How Digital Scheduling Platforms Effect Insurance-Based Disparities in Access to Specialist Outpatient Care: A Cross-Sectional Audit Study in Berlin, Germany (Preprint)
Year: 2025
Type: preprint
Abstract: BACKGROUND Digital appointment scheduling platforms have the potential to be widely adopted but may interact with insurance-driven incentives to amplify access inequities. In Germany’s dual insurance system, privately insured (PHI) patients may obtain earlier specialist appointments than statutory health insurance (SHI) patients. OBJECTIVE To quantify differences in wait times to first-available specialist outpatient appointments for SHI versus PHI profiles on a large commercial online scheduling platform (Doctolib) in Berlin, and to assess whether providers offering equal appointment options for both insurance types are deprioritized by the platform. METHODS We performed a cross-sectional internet-based audit between January 6 and February 26, 2025. Two standardized simulated patient profiles (SHI and PHI) were used to query 1,867 platform listings; providers with at least one bookable slot for both profiles were retained (n = 492). Primary outcome was wait time in days to the earliest available appointment. Paired t-tests compared within-provider wait times; subgroup analyses examined specialty-specific differences. Sensitivity analyses excluded the top 5% longest waits. Effect sizes (Hedges’ g) were computed. RESULTS Across 492 providers, mean wait times were 50.3 days (SD 52.2) for SHI and 22.6 days (SD 36.8) for PHI, yielding a mean difference of 27.7 days (95% CI 23.6–31.9; t(491) = 13.05; p < .001; Hedges’ g = 0.59). After excluding the top 5% of wait times (n = 44), the difference remained significant (Δ = 23.1 days, 95% CI 20.0–26.2; t(447) = 14.77; p < .001). The largest specialty gaps were observed in urology (Δ = 45.8 days; p < .001), general surgery (Δ = 34.9 days; p = .012) and ENT (Δ = 31.6 days; p < .001). Providers that offered earlier PHI appointments showed substantially longer SHI waiting times (61.8 vs 37.5 days; p < .001) and substantially shorter PHI waits (12.0 vs 38.2 days; p < .001). Platform ranking was correlated with earlier PHI availability (r = 0.574; p = 0.001), suggesting algorithmic amplification of differential access. CONCLUSIONS On this commercial scheduling platform in Berlin, SHI patients experienced substantially longer waits for first-available specialist appointments than PHI patients across multiple specialties. Platform ranking and differential slot allocation appear to amplify pre-existing insurance-based access inequities. Algorithmic transparency and insurance-neutral ranking criteria should be considered to promote equitable access. CLINICALTRIAL no registration
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: gold
OpenAlex ID: W4413307978