Calculate your ideal patient load: How to strike the correct balance

Groups or individual doctors in a group with too large -- or too small -- panels may represent a serious threat to a practice's health. So how do you figure out the right size?

By — Posted May 12, 2008

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Most doctors are well aware of the problems related to having too few patients: There are just not enough time slots filled each day to generate needed revenue. And they are aware of problems related to having too many patients: There is just not enough time each day to take care of patients and administrative work without feeling harried.

But solving the problem is not just about scheduling. Solving the problem also might be about analyzing the patients in your panel. Calculating whether your panel is the right size involves not only looking at the number of patients compared with the number of doctors but also looking at other factors.

For example, how much time does each individual patient need (say, a chronic care case compared with a checkup of an otherwise healthy person)? What is the optimal number of visits per day that the practice wants? How many visits per patient do you expect -- or seek?

In a multiphysician practice, there also is the question of how many patients are assigned uniquely to each individual doctor, and whether you plan to have an equal panel size for each physician or distribute patients unevenly depending on past relationships or other factors.

Because practice styles, work preferences, patient demographics and other issues vary among groups, comparing one practice to another is not always helpful. "There are plenty of benchmarks out there. But it's very hard to know if you're really comparing apples to apples," said Greg Broffman, MD, a pediatrician and, before he retired last year, the medical director of Lifetime Health Medical Group in Buffalo, N.Y.

So rather than comparing one group to another, experts say it is better to find the best panel size for your own practice.

Assessing the problem

The first step to solving the panel-size problem is to determine if panel size is really the issue, and, if it is, to pinpoint it to the specific doctor or doctors or to the group as a whole. And if your practice employs physician extenders, you need to take those persons into account.

Many consultants say that before going though the somewhat arduous process of right-sizing panels, physicians should try to rule out other possible causes of overwork. Says Kenneth T. Hertz, a principal with the MGMA Health Care Consulting Group, "As in medicine, you want to start with less aggressive remedies. Sometimes just adding another medical assistant or making a change in patient flow can solve the problem." He adds that even if the group eventually has to move on to making changes to panel size, work in improving the functions in the group is never wasted.

If the less aggressive remedies don't work, experts say, then it's time to look at panel size.

Groups have to determine if the issue is the entire group's panel or the panel of individual doctors. Catherine Tantau, RN, with the Tantau & Associates consultancy in Chicago Park, Calif., says that one sign that a practice with a large backlog is actually in equilibrium in terms of panel size is that the backlog isn't getting any bigger.

"If you have a chronic backlog but it's the same backlog, there's an issue with how you schedule appointments, or with the panel size of individual doctors, not necessarily with the group's panel size," she says. Tantau specializes in helping practices move to same-day access, and repairing panel size problems is often her first step.

Tantau says that if the entire group's demand, as opposed to the demand on only some of its doctors, is actually greater than its supply of appointment slots, "the group has a disastrous problem which will become obvious."

More commonly, individual doctors in the group have wrong-sized panels. This problem cannot be confined to an affected doctor or doctors because other clinicians in the group will have to fill in. "If one doctor in my group takes on too many patients, what he or she is really doing is giving me more patients," Dr. Broffman says.

Groups can check their current panel size by counting the number of unique patients they have seen over a fixed period, usually the previous 12 to 18 months. Experts suggest determining the group's baseline panel size by taking those unique patient visits and dividing them by the number of full-time equivalent clinicians. For example, a doctor who spends 25% of his or her time doing administrative work would be considered a .75 FTE.

Then it gets more complicated.

Determining a single doctor's panel size is not always as easy as one might expect, Dr. Broffman says. Even his 45-physician group that was in a heavily managed care environment, where insurers require each patient to be assigned to a single primary care physician, the practice didn't have all patients matched with the right doctor in the computer.

"A patient may have Dr. X listed as her [primary care physician] while in reality she more often sees Dr. Y," Dr. Broffman says.

In many groups, the situation is much worse: The practice keeps absolutely no record of each patient's primary care physician. The receptionist relies on the patient to indicate the doctor the patient wants to see.

Groups that do not have a panel of record assigned to each doctor should create one using the number of times each patient saw each doctor -- and extender, if that patient did not see a doctor -- over the same period used to calculate the group's panel size as a whole.

