In Soviet Russia, Line Waits You

That's part of an advertising campaign launched by an industry group Health Care America who's agenda is to convince you that government-run health care would be evil. And, of course, it's true -- in systems with government-run health care systems you sometimes need to wait to see a doctor. Much as in the United States you need to wait on line to see a movie. Or how in the United states you need to . . . wait to see a doctor.

I'm fascinated as to what planet the maker of this ad lives on. Back in December I called my primary care physician's office to schedule an appointment. I got one in mid-March. Such is life. Waiting times are, obviously, a function of supply and demand. The private sector could easily organize an insurance scheme that made it much quicker and easier to get in to see your doctor -- your premiums and/or copayments would just need to be way higher. Similarly, just as a government-run subway system can reduce crowding by spending more money to run more trains, a government-run health care system featuring long waiting times for MRIs could . . . spend money and buy more machines.

It's far from obvious that zero waiting really is the optimal arrangement for all procedures, but one way or another the waiting issue has very little to do with whether or not the system is, in some sense, "government run." Indeed, my sense is that American Medicare recipients -- that's government run healthcare for the uninitiated -- tend to do less waiting than your average person with private insurance.

Comments

So, with a true free market system, we'll no longer have to wait to see a movie?

Posted by El Cid | July 23, 2007 4:45 PM

private insurances tend to provide higher fees to doctors than medicare and, obviously, medicaid. incentively-speaking (word?), why, exactly, would a doctor be willing to facilitate collection from the latter rather than the former?

also, i'm not sure if this is accounted for in the studies/metrics, but what does "waiting time" actually mean and how is it measured? is it "when can i get appointment that fits into my 21st century schedule" or "when can i get an appointment asap"? it seems like the plays a huge role in our puritanically-inspired society, as compared to France, where you can probably ditch work and not get fired to have someone check out that purple-hued mole that's probably a stain from dirty clothes.

Posted by neil | July 23, 2007 4:51 PM

See, the forthcoming evil Soviet universal health care Great Leap Forward will force you to wait in LINE. The miracle of the free market allows you to wait in a ROOM with dogeared copies of Time and Better Homes & Gardens from March, 2004. The first despotic action following the Stalinist takeover of our health care system (perhaps Pete Seeger will be our Health Minister bwahahahaaaa) will be the removal of all magazines and ugly chairs from waiting rooms, to be replaced with ropes cordoning off the breadline...er, medline?

Posted by Jake H. | July 23, 2007 4:54 PM

Just to be clear, when we say industry group here, it looks like were talking specialists and pharmacutical companies, and that their primary opposition is to any sort of attempt to curb healthcare spending, or define what aspects of healthcare get to be universal. Lots of osteopaths on their board.

It's important to keep the teams straight here. These guys are the natural enemies of insurance companies.

Posted by Boring Commenter | July 23, 2007 4:54 PM

If there was no wait to see a doctor wouldn't that mean there were too many doctors in the area you went to see one? That doctor you popped in on was literally parked at a computer screen, playing solitaire, hoping you'd knock on his door?
"What's with this 'I thought I'd have to wait til next Tuesday' gibberish? I kept my entire day's schedule clear just in case you showed up. Can't have anyone stand in line for my services, no sir!"

Posted by steve duncan | July 23, 2007 4:55 PM

I'm fascinated as to what planet the maker of this ad lives on.

It's called Planet Liar.

Posted by Mike | July 23, 2007 4:59 PM

Who waits in line to see a movie anymore?

Posted by Steve Sailer | July 23, 2007 5:00 PM

Ask your doc whether his staff spends more time hassling with Medicare or private insurers. Last week my physician said the admin staff in his clinic spends half their time securing insurance approval. If Medicare/Medicaid upped their payment rate to something approximating the private insurance industry standard the argument for single payer would be over.

