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I’m quoted in the Boston Globe today (A new practice: The doctor will see you today) on open access scheduling. (I’m all the way down at the bottom of the article.)

Open access is one of my favorite innovations because it improves customer service and quality levels. As we add patients to the system open access provides a way to preserve or improve access to the physician. It’s better—in my view—than other solutions such as using more mid-level practitioners and trying to boost the total number of doctors.

Open access means seeing today’s patients today rather than forcing them into a slot far in the future or trying to squeeze them in to a crammed schedule. The example given in the Globe article is a more extreme version than what I’m used to. I’m not sure such a radical shift to open access is optimal. It might be best to preserve a lower percentage of slots for same-day access rather than forcing folks in today who’d prefer to wait a bit!

What’s required to make open access work?

  • Working overtime to chip away at the existing backlog (otherwise there’s no free time to offer up)
  • Varying number of hours worked per day to accommodate fluctuating demand
  • Having the right sized patient panel—something that’s somewhat hard to assess in advance, since the true demand is unknown (offices usually just know how far out they are scheduling)

Why does it work?

  • There’s a high no-show rate from appointments made weeks or months in advance

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma,  biotech, and medical devices. Formerly with BCG and LEK. He blogs regularly at Health Business Blog, where this post first appeared.

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18 Responses for “Open access scheduling at the doctor’s office”

  1. propensity says:

    Like Southwest Air’s program for seat assignments. A doctor must always have slots open to see cases of urgency. This program is a no-brainer. If you can wait 60 days, you are not sick, so why are you going in the first place?

  2. MD as HELL says:

    An unfilled open slot is a missed opportunity in today’s primary care office. Urgent Care arose to meet the need of the patient who could not or would not wait to see his or her own physician. Urgent care does not manage chronic disease, although we find many people coming in to see us since we have the flexibility to spend more time with patients, having no schedule to meet. per se.
    Propensity must have dozed through all the posts espousing the benefits to be reaped from preventive care, which could wait. Better get used to wating with this bunch in charge; bring a book and several meals while you wait.
    If patients miss apoinments they may be dropped by the doctor.
    Doctors already work “overtime”. What do you want, blood?

  3. Truth Seeker, MD says:

    I seek the truth and I seek disease. I allow time for patients who need urgent visits because urgent care centers oft screw up the prior care I organized previously. Preventive care other than aspirin, paps and mammos, BPs, and lipid control are massively cost ineffective. The worried well waste time.

  4. MD as HELL says:

    In general I agree with Truth Seeker, MD. My urgent care is the preference of all our top tier primary care docs as the alternative when they cannot see their own patients. We have been the ED docs for 30 years. They know us and trust us.
    Of course “preventive care” is not cost effective. That is why we are broke; because the worried well tap into resources because it costs them nothing. A nervous Medicare patient can burn through $250k per year and have nothing wrong.
    Open access works when their is excess capacity. The feds have deliberately reduced the primary care capacity with their reimbursement policies and with EMTALA allowing everyone to seek instant gratification in the ED, leading to loss of capacity for real emergencies.
    Not until the patient controls the money AND puts up the money will there be sanity in American health care.

  5. Hommer says:

    “Working overtime to chip away at the existing backlog (otherwise there’s no free time to offer up)”
    Exactly was key for me !
    thanks for your wonderful post.

  6. pcp says:

    “Open access is one of my favorite innovations because it improves customer service and quality levels.”
    Good docs have been doing this for centuries. To pretend that this is new and innovative is typical of the administrative baloney that makes up the PCMH and other “new” models of medicine.

  7. Anon says:

    @pcp you are exactly right. I instruct my receptionist that all sick patients that want an appointment get seen today! No triage, make them an appointment if it means I work until 8 PM. We leave 4-6 slots open per day. We almost never have no shows because we call to confirm the day before. We often get patients who forgot and have other commitments at that phone call then we reschedule them and the appt opens up for someone else. The problem with most practices is they let their panel size get too big (especially too many resource sucking/underpaying Medicare patients). Then there is no way to do both primary care and urgent care. I tell my staff, “Of course I want to see my patients when they are sick! That’s why they have a primary care doctor!”. I’m sure the current crop of clock punching residents love this open scheduling idea.

  8. Gary Lampman says:

    The answer is to delegate to nurse Practioners and Doctors provide oversite for the decidions that are Made.
    A comprehensive overhaul of the medical field is clearly needed as the cracks in care by speciality are clearly obvious in the Health Care Field. Often times patients have the misconception that the ER is the end all of treatment, but their job is to provide the bare essentials to stabilize a patient.
    Your patients are clueless of your field responsibilities and where they end.The lapse in communication and understanding has been fatal for some patients.
    As I have seen new bill boards along the interstate that show ER wait times. I think of how commerialized Hospitals have become to recruit warm Bodies. What keeps people away is lack of insurance,High infection rates such as MRSA, under staffing,symptom only treatments,over use of testing to share the wealth and re admission for the same Problem.
    However,the message is clear that Health Care has overpriced their services and accountability for botched procedures leaves the patient with all the financial burdens. A win-win for the provider.

  9. Kenz300 says:

    Health insurance prices keep going up. I wonder why health insurance companies still use an out dated pricing policy. They generally have three tiers for rates.
    1. Single
    2. Married
    3. Married with children
    I wonder why they do not charge a per person rate. Why should someone with one or two children subsidize a family of 6 or 8? Rates should be based on the numbers of users. If you have 6 or 8 children using insurance then your cost for insurance should incrementally reflect it.

  10. Anon says:

    @Gary,
    How does one find a good nurse practitioner? Please enlighten us. How is your NP treating you and your children? Do you choose one right out of NP school when their knowledge is fresh or is it better to choose an experienced NP? Or should I just let the doctor or practice choose one for me and see whomever they hire?

