Extending Access to Primary Care Cuts Costs 10%

There is a lot of discussion around expanding access to primary care. If physicians were available to patients beyond traditional business hours, overall healthcare costs would drop, data suggests.

Along that thread, physicians have started to make themselves more available to patients via text messaging and email, but what about increasing the opportunities for more face-to-face time?  Can physicians afford to do that? Can they afford not to?

"Access to care isn't just answering patients on email," says Patricia Czapp, MD, Medical Director of the Primary Care Division of Anne Arundel Physician Group in Maryland. Since each of the physician group's 10 practices started offering extended hours over a year ago, Czapp says they have seen an increase in patient volume, satisfaction, and business.

This month, a report in The Annals of Family Medicine provides evidence that increasing access to care through the extension of physician practice hours into the evenings and weekends decreased total healthcare cost expenditures by over 10 percent.

Researchers examined the association between reported access to extended office hours, healthcare expenditures, and mortality by surveying a patient pool of 54,624 patients between 2000 and 2007.

"When you say there is a 10% saving in healthcare expenditures, certainly practices didn't save any money. The payers saved money, because they are the ones paying the bills," says Czapp.

For example, if a patient has the option to visit their primary care physician for bronchitis at night or on a weekend instead of making a trip to the ED,  there is a potential cost savings.

The jury is still out as to whether the upfront costs of extending office hours would necessarily lead to savings down the road. And physicians expect to be compensated for those costs.

There are some pilot programs where payers are adopting a shared-savings approach and paying practices upfront to get them to expand their hours in an effort  to reduce downstream spending. But it's still experimental.

"[Ten percent is] huge in our healthcare system. I would've expected 1 or 2 percent. Now the payers have a compelling case to recognize extended hours coverage in their payment models," says Robert Berenson, MD, a fellow at the Urban Institute who researches healthcare cost expenditures and physician payment structures.

What about the work-life balance issues for physicians and staff?  

"It doesn't necessarily have to require added hours, it can be substituted hours," says Berenson. "I think most practices would find it financially a desirable thing to have extra hours coverage if it's consistent with people's lifestyles."

"Obviously if you just have a few staff and they have childcare responsibilities and have to be home, well then it's hard to work from 12 to 8 in the evening, but again I think that many practices would actually find that some of the staff members would prefer to have time off during the day and to work the evenings."  

The Anne Arundel Physician Group looks for ways to be creative around this issue, says Czapp, because it recognizes that the need for extended hours varies for each of its 10 offices scattered around the greater Annapolis area.

"So the total number of hours doesn't change, you just stagger your schedule," says Czapp. "We try to say to our physicians, okay, look at your lifestyle and what works for you, and let's say if once a week it's better for you to start seeing your patients earlier at 7am and to leave earlier, then we say, ‘do that!'"

It's a rare type of person, Czapp says, who refuses to work any hours other than Monday through Friday 8 a.m. to 5 p.m.

In terms of the day-to-day business of treating patients, Czapp notes that quick cases—the kind that might otherwise wind up going to an urgent care center, take so little to do, and require so little overhead—that doctors find them refreshing.

Despite the appeal of opening your practice up to "minute clinic"-style appointments, there is the business imperative. To compete with urgent care centers, practices must bring in enough business to make up for any additional possible labor costs and overhead of extended office hours.

"The patients that come in on extended hours are the profitable patients," said Berenson. "People that are more likely to come in the additional hours have the more acute care problems (headache, back pain, whatever it might be). That's the gravy of the practice. That's the sort of revenue, if the physician practice isn't open, that the urgent care center will see instead."

Twenty-five years ago, in his own practice, Bergeson initiated increased access by offering appointments on Saturdays and rotating duties among the six physicians in the group. Even though they were making enough money and staying busy,  after Bergeson left the practice the rest of the physicians stopped offering the Saturday appointments. They simply didn't want to be there on the weekends.

Czapp, at The Anne Arundel Physician Group, also noted that after one of its practices adopted Saturday hours as a pilot program, the extended hours were stopped because neither patients nor physicians wanted to be in on the weekends.

Balancing the lifestyles of the physician with the needs of the community is the strategic challenge of expanding patient access. According to Czapp, active physician participation in scheduling decisions is key.

"Access is really about an attitude, and not so much an office hour, because you can have lousy access even during your current office hours if you turn people away and you teach them to get care at an urgent care center and not with you," she says.