Posted by Nat | July 23, 2007 5:05 PM

Absolutely right. Even if the evidence supported the statement, "People in Canada, France, England and Germany have to wait longer than they do in the US to see a doctor", it's a logical error to conclude that this variance is caused by those systems being government-funded. How the system is funded is one factor; how much funding it gets is another. Wait-times can be reduced in a number of ways, but they're all a variation on "provide more of what is in short supply: GPs, devices, ORs, nurses, X-ray techs, etc." I don't see how anyone can argue with a straight face that switching from a single-payer system to a hybrid mess like the US system would, in itself, resolve these problems.

The solution for wait-times is more funding. It has nothing to do with choice of overall system.

Posted by DNS | July 23, 2007 5:06 PM

This isn't an issue I know a lot about but isn't Medicare not really a government-run healthcare system so much as a government funded system? If the government pays for individuals to receive care from private providers (like Medicare here and, universally, in Canada) how can they increase the supply of providers by "increasing funding"? Wouldn't you need to make the government a major provider to affect the supply of doctor's etc. though public funding? (Not that the latter is a bad idea...)

Posted by Jack | July 23, 2007 5:07 PM

Who waits in line to see a movie anymore?

People without a credit card (i.e. poor people) for whom Fandango is but a dream.

Posted by sangfroid826 | July 23, 2007 5:17 PM

Matt points out that people with private health insurance have to wait to see doctors. I'd like to know just long those wait times compare to how long the nearly 50 million Americans without any health insurance, private or public, must wait to see a doctor?

Posted by CKT | July 23, 2007 5:22 PM

Medicare is a system in which private doctors who agree to accept Medicare recipients are paid a set amount for a whole range of procedures and treatments. The amount is set by the govt., the payments are made by the govt., but the physicians are in private practice.

The managed-care system is surprisingly similar: doctors who 'participate' in a managed care plan sign a contract with the managed-care plan under which they agree to accept the contract rate for each procedure or treatment and, in exchange for agreeing to that rate, they get access to that plan's patients.

A key difference between managed care and Medicare, though: Medicare almost never denies care in advance, during treatment, or after treatment, and certainly doesn't have an entire bureaucracy devoted to nothing else (in managed care plans, this function is called Utilization Review and it costs a lot of money).

Defenders of the status quo still wave the same red flags, warning about what would happen if we moved to a single-payer system. Almost all of the warnings are bogus, either because they are based on outright lies, or because we have those problems already:

- "You won't be able to choose your own doctor!" Untrue, and anyway, managed-care plans already limit choice of doctor.

- "Medical decisions will be made by bureaucrats instead of by you and your doctor!" Untrue (doctors in Canada never have to consult with anyone before deciding what you need), and this is precisely how managed-care plans try to control costs -- by having someone at a distance second-guess the doctor's judgment.

- "Those systems ration care!" So does the US. All managed care plans have a list of covered benefits, a list of exclusions, and mechanisms for denying coverage. That's rationing.

- "Doctors will become government employees!" Not necessarily true. In some systems, yes; in others, no. And what's the problem with this anyway? Police officers and firemen are government employees.

- "Government management and/or funding will destroy innovation!" Not true. Other western countries have amazing medical technology of their own. In any case, if govt involvement killed innovation, where did laser-guided bombs come from?

Posted by DNS | July 23, 2007 5:30 PM

Soooo...movie lines are government run? Movie tickets are Federally subsidized and not a matter of free-market supply and demand?

Posted by Tom | July 23, 2007 5:30 PM

For most of my life I had medical insurance through my employer (IBM). Most of that time it was Blue Cross Blue Shield and they would occasionally refuse to cover various blood tests, etc. For the last four years I have been under Medicare and it has been excellent. I see no difference in waiting times. I had a doctor refuse me because of BCBS once, but haven't experienced that under Medicare. They pay the items that BCBS refused. Their payment reports are very clear about how much I should be charged and also specify items for which I should not be charged. Perhaps I am lucky, but if everyone were getting the coverage that Medicare provides to me, I think most of us, at least, would be quite satisfied.

