It’s hard to get a doctor’s appointment — with either a primary care doctor or specialist.
We last wrote about this in 2023, saying the problem was caused by a doctor shortage related to several other factors — burnout for all medical workers, early retirements, workforce departures not related to retirement and other reasons.
Fast forward to today, and access to care is getting worse: One woman found she has a broken wrist, but has to wait two weeks for surgery. One woman has gastrointestinal issues, but she was told at several offices that a colonoscopy could be scheduled only three months out.
And wait times are growing: “This year, Boston has the longest waits for new patient appointments among 15 major metropolitan areas, including Los Angeles and New York,” The Boston Globe wrote recently. “On average, patients here wait 69 days for new primary care appointments, and 84 days to see an Ob-Gyn, according to a survey of physician offices to be published later this month by AMN Healthcare, a staffing company.”
Many patients wind up in the emergency room because that’s their only option. Emergency room visits have been found to cost five to six times more than a visit to an office or an urgent-care center, but if there’s no office or urgent care available, the emergency room may be your only option.
So, what to do? We never give medical advice, but here are some thoughts.
Direct primary care
One Midwesterner wrote that he likes his direct primary care doctor, who he has had since 2018: “It’s cheap and super convenient.” With direct primary care, you pay a monthly fee for full access to a primary care doctor, often with add-ons like inexpensive prescriptions and access to X-rays and MRI’s and referrals and such. Insurers typically won’t pay the monthly fee, but will pay for procedures.
“I like it because I get to have a real doctor and I can send them text messages basically whenever, and I can go to an office that’s like a mile from my house instead of a half hour drive into some useless suburb,” the man, a Rust Belt city planner who teaches at a Midwestern research university, wrote in response to a query on an online forum.
He pays $75 a month in Michigan. His primary care office dispenses something like 100 different medications that are prescription “but that they stock and sell at cost, and then for referrals there’s no economic benefit but they usually know somebody who’s legit. Same with other medical procedures although they do do a variety of blood tests and other antigen/antibody/whatever tests in house for stuff like Covid or whatever,” he wrote.
Anything beyond primary care is not covered.
He and his wife are on a high-deductible plan with a near-zero premium. He alone is on the D.P.C. plan, he said, not his wife. “She likes her P.C.P.,” he wrote. “Her doctor is also super close….. Back when I had a different healthcare plan I would have to wait weeks to see somebody and I’d have to drive somewhere far away.”
2-week wait for broken wrist
A Fresno, Calif., woman had a challenging experience with a broken wrist. “Fortunately, we have a top-notch orthopedic center with a walk-in urgent care clinic for orthopedic injuries that is open at 6 AM five days a week and 2 hrs. later on Saturdays,” she wrote in response to a query on an online forum.
“I was seen in very short order, got scheduled for surgery and completed all pre-op tests, etc. that same day in the same facility. Sadly, a two week wait for the surgery for my broken wrist.” She is an 82-year-old retired speech-language pathologist.
The surgery will be at the same facility, she wrote, adding: “I’m very, very fortunate to have this facility available — and it’s only about 5-10 minutes away from my home.”
Weeks and weeks
A 53-year-old Washington State professional woman is struggling with this problem right now.
“I tried to make an appointment online to see a specialist for a minor knee injury (fell on both knees while ice skating–twice),” she wrote in response to a social media query. “The nearest available date to see a doctor (M.D., and not just a physician assistant) was three weeks out. The P.A. availability was two weeks out.
“After my doctor’s appointment, he suspected I did something to my [medial collateral ligament] and said I needed an MRI. Nearest date was another three weeks out (in the same building). Got the MRI done. Had to schedule a time to find out and go over the results. You guessed it, that’s another three weeks out, and that’s only because this time I decided to go with the P.A. To see the actual doctor would have been another three weeks after the P.A. visit.
“So after nine weeks (two months), I might finally make some actual progress. Diagnosis may be surgery or may be just some PT (more likely), but I am literally left hobbling until I get some answers. Thankfully it’s not too severe and I only have to travel about 20 minutes each way and one highway toll to make the trip.”
A 54-year-old woman who lives in a town of 10,000 in central Texas wrote: “In order to get a [primary care provider] I had to leverage a contact I had that was working in the clinic. Not proud I did that but there was no other way. Thankfully that allowed me to get the rest of my family providers there but I still had to sell them on us — no chronic conditions, insured, etc.
“Also, if we have to cancel a dental cleaning due to a conflict it can be 4-6 months before we can get another appointment. So basically make your next appointment while you’re there at the office and hope nothing comes up!!”
The doctor’s view
From the doctor’s side, the problem is completely evident. Dr. Jeff Gold, who owns Gold Direct Care, in the Greater Boston area, wrote: “I do have a wait list but it’s always moving as people do leave, move, cancel, pass etc so we usually get patients in for routine visits within 2-3 months but once they sign on we have same day/next day availability for all urgent issues including Telehealth if needed.”
To respond to this problem, Dr. Paula Muto, a vascular surgeon in the greater Boston area, founded a company called Uberdoc, which she describes as a marketplace for direct-pay specialty and primary care across the nation.
