If you get sick at night or the weekend, all too often the local emergency room is the only medical facility with an open door. You may know that your regular doctor could treat your asthma or that nagging cough, but you wind up in the emergency room because your symptoms inconveniently occurred outside regular business hours.
A study this month in Health Affairs found that Americans bypass their primary-care doctor more than half the time when they have an acute problem. The study found that 28 percent of visits for acute care occurred in the emergency room between 2001 and 2004. Another 20 percent were handled by specialists.
When faced with potentially dangerous conditions such as chest pain or a high fever, going to the ER is the smartest move. But other acute problems -- such as a flare-up of a chronic condition or an upper respiratory infection -- could often be handled outside the ER if the patient's own doctor were available, researchers say.
"We have a health-care system that all too often expects patients to accommodate themselves to its needs rather than the other way around," says study co-author Arthur Kellermann of the Rand Corp., a nonprofit research group.
In some places, that has been changing. The Myrtue Medical Center's family practice clinic in Harlan, Iowa, is open until 7 p.m. on weekdays and on Saturday mornings as well. Ruth Neill's cousin drove her there one Saturday morning a few years ago when she became concerned because Neill, who is now 60, seemed disoriented. At the clinic, about 40 miles east of Neill's home in Mondamin, Iowa, her regular doctor was on duty. She whisked Neill into the examining room and in short order admitted her to the hospital. It turned out that Neill was disoriented because her oxygen levels were too low. Diagnosis: pneumonia.
Physicians are also becoming more accommodating in their scheduling. The number of primary-care physicians who offer same-day "open access" scheduling has grown to 62 percent, according to the American Academy of Family Physicians, a substantial increase over the 29 percent who offered it in 2008. Still, only about a third of doctors said they offer evening or weekend appointments.
This is in stark contrast to other countries, where primary-care doctors are routinely available after hours. In a 2009 survey, 97 percent of primary-care practices in the Netherlands had arrangements for after-hours care by a doctor or nurse, according to the Commonwealth Fund. In the United Kingdom, the figure was 89 percent, and it was 78 percent in France.
Health-care experts and patient advocates point to a coordinated system of care as one of the options that can help ease the problem of finding a doctor outside regular work hours. The wider adoption of the "patient-centered medical home" model of primary care, like the clinic Neill visited, does just that.
The medical home model is an approach that harkens back to the days when family doctors were so familiar they almost seemed like part of the family. In today's medical home, a primary-care doctor leads a team responsible for coordinating and managing all of your care, whether it's making sure you're on top of routine lab tests to keep your diabetes in check or being available to handle unexpected problems, even during off hours. That coordination improves patient care and may help control costs, advocates say.
Embracing the medical home model generally requires physicians to retool their entire practices, rethinking how they schedule and communicate with patients, adding electronic medical records to better track patients and incorporating techniques to ensure that treatment is coordinated among primary-care doctors and specialists.
"It was a hard transition, kind of a rocky road," says Don Klitgaard, medical director of the Myrtue Medical Center, where Neill is a patient.
Improving patient access is critical to the success of medical homes. If you can't reach your doctor when you're sick, either to get in for an appointment or to chat by phone or e-mail, the physician can't coordinate your care.
Several provisions in the new health-care overhaul give a boost to the medical home model. The law provides for grants to create interdisciplinary community health teams to support patient-centered medical homes. It also provides grants to support networks to provide coordinated care to low-income patients. And it gives states the option of designating certain providers or groups of providers as health homes for Medicaid members with chronic conditions.
The law also requires the development of provider payment guidelines that reward the type of care provided in medical homes, such as care coordination and case management.
In the end, it may be up-and-coming doctors who provide a real incentive for practices to embrace the medical home model. At a recent conference for medical students, many were excited about the concept, says Lori Heim, president of the American Academy of Family Practitioners.
"They're looking for residencies that offer it, and they want to practice in that environment," she says. "I think it will be a recruiting tool." In that case, what makes doctors happy may be good for patients, too.