3 ways to cut specialists’ wait times without adding more specialists

Add lanes to a highway and the traffic only gets more congested. Add doctors to a local health system and waiting times increase. What explains these parallel paradoxes? 

Simple: The lowering of people’s thresholds for accessing highways and healthcare. Where once many avoided predictable traffic jams and expected waiting lists, now they flood the zone, anticipating ease of access. 

The rush causes the negative effect the logical solution was intended to solve. 

Focusing on medical specialties, researchers suss out the dynamics of the healthcare version of the phenomenon in a study published in NEJM Catalyst. 

“Waiting times for specialist visits in the United States are increasing, and many organizations are responding by seeking to hire more physicians,” write Leemore Dafny, PhD, of Harvard and colleagues. “However, regional data on the supply of physicians in various specialties and waiting times suggest that this approach alone is unlikely to be effective and may even worsen the problem.”

Extending the highway analogy, they suggest taking one or more of three tacks rather than resort to the costly—and potentially counterproductive—step of adding specialist physicians.

1. Expand care options.  

Instead of adding physicians, redesign care around options other than visits to specialist physicians, Dafny and co-researchers advise. They identify several potential redesigns, including: 

• PCP education and electronic health record support. Educational programs paired with built-in support in electronic health records, the authors point out, “can enable primary care providers to manage common problems instead of referring them to specialists.”
   
• Expansion of roles and the number of advanced practice providers. Building out the job descriptions of physician assistants and nurse practitioners, allowing these care professionals to provide initial and follow-up specialty care visits, can “better leverage specialist time,” the authors write. 
   
• Virtual group specialty care. Visits in this category “can provide patients access to specialists in situations where there is a long delay in scheduling a 1:1 visit.” 

2. Change financial incentives. 

In cities like New York, London, Singapore and Stockholm, planners have successfully used monetary sticks and carrots to relieve busy roads during peak hours. “Some cities encourage the use of public transportation by reducing or even eliminating fares,” Dafny and colleagues note before naming two possible equivalent strategies for specialized healthcare. 

• Higher copayments for specialist visits than for PCP interactions. This arrangement could provide an incentive for patients to rely upon primary care teams for the management of common problems, the authors suggest. 
   
• Reducing or eliminating out-of-pocket costs for patients who receive chronic disease care from teams staffed by nurses and APPs. These non-physician professionals “can effectively handle many concerns and obtain specialist input as appropriate,” Dafny and co-authors remind.  

3. Set patients up with IT tools. 

Just as smart traffic signals adjust the timing of red and green lights, so healthcare orgs could: 

• Give patients more direct control in the scheduling process. “If patients can make and reschedule their own appointments online, most organizations find marked drops in no-show rates,” the authors write. “[This]  means physicians are less likely to have unused slots in their schedules and can easily fill them with patients from their waitlist.”
   
• Use AI to answer patients’ questions and head off brewing problems. “It will take years to understand the potential of such innovations, but few doubt that the potential exists,” Dafny et al. write.

The challenge of redesigning care and changing the way physicians work is “not for the faint of heart,” Dafny and colleagues caution. “Specialists often enjoy seeing a patient who is doing very well a decade after their medical crisis, and new patients with complex issues take much more time and energy.”

“Practicing at the top of one’s license is exhausting,” they add, “and redesigns of care must incorporate support to help specialists take care of complex patients who really need to be seen.”

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