Abstract
Underinvestment in primary care and erosion of the primary care physician workforce are resulting in patients across the US experiencing growing difficulty in obtaining access to primary care. Compounding this access problem, we find that the average patient panel size among US family physicians may have decreased by 25% over the past decade (2013 to 2022). Reversing the decline in access to primary care in the face of decreasing panel sizes requires both better supporting family physicians to manage larger panels, such as by expanding primary care teams, and substantially increasing the supply of family physicians.
Inadequate investment in primary care (PC) financing and workforce development has led to well-documented declines in the proportion of Americans with a usual source of primary care and increasing difficulties among those with a regular source of care to get timely appointments.1,2 The decreasing supply of primary care physicians (PCPs) per capita in many regions contributes to deteriorating access to PC.3 Less is known about additional factors that may affect PC capacity, such as possible changes in the number of patients cared for by each physician (that is, patient panel size). A variety of countervailing currents may be influencing Family Physician panel sizes, such as organizational pressures on employed physicians to increase panels, and the demands of increasing patient complexity, expectations to deliver greater value, and rising burnout and shifting clinician work-life preferences putting downward pressure on panel size, with the most extreme example being concierge practices with very small panels.4 We used self-reported data from practicing Family Physicians on their estimated panel size, collected on the American Board of Family Medicine Continuing Certification Questionnaire from 2013 to 2022. The questionnaire is a mandatory component of examination registration, resulting in a 100% response rate and a partial annual census that captures all diplomates once every 10 years (Figure 1).
Trends in Reported Family Physician Panel Size, 2013–2022.
Trends in Reported Family Physician Panel Size, 2013 to 2022
Among the 55,605 US-based Family Physicians completing the survey between 2013 to 2022 who reported providing ambulatory continuity care (imputed before 2016 based on other available variables), 29,463 (53%) were able to estimate their panel size. Self-reported mean panel size steadily declined from a high of 2,362 in 2013 to a low of 1,760 in 2021—a 25% decrease. We conducted sensitivity analyses using linear regression to test whether a reduction over time in self-reported hours-worked might explain this panel size trend, confirming that decreased work hours accounted for only a small portion of the decline. Although there may be imprecision in self-reported data on panel size, it is unlikely that the observed dramatic, decade-long trend of steadily decreasing panel size is due to systematic bias in reporting that changes over time in 1 direction. These reported decreases in panel size may be compounding the decline in overall supply of PCPs to reduce the effective capacity of the PCP workforce, contributing to worsening PC access. Further investigation is needed to better understand the factors driving declines in panel size. The many potential factors may include task-shifting of less complex patients and visits to urgent care, Nurse Practitioner & Physician Assistant team members that increase overall physician panel complexity and time demands, emphasis on value-based payment and reporting, burnout, hours worked, and changing physician demographics. There is critical need to further study the forces driving many Family Physicians toward smaller panels, to advance our understanding of optimal panel sizes amid an increasingly consolidated PC delivery system, and to support interventions such as robust PC teams, that may make it more feasible to manage larger panels.5,6 A sustained trend of decreasing panel size will make it even more imperative for the US to invest more in substantial increases in PCP supply to achieve the goal of equitable access to high-quality primary care highlighted by the National Academies of Science, Engineering and Medicine as the foundation of an effective health care system.7
Notes
See Related Commentary on Page 502.
This article was externally peer reviewed.
Conflict of interest: None.
Funding: None.
All authors listed are qualified for authorship and all who are qualified to be authors are listed as authors on the byline.
To see this article online, please go to: http://jabfm.org/content/37/3/504.full.
- Received for publication November 19, 2023.
- Revision received January 17, 2024.
- Accepted for publication January 22, 2024.
