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Fredrik Broden

DIAGNOSIS:
Doctor’s Office Rebellion
PRESCRIPTION:
Put the patient first.

What does this mean for you? Same-day appointments, no more sitting for hours in crowded waiting rooms, and -- gasp -- weekend availability from a doctor!


At the office of Lynn Ho, MD, the doctor is essentially always in. If she’s with a patient, voicemail picks up and asks you to leave a message on an in-office answering machine; she typically returns messages within the hour. Need to speak with the doctor urgently after her office has closed? No worries -- her voicemail lists her cell and home numbers.

But that’s not the most startling part, at least from the perspective of this longtime medical reporter and occasional patient. Rather, it’s the fact that no more than one or two patients call those numbers after hours in a given week. Why?


Dr. Ho cites the trust that she’s built over time. “That’s the paradox of really good access,” she says. “People know they can get you in the office. They know you’re going to return their calls.”

The Rhode Island family physician runs a micro practice, a solo physician office that strips overhead to the bare minimum, works without staff, and leverages computer software and other technology to maximize patient access and care. Dr. Ho designs her schedule so that roughly two-thirds of the available appointments on any given day are open in the morning of that day. Thus, any patient who calls in for a same-day appointment can get one. (Using an online scheduling system, patients can select the most convenient time from all remaining available appointments.) She also offers evening hours and some weekend availability. And in recent months, she’s added online physician consults.

To better address the long-standing disconnect between patient and physician needs, other primary-care doctors are starting to take similar steps, albeit typically to a lesser degree. They’ve been inspired by the ongoing work of numerous groups, including the American Academy of Family Physicians (AAFP) and the Institute for Healthcare Improvement (IHI). Their goal: to focus on patient-centered care and still build a financially thriving practice.

It’s a tall order, for sure, but one that’s driven in part by competitive pressures, as well as by a desire of physicians like Dr. Ho to provide better treatment. One major challenge is the surge in retail health clinics nationally, from just 141 clinics in April 2006 to nearly 1,000 today, according to data from Merchant Medicine, a Minneapolis-based research and consulting firm for retail and onsite clinics. The clinics, located within pharmacies and other retail settings, offer walk-in access and a set list of charges.

MINUTECLINIC, FOUNDED IN 2000, is currently the nation’s largest provider of retail health clinics. The company operates as a subsidiary of CVS, and the clinics are located on-site, although prescriptions can be filled elsewhere. The clinics follow a specific model, with a list of relatively minor medical conditions they’ll treat and a price list for each service, whether it’s a shot, an office visit, or a strep test.

Vickie Knox visited a MinuteClinic in her Fort Worth, Texas, suburb after she developed a sore throat that was so painful it was keeping her awake at night. She was slated to run a marathon -- her first -- two days later, and she didn’t want to lose crucial time attempting to get an appointment with her family doctor. At the clinic, she was able to walk in, get a test for strep, and learn that the result was negative, all in roughly 30 minutes. The visit, including the rapid strep test on-site and the additional follow-up lab confirmation, cost only $100, which, since Knox is covered by a high-deductible plan, counts toward her deductible.

Intrigued by the concept, Knox says she would definitely visit the walk-in clinic again. “An antibiotic is an antibiotic,” she says. “A lot of times, you know that’s [all] you need, and you [just] want someone to write [the prescription] for you.”

This spring, there were at least 517 MinuteClinics operating nationally, with additional sites in the works. In the Dallas/Fort Worth area, the first clinic opened in August 2007. By mid-April 2008, 24 were operating in the metropolitan area. Other retailers, including Walgreens and Wal-Mart, also are affiliated with on-site health clinics.

Some physicians grumble that the retail health clinics, which are primarily staffed by physician assistants and nurse-practitioners, are skimming off the easier medical problems, leaving the more complex and costly care to the patient’s regular doctor. In a statement published in late 2006, the American Academy of Pediatrics listed a series of potential concerns, including fragmentation of medical care and a missed opportunity to discuss chronic health issues, such as obesity, if so-called minor conditions were diverted to the retail clinics. Michael Howe, MinuteClinic chief executive, counters that his clinics shouldn’t be viewed as a direct competitor to local doctors but rather as an adjunct. “The reality is that physicians will tell you that they didn’t go to medical school to treat ear infections,” he says.

With the patient’s consent, a summary of the clinic visit can be forwarded to their regular doctor, Howe says. And when a patient doesn’t have a regular doctor -- nearly a third of MinuteClinic patients don’t -- a list of physicians accepting new patients is provided, he says.

Still, some physicians remain wary, says Jim King, MD, president of the AAFP, one of the leading physician groups promoting the concept of patient-centered care. To remain competitive, and to discourage retail-clinic openings, Dr. King’s multiphysician practice in rural Tennessee recently added a fast-track room for strep throat, bladder infections, and other easy-to-resolve medical issues.