Posted by Jerry | July 23, 2007 5:52 PM

This ad is hilarious. My instant unthinking reaction was, "A wait for a doctor so short I can just stand in line for a few minutes?" Then I got confused about what it was supposed to mean. Then it was hilarious.

They ought to just factor out the BS and run ads that say, "Your health care isn't a baffling ordeal -- it's GRRR-EAT!"

Posted by chris | July 23, 2007 6:24 PM

Wait, I'm confused. Can I get my appendix removed via Netflix?

Posted by Gregorio | July 23, 2007 6:34 PM

The ideal response ad is one that features this image as an inset, with the caption: 'Your health insurance premiums paid for this.'

Posted by pseudonymous in nc | July 23, 2007 6:36 PM

I think we're all missing the point here.

There's a BEAR in our health care system. A motherfucking BEAR.

What this has to do with single-payer health care, I'm not sure. I assume it's supposed to be a semi-subliminal association with the USSR, or perhaps an idea from someone who missed the memo that The Colbert Report is a parody.

But seriously. A bear.

I'm never going to the hospital again without a hunting rifle.

Posted by Peter | July 23, 2007 6:36 PM

Actually, they have a point. If single-payer, universal health care is government run, the last thing I want to do is bend over for Bill Frist wearing latex gloves.

Posted by Gregorio | July 23, 2007 6:38 PM

Actually, this is an argument we should be glad to see them make. First of all, we know it's a lie, and a big fat juicy one. Americans wait about the same time or longer than people in France or Germany, and you can confidently hammer them with that fact because....

It ain't gonna change. First of all, the industry can't turn on a dime, they couldn't change it if they wanted to. Second, as some of us have noticed, no waiting means too many providers. That works for grocery stores, where the tellers can stock shelves when they're not needed, but not for health care. Thirdly, the biggest consumers of health care are older people who understand that gratification doesn't need to be instant. (There's a high early mortality in the instant-gratification crowd.)

So go ahead, memorize the basic facts (they won't change), learn how to deliver the message, and after you deliver it, add- "So if they lied to you about this, what else do you think they might be lying about?"

Posted by serial catowner | July 23, 2007 7:13 PM

Re: Back in December I called my primary care physician's office to schedule an appointment. I got one in mid-March.

I'm surprised at that. I've never had to wait more than a day or two to se a PCP. Heck until I moved last year I had a doctor who allowed walk-ins. It's generally specialists you have to wait a while to see-- and this tends to be the rule in other countries' systems too. Which makes sense. A visit to a PCP is cheap (relatively speaking) so there's no reason either a for-profit system or a socialized system would choke off access there.
By the way, who waits any significant time to see a movie? I usually arrive c. 5-10 minutes before show time and wait no longer than need be to purchase the ticket, grab the coke and popcorn and head inside the theater. Also, what does paying cash have to do with it? I've never used Fandango and occasionally pay cash. Still, no real wait.

Re: Medicare almost never denies care in advance, during treatment, or after treatment, and certainly doesn't have an entire bureaucracy devoted to nothing else

This is partly incorrect. Medicare does indeed deny reimbursement to providers after the fact if the i's are not dotted and the t's are not crossed on the claim form. Also, I believe that Medicare, like private plans (and almost all single payor plans elsewhere), has gotten into the precert/auth business too. Which is not a bad idea since unscrupulous providers do try to inflate their tabs by ordering up expensive and unneeded tests and the like.

Re: in managed care plans, this function is called Utilization Review and it costs a lot of money

Maybe up front for the UR software, but afterwards not so much, and yes, UR is utilized by public plans too. I keep seeing this naivte about how public plans, both here and abroad, work. None of them are old fee for service: there's a strong dose of managed care in them (which is why those infamous waiting times exist). Care is denied. An army of clerical workers must adminsiter the plan (but without marketing expenses or oversized executive salaries). What doesn't happen though is that no one ever gets stuck with a bill. Doctors are obligated to accept what they get and cannot bill the patient beyond the amount allowed by law. A claim that is denied (absent fraud by the patient) simply bceomes an unpaid bill and the patient is not dunned for it. Also, no one is ever dropped from coverage except by very gross error.

