Removing barriers to the timely provision of medical care, including excessive wait times for doctor visits, has been identified by the Institute of Medicine (IOM) as a key quality goal for healthcare systems.¹ In its 2001 report, entitled “Crossing the Quality Chasm: A New Health System for the 21^st Century,” the IOM stated that the excess time patients spend waiting for care, which does not convey information or allow for healing, suggests that “care has not been designed with the welfare of the patient at the center.”² However, in many healthcare settings, patients today are often still forced to wait for long periods of time before receiving care. In the emergency room context, on average patients are forced to wait anywhere from 17 to 54 minutes before being seen by a physician and receiving care.³ A patient’s entire emergency room visit – from arriving at the emergency room to receiving care and being sent home – can average as long as 191 minutes in some states.⁴ Excessive wait times may cause adverse effects to patients, including injuring patients further.⁵ For this reason, addressing excessive wait times and the costs to patients is crucial to promote efficiency and improve patient outcomes in the healthcare system. This Health Capital Topics article will discuss the causes of excessive wait times in emergency rooms and doctor’s offices, why excessive wait times can lead to adverse patient events, as well as suggest solutions to reduce excessive wait times.

Numerous groups, including the Centers for Medicare & Medicaid Services (CMS), IOM and ProPublica, have examined the issue of patient wait times in hospital emergency rooms. According to ProPublica, the national average of time spent in emergency rooms waiting to see a doctor may reach as high as 54 minutes.⁶ CMS has also compiled data pertaining to emergency room wait time, from the time a patient arrives to the time they are seen by a physician, ranging from 21 to 32 minutes.⁷ Additionally, CMS has reported that, nationally, when a physician deems an emergency room patient requires inpatient hospitalization, that patient waits an average of 97 minutes before being transferred from the emergency room to their inpatient room.⁸ ProPublica has also reported excessive wait times of patients waiting to be taken to their inpatient room, ranging from 43 minutes to 270 minutes.⁹ As patients are forced to endure excessive wait times in order to see a physician, serious injuries can result, including loss of limbs or death.¹⁰ Additionally, patients may become impatient and leave without receiving care, or hospitals may reach capacity and refer patients elsewhere, further delaying care.¹¹

A number of factors may cause the long wait times in emergency rooms faced by patients, including: (1) the triage model of care, which prioritizes treatment for the “most critically ill or injured patients” instead of the first patient to arrive at an emergency room;¹² (2) the lack of coordination between peak emergency room staffing times (Monday through Friday between nine a.m. and five p.m.) and peak times for patient visits (evenings, weekends, and holidays);¹³ and (3) the practice of “boarding” patients, which involves a hospital emergency department holding an admitted patient in the emergency room until an inpatient hospital bed is available.¹⁴ Overcrowding of emergency rooms may be exacerbated by the implementation of the Patient Protection and Affordable Care Act (ACA).¹⁵ Although many provisions of the ACA seek to encourage the utilization of primary care services, including the increase in Medicare reimbursement for primary care services under Section 5501,¹⁶ many patients may still not be able to access primary care physicians due to the large caseloads already faced by many primary care physicians.¹⁷ Patients unable to establish a relationship with a primary care physician often rely on the emergency room to provide them with basic primary care services; if this pattern continues with increased rates of insured patients, emergency room wait times may also rise.¹⁸

In addition to long waits for emergency department care, many patients are experiencing excessive wait times in initially getting an appointment.¹⁹ A survey conducted by Merritt Hawkins examined the average wait time, in 2013, between the date of scheduling and the date of the appointment for patients seeing a new physician across numerous specialties in 15 major U.S. metropolitan areas.²⁰ For appointments with family physicians, patients waited, on average, 19.5 days between the date of scheduling and the date of the appointment.²¹ Patients waited, on average, only 16.8 days for cardiology appointments; however, patients waited, on average, 28.8 days for dermatology appointments.²² However, patients are waiting for shorter periods of time within a physician’s office before receiving treatment. According to Vitals, an online resource for patients to connect with and review physician profiles online,²³ the national average for patient wait times in physician offices decreased to just over 19 minutes, a decrease of over one minute from the 2014 average.²⁴

Although excessive wait times for medical services are common in many parts of the U.S., many health systems have developed innovative solutions to reduce this burden and patient safety hazard. In response to emergency room wait times, the Cleveland Clinic has developed a split-flow process.²⁵ The split-flow process reduces wait times by: (1) performing more thorough assessments immediately upon check-in; (2) simultaneously registering and accomplishing triage; (3) immediately ordering the diagnostic tests needed; and, (4) administering care based on an acuity level, which accelerates the treatment of relatively healthy patients while also admitting patients needing immediate care more promptly.²⁶ The Cleveland Clinic has also developed protocols to reduce the time patients wait inside a physician’s office through an innovative tool: the same-day appointment.²⁷ By allowing patients to see physicians same day, or by utilizing technology to “conduct virtual visits,” physicians could reduce the frequency of overbooking patients as well as the number of patients having to make appointments for simple questions. Additionally, the Cleveland Clinic has developed a broader solution to reduce patient wait times and treatment inefficiencies: the Group Practice Model.²⁸ The Group Practice Model streamlines the process for taking care of patients by providing the organizational infrastructure for clinicians to communicate more efficiency with each other regarding a patient’s case.²⁹ Also, by allowing physicians to take part in the decision-making process, physicians can take on a leadership role in ensuring the health and welfare of the patients is priority.³⁰

There are a number of other solutions available to healthcare providers to assist in reducing patient wait times. In the emergency room context, a clinician, in conjunction with a nurse or other mid-level provider, could meet patients upon arrival to conduct triage and registration simultaneously.³¹ If beds are available, a nurse could bring the patient to an exam room immediately; from there an evaluation would take place to determine the acuity of the patient which helps the physician become aware of the patient’s situation.³² In the physician office context, the administrative staff of an office can send patients any intake or registration forms required to be completed before the appointment, which may reduce one reason why patients wait in physician offices.³³ Further, offices should more strictly enforce policies covering late or no-shows (which may include charging cancellation fees), which may deter patients from arriving late to appointments.³⁴