Study quantifies practice boost from physicians delegating tasks
■ Delegation to nonphysician staff is pitched as an effective way, particularly in small practices, to see and treat more patients.
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When payments started going down for many of the services provided by Florida Cardiac Consultants, the six-physician independent practice in Sarasota needed to increase the number of office visits without running doctors ragged. They came upon a radically simple idea: Let physicians do tasks only they can perform, and leave the rest to everyone else.
As a result, office visits increased 65% from 10,890 in 2005 to 17,928 in 2011, with only one physician added in the interim. “This is much more efficient,” said Mark Spetsios, the practice’s administrator.
The topic of delegation is coming up as small practices look for ways to see more patients without straining themselves, and as more payment models reward doctors for preventive care, care coordination and quality, analysts said. A study in the September/October Annals of Family Medicine showed the effect of putting the physician in a supervisory role in tasks such as patient education, behavior-change counseling, medication adherence counseling and protocol-based services to nonphysician staff.
Researchers created simulation models incorporating estimated times to provide acute, chronic and preventive care services at recommended levels and took into account the potential for delegation to other practice staffers. Physicians who delegated 77% of preventive care and 47% of chronic care could provide services for a panel of 1,947 patients. Physicians who passed on only 50% of preventive care and 25% of chronic care could handle a panel of 1,387 patients.
Although the study noted the average panel size per doctor is 2,300 patients — and growing — they said the numbers make clear that physicians will serve themselves and their patients best if they enlist nonphysician staff as much as possible. They said a doctor with a 2,500-patient panel trying to accomplish all recommended services without delegation would have to see patients for 21.7 hours per day.
“We need to figure out how we're going to provide primary care to the population that needs it, and this means figuring out how to share the care with other people in the practice,” said Thomas Bodenheimer, MD, MPH, lead author and a professor in the Dept. of Family and Community Medicine at the University of California, San Francisco.
Most physicians already hand off at least some duties. What researchers advocate is looking to see whether delegation can go further. Diagnosis, assessment and many procedures would remain in the physician’s hands, but supporters of this approach say teams should meet to discuss how tasks can be divvied up appropriately. Discussion should take into account what nonphysician staffers already do, how new duties may fit in and what the limits of respective licenses allow. Physicians also should be comfortable with giving up tasks.
The goal is not to overburden staffers or take away jobs from physicians but to allow doctors to care for more patients. Some practices may find it cost effective to hire additional personnel. For example, Florida Cardiac Consultants hired 10 nurse practitioners and physician assistants.
“As a team, discuss care-coordination tasks to be done and take a divide-and-conquer approach to all tasks,” said Joseph Scherger, MD, MPH, vice president for primary care and academic affairs with Eisenhower Medical Center in Rancho Mirage, Calif. Dr. Scherger said he delegates as many tasks as possible to medical assistants, nurses and others at the practice. “Like any created system, the form follows from the functions to be done.
“It’s still the physician’s responsibility for everything that is done. We’re not shirking the responsibility. It’s your team, but we need to step back from all the work and be way more selective as to what the doctor does.”
The impact of delegation is getting more attention because it is viewed as a critical component of team-based care models, such as the patient-centered medical home. Finding ways to increase physician panel size is considered particularly important, because 30 million people are expected to become newly insured under the Affordable Care Act. And an aging and increasingly obese population also will raise demand for services. The physician supply, however, is projected to fall short. The American Medical Association and many medical societies support some form of a physician-led team-based care model to address the problem.
“As the report illustrates, physician-led health care teams can help meet the surge in demand as millions of Americans obtain health insurance and can access ongoing health care,” said AMA President Jeremy A. Lazarus, MD. “Physicians and other health professionals have long worked together to meet patient needs for a reason: The physician-led team approach to care works. Patients win when each member of their health care team plays the role they are educated and trained to play.”