Panel Sizes and New Patient Access

[Psych19]

I work outpatient for a large academic organization.
There's been discussion and pressure from the organizational leadership to increase new patient access.
I'm wondering whether and where there are resources to find information about standards for new patient access and panel sizes for outpatient psychiatry. An informal poll among folks on this forum is fine, but if there are any official resources anyone knows of, that's even better. I think the big question is how many new patients per week should a full time (1 FTE) outpatient psychiatrist see? (assuming this is an established provider, not someone new just starting)

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[FlowRate]

I'm not aware of an official resource. As far as I know, benchmarking data sources like Sullivan-Cotter and MGMA don't collect that information.

You can back-calculate typical panel sizes based on practice patterns (follow-up timing, attrition rate, repatriation rate.)

Most FFS docs don't carry more than 500 patients (typical range 250-500 as best I can gather.)

In a value-based care system that leverages asynchronous care methods (messaging, nursing support staff) and sees average non-acute patients for scheduled follow-up appointments less frequently than typical for FFS, panel sizes of 800-1200 are normal.

It also depends on how you define panel. (Unique patients seen in the last 3 years? Unique in last year? In last 3 mo? Unique and not repatriated?)

 

[Bartelby]

I would love to see if anyone has real citations for this! I think this is a question many of us face at one time or another. I would start by working backwards. For the sake of maximizing panel size, let's assume:

• You only see follow-ups (30 min), never intakes
• You work 36 clinical hours per week
• You only see people every three months
• You have a 100% fill and show rate

That would yield 36 x 2 slots per week = 72 follow-up slots each week.
12 weeks between appointments x 72 follow-up slots = 864 patients.

These are of course absurd assumptions, but that yields a panel size where this is no realistic chance you can provide adequate care.

Let's tweak that to the same assumptions but an average of Q6 week follow-up (some are Q6 months, others are seen monthly or more, but let's average it to Q6): Now you have 72 follow-up slots per week x 6 weeks between patients = 432. This again assumes 100% fill rate, 100% show rate, zero intakes.

You can then factor in how many intakes you will do and insert more realistic fill/show rates. For example, for Q6 week follow-ups (no intakes) at an 80% slot utilization rate we are down to 345 (and you are still doing zero intakes).

When you factor in intakes, I think 250-300 patients is a full panel. If you carry a lot of patients who are pretty much completely stable and only see you once or twice per year, that number can go up. Many of those patients, though, should probably go back to their PCP if they are truly that stable.

I have had these conversations with admin before and you need to go in ready. Really do the math and don't accept handwaving about what a reasonable panel should be. Also stand firm about quality of care. If your panel size will require seeing everyone only a couple times per year (regardless of need) you should just say no. In the end you are the licensed professional and you will be legally liable for the care you provide, we can't hide behind a "my employer made me do it" argument.

As an aside, I think an RVU expectation is a much more reasonable way to proceed than a number of patients expectation.

 

[Sushirolls]

Before I left a Big Box job, I talked with some of the other folks there. They were seeing some people once a year.
It equated to 100 patients per 8 clinical hours, and it was a mix of schizophrenia, GAD, MDD, bipolar, ADHD, etc. so not entirely a high functioning population.

I require to see my patients every 3 months at minimum, and some patients find value and choose to see me sooner. Currently I have ~150 patients for 11 clinical hours for an outpatient practice that isn't taking schizophrenia, dementia, medicare or low functioning ASD. This is a commercial FFS practice, with a pinch of cash pay sprinkled in.

It's easy to get intakes in timely fashion. You simply have them blocked on your schedule. Then set the parameters of who gets them. If people calling in... they'll quickly fill. But what I presume the Admin is wanting, PCPs feeling like they aren't getting their patients in promptly, OR its the insurance companies putting in new mandates saying 'YOU MUST GET PATIENTS IN before x days if discharged from hospital or y days if calling for services.' Which we all know is completely laughable and just not obtainable. And are they telling people that a-fib must be seen by Sleep Medicine in 1 week of discharge from hospitalization? Or migraines 2 weeks to see neurology? I digress. So knowing what/why admin is really wanting will help in these discussions.

