The Great Practice Makeover: How Much Is Enough?

Gastroenterologist Dordaneh Maleki has created a fulfilling balance for herself by working three days a week at a local hospital and seeing patients in her own practice two days a week. As far as she’s concerned, what’s not in balance is the amount of staff time required to maintain that small private office.

Regardless of the number of staff on the rolls, the human element is probably the trickiest aspect of any practice’s overhead. Physicians often ask us for a benchmark that will tell them how productive their employees are - or should be. How much work is it reasonable to expect each person to do?

A starting point

According to the MGMA’s “Cost Survey for Single-Specialty Practices: 2006 Report Based on 2005 Data,” the median total number of support staff per full-time-equivalent (FTE) physician in GI practice is 4.53 (divided among business operations, front office, and clinical and ancillary support). Maleki puts in two 10-hour days at her practice - about half time - so based on the MGMA median, she could expect to have about 2.25 full-time support staffers. Michele DeRose, who handles the bulk of Maleki’s office work, puts in 35 hours a week, and a medical assistant is there 20 hours a week. Maleki has also been experimenting with bringing in an additional person for a few hours to handle insurance precertifications, which have proven time-consuming for DeRose. Not counting the latter, this works out to just 1.38 FTE staff members.

In a specialty practice that naturally depends heavily on referrals and draws a relatively large base of managed-care patients, administrative costs accrue even when the physician isn’t in the office. A routine colonoscopy might take only half an hour from start to finish, but the attendant background and follow-up work of certifications, referrals, and payment tracking could amount to several hours per procedure.

Practices with more staff members per physician tend to perform better financially than those operating with skeleton crews. Perhaps counterintuitive but true nonetheless, according to industry research. Staffing ratios have fluctuated a bit over the past few years, but overall levels haven’t changed much; what has changed is the complexity of medical practice during that same time frame, with financial pressures forcing many practices to downsize. More staff isn’t always better, of course - the “correct” level depends largely upon the physician’s work style and expectations for the practice.

Maleki could also use relative value units (RVUs) to get an idea of how she compares with her peers in terms of productivity, but the point is to avoid getting hung up on statistics like these in the first place. What matters more is whether the practice is providing what she needs in terms of professional and financial satisfaction.

Meeting of the minds

Before she can determine whether she’s over- or under-staffed, Maleki must get a better idea of the tasks that are currently filling her employees’ days. Not surprisingly, there’s a disconnect between physician and staff thoughts on the practice’s workload. In general terms, says Maleki, “it just wasn’t clear to me how two days in a practice could create a situation in which there would be too much work for two people working 35 and 20 hours.”

But filling those hours is a catalogue of tasks the doctor may not even know are happening; when a process is running smoothly, it tends to go unnoticed. In addition to those precertifications, DeRose lists documentation requirements and reminder calls, noting, “Sometimes there’s a lot of repetitive work being done, but you’ve got to follow up on those things.” She also spends time reviewing new policies and other payer communications, and rightly considers preparing charts for use in the off-site procedure suite to be an important job worthy of her extra attention.

Maleki thinks ringing phones are a distraction for the staff, and on this point they agree. When asked what would make her days go better, DeRose says simply, “Somebody to answer the phone once in a while [I’m] in the middle of a task.” She worries that interruptions during chart prep could translate into missing pieces of information for Maleki in the procedure suite. This provides an important clue about DeRose’s preferred work style, and lots of physicians might gain valuable insight from such hints.

According to management consultant Owen Dahl, “Eighty-five percent of the time, practice problems are process problems - not people problems.” The phones represent a distraction, to be sure, but does Maleki want lots of calls going to voice mail during business hours? Are staff members aware of their individual priorities? As a first step, Maleki should sit down with her employees and create written job descriptions for each of them. In addition to prioritizing tasks related to each person’s role, she should also list the tasks to be completed during inevitable chunks of downtime. It may not be important to Maleki to have the waiting room trash can emptied twice a day, but a neat-freak receptionist might be doing just that.

Maleki will feel better about laying out cash for salaries if she has a clearer picture of exactly where it’s going. Once her employees’ job responsibilities have been clearly articulated, it would be smart to meet regularly to continue to head off guessing games about what’s occupying staff time. Maleki should aim to consider results, rather than raw hours logged, as the barometer for individual success. “The doctors don’t have time to sit with the MAs who do the precerts and say, ‘Well, this is the diagnosis, and these are the symptoms,’” acknowledges DeRose. However, “I’ve gotten smarter in doing [the precertifications], so I don’t get many denials.”

Learning on the fly like this, though, is a slow process that involves trial and error. A long-term agenda for formalized training would minimize some of the time Maleki’s staff spends trying to make sense of changing payer rules. DeRose seems surprised, for example, that payers ask for diagnosis and procedure codes, which speaks to the lack of training she’s received specific to her job. Here again, doctors should pay attention to potential physician-staff disconnects. Think about the last lecture you attended: Did the subject matter relate to something you’d use in your daily practice? If not, you probably had to fight to keep your chin off your chest, no matter how dynamic the speaker was. It’s much easier to teach someone what she needs to know than to teach her what you think she needs to know.

Looking ahead

Back to that pie-in-the-sky bit about expectations: Satisfied physicians always have a vision for what they want from their practices and a long-term plan for getting there.

Maleki would like to do more cancer screening and less chronic care, so she’ll need to implement a marketing plan that targets the type of patients she wants to attract to reach her goal. But Maleki lives an hour away from her practice and therefore isn’t necessarily out and about in the community. During her job description discussions with her staff, it would make sense for Maleki to involve her employees in her marketing plans. Maleki will have to give clear direction as to how she wants her practice represented, but she’ll most likely end up with more satisfied employees if they feel necessary to the practice’s growth.

Finally, Maleki shouldn’t be overly hard on herself. Her practice has been open for only a short time, and a learning curve for both her and her staff is unavoidable. In fact, in order to allow the new business to respond effectively to changing preferences and other personal considerations - not to mention continuous payer and policy updates - the practice’s evolution should never end.

Laurie Hyland Robertson is managing editor for Med-IQ, the parent company of Physicians Practice. She has been in the medical publishing field for nearly 10 years, working editorially on both clinical and management topics. She can be reached at lrobertson@med-iq.com.
This article originally appeared in the May 2007 issue of Physicians Practice.