In addition to empanelment of sub-populations based on health needs, there are three general methods of empanelment: geographic, voluntary, and insurance-based (though other forms can exist, including empanelment to private provider groups). These methods are not mutually exclusive and can occasionally co-exist, such as in Turkey. A brief case study on Turkey is described in “What others have done”. Countries may also choose to begin empanelment by focusing on target groups with specific health needs, as discussed above. However, this should be supplemental to efforts to achieve widespread empanelment using one or a combination of these three methods.
Geographic empanelment uses pre-existing geographic or municipal boundaries to assign individuals to a provider or care team. While this is the simplest method of empanelment and supports strong geographic access to PHC, it may be perceived as limiting the autonomy of patients to choose their providers and subsequently decrease patient trust in the system. Geographic empanelment is also dependent on PHC services provided by a governmental entity, and low rates of private PHC use.
Voluntary empanelment prioritizes patient autonomy and allows patients to choose their provider or care team.2 It is often more adaptable to mixed private-public PHC markets. The final method of empanelment is insurance-based, which may be feasible if providers and patients are linked to a specific insurance scheme, and a care team only sees or is responsible for particular enrollees in an insurance scheme. In these cases, the insurer may assign the provider or care team. Insurance-based empanelment can work in a variety of public, private, or mixed systems, but it is dependent on a formal insurance entity and broad universal health coverage by that entity or mix of entities.
Stakeholders may ask some of the following questions to help identify which method would be best in a given context:
- Are there sufficient numbers of providers within a geographic area to give patients a choice of providers while also ensuring that they are geographically accessible?
- Are there certain insurance schemes in place in the region such that providers’ workload or logistical requirements would be significantly more efficient if they only provided care to enrollees?
- Are there any insurance schemes in place that already have an informal or formal empanelment systems but are not at a national level?
- Are there sufficient information systems in place to track patients if they were given the choice to switch providers? Are they capable of tracking a panel for facility and outreach care?
After establishing the appropriate method for assigning panels, stakeholders must determine how many individuals or families should be included in each panel. This requires consideration of patient-provider supply and demand to ensure that providers are not overburdened and can effectively care for all people within their panel. However, the size of a panel and the specific considerations involved in determining panel size will differ based on local context. Population profiles and needs should be considered to ensure that care teams are not overburdened by caseload or by substantial health needs. In general, stakeholders should consider the number and capabilities of the providers within a care team, the time and human resources needed to fulfill various activities undertaken by the team (i.e. education, community outreach, curative care, preventive care), and any data on the specific needs of the population that may influence the degree of care they require. Once patients are linked to a provider or care team, a patient’s first point of contact has been clarified and should be deliberately reinforced during subsequent visits to the facility and during community-based care.
An implementation guide developed by the Safety Net Medical Home Initiative in the United States highlights various considerations for implementers when instituting empanelment. Although these guides were developed for a high-income setting, they provide relevant information on the sequential steps needed to empanel a population and tools that would facilitate decisions regarding appropriate panel sizes.
Recognizing that empanelment relies upon data on the relevant populations, the absence of a civil registration and vital statistics (CRVS) system may present a bottleneck to the establishment of patient panels. Without a CRVS system, stakeholders seeking to empanel their population may have to perform a census which is timely, costly, and often not within the scope of providers’ training. More information on CRVS systems is provided by the WHO and the Health Data Collaborative.