Now if you do block off designated intake time (which I plan to do in future once I get more full) a stat that is harder to keep, but one what is valuable is missed follow up time. If you have baseline data for "I want patient to follow up in 6 weeks" but schedulers see you have no openings until 9 weeks, this could be noted as -3. Keeping track of how much you miss the mark for scheduling patients now is your informative baseline. Then when you carve out your follow up time for new consults, that number will get more negative. I.e. is it really worth bringing in new patients to some doctors who should just be closed because of decreased access to existing panel.

But really, trying to quantify, and have a non-flexible numbers driven approach to this is ludicrous and is less likely to lead to Physicians feeling valued, respected, and able to practice their most professional medicine. [BURN OUT INCREASES] and any gains an admin makes, see above, is likely to be so marginal it just isn't worth the squeeze nor the meetings. [meetings take away clinical time]

@Bartelby Nailed it. Left field, upper deck, right to the kid with a big smile and a glove in his hand. wRVUs are the means to keep clinics full, and docs pushing for new intakes to facilitate meeting those numbers.

Now if admin is set on pushing something forward, discussions need to be had that forcing arbitrary patient numbers should and will be viewed externally as dictating the practice of medicine to a physician and forcing worse care on patients. One need only look at MSWs in CPS land.

**Thank for this mental exercise and recall of past Big Box shop experiences, and helping me re-invigorate that PP is the closest thing to the promised land. Great start to 2025!

 

[Sushirolls]

Another real world solution to access when access discussions occur...
It should really be directed to reality, you need another Psychiatrist.

But for many Big Box shops, that dances around the [Elephant in room] issue of not being able to find and hire one because, well, they are scat and have bad admin, bad pay... But don't worry, hemorrhaging money on locums is a quality solution. /sarcasm

 

[FlowRate]

I would love to see if anyone has real citations for this! I think this is a question many of us face at one time or another. I would start by working backwards. For the sake of maximizing panel size, let's assume:

• You only see follow-ups (30 min), never intakes
• You work 36 clinical hours per week
• You only see people every three months
• You have a 100% fill and show rate

That would yield 36 x 2 slots per week = 72 follow-up slots each week.
12 weeks between appointments x 72 follow-up slots = 864 patients.

These are of course absurd assumptions, but that yields a panel size where this is no realistic chance you can provide adequate care.

Let's tweak that to the same assumptions but an average of Q6 week follow-up (some are Q6 months, others are seen monthly or more, but let's average it to Q6): Now you have 72 follow-up slots per week x 6 weeks between patients = 432. This again assumes 100% fill rate, 100% show rate, zero intakes.

You can then factor in how many intakes you will do and insert more realistic fill/show rates. For example, for Q6 week follow-ups (no intakes) at an 80% slot utilization rate we are down to 345 (and you are still doing zero intakes).

When you factor in intakes, I think 250-300 patients is a full panel. If you carry a lot of patients who are pretty much completely stable and only see you once or twice per year, that number can go up. Many of those patients, though, should probably go back to their PCP if they are truly that stable.

I have had these conversations with admin before and you need to go in ready. Really do the math and don't accept handwaving about what a reasonable panel should be. Also stand firm about quality of care. If your panel size will require seeing everyone only a couple times per year (regardless of need) you should just say no. In the end you are the licensed professional and you will be legally liable for the care you provide, we can't hide behind a "my employer made me do it" argument.

As an aside, I think an RVU expectation is a much more reasonable way to proceed than a number of patients expectation.

You implicitly highlight some of what I was referring to above. For our system, a patient on your panel currently means a patient you've seen within the last 3 years who hasn't left the system since. Other data analysis I've done uses a definition of patients you've seen in the last 1.5 years. I am confident I provide excellent care and I saw about 800 FTE-adjusted unique patients in the 1.5 year time span before that data pull. But that's not the same thing as 800 patients requiring active, regular treatment and monitoring. Roughly 1/2 of patients only need 1-2 follow-up appointments within the year after their intake appointment. There are lots of patients I see once a year because they're stable, but I can't send them back to PCP (can't repatriate lamotrigine, antipsychotics, complex regimen, any benzo use, etc.)

I agree that 250-300 patients requiring active monitoring/intervention (needing to be seen within 12 weeks, usually sooner) is probably about right for quality of care.

