Marina Krakovsky talks with readers about same-day access to physicians.

Marina Krakovsky: Hello everyone! Marina Krakovsky here—glad to be here and looking forward to your questions.

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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.

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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.

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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.

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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.

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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?