Improving patient access to primary care

At a recent faculty meeting, the attendings in our practice were asked about their availability for new patient appointments. The vast majority reported that due to time constraints and patient volume, they had closed their panels to new patients.

For those of my partners with open schedules, the wait for new patients to be seen was averaging 2 to 3 months, a few up to 6 months. The time to the third next available revisit (an industry standard for schedule monitoring) was several weeks.

The department of medicine has a strong desire to increase/improve access to primary care, as a way to bring in more patients from our catchment area, and to provide fuel for the fire that is our large academic medical center.

More patients means more laboratory services, more consultations with specialists and subspecialists, and more admissions to the hospital. In our view it also means more people getting primary care, which is a good thing.

The problem is, we are also finding it more and more difficult to take care of the patients we have, and patients do not have the ability to get in and see us when they want to.

Expanding and ensuring access is a complicated process, with many different models such as open scheduling and advanced access having been tried, with variable success.

In my own practice, I work in a model of advanced access, trying hard not to book out future appointments 3 months ahead (these kinds of appointments tend to have a very high no-show rate), telling my patients that if they want to be seen in a particular week, they should call then to be seen.

Seriously, we all as providers should only be managing a panel of patients of a size such that we can see them when they need/want to be seen. There will always be some overflow, some interims, some urgent appointments that need to be scheduled during a time when we’re not in practice. There are days when we as clinician educators are teaching all day long, not in practice at all.

Our nurse practitioners have expanded our coverage ability, and will frequently see patients for urgent interim appointments when we cannot. The resident’s fractured schedules present a whole other set of access issues, with our pod team system working to fill this need.

One of the nurse practitioners in our practice recently saw a patient who was transferring care to us, who had an urgent need for an appointment (a splinter buried in her finger). He was able to examine her, perform a digital block in the office, and remove the offending splinter, saving her a trip to urgent care.

We have all been through the experience of being sick, and finding ourselves in need of seeing our doctor, the covering doctor, another health care provider, somebody.

The first hurdle is getting through on the phone, the second hurdle is the person answering the phone, the third hurdle is the person controlling the schedule, and the fourth hurdle is proving you’re sick enough to be seen.

The literature is full of studies that have attempted to figure out the optimal panel size for a practicing internist, but I think we all know when a panel gets too big. We have all seen that patient on the schedule, and said, “Boy, that name does not sound familiar. Is that really my patient?”

Time to downsize.

There are many ways to improve access in the patient-centered medical home model. These can include the use of an extended care team, with the ability for interim appointments to be handled by providers other than the PCP. Also additional types of appointments such as group appointments or disease specific appointments for patients with multiple diseases where all of their issues cannot be handled at one single appointment.

Looking back at my schedule from yesterday, the patients who were added to my schedule because they “absolutely positively had to be seen” included “still not feeling well,” acute low back pain, and fevers without localizing symptoms.

The effect of this on my already full schedule led to a fairly busy day, which started out with an elderly patient with seven medical problems, all of which were not doing well, and she was mad at all of her subspecialists. A recipe for falling behind, for not being able to pay attention to each patient in the way in which we really think they deserve.

Tell me what works for you. “Frozen” appointment times in the electronic health record that “thaw” less than 24 hours from the time slot? Overbooking on initial visit times? Electronic scheduling, where patients are allowed to insert themselves into any available appointment times? Or even complete open access, where no future appointments are scheduled (except for the most complex, or maybe those patients that need to know that an appointment is waiting for them in the future).

Access takes many different forms, and improving it will take quite a bit of effort. The solutions may be protean, but should be worth that effort.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • guest

    Direct -pay primary care is probably the only answer. Once you have third-party payers in the mix, the administrative burden of running the practice is so expensive that by definition, the doctor’s panel has to be too big to be able to provide adequate care. We can squirm and wiggle and look for workarounds all we like but at the end of the day, our patients need more time with us, and nobody other than the patient is going to be willing to pay for that.

  • Close Call

    “use of an extended care team”, “medical homes”, “group visits”… ugh.

    That’s not really what patients want. They want access without the gimmicks. They want to be seen by their doctor, who knows them, and has built a relationship through bad times and good… through the “easy stuff” like coughs and colds, and the “hard stuff” like chronic disease or worse.

    How about you read Josh Umbehr’s article on direct primary care:

    http://www.kevinmd.com/blog/2014/05/affordable-direct-care-doctors-longterm-health-care-solution.html

    That’s how you improve access, patient satisfaction, and reinvigorate primary care. Rinse and repeat.

    • SarahJ89

      We want a doctor, not a jargon-laced “team” of people we don’t know, who don’t know us and have no time to get to know us because they’re too busy reading the error-laden EHR on their laptops.

      Just… a doctor. Is that so hard? Apparently so. Somehow your profession has been hijacked.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This is really mind boggling to me. There is a simple math that can be done here: assuming 2000 hours worked during a year, there are 8000 15 minutes appointments available. Considering the 4 appointments per patient per year on average, and considering that not all those appointments are with PCPs, and throwing in some appointments longer than 15 minutes, the approximate panel size per physician is about 2000 to 2500 patients.
    We can turn and twist the schedules in multiple ways, and I believe there are all sorts of consultants now that will be more than happy to take your money to “fix” or “open” your schedule, but the basic math will remain the same.
    Sure, shoving a whole bunch of people into “group visits” or passing them down to other “team members”, is always an option, if those people don’t mind, but it shouldn’t come as a surprise that nobody then knows their name.
    Maybe if the academic center is so busy, it could refer some patients to community docs and forgo some of the “fuel for the fire” that is consuming all our health care dollars.

  • southerndoc1

    You can’t put a gallon of water in a one-quart jar. Fact. Non-disputable. No discussion allowed.

