Primary physicians spent a median of 7.9 h per week on patient work between office visits. Because study physicians estimated their capture rate to be only 80%, the real time spent may be closer to 10 h per week. This estimate is consistent with that reported in two other recent studies: a family practice averaged almost one fifth of the workday on patients not currently in the office, and an academic geriatric clinic averaged an extra 7.8 h of work/physician outside of office visits.6,7
In contrast to those two studies, this work was measured in a system with an EMR and a mandate to report all results to patients within 2 weeks.9,10
This study provides new data on the complexity of care performed between office visits in primary care revealing that 82% of the time was spent on events involving change in diagnosis or management, with almost half the time involving two or more diagnoses.
The wide variability observed among the providers may be due to multiple factors, including practice efficiency, which may be within a provider’s control, patient severity/complexity, which is generally outside the provider’s control, and inaccurate measurement, which does not represent true variability in time spent. This study did not have the statistical power to confirm whether or not a significant relationship does exist between DCG scores and workload. Future studies may address this. Practice efficiency factors include variation in ensuring that patients have diagnostic testing completed preceding visits so results can be discussed during the visit, nurse/physician staffing ratios, communication style (phone versus letter), and delegation of chronic disease management to nurses and pharmacists. Now that the time and complexity is known, each team is working to improve efficiency. Sources of inaccurate measurement include variation in capture rate and varying interpretations of the complexity levels despite concise rules and uniform training. For example, in Table D2 and P2 were high outliers in total events per week, because they were two of the three physicians with the highest capture rates (measurement) and also two of the three physicians with the most complex patients as measured by DCG score (patient complexity).
The higher complexity of much of this work between visits has implications as to the amount of work that could be delegated to non-physicians. Future studies may explore how much efficiency can be improved through the use of algorithms by nurses or pharmacists for simple medication changes, diagnostic test ordering, and chronic disease management.
Limitations of this study include: a VA population that is 95% male versus the US population. Standard panel size on our teams is 1,200 patients. To the extent that patients represented in this study also had non-VA physicians from whom they obtained (even the bulk) of their care, the conclusions regarding non-visit-based time may be underestimated. Data were self reported and capture incomplete.
The quantity of unreimbursed, complex work between office visits may contribute to the high burnout rate of existing primary internists and the diminishing interest of medical student graduates in primary care. Fair compensation for this work could be reasonably addressed in multiple ways. In primary care, flat capitation payments could be made to cover between-visit work and panel management activity aimed at optimizing patients’ health based on current evidence-based standards. This mechanism would be an incentive to improve efficiency. Alternatively, additional CPT codes for evaluation and management services could be established to compensate fairly for high-volume physician patient interactions conducted over the phone, by secure e-mail, letters, and even secure video. Decreasing the frequency of office visits would also benefit patients, for whom travel to the office may be logistically difficult, unaffordable, or simply inconvenient. A smarter, more equitable reimbursement design could improve the efficiency and effectiveness of the health care system for both providers and patients.