Marina Krakovsky was online at Washingtonpost.com on Thursday, Sept. 6, to discuss doctors' offices where patients don't wait long to be seen. An unedited transcript of the chat follows.
Marina Krakovsky: Hello everyone! Marina Krakovsky here—glad to be here and looking forward to your questions.
Midwest: Hi—thanks for the article. I thought that it was standard practice to schedule regular exams in advance, but that most clinics leave room in the doctor's schedule for urgent visits. It seems this offers the best of both worlds—the patient can plan a regular physical far enough in advance to make arrangements for work or child care, and the doctor has the flexibility to work in patients who need help immediately. Are you familiar with this model, and why don't you think it works?
Marina Krakovsky: You're describing the so-called "carve-out" model, and it is indeed a very common approach to scheduling. It's better than booking up all your slots in advance, but it has its problems, too, some which I touch on in the article. It's inefficient because it requires lots of triage to determine what's truly urgent, and it gives patients a perverse incentive to basically lie about their symptoms. Also, because there are fewer same-day spots for non-urgent visits, the wait for non-urgent visits is really long.
Beltsville, Md.: I read your article. This is why I have Kaiser Permanente; I know that if I get sick and have to be seen that day that they will fit me in—even if I don't get to see "my" doctor, I will see a doctor. Their everything-under-one-roof system just works.
Marina Krakovsky: It's interesting that this trend started at Kaiser, with Mark Murray's work there. It seems hard to believe that such a behemoth can be made to run more efficiently. Should be an inspiration for others. Not being able to see your own doctor is a real problem, though. A friend who's a pediatrician at a Kaiser our here says she often has to see other pediatricans' patients, and that's definitely not the ideal of continuity of care. Mark Murray's solution worked better because it eliminated waits and improved access to your own doctor.
Bethesda, Md.: What a great article. I think that waiting times are one of the biggest issues in medicine today. I myself have ended up in the ER for issues that might have been able to wait 24 or 48 hours, but couldn't wait the three weeks it took me to get an appointment at my primary doctor (and don't even start on specialists)! It seems to me that getting the health insurance companies to push for this would be the easiest way to see it implemented for average patients. Any idea if that is happening?
Marina Krakovsky: I haven't heard of insurance companies taking a stand on open access. Seems like it would be a good idea in the long run, what with the superior clinical outcomes. But as long as insurers get paid based on the number of patients they cover—not on how many claims they pay out!—my hunch is they're not going to rush to endorse open access.
Anonymous: I am a Physician Assistant who does a lot of same-day urgent care visits. You did overlook one other issue with scheduling—the patient who expects only their schedules to be considered. If I already have four people scheduled right after lunch, but you "can't make it" at 11 a.m. or 3 p.m., then maybe you aren't that sick that you have to be seen today. Those other four people deserve to have their appointments respected also. And if you have been sick all week, calling at 4 p.m. Friday and demanding to be seen is not all that reasonable a request given that not only the provider but his/her entire staff may have other obligations after 5 p.m., including children at daycare or a second job. There are only so many hours in the day, and if 40 people call today I may not physically be able to see all of them. I try to accomadate people who need to be seen for illness or injury, but a little common sense and respect for others—including your provider and their staff—seems in order also.
Marina Krakovsky: You bring up a good point: some of the problems stem from patients not understanding what goes on in the office, and the ripple effects of their individual choices. (Likewise, doctors should understand how they affect their patients' lives by having them wait, even in the waiting room weeks after the appointment was made.)
But I would also ask why the doctor is scheduling four people right after lunch—how is one doctor going to be able to see them all at once? The doctor is probably used to some no-shows, but what if they all do show up on time? You're probably going to have three disgruntled patients.
Edmond, Okla.: Studies have shown that it takes considerably longer to get into a dermatologist's office to have a mole evaluated for possible malignancy than it does for botox injections, which are cosmetic and are paid out-of-pocket by the consumer. Don't the lower rates of compensation and lengthy claim-submission processes used by health insurance companies and Medicaid provide a financial incentive for doctors to mismanage their practices by overbooking and delaying patients whose lower-paying but neccessary treatments will be covered by insurance, while catering to more lucrative cosmetic procedure patients?
