Right-sizing your technical department’s staffing levels

Understanding practice labor costs can help physicians reach optimal technical staffing efficiency.

“I love being an ophthalmologist, but it means you have to deal with a lot of people. Patients. Partners. Staff. Vendors. It sure would be nice if I could do my work at our lake house. I’d sit down by the water in the morning, with a nice cup of coffee. The FedEx guy would swing by twice a day with a bag of eyes for me to fix. I wouldn’t have to deal with all the people.”

– Anonymous ophthalmologist

Most ophthalmologists — even the scientists and engineers at heart — get an important measure of career satisfaction from all of the people in their lives. But enough is enough. A surfeit of patients is fine, and as fees constrict, a necessity. But we are moving swiftly past an era when excess support staff can be tolerated.

John B. Pinto

The most expensive practice cost is lay staffing, at an average fully burdened cost today of about $45,000 per year — each. The most expensive segment of your lay team is your technicians, inclusive of workup techs, scribes and chair-side assistants, special testing staff, back-office runners, and even those clerical staff who may be drafted to room patients or supervise the occasional visual field test.

This month’s back-to-basics column will help you assess your own tech staffing levels.

Calculating productivity

To be able to compare one practice with another as we calculate the labor productivity of your technical staff, we want to be sure to exclude any time they may be spending on surgical counseling, helping out at the front desk or assisting with transcription. You should also omit any time they may spend on research studies or community outreach and screenings.

Here are some starter parameters:

• Imagine you have a solo general ophthalmology practice.
• You employ a total of three techs, each working an average of 36 hours per week.
• You see 550 patient visits* per month (a reasonable baseline goal in today’s world).

*A note on patient visits: A patient visit, by convention, is a patient seen by a provider (an MD, DO or OD professional). This includes compensated visits as well as uncompensated postop visits, when seen by a provider, and excludes patients seen by a technician only, such as for a pressure check or visual field exam. This metric omits surgical encounters. As a matter of routine, it does not count those few patients per month who may drop in for a minor clinic procedure with the doctor, unless they also receive an exam on that day, nor does it count the occasional patient seen in the ER or hospital.

The math is simple:

• By convention, we need to count “total compensated work hours,” whether regular time, overtime, paid sick leave or vacation time. Typically, a full-time 40-hour-per-week staffer will be paid for 2,080 hours of work per year (40 hours × 52 weeks), or an average of 173 hours per month.
• In this sample practice, each tech is a 0.9 full-time-equivalent, or FTE. The three techs taken together add up to 2.7 FTEs.
• Multiplying 2.7 FTEs by 173 nominal hours in a month yields a total of 467 tech hours in the month.
• Dividing 467 hours by 550 visits boils down to 0.85 tech payroll hours per patient visit, or about 51 minutes.

Assessing norms

What’s normal? In this sample general practice, liberal norms could be everything from 0.6 to 1.0 tech hour per patient visit.

It would be reasonable to be at the low end of this wide range if you liked to do relatively more of the patient workup yourself or had a static practice and were nearing retirement, with fewer new patients to work up and a desire to spare costs and top up your retirement savings.

At the other extreme, it might be reasonable to be at the high end of this normal range if as a generalist you dislike routine workup chores and choose to delegate as much of the exam as possible. Here are some other potential pretexts for having a somewhat heavier tech staff:

• You have a young crew of only half-trained techs who are not yet functioning fully.
• Your head tech is new and not yet managing the floor very efficiently; you and she have decided to keep things “fat” until she settles in.
• You have a high surgical density(as is common in a co-management-based practice) and a significant percentage of your patients are surgical workups.
• You have an aggressive approach to testing and want patients to receive all such testing during a single visit.
• You put a premium on concierge-level patient care and never want a patient left waiting for lack of a tech.
• You have a number of satellite offices, and techs travel routinely to several office locations throughout the week, resulting in some efficiency being lost to travel time.

The influence of subspecialty care

Tech levels needed in your practice will vary markedly based on your subspecialty. With lower patient volumes, pediatric and oculoplastic subspecialists will commonly cluster together at about 0.6 tech hours per visit. Glaucoma subspecialists, especially those striving for higher production levels, are in line with generalists: about 0.8 to 0.9 hours per visit. Pure refractive surgeons will typically need 1.1 tech hours per patient visit to accommodate the extensive workup demands of this subspecialty.