Re: and this is precisely how managed-care plans try to control costs -- by having someone at a distance second-guess the doctor's judgment.

That someone is generally an RN who has access to the patient's complete medical history-- maybe even more than the doctor has. In truly complex cases that someone may even be another MD. It is not the case (as often stated) that accountants are in this role.

Posted by JonF | July 23, 2007 7:16 PM

the most interesting question is what vendor/agency made these ads for healthcare-america.org???

Posted by jmh | July 23, 2007 7:24 PM

JonF --

Thanks for your post. Good detail, factual, informative. I would agree with almost all of it, and the stuff I might quibble with isn't that important.

But I'm left wondering where you stand on the issue of reform. Are you defendig the status quo? Agreeing that a single-payer system would be preferable (and just tweaking some of the factual content of the thread)?

I'd say that none of what you wrote presents a serious challenge to the arguments in favor of a single-payer system, or none of it offers a decent defense of the status quo. Your points are essentially of one kind: "Well, the same is true of the other system as well, to some extent." And that in itself doesn't contradict what I wrote.

Is there bureaucracy in a single-payer system? Of course. But less than there is here.

Is there UR of some kind in a single-payer system? Of course, but less than there is here.

So, ummm..., what exactly are you trying to point out?

Posted by DNS | July 23, 2007 7:40 PM

When I make an appointment with my PCP the wait is over four months therefore I generally only see her for the annual physical and a few chronic things - bad knee, allergies, etc. Most of the time I see a doctor, it is a same day "urgent" care appointment and involves an intern. They get to practice on me and I leave with a prescription for antibiotics.
It is a win-win.

Posted by socalized medicine | July 23, 2007 7:48 PM

Re: But I'm left wondering where you stand on the issue of reform. Are you defendig the status quo?

Absolutely not. I'm just counselling realism on how public plans work. But if I had one political wish I would use it to bring about universal healthcare-- even before getting out of Iraq or consigning George Bush & Co to perdition. I do suspect however that private health insurance is going to be with us for a long time yet. Even Medicare is supplemented with Medi-gap policies after all. And many European systems have a role for insurance too-- but strictly regulated so it serves the interest of the patient not some rentier class.

Posted by JonF | July 23, 2007 7:57 PM

JonF --

Cool.

Posted by DNS | July 23, 2007 8:25 PM

JonF: "This is partly incorrect. Medicare does indeed deny reimbursement to providers after the fact if the i's are not dotted and the t's are not crossed on the claim form. Also, I believe that Medicare, like private plans (and almost all single payor plans elsewhere), has gotten into the precert/auth business too. Which is not a bad idea since unscrupulous providers do try to inflate their tabs by ordering up expensive and unneeded tests and the like."

I gather JonF has no direct experience of Medicare (I've been under Medicare for 2 years, my wife for 5, and I managed my mother's Medicare EOBs for 15 years).

Most providers that accept Medicare apparently have mastered the forms and so I can't recall the last time I saw a claim refused because of an improper diagnostic code.

My wife and I have had a lot of different procedures recently, and I haven't encountered any instance of the "precert/auth" that JonF believes is being practiced. On the contrary, I've had several instances recently where I was informed by the provider that Medicare would probably not cover a test, and they did.

On the whole, Medicare has been easier to deal with than the insurance provider by my wife's and my former employers.

Posted by Bob Gaines | July 23, 2007 8:29 PM

I posted something similar before on a different thread on health care, but I'll repeat it here because it's extremely relevant now:

If you want to look at what government run health care looks like, examine the VA Health Care System.

I am a 4th year medical student who rotates through the main VA Hospital in Baltimore. There are certain things the VA does very, very well, and other things that it does absolutely terrible.

