Fam Pract Manag. 1999 May;6(5):53.

FPs and productivity


Is there any recent information about family physicians and average productivity expressed in RVUs (relative value units) per year?


The Medical Group Management Association collects this data every year as part of its annual compensation and productivity survey. According to MGMA's Physician Compensation and Production Survey: 1998 Report Based on 1997 Data, family physicians in group practices generate mean RVUs of 5,900 with obstetrics and 5,980 without obstetrics.

ADA's effect on solo practice


How does the Americans with Disabilities Act (ADA) affect solo family practice? What are the physician's responsibilities regarding deaf patients and obtaining signers for them? Who is responsible for paying the signers?


The ADA probably does not affect your employment practices since the labor provisions of the law apply only to businesses that have at least 15 employees. However, your office is considered a public accommodation and, under the law, is generally required to be accessible to disabled patients.

You need to ensure that people with disabilities can use your office building and suite. Barriers to access must be removed if alterations are “readily achievable,” which is determined by considering factors such as the nature and cost of the action, the owner's and tenants' financial resources and the impact of the action on the operation of the business. Required accommodations might include installing a ramp, making curb cuts, rearranging furniture, widening door openings or modifying rest rooms. These accommodations are usually at the expense of the building owner. (For more information, see “ADA Compliance: How Are You Doing?” April 1995, page 24.)

Another type of accessibility is the communication between you and your patients. Under ADA guidelines, the need for an interpreter depends on the complexity of the medical matter. An exchange of written notes may suffice for a patient with a simple cold. However, if the condition or treatment is more complex, an interpreter may be needed to ensure that you and the patient understand each other fully.

It is normally the health care provider's obligation to pay for the interpreter unless it can be shown that the cost would impose an undue burden on the provider. The financial resources of both parties and the impact of the cost on the practice are relevant. The cost of the interpreter may exceed your charges for that patient's care, but this alone does not constitute an undue burden. The ultimate decision maker may be a court, so it is safe to err on the side of absorbing the cost. Some providers have an interpreter in the office regularly, such as one-half day per week, and try to schedule appointments with hearing-impaired patients during this time.

Optimal practice size


Our practice of two physicians and one nurse practitioner is considering a move and an expansion. How many physicians and how much space should we have per site for optimal efficiency?


In my experience, a good range for a family practice is three to nine physicians (four to six, ideally). Practices with 10 or more physicians require a different, more costly, level of management. Practices with one or two physicians may have difficulty maintaining large enough panel sizes to operate efficiently.

You should have two and a half to three exam rooms for each provider who sees patients in the office and a total of 1,250 to 2,000 square feet per provider. Plan on at least eight chairs in the waiting room per provider.

Typically, a practice will be more profitable with all providers at one site, but if you want multiple sites, keep at least four providers at each site.

Supervising MLPs


Recognizing state-to-state variations, what are the legal pitfalls to avoid when supervising midlevel providers?


It's important to know whether your state requires physicians to be on the premises to supervise midlevel providers and, if so, the extent of the supervision state law demands. Certain providers, such as nurse practitioners, must have collaboration agreements but function relatively independently. Others, such as physician assistants, have a broad scope but are closely controlled and are often required to follow clear delegation protocols.

Liability issues arise in an employment relationship if the ancillary personnel cause problems by functioning too independently. Although Medicare now allows nurse practitioners, physician assistants and clinical nurse specialists to perform without on-premises supervision, practices still must comply with state laws, which control the extent of physician delegation permitted. In some states, the midlevel providers' scope of practice requires that physicians delegate only to licensed or certified individuals.

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Copyright © 1999 by the American Academy of Family Physicians.
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