Interview with Dr. Thomas Lee on the financial incentives that keep providers from reducing patient waiting times.
When patients wait weeks or months for physician’s appointments, bad things happen. Some adverse consequences are emotional: patients become anxious and even angry. Some are clinical, such as medical issues that worsen, especially if patients don’t show up when their appointments finally roll around.
But other consequences of long waits are financial, and they help explain why most health care providers have dragged their feet in cutting waiting times for all types of visits, but particularly for specialty care. Redesigning care to reduce waits requires investing in systems, may reduce revenue, and will irritate physicians who like to control their schedules.
Understanding the financial dynamics of the “Waiting Game” can clarify the strategic context in which waiting times are most likely to fall. It also sheds light on the implications of fee-for-service versus value-based payment methods for the way practices and systems approach the access conundrum.
Waiting has emotional effects on patients. Uncertainty causes anguish, particularly in patients concerned that disease may be progressing and intervention opportunities may be lost. Other variables such as teamwork, communication, and empathy are more powerful drivers of patients’ likelihood of recommending clinicians to others, but no one likes to wait. Data reveal a dose–response effect: the longer the wait, the lower patients’ satisfaction with care. When patients have to wait weeks for a specialist appointment, their satisfaction falls off a cliff.
Given this trend, it’s ironic that physicians often cite long waiting times as evidence of their excellence. Physicians and practice administrators rationalize delays by noting that they’re already working flat out and demand for their services is simply too great. Most deny that they like having long waiting lists, but when their lists shorten they worry that competitors are taking their business. In a fee-for-service environment, physicians dread having open slots in their schedules, bringing in no revenue while expenses mount.
The longer patients wait for their appointments, the greater the chance that they won’t show up (see graph). No-shows are as problematic from a fiscal perspective as unfilled schedule slots. To reduce their impact, practices often “double-book” patients, which makes volume surge when all patients show up. The result may be chaos, with angry patients waiting an hour or more and dispirited clinicians and staff trying to both appease and care for them.
Beyond chaos and anger, long waits before appointments, particularly specialist appointments, often contribute to the development of avoidable complications that can lead to provision of care in less desirable (and more costly) environments such as emergency departments (EDs) or hospitals, where care is often more fragmented.
Physicians and practices might think they minimize the clinical consequences of long waits by prioritizing the patients they squeeze in by double-booking. For example, all else being equal, a hematology–oncology practice might schedule the patient with a known cancer faster than the one with a benign hematologic issue, or a cardiology practice might accommodate a patient with complex arrhythmia sooner than one with stable angina. This approach not only makes sense clinically; it’s also good business. Higher-acuity conditions tend to drive more tests and procedures, which translates to more services billed and more dollars collected. In fact, in busy practices that maintain a patient mix heavily weighted toward sicker patients, improving access for patients across the board could bring down the average weighted productivity and profitability.
The painful reality is that the fee-for-service system rewards long waits and overbooking to squeeze in sicker patients. Practices maintain a higher-acuity mix, while health systems benefit from care spilling over into more costly settings. The system does not reward providers who organize care to reduce waits for all patients, even though that might keep some patients from becoming sicker. And that may be why most providers have been slow to invest in systems that might reduce waiting time.
We found that longer waits for specialist appointments at Geisinger Health System generally led to higher costs from the perspective of Geisinger Health Plan (our insurance arm) and higher revenues for the provider side of the business (albeit with higher operating cost due to no-show inefficiencies and patient dissatisfaction). Among patients awaiting specialist appointments, the 30-day rate of ED or inpatient utilization was 8.7 times the rate among patients who weren’t awaiting appointments (329 per 1000 vs. 38 per 1000) — presumably indicating that these patients were sick and at high risk for complications.
When we controlled for other variables such as demographic characteristics, clinical conditions, and prior care considerations, we found that patients who waited longer until their specialty appointment generally had a higher rate of ED utilization during the 30-day period beginning with the identification of the specialty care need. We cannot know how many of these ED visits or admissions were inevitable, and calculations of the financial impact of preventable visits or admissions would be different for every health care system. But our back-of-the-envelope calculations based on Geisinger costs, volume, and line-of-business mix is that each 5-to-8-day reduction in waiting time would lead to a $1-million-to-$2-million reduction in costs — or in revenue, depending on one’s perspective.
Beyond lowering revenues, reducing waiting time requires investment in systems. When the Cleveland Clinic began offering same-day ambulatory care visits, it had to change and enhance its call-center system and the ways its practices related to each other. Similarly, as we’ve worked to provide more timely access at Geisinger, we’ve had to invest substantially in our call-center and scheduling systems and processes. One oft-told joke among health care managers is “in our business, sometimes you have to spend money in order to lose money.” Under the fee-for-service system, investing in systems to reduce waiting time is an example of this dynamic. Few, if any, health care managers would deliberately allow patients to wait longer and become sicker in order to enhance revenue, but when resources are scarce, it’s hard to argue for projects with a negative return on investment.
Why, then, are some delivery systems doing just that? One reason is the fight for market share. When the Cleveland Clinic started offering same-day appointments in 2011, other providers quickly realized that they risked losing patients if they didn’t offer more timely access. Another reason is the spread of value-based payment models that reward providers who drive care to more efficient settings, making it strategically important to provide timely access for all patients. Preventing one $15,000 hospitalization through earlier intervention is much more efficient than switching hundreds of patients from a brand-name to a generic medication — and more satisfying to clinicians. Having patients seen regularly, conveniently, and expeditiously helps in addressing care gaps and managing conditions effectively.
Value-based payment models also create possibilities for providing specialist access through innovative channels. Geisinger, Kaiser Permanente, Group Health, and other health systems have leveraged platforms such as secure messaging, telephone visits, and electronic or telemedicine visits to provide more timely, efficient, and convenient care. Such “virtual medicine” has generally led to improvements in patient experience, clinician experience, and quality of care, while reducing unnecessary inpatient and ED utilization.1
Under new payment models or in systems fulfilling both insurance and provider functions, the distinction between cost to the health plan and revenue to providers becomes unimportant. The focus is instead on reducing waste, and preventable ED visits and hospital admissions epitomize “waste” — as does unnecessary anxiety of patients awaiting appointments.
We can’t reduce waiting time by asking physicians to work faster or longer. It requires teamwork within practices, so that nonphysicians can serve patients with less complicated needs; teamwork with patients, who need reassurance that they may not need routine follow-up visits if all is going well; teamwork with other practices within physicians’ specialties; and providing others (even patients) with access to physicians’ schedules so that open slots can be booked more easily.
In short, it requires recognizing that the Waiting Game provides rewards for letting patients wait, or at least makes investments in reducing waits less attractive than other uses of providers’ resources. But as providers compete on their ability to improve value for patients, the Waiting Game should be subsumed under the more strategic challenges of attracting patients and meeting their needs as efficiently as possible.
From Geisinger Health System, Danville, PA (J.R.); Press Ganey, Wakefield, MA (T.H.L.); and Harvard Medical School, Boston (T.H.L.).
1. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood) 2010;29:835-843. CrossRef | Web of Science | Medline
This Perspective article originally appeared in The New England Journal of Medicine.