For example, the current wait list for elective hernia surgery at the Baltimore VA Hospital is around 15 months. You can be evaluated by surgeons earlier, usually within the month, but you'll spend at least a year on the waitlist before you get your surgery. If you are a patient across the street at our university hospital, the wait time for elective repair is less than a week.

Now, to counter this - it is for ELECTIVE hernias which aren't life threatening, and aren't extremely painful (and recent medical evidence suggests that "watchful waiting" in hernia repair is at least equal to operative repair). Hernial emergencies are repaired right away. And the VA Hospital system is, according to recent reports, much better at patient tracking and long term care of chronic conditions (Diabetes, hypertension, heart failure) mostly due to their patient tracking abilities.

So, when talking about things like wait times, it is absolutely the case that government run health care will lead to longer wait times in a number of circumstances. The question is whether the tradeoffs will be sufficient and whether there will be a "private" option for those who wish to pay for elective services.

Posted by GeorgieTheK | July 23, 2007 9:25 PM

Is it unreasonable to question why, if we wait so long to see a doctor, don't we simply increase the supply of doctors?

Establishing new medical schools, funding them federally to remove the burden of repaying tuition, admitting as many qualified applicants as possible, and let the supply curve shift outward.

It's not a magic bullet solution, but it could ease some of the pressure on our current system. Plus, it need not be terribly expensive.

Posted by mesbah | July 23, 2007 9:33 PM

Re:I gather JonF has no direct experience of Medicare

Not on my own, no, but through my father, whose affairs I managed, increasingly, during the last two years of his decline. And yes, Medicare denied claims all the time. Sometimes the providers corrected whatever problem there was with the paperwork and the claims got paid (after ten months in one case), and sometimes they never did get paid (as executor of his estate I kept careful watch on all the Medicare EOBs that kept coming for almost a year after his death). The average patient is probably unaware of all this because the patient is never actually billed for denied claims. But the providers are definitely aware of it, which is why there's a small but significant frcation of them who will not take Medicare-- not to mention a much larger number of physicians who want nothing to do with Medicaid whose reimbursements are even stingier and less likely to be approved.

Re: I haven't encountered any instance of the "precert/auth" that JonF believes is being practiced.

Again, you do not see this, the providers do. The secret to Medicare's success is that it keeps all the nasty stuff hidden from the patients. And that's not a bad idea, I agree, but it doesn't mean that stuff isn't there behind the curtain. Don't imagine for one moment that if you have to have some uber-expensive surgery done someone somewhere doesn't have to get approval for it. And as for Medicaid, I used to work in healthcare IT. I have direct experience with the use of precerts and authortizations in Medicaid, as well fee schedules so incredibly byzantine that they make any of the private stuff I worked on look like second grade arithmetic. Now, I worked with Medicaid programs for Florida (a lot) and South Carolina and Ohio (some). Feel free to argue that the other 47 states have simple-as-pie Medicaid systems. But again I am not trying to argue against public programs, as I made clear above. I am trying to disabuse people of their rose-tinted Pollyanna view of such things. Believe it or not even Canada and France have features of their public programs which piss their patients and doctors off mightily. Universal coverage is a moral imperative-- I'd take it over withdrawl from Iraq for crying out loud!--but don't expect healthcare Nirvana to descend from on high with the Holy Spirit's dove and singing angels.

Re: If you want to look at what government run health care looks like, examine the VA Health Care System.

No this is not a valid analogy. The VA employs doctors and runs hospitals directly, like Britain's NHS. No one is proposing that-- not even Michael Moore or Dennis Kucinich. The far outskirts of the proposals is single payor, like Canada (and our Medicaid); more likely a public-private mix, like Medicare with Medigap for our elderly. The VA is not the model at all.

Posted by JonF | July 23, 2007 9:44 PM

So if we get a single payer system does that mean we get to watch movies when we go to the doctor?

