Family Physicians Unlock Advantages with Open-access Scheduling Options

When Jason Schulz's two sons fell ill on the same day recently, he wasn't surprised that Doug Iliff, M.D., was able to see them that very day. It's the sort of service Schulz has come to expect from Iliff's solo practice in Topeka, Kan.

We've used (same-day appointments) quite often," Schulz said. "I don't remember ever not being able to get in the same day."

That's because Iliff's practice uses a variation of open-access scheduling, which is advocated in the Future of Family Medicine report. The project's Task Force 6 report said open-access scheduling would decrease the number of visits per patient and increase the "intensity" of services provided. The report estimated compensation would increase $9,133 per physician.

Iliff wouldn't have his practice any other way. He asks his staff to leave all appointments open after 2 p.m., usually six to eight appointments, for patients calling in that day. It's simple practicality, he said.

"There's nothing more efficient than handling something right now. It makes sense to see someone when they've got the problem," he said.

Iliff noted a competitor's patients must schedule their physicals four to six months in advance. Iliff's patients can schedule physicals in about a week.

"The way we do this is not the most convenient to us," said office manager Gay Schneider. "But I can look our patients in the eye and know that we're putting them first."

In the world of supply and demand, scheduling methods can be viewed along a continuum from traditional to advanced-access. Advanced-access purists leave most of their appointments open until the current day. By comparison, the traditional model fills all openings before the physician arrives in the office each day; the doctor accommodates last-minute visits by double-booking, working late or playing catch-up. Physicians somewhere in the middle, like Iliff, carve out some times for same-day appointments.

Offices can establish urgent care centers as an alternative to truly open-access scheduling, but patients usually don't see their primary care physicians, which goes against continuity of care. Furthermore, the patients often defer routine needs to another office visit.

Office manager and self-described "master scheduler" Cheri Murray of Wichita Clinics, which includes FPs, pediatricians and dermatologists, recalled days when the facility used traditional scheduling.

"We weren't really making effective use of our time," she said, because physicians -- concerned they might have a glut of physicals -- had established an elaborate system that qualified types of visits. One doctor had about 250 visit types.

"It was a behind-the-scenes scheduling nightmare," said Murray, estimating that patients waited six weeks for physicals.

Now there are no restrictions, except for surgical procedures that must be done in the mornings for practical purposes.

"We want the patients who call in today to get in and be seen today," she said.

FP Mark Murray, M.D., M.P.A., of Sacramento, Calif., several years ago helped engineer Kaiser Permanente's switch to advanced access in northern California, replacing a 55-day wait for an appointment with same-day scheduling. The change worked for more than 100 primary care physicians caring for more than 250,000 patients.

Delays, he said, result from mismatches between supply and demand, and the traditional method of scheduling exacerbates the problem by reducing supply.

"What I recognized over a long period of time was that the distinction between urgent and routine appointments actually became a barrier to solving the capacity and continuity problems," he said.

Open-access scheduling is "basic queuing theory" used by industry, be it fast-food chains or other concerns, he says.

He advises practices to begin by measuring supply and demand. Supply is the amount of time allotted for patient visits. Demand is the amount of work generated on a daily basis, whether the appointments are walk-ins, call-ins or follow-up visits.

Of course, most physicians want to see an increase to their bottom line when they implement change. FP Todd Fristo, M.D., of Lee's Summit, Mo., measured statistics before and after implementing open-access scheduling. Before, the rate of no-show patients was 6 percent to 8 percent; after, the rate dropped to 2 percent to 3 percent. But there are other tangibles, he said: "My patients are happier and my front staff loves it."