Managing Outpatient Service with Strategic Walk-ins II: The Triage Model Costs Less When C_L/C_O ≤ α̲ and the Strategic Model Costs Less When C_L/C_O ≥ ᾱResearch Paper
Motivation
Many outpatient clinics offer two ways in: an appointment booked online, and walk-in hours on the day. Some patients have no choice (acute cases arrive as walk-ins), but many can pick either channel, and they pick the one that costs them less: a long appointment delay pushes them into the walk-in room, a crowded walk-in room pushes them to book or to give up. A clinic deciding how to split its daily capacity between the two channels therefore faces a game, not a forecasting problem.
Liu, van Jaarsveld, Wang and Xiao (SSRN 3558209; Management Science 2023, doi:10.1287/mnsc.2023.4676) model this game and compare three operational levers: the capacity split, how much delay information the booking system reveals, and triage, that is, reserving walk-in hours for acute patients only (as some practices do, e.g. Centre Pediatrics 2021). This mission formalizes the triage comparison, Proposition 6 of the paper: closing walk-in hours to patients who could book pays off exactly when lost demand is cheap relative to overtime.
Setting
Patients. Exogenous walk-ins arrive at rate and are always served on the day, possibly in overtime. Strategic patients arrive as a Poisson process of rate . A served patient gains .
Capacity. The clinic has total capacity per day, split into appointment hours and walk-in hours , with .
The appointment queue. Appointments form a single-server queue with deterministic service time . In the observable setting a patient sees the queue: with patients waiting, the delay is , uniform on . A patient schedules when this delay is at most a threshold , and scheduling at delay is worth . The fraction of strategic patients who do not schedule is the blocking probability of this M/D/1/K−1+p queue, where and . With it has the closed form , where is built from the Poisson weights by the Brun–Garcia recursion (Online Appendix C, (26)–(27), Corollary C.1). With no appointment hours, .
Walking in and balking. A patient who does not schedule walks in with probability proportional to or balks with probability proportional to . Walking in is worth , with convex, strictly increasing and ; balking is worth . An observable equilibrium is a solution of conditions (6)–(10): the threshold makes scheduling at least as good as the walk-in/balk mixture up to and worse beyond it, , and patients walk in (balk) only if walking in is worth at least (at most) zero.
Costs. The provider pays per balking patient and for overtime, with convex and strictly increasing. In the strategic model patients choose freely, and the cost at allocation and equilibrium is
In the triage model strategic patients may only schedule or balk, so they behave with threshold and
Let solve (15): below these walk-in hours the exogenous walk-ins alone make walking in worthless.
Formalization targets
Goal: Proposition 6
Suppose and set
Then
where the infima are over allocations and, on the strategic side, over the equilibria at each allocation. The Lean statement says this without infima: every strategic configuration is matched by a triage allocation that costs no more, and every triage allocation is matched by a strategic allocation at which an equilibrium exists and every equilibrium costs no more.
Milestones
- Proposition C.2 (-part): is continuous and strictly decreasing on .
- Proposition 1 (observable setting): an observable equilibrium exists at every allocation.
- Proposition 2 (1): if , every equilibrium is schedule-and-balk, , , .
- From the proof of part 1: at every equilibrium.
- From the proof of part 2: if nobody balks, .
- From the proof of part 2: if patients mix between walking in and balking, .
Significance
Proposition 6 turns a qualitative trade-off into two explicit thresholds on the ratio of the lost-demand cost to the overtime cost. Free choice reduces balking but lets strategic patients crowd the walk-in hours; triage removes that crowding at the price of more balking. The thresholds and depend only on the overtime function, the capacity and the blocking probability, so a clinic can evaluate them from its own data. The paper also shows (Remark 4, Appendix D.8) that the same insight holds in the unobservable setting, with capacity playing an additional role; that variant is not part of this mission.
The result is proved in the paper (Online Appendix E.3, pp. 35–37) and has no machine-checked proof. The formalization adds three things. It fixes the equilibrium concept precisely, including the mixture weights and the endpoint conventions. It states the comparison of optimal costs without presupposing that the optima are attained; the paper's proof begins "denote the optimal capacity allocations" without proving existence. And it ties the blocking probability to the paper's closed form, so the monotonicity in that the proof invokes becomes a statement about an explicit function rather than about a queue described in words.
Difficulty
The comparison itself is a chain of convexity inequalities at a single allocation. The hard part is the blocking probability. The paper proves that decreases in by a sample-path argument on the queue, but a formal development has only the closed form, in which jumps at every where is an integer, jumps from to there, and moves continuously. Monotonicity and continuity must be shown across these seams, through alternating sums whose terms cancel heavily. The obvious route, differentiating the closed form for fixed , does not give the sign without a further structural argument on the coefficients .
Existence of an equilibrium (milestone 2) is an intermediate-value argument in , which in turn needs continuity of in and positivity of .
Formalization scope
Everything lives in the namespace OutpatientWalkIn.Triage. The definition Queue contains the closed-form blocking probability blockProb lam δ μS; the definition Setting contains the model, the standing assumptions, the utilities, the equilibrium IsObsEq, the costs obsCost and triageCost, and the thresholds alphaLow, alphaHigh.
Conventions:
- Standing assumptions, hypotheses of every theorem: , , , , ; convex and strictly increasing on with (Assumption 1); convex and strictly increasing on (Assumption 2).
- Allocations range over on both sides, so that ; the paper's leaves the exogenous walk-ins with no walk-in hours.
- ; the observable setting is defined directly (the paper's ).
- The equilibrium carries the guard , which by (8) is and excludes no equilibrium of the paper.
- Added hypotheses of the goal: , , given by (15), and differentiability of at and (where is evaluated). Without them Lean's and the zero derivative of a non-differentiable function would make and turn part 1 into a different claim.
- "Costs less" is "costs no more" (p. 26).
A formalization that compares the two models at one fixed allocation only, that lets the prover choose a cheap equilibrium when several might exist, or that replaces by an arbitrary decreasing function, is not the paper's theorem; the statements here rule these out.
Contributions welcome: properties of the closed-form (positivity, , monotonicity and continuity in both arguments), the existence of equilibria, and the convexity estimates of the final comparison. The queue file is reusable for any M/D/1/K model with partial joining.
Selected references
- N. Liu, W. van Jaarsveld, S. Wang, G. Xiao, Managing Outpatient Service with Strategic Walk-ins, SSRN 3558209 (version of 2022-07-05); Management Science, 2023. https://ssrn.com/abstract=3558209, https://doi.org/10.1287/mnsc.2023.4676
- O. Brun, J.-M. Garcia, Analytical solution of finite capacity M/D/1 queues, Journal of Applied Probability 37(4), 2000 (the source of the recursion, cited in the paper's Online Appendix C).
- P. Naor, The regulation of queue size by levying tolls, Econometrica 37(1), 1969. https://doi.org/10.2307/1909200