Sustaining primary care practice: a model to calculate disease burden and adjust panel size

In late 2008, the Ohio Permanente Medical Group (OPMG) faced severe staffing shortages in its primary care physician group. In addition, the local market for recruitment did not look promising. As a result, many OPMG primary care physicians had very large patient panels, resulting in physician burnout and the Region faced member dissatisfaction in getting appointments. One solution explored was to hire nurse practitioners (NPs) to fill the staffing gap. To do this, Kaiser Permanente Ohio needed to understand what its model of care would look like with NPs. How would the group use the NPs to support its primary care physicians, and which physicians needed the additional support?

In addition to looking at panel size, the group also wanted to know which physicians needed additional support with disease management. Their demand model estimated the number of each physician's office visits; however, it was important to consider the disease component (disease burden) of a physician's patient panel. With the recent implementation of the Permanente Online Interactive Network Tool (POINT), the group planned to use data from the tool to determine the disease burden of each physician's panel. By identifying six chronic diseases from the POINT data and attaching a value, they determined both the disease burden of a physician's panel and the necessary level of support needed from the NPs. This created a new delivery structure that partnered one or two physicians on a team with an NP.

This process resulted in a recommendation to hire 4.5 to 5.5 total NP full-time equivalents to fill the gap identified in capacity and correctly identified the physicians who needed NP support. In 2010, OPMG had 10 NPs, compared with 4 in 2008. The majority of these NPs are working in small teams and successfully supporting physicians with large panels and/or high disease burdens.

On the Patient Satisfaction Survey, patients' satisfaction with the time elapsed between scheduling an appointment and date of the visit went from 68% at the end of 2008 to 77% in the first quarter of 2010; the average days elapsed went from 33 in December 2008 to 23 in May 2010. Additionally, staffing shortages of 2008 have all been resolved, and the Region's clinician-retention rate has improved. Physician feedback has been very positive.