Why Do You Have to Wait So Long?
Case #1 - Episode 4 - Waiting is the #1 Complaint about Healthcare
When you pass a restaurant at dinner time that has only a few cars in the parking lot, you wonder why no one is eating there. An empty waiting room in a doctor’s office can mean something entirely different. Why are doctors’ waiting rooms always full?
THE PATIENT JOURNEY
The 24-year-old female was well for two months after her second urinary episode, but her symptoms reoccurred. She called the office and requested an immediate appointment for a problem she had been previously treated for, but, like last time, she was told by the pool receptionist that she would have to speak to the nurse to be seen by her doctor earlier than 2 months. She waited until the end of the day to have the nurse return her call. The nurse told her she could come in the morning and wait for an available provider to be seen.
Waiting in the Doctor’s Office
The goal of the large health system is to keep the doctor’s schedule full. The pool receptionists fill the schedule months in advance without regard for patients or physicians. I recently got an appointment for myself a year in the future. Schedules are full for several reasons:
Patients’ time doesn’t matter. There is no reason to consider patients’ time because they aren’t paying the bill, their insurance company is. The health system’s contract is with the insurance company who is representing the employer, not the patient. As long as the waiting room is full, health system management is happy. Just waiting all day to talk to the nurse to even know if you can be seen is ignoring the patient’s anxiety over being sick. When you arrive at the office, doctors often run late, patients begin to arrive late, so it pushes back the entire schedule, making subsequent patients wait even longer. Many practices don't have late policies or incentivize punctuality because management prioritizes the maximal number of office visits which equals the most money.
Inefficient scheduling practices. There is no incentive for the big health system to adhere to a timetable because nobody pays for scheduling an appointment. Many practices don't effectively manage their schedules, overbook patients, fail to account for inevitable delays, and don’t consider longer appointments for certain complaints. Insurance companies typically cover only seven to ten minutes of a primary care doctor's time face-to-face with a patient because of added five to eight minutes of administrative paperwork.1 Ten minutes is insufficient for diagnosing and treating anything beyond the simplest conditions. When a patient comes to a primary care physician, the patient may have any number of a myriad of health problems which takes time. A simple urinary infection takes less than ten minutes, but a “personal problem” that involves thoughts of suicide can take more than an hour to diagnose and make a referral that must be approved by the insurer. With four patients scheduled per hour, the result is a cascading effect of longer waiting times throughout the day even if doctors work through lunch.
Shortage of primary care physicians. The United States is facing an increasing shortage of primary care doctors.2 Reduced reimbursement rates from insurers and other factors finally made it difficult for family physicians to operate sustainably as discussed in “Why Won’t the Doctor See You Now?”3 Consequently, many medical students, burdened with significant student debt, choose higher-paying specialties over primary care.4 As more doctors retire, their patients struggle to find new providers, exacerbating the strain on the already limited supply of primary care physicians. This shortage ultimately results in fewer available appointments for patients.
High patient demand. With fewer primary care doctors, the remaining physicians have to take on more patients, resulting in overbooked schedules and long waits for appointments.5 COVID made people delay care which has resulted in more demand subsequently. The delays in care have caused people to ignore preventive measures and to have more advanced disease.
Flawed third party reimbursement model. The fee-for-service insurance model incentivizes doctors to see more patients quickly, rather than taking time with each patient to make a diagnosis by talking to the patient. The famous Canadian physician Sir William Osler, considered one of the founding figures of modern medicine and known for his emphasis on patient care and bedside manner, said, “Talk to the patient long enough and they will tell you their illness.” Today when a doctor is unsure of the diagnosis, instead of taking additional time to gather historical data, they order tests to confirm their hasty impression. Today’s motto is “Greet ‘em, treat ‘em, and street ‘em.” Worse, the system pays the doctor more to order tests, use ancillaries, and make referrals to specialists than to make a diagnosis by talking to the patient. This leads to tightly packed schedules prone to delays if anything unexpected happens.
THE PATIENT JOURNEY
When the 24-year-old returned in the morning, she waited 3 hours to see yet another provider to have her urinary symptoms treated. She had only a short interaction with the provider and received the same treatment she had gotten before.
Long Waiting Causes Unhappy Patients
When patients wait too long they become dissatisfied in significant numbers:
23% will get up and leave without seeing the physician6
22% will tell friends and family to not visit that practice7
7-9% will leave a negative review about the practice8
And nearly 20% will switch to a new doctor9
Many doctor’s offices don’t appear to have positive reviews on the internet. Was the experience of the 24-year-old female with urinary symptoms typical of that of other patients - difficulty getting an appointment, frustration with office processes, and seeming lack of concern about the patient’s time?
Anecdote:
Twenty-five years ago, before insurance paid for doctor’s office visits, the patient decided about the doctor and office in a simple manner. After a visit, they came to the front desk to check out and either wrote a check or “forgot their checkbook” and never returned. Patients had control over the quality of care, access to care, and cost of care.
Opinion:
The patient’s time is valuable. There is no excuse to waste a patient’s time considering modern information tools can easily manage healthcare. Today, patients are irrelevant to how health care is delivered by large health systems.
Preview:
The next Episode will explore how doctors have become helpless to improve patient care in the healthcare system. A future episode will examine why tattoo parlors have better Yelp reviews than medical offices.
PATIENT ACTION
When you arrive for an office visit, ask if the doctor is on time and how long you can expect to wait. If the wait will be protracted, ask if you could leave and be re-scheduled later in the day or receive a text when it is closer to the time you will be seen.
Speak to the office administrator about how the scheduling might be improved.
Look at internet reviews and comments about the practice. Ask the office manager if they have looked at their reviews?
Does the practice have a patient advisory group?
PHYSICIAN ACTION
Does your office offer non-visit care options for patient visits? With minimal clinical information this patient could have been sent to the lab for a urinalysis and this patient’s complaint addressed quickly. This was the primary approach during COVID.
Has this office considered pre-visit screening using patient interview software to access patient needs before arrival? The office can get paid for Code G2012 for efficiently planning the patient’s visit. The History of Present Illness generated by the software can go directly in to the EHR saving documentation time if an office visit is needed.
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