Retinal subspecialists need the most back-office support, with 1.3 tech hours per patient visit. This is driven by older, sicker, slower-moving patients and by the extensive testing and treatment regimens in this subspecialty. Given the profoundly stronger economic productivity present in retina, the extra labor costs are rarely of any consequence. Indeed, retinologists can typically get by spending around 25% of their cash flow on the full complement of lay labor, while generalists commonly spend 28% to 32%.

Rising tech coverage levels

As a general observation, tech coverage levels in client general/anterior segment settings have been creeping upward with three factors: the rising number of visits seen in a day, the addition of special testing and the increased use of scribes (driven in turn by the shift to electronic health records).

If you only see 400 visits per month, you can handle more of your own workups, and you can probably get by fine with 0.6 to 0.7 tech hours per visit. As your monthly load grows to 500+ visits, you are likely to delegate more care and need proportionately more coverage. In selected “hyper-volumetric” settings — some general ophthalmologists are now stretching to 800+ visits for one doctor in a month — even more patient care and communication are delegated.

The addition of special testing, and particularly the proliferation of OCT testing, now has the average client practice staffing at a level of 0.9 tech payroll hours per visit to be able to fit in all of the extra services and not run behind. Indeed, when I visit a practice and see lower levels of testing utilization when compared with peers, the top driver is rarely physician circumspection or conservatism, but rather a lack of support staff, leading providers to simply say, “Well, we’re kind of backed up today. Let’s just get that test the next time you’re here in 6 months.”

The increased use of chair-side scribe-assistants is also escalating tech coverage levels. Two generations ago, vanguard doctors would use an assistant to room patients and perhaps take a basic history. Back then, the entire chart note, often on 3” × 5” index cards, would proclaim, “Patient doing better. See in 6 months.” Medical records diligence has expanded steadily since then and recently exploded with the galloping adoption of electronic health records.

Striking a balance

At the same time that we are trying to rationalize down labor costs, remember that ophthalmology is a largely fixed-cost profession. At typical net revenue yields per patient encounter, adding another tech is more than paid for by seeing just two additional patients per day. If you are not scheduling a backlog of patients because of a lack of technical support, you should be adding, not subtracting, tech payroll hours.

Remember that it is your practice, and you get to create your own environment. Some surgeons prefer a small, crack team of highly experienced and highly compensated techs. Others prefer to focus on raw head counts and would rather employ a large number of low- to mid-level assistants. Fifteen techs at $25 per hour cost the same amount as 25 techs at $15 per hour (at least before adding in benefits costs for the extra FTEs).

You may encounter an efficiency problem when you compress your clinic schedule into a few, intense hours each week while paying for the same number of technical staff hours every day. This feast-or-famine approach is not only tough on the economics of the practice — especially if you staff for peak patient hours — but can also harm morale and frustrate providers and patients. You have two solutions to apply: either spread patients out more evenly through the week, which can also result in more efficient facility utilization, or keep the intense sessions, sending staff home during downtimes.

Interestingly, technical staffing efficiency does not increase with practice size. Indeed, if you are not cautious, doctors in a large group practice can start competing with each other to build their own staff empires. To overcome this, some group practices directly charge each owner for their technical support staff. When this transition is made, overstaffed departments become leaner almost overnight as each surgeon begins to rationally meter their personal needs rather than build an empire.

Now is the time to develop a more robust understanding of practice labor costs. Every expected trend for eye care — as demand soars and MD cohorts shrink — will lead to a continued substitution of labor. It may be hard to fathom today, but the year will come when paraprofessionals (and computers) will not only room and work up a patient for you, but will also generate a suggested diagnosis, course of treatment and return interval for you to approve or revise. It’s coming fast. Don’t blink.

• John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. He is the author of John Pinto’s Little Green Book of Ophthalmology; Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement; Cash Flow: The Practical Art of Earning More From Your Ophthalmology Practice; The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees; The Women of Ophthalmology; and his new book, Legal Issues in Ophthalmology: A Review for Surgeons and Administrators. He can be reached at 619-223-2233; e-mail: pintoinc@aol.com; website: www.pintoinc.com.