Primary care physician practice styles and quality, cost, and productivity.

OBJECTIVES: To assess quality, cost, physician productivity, and patient experience for 2 primary care physician (PCP) practice styles: the focused, who typically address only the patient's acute problem, versus the max-packers, who typically address additional conditions also. STUDY DESIGN: Retrospective observational study using administrative data, electronic health record (EHR) data, and patient surveys. Data represent 285 PCPs (779 PCP-years) in a large, multispecialty group practice during 2011, 2012, and 2013. METHODS: PCPs were ranked each year by their number of additional conditions addressed during acute care visits. The top one-third (max-packers) addressed 25.4% more "other problems" than expected, while focused PCPs (bottom one-third) addressed 20.3% fewer than expected. Outcomes were resource use, clinical quality metrics, patient-reported experience, physician time using the EHR, and physician productivity. All measures were risk-adjusted to account for patient mix. T tests were used to compare measures. RESULTS: Relative to a focused pattern of care, max-packing was associated with 3.4% lower overall resource use, consistently better scores for the available clinical quality metrics, and comparable patient experience (except for worse wait time ratings). Patients of focused PCPs used 7.3% more specialist services, in terms of costs, than patients of max-packers ($1218 vs $1136; P <.001). Max-packers spent 40 minutes more per clinical day using the EHR. PCPs with less appointment availability and who used a mix of appointment slots were more likely to be max-packers. CONCLUSIONS: Max-packing behavior yields desirable outcomes at lower overall cost but involves more conventionally uncompensated PCP time. Alternatives to compensation just for face-to-face visits and using more flexible scheduling may be needed to support max-packing.

Standardizing primary care physician panels: is age and sex good enough?

OBJECTIVES: To determine if patient clinical conditions need to be considered when assessing primary care physician (PCP) workload in the context of standardizing panel sizes. STUDY DESIGN: Work resource value units (wRVUs) were used to standardize PCP panel workload. Standardized panels were created using (1) age and sex- and (2) clinical condition-based risk indicators. Billing data were used for all patients, regardless of insurance, for PCPs in a group practice (n = 190). Weighting methods were assessed for subgroups based on PCP specialty (family medicine, internal medicine, and pediatrics) and patient age (adults vs children) and for different levels of aggregation (patient vs PCP). METHODS: Groupwide weights based on wRVUs of all primary care services delivered during the year were applied to individual patients and then aggregated to PCP panels. For age/sex weighting, only patient age and sex were taken into account. For condition-based weighting, 1275 disease categories, based on a combination of episode treatment groups (ETGs) and age and/or sex, were used. RESULTS: As expected, at the patient level, condition-based weights were far more discriminative than age/sex. At the PCP level, this discrimination was less important; panel weights varied 1.9- (age/sex-based) to 2.6-fold (condition-based) across PCPs. Correlations between the 2 weighting methods were high (r = 0.93) for child panels and moderate (r = 0.71) for adult panels (all P <.001). CONCLUSIONS: The heterogeneity of PCP panels should be considered when assessing PCP workload for panel management. Panel variability in workload is well captured by age/sex-based weights for children, but for adults condition-based adjustment may be necessary.

Now what should I do? Primary care physicians' responses to older adults expressing thoughts of suicide.

BACKGROUND: Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI). OBJECTIVE: Identify patterns in physician-patient communication regarding suicide to inform QI interventions. DESIGN: Qualitative thematic analysis of video-taped clinical encounters in which suicide was discussed. PARTICIPANTS: Adult primary care patients (n = 385) 65 years and older and their primary care physicians. RESULTS: Mental health was discussed in 22% of encounters (n = 85), with suicide content found in less than 2% (n = 6). Three patterns of conversation were characterized: (1) Arguing that "Life's Not That Bad." In this scenario, the physician strives to convince the patient that suicide is unwarranted, which results in mutual fatigue and discouragement. (2) "Engaging in Chitchat." Here the physician addresses psychosocial matters in a seemingly aimless manner with no clear therapeutic goal. This results in a superficial and misleading connection that buries meaningful risk assessment amidst small talk. (3) "Identify, assess, and…?" This pattern is characterized by acknowledging distress, communicating concern, eliciting information, and making treatment suggestions, but lacks clearly articulated treatment planning or structured follow-up. CONCLUSIONS: The physicians in this sample recognized and implicitly acknowledged suicide risk in their older patients, but all seemed unable to go beyond mere assessment. The absence of clearly articulated treatment plans may reflect a lack of a coherent framework for managing suicide risk, insufficient clinical skills, and availability of mental health specialty support required to address suicide risk effectively. To respond to suicide's numerous challenges to the primary care delivery system, QI strategies will require changes to physician education and may require enhancing practice support.