially insured patients, who average 2 office visits per year and 0.2 hospital admissions each, can theoretically manage a larger number of patients compared to a PCP treating primarily Medicare patients, who average 7 office visits per year, 0.4 admissions each, and carry a wider range and severity of chronic conditions.

Downstream panel utilization

Health system leaders should also consider the activity generated outside of the primary care visits. A high acuity panel results in more patient management responsibilities due to specialist referrals, post-discharge visits, and other coordination of care for the primary care provider, reducing their capacity for additional patients.

For example, a primary care physician whose patients average 0.6 hospital admissions and 6 specialist visits might be allocated a smaller panel compared to a PCP whose patients average 1.5 admissions but only 3 specialist visits.

A deep understanding of population complexity, as well as downstream utilization, proves crucial to synchronizing patients’ true disease burden with providers’ capacity. In tandem, these elements enable organizations to create better calculations of PCP panel size and overall clinician need.

When thinking about risk-adjusted panels, consider:

• How do we currently determine panel sizes for primary care providers? What variables do we need to weigh differently in our assumptions?
• What key health indicators and social factors are present in our markets? How do these affect PCP capacity and workflow?
• How could an approach that considers risk adjustment and downstream utilization more accurately refine PCP panel sizes based on patient complexity at our system?

Referral leakage is an important factor when determining the number of specialists required for a network. Organizations with high leakage lose potential revenue to other providers or systems. In response, organizations may decide to hire more specialists to retain more services and ensure continuity of care. While important as a consideration, overall leakage rates provide an incomplete picture.

Market-contextualized leakage

To create more tailored estimates of specialist need, health system leaders must develop a more detailed understanding of leakage and its drivers. Not all instances of leakage represent failure points. Some leakage will occur for valid reasons. The health system may not offer the service referred, the service line may have a partnership with an unaffiliated provider, or the out of system referral may be based on prior professional relationships. Differentiating between acceptable and unacceptable leakage, as well as uncovering root causes for the leakage, prevents incorrect assumptions about physician network needs.

For instance, health system leaders might be alarmed if they were losing a large portion of initial orthopedic consultations. However, further exploration could show that most of the resulting surgeries still occurred within their facilities. Focusing solely on leakage might suggest expansion, but understanding the full context prevents a potentially strategically detrimental decision.

Leaders can take the following steps to develop a market-contextualized leakage assessment:

An access assessment can also diagnose other supply concerns, like care deserts in the service area. Deeper assessment of access across the market should inform clinician supply or partnership needs.

Conclusion

Proper primary and specialty care adequacy extends beyond just meeting general operational benchmarks. It is about delivering effective, accessible, and coordinated care that corresponds with evolving patient needs and organizational goals. Data-driven and contextualized metrics help leaders of organizations understand their market dynamics, provider capacity, and patient care. This fosters a more patient-centric approach to care delivery, while simultaneously supporting organizational success.