The Influence of a Change in Practice Setting on Pediatrician Activity: A Case Study

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The

Influence

of a Change

in Practice

Setting

on

Pediatrician

Activity:

A Case

Study

Lawrence Kahn, M.D., Patricia Wirth, B.A., and James K. Turner, M.D.

From the Edward Mallinkrodt Department of Pediatrics, and the Division of Health Care Research, Washington Unicersity School of Medicine, St. Louis, Missouri

ABSTRACT. A time-and-motion study was performed of a

pediatrician’s activities in his fee-for-service solo practice and again after he joined a prepaid group practice. A

comparison was made between time spent with fee patients

in solo practice and time spent with fee patients continuing

to see him in group practice. Total time per patient visit was

not changed significantly by the group setting. Activities within the visit were modified in the group setting.

History-taking and physical examination were reduced; counseling

and charting were increased.

Time spent in well-child visits in the group setting was

significantly longer with the increased time spent in

counsel-ing. For sick visits there was no change in total time per visit

nor in activities within the visit. Pediatrics, 59:69-72, 1977, GROUP PRACTICE, SOLO PRACTICE, HEALTH CARE DELIVERY,

PHYSICIAN-PATIENT RELATIONSHIP.

The operation of office practice and the

utiliza-tion of the physician’s time in primary care relate closely to the nature and quality of delivered health services. It has been stated that fee-for-service physicians are likely to devote more time

to direct patient care than are prepaid

physi-cians,1 that salaried physicians are generally not aware of the method of payment of their patients,2 and that more authority is delegated to ancillary personnel in a prepaid group practice.3 Understandably, these studies involve compari-sons either of different physicians or different

patient populations. Few occasions arise for

examining the effects of a change in practice organization on the same physician’s activities

relating to the same patients. Therefore, when a

pediatrician (J.T.) decided to join a prepaid group practice as a full-time salaried staff member after

16 years in solo fee-for-service practice, a unique

opportunity presented itself to study the impact

of a group practice setting on the professional

behavior of one physician who had been

estab-lished firmly in solo practice. This paper reports

the results of a time-and-motion study of this

physician before and after joining the Medical

Care Group of Washington University. Although

the Medical Care Group is organized mainly on a

prepaid basis, in this study the pediatrician’s

professional activities involving patients in his fee-for-service solo practice are compared with

his activities involving those same patients who continued on a fee basis to seek his services in the

group practice. The method of payment for these

patients remained the same. However, the

physi-(Received December 29, 1975; revision accepted for publi-cation April 21, 1976.)

Supported by a grant from the Robert Wood Johnson

Foundation, Princeton, New Jersey.

ADDRESS FOR REPRINTS: (L.K.) Washington University

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70 CHANGE IN PRACTICE SETTING TABLE I

TISIE DISTRIBUTION PER HALF-DAY OF OBSERVATION

Time Solo’ Group’

________Th

Mean % Mean %

Hours Hours

Patient time

Direct (DPT)t 1.79 52.5 1.14 34.8

Related (PRT)* 0.41 12.0 0.51 15.5

Total (TVT) 2.20 64.5 1.66 50.6

Non-patient time

Paperwork 0.34 10.0 0.56 17.1

Administration and 0.22 6.5 0.30 9.1

staff communication

Telephone 0.40 11.7 0.36 11.0

Travel

_

0.11 3.2 0.12 3.7

Other 0.14 4.1 0.28 8.5

Total (NPT) 1.21 35.5 162 49.4

half-day 3.41 100.0 :3.28 100.0

‘SIIIS n3av not total exactly due to rounding.

tP < .001.

:I:P .05.

§P .01.

cian’s reimineration changed from receipt of fees

for services rendered in the solo setting to salary

in the group practice setting; payments from fee patients were paid to the Medical Care Group.

METHOD

A stopwatch study was conducted as described previously. ‘ Observations were niade during 16 half-day periods in the solo practice. J.T. was

oI)serVed again for ten half-days after 15 months

iii the group practice and again for six half-days after an additional 13 months in the new setting.