 

[J ROD]

I think a big factor is if you are going therapy as well. Not just supportive but traditional therapy. I do not and my panel sizes have ranged from 800 - 1200. Adult. Do 20 min follow up. 24 slots per day. Mainly med management with supportive therapy. 6 months longest I will go without seeing someone. I have some PCP just send me folks for a SSRI and mild depression. Really do not need to see me but patients prefer to have me manage the medication.

 

[TexasPhysician]

No such numbers exist. It is highly dependent on the psychiatrist.

Some psychiatrists will refer back to PCP’s whenever a patient has been stable for 3+ months. This results in continual turnover and daily new evals forever. Others prefer to keep their patients indefinitely. This results in slow turnover at some point which may produce 1 eval every 2-4 weeks.

 

[clausewitz2]

My active PP panel is about 150 people. This is about 25 clinical hours per week. @TexasPhysician 's point is spot-on based on what I am reading in this thread. On average I see my patients every 3-6 weeks and get one new eval every 2 weeks or so. It's just so hugely variable based on your practice pattern. If someone can really get away with only seeing me every three months I do tend to think about sending them back to their PCP.

EDIT: although for some of those people that's not an option since their PCPs are uncomfortable with neuroleptics, TCAS or very high doses of SSRIs

 

[clozareal]

The large academic organization near me has a similar pressure on their attendings.

One of the ways I proposed to deal with increasing new patient access is to hire new attendings and grow the clinic. They said no because they did that before and the new attending just fills up and the waitlist becomes the same after a period of time. I was confused because I would imagine they can just keep doing this and expanding, which should increase revenue, more patients for their clinical and academic/research goals, and have a wider impact. They heavily implied that they don't want to grow or expand.

Their solution was to see patients for one time consultations and discharge as many patients back to their primary care physician or a community psychiatrist as possible.

 

[clausewitz2]

The large academic organization near me has a similar pressure on their attendings.

One of the ways I proposed to deal with increasing new patient access is to hire new attendings and grow the clinic. They said no because they did that before and the new attending just fills up and the waitlist becomes the same after a period of time. I was confused because I would imagine they can just keep doing this and expanding, which should increase revenue, more patients for their clinical and academic/research goals, and have a wider impact. They heavily implied that they don't want to grow or expand.

Their solution was to see patients for one time consultations and discharge as many patients back to their primary care physician or a community psychiatrist as possible.

This is often because OP services are actually a net money loser a lot of the time for institutions, or pretty close to it. They have mandates for access etc but many times expanding the clinic would actually mean a bigger loss for the system.

 

[Sushirolls]

***Shared Medical Appointments***
Mic Drop

 

[comp1]

Okay I saw medication management groups done at a county clinic and they were AMAZING. Really helpful for the patients and so efficient. They had residents or medical students transcribing while the attending conducted the session. Just so cool. The attending got to provide some psychoeducation while checking in on everyone's side-effects and efficacy in a kind of rapid fire manner. All of the patients were dealing with similar issues and on similar, although not identical regimens. The patients felt supported by the attending and by each other. I could see how it wouldn't work for every setting, but wow did it work there and left a lot more time for individual intakes. I mean I'm inpatient for life, but I could vaguely see myself doing something like that outpatient if inpatient ever fell completely apart.

 

[clausewitz2]

Okay I saw medication management groups done at a county clinic and they were AMAZING. Really helpful for the patients and so efficient. They had residents or medical students transcribing while the attending conducted the session. Just so cool. The attending got to provide some psychoeducation while checking in on everyone's side-effects and efficacy in a kind of rapid fire manner. All of the patients were dealing with similar issues and on similar, although not identical regimens. The patients felt supported by the attending and by each other. I could see how it wouldn't work for every setting, but wow did it work there and left a lot more time for individual intakes. I mean I'm inpatient for life, but I could vaguely see myself doing something like that outpatient if inpatient ever fell completely apart.

I'll take "models of psychiatry most vulnerable to being straight up replaced by LLMs" for 1000, Alex.

 

[Merovinge]

I'll take "models of psychiatry most vulnerable to being straight up replaced by LLMs" for 1000, Alex.

Given that China already does the above, I can't imagine how much some places are chomping at the bit to do it. I wouldn't be surprised to see a country (likely China) doing this within the next 5 years.

