• Enough with the wait times, already

    This post has been cited in the 3 March 2011 edition of Health Wonk Review.

    It constantly amazes me how entrenched many people get in opposing health care reform. I’ve been getting a strange number of emails defending the health care spending seen in my post yesterday. Please understand, that spending is what’s bankrupting us. You can hate the PPACA, you can hate single payer, you can hate any form of government regulation at all, and stil recognize that we spend too much on health care.

    But forget that for a second. Many of you are defending the high costs of our health care with the usual “wait times” meme. You defend our very, very high level of spending by accusing other systems of having long wait times. You believe that we are buying “no wait times” with our spending.

    No.

    First of all, what do you mean by wait times? Perhaps it’s “do you have to wait to see a doctor when you’re sick”?

    Let’s own something right up front. We beat Canada. Let me say that again: WE BEAT CANADA. There’s a reason people always cherry pick Canada to talk about wait times. But many, many other countries do better in terms of getting people in to see the doctor when they are sick.  We also do better in terms of getting people in to see specialists (although we’re not #1), and we do better in how long people need to wait to get elective surgery (which is ELECTIVE), but that’s not the same.

    Here’s another telling metric, however:

    People in the US feel like their doctors don’t know them. Why could that be?

    One reason is that more people feel like they don’t get enough time with the doctor. Since we’re so obsessed with wait times (even though we don’t do very well in winning that battle), doctors are forced to see more patients every day in order to avoid them. So, yes, you might not wait as long to see your doctor, but when you get there, he or she won’t have much time for you.

    One of the reasons for this is that we have so few doctors in this country:

    And that’s after spending way, way, way more money than anyone else.

    How is this defensible? We’re failing. We really are. I have no problem with disagreement on how to fix the system, but it’s hard to believe some many of you want to defend the status quo.

    UPDATE (from Austin): Colleague and occasional co-blogger Steve Pizer has co-authored (with Julia Prentice) a recently published paper on wait times and diabetes care. They conclude, “Decreasing wait times has the potential to reduce A1C levels by 0.18 percentage point for patients with baseline A1C levels exceeding 8%. This effect is roughly one-third of what is achieved with the most successful existing quality improvement strategies.” I will encourage Steve and Julia to write a blog summary of their paper.

    UPDATE #2 (From Aaron): Fixed a denominator problem in the title of the GP chart.

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    • Good stats – reality and truth are central to dealing with issues.

      However, you point out good points of our current system – which are defensible – and then argue that those disagreeing with the current regime in Washington andy defending anything about the current system are against any change at all. This is factually incorrect.

      Straw man. Just like Obama.

      Opposing Obama does not equal opposing any change to our current system (there are a whole host of documented recommendations that were ignored by the administration and the press). Opposing a plan that was put in place without public review and with so much left to an unaccountable bureaucracy is not opposing change at all.

      How is this defensible? How is this an intellectually honest argument.

    • The first chart is appears to be very misleading. I’m going to assume it is the wait time to see your family doctor, because in Canada we have walk-in clinics, where it is free to go see a doctor. The wait times vary at the clinics, but they are measured in minutes and hours, not days. For minor ailments, you go in, get treated, get your treatment information sent to your family doctor for their records, then leave.

      Now wait times to see specialists? That can be very very long in Canada. I’ve known for people to have to wait years for ‘elective’ surgery for torn tendons, back surgery, etc.

    • Does the data for the US (for all graphs) include citizens who do not have medical insurance? Or just those who do?

    • @Alan,

      Sorry, but I explicitly said that I have no problem with people who think that the PPACA (President Obama’s approach) isn’t the way to fix the system. So you’re the one constructing straw man arguments. I have a problem with the “best health care system in the world” crowd.

      @bryan,

      You’re giving me anecdotes. This is the data out of Canadians’ own mouths.

      @Ed,

      It’s everyone.

      • “You’re giving me anecdotes. This is the data out of Canadians’ own mouths.”….UH… I believe that is the very DEFINITION of “anecdonte”! LOL!

    • Nice post Aaron

      I have my own anecdotal story. My wife, who works at a hospital that has its OWN health care plan through its OWN insurance company and has been employed in a managerial position for ten years and worked for the system for thirty years (if this isnt someone who should get “special treatment” I’m not sure who should) was told just the other day that she wouldnt be able to see the specialist she’s been referred to for almost four months!! She has a near cadillac plan and is entirely within network and cant see her specialist for almost a third of a year!!??

    • My two cents worth: I think Canada and the US are very similar in results because they are both on the pay for procedure system. Piece work (I’m an economist who used to work in construction so I know of what I speak) always encourages people to do things fast and dirty. That’s why doctors in the US and Canada tend to walk in scribble out a prescription and leave (I’m and American who has been living in Canada for nine years now. Again, I know…).

      Although, the UK is an outlier here as the NHS has all their doctors on a salary. But then the Brits are legendary for being able to mess up a good thing for decades that others make work just fine. Just compare a Jaguar or a Mini Cooper (both having infamously faulty electrical systems) with a Mercedes or an Volkswagen (both known for being very dependable).