A fast-track patient is guaranteed to be in and out within 30 minutes, Dr. King says. In return, the patient agrees to see any available doctor. He or she also waives the right to what Dr. King describes as the “by the ways,” such as, “By the way, I need to get my cholesterol checked.”

The patients are happier, and so are the physicians. By limiting the fast-track room to uncomplicated medical issues, the doctors can duck in when they have a few minutes of downtime. As a result, they are treating -- and billing for -- more patients.

INNOVATION, THOUGH, can be more than a bit chaotic and frustrating.

In 2006, TransforMED launched the two-year National Demonstration Project, which involved 36 family-medicine practices, to assess the challenges and results related to same-day scheduling (also called open-access scheduling) and other patient-friendly strategies.

To reach the goal of seeing patients on the same day that they call, doctors may have to work longer hours for a stretch -- sometimes for up to four to six months -- to chip away at the backlog of appointments, says Terry McGeeney, MD, TransforMED’s chief executive. Physicians have to analyze their own practice rhythms to figure out when and how appointments stack up. They need to be honest about staffing. Do they have enough staffers to clear the schedule each and every day?

When the transition is completed successfully, physicians can reduce by half one of their biggest frustrations: no-show patients. Seven to 20 percent of appointments in a doctor’s practice may turn out to be no-shows, says Gordon Moore, MD, a faculty member of the IHI and one of the first physicians to adopt and write about the micro-practice concept. When patients can book appointments when they need them, they’re less likely to forget about them; in addition, their medical problems won’t have improved by the time of the appointment.

Open scheduling has the added draw of stabilizing a physician’s schedule. To compensate for the anticipated no-show patients, doctors may overbook. Thus, some days, the waiting room is crammed. Other days, when the no-show rate runs particularly high, the doctor might be itching for more to do.

Other efficiencies can also be achieved. Dr. Moore says that with the back-and-forth conversation required to determine the relative urgency of the patient’s condition and the doctor’s availability, a traditional practice may take nine minutes to schedule a patient. With open scheduling, at Dr. Moore’s practice, that call takes less than 30 seconds, which leaves more time to devote to the next patient.

IN A SENSE, THESE physician pioneers are swimming upstream by attempting to revamp medical treatment amid escalating financial and logistical pressures.
Since primary-care doctors are historically some of the lowest-paid physicians, it’s difficult to interest medical-school graduates in the specialty. And as the population grows and ages, signs of strain in the field are becoming visible. A Commonwealth Fund study published last year assessed primary-care access, among other medical issues, by surveying approximately 12,000 residents in seven countries. In the United States, just 30 percent of those surveyed reported that they could obtain a same-day appointment with a doctor when they were sick. Only Canada, with a 22 percent rate, fared worse among the seven countries studied, which also included Australia, Germany, the Netherlands, New Zealand, and the United Kingdom.

Meanwhile, reimbursement models encourage doctors to adhere to a well-worn practice model. Only recently, for example, have a few insurers started to reimburse for online consults, says Dr. McGeeney. (Dr. Ho, who has yet to be reimbursed by insurance for virtual consults, charges her patients $25 out of pocket per session.) But doctors are learning that better patient care can dovetail with good business practices -- in the long term, at least, he says.

Smarter use of technology is crucial. Ever since Dr. Ho launched her micropractice in 2004, she has managed to run a paperless office, which is more efficient for her practice and her patients. Prescriptions are sent to pharmacies electronically, so patients don’t have to spend time waiting around for their medications to be prepared. And when Dr. Ho decided that the scheduling of patient appointments was taking too much time, she developed an online system.

As she has fine-tuned her practice, Dr. Ho has also benefited from information and feedback that she has received from two groups that are focused on the ideal medical- practice model: an informal Yahoo! Groups listserv called “practiceimprovement1,” which has more than 650 members and was started by Dr. Moore in 2003, and the more formal grant-funded national collaborative study called IdealMedicalPractices, headed by Dr. Moore and Dr. John H. Wasson. The techniques developed by IdealMedicalPractices, whose participants include Dartmouth researchers and the IHI, among others, can be applied to physician practices large and small alike, says Dr. Moore.

“What we’re about is how to achieve low overhead so you [the physician] can step off the hamster wheel and still deliver good care,” Dr. Moore explains. “What’s driving a lot of doctors to test this model is the desire to get back to what drew them into health care in the first place.”

Plus, today’s patients are more willing to shop around than they are to cool their heels in their doctor’s waiting room, says Dr. King. “Even though most of us don’t want to admit it, we [doctors] are physician centered. We center the appointments, and the day, around our lives. We’re going to have to rethink that. We provide high-quality care, and we need to start looking at satisfaction for the patients.”