by Dr. Sue Kressly, MD, FAAP
Balancing the ability of a primary care practice to appropriately care for a panel of patients, with the business viability of doing so, is a constant challenge and hotly debated topic.
The AMA offers a robust toolkit to approach this problem. However, it does not necessarily take into consideration factors that are unique to pediatric practices.
How can you logically approach calculating the optimum panel size for your practice? Start by considering the following key components.
Infants/toddlers require significantly more office visits and generate more practice visit income than older patients. Children require 10 preventive care visits alone in the first 2 years of life, and have more frequent acute/illness visits, especially if they are in a daycare environment.
Contrast a start-up practice with a high proportion of newborns to a well established practice where the community is aging, schools are closing, and there are not as many newborns available to the practice. If a practice is in a maintenance phase without anticipated growth and they are serving their patients well, ideally they should have an even distribution of ages of patients and are replacing adolescents who are aging out with newborns entering the practice.
Whether you are strictly fee for service, capitation or a combination, payments for care are directly related to patient age.
If your practice is caring for a broad variety of chronic conditions (including asthma, obesity, ADD/ADHD, breastfeeding difficulties, children with complex healthcare needs), those patients will generate more visits in your office and additional practice income.
If you practice in an area where the expectation is that patients are followed by a specialist for most/all chronic conditions, more of that revenue will fall to the specialist than your general pediatric practice. Your practice panel must be larger in order to generate enough visit volume and subsequent revenue.
Understanding practice referral patterns, identifying opportunities to increase expertise within your practice can generate additional revenue and decrease total cost of care for patients. Some common pediatric conditions, in addition to those mentioned above, which can be appropriately managed in the medical home with appropriate education/support include: concussion management, infant reflux, chronic constipation/encopresis, acne, eczema, functional abdominal pain, developmental delays, and behavioral concerns.
If you have extended hours (including evenings/weekends, Telehealth offerings, patient self-scheduling, virtual or in-person walk-in visits) and work toward capturing the majority of acute care visits within your medical home, you will generate more visits per patient in your panel.
On the other hand, if your office hours are 9-5 and you send patients to the local Urgent Care outside those hours, or don’t offer Telehealth and patients access direct-to-consumer virtual visits outside your medical home, you will need a larger panel of patients to support your practice finances.
There may be other unintended consequences of limiting acute access. If families have a positive experience in “off hours,” they may have no incentive to be seen in your office while you are there. Especially if the outside entity met their needs and was equally or more convenient. This can result in an overcall decrease in patient visits to your medical home, drive up the total cost of care per patient (which payers may be using to rate your value), and fragment care which decreases quality and outcomes.
Practices who have developed expertise and partnerships in managing pediatric mental health issues can be profitable with lower panel sizes. Caring for mental health issues generates additional visits and potentially other sources of income.
Using a care team approach can potentially add additional income from non-medical provider services.
Practices who function as a well-coordinated team with care coordinators, recall and referral coordinators, and participate in pre-visit planning, can allow providers to handle a higher patient panel load. In addition, using the team approach increases provider and care team satisfaction and often makes patients/families feel not only cared for, but cared about.
There are widely disparate numbers for pediatric panels that have been identified by various investigators. Except in unique circumstances, it is difficult to maintain a healthy practice with <1,000 patients per full time FTE provider. Ballpark averages for many pediatric practices are approximately 1,500 active patients per FTE but there is wide variability based on regional and practice factors.
It’s important for all practices to maintain their active patient list, understand their demographic and payer distribution, set goals for team based care, and make sure their panel supports their practice financial goals.