Telephone calls were made between 9 AM and 5 PM, Monday through Friday. Once an appointment representative for the primary care physician was reached, the interviewer attempted to make an appointment for an initial physical examination, using a standard script. The interviewer stated that she was a new employee, and was in the process of choosing a health plan, based on which insurance plans the primary care physician she was calling currently accepted. If asked what her insurance choices were, the interviewer named the 3 managed care plans used for selecting physicians for the study. If asked for an insurance card number, the interviewer stated that she would bring the appropriate insurance card to the appointment, and would cancel the appointment in advance if the insurance card had not arrived in time for the appointment. If asked, the interviewer stated that she had no urgent health problems. If an appointment was available for a date more than 2 weeks away, the interviewer booked the appointment and canceled it within 1 business day of the initial call.
If the appointment date was less than 2 weeks away, the interviewer noted the time and date but did not book the appointment.
Interviewers recorded information on appointment availability, date and time of appointment, and reason for unavailability. This study was approved by the Committee on Human Research, University of California, San Francisco.
Data and statistical analysis
Several potential predictors of physician availability were examined, including physician’s sex, race/ethnicity, years since graduation from medical school, medical school location, county of practice, and median per capita income of the zip code in which the practice was located. Descriptive statistics on these demographic factors were generated according to appointment availability with Pearson χ2 tests.
We analyzed the ability to get a new-patient appointment with a given primary care physician using a multivariate logistic regression model. Variables were included in the model based on a priori hypotheses. A new race/ethnicity category was created for the logistic regression models by combining African American, Latino, and other, due to small numbers for these groups.
The length of time to an available appointment was also examined. Time to appointment was dichotomized into early appointment (within 0–30 days) and late appointment (>30 days’ wait).
Results
Of the 438 physicians included in the final sample, 328 (74.9%) had an appointment available for a new patient with managed care insurance. Availability varied by physician race/ethnicity, medical school location, years since graduation from medical school, and the median per capita income of the residents in the zip code of the primary care physician’s practice (Table 1).
Appointments were not available for several reasons. Of the 110 primary care physicians who had no appointment available to new patients, 87 (79.1%) were not accepting new patients because of a full practice. Three (2.7%) were on leave or were about to retire. Ten (9.1%) receptionists were unable to book an appointment either because they did not have access to schedules far enough in advance, or because of a basic communication difficulty during repeated calls. One (0.9%) primary care physician was only accepting referred patients. One (0.9%) primary care physician saw only monolingual Chinese-speaking patients.
Eight (7.3%) primary care physicians classed as unavailable required some form of screening, separate from inquiries about insurance or intake assessment forms, before a new patient could be considered for an appointment. Of these 8 physicians, receptionists for 5 said that the physician needed to speak directly with the patient to determine eligibility (not related to insurance), and 1 required a receptionist-administered telephone interview that would be shared with the primary care physician. One required that a written personal questionnaire be filled out and returned for this purpose. The sole remaining primary care physician did not accept current smokers as patients.
TABLE 1
Characteristics of physicians in study
| Characteristic | N (%) | Appointment available (% of total) |
|---|---|---|
| Sex | ||
| Male | 328 (74.9) | 74.7 |
| Female | 110 (25.1) | 75.5 |
| Race/ethnicity | ||
| White | 170 (38.8) | 68.8 |
| Asian | 117 (26.7) | 74.4 |
| African American | 7 (1.6) | 85.7 |
| Latino | 4 (0.9) | 100 |
| Other | 8 (1.8) | 100 |
| Missing | 132 (30.1) | 80.3 |
| County | ||
| Alameda | 217 (49.5) | 74.7 |
| San Francisco | 221 (50.5) | 75.1 |
| Years since graduation from medical school | ||
| ≤10 | 61 (13.9) | 88.5* |
| 11–20 | 123 (28.1) | 74.8 |
| >20 | 254 (58.0) | 71.7 |
| Medical school location | ||
| US | 344 (78.5) | 71.5† |
| Foreign | 94 (21.5) | 87.2 |
| Yearly median income of residents in zip code of practice‡ | ||
| Low | 148 (33.8) | 75.7§ |
| Middle | 144 (32.9) | 81.3 |
| High | 146 (33.3) | 67.8 |
| Total | 438 (100) | 74.9 |
| *P=.02 for x2 comparing differences in appointment availability by years since graduation from medical school. | ||
| † P<.01 for x2 comparing differences in appointment availability by medical school location. | ||
| ‡ Low: $5,106–$22,370; middle: $22,371–$36,507; high: $36,508–$51,926. | ||
| § P=.03 for x2 comparing differences in appointment availability by yearly median income of residents in zip code of primary care physician’s practice. | ||
Predictors of appointment availability
Recent graduates were more likely to have an appointment available than more established physicians (OR=4.2; 95% CI, 1.7–10.3) ( Table 2). Foreign medical school graduates were also more likely to have an appointment available than US-educated physicians (OR=3.5; 95% CI, 1.7–7.3). Primary care physicians practicing in middle-income zip codes were more likely to have a new-patient appointment than those with offices in high-income zip codes (OR=2.1; 95% CI, 1.1–4.0).