“A simple platform connects patients for in-person or telemed appointments with qualified, trained physicians for a transparent price,” she wrote in response to a query. “For the first visit only. Subsequent care follows the rules of the health plans, or can remain direct-pay. Patients only pay for the visit. Doctors join the platform by offering as few as one appointment per week.” It’s all compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), she wrote, “so patients can step into direct pay without violating contracts with health plans” and it’s compatible with Health Savings Accounts because “the doctors, not a third party, receive the payments. We hold no patient data.”
She added: “We were built by highly skilled doctors who just want to take care of patients and who don’t want to be held back by arbitrary network restrictions. My goal is to have a seat in every physician waiting room for a direct-pay patient. Our network is close to 6,000 — every state, every specialty and we have contracts with agencies that need to schedule appointments for the vets, active duty, and disabled.
“We are an easy add-on to any employer that uses H.S.A.’s and who wants to give their employees priority access to the best,” she wrote.
‘Favor chits’
It is widely believed that people inside of the healthcare system have ways to navigate around this and get appointments, and thus may not be personally feeling the pain that civilians do — for example, an orthopedist’s son will have an easy time getting an appointment.
One healthcare executive, asked about the topic, wrote: “It’s absurdly hard. I’ve had to call in favor chits, which I hated to do.”
When I asked him to tell more, he wrote, “I can’t tell ya about favor chits because that’s the whole point of favor chits, that they are on the QT.”
Gregg Masters, a longtime healthcare executive and well-known digital content figure, wrote: “Be clear to differentiate between the billing and collections model or primary care (at the systemic level) and the variable access enabled by convenience-based medicine, whether membership model (inclusive of DPC, direct primary care to elitist concierge Medicine — all catering to the convenience demands of the worried well) or other ‘off grid’ primary care models leveraging tech (Forward, OneMedical, Qliance, AmazonCare, VillageMD, CitiMD, HelloHealth, Myca, yada, yada, yah.)”
Ray Kober, C.E.O. of the healthcare consultancy Benefixa, has talked about it taking 6-9 months to get a primary care appointment in New York City, including in this podcast about direct primary care. He also sent a screenshot of his results when trying to get an appointment for an annual physical, which looks like it’s months out.
Also he noted that for sick visits, telehealth is the only option. He did not want to name the doctor.
Strategizing
Dr. Owen Muir, a New York psychiatrist who treats adults and children and also writes about healthcare at TheFrontierPsychiatrists, strategizes for himself and his patients. He practices in New York City, South Carolina, Illinois and California.
“The great news? Extreme delays in getting an appointment are disincentives bothering to get said appointment at all,” he wrote. “It’s a problem that creates its own solution! This is from the perspective of fully funded health plans that make money based on a percentage of total healthcare costs. This difficulty in getting outpatient care increases the chance you will end up in an emergency setting when the problem gets even worse.
“I have personally chosen to defer making appointments for myself, more than once. I select referral sources for my patients based on who doesn’t take insurance — because I know I can get an appointment more rapidly with those doctors.
“My personal rheumatologist is completely out of network, as is my ophthalmologist, because for both of the sub-specialists, I know I might rapidly need an appointment, and can’t put up with the delays of six months or more to see somebody who’s in network when those organ systems are vital to my life. I can’t afford a delay in my vision care, for example.
“Medical care thusly becomes game theory for patients: ‘What sub-specialties can I afford to have be completely inaccessible in an urgent timeframe?’ Only if the problem can wait do I bother to make in-network referrals.”
Some people wanted us to know that there is not a doctor shortage, but rather an inequality in the system: Specialists are paid more than family medicine doctors or pediatricians, which means that more med school graduates choose specialties like radiology, anesthesiology, and other specializations that pay more.
Health Network
If you know the right people, you can maybe get a referral to top-notch docs. The Health Network Foundation offers almost immediate access to top doctors for members — and people who know members.
Here’s how it works: HealthNetwork says on its site that it is “the only nonprofit to connect CEOs and business leaders with top hospitals and doctors to provide fast access to world-class care and increase philanthropic funding for medical research.”
The testimonials page offers story after story of patients looking for immediate treatment. One woman received a scary diagnosis for her toddler son requiring specialist treatment. Then her uncle called: “Randy told his niece, ‘I have a contact for you. Once I call them they’re going to move fast. I know it’s been slow going so far, and you’ve had time to think. If we get this ball rolling, you have to be willing to drop everything and travel to where there’s a specialist.'” The contact was made, the family traveled to Cincinnati, and the proper treatment was available, immediately.
A Detroit executive diagnosed with mesothelioma found immediate treatment as a new member of the foundation. A woman with breast cancer found that, as a member of Baptist Health’s Giving Society, her member benefits included access to Healthnetwork Foundation and therefore to the best doctors.
The “make a medical request” button on the signup form asks how the person is connected to the foundation. The choices are CEO, Vostage, YPO/YPO Gold, EO, Vistage Florida, Vistage Michigan, Healthnetwork GOLD supporter, and Legatus. If your business offers the service, or if you know of anyone whose business offers the service, you can ask for help.
