Though time spent on AOVs is generally not reimbursed, primary care general internists spent significant time performing AOVs, much of which they perceived to substitute for visits that would otherwise have occurred. Policies supporting physician and staff time spent on AOVs may reduce health care costs, save time for patients and physicians, and improve care coordination.

PURPOSEIn the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges. METHODSWe identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers-leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes. RESULTSThe groups' physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale.CONCLUSIONS Large, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.

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Objectives. To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease. Data Sources. Data were extracted from electronic health records. Study Design. Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and lowdensity lipoprotein measurement and control. Principal Findings. Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality. Conclusions. A shared, low-intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.

Authors reply:-We thank Dr. Schattner for his response to our article. We agree that, in addition to the time constraints placed on primary care physicians due to patient care activities outside of office visits (AOVs), physicians also face significant time constraints in providing comprehensive care to patients during office visits 1,2 . The proposed time-to-task ratio may be a useful way of studying time allocation to essential components of patient care both in and outside of office visits. The time spent performing AOVs is separate but related to in-visit care time, both of which are major parts of the physician workday. Our study found that the majority of AOVs were "non-visit specific," meaning that they did not pertain to patients seen for an office visit on the study day. We found that general internists perceived that a substantial portion of these non-visit-specific AOVs substituted for office visits, with each performed in less than a quarter of the time that a visit required. If policies were realigned to encourage substitution of non-visit-based care encounters for visit-based care when appropriate, more time might be freed up for physicians to spend in fewer but longer office visits with the patients that require face-to-face care encounters.