I wrote an essay about how there are words we use in healthcare that carry with them unintended baggage. Yesterday, though, I was reflecting on one word that is both ubiquitous in healthcare conversations and has so many different meanings that it has functionally no useful definition without significant context and positioning. That word is access. I have heard it countless times in meetings with all levels of leaders and every different department in a hospital. I have heard patients and PFACs reference it countless times as well, also with an array of meanings. Brought together, it fits in a specific space where it has so many meanings across these audiences and it STILL has no common understanding. This essay will explore, then, some of these varied meanings and why it so often leads to confusion.
Why is this important? Many words have confusing, even conflicting, meanings. Access, though, is a word that often leads to radically different conclusions. Organizations will declare that progress has been made, even as communities will say that nothing has changed. Part of this is that healthcare’s definition often has no relationship to how patients define it. Part of this is that process changes (from the hospital’s perspective) don’t lead to outcomes changes (from the patient’s perspective.) Combined, we have built a Tower of Babel scenario, where the language we use prevents any communication.
It seems like a fool’s errand to try to define something that I JUST SAID has no useful definition. My focus here is less to cover all the ways the word is used and instead to focus on why its use leads to confusion and miscommunication with patients and communities. As always, if I miss a useful definition, I encourage you to leave a comment. In this essay, I will focus on how hospitals often define access and discuss how patients respond to those definitions. Those familiar with my essays can guess that I will address patient definitions and hospital responses in the next essay.
The easiest way to define how healthcare sees access is to imagine that the hospital is a trendy nightclub with a big burly bouncer outside, managing entry. If the nightclub is popular, then there are more people who want to get in than there is space to let them in. There are external limits put on the nightclub. The fire department will dictate maximum occupancy. OSHA will dictate the safety of the structure. Every state has rules about the sale of alcohol, including perhaps the size and training of staff. All of these regulations carry with them penalties for noncompliance.1 So, a hospital views access as an exercise of getting as many asses in the door as they can safely manage while providing a top-notch experience, all under the watchful eye of external evaluators. For those who think I am being disrespectful to a hospital’s mission statement, I apologize. Anyone who reads my essays, though, knows that I am not interested in throwing shade or kicking shins and instead in using the most clear, if sometimes odd, analogies.
But since there are more people wanting care than there is space for them, hospitals can be choosy about who is on the list. That bouncer, then, is regulating access. This means who gets in as well as how far they are allowed in. From a hospital’s perspective, there are clear reasons why they do this. So, when they prioritize a patient who already exists on a provider’s patient panel, or a patient for whom this hospital is in-network for their insurance, these are reasonable criteria. Since doctors and hospitals are judged by how well they take care of their patients—managing chronic conditions or getting needed screenings for patients on their panels—they will give priority to their patients. Adopting a first-come, first-served approach with limited resources (like scheduling slots for mammographies), may be marginally more efficient, but giving services to an unaffiliated patient isn’t seen and doesn’t count in the eyes of CMS. It may seem odd, even aggravating, that healthcare is always looking for credit for its work, but when those external evaluators can limit payments from CMS, fine hospitals, or even shut a hospital down, it is not surprising that hospitals are attentive to these things.
While this may not be a sentiment or desire that is publicly visible, patients do perceive a two-tiered system. These perceptions are often rooted in other criteria, like imagining preferential treatment delivered based upon money or VIP status. While these may be incorrect, even irrational, patients will often imagine that for whatever reason, their need or their pain, is not a priority. They will blame their lack of access on these perceptions. Even if confronted with the reality of the situation, many patients have argued (as I have seen in personal conversations or PFAC discussions) that the only ‘fair’ approach to access is a basic first-come, first-served approach.
Further, over the past twenty years or so, hospitals have been shifting where care happens. In part because of insurance reimbursement and in part because of general increased demand, things that would have been inpatient procedures get migrated to outpatient procedures. Outpatient procedures get migrated to clinics. Doctor appointments become nurse-only or physician-assistant appointments. So, even when you make it past the bouncer, you are only allowed to have a drink at the bar and cannot get on the dance floor.
Patients have a far more nuanced understanding of this where they will balance their desire for access against issues of convenience or cost/benefit equations. So, being sent home with a glucometer or a blood pressure cuff and instructions for self-monitoring can be desirable if it is easier and faster than driving to the clinic multiple times a week. Likewise, being able to see a PA today, versus seeing an MD in two weeks, may be an acceptable tradeoff. Obviously, this is predicated upon an individual patient’s preference, but the main concern expressed by patients is whether they were allowed input in how that decision was made.
When COVID shut the world down, most patients were being shunted to video appointments for obvious reasons. CMS and insurance providers even made allowances for billing commensurate with an in-office visit and the waiving of co-pays. But when the pandemic ebbed and reality set in, patients complained that the costs of seeing a doctor were the same, even when it was a video appointment. Many expressed that it seemed unfair to pay premium prices for an inferior experience, at least as judged by them.
