“How many staffers should we have per doctor?” was the opening question in a recent column . We looked at the impact of staff on provider productivity and ultimately practice profitability as an approach to address that question.

In that piece, we focused primarily on clinical staff, but in this column, we’ll dig even deeper into medical practice operations, looking at the way a practice utilizes nonclinical support staff for traditionally administrative functions, such as check-in, check-out, patient scheduling, and telephone management. Those functions, too, can affect efficiencies and, ultimately, the bottom line.

First, let’s look at when and how a new patient is registered with the practice.

A patient new to the practice calls the office for an appointment. Practice A gathers minimal information (name, phone number, date of birth) over the phone. Practice B captures the full demographic and billing information from the patient on that initial phone call, or sends the patient history form to the patient to fill out and send back before the appointment.

What happens next?

When the patient presents at Practice A, the staff has to collect the patient’s demographic and billing information in addition to getting the patient to sign a release of information and notice of privacy form. Typically, the patient sits and fills out page after page of this information. That process can take 10 or 15 minutes or longer. Sometimes the providers in Practice A are pacing the hallway waiting for the nurse to room the patient, because there is a delay getting the paperwork finished, the data entered into the computer, and insurance coverage verified.

When the patient presents at Practice B, however, the most that needs to be completed is a signature on the release of information and notice of privacy forms. Practice B has already verified insurance eligibility because they obtained the required information over the phone at the appointment request call. The front desk triggers the nurse to room the patient sooner in the process.

Does it seem like Practice B has a better process? To those Practice As who say they couldn’t afford the additional staff they’d need to take incoming phone calls, Practice Bs would say that they need fewer staff operating the front desk and so can shift staff to the incoming phone calls.

Is it a wash in the numbers? Let’s look at how the practices are staffed based on each seeing about a hundred patients/day.

Seeing 100 patients/day	Practice A	Practice B
Telephone appt. and registration process	2-3 minutes	5-6 minutes
In-office registration	5 minutes	1 minute
In-office insurance eligibility verification	2-4 minutes	0 minutes
# Telephone staff	1.0 FTE	1.25 FTE
# Check-in desk staff	1.6 FTE	0.80 FTE

It can get a bit more complicated if we pose slightly different scenarios: Practice B uses a service that uploads patient insurance information for every patient on the schedule two days in advance and automates insurance eligibility verification. Practice A uses an in-office kiosk where patients check themselves in and complete their registration process on the kiosk which sends a real-time insurance eligibility request out for verification.

Now, which process uses fewer staff or gets better results?

As it happens, adding the kiosk will mean that Practice A will require just 1 FTE, instead of 1.6. So letting patients do the keystroking actually gives practice A a slight edge over Practice B as far as number of FTEs goes (2.0 versus 2.05), but Practice B still comes out ahead in terms of time — the process takes a total of six to seven minutes in Practice B versus nine to 12 minutes in Practice A.

And that’s only at the beginning of the encounter; how about the end of the encounter?

Look at how follow-up appointments are scheduled in two busy practices. The providers in Practice X and Practice Y have schedules that are fully booked about four weeks out into the future. To monitor a patient’s problem, the provider orders a follow-up appointment to see the patient in about one week.

The check-out staff in Practice X handles scheduling for follow-ups, but the clerk must call back to the provider’s nurse and ask for guidance on where to double-book (or even triple-book) the patient.

In Practice Y, the provider’s nurse schedules the patient’s appointment because the order for a one-week follow up falls within the standard established by the practice: provider-specified appointments that are to be scheduled during the subsequent four-week booking period are scheduled by the provider’s nurse, who can best determine the appropriate spot during the day for adding the patient onto a fully-booked schedule.

Does Practice Y need more nurses than Practice X to take on the scheduling duties? Or does Practice Y need fewer nurses because they are not interrupted or called away from their work to take a call and look at the schedule? Let’s chart it:

	Practice X (follow-up at checkout desk)	Practice Y (nurse schedules follow-up)
Check-out staff time	2-5 minutes	0 minutes
Nurse time	3-4 minutes	2-3 minutes

The total time investment is more with the traditional model of scheduling follow-up appointments at the check-out desk, and the nurse-only time is actually less when we think outside the norm and implement a different work flow.

Work flow, technology, and shaking up traditional job duties can all have an impact on headcount. Dig into your processes to get the numbers right.

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.