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The wait for a doctor appointment

Patients in the U.S. are having to wait longer than ever to get medical appointments with both general practitioners and specialists. Systemic problems that have been mounting for decades are now being pushed by the pandemic to a breaking point, experts said.

Nicole Millard, who lives with an autoimmune condition, in Pleasanton, Calif., has been looking for a primary care doctor for months. She said she has called dozens of providers and even asked her insurance company for help but neither tack has worked.

“There are zillions of doctors, and I’m just calling one after the other and not one is accepting new patients,” she said in a phone interview. “And then I found one that was accepting patients, but for a new patient [the earliest] appointment was next June.”

Nicole is not alone. In the 15 largest metropolitan areas in the U.S., wait times have increased by 24% over the past 20 years, an industry study found last year. The trend is similar in rural areas.

While the severity of the problem varies geographically and by specialty, the problem affects the whole country with clinicians in all specialties feeling the heat.

A primary care doctor in Texas, who spoke on condition that we not use her name to protect her privacy at work, told us she doesn’t even allow patients to schedule appointments more than two months out anymore.

“They book every possible slot within about 24 hours of me giving them dates,” she said of her office management staff. “By then, I have already lost the ability to get people in for follow-ups or anyone else who needs to be scheduled urgently.”

Complications arise, especially for acute patients

While relatively healthy people may be able to afford a longer wait for routine care, the stakes go up for more critical patients.

Dr. Amy Faith Ho in Dallas, Tex., said that while emergency room overcrowding has been a problem in the U.S. for years, lately the E.R. where she works has been literally overflowing with more patients than ever. This is in part because they can’t get in to see a regular doctor or specialist, leaving the E.R. as their only option.

“I don’t know a single emergency medicine doctor that hasn’t at some point in the past, let’s say six months, gone out to the waiting room to try to see patients,” she said in a phone interview.

“There’s always a joke like, ‘hey, the waiting room is now so overcrowded, like, are we just going to be in the parking lot next?’”

Doctors and industry experts told ClearHealthCosts that today’s crisis has its roots in a long-term shortfall of clinicians that has been exacerbated by the Covid pandemic as well as changes from the business side, namely changes within the insurance industry and the trend of medical practices consolidating with bigger health systems and being bought by private equity companies.

More and more, private equity firms are buying medical practices and clinics as an investment, a trend some physicians say has set off a downward spiral taking away resources from patient care and overwhelming staff.

“[There is] actually not enough M.D. specialist clinic slot availability,” a pulmonologist in California said, who spoke on condition that we not use his name because his employer did not give him permission to speak on the record. “MBAs that have taken over the U.S. healthcare system have been working on this to better ‘optimize’ our time. However, that often contributes to burnout and MDs resigning or moving elsewhere whenever pushed too hard to see more patients within a given workday.”

That is, when a practice’s primary goal is to make a profit, they cut spending. That means fewer doctors, leading to physician burnout and longer waits for patients. As those patients wait, some of them will get sicker and end up in Dr. Ho’s emergency room.

Insurer obstacles make it harder

Another factor is what doctors say is the problem of insurance companies becoming more aggressive, requiring patients and providers to jump through hoops before consenting to pay the patient’s bill: things like requiring referrals and prior authorizations before they can see some of these specialists. All this red tape not only causes delays for patients, but requires more administrative manpower and steals more time that doctors could be spending with patients. It also chases more providers out of network. That means fewer patients can see their physicians.

“The more you squeeze the physician the more you squeeze the patient,” Dr. Ho said.

Physician shortages persist

On top of that, the country is experiencing a physician shortage that has been growing for decades. The number of doctors the U.S. trains each year has not increased since 1997 even though the country’s need has grown.

Dr. Jeff Gold, a physician in the Boston Mass. area, said the predicament comes down to basic economic principles.

“You can’t have an unlimited demand, with a very limited supply of people to provide the care and the service,” he said in a phone interview.

In 2020, catastrophe hit an already tenuous situation as a surge of people infected with the coronavirus took over the medical establishment overnight. Doctors, nurses and other frontline workers were called in to work around the clock, fighting to save as many people as possible.

The result was overworked, exhausted and sometimes traumatized medical workers who confronted mass death on every shift. In the aftermath, many doctors and nurses felt the need to leave the profession for the sake of their own wellbeing, shrinking the workforce further.

“COVID [put] the spotlight on all the inefficiencies and problems that were already there,” Gold said. “I don’t think it’s a direct cause, other than the fact that a lot of people burned out, because of what happened with the pandemic, and didn’t go back to work and had enough.”