Broadening the definition of access by hospitals didn’t stop with video visits. Health systems, for example, are finding value in scheduling group appointments for diabetic patients with a diabetic educator. This can certainly create capacity, by allowing one clinician to see multiple patients at once. If it helps patients remain compliant as well, then it is a win-win. I am not dragging healthcare here. If it works and if patients like it, then it is not my place to judge the transition. What is important to realize here, though, is that this is considered a WIN when it comes to access, from the hospital’s perspective.
It is less clear if patients consider this a WIN. Again, this can vary between patients, and it can vary depending on the chronic condition being treated. When I have talked to patients, many find this convenient and the support-group atmosphere to be helpful. Others, though, expressed embarrassment at having to share their dirty laundry, especially in a setting where they may be concerned over their personal privacy. As above, satisfaction with this revolved around whether the patient felt included in this decision about their access to healthcare or if it was made for them.
There are other elements to access that a hospital considers. Two measures that hospitals will discuss and internally report are abandonment rates and third-to-next numbers. Both speak to how efficiently healthcare can manage the delay in providing that access.
- Abandonment rates: As anyone who has called for an appointment knows, the busy signal has been replaced with a call queue.2 Usually hold music and someone saying, “your call is very important to us.” If you hang up after waiting fifteen seconds of fifteen minutes, you are logged as an abandoned call, and the percentage of abandoned calls is tracked by the hospital. While you might think that one abandoned call is too many, hospitals generally shoot for 5% or fewer calls ending in this way.
- Third Next Available Appointments (TNAA): TNAA (aka ‘third-to-next’) is a way to evaluate access. It measures the number of days between when I call for an appointment and the third open appointment slot on the schedule. Why third? I will save the long version for another time, but it is designed to provide a more reliable measure that won’t be skewed by a random same-day cancellation.
These are ways that hospitals use to measure their responsiveness to access requests. As I have discussed in the past, hospitals improve by creating metrics that they can track and trend. These are all great ways to measure how well hospitals are doing by maximizing the number of people who are getting past the velvet rope and into the nightclub in a timely fashion.
From a patient’s perspective, these measures have two problems in common with, frankly, all customer service. First, they all assume an equivalence in urgency or a standard need. Scheduling a routine mammogram because it’s that time, and, scheduling a mammogram because an abnormality was felt in a self-exam and verified by a provider, are palpably different experiences. Second, they establish a standard acceptable fallout rate without evaluating the nature of the fallout. Hanging up after waiting twenty seconds is counted the same as the same as hanging up after waiting twenty minutes. This does not mean that hospitals don’t care about these nuances. It is that there are no clear ways to quantify these nuances. Hospitals will generally create different tracks for different needs, so a diagnostic colonoscopy will get priority over a screening colonoscopy. But if the need has not been quantified with a Current Procedural Terminology (CPT) code or an ICD-10 code, it cannot be easily quantified or prioritized. Likewise, everyone would want 100% answer-rates to phone calls and 100% same-day appointments, that is not possible. Just like wait-times are a function of call volume and complexity as much as anything else.
Patients’ response to this is that their needs are not present in the equations. They have anxiety and fear that is driving their impatience and expectation. Treating the process with the same metrics that a cell-service provider or cable company might use fails to appreciate the gravity. “I am not trying to get the Hallmark movie channel in time for their Christmas movie season, I think I am dying!”3 While people may roll their eyes at the notion that the measures do not quantify the level of self-centeredness or selfishness of patient needs, remember that patients are operating in an informational vacuum. They are not well-equipped to know whether that test result is an aberration or a concern. They don’t know what an acceptable time is to wait for an oncologist appointment. A hospital does not get to gate-keep the appropriate amount of anxiety that a patient can feel.
As I read this, I feel like I just wrote an essay that everyone will hate. It is likely that you either feel like I was too aggressive in my treatment of hospitals, or you feel I was not aggressive enough. But this is not a zero-sum game. My point was not to identify villains and heroes or winners and losers. It was simply to show how sometimes even the words we use are so broken as to be completely useless. Hospitals talk a lot about access without tailoring their message to what matters for patients. Assigning blame is beside the point, because it benefits no one.
1For my readers in larger cities, with less charitable feelings about local enforcement agencies and their commitment to the letter of the law, my apologies. I am speaking about how the process should work and not necessarily how the process does work.
2Though, there are times that patients have relayed their stories of no busy signal, no hold queue, just an unending ringing, waiting for someone to answer.
3All due respect to those for whom the Hallmark Christmas movies are a subject of life and death.
PX Matters with Joseph Snipp 
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