Five Ways to Improve Patients’ Access in Your Practice

Dermatology faces a potentially serious problem regarding patient access to adequate care. The following five suggestions are practical opportunities to improve the ever-growing backlog of patients in need of dermatologic care.

Throughout our short careers, our research and clinical interests have focused on improving access to dermatology, especially where there are disparities in care. Once we began practicing, these research interests were separately confronted with the reality that access to dermatology care was not improving.^1,2 While there are few studies demonstrating possible solutions to the access issue, many of those solutions are potentially impractical and daunting to implement.³ For example, while teledermatology has been touted as a solution to access, the capital expenditure, limited reimbursement, and medical liability are formidable barriers to implementation. 

Moreover, the most obvious change is perhaps the most contentious of all. If one wants to see more patients, one likely needs to add more physicians or advanced practice providers (APPs).^2,4 A problem faced by dermatology is the workforce shortage due to fixed residency slots, limited graduation medical education funding, and decreased density of dermatologists in rural and suburban areas. This has contributed to the increased use of APPs in dermatology.⁴ There has been a lot of debate as to whether APPs have alleviated the shortage since they are predominantly located in urban areas, and many of them are increasingly performing cosmetic and surgical procedures, rather than medical dermatology.^5-8 What most people can agree on is that we need more well-trained clinicians to see our patients. Whether it is dermatologists who are committed to medical and surgical dermatology or APPs who are appropriately trained and supervised, we need qualified professionals to ease the backlog of patients to be seen. 

Therefore, we wondered what individual practitioners could do (or were already doing) in their practice to improve patient access. We identified these five suggestions that may apply to the practicing dermatologist. 

Minimally Increasing Clinic Hours
If you are not able to bring new clinicians on board, it may be possible to slightly increase hours worked to improve patients’ access to dermatology. A lesser known reason for the workforce shortage is the effective decline in physician working hours for medical and surgical dermatology. As more dermatologists choose part-time schedules or devote more of their working hours to cosmetic dermatology, the workforce supply to perform medical and surgical dermatology will decrease.⁶ If one provider in the practice worked for one more hour per week, they could help at least three additional patients per week, which would lead to well over 100 patients per year. This number is sizeable, and for each patient, this is meaningful. Working more does not have to be a big change to our already busy lives. It is possible to build it into an earlier morning start time that can seamlessly blend in with our week.

Meet a Rural or Suburban Primary Care Group
We often gripe about how we would love to see the “sick” and “marginalized” patients, but those patients just do not show up at our doorstep. One reason might be that those patients do not know that we exist or that we are the experts for certain conditions. We all have had moments when we speak about our day at work to friends and family, and they comment, “Oh, do dermatologists also take care of [condition]?”–you can fill in the blank. Yes, we treat nail disease, hair disorders, autoimmune diseases, and skin cancers, in addition to wrinkles and photoaging. As much as we would like to think that our physician colleagues know about our clinical repertoire, many do not know about what to do or where to find us. Thus, we can go to them.⁹

Doing a quick online search can get you the top three primary care groups in a rural or suburban location near you. Once you have this information, you can send these practices a simple letter introducing your practice and your clinical expertise. Although many of the patients from these practices may not have compatible insurance, you just might be surprised at who shows up at your doorstep.¹⁰ 

Dedicated Urgent Appointment Slots 
When one of the authors started at her new practice, her availability made her the “go-to” person for urgent appointments. She initially underestimated the number of patients who would want to make appointments to see a dermatologist within a week, and she has since been surprised. Each day, she has around five patients who have a new concerning lesion or a very uncomfortable eruption who want to be seen. At the end of those appointments, these patients have so much gratitude from being seen. This made us wonder about whether there is a sustainable way of seeing urgent patients. Going forward, that author will have one appointment a day that can only be filled no further than one week before with an urgent appointment.¹¹ Full skin checks or other nonurgent appointments can be seen at the next available visit, but if there truly is no urgent patient to be seen, that slot can be given on the day before. 

Improving Reachability for Appointment Scheduling
“Availability is the key to success.” This unsolicited advice from an attending in residency was perhaps one of the major gems during residency training. Availability does not mean always having open slots; it also encompasses the patient’s ability to reach you to make an appointment. If a patient is unable to make an appointment, then they effectively have limited access to you. Therefore, educating the front desk staff about patient access or utilizing technology to augment appointment scheduling services will prove helpful to improve patients’ access. Already, some colleagues utilize HIPAA-compliant online scheduling service or answering services that transcribe all nonurgent messages, which improves accountability and efficiency for the administrative scheduling staff. There are also some inexpensive subscription services that automatically try to fill cancelled appointment slots. These services effectively pay for themselves monthly if around two cancelled appointments are rescheduled. One limitation to this the electronic medical record compatibility and integration.