  11. IMP 110 says:

    I have been doing open access scheduling for 5 years It is not necessary, as stated above unfortunately, to work down the backlog- eg work overtime- so as to “find” “free time to offer up”
    The most crucial thing to be successful at this is to be willing to manage panel size One can begin by picking a start date a few months ahead, when the schedule is already largely empty A good rule is not to have more than 1/3 of the patient-seeing time of the day blocked out ahead of time.This makes it possible for anyone who wants an appointment that day to be seen no matter what the reason
    There are fine points however tailored to differnt practices.
    I have taught this tomany
    This way of taking care of people reduces ER over utilization, improves confidence and is good for both patietns and docs
    No need for all this bluster and huff on these blog comments! Good grief folks.
    Open or advanced access scheduling can be put into place by anyone willing to learn and plan a nd it is the only thing I have ever seen that makes doctors(providers) and staff and patients ALL happy.
    member impcenter.org idealmedicalpractices

    • HM says:

      IMP 110, My organization is making plans to offer open access scheduling within the next year. Your comment about not needing to work down the backlog is intriguing. What panel size threshold do you recommend for a physician planning to work 36 hrs per week? Rather than working down the backlog, did you simply freeze your schedule a few months ahead so that future appts were not scheduled in advance and then educate patients about calling for appts as they would like to come in? How many visit types do you recommend? Any suggestions you can give will be greatly appreciated.

      • J Antonucci says:

        Ideal panel size is not determined by numbers Panel size is defined really as having the number of patients in your panel to whom you can offer an appointment that day for any reason the appointment is desired( tortured grammar) If you see older complex patietns or mostly HIV patietns for example thus needing fewer but longer visits ,your panel size will be smaller. If you work 10 sessions a week vs 8, panel size then can be bigger And so on If you take on more patients than you can accommodate in a day( roughly 1 % or less of your panel will call in a day asking to be seen-roughly10 people call/day in a panel of 1,000,…actually less in mine .There are some fine tunings for which this venue has not enough space,,,)) Primary care can extend by offering e visits or extending re visit interval time….
        Common complaint is the whine of this panel is too small! There aren’t enough PCPs.. I have to have a panel of 2500- this is a societal issue and burns out docs as they zoom around barely offering good care to too many people; and cannot be addressed in this reply email blog.:)
        PIck a day a few months from now when the schedules have few people already booked
        PIck one of those days for the start date. Before that prep yourself and most esp. the team- the most important person is the person who answers the phone S/he must know what to say-which is is basically”would you like to see your doctor (nurse) today?’
        Then give them a time More can be said but that is the short version that works .You CAN of course book appointments ahead , of course but NEVER have more than 1/3–1/2 of any given day prefilled When you come in to work on any given day there should be 1/2–2/3 of the time still open. for those who call. When you see patients you can offer them the f/u visit time as you are used to doing – just never add them in to a day that has more than 1/3 or 1/2 of its visits already booked ,OR, once patietns find you mean what you say , instead of the appointment card for a date in November say, you give them a card/visit summary that says call to be seen in early November. You must have a tickler system so they do not get lost However mostly patietns returning have chronic meds Do the refill until they need to be seen…. If they have no more refills-if as of November they are running out of pill s they know to call and you see them that day and then do their refills until they need to be seen again This works fabulously I have been at at for 6 + yrs. I have virtually zero no shows
        If you want to put you email in your reply I can tell you m ore off list
        I d o work with IdealMedicalPractices . IMPcenter.org We are a 501 c3 nonprofit teaching docs to transform their practices Have a conference in October outside Washington DC where we teach cutting edge stuff. This blog is not enough space to say more I think However open access scheduling is the best thing I have ever done It makes staff happy docs happy and patietns happy AND it reduces ER use Which drives down costs and increases good experience of care

        • Adel Miles says:

          If you would be so kind as to give me your contact information, I would like to talk with you. I am a healthcare consultant and find practices with access problems all the time. They are very resistant to change however, I would like to learn more about your Nonprofit teaching. Perhaps I can become present the idea of open access more successfully. Thank you in advane.

          Adel Miles CPC, CHA

      • J Antonucci says:

        Did not understand here IMP 110 and J Antonucci- I am the same.:)

  12. Ana says:

    David, I agree and respect your thoughts on open access scheduling. In today’s time when patient’s satisfaction is declining because of long wait times, open access scheduling “doing today’s work today” concept will surely help. I am working on a similar concept at http://www.DocAsap.com, enabling patients to utilize open access to book their appointments over the internet in a timely manner.
    With timely appointment, we will see sharp decline in ER visits and at the same time practice utilization can be improved by matching unmet patient demand with available doctor supply.
    Thanks for making people aware of this very important concept.

  13. Marina says:

    I personally use an online scheduling software ZocDoc in my practice. I found it to be a cost-effective solution, and I slowly convert my patient base to use that option instead of calling in. Overall, I believe these breakthroughs in IT and technology help lift the cost burden from the doctors and provide ease of online environment to the patients.

  14. Adel miles: I am Jean Antonucci MD and I have a website jeanantonucci.com The 501 3c is Ideal Medical Practices impcenter.org We have a confernce in SanDiego in late October Come to it. Send the practice you work with You can hiire me to teach the practices if you would like:)

    Practices are resistant to change becasue of several things- money in primary care is soo bad people are afraid o f losing revenue; or people have been told that to do this they have to work MORE– to work down the backlog .Working MORE is cruel and not needed Also practices are chasing their tails -visits are too busy and without “breathing room’” change does not get made Ideal Medical Practies knows alot about all of this.I can’t type though…

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