What is the right number of clinic appointments?: Visit frequency and the accountable care organization.

In the United States, patients make 1 billion visits to physicians’ offices every year.1 These visits are the principal way patients access health care and are the building blocks of the patient-physician relationship, at an estimated annualcostofnearly$600billion.2 Paymentsystemchanges are fueling growth in alternatives to the traditional office visit, raising the question of how often patients should visit and interact with their clinicians. The large variation in practice, the paucity of research on the subject, and the emergence of accountable care organizations (ACOs), in which health systems uphold quality standards and assume a share of financial risk for patient costs, present new impetus to examine this question from an individual and a population health perspective. Physicians tend to schedule routine health visits for adults every 3, 6, or 12 months, but this frequency does not always satisfy the complexity of care needs. Little is known about the optimal follow-up interval—whether defined by health outcomes, care utilization, or clinician or patient experience.3 Despite relatively low visit rates by international comparisons, some limited studies suggest that patients may need fewer visits than physicians may think are necessary.3 Nonetheless, consensus guidelines for adult visits tend to offer wide ranges of follow-up times or avoid making recommendations because of concerns about patient and disease heterogeneity and lack of evidence. This ambiguity, coupled with the subjective yet critical task of building the patient-physician relationship, differing patient expectations, and concern about litigation, has led to wide variation in how frequently physicians schedule follow-up visits with their patients.4 In a study using clinical vignettes, Cutler et al5 found that 23% of 500 responding cardiologists recommended follow-up intervals for patients with stable angina that were shorter than the 4to 12-month range advised by 2005 guidelines. In 2013, at Massachusetts General Hospital, each physician (n=1594) saw his or her outpatients an average of 1 to 24 times, averaging a visit every 8.4 months, whereas nearly 20% of physicians (n=306) saw patients every 6 months or more on average. When generalists and specialists co-manage patients, there is variation in which physicians perform which tasks and in turn, in the frequency of visits. Underlying this variation is the traditional fee-for-service payment model that rewards individual clinicians and health systems for more frequent visits and limits alternative touch points customized to individual patients’ needs such as telephone text messages or home visits. The ACO, along with other forms of bundled payment, is an increasingly prevalent model designed in part to counter the incentive for excess. Since the Affordable Care Act mandated the creation of ACOs for Medicare beneficiaries in 2010, more than 600 public and private versions of the ACO have been created covering more than 18 million patients nationally.6 The success of ACOs depends on their ability to improve care and serve more patients within the constraints of their current infrastructures, so they benefit financially from the “right” number of visits—the lowest number that maintains good outcomes while preventing avoidable hospitalizations. Excess visits are costly in their own right by virtue of patient time and transportation costs, as well as through the tests and treatments that accompany them. In one study, one-third of 30 000 patients at Veterans Affairs hospitals underwent lipid tests unsupported by guidelines, attributed in part to more frequent visits to primary care practitioners.7 Fewer follow-up visits for marginal indications would create capacity for more acute care visits, complex care, and new patients. By a conservative estimate, cost savings may also be substantial. For instance, based on information from the 2014 Medical Expenditure Panel Survey and from the Partners HealthCare ACO, and assuming a median per-visit cost of $286, it is possible that among patients who make 3 or more visits per year (36% of patients), reducing visits by one-quarter of a visit each year would save $1.9 million (0.24% of per-member, per-year cost) among Partners HealthCare’s Medicare ACO patients and $470 million among all ACO patients nationally. Annual reduction by 1 visit would save $7.6 million (1.0%) at Partners HealthCare and $1.9 billion nationally.2 So how might physicians and health care organizations work toward the optimal number of visits? The solution involves analysis of current practice, coordination among clinicians, and alternatives to traditional visits. To start, ACOs could use scheduling data to examine variation in clinician-specific follow-up rates. More ambitiously, they could study factors that drive visit rates and associations with clinical outcomes. Clinicians could use decision support to operationalize existing guidelines, then create and implement new ones based on consensus-driven clinical goals. Visit interval guidance could be modified in real time based on clinical inputs such as medication changes and patient-reported outcomes to reflect true need. For example, a patient beginning therapy with a diuretic for heart failure may be scheduled to have a return visit in 1 month to assess medication tolerance and to check electrolytes and renal function. Future visit VIEWPOINT