Give a Presentation to Your Referral Sources
Patient cases are powerful reminders to nondermatologists of our vast knowledge and skillset. The data shows that dermatological diagnoses are better treated by a dermatologist than a nondermatologist.^12,13 However, many of our colleagues believe that all we do is prescribe “creams.” More than likely, our colleagues are not aware of their misdiagnoses and the consequences. For example, in one of our clinics, we were confronted with a straightforward case of venous stasis dermatitis. The primary care physician had prescribed a high potency steroid for 8 months and had sent the patient for evaluation of deep vein thrombosis due to lower extremity edema. When the patient’s condition did not improve, the primary care physician did a biopsy, which the pathologist called “dermal hypersensitivity with a subepidermal blister.” The patient was told that he likely had an allergy to something and was sent for evaluation. What the primary care physician did not understand was the concept of steroid atrophy leading to skin fragility, the ways in which pathology can augment diagnoses, and the importance of treating lower extremity edema for stasis dermatitis. You can remind your referral sources of your skillset by digging up helpful articles during your dermatology education and helping them improve their medical knowledge. This will reinforce the importance of referrals to dermatologists to ensure that patients have appropriate access to a dermatologist for evaluation. 

Conclusion
Even with these bits of advice, there is no quick fix to solving the access problem to dermatologists. However, we all have a role to play in improving access. If we fail to improve this issue, the medical establishment will continue to underestimate the importance of our skillset and may substitute our services for less adequate ones. Most of all, our patients will suffer because they will not get the care they deserve. What has worked in your practice to improve access?

Dr Ogbechie-Godec is a general dermatologist and the director of clinical strategy and quality assurance at APDerm in Acton, MA. Dr Feng is an assistant professor of dermatology and the director of laser surgery and cosmetic dermatology at University of Connecticut Health in Farmington, CT.

Disclosure: Dr Ogbechie-Godec is an employee of APDerm. The authors report no relevant financial relationships.

References
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2. Kimball AB, Resneck JS Jr. The US dermatology workforce: a specialty remains in shortage. J Am Acad Dermatol. 2008;59(5):741-745. doi:10.1016/j.jaad.2008.06.037

3. Ogbechie OA, Nambudiri VE, Vleugels RA. Teledermatology perception differences between urban primary care physicians and dermatologists. JAMA Dermatol. 2015;151(3):339-340. doi:10.1001/jamadermatol.2014.3331

4. Resneck JS Jr, Kimball AB. Who else is providing care in dermatology practices? Trends in the use of nonphysician clinicians. J Am Acad Dermatol. 2008;58(2):211-216. doi:10.1016/j.jaad.2007.09.032

5. Coldiron B, Ratnarathorn M. Scope of physician procedures independently billed by mid-level providers in the office setting. JAMA Dermatol. 2014;150(11):1153-1159. doi:10.1001/jamadermatol.2014.1773

6. Jacobson CC, Resneck JS Jr, Kimball AB. Generational differences in practice patterns of dermatologists in the United States: implications for workforce planning. Arch Dermatol. 2004;140(12):1477-1482. doi:10.1001/archderm.140.12.1477

7. Glazer AM, Rigel DS. Analysis of trends in geographic distribution of US dermatology workforce density. JAMA Dermatol. 2017;153(5):472-473. doi:10.1001/jamadermatol.2016.6032

8. Adamson AS, Suarez EA, McDaniel P, Leiphart PA, Zeitany A, Kirby JS. Geographic distribution of nonphysician clinicians who independently billed medicare for common dermatologic services in 2014. JAMA Dermatol. 2018;154(1):30-36. doi:10.1001/jamadermatol.2017.5039

9. Feng H, Berk-Krauss J, Feng PW, Stein JA. Comparison of dermatologist density between urban and rural counties in the United States. JAMA Dermatol. 2018;154(11):1265-1271. doi:10.1001/jamadermatol.2018.3022

10. Resneck J Jr, Pletcher MJ, Lozano N. Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times. J Am Acad Dermatol. 2004;50(1):85-92. doi:10.1016/s0190-9622(03)02463-0

11. Jayakumar KL, Samimi SS, Vittorio CC, et al. Expediting patient appointments with dermatology rapid access clinics. Dermatol Online J. 2018;24(6):2.

12. McCarthy GM, Lamb GC, Russell TJ, Young MJ. Primary care-based dermatology practice: internists need more training. J Gen Intern Med. 1991;6(1):52-56. doi:10.1007/bf02599393

13. Federman DG, Kirsner RS. The abilities of primary care physicians in dermatology: implications for quality of care. Am J Manag Care. 1997;3(10):1487-1492.