Pandemic shutdowns also forced medical institutions to cancel all non-urgent procedures and services. When they reopened, they faced a months-long backlog of patient appointments that they are still struggling to catch up with today.

Three years later the country has fewer doctors and a bigger patient load, a situation that further increases the strain on the system with each passing day. The primary care doctor in Texas put it this way:

“No, I really can’t stay late to allow for overbooking or accommodate more appointment slots, because I usually go directly from the clinic to the hospital to work another 12 hours overnight.”

As the strain on doctors grows, so does the risk of losing more of them to burnout – a vicious cycle.

Patients’ problems multiply

These strains on medicine and the shrinking of appointment slots can become more than a mere inconvenience. The wait can cause bigger problems for patients.

Nicole Millard, the California patient who was told she would have to wait a year for an appointment, is experiencing complications from the delay. Her insurance company requires a primary care provider to sign off on any visit to any specialist – a high hurdle to jump.

Millard had to have her entire lower intestine removed. She had no issues with it for years but has been suffering from flare-ups in recent months. And she needs treatment from her rheumatologist and gastroenterologist.

“It just causes severe body pain all over,” she said.

Millard doesn’t use pain medications, but she has had success with other immunosuppressive drugs, many of which have to be administered by infusion in a clinical setting.

“But if I can’t get to my rheumatologist,” she said, “not being able to see those two doctors is just making me miserable.”

The consequences of delay

Dr. Ho has also seen troubling outcomes for patients who can’t get a timely appointment to see a doctor.

“What I’ve seen the most is — because they weren’t able to get seen in the outpatient world appropriately — by the time they have to come to the E.R. and things have progressed,” she said.

“A classic example is, say, a cancer patient. Let’s say their primary care doctor saw that they had a little [spot] on their lungs and was worried about cancer,” she said, “but the patient couldn’t get their imaging studies, a CT or PET scan, done for several months. By the time they come to the E.R., let’s say six months later, they’re coughing up blood, they’ve lost 30 pounds, you know, their cancer is now metastatic,” Ho said.

“Had they gotten intervention and appropriate treatment and diagnostics earlier, yes, certainly they would be much less sick, there would be less suffering, there could be more treatment options, et cetera.”

Dr. Ho said outcomes like these tend to be more common for the country’s most vulnerable groups: racial and ethnic minorities that suffer the burden of social determinants of health as well as people who live in poverty. The inequities are even more extreme for people in these groups with less access to medical care – for example, people without insurance who can’t afford to see a doctor and even people enrolled in Medicaid in certain states.

“A lot of specialists might not take Medicaid,” Ho said. “What’s really sad is Medicaid is designed to help the poor, the disabled and children. And so you absolutely see that patients who are lower socioeconomically have no other options.”

What you can do

One physician in Texas told ClearHealthCosts “when I’m referring patients to other specialists, I usually try to set expectations and give them the typical waiting time to get an appointment with that particular specialty locally.”

And some physicians say the problem can be solved by going around your health insurance. A business model called direct primary care, which doesn’t take insurance, charges patients a monthly membership fee that covers all their primary care. Proponents say that doctors in these are less overwhelmed with patients so they can get you in much sooner than a typical practice and even spend more time with you at the appointment. Direct primary care is not available everywhere, and many people prefer to stay inside the insurance system rather than paying out of pocket. Also, direct primary care does not extend to specialists’ services, but is generally only primary care.

One person we spoke with said she had moved north of New York City, to a relatively sparsely populated area. “I think there are just not enough doctors in these rural areas to handle the influx of new residents. My husband and I found it impossible to try to find general practitioners that would take on new patients unless we were booking 8 or 9 months out. So I just make the two hour trek to the city to see my doctor instead,” she wrote in an email.

Several people said they had found themselves seeing not a doctor but a nurse practitioner connected with the practice. 

Others said they are going to urgent-care or walk-in clinics instead of seeing their regular primary care doctors if those doctors are booked up. Scheduling on the online scheduling platform ZocDoc was a tactic used by some, though it is not available in all areas. Of course, this does run the risk of less continuity in your care.

One person told us that she has had trouble getting in-network care, but when she ultimately decides to go out of network – and thus pay full freight out of pocket – she can be seen quickly. 

One woman told us that she has been trying to be super-nice when scheduling an appointment. She also said that she has been planning “a twice-a-year preventative health week (where you stack all of your preventative health stuff into those blocks of days,” which makes it easier to plan and can be less disruptive to work and life.

Virginia Jeffries is a journalist in New York City. Since 2020, she has reported on long Covid, medical billing and the U.S. vaccine rollout for ClearHealthCosts. She earned a master’s in journalism...