Estimating the Staffing Infrastructure for a Patient-Centered Medical Home

This study suggests that implementing a patient-centered medical home requires additional staff with specific expertise based on the needs of the practice and its population.
Published Online: June 21, 2013
Mitesh S. Patel, MD, MBA; Martin J. Arron, MD, MBA; Thomas A. Sinsky, MD; Eric H. Green, MD; David W. Baker, MD; Judith L. Bowen, MD; and Susan Day, MD, MPH
Background: The patient-centered medical home (PCMH) offers an innovative method of delivering primary care. However, the necessary staffing infrastructure is not well established.

Objectives: To evaluate the roles of personnel within a PCMH and to propose necessary staffing ratios and associated incremental costs to implement this model of care.

Methods: We sampled primary care clinical practices that either have successfully deployed or were in the process of implementing a PCMH practice model. We conducted targeted interviews of administrators from these practices and reviewed published literature on the personnel roles within a PCMH. Collectively, these data were compared with current staffing standards and used to inform an analytical model and sensitivity analysis.

Results: Primary care practices that successfully transitioned to a PCMH have incorporated a range of new staff and functionalities. Based on our model, we estimated that 4.25 full-time equivalents (FTEs) should be allocated to staffing personnel per 1 physician FTE. Compared with the base-case model of current staffing in the United States of 2.68 FTEs per physician FTE, this is a 59% increase. After applying sensitivity analysis for variability in staffing and compensation, the incremental staffing FTE per physician FTE was 1.57 (range 1.41-1.73) and the incremental associated cost per member per month was $4.68 (range $3.79-$6.43).

Conclusions: Our study suggests that additional staff with specific expertise and training is necessary to implement a PCMH. Further study and opportunities for funding additional staffing costs will be important for realizing the potential of the PCMH model of care.

Am J Manag Care. 2013;19(6):509-516
In this study we evaluated the personnel infrastructure, staffing ratio, and associated costs needed to implement a patient-centered medical home (PCMH).

  • Experience from successful PMCH practices suggests that additional staff with necessary expertise and training will be required in order to achieve the goals of improved outcomes and better care at reasonable cost that incorporate effective care coordination, medication management, and support for behavioral health and population management.

  • This additional support may need to be further augmented in practices serving vulnerable populations and/or providing practice sites for resident trainees.
Amid a shortage of primary care physicians, the need to provide high-quality, affordable care to a growing population drives the patient-centered medical home (PCMH) movement as an innovative method of delivering primary care in the United States.1 The key premise is that improvements in the quality and efficiency of care will result from a interprofessional teambased approach where each member of the team works collaboratively with other team members, all performing at the top of their scope of practice.

Although implementation of a PCMH is highly contextual, there is growing evidence to suggest that certain functionalities are important for success.2-6 In 2007, Joint Principles for the Medical Education of Physicians as Preparation for Practice in the Patient-Centered Medical Home summarized the overarching principles that seek to strengthen the physician-patient relationship by replacing episodic care with coordinated, proactive, team-based, and accessible care that emphasizes safety and quality.7 Practices have used the following key strategies to help transition to the PCMH model: enhanced care management,8,9 integration of behavioral health into medical care,10-15 improved medication management,16-20 improved triage and appointment availability, 6,21,22 population management,23,24 and engagement of patients and families including community outreach.25-30 All these elements require a strong health information system, the capacity to analyze data for quality improvement, and an emphasis on team-based care involving a range of personnel.

Given these new functionalities, the decision to implement a PCMH requires completing a needs assessment that examines existing staff roles and functions, considers the extent to which existing staff can meet the new and expanded roles of a PCMH, and determines whether additional personnel and financial support will be needed to fill the gaps. Thus far, there are limited data on staffing requirements for practices that are interested in transitioning to a PCMH.2-5 The objective of this study was to evaluate the roles of personnel within a PCMH and to propose necessary staffing ratios and associated incremental costs to implement this model of care.

METHODS

This study was initiated based on the deliberation of a work group created at the PCMH Education Summit convened by the Society of General Internal Medicine in 2011. The purpose of this summit was to discuss the challenges of advancing the PCMH model within academic medical centers in the United States and to create work groups to address specific topics ranging from curriculum and scheduling to infrastructure. The summit, but not this study, was supported by the Josiah Macy Jr Foundation and others. This study was approved by the institutional review board at the University of Pennsylvania.

There is limited published literature to address our research question: what is the appropriate staffing infrastructure of a PCMH? Because limited role-specific data exist in some contexts (eg, role of pharmacists in the PCMH16-20), we used published data when available and conducted targeted interviews of a small sampling of practices implementing a PCMH to fill in the gaps when published data were not available. Collectively, these data were compared with current staffing standards and were used to inform an analytical model and sensitivity analysis to propose insights into the necessary staffing infrastructure for a PCMH.