      • “But then the Brits are legendary for being able to mess up a good thing for decades that others make work just fine. ”

        The US federal government, on the other hand, is just SO EFFICIENT in managing……wait….what was it they EVER IN RECENT HISTORY managed efficiently????

        I continue to pose the query, “What three programs has the federal government EVER managed efficiently?”

    • Re: Bryan & Ed –

      Bryan’s data are not statistical, but he was not merely retailing “anecdotes”, and his point is certainly true. The Canadian health system covers walk-in clinics providing immediate service for minor care. Your data may come from Canada, but Bryan’s implicit question – what “visits” are at issue here? – is a good one. There are visits to see your usual primary care doctor, and visits to see whoever’s on duty at the clinic when you need outpatient care right away. If each no-wait clinic visit were factored in against all the make-an-appointment-and-wait office visits, and if the total number of clinic visits were even a small fraction of the total number of office visits, the mathematical effect on the resulting average wait time would be considerable. So either the waiting time for primary-care office visits alone is much longer than the figure on the graph above (if clinic visits were factored in), or the waiting time to see a doctor when you want to, regardless of location, is much shorter than that figure (if clinic visits were not factored in). I’m guessing the latter, but either way it’s an important distinction.

      Your response to Ed is hard to believe. Mathematically, the average waiting time for almost any medical treatment in the United States is “forever”. That is to say, a large fraction of the population has no access at all to most care, other than in frank emergencies and often not then. The waiting time for the uninsured or underinsured population is essentially infinite. Factoring their waiting times into the average wait for patients who actually get treated would push the overall average off the chart, no matter how tall your chart is. Even if you limit their calculated waiting time to the time period between diagnosis and their eventual death after remaining untreated – as it is for so many – that waiting time turns out to be decades in many cases. This is not a joke or a fluke. You cannot reasonably calculate average waiting times for treatment without taking into account the fact that a large fraction of the population is prohibited from getting any treatment at all for a given condition (a complication that applies only and uniquely in the United States, among the developed world, but is unmistakably real). I suspect that your waiting time for “everyone” is limited to “the average time waiting by everyone who actually got treated”, but that is not a fair or realistic figure.

    • The last chart has seven countries listed and only six visible lines. Also, the color scheme appears to have been chosen to maximize the difficulty of distinguishing the non-US countries.

    • Help, please. Somehow, I can’t make sense of the numbers in the last chart showing GPs per 100,000 population. If we have about 300 million people in the U.S., how many GPs does this chart suggest we have?

    • Funny, nobody has ever surveyed me about wait times. No one I know and whom I have asked about it share my lack of being surveyed. How do the surverers get this data?

    • Forgive me. “…Those I know whom I have asked about it say that they have never been surveyed on the subject either…”

    • The low number of general practitioners per 100.000 population is probably influenced by the lack of universal health care. People with no or poor insurance probably don’t visit the doctor as often as they should.

    • The US has 50 million people without health insurance and yet our 5 year survival rate for some cancers are better than Europe where everybody has health insurance. What is the point of seeing a doctor instantly only to learn that there is a 6 month waiting list to begin treatment?

      The main concern those of us have about Obamacare is that it will lead to healthcare rationing. Remember, coverage is not care.

      http://4.bp.blogspot.com/_otfwl2zc6Qc/SoG4Vv5-y-I/AAAAAAAAK3A/afilDKt_4ks/s1600-h/cancer.bmp

    • Gazillions of data have already been published on these points.
      Yesterday I met a 61 year old lady who weighs about 300 pounds. Her BMI must be 60. Which meanss she is grossly fat. Her abdomen hangs down to her knees. She is balding. She has been to the hospital twice by going though the emergency room. Once for a headache, The other I forget. She had her hospital bills forgiven because they allege inability to pay the bills. Both she and her 72 year old husband work full time. He is an epileptic so he doesn’t have a drivers license. They share one car. She claims her new problem is feet swelling, on top of hypertension. Maybe she has heart disease.

      Since she is uninsured I told her to go to a free clinic. She said she doesn’t like the free clinic. I told her I only treat insured patients.

      She is twenty years too late to be putting her half dead carcass on my responsibility. No insurance no care. No insurance –she is not paying her share of my malpractice policy. I can’t spend enough time to beg for her ; free specialty care, and free testing. I can’t front her lab bills. I already have three decades of accumulated discount uninsured patients. I never abandon a compliant patient even if they lose their insurance.

      Now those of you who deny human beings like these health care in a physician office and hope your conscience is clear cause it is up to me and not you –think again. Your are dead wrong This is your social problem Persons like this pathetic health wise disenfranchised person are dying on your hands not mine. My responsibilities are to the patients I accept. Yours are to the uninsured.

      You the voters and citizens of America have a direct hand in setting up this person’s death. You are murdering her. How can you live with yourselves. I have disgust sharing the same country.

      All the sophistry strewn by you cruel people is nought but big fat excuses.

