BARRIER #2: Capacity
The number of hours per week that a PCP sees patients and the number of patients scheduled per hour determine that physician’s visit capacity. Quality of care is also at stake. Although physicians who schedule 1 patient every 10 or 15 minutes can, of course, accommodate more patients than doctors who spend 20 or 30 minutes per visit, shorter appointments have been found to adversely affect quality.15
Further complicating things is the increasing number of physicians who are opting for part-time work.16 Added to the hospital and nursing home responsibilities many PCPs share, working fewer hours imposes further limits on the number of patients they can care for.
BARRIER #3: Distance
The uneven geographic distribution of PCPs makes access difficult for patients living at a distance from the nearest primary care practice, a particular problem for the homebound and those without transportation. Telemedicine could help mitigate this problem, but few primary care practices are equipped to practice “distance” medicine.
BARRIER #4: Medicaid/Medicare issues
Some primary care practices make decisions about which new patients to accept based on the kind of coverage held by the prospective patients. Medicaid patients have an especially difficult time finding a PCP—far harder than privately insured individuals. Also, in areas in which Medicare fees are below the market rates paid by private insurers, many practices limit the number of Medicare patients they accept.
The bottom line: Already stressed by the economy and low fees, some PCPs say they have little choice but to restrict the number of patients whose care costs them more than they’re paid to provide it.
BARRIER #5: After-hours care
Many patients try, unsuccessfully, to reach their PCP in the evening or on the weekend. The dearth of after-hours access has led to an explosion of “convenience clinics” in pharmacies and shopping malls—and to overuse of the emergency department (ED). In a 2007 national survey, 67% of adults said they had difficulty getting care at night or on weekends unless they went to the ED.17 In another survey, conducted in California in 2006, nearly half of those who sought care in the ED believed their condition could have been handled in a primary care setting, had it been available.18
BARRIER #6: Scheduling
Many patients call their PCP’s office for an appointment, only to find that the next available opening is 3 weeks away. While some groups have introduced open-access scheduling—also called same-day scheduling or advanced access—such a system can only be sustained if the demand for appointments is in balance with the practice’s capacity to see patients.
Part of the problem appears to be organizational. Some physicians routinely make monthly follow-up appointments for patients with chronic conditions, such as hypertension, diabetes, or arthritis. However, the return visit interval is often based on the habits of the individual physician or provider group, rather than on the medical needs of the patients. Indeed, 1 study found that prolonging the visit interval resulted in an improvement rather than a decline in quality of care.19
BARRIER #7: Virtual visits
Many chronic care and preventive care issues could be handled in brief patient encounters via telephone or e-mail. In addition to being convenient for many patients, such virtual visits would increase the practice’s capacity for patients who require in-person visits.20 Here, too, the problem is financial: Insurers generally do not provide reimbursement for virtual visits.
BARRIER #8: Troubles with team care
At some medical groups, nonphysician providers, including registered nurses and pharmacists, use doctor-created protocols and standing orders to address routine chronic care issues and preventive measures for individuals with certain conditions—identified via patient registries. Similarly, medical assistants and community health workers may be trained as health coaches to work with patients on behavior change and adherence to medication regimens, thus freeing up physician time.21 Despite the benefits of team care, most insurers only reimburse the services of MDs, NPs and PAs, meaning that no incentives exist for primary care practices to hire other team members.
The solutions: Policy shifts and culture change
What will it take to improve access to primary care and tear down these barriers? First and foremost, we believe the following policy changes are needed:
- Increase reimbursement for primary care.
- Increase loan repayment programs for medical students who establish primary care practices in areas with established shortages.
- Standardize fees paid by private insurers, Medicare, and Medicaid plans.
- Provide financial incentives for PCPs to deliver after-hours care.
- Invest in a national program aimed at helping primary care practices implement same-day scheduling, team care, and other access improvements.22
- Provide reimbursement for e-mail and telephone encounters and team care, including fees for all allied health professionals who assist PCPs in managing chronic disease and preventive care.