Evaluating Open Access: Problems with the Program or the Studies?

IN RESPONSE:

Dr. Murray and Dr. Anderson question the implementation of open access described in our article and raise concerns about whether supply and demand were adequately assessed. In fact, the participating practices used all 3 measures that Dr. Murray recommends, but panel size, as he has noted, has limited utility in predicting demand (1). On the basis of these 3 measures, the practice leaders judged that supply and demand were in balance at the start of implementation. As detailed in our article, the loss of providers threw off the balance of supply and demand, leading to worsening access and difficulty in convincing providers to reduce the scheduling backlog a second time.

Dr. Murray worries that the model was incompletely or incorrectly implemented. Open-access experts judged that the practices had implemented the model correctly, including adequately working down the scheduling backlog using extra sessions and “max-packing.” Practices did not force the elimination of follow-up appointments, but a system was created to track follow-up appointments if physicians and patients chose not to prebook appointments months into the future.

Dr. Murray and Dr. Anderson also assert that because the practices did not achieve same-day access, our results are not a fair assessment of the impact of open access. However, we have not concluded open access cannot work but instead evaluated why it did not achieve the desired results in the 6 practices we studied.

We appreciate Dr. Salisbury's evaluation of an open-access initiative in England. Although the initiative was implemented within a different health care system, his findings were very similar to those in our report. The practices were able to increase access to care, but this did not result in improved patient satisfaction or reduced no-show rates. Our concern is that evidence supporting open access is mixed; we hope our study can prompt other rigorous evaluations in the future.

Providing more timely access to primary care is an important goal for many health care systems (2). As Dr. Kellermann notes, emergency departments should not be used as a “Band-Aid” for poor access. Enhancing access is a key component of other proposed reforms to improve primary care, such as the model of the patient-centered medical home (3). We believe all such reforms should not be accepted simply on face validity or anecdotal evidence but rather should be subject to rigorous evaluation to determine how and why they succeed or fail.