“It’s definitely a common perk of memberships to things like YPO,” Young Presidents Organization, a friend wrote in an email.
The website says the staff “handles over 5,000 medical requests each year” and has worked for more than 30 years, “sustained by the generosity of our members, ensuring that we have the resources to serve and grow. As a nonprofit, we donate back to our physician and hospital partners to support medical research, advancing medicine for all.”
In that vein, it is widely known that major donors to hospital systems can get VIP access to healthcare, along with box seats or season tickets if it’s an academic medical center.
Manners, manners
A lawyer who lives in the New York metropolitan area wrote: “My OBGYN in NYC was amazing before they were acquired by Mt. Sinai Health. If there was ANY issue while I was pregnant, they would see me the same day AND arrange for any other healthcare providers outside of that practice to do the same if I needed it.
“I will give them the benefit of the doubt that they still do that for pregnant patients – frankly, any practice should make time.
“Otherwise, I have found that (still), if I have a good relationship with the doctor and I am super nice to everyone (which I would be anyways), they will move mountains. A podiatrist contacted a surgeon who moved mountains within 24 hours with United Healthcare to get my surgery appt made and approved within 24 hours for surgery 4 days later – which he did via a text. #oldschoolmanners”
She added: “Only 1 good experience. The rest are terrible.”
What you can do
Some suggestions:
Try direct primary care, sort of like a subscription service for primary care. These practices can charge a monthly rate — typically as little as $39 for a younger person, or $139 for someone over 65 — for all-you-can-eat primary care. Often there are add-ons like lower-price X-rays and MRI’s, and good prices on many prescriptions. The primary care doctor will typically be able to make referrals to specialists, but specialist care is not covered. Many will be able to do things that are typically an emergency-room visit, like stitches for a wound. Insurance typically will not pay for D.P.C.
Somewhat similar: There’s always concierge medicine, which is also a membership model, but typically more expensive. These memberships can cost $5,000 a year and more, and generally cover primary care and no more. Falling into this basket are also “longevity centers” like Princeton Longevity and Elitra Health, many pitched to the moneyed, and few of them posting their prices on their websites. Insurance typically will not pay for concierge medicine.
In between the two are things like One Medical, which is now part of Amazon. Amazon Prime members pay an annual membership, $99 as of this writing, for what Amazon calls “same- and next-day remote or in-person appointments, and a membership that includes 24/7 virtual care services.” OneMedical says it has hundreds of offices across the United States — three in Connecticut, eight in the Chicago area, twenty in New York (all but one in the city), but none in Iowa or Nebraska or many other states. It does primary care. Non-Amazon-Prime members pay $199 annually for the service. Medical staff members include doctors of medicine (M.D.), doctors of osteopathic medicine (D.O.), nurse practitioners (N.P.), and physician assistants (P.A.). Insurers typically will not pay the membership fee, but will pay per visit.
For imaging like X-rays, MRI’s, CT scans, ultrasounds, mammograms, bone density scans and the like, Green Imaging is a nationwide company that contracts with individual providers to schedule cash-pay services. On their website, you can schedule a visit and pay up front. The company says it works with 1,400 facilities. Self-pay patients can buy scans from under-capacity centers which are then interpreted by Green Imaging doctors.
A common fallback: Urgent care and walk-in centers. The doctors I talk to say that results there can be spotty, delivered by nurse practitioners or physician assistants in a for-profit speed-it-up model. Medical professionals do advise that if you are going this way, you should try to find a place that is staffed by M.D.’s and D.O.’s instead of exclusively nurse practitioners or physician assistants. When we wrote about it before, it seemed clear that many of these centers and clinics choose clinicians with lesser qualifications to save money, and that’s why you often get a prescription for antibiotics, no matter what the problem. Proceed with caution.
See Uberdoc, mentioned above.
One woman told us she is super nice on the phone when she calls to schedule.
Try volunteering at a hospital. One woman in Canada took this path when she needed a hip replacement and saw a long wait-list. She volunteered at the gift shop, and made connections there that helped her get an appointment much faster than she would have if she had waited in line. Watch her TED talk here.
Many places have a wait-list. I have frequently scheduled something weeks out but asked to be put on a wait-list, where they will call you if they have an opening.
There’s a lot of buzz about using AI to help inform yourself — it’s not a substitute for a doctor, but while you’re waiting for your appointment, you can use AI to educate yourself about the questions you have. Be clear on the plusses and minuses of AI. Be aware of privacy issues. And most people will tell you AI makes frequent mistakes, so check it carefully. Veteran AI users will ask the same question of two or more Large Language Models and compare the results. (More to come on this.)
Many people said they had found themselves seeing not a doctor but a nurse practitioner or physician assistant connected with the practice.
Several people, like Dr. Muir above, said that when they were willing to go out of network and pay full freight, many opportunities opened up.
Related: “Fewer doctors and patient backlogs: Inside America’s long wait times for medical care,” July 2023.
Next: What can be done to improve this situation?
