Tuesday, June 17, 2008

Open Access and the Patient Centered Medical Home: Uh-Oh!

If you know about the ‘patient centered medical home,’ you know that one of its underlying ‘joint principles’ is ‘enhanced access’ or making ‘care… available through systems such as open scheduling [bolding mine], expanded hours and new options for communication between patients, their personal physician, and practice staff.’ ‘Open scheduling’ has been the topic of an extensive body of peer review literature, much of which has been authored by the same folks that have championed the chronic care model.

Open scheduling or open access is based on principles of just-in-time engineering, queuing theory and other industrial process improvement approaches that rearrange the availability of primary care appointments, including for the same day that patients request it. Tired of being told that your primary care doctor can’t see you for that check up for 6 months? Have you already read all those National Geographics in the waiting room an hour or more after your scheduled appointment? Have you had to choose between being seen late today by an unknown provider versus having to go to the emergency room now for an urgent problem? Open access could be the answer you and your hapless doctor have been looking for.

Or is it?

In the latest Annals of Internal Medicine, Mehrotra, Keehl-Markowitz and Ayanian describe the (pre-post) outcomes associated with a state-of-the-art implementation of an open access scheduling system in six primary care sites in Massachusetts. One practice dropped out. For the remaining five, there was an initial dip in patient waiting times for an appointment, but a) no practice was able to achieve consistent same day access and b) over two years, the gains in waiting times eventually vanished for four of the clinics. In fact, two of them ‘became worse than what we observed before implementation.’ Four of the five clinics were able to complete patient surveys: patient perception of their primary care sites’ access did not change.

The authors point out that the open access was undermined by physician turnover, lack of economic incentives, difficulty in assessing the physicians’ panel sizes and provider skepticism about the ultimate value of same day access. They also noted that the advent of greater availability of health insurance in Massachusetts combined with briefly shorter waiting times paradoxically increased demand from new patients, which exacerbated availability.

The authors deserve a lot of credit for pointing out the limitations of their study, including the lack of concurrent control practices, sample size limitations and incomplete data sets. Interestingly, they also discuss other peer-reviewed publications on open access and note:

'Nearly all the studies have important methodological limitations (many of which our study shares), including no statistical testing, limited access-to-care measures, lack of concurrent control groups, small sample size, and inconsistent methods. Among the few studies that assessed outcomes beyond access to care, open access had mixed effects on patient satisfaction (2 of 5 studies reported improvement) staff satisfaction (1 of 2 reported improvement), and no-show rates (3 of 6 reported improvement). Our results add to this literature and raise the question of whether open-access scheduling truly leads to the ancillary benefits that advocates have proposed.'

Is open scheduling a big, really big promising solution for broadening primary care access under the patient centered medical home? Readers of the Disease Management Care Blog will need to judge for themselves. However, it is at times like this, when so many patients are competing for a limited number of appointments with an even more limited numbers of doctors, that the DMCB turns to the time-tested wisdom of its father.

Years ago, when he critically appraised a new-fangled bathing suit for one of the DMCB’s sisters, his comment was prescient: “It’s like trying to put 30 lbs of potatoes in a 20 lb bag.”

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