 

[clausewitz2]

Given that China already does the above, I can't imagine how much some places are chomping at the bit to do it. I wouldn't be surprised to see a country (likely China) doing this within the next 5 years.

China is a bit behind on LLMs because of American GPU export controls seriously limiting their available compute but if DeepSeek V3 is any indication they are making some headway in optimization of the resources they have.

 

[Attending1985]

This is often because OP services are actually a net money loser a lot of the time for institutions, or pretty close to it. They have mandates for access etc but many times expanding the clinic would actually mean a bigger loss for the system.

Is this due to high no show rate or other factors?

 

[nexus73]

Is this due to high no show rate or other factors?

I suspect high medicare/medicaid population, if the clinic is part of a non-profit health system they can't run like a private practice taking only commercial insurance. So a high percent of low reimbursement visits might make it a money loser.

That, or whoever is saying the clinic is running at a loss is being deceptive in how they are accounting for things.

In the world of outpatient hospital clinics charging facility fees on top of regular reimbursement, and the fact the psychiatrists in regular private practices are obviously making money (because otherwise they'd go out of business), I cannot imagine a psych clinic attached to a hospital is truly losing money. I would not be surprised if administrators don't look at the facility fee generated as counting towards the clinics financial profitability. The facility fee may be viewed as the health system's money, and they expect the clinic to be profitable based purely on the physician professional fee reimbursement, even though that's just half the story. But with a straight face they can say the clinic loses money.

I've also heard stories of health systems where the accounting for overhead costs is proportionally shared across all clinics. Like the overhead for ortho, neuro, nephro, heme/onc, family med, psych, etc are all put into one bucket. Then each outpatient doc is assigned a share of clinic overhead. Even though psych has extremely low overhead themselves, they look like they lose money because they are given a proportional share including all clinics that have high overhead cost.

 

[Ironspy]

I suspect high medicare/medicaid population, if the clinic is part of a non-profit health system they can't run like a private practice taking only commercial insurance. So a high percent of low reimbursement visits might make it a money loser.

That, or whoever is saying the clinic is running at a loss is being deceptive in how they are accounting for things.

In the world of outpatient hospital clinics charging facility fees on top of regular reimbursement, and the fact the psychiatrists in regular private practices are obviously making money (because otherwise they'd go out of business), I cannot imagine a psych clinic attached to a hospital is truly losing money. I would not be surprised if administrators don't look at the facility fee generated as counting towards the clinics financial profitability. The facility fee may be viewed as the health system's money, and they expect the clinic to be profitable based purely on the physician professional fee reimbursement, even though that's just half the story. But with a straight face they can say the clinic loses money.

I've also heard stories of health systems where the accounting for overhead costs is proportionally shared across all clinics. Like the overhead for ortho, neuro, nephro, heme/onc, family med, psych, etc are all put into one bucket. Then each outpatient doc is assigned a share of clinic overhead. Even though psych has extremely low overhead themselves, they look like they lose money because they are given a proportional share including all clinics that have high overhead cost.

Also, as I discovered recently, some of these clinics have appallingly low collection rates due to poor administration. Psychiatrists seeing more volume isn’t more profitable if no one makes sure we’re getting paid for our work

 

[Candidate2017]

I work outpatient for a large academic organization.
There's been discussion and pressure from the organizational leadership to increase new patient access. profits

It's almost never an access issue. Unless you're a bigshot researcher bringing in tens of millions, this is The Man's real goal:

More volume = more profit

Squeeze existing providers = more profit (existing labor churns out more widgets without having to hire new labor)

More throughput = more profit (steady pipeline from ED to psych ward to outpatient clinic will free up the ED for quick, profitable medical patients, and psych beds are also freed up to take more psych patients (and those sweet facility fees) from ED)

 

[Psych19]

It's almost never an access issue. Unless you're a bigshot researcher bringing in tens of millions, this is The Man's real goal:

More volume = more profit

Squeeze existing providers = more profit (existing labor churns out more widgets without having to hire new labor)

More throughput = more profit (steady pipeline from ED to psych ward to outpatient clinic will free up the ED for quick, profitable medical patients, and psych beds are also freed up to take more psych patients (and those sweet facility fees) from ED)

Actually it is very much about access. PCPs and other providers in the larger health system can’t get their patients in to see psychiatry or therapy. They’re understandably bothered by this. EDs and inpatient units can’t secure outpatient follow up for their patients. This is also a big problem. But the institution has been unwilling to hire more OP providers, probably because OP psych is losing too much money right now. The bigger they grow the more money they lose it seems.

