The paradoxes of open-access scheduling

When I opened my private practice in 1986, I decided that I would never fall behind my workload. As I wrote in 1998, “If you need an appointment today, you get an appointment today.” If you wanted a database physical in a week, you could get it in a week. That just seemed like common sense.

Access, I think, is the most important factor in family practice management. I’m surprised that the “medical home” folks give it so few points (9 out of 100 in the NCQA's medical home scoring system). An accessible physician is better than a smart physician, if you have to choose. For that matter, an accessible NP or PA is better today than a smart FP tomorrow.

The “open access” movement came along about 14 years later. “Advanced access” scheduling means the patient is not only seen today but by his own doctor as well. There is evidence that as the percentage of patients seeing their primary care provider rises, so do average charges. In solo practices, like mine, that percentage is very high.

Here are the paradoxes (G.K. Chesterton: “truth standing on its head”) of just-on-time medical care, as seen by someone who has been doing it for 22 years.

1. It ought to result in a lower income, due to open appointments. But it doesn’t. I won’t review the theories why, but it works.

2. It ought to result in scheduling chaos, but it doesn’t. Patients never panic. They know they can be seen when they need to be seen, so they don’t reserve an appointment 10 days down the line in case they are still coughing – and then no-show when the cough is gone.

3. It ought to result in spoiled, dependent patients who call the doctor at the first hint of trouble, but it doesn’t. My home phone is in the book. Patients can reach me 24/7 through a live operator (never a phone tree). They just don’t. I average one page every other night. When patients know they can interrupt your life at any time, they respect your privacy.

4. It ought to result in a healthier population of patients, and it does. In a recent audit of type-2 diabetics treated for over a year in my practice, 40 percent had an A1C less than 7 at diagnosis. But your insurers will decide that this is a result of good luck or covert selection bias, rather than quality care delivered on time.

5. It ought to attract patients to your practice, and it does. That ought to prompt other area practices losing those patients to shape up and quit delaying physical exams for six months. But it doesn’t. I guess working off that backlog is too much trouble.

6. It ought to save your nurses time on the phone. But it doesn’t, because when your patients can’t get through to their neurologist, surgeon, dentist or veterinarian, they call you to find out what’s going on. (Refuse, politely.)

Take-home lesson: Do it right, from the start.

Posted at 02:58PM Feb 27, 2009 by Doug Iliff  |  Comments[2]