    As others have indicated, the work-arounds you are considering don’t solve the problem, and only create more stress and worry for the doctors and staff.

    The ONLY solution is to dramatically reduce the patient panel size for primary care docs. And that ain’t gonna to happen. So deal with it, and stop wasting time trying to fix an insoluble problem.

  • DrTWillett

    That is definitely the case in pediatrics. Partly because we have so many well visits to do for the little ones, but also because of the excessive panel size required to feed the business.

  • Robert Bowman

    Recovery of Primary Care
    1. Over 30% more national spending specific to clinicians and team members who actually deliver care – not higher cost of delivery pinching off revenue for those who deliver care, not lower volume per clinician as the result of every type of innovation and new mode of care
    2. Less paid for MD, DO, NP, PA, and RN who specialize relative to more paid for those who choose primary care training and remain delivering primary care
    3. More revenue made specific to 40,000 zip codes or 2400 counties with lower to lowest concentrations of clinicians where over 65% of Americans are found – less paid to 1100 zip codes and 100 counties with top concentrations of health spending and health workforce
    4. Permanent primary care result from training – not 30% found in primary care as an average career contribution
    5. Family practice position as the predominant outcome of primary care training as measured over an entire career – the only MD, DO, NP, and PA graduate result with multiple times greater distribution to all needed locations. The current design flexible for primary care result from IM, PD, MPD, NP, and PA (read more non-primary care than primary care) is a contrast with 90% family practice from Family Medicine. Family medicine itself will need some protection from the primary care theft promoted by our designs for training and revenue support.

    None can grow primary care result, primary care where needed result, or workforce in most states in need of primary care without very specific instate, primary care, where needed focus of training design and payment design coordinated together – something lacking for over 30 years and still counting. Continued focus upon cost cutting, hospital and practice payment penalties specific to areas in most need of workforce, higher cost of delivery, and lesser volume by design are exactly the wrong directions for recovery of primary care.

  • LeoHolmMD

    “More patients means more laboratory services, more consultations with specialists and subspecialists, and more admissions to the hospital.”

    You just summarized what is killing Primary Care. I don’t think “tool” is too strong a word in this circumstance.

  • LeoHolmMD

    “The vast majority reported that due to time constraints and patient volume, they had closed their panels to new patients.”

    “The problem is, we are also finding it more and more difficult to take care of the patients we have, and patients do not have the ability to get in and see us when they want to.”

    “The first hurdle is getting through on the phone, the second hurdle is the person answering the phone, the third hurdle is the person controlling the schedule, and the fourth hurdle is proving you’re sick enough to be seen.”

    “Overbooking on initial visit times?”

    Is there anyone who can explain what is “Patient Centered Medical Home” about any of this?

  • LeoHolmMD

    Correct. So much care is being given to people with nothing wrong with them, there is no time for sick people. Welcome to the perverse incentive machine where access is punished. It is shameful that institutions like CVS are salvaging this situation. The PCMH has done absolutely nothing to address this situation.

    • Wannabmd

      I have found that questioning the necessity of so much “well” care is a touchy subject. Accusations of “rationing” usually quickly arise. If this issue is not addressed, especially with the promised increase in “free” preventative care as part of the ACA, I fear we will see physician offices filled with well people while the sick are at CVS.

  • Patient Kit

    I’ve been struggling to understand the growing popularity of urgent care chains that are popping up like mushrooms all over NYC (and I hear they have been popular elsewhere in the country for a long time now). But now I get it.

    If I choose a primary care doc because he’s a good doctor, but I often don’t get to see him but see someone “on his team” instead. If I never get to build a relationship with this good primary care doc, then there is zero incentive to choose him as my doc, especially if it’s hard to get an appointment when needed. And if I do get an appointment, I may see that good doc or I may see someone on his team who doesn’t know me. And whoever I see, it will be slam bam, thank you mam short and not sweet. Really, under those circumstances, there is less and less incentive for patients to seek out a specific doctor.

    Under those circumstances, we might as well go to the most convenient walk-in urgent care center, see a random stranger doctor and get whatever we need there much more conveniently. If there is no possibility of a doctor-patient relationship, there is no incentive to seek out or stay with a specific doctor.

    Suddenly, I get the appeal of urgent care centers for primary care. And patients who have never actually experienced good primary care don’t experience the loss. Because they don’t miss what they never had.

    • guest

      Exactly. I frequently go to Urgent Care and take my children there for exactly that reason. If the kids need a sick visit, there is zero chance that they will see their primary pediatrician, and the office visit will be highly inconvenient for me, a working mother, to get to. I might as well take them to Urgent Care for their strep tests.

      If I get sick, I see my own PCP (who has a cash-only practice) and his office is usually pretty good about working me in right away, but he is “efficient” and has a pretty superficial relationship with me, so often it really is no different (and quite a bit more convenient) to go to Urgent Care.

      • Patient Kit

        Thank you. I really appreciate your response and newly understand why you prefer to post as “guest” here. ;-)

        It’s very interesting that you, a doctor, often take your kids to an urgent care center when they are sick. It’s not hard to understand the importance of the convenience factor for a working mom and I’m sure you wouldn’t take them there unless you thought they are getting the care they need there.

        It’s even more interesting that you, a doctor, feel that your relationship with your own direct pay/cash only primary care doctor is pretty superficial and no better than what you get at an urgent care center — given that DPC is so often proclaimed here as the only thing that will save primary care and the doctor-patient relationship.

        I think the last time I had the kind of primary care that people lament here was when I was a child. Growing up, we had the same family doctor for many years. I don’t think I’ve ever experienced that kind of primary care as an adult. And I’m fiftysomething. Maybe I should stop hoping for it.