Physician activity’ was divided into three major categories: (1) direct patient time (DPT), which included all tinie spent in the presence of the patient; (2) patient-related time (PRT), which

included tinie spent on matters involving patients

seen that day but not in their presence; and (3)

non-patient time (NPT), the remainder of office

time. Total visit time (TVT) was the sum of DPT

and PRT. The subdivisions of all these categories

and precise definitions have been described uy’ Payment method, age, and reason for visit, i.e., whether for routine care (“well visit”) or for illness (“sick visit”) were noted for each

patient. Comparisons of physician activity were made for sick, well, and total fee patients.

There were niore patient visits per session in

the solo than in the group practice (13.9 vs. 9.6).

In order to determine what effect the difference

in patient load niay have had on physician

activ-ity, the mean time per patient visit was correlated with the number of patients scheduled per hour in

each setting.5 No significant relationship between

the two factors could be demonstrated.

THE SETTINGS

Physical facilities were similar for the two

settings. There ‘as additional available support personnel in the new setting. The oiil’ major procedural differences l)etween the two settings

were the use of the problem-oriented record and more printed instructional material in the group practice site. Relatively few of the patients the pediatrician saw in the group setting were neW to him; 78.8% of his patient load consisted of fee patients froni the solo practice who continued to seek pediatric care from him in the Medical Care

Group.

RESULTS

Table I shows the mean time distribution for the observation periods in both settings. Mean duration of the periods of observation were similar for the two settings. TVT was greater in the solo practice than in the group setting. The niajor difference was in less DPT in the salaried

group practice. PRT, primarily involving

chart-ing activity, was greater in the group setting. Physician activity involving fee patient visits in

the group practice were compared to those for the same cohort of patients seen previously in the solo setting (Table II). There was no difference in physician activity time between the two observa-tion periods in the group practice setting. The time spent per visit in the group practice was about the same as in the solo practice. PRT accounted for the slightly increased time in the group practice, mainly in charting, while total

DPT was not significantly different. However,

there was a decided difference in time distribu-tion of DPT. Iii the group practice, there was less

time spent iii history-taking and physical

exami-nation and niore time spent in counseling.

Differences in physician activity in the two settings are further identified when well visits are separated from sick visits. Results are shown in

Table II. Well to sick visit ratios were 39.5 to 60.5

in the solo practice and 36.1 to 63.9 in the group setting. For well visits, TVT was significantly longer iii the group setting than in the solo

setting; there was no change for sick visits.

Decreases in history-taking and physical

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DISCUSSION

TABLE II

TIME DISTRIBUTION BY REASON FOR VISIT AND PRACTICE

SETTING

‘Group 1 observations were taken 15 months and group 2

observations were taken 28 months after entry into the group

setting.

tSums may not total due to rounding.

:I:P .001.

§P .05.

tion and increases in PRT in the group setting occurred for both sick and well visits, but the major difference between well and sick visits was the increased counseling time for well visits only in the group setting.

The decision by a pediatrician to discontinue solo fee-for-service practice to join a prepaid group practice wherein he continued to see his

former patients on their established fee basis

provided an opportunity to observe the effect of the practice setting on his professional activity. Since this study involved only one physician, it

must be considered as a case report. Yet data showed that the change in activity as measured in

two

separate periods of observation was remark-ably consistent over a period of two years in the

group setting.

The physician’s half-day activities in the group setting show less time in the aggregate was spent in TVT, predominantly in DPT. However, the aggregate time spent in patient care in the group site was the result of fewer patients seen, not less time per patient; in fact, the mean time per visit

was longer in the group setting than in the solo

setting. The lower patient load was the result of a

small pediatric population in the newly devel-oping group practice. However, differences in patient load were of little relevance since there

was only a small negative correlation between mean time per patient and patients per hour in either setting. The differences in physician activity in the two settings were further validated by matching half-day periods of observation in which the patient load was essentially the same.

Fortuitously, it was possible to examine the

same population served in both settings since

many patients from the solo setting elected to continue receiving pediatric care from the pedi-atrician at the new setting; they continued as fee patients, not as enrollees in the prepaid practice. Because the enrollment of prepaid patients was still relatively small, the majority of the study physician’s patient load remained fee patients during this study period.

