As the head of a large primary care department at a Kaiser Permanente facility in Northern California, Dr. Mark Murray knew he had a problem. The average wait time for an appointment was 55 days, and even then, patients had less than a 50-50 chance of seeing their own primary care physician. On a personal level, listening to complaints from his dissatisfied patients was frustrating. And as a doctor, the situation made him extremely uncomfortable. "I knew that inside those 55 days there were mammograms that needed to be done, patients with chronic conditions that were getting worse," he says.
During the 1990s, Murray tried everything from increasing overtime to centralizing the phone system, but nothing seemed to have any effect on the bottlenecks. He was responsible for 250,000 patients, 100-plus doctors, and 400 support staff, and nobody was happy. That's when he realized that his problem was one the business world had solved long ago. "If you go to Starbucks (SBUX), they don't ever say, 'we don't have lattes today, come back later,'" he says. "They have a plan to match their supply with your demand as quickly as possible. Why can't [health care] be the same way?"
The Open-Access Model
Borrowing principles from operations research, he decided the solution was to create a lean production system—reducing inventory (the appointment backlog) by as much as possible. Under the traditional appointment system, routine visits were scheduled well in advance, while a few slots were kept open for urgent cases. But the longer the wait time, the higher the likelihood of cancellations and no-shows. Those missed appointments left gaps in doctors' (officially "full") schedules while adding to administrative work—hurting the doctor's bottom line and driving up overall health-care costs. A 2001 study showed missed appointments at a family clinic were resulting in a loss of 3% to 14% of annual revenues.
But Murray's just-in-time approach—called open-access or advanced-access scheduling—eliminates those inefficiencies by offering every patient a same-day appointment, no matter how serious their condition. And surprisingly enough, it works.
Studies have shown the approach to be an effective way of cutting wait times in both managed-care and fee-for-service settings. The idea of "doing today's work today," encourages doctors to eliminate unnecessary follow-up visits (and the administrative costs they entail) by grouping more services into each appointment—and billing accordingly—improving patient satisfaction while making practices more profitable. It was welcome news for doctors concerned about their ever-shrinking profit margins, especially for the three-quarters of physicians across the country working in solo or small-group practices.
Putting It Into Practice
Murray wrote several papers about the approach for journals related to family practice management, and the idea was widely circulated. Murray's Sacramento (Calif.)-based consultancy, Mark Murray & Associates, works with health-care organizations across the country to apply open-access scheduling and other efficiency strategies.
Murray estimates that as many as 20% of primary care physicians are currently using open access, but for most Americans, getting a timely doctor's appointment remains a pressing concern. According to a study by the Commonwealth Fund, a health policy think tank, only 30% of U.S. patients in 2005 had same-day access when they needed to see a doctor, and 23% waited six days or more.
Why aren't more doctors making the switch? For one thing, even doctors on board with the principles of open-access scheduling find that the implementation is challenging. To work, it requires doctors to first figure out how to bring into balance their supply (the number of available physician hours) with their demand (the number of patients), by reducing the amount of time spent with each patient, working more hours, or closing their practice to new patients.
While the question, "How big should my practice be?" seems simple, it's actually a complex calculation—one that Murray says requires doctors to think differently "by relying only on data, rather than anecdotes or feelings."
That's no small feat, especially for smaller practices that don't typically collect the relevant data.
But as Columbia University Professor Linda Green realized, answering the size question was a matter well suited to her expertise in operations research. Working with a department colleague, Professor Sergei Savin, the researchers designed a mathematical model that doctors could use—in the form of a simple Excel spreadsheet—to determine how many patients they could accommodate and help predict how many hours of overtime they'd need to work to keep up with changing levels of demand.
A paper about their research is set to be published in the April issue of the Joint Commission Journal on Quality and Patient Safety, but Green and Savin have already gotten more than a dozen e-mails from interested doctors who read about the model on Columbia University's Web site, including requests from several large Midwest practices. Green admits, "There's more interest in this than we ever expected."
Some of that interest may be due to the fact that—at least for now—Green and Savin are giving the spreadsheet for free to any doctor who asks, though they have begun talks with at least one software vendor interested in licensing the technology. Green says the model has potential applications not only in other areas of health care, but in any setting—such as a busy salon—that deals with serving a defined amount of customers in a limited amount of time.
Of course, ending wait times at doctor's office will take more than a spreadsheet. "It will help, but it's not the Holy Grail," Murray says. The underlying challenge, the researchers say, is to change the way doctors think about the management aspects of health care. "We think we're different—that things like supply and demand don't apply to us. But we're no different from Starbucks or Wal-Mart (WMT)," Murray says.