Marina Krakovsky: I did read about that study, which compared the waiting times for the two types of visits. The study didn't examine the reason for the disparity, though your explanation certainly seems like the most likely, and that's deeply disturbing. Talk about the changing face of dermatology.
Interestingly, the "changing mole" study I mention in my article found virtually no difference in the waiting times for Medicare patients versus other patients.
Richmond, Va.: That opening fact, that "the wait time for a doctor's appointment in the United States is one of the worst among peer nations" is all the more interesting, because a long wait is the most common arguement against national health care! Now we have proof that aruguement is unwarranted, we can have an intellectual converstation about national health care without the false scare tactics. Thanks.
Marina Krakovsky: Not so fast. Nations with national health care do have long waits. Depending on which stats you look at, Canada's waits are worse than ours, and the UK's are better but not anything to crow about. And what works in one country may not work in another. But as with so many things, a lot depends on the actual execution.
I do think that even in the current system, misaligned incentives—for patients, doctors, and insurers—is part of the problem.
Richmond, Va.: They manage to do it fine that the neighborhood "doc in a box," where there are no appointments—it's first come, first served.
Marina Krakovsky: Yes, and doesn't that make you wonder how they manage to do it?
But if you haven't experienced long waits in these clinics, maybe part of it was luck. It seems to me that a strictly first-come, first-served approach can create long waits in the waiting area, unless there are lots of extra doctors just in case. Open access isn't that radical—patients make appointments for a specific time during that day.
Washington: I loved your article because I recently had a major problem with this ... I had a skin infection and really needed to say a doctor ASAP, but my regular doctor's office said there were no openings, even for emergencies, for two more months. Luckily after about a dozen calls I found someone who would see me, but turning down a patient who really needs help seems almost like malpractice. Why don't doctors do more to fix this delay problem? Should we just go to the emergency room in those types of situations?
Marina Krakovsky: Yeah, what happened to "do no harm," right? But look at it from the doctors' point of view. If it took a dozen calls to find anyone who could see you, I'm guessing there's a genuine doctor shortage in your area. And if that's the case, no scheduling system is going to solve the problem.
Individual doctors can only weigh their options and the trade-offs involved. Do they increase their hours? Do they send patients to urgent care? Do they stop taking on new patients altogether? Or do they tack you on to the end of a very long queue? The last option may be well-intentioned, but we now know it creates all sorts of problems and makes the whole system less efficient.
San Mateo, Calif.: I enjoyed your article and the fact that it is producing discussion on a topic that needs addressing for all involved, including doctors and patients. The comment from Bethesda, Md., brought up the ER issue, i.e. the congested ER waiting rooms because of a patient's inability to be seen by his own primary care physician, because of alack of open access. As you cited via Palo Alto Medical Foundation in your article, I can attest to its ability to efficiently and effectively handle patient care with its same-day scheduling.
When my child has an accident or is ill, I first contact PAMF's advice nurse, who helps determine whether or not his condition warrants being seen by the clinic. If so, the nurse transfers me to the scheduling desk and a same-day appointment is made. If, during that visit, his doctor feels he needs more immediate attention that cannot sufficiently be addressed or handled by the facility, my son is directly transferred to the ER for further care. PAMF's open access is providing quality care to its patients while assisting in decreasing unnecessary and unwarranted visits to the ER.
Marina Krakovsky: Hello, neighbor! Yes, I've heard wonderful things about PAMF. And they weren't always like this, not by a long shot. So that's another testament to the possibility of change that I hope will be an inspiration to others.
Alexandria, Va.: As a "sicker adult," the ability to make an appointment on the same day has been a need for me for several years. I am lucky to have an internist who usually can accomodate me, but I have two specialists who enlist a phone tree answering system that makes it virtually impossible to even speak to someone in a day or two, let alone make an appointment—taht usually takes two to three weeks. Especially annoying is the warning that the recorded system provides, saying that "if this is an emergency, hang up and dial 911." It's as if they are preempting any attempt at obtaining an appointment quickly. I'd like to think that this new system you describe would be the future of medicine, but I fear that my experiences suggest that it only will become worse.
Marina Krakovsky: I'm optimistic, and hope that by continuing this discussion, we can help the open-access movement along.
Marina Krakovsky: Thank you all for participating, and I'm sorry we didn't have time for all the questions. Best wishes on speedy access!