Financial solvency is certainly a goal as well. But that problem is very hard to solve for the following reasons:
-poor payor mix
-no built-in mechanism to reward providers for productivity beyond the minimum required by the institution. We don’t get RVU bonuses.
-salaries and benefits necessary to compete for a workforce
-high no show rates with little way to curb this
-high overhead costs consistent with any big organization

 

[Bartelby]

Actually it is very much about access. ... But the institution has been unwilling to hire more OP providers, probably because OP psych is losing too much money right now. The bigger they grow the more money they lose it seems.

I agree it is about access, but as you point out the access issue boils down to a money issue. The system does not want to spend to adequately staff outpatient psychiatry departments, and if as providers we will solve that issue by taking on huge patient loads they will go for it.

As a side benefit, if one provider sees a significantly larger number of patients with the same infrastructure and by doing things like wrapping up notes in the evening after clinic then the institution also gets to see a more positive cashflow.

Of course, we then transfer the institution's problem (not wanting to hire adequate staff) onto ourselves. When we burn out wrapping up work on nights and weekends, when we can't see urgent issues in a timely manner because we are already overbooked, and when care spreads so thin that serous bad outcomes occur we have basically agreed to take the brunt of the system's failure.

 

[Bartelby]

You implicitly highlight some of what I was referring to above. For our system, a patient on your panel currently means a patient you've seen within the last 3 years who hasn't left the system since. Other data analysis I've done uses a definition of patients you've seen in the last 1.5 years. I am confident I provide excellent care and I saw about 800 FTE-adjusted unique patients in the 1.5 year time span before that data pull. But that's not the same thing as 800 patients requiring active, regular treatment and monitoring. Roughly 1/2 of patients only need 1-2 follow-up appointments within the year after their intake appointment. There are lots of patients I see once a year because they're stable, but I can't send them back to PCP (can't repatriate lamotrigine, antipsychotics, complex regimen, any benzo use, etc.)

I agree that 250-300 patients requiring active monitoring/intervention (needing to be seen within 12 weeks, usually sooner) is probably about right for quality of care.

I will add that this is a good point. If you have infrastructure in place to allow you to meaningfully see people less often on average then higher panel numbers can be more feasible (great connections to IOP, solid psychotherapy follow-up, nursing line coverage, etc.), or if you see some people in a kind of brief consultation model within an integrated system.

For example, if you think about how a follow-up only panel of four patients seen weekly for 30 mins per session compares to 100 patients seen Q6 months for 30 mins per session, which takes more time? It turns out they're about the same!

4 patient scenario for six months: 2 hours per week x 26 weeks = 52 hours
100 patient scenario: 50 hours (100 x 0.5) once every six months = 50 hours

I know seeing people weekly for 30-min visits in perpetuity is unusual, but the frequency of follow-up still matters a lot. For example, one monthly patient = 6 Q6 month patients.

So if you have safe and reasonable ways to decrease visit frequency, the panel size can balloon up in the available time. You still, of course, have to make sure everyone is getting adequate care including prompt responses to urgent issues. In most fee for service practice models, that means you want some breathing room built into the schedule (in my opinion) and it imposes some real limits.

 

[Mad Jack]

The large academic organization near me has a similar pressure on their attendings.

One of the ways I proposed to deal with increasing new patient access is to hire new attendings and grow the clinic. They said no because they did that before and the new attending just fills up and the waitlist becomes the same after a period of time. I was confused because I would imagine they can just keep doing this and expanding, which should increase revenue, more patients for their clinical and academic/research goals, and have a wider impact. They heavily implied that they don't want to grow or expand.

Their solution was to see patients for one time consultations and discharge as many patients back to their primary care physician or a community psychiatrist as possible.

This is something I've seen as well. It's like organizations are allergic to money (or just unwilling to put in the investment for things that aren't big earners like procedural specialties)