n engl j med 366;21 nejm.org may 24, 2012
their communities. In all this
work, the Center for Medicare
and Medicaid Innovation should
provide as much flexibility as
possible to HICs, respond rapidly
to their needs for federal data,
and minimize any regulatory and
reporting burdens not vital to
ensuring cost containment and
For decades, the United States
has seemed powerless to curb ex-
cessive health care spending and
improve the quality of care. Now,
the tools for achieving fundamen-
tal reform are in place, but using
them requires the federal govern-
ment and its private and public
partners to leave business as usu-
al behind and to create and imple-
ment a plan that addresses the
root causes of our health care
crisis. Our commission believes
that the establishment of HICs to
transform the care of patients
with multiple chronic conditions
could provide such a plan. Other
approaches may be equally sound.
But above all else, we must act.
Disclosure forms provided by the author
are available with the full text of this arti-
cle at NEJM.org.
From Harvard Medical School, Boston; and the
Commission on a High Performance Health
System, Commonwealth Fund, New York.
This article (10.1056/NEJMp1203427) was
published on April 25, 2012, at NEJM.org.
1. Commission on a High Performance
Health System. The performance improve-
ment imperative: utilizing a coordinated,
community-based approach to improve care
and lower costs for chronically ill patients.
New York: The Commonwealth Fund, April
2. Anderson G. Chronic care: making the
case for ongoing care. Princeton, NJ: Robert
Wood Johnson Foundation, February 2010.
3. Bodenheimer T, Wagner EH, Grumbach
K. Improving primary care for patients with
chronic illness. JAMA 2002;288:1775-9.
4. Guterman S, Davis K, Schoen C, Stremi-
kis K. Reforming provider payment: essential
building block for health reform. New York:
The Commonwealth Fund, March 2009.
5. Holahan J, Schoen C, McMorrow S. The
potential savings from enhanced chronic
care management policies. Washington, DC:
Urban Institute, November 2011.
Copyright © 2012 Massachusetts Medical Society.
Performance Improvement in Health Care
Sharing the Care to Improve Access to Primary Care
Amireh Ghorob, M.P.H., and Thomas Bodenheimer, M.D.
cern for all American adults. In
Massachusetts, average wait times
for new patients to obtain an in-
ternal-medicine appointment rose
by 82% in the 2 years after health
insurance coverage was expanded;
current wait times average 36 days
for family medicine and 48 days
for internal medicine.1 In a 2011
national survey, 57% of patients
who were sick and needed medi-
cal attention could not obtain ac-
cess to care promptly, up from
53% in 2006.2
The reason for the access prob-
lem is an imbalance between de-
mand for care and capacity to
provide care. Demand is growing
as the population expands, ages,
and faces obesity and diabetes
epidemics. Capacity is shrinking
as the ratio of adult primary care
clinicians (family physicians, gen-
eral internists, nurse practitioners,
and physician assistants) to pop-
ulation drops; this ratio is ex-
pected to fall by 9% between prise.
aining prompt access to pri-
mary care is a growing con-
2005 and 2020.3 Even with a dra-
matic increase in the proportion
of U.S. medical students choosing
primary care careers, it would
take decades to reverse this
The access problem creates a
serious dilemma. On the one
hand, the deepening shortage of
adult primary care clinicians
means that panel size — the
number of patients cared for by
each clinician — will increase.
On the other hand, average panel
size is already too large, and its
further growth will worsen ac-
cess, compromise quality, and ag-
gravate burnout among primary
care clinicians. Clinicians with
panel sizes of 2500 patients (the
national average is about 2300)
would have to spend 18 hours per
day to provide excellent chronic
and preventive care4 and would
require even more hours for acute
care and care coordination. Adult
primary care as currently orga-
nized is not a sustainable enter-
The problem becomes clear
when we define the relationship
between demand and capacity.5
Capacity equals the number of
clinician visits per day times the
number of working days per year.
Demand equals the panel size
times the average number of visits
per patient per year. If a clinician
sees 20 patients per day and
works 210 days per year, capacity
is 4200 visits per year. If the panel
size is 2000 and the average pa-
tient sees the clinician 3 times a
year, demand is 6000 visits per
year — and there’s an intolerable
mismatch between capacity and
demand. To balance capacity and
demand, panel size would need
to be reduced to 1400, which
would bring demand down to
4200. Panel size also needs to be
risk-adjusted, because older and
sicker patients require more visits
per year; for a geriatric panel re-
quiring an average of 6 visits per
year, a reasonable panel size
would be 700.
How can primary care respond
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