    • I’m curious about “wait times” means, too.

      I live in the UK, and I used to live in America.

      I wait a couple-few hours for an appointment to see my doc when I’m sick. Once I arrive at his office, I wait maybe a few minutes to see him – sometimes I don’t even have time to open the book I brought.

      If I’m not sick, I might wait a day or two, but I usually don’t have to unless it’s flu season. (We also have the free walk-in clinics, which is handy if you have an emergency in the middle of the night.)

      If I need to see a specialist, I get referred and get a timely appointment. If I need surgery, that’s timely, too.

      As near as I can tell, the difference between what I have here and what I had in the US when I still lived there is that (a) I spent much more time in my doc’s waiting room in the States, (b) I am much more sure to see my own doctor here rather than some random selected partner, and (c) I do not have to waste months on the phone arguing with some insurance company about whether I can get a needed treatment.

      It may very well be that you get your surgery within days in the US once your insurance company agrees to cover it, but if you’ve spent months convincing them first, how long is the real “wait time”. Or should we call that “fight time”?

      I don’t have to fight to get treatment I know I can afford.

    • Is the lack of GPs a problem created by excessive licensing. Are other problems the result of to few GPs.

    • Doesn’t this assume that the ideal is no wait time? Isn’t there a cost benefit to putting up some sort of barrier to receiving care (in this case, inconvenience) so that folks who have a cold don’t waste a doctor’s time?

    • The last chart shows that the US lags the other countries in the chart by a large margin in general practitioners per capita. My understanding is that GP = primary care provider. The chart’s claim is that we have far fewer docs in general per capita than other countries, which may be mistaken.

      Many in the health policy world will admit that we’re short of primary care docs, and most people who aren’t specialty docs will say that’s not a good thing.

      In the future, we will need public policy mechanisms to get med school grads to go into primary care specialties. My understanding is that for about the same amount of effort, a medical student can go into a primary specialty and earn $100-200,000 a year, or into a specialty where they might earn $300-600,000 a year. It’s no contest except for the true believers.

      Unfortunately, from a public policy stance, most ways to get more people into primary care would involve reducing reimbursements to specialists (either procedure rates or number of procedures) and increasing them for primary docs. Health reform punted on this, and any action will create fierce opposition from the specialists and from the Republicans. Imo, both of these groups need to get with it.

    • Hi Aaron,

      Not sure if you’ve represented wait times, doctor supply, etc. in the fairest way in these slides. Too lengthy of a discussion for a comment, but it’s certainly premature to say “enough with the wait times already.” Fair to say that there are ways to save money without worsening wait times—but unfair to say that opponents of Obamacare don’t have ideas to do just that.

      Two simple criticisms: you haven’t represented wait times for common surgical procedures in these slides, and your doctor supply slide doesn’t include specialists.

    • The scarcity of GPs…and of all primary care physicians…is a product of far more than economics, and there’s a fairly robust literature describing the identified causes.

      Increasing the relative incomes of primary care physicians would be a simple solution to the problem, but I’m reminded of the old saying: for every complex problem there is a solution that is simple, straightforward and wrong.

    • We have a low number of GPs in this country, of docs in this country, because the AMA lobbies to make it difficult to bring in doctors from other countries. The AMA works hard to keep these regulations in place which artificially boosts the income of docs. If the US allowed more doctors to come to the US to practice, the majority of people would experience a real (not nominal) gain in incomes but our country prefers to distribute wealth upwards…

    • We recently launched a website called http://www.TheDocClock.com where patients can check and report on wait times at doctors offices and ER’s before they leave home and then self report wait times from smart phones when they are waiting in the waiting room or exam room. Interestingly enough, in line with the chart, we have had numerous requests to add Canadian hospitals to the list due to an untenable situation that currently exists over there. Thank you

    • That last slide is the most telling. We have fewer doctors. Smaller supply, high demand, prices will be high. At the end of the day we need more doctors and we need the doctors to get paid less.

      Fundamentally we have an education problem. This country needs to train more doctors and engineers, while graduating fewer lawyers and business majors.

    • This article is featured in the March 3rd edition of the Health Wonk Review. Thanks for your submission!

      http://lucidicus.org/editorials.php?nav=20110303a

    • Three words:

      AMERICAN

      MEDICAL

      ASSOCIATION

      The question: Why are health care costs so high in the US?

    • Whatever person thinks we need to just allow more doctors in and lower the salaries of doctors to fix our problems is obviously thinking the medical profession is like farming or something. These are the brightest and most dedicated people in the world for sure and in most cases they are choosing the medical profession to capitalize on their intellectual ability. If you lower their income or flood the market with incompetence, you will drive out the best doctors, for sure, and erode the medical care quality.

    • I don’t care if Obamacare is the greatest thing to come down the pike since sliced bread and vanilla ice cream. It is a freedom issue. People compare it to the government telling us we need to buy auto insurance. If you don’t want to buy car insurance, then don’t own a car. With Obamacare, there is no opt out clause. You must participate. Our right to be left alone is gone.