16 Barriers in Underserved Medicine

And How to Overcome Them

I recently saw a workflow diagram in Medical Economics:

It says: patient calls to make appointment, patient arrives and checks in, nurse rooms patient, provider sees patient, and patient checks out.

That is five steps.

My goal is one: Patient sees provider. Period.

That is: the patient walks in whenever they want, walks right into my office, and sits down in front of me, the provider.

Here are some of the barriers that can prevent this from happening:

  1. Appointments. Calling for an appointment is embarrassing if you can’t speak English, and being on time is tough if you must take care of kids or parents, find a friend to drive or interpret, or take the bus. Also, more than half of my visits are for issues that can’t be planned. To solve this, I have an entirely walk-in practice with no set appointment lengths. An average patient may wait 10 minutes, and then have a 10 minute appointment. Sicker patients get triaged to the front, while impatient ones can return if we are too busy. This also saves staff time and frustration by eliminating no shows and late shows.
  2. Hours. The more, the better. We’re open evenings and Saturdays, and don’t close for lunch or other breaks.
  3. Phone trees are barriers if you don’t speak English, can’t hear, can’t see the buttons, live in a loud apartment, have kids that scream alot, or have poor reception. These are all more likely with indigent patients, who shouldn’t have to rely on someone else to help navigate a phone tree. My goal is for a human to answer the phone every time, and to return any missed calls and messages immediately. My MAs usually answer the phone, but they have a very low threshold for passing the phone to a provider. If no one answers the office phone by the third ring, then it starts also ringing my cell phone, which I answer, whether in the office or in another country. Medicine is a customer service industry, and better access means better outcomes.
  4. Answering services, used after hours or during lunch, are huge barriers. Instead calls route to my cell at all off-hours. Even so, I get zero calls at night, and only about one call each evening or weekend—and this is with a few thousand patients on my panel. Patients respect providers’ cell phones, a secret that any doc with this setup knows.
  5. Centralized scheduling is the antithesis of individualized or efficient service. Better hospital systems have unique phone and fax numbers in every department or office, and this is a nonissue in small practices.
  6. New patient paperwork is rarely filled out correctly, and doctors often ignore it, so my practice skips it altogether, and the provider simply takes the history by asking the patient. We type the demographics and insurance info straight from the cards into the computer, avoiding embarrassment for patients who can’t write English, and saving errors from transcribing. Our one page of paperwork combines HIPAA, medical record release and other ignored legalese into one quick signature.
  7. Check in. Although our MAs usually take demographics, eligibility and copays, our providers can enter or check them also (from anywhere in the world). When a mom in my room says her other son is sick too, I can quickly add the second child to the schedule, instead of sending them back to the front desk. In many practices, the providers can’t even edit a phone number. Also, eligibility and copays are necessary evils, but a provider can easily learn to do these tasks in seconds, and then better care for patients. Insurance is a vital sign that providers must understand anyway, since costs affect care.
  8. Rooming. Many practices have staff get the patient from the waiting room, take vitals, and put them in another impersonal room to wait some more. I prefer to stay in one room all day, and I go out to the waiting room to bring patients to my room. This allows me to triage the waiting room between each patient, while answering quick questions and greeting new arrivals. Also, I do all vitals myself. I can take a full set in seconds, while talking to the patient (“your pressure is high”), and rechecking any abnormalities right away. Most patients don’t need every vital, so I only do what’s needed. The layout of our office is designed with all this in mind, without a “front” and “back” office for providers to hide behind.
  9. In house tests, such as UA, hcg, strep, and EKGs, are better if done by the provider, who can interpret the results immediately, rather than wondering whether the MA made an error in the test or recording the result.
