ABSTRACT
Objectives: Primary care physicians function as “gatekeepers” in many managed care systems. With the rapid growth of managed care enrollment, it is crucial that patients have adequate access to primary care physicians. We investigated factors associated with new-patient appointment availability of primary care physicians in the San Francisco Bay Area.
Study Design: Observational cohort.
Population: Cross-sectional survey of primary care physician offices in 2 San Francisco Bay Area counties (n=438).
Outcomes Measured: New-patient appointment availability.
Results: Seventy-five percent of primary care physicians participating in managed care had an appointment available for a new patient.
Conclusions: The limited availability of appointments for new patients may create barriers to primary care in the San Francisco Bay Area, a region with high managed-care penetration.
Recent studies and reports have examined the effect of physician supply on patient access to health care.1,2 However, physician availability is affected not only by distribution of practices, but by whether a patient can actually make an appointment with a provider.
The availability of primary care physicians is central to access to care in most managed care plans. Managed care systems often designate the primary care physician as the “gatekeeper,” the decision maker about patients’ referrals to specialists. Within this kind of system, a patient may not be able to obtain nonemergent care, including specialty care, without access to a primary care physician.
Furthermore, with at least 12% of people changing providers each year,3,4 it is not uncommon for an individual to need to find a new primary care physician who participates in their health plan. The amount of effort needed to find a primary care physician who is accepting new patients, and the possibility of waiting more than a month for an appointment, may affect an individual’s access to care.
Because access to a primary care physician may be limited by these factors, our goal was to characterize the availability of a new-patient appointment with a primary care physician in the northern California counties of Alameda and San Francisco. We further examined whether physician characteristics (eg, sex, years of experience in practice) were associated with appointment availability.
Methods
Study sample
The focus of the study was to examine the availability of primary care physicians for adults between the ages of 18 and 64 years with employer-sponsored insurance in the San Francisco Bay area. Interviewers, posing as patients, made telephone calls to primary care physician’s offices, to parallel the experience of an actual patient seeking a new primary care provider. Current print and online directories of 3 large, open managed care plans available to employees of a large employer were reviewed.
These managed care plans function through an Independent Practice Association model. Two of the 3 plans require primary care physicians to be gatekeepers for all care within the system; ie, a patient must obtain a referral from the primary care physician to have a specialist visit covered by the insurance. The third plan allows patient self-referral to a specialist, but with a higher copay and deductible than with a specialist visit that has been approved by the primary care physician. Physicians working for Kaiser Permanente, the only closed-HMO plan in the study area, were excluded because Kaiser requires a member identification number prior to making an appointment.
Physicians were chosen if they were listed in each of the 3 plan directories, if they had practice addresses in the counties of Alameda or San Francisco, if they listed specialties of internal medicine or family medicine, and if their stated primary activity was clinical care. Doctors of osteopathy were not included.
This selection process identified 469 office-based physicians. Thirty-one physicians were determined to be ineligible during the data collection process (eg, did not meet the original study criteria when the interviewer called). The final study sample was 438 physicians.
Information on 157 physicians was available from the 1997 American Medical Association (AMA) Masterfile, including sex, race/ethnicity, medical school attended, and year of graduation from medical school. For physicians not listed in this older version of the Masterfile, the physician’s sex was obtained either at the time of the interview or from an online plan directory that had this information.
For physicians not listed in the Masterfile or for those with missing information on race/ethnicity, Asian race was determined by investigator review of last names; race/ethnicity for all others was coded as “missing.” Medical school location and year of graduation from medical school for all physicians were obtained from the physician lookup feature of the Medical Board of California Web site.
Data collection
Interviewers made telephone calls to primary care providers’ offices from July 1999 to January 2000. The interviewers posed as patients new to the area, to parallel the experience of an actual patient seeking a new primary care provider.