Although DPT per visit was the same in the

two settings, the time was apportioned

differ-ently. Less time was spent on history-taking and

physical examinations in the group practice and more time was devoted to counseling and expla-nation. Because there were more support services in the group setting, some routine history-taking and screening procedures were delegated to nonphysician personnel. The increase in time

Activity Practice Setting

(mean time in minutes)

Solo Total Group Group Group 1#{176} 2#{176}

All Visitst

No. of visits 223 1 19 75 44

DPT 7.6 7.0 7.0 7.3

History and physical 4.3 3.3 3.3 3.4

exam

Counseling 2.0 2.6 2.5 2.8

Other 1.3 1.1 1.1 1.1

PRT 1.8 2.9 2.9 2.8

Charting 1.4 2.2 2.3 2.2

Other 0.4 0.6 0.7 0.6

‘lyr 9.3 9.9 9.8 10.1

No. of visits

Well Vi.sitst

88 43 27 16

DPT 8.7 9.2 9.1 9.4

History and physical 5.8 4.7 4.7 4.8

exam

Counseling 1.9 3.5 3.5 3.5

Other 0.9 1.0 0.9 1.1

PRT 1.7 3.2 3.2 3.3

Charting 1.6 2.4 2.3 2.5

Other 0.1 0.8 0.8 0.8

TVT 10.4 12.4 12.4 12.6

No. of visits

Sick Visitst

135 76 48 28

DPT 6.4 5.8 5.7 6.3

History and physical 3.0 2.5 2.4 2.7

exam

Counseling 1.9 2.1 2.0 2.6

Other 1.5 1.2 1.2 1.1

PRT 1.8 2.8 2.8 2.5

Charting 1.4 2.2 2.2 2.1

Other 0.4 0.5 0.6 0.4

TVT 8.1 8.5 8.5 8.7

spent on counseling and explanation resulted in

part from procedural changes which placed

increased emphasis on patient education. Much

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72 CHANGE IN PRACTICE SETTING

group practice site which stimulated more

parent-physician discussion. Virtually all of this related to well-baby and well-child care which

explains the increased counseling time being

devoted to well-child visits and relates directly to

the modifications imposed by the practice orga-nization.

The increased time spent in PRT, mainly in

charting activities, can also be related specifically

to the practice setting. While a physician in solo

practice can maintain his records to satisfy his

own

needs for reference and information, in

group practice it is necessary to record

informa-tion in a way which can be understood by several

physicians. This requires more organization and

care in recording one’s observations. Further, the

pediatricians in the group setting use the

prob-lem-oriented record to facilitate use of a uniform

set of procedures in handling routine and

common problem visits. Although such a record

lends itself to quicker interpretation and shortens

the history-taking time of the physician for

subse-quent visits, it does indeed require greater time to maintain.

One or more of the components of the

organi-zational structure may have accounted for

modi-fications in the physician’s behavior. These might include the change to salaried status, working in

collaboration with other physicians, the increased

support services of ancillary personnel, or the

method of recording patient encounters. This

study does not identify specifically the extent to

which these factors apply; each might well have contributed.

Nonetheless, through the comparison of patients between the two settings, the popularly

held view that removing the financial incentive

for physicians might weaken their interest in patients was not supported by the findings here. However, observations of several physicians

tinder siniilar circumstances will be required

before the impact of a prepaid group practice on physician activity can be definitively

deter-mined.

REFERENCES

1. Mechanic D: The organization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings. Med Care

13:189, 1975.

2. Broida JH, Lerner M: Knowledge of patient’s method of

payment by physicians in a group practice. Public

Health Rep 90:113, 1975.

:3. Eisenberg J, Whitney A, Kahn L, Perkoff GT: Patterns

of pediatric practice b’ the same physicians in a prepaid and fee-for-service setting. Clin Pediatr

13:352, 1974.

4. Kahn L, Wirth P: The modification of pediatrician

activity following the addition of the pediatric

nurse practitioner to the ambulatory care setting: A

time and motion study. Pediatrics 55:700, 1975.

5. Lipscomb J, Scheffier RM: Impact of expanded-duty

assistants on cost and productivity in dental care delivery. Health Serv Res 10:14, 1975.

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1977;59;69

Pediatrics

Lawrence Kahn, Patricia Wirth and James K. Turner