A few weeks ago, while at an out-of-state wedding reception, I began having chest pain that didn't immediately go away with rest and antacids. Although it was unlikely to be an early symptom of a heart attack (I'm relatively young, have good cholesterol levels, and have no relatives with early heart disease), I felt uncomfortable enough to want another physician to confirm that it was only a bad episode of heartburn. But with my family doctor's office hundreds of miles away, the only medical option seemed to be the nearest hospital emergency room. And like most people, I avoid emergency rooms unless I have a broken bone or life-threatening medical emergency.
Fortunately, the pain disappeared and I didn't need to see a doctor that night. But you don't have to be hundreds of miles from home to know that it's tough to get a doctor's appointment when you need one. According to a 2009 survey, the average wait time for an appointment with a family physician was nearly three weeks, and up to two months in some cities. Because last year's health reform law is expected to result in more people having health insurance, these wait times may become even longer, as more patients compete for increasingly scarce spots in doctors' schedules.
Primary care offices have historically handled patients with urgent problems by assigning one doctor "acute care" responsibilities for the day or squeezing extra patients into already crammed schedules. The downside: Patients can end up seeing doctors who are unfamiliar with their medical histories, harried due to time pressures, or both, which raises the risk of misdiagnosis or improper treatment.
That's why some practices (including the federally funded Veterans Heath Administration clinics) have switched to "advanced" or "open-access" scheduling. Rather than scheduling a visit weeks or months in advance, patients can call for an urgent or routine appointment the day before or the same day they want to be seen. This arrangement works because physicians' schedules are kept empty until 24 hours ahead of the appointment time. A recent review of 28 studies published in the Archives of Internal Medicine found that advanced-access scheduling increases the chance that a patient will be able to see his or her doctor and reduces no-show rates. Although there were too few data to draw firm conclusions, many experts believe that advanced access decreases emergency room visits and improves patient satisfaction and medical decision-making, too.
Another innovation to improve access is the "concierge" or direct-pay medical practice, where patients pay a monthly or annual membership fee directly to the doctor—rather than to the insurance company. Freed from the administrative expenses associated with filing insurance claims, these practices offer shorter waits, longer visit times, and unlimited telephone and E-mail consultations. Although the first direct-pay practices charged thousands of dollars per year and were therefore available only to the rich, direct-pay practices with affordable fees are increasingly cropping up. For example, California's MedLion and Seattle's Qliance Medical Group charge patients $49 to $89 per month. The Direct Primary Care Association has a state-by-state list of direct-pay practices on its website.
For patients who don't live near advanced-access or direct-pay practices, telehealth technology has made speaking with a primary care doctor by phone or online video conference easier than ever. Teladoc offers 24-hour access to board-certified primary care physicians in every state. Since virtual consultations are less expensive than in-person visits (and far cheaper than an emergency room visit), many insurers will pay for them. If you would prefer to consult your own physician, groups like Hello Health are connecting doctors with patients via online "portals" that also allow you to access portions of your electronic medical records, such as specialists' notes and laboratory test results.
So the next time you need to consult a doctor but can't wait weeks for an appointment, consider choosing a practice with advanced-access scheduling, direct-pay models, or telehealth services. These innovations will never replace the old-fashioned house call, but they are probably the next best thing.