“How many staffers should we have per doctor?” That’s a question I’m asked at almost every seminar I present. Of course, like many good consultants, I almost invariably respond “it depends.”

One of the factors that needs to be considered is what jobs we’re talking about — clinical or front office. It’s staffing in the clinical area that will do most to enhance a physician’s productivity, so that’s what we’ll focus on in this discussion.

Another thing to consider is specialty, since some specialists can get by with far fewer support staff than others.

But even with specialty clarified, the definitive answer can be a surprise to many. Most practices think they need to be lean and mean, yet all too often that means understaffing!

In fact, the more profitable practices generally have more staff per full-time equivalent (FTE) physician.

The following table is from “Performances and Practices of Successful Medical Groups: 2009 Report Based on 2008 Data” published by the Medical Group Management Association (MGMA). It demonstrates the consistently higher ratio of support staff to physicians in better performing practices. Note: the numbers presented here are for total FTEs, including both clinical and nonclinical support staff.

	Staff FTEs per FTE MDBetter Performers	Staff FTEs per FTE MDOther Practices	Medical revenue after operating and NPP cost per FTE MDBetter Performers	Medical revenue after operating and NPP cost per FTE MDOther Practices
Multispecialty	5.24	4.43	$321,894	$216,515
Orthopedic surgery	7.70	5.49	$642,572	$537,266
Cardiology	6.86	5.41	$675,977	$504,676
Primary Care — Single Specialties	4.56	3.50	$242,142	$136,479
Surgical — Single Specialties	5.95	3.54	$558,533	$445,618
Medicine — Single Specialties exc. General Med.	5.61	3.09	$550,185	$379,237

But you can’t focus myopically on the FTE count only! You have to understand the impact that head count has on operations.

For example, look at the key performance indicators (KPI) for orthopedic surgery when differentiated by practices that use paper medical records, electronic health records, or a hybrid solution.

The data for the 2009 median per FTE physician displayed in the following table demonstrates that the practices using an EHR have a higher ratio of support staff per FTE physician than other practices while generating a greater percentage of medical revenue after operating cost — the bottom line!

KPI	Paper records/charts	EHR	Hybrid
Total support staff FTEs	5.25	5.44	5.10
Total RVUs	21,579	25,063	23,098
Patients	1,708	1,823	1,758
Total operating cost (% of medical revenue)	47.93%	46.65%	48.35%
Total medical revenue after operating cost (% of medical revenue)	52.07%	53.35%	51.98%
Days gross fee-for-service charges in A/R	45.24	37.19	35.79

Staffing and productivity is also dependent upon facility resources.

Like many physicians, those in your practice probably work out of three exam rooms. Consider a lean staffing model in such a situation: The physician has one nurse assigned for the day, and that nurse is responsible for all the clinical support throughout the patient flow.

That may seem reasonable until you actually observe the flow. For example, let’s take a urology hallway, one room has a female patient ready for an exam, the nurse is rooming another patient, and the physician has just exited his third exam room.

What happens next? Nothing!

The physician cannot perform the exam on the female patient because he needs a chaperone and his nurse is busy with another patient intake.

So the physician waits, idle, and frustrated. Ditto the patient. The physician’s time cannot be inventoried; the wait time cannot be billed; and the patient’s good will (and referrals) are going out the window.

If the physician was additionally supported by a float nurse, or shared a nurse with another physician, downtime would be minimized, patient wait time would be minimized, and the nurse who’s doing the intake — who knows the doctor is getting annoyed — will be less frazzled and will get more complete information.

So, more often than not — and certainly in the lean model above — I’d say “get fatter!” Add another medical assistant to the head count (approximately $32,000 annual salary and benefits) and generate more revenue (approximately $46,000 net revenue for two additional patients per session).

Maybe the real question is not how many FTEs do you need, but how much medical revenue can you generate and what number and kind of employees will you need to get it?

Rosemarie Nelson is a principal with the MGMA Health Care Consulting Group.

Originally published in MedPage Today. Visit MedPageToday.com for more practice management news.