  10. Referrals. In my office, these are all done by the provider, who makes a phone call, and/or sends a fax, right during the patient visit. The provider then gives a map with appointment time and date, and adds it to our tickler calendar to remind them if we think they will forget. Many practices have a “referrals person” who comes in only on Tuesdays; this creates barriers such as guessing the medical reason for the referral, scheduling patients at an inconvenient time, or trying to call the patient later with details. That said, about 10% (only 10%) of our referrals are to places that don’t schedule immediately, and instead require a painful back and forth of sending notes, waiting for review, etc. For that dance we do seek help from our MAs.
  11. Check out. Since our provider can schedule appointments, and since we usually take required payments up front, we have no reason for patients to stop at a check out station. For the rare occasion when we need to swipe a credit card after the visit, I follow the patient out and tell the MA to do this, or I just swipe it on my phone. Also, I keep a work/school excuse Word document open on my laptop, so I can quickly enter a name and click print, instead of having to ask my MA to do so.
  12. Faxes. In most practices, paper faxes about meds, supplies, records, and everything else imaginable are routinely misplaced, resulting in a paper version of the telephone game, with dropped care and HIPAA violations. I would prefer if everything moved to more secure web based solutions, such as CORHIO or even email, but until then, we use efaxing. In my practice, incoming efaxes are assigned to one person: me. I personally follow up on every fax, I e-sign immediately without printing, and I can search or resend any fax ever sent or received within seconds. Our other provider and MAs can do these tasks also, but when the workflow places sole responsibility on one provider, faxes rarely get dropped.
  13. If you don’t hear from us it means everything is ok.” If you wouldn’t accept this answer when you drop your kid off for college, then you shouldn’t take it regarding your health. Not hearing means the wrong tubes were used, the wrong test ordered, or the result was lost. In my practice, the provider who ordered the test contacts the patient (call, email, or text), with every result, even the normal ones. By contacting myself, rather than having an MA do so, I can differentiate less important labs for which I just text once with results, from more important ones, where I call the patient repeatedly or even go to her house. Plus, patients appreciate hearing from me, and can ask questions if needed. Practices that require patients to return for every lab result are just greedily gaming reimbursement, and wasting patient time.
  14. Contacting patients. If your office phone shows as “unlisted” on caller ID, this is a barrier to patients contacting you. It should mask as your office phone even when you call from your cell—this technology exists. Also, never mind emailing, texting is one of the greatest means of removing barriers. The patient can show the text to someone who can read English, can save the specialist appointment address for later, or can text you back to ask for refills much easier than emailing or calling. Practices without these technologies are getting left behind.
  15. Care Coordinators, Health Navigators, Health Coordinators, etc. Concocted to help patients around all of these barriers, these make-work positions often end up doing the opposite, in an attempt to justify their existence. “You must go through me” is the mantra of one local refugee health coordinator, who managed to scare a sick child’s mom out of my waiting room last week, when I was ready to see him that second.
  16. Polyprovider Syndrome. Using multiple rotating providers to cut costs in low income practices may seem smart, but really just creates a circus of dropped care, results in worse outcomes, and doesn’t actually save money. See my writeup on this topic. Poor people deserve continuity of care too.

This list could go on, including large practice entities, insurance companies, subsidized practices, prior auths, excessive legal requirements, sham medical review boards, and inefficient medical nonprofits, but I am focusing here on things any small practice can consider, especially practices in underserved medicine.

Some of our patients do walk in the front door, continue right past the MA, and walk right into the provider’s office. When this happens I don’t feel annoyed, I feel excited that I can create this level of closeness with my patients.

I recognize this list suffers from imrightitis, but I am not suggesting these tactics for every practice type, specialty, or city. Also I’m not the only one with some of these ideas. I see refugees who are on Medicaid or uninsured, and these systems are what allow me to get paid well while providing intimate care to an average of 25 patients a day.

My patients realize that by calling 911, they don’t have to deal with the first eight of these 16 barriers, and as a bonus, they get a free immediate ride to a doctor, anytime of day. Therefore I must make it even easier than that to see me. The more underserved the patients, the harder I have to work to break down barriers to help them.

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