Can I find a doctor? Availability of primary care physicians in the San Francisco Bay Area
TABLE 2
Characteristics associated with appointment availability (multivariate logistic regression)
| Characteristic N=438 | OR | 95% CI |
|---|---|---|
| Sex | ||
| Male | – | – |
| Female | 0.7 | 0.4–1.3 |
| Race/ethnicity | ||
| White | – | – |
| Asian | 0.8 | 0.4–1.5 |
| African American/Latino/other | 6.5 | 0.8–52.7 |
| Missing | 1.7 | 1.0–3.0 |
| County | ||
| Alameda | – | – |
| San Francisco | 1.7 | 1.0–2.8 |
| Years since graduation | ||
| ≤10 | 4.2 | 1.7–10.3 |
| 11–20 | 1.1 | 0.6–1.9 |
| >20 | – | – |
| Medical school location | ||
| US | – | – |
| Foreign | 3.5 | 1.7–7.3 |
| Yearly median income of residents in zip code of practice* | ||
| Low | 1.7 | 0.9–3.1 |
| Middle | 2.1 | 1.1–4.0 |
| High | – | – |
| OR, odds ratio; CI, confidence interval | ||
| * Low: $5,106–$22,370; middle: $22,371–$36,507; high: $36,508–$51,926 | ||
Predictors of length of time to appointment
The length of time to appointment among those primary care physicians with an available appointment ranged from 0 (same-day appointment) to 151 days; the median was 13 days. Seventy-five percent of appointments were available within 30 days. As shown in Table 3, female primary care physicians were significantly less likely than male primary care physicians to have an appointment available within 30 days (OR=0.4; 95% CI, 0.2–0.7).
TABLE 3
Physician characteristics associated with early appointment availability* (multivariate logistic regression)
| Characteristic N=309 | OR | 95% CI |
|---|---|---|
| Sex | ||
| Male | – | – |
| Female | 0.4 | 0.2–0.7 |
| Race/ethnicity | ||
| White | – | – |
| Asian | 1.5 | 0.7–3.3 |
| African American/Latino/other | 0.4 | 0.1–1.6 |
| Missing | 1.0 | 0.5–2.0 |
| County | ||
| Alameda | – | – |
| San Francisco | 0.8 | 0.4–1.5 |
| Years since graduation | ||
| ≤10 | 0.5 | 0.2–1.1 |
| 11–20 | 0.9 | 0.4–1.6 |
| >20 | – | – |
| Medical school location | ||
| US | – | – |
| Foreign | 2.0 | 0.9–4.5 |
| Yearly median income of residents in zip code of practice† | ||
| Low | 1.0 | 0.5–2.1 |
| Middle | 0.7 | 0.3–1.6 |
| High | – | – |
| OR, odds ratio; CI, confidence interval | ||
| * Early appointment is within 0–30 days; late appointment is over 30 days’ wait | ||
| † Low: $5,106–$22,370; middle: $22,371–$36,507; high: $36,508–$51,926. | ||
Discussion
These results suggest that in a highly capitated urban area in California, access to primary care physicians may be restricted for patients seeking a new provider. The median waiting time for a new-patient appointment was 13 days, but the range was wide, from same-day appointments to 151 days of waiting time.
The most common reason for primary care physician unavailability was a “full practice.” In addition, a few primary care physicians required some form of screening before they would consider accepting a new patient into their practice. These screening practices may be a barrier to care. Under current managed care systems, appointment unavailability and long length of wait affect not only primary care services, but also access to specialty care.
This study gathered information on physician availability by means of research assistants posing as patients. We believe that surveying physicians using concealed intent was necessary to directly assess the experience of patients. This design was chosen to minimize inaccurate and potentially biased information.
Similar studies
At least 3 previous studies have used this method to obtain direct information on physician availability. After surveying ambulatory care clinics in 10 US cities, the Medicaid Access Study Group reported a difference in the length of waiting time to an appointment according to insurance status.5 Schwartz et al,6 who studied New York City obstetricians, found that only 42% of pregnant women were able to obtain a prenatal appointment with a physician, with waiting times ranging from 2 days to 7 weeks. Gifford,7 in a survey of Chicago area obstetricians, found that 36% accepted new Medicaid patients, and that fewer obstetricians worked in the poorest zip codes.
Physicians’ characteristics
Certain characteristics of the physicians were associated with availability or time to appointment. Female primary care physicians were significantly less likely to have an “early” appointment (within 30 days) available compared with male primary care physicians. Primary care physicians who had graduated from a medical school outside the US were more available than those who had attended a school in the US. Less experienced primary care physicians were more available than more experienced providers.
We were not able to analyze the availability of African American and Latino physicians separately due to their small numbers. When physicians identifying themselves as African American, Latino, or “other” were combined, the result did not significantly predict availability. The dearth of African American and Latino primary care physicians was striking: these 2 groups comprised only 2.5% of the study sample (n=11).
Limitations
Our study has several limitations. By excluding pediatricians, we were unable to determine primary care physician availability in Independent Practice Association plans for children in the study area. Osteopathic and general practitioners were also excluded; however, these practitioners comprise only a small percentage of primary care physicians in the study area. Information about physician race/ethnicity was frequently unavailable, which limits our ability to make conclusions about the effect of race/ethnicity. Moreover, to minimize missing data on race, we assumed Asian ethnicity for primary care physicians with Asian-origin surnames, and these assumptions may be a source of bias. We repeated analyses without the Asian race assumptions and found a similar lack of association for race in the multivariate models.
Also, we examined only new-patient availability. We do not know what proportion of adults in the study area have an established primary care provider. However, Medical Expenditure Panel Survey data have shown that 73% of the US population has an office-based usual source of health care, and almost 12% of families have members who change their usual source of care each year.3
