Achieving the holy grail of wait-free medical care

We’ve all come to expect our doctors to run late for appointments. I’m a doctor, and when I go to see my doctor, I expect the same. I bring my laptop or something to read to bide the time. Waiting makes us feel like we or our time isn’t valued, and doctors know this. So why is it so hard for doctors, including myself, to stay on time?

 

Most doctors have tightly packed schedules with appointments spaced ten to twenty minutes apart. While some patients are too complicated to be seen in such brief visits, it’s hard to predict how long each patient will need. We aren’t given more time, so we run over, let some things slide, or bring our patients back more often.

The time you have to wait in a doctor’s office is also a downstream consequence of how long you’ve had to wait for an appointment in the first place. Patients often cancel at the last minute or no-show because their visits are booked so far in advance. The average wait time for a doctor’s appointment across the country is nineteen days, and this is likely to get even longer with more people getting health insurance and wanting to see a doctor. Most patients don’t know their schedules that far out, and conflicts arise. In the meantime, while waiting for their appointment, their problem may have resolved. As the risk of last minute cancellations and no-shows increases, so too does the rate of double-booked appointments.

Under our current fee-for-service model, time is money. Doctors are paid based on how many patients they see. It’s hard to predict how many patients will miss their appointments on any one day — the average is about a quarter — but it’s better to have too many patients come in than too few.

Companies like ZocDoc, DocASAP, HealthPost and DrDoctor are making cancelled appointment slots more available for last minute rebooking. Such systems help keep doctor’s appointment schedules solidly booked, but it isn’t clear this does much to reduce rates of double-booking or to reduce patient time in the waiting room.

We could better manage double-booking to reduce the likelihood that one patient will be forced to wait. A small Cambridge-based startup, SmartScheduling, is using information about patients’ prior appointments to identify those who are most likely to cancel at the last minute or no-show. If these patients don’t confirm their appointments, SmartScheduling opens their time slots for double-booking forty-eight hours ahead. Doctors are less likely to have two patients show up for the same time slot and can more easily fit in patients with an urgent issue.

Some doctors’ offices are changing the way they manage their schedules to provide more same-day appointments, whether for urgent or routine visits; you might call it “just-in-time” patient care. It might seem counterintuitive, but same-day booking makes our schedules more predictable. Our patients are more likely to show up and be on time. They are available and have an issue they want addressed that day. In turn, this all means that we doctors don’t have to overbook patients and are more likely to run on time.

It makes sense for us to make room in our schedules for more same-day appointments. Our patients want to see their regular doctor, who knows them best, when they are sick. When we can’t fit them in, they go elsewhere — an emergency room or an urgent care clinic — resulting in discontinuous, fragmented care. No one has the whole picture. Plus, the opportunity to deliver other important preventive or chronic care services is lost.

Dr. Mark Murray, former assistant chief of medicine for Kaiser Permanente in north Sacramento Valley, CA, advises physician practices on how to implement the advanced access model, which allows for a large proportion of same-day booking, what Murray calls “doing today’s work today.”

A number of steps are necessary to make this work. The supply of appointments should match the demand from patients. Each doctor should be responsible for a manageable number of patients. Administrators can measure when patients are most likely to want appointments and ensure clinics are adequately staffed to meet patients’ needs. Patients should be scheduled to see their own physician, who can see them most efficiently. Much of the work doctors do — checking vital signs, reviewing medication lists, tracking down lab and radiology results, offering preventive screening and counseling – could be delegated to others, freeing doctors to focus on more complex diagnostic and treatment decision-making.

By increasing the availability of same-day appointments, the Henry J. Austin Health Center in Trenton, NJ cut their no-show rate in half and no longer has to double-book. According to Dr. Kemi Alli, Henry J. Austin’s chief medical officer, teamwork is key. The workload needs to be better spread across a team, not just the doctor, each with specific defined roles for which they are held accountable. When only the doctor is held responsible for patient outcomes, whatever work hasn’t been done ends up back on the doctor’s shoulders. That slows us down and makes it harder to fit in same-day appointments.

Clinica Family Health Services in Denver, CO implemented the advanced access model several years ago. Clinica cares for over forty thousand patients, most of whom are Hispanic and poor. Since the new system was rolled out, average waiting room times for patients have dropped to ten minutes, and the no-show rate dropped from about 25% to 10%.

According to Dr. Justin Wheeler, Vice President of Clinical Services at Clinica, “Our systems build resistance and fear because we’re denying patients something they need or want.” We make patients schedule days, weeks or months ahead for an appointment, and then keep them waiting in our offices before we see them. But we could re-engineer our systems for wait-free care.

Celine Gounder is a physician and medical journalist.  She can be reached at her self-titled site, CelineGounder.com. All views expressed in this article are hers and should not be attributed to any of her employers.

View 8 Comments >