Experts say that once you've established the current panel size, you then can determine the panel size you might want.

Getting the right number

There are numerous techniques and programs available to help compute the ideal panel size.

For example, Linda Green, PhD, and Sergei V. Savin, PhD, professors at Columbia Business School with backgrounds in operations management, created a Microsoft Excel program they call Rightsizer 1.0. It considers factors such as the amount of time off doctors want and the amount of overtime they're willing to put in, how many patients they are able to see per day and other issues affecting panel size. Contact Dr. Savin via e-mail([email protected]" target="_blank">link), and he says he will send the tool to any doctor who requests it.

Among other issues to consider in determining the right panel size is demographics. Who sees the most children? The most women? The most new patients? The most chronic care patients?

If, say, the group determines that children up to age 2 visit the group 1.3 times the overall average, you can refigure all doctors' panels considering children in that age range as 1.3 patients.

After groups determine the baseline, they need to find out how each doctor's individual panel compares with baseline.

Once the group's baseline and each doctor's panel have been determined, it will be easy to see which clinicians' panels may be too large or too small (always keeping in mind the percentage of time the doctor devotes to patient care.)

If a doctor's panel is too large, Tantau suggests a number of "soft" techniques, which include closing the panel to new patients, having doctors with too many patients write a letter to their panel explaining the situation, and introducing other doctors into the group (without explicitly requesting that patients move to another doctor); or avoiding giving that doctor any spillover patients from other doctors in the group.

In more drastic cases, groups may have to resort to the harder approach of moving some patients to another doctor.

Dr. Broffman agrees that this approach may be necessary in some cases, but he says it should be used only as a last resort. "Patients do not like to feel their choice of doctor has been taken from them," he says.

Doctors whose panels are too small represent another problem.

Remediation would take the form of trying to help the doctor become more productive. But experts acknowledge that doctors have diverse practice styles.

Says Tantau: "I would never tell a doctor how [to] practice medicine. But if a doctor can only see, for example, 70% of the number of patients other doctors in the group see, the group may well consider [that doctor] a 70% full-time equivalent, possibly even when determining compensation."

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Calculating a panel

Two Columbia Business School professors, Linda Green, PhD, and Sergei V. Savin, PhD, came up with a simple program that can help physicians determine the optimal number of patients in their panel. It is freely available from Dr. Savin by e-mail (link).

Here is an example of how it works:

Category Input
Average weekly number of patient visits 70
Current panel size 2,500
Desired number of appointments per day 20
Average number of days per week seeing patients 5
Out-of-office time (days per year) 155
Desired maximum overtime frequency (40% equals twice per week, 20% equals once per week, 10% equals twice per month, 5% equals once per month) 20%

Note: Under the program's calculation (which isn't explained -- you hit CTRL plus A to get the number), the optimal panel size for this physician would be 2,392. This result is based on the assumption that a physician is using a scheduling system heavy on same-day appointments, with the average appointment utilization rate at 83%.

Source: Sergei V. Savin, PhD, Columbia business school

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6 steps to your right panel size

1. Identify the current size. Count how many patients visited your practice over a fixed period, such as the last 12 or 18 months. Count each patient only once, regardless of the number of visits.

2. Estimate the daily visit rate. Count total visits made over that period and divide by the number of patients.

3. Set daily appointment slots. Determine your ideal number of daily appointments. For example, how many patients do you need to see each day to be financially healthy, or how many can you see within the hours you want to be at the office?

4. Calculate the current overflow frequency. How often do you run late?

5. Set the target overflow frequency. This could be zero, or you could set a target based on expected number of no-shows or the daily appointment mix.

6. Compute the panel size based on the target flow. The target flow is the number of patients you wish to see each day. This can be complicated to compute, because every appointment isn't equal. You could set a base rate of 1 for your standard appointment duration. Then increase the value based on time spent. So, for example, a category of appointment that runs 30% longer would be a 1.3. From there, you can compute your panel size. Various formulas are available online, including a few offered in a Joint Commission journal article (link).

Source: "Providing Timely Access to Care: What is the Right Patient Panel Size?" Linda V. Green, PhD, Sergei Savin, PhD, Mark Murry, MD, The Joint Commission Journal on Quality and Patient Safety, April 2007

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