Data Sources and Collection

To inform the staffing and cost estimates of our analytical model, we reviewed published literature on the staffing roles within Joint Principles for the Medical Education of Physicians as Preparation for Practice in the Patient-Centered Medical Home,7 conducted interviews with leaders and administrators at a small sampling of primary care practices, obtained current staffing estimates from the Medical Group Management Association (MGMA),31 and gathered staffing compensation estimates by geographic location.32,33

After determining key functions of a PCMH based on practice principles, published literature on staffing roles within a PCMH was reviewed to determine which professionals within current PCMHs carried out those roles in practice. In Table 1,6,8-30,34,35 we display the PCMH principles based on the 2007 Joint Principles7 and the key strategies and components for each principle. Based on this information, we elucidated the implications for staffing and conducted a keyword search for the staffing role (eg, care manager) and combinations of the staffing role and a PCMH (eg, PCMH, patient-centered medical home, medical home).

During the Society of General Internal Medicine Education Summit, we identified a convenience sample of primary care clinical practices that were known to have either successfully deployed or were in the process of implementing a PCMH practice model. These practices were selected because they had published their results in peer-reviewed journals, they had presented their approaches at academic meetings, or their efforts to deploy the PCMH were known to members of the Society of General Internal Medicine Education Summit working group. We chose to interview administrators because they were often cited as the primary decision makers for staffing their medical practices. Administrators of eligible practices, physician or nonphysician, were interviewed over the telephone and asked the following questions: (1) What are your average attending and resident panel sizes? Do you use any risk adjustment methodologies? (2) What types of health professionals (including care managers, nurse practitioners, physician assistants, clinical pharmacists, health coaches/educators, social workers, behavioral health providers, or nutritionists) have been incorporated in the care team, and what are their roles? (3) Have any other administrative personnel (eg, data analysts) had been added to the team? (4) What are the staffing ratios between these positions and physician full-time equivalents (FTEs) in the practice? (5) Is the practice certified as a PCMH by the National Committee for Quality Assurance (or other organization)? (6) Does the manager directly overseeing the practice have a master’s degree in business, healthcare administration, public health, or a related field?  

Nine administrators with knowledge of their institution’s primary care practices and PCMH initiatives agreed to be interviewed. They represented academic medical centers, nonprofit and for-profit institutions, and government-owned health systems. Of these institutions, 7 had at least 1 practice certified as a PCMH (6 by the National Committee for Quality Assurance, 1 by a health insurer). One practice had applied for certification. One large practice group had not sought formal PCMH certification. Between January 2011 and May 2011, a single investigator (MJA) conducted the telephone interviews and followed up by phone and/or e-mail to confirm findings when additional clarification was needed. Interview results were de-identified and aggregated for review by study authors.

Data from the MGMA 2010 cost survey report31 were used to assess current staffing models in the United States. The median staffing level for all internal medicine practices owned by a hospital/integrated delivery system was used as the benchmark for comparison in our study. Data from Kenexa CompAnalyst Market Data,32 a national proprietary database, were used to determine the median annual total salary for the clinical and administrative staffing roles. Variances in compensation by geography were based on data from the Economic Research Institute’s Geographic Assessor pay survey.33

 Data and Sensitivity Analysis

Data from literature review and interviews were aggregated for role-specific comparison. A model incorporating an estimate of staffing of each role was developed as follows. Published estimates of staffing ranges were used when available. When published data were unavailable, current staffing baselines were compared with interview ranges and the median from our survey of 9 administrators was used. Using the median staffing level in the 2010 MGMA cost suvey31 as a baseline, the incremental staff necessary to meet our proposed staffing model was then determined. Data were reported as FTE requirements per physician FTE. Sensitivity analysis was applied at ±10% to each staffing estimate. Median annual compensation for clinical and administrative roles in the PCMH was estimated using the Kenexa Compensation Analysis.32 The cost of fringe benefits, estimated to be 30% of base salary, then was added to estimate total annual employee compensation. Sensitivity analysis for compensation was conducted by using the Economic Research Institute survey data to estimate the range among the 9 institutions in our study. A range of –10% to +25% was applied to represent geographic variations between 2 cities: Dubuque, Iowa (a city with lower salaries) and Manhattan, New York (an area with high salaries). Incremental cost estimates were calculated by multiplying the incremental FTEs per physician by the annual compensation estimates. The incremental reimbursement required to offset the incremental costs were estimated. Assuming a typical panel size of ~2150 patients per physician FTE (approximately the median among the 9 practices in our study), the incremental cost per member per month was computed, where each member was a patient within the physician’s panel.

RESULTS

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