Posted by El Cid | July 23, 2007 10:21 PM

Weeeelll, oddly enough, I just came home from visiting my 48 - year -old husband in the hospital for acute pancreatitis. I have no idea how much this is going to cost us, because he has had to have numerous tests, include repeated ones, he's a diabetic, and his treatment, while not requiring ICU, is still pretty unusual. We have insurance through our employer, in fact, some of the best still available. Still, my recollection is the Blue Cross's HealthSelect has a 10% copay for hospitalizations, and that might or might not include the ER visit yesterday and the myriad tests and bloodwork he's had. We may very well be left with $5,000 or more in bills, which will put a VERY severe strain on us, even with middle-class salaries. I have no idea what tests are useful and which are not, as I'm not a doctor. Also, he's so out of it on pain meds, I have to be his advocate. As well as care for our two sons

See, this is the problem with the current system. Some people, like my husband, are more vulnerable than others. He takes his medicine and gets a lot of exercise, but he's still a 48 year old diabetic. If we don't treat him, he dies. Not a desirable result. As it is, his health problem will deplete most of our available savings. At least in single-payer I would only be worried about Steve coming home, not about how we're going to pay for this.

Posted by Karen | July 23, 2007 10:34 PM

I'm not sure if others upthread have noted this but

"A survey of six industrialized nations found that only Canada was worse when it came to waiting for a doctor’s appointment for a medical problem"

http://tinyurl.com/3x9ovn

In Italy I just go to my primary care physician's office without an appointment and he sees me that day (it does involve considerable waiting which is much appreciated by my graduate students whose chapters get read).

Posted by Robert Waldmann | July 23, 2007 10:45 PM

"Even if the evidence supported the statement, "People in Canada, France, England and Germany have to wait longer than they do in the US to see a doctor", it's a logical error to conclude that this variance is caused by those systems being government-funded."

The best part is that unlike the Europeans, we don't keep track of and measure wait times, so the conversation can just turn into "he said, she said," which works to the benefit of those who want the status quo.

Posted by Reality Man | July 23, 2007 10:56 PM

The best part is that unlike the Europeans, we don't keep track of and measure wait times, so the conversation can just turn into "he said, she said," which works to the benefit of those who want the status quo.

Exactly. It's a poo-flinging ad, designed to play on hoary myths.

Which is why 'your health insurance premiums paid for this ad' is the correct response. Every promotional campaign run by anti-reform groups should get that treatment: 'your premiums paid for this.' A swift way to ensure that people have the appropriate reaction to this well-funded bullshit is to make them aware that they're indirectly providing the funding.

Posted by pseudonymous in nc | July 24, 2007 2:15 AM

Speaking from the Canadian perspective, we Canadians complain all the time about our health care system -- its the way we make our politicians continue to put money into it. Politicians don't like putting money into health care -- because they can't cut any ribbons -- but the Canadian public forces them to do it. Our federal politicians (first the Liberals, then the Conservatives) had to promise to do something to cut waiting times in order to get elected. As a result, they are funding more medical school admissions, speeding up the certification of foreign-trained doctors, buying more MRIs and other medical equipment, etc. Our system isn't perfect, particularly for Canadians who live outside of the cities and who have to travel to see a specialist, but most of the time we can get the medical treatments we need, when we need them.

Posted by CathiefromCanada | July 24, 2007 2:46 AM

there is no reason healthcare needs to be implemented at the federal level. do it at the state level - they are the sovereign entities in this country, and 50 approaches will weed out what works the best. having the federal government take care of it just means less responsiveness, and more money to gut and fund the war machine

Posted by mind | July 24, 2007 3:16 AM

Like Robert in Italy, in Germany I just walk down the street to go to my primary care physician's office without an appointment and he sees me that day. Unlike Robert in Italy, it is usually within an hour.

The only time I had to wait a significant amount of time here in Germany was when I had an unscheduled visit to a specialist at a University hospital in another city. And this amount of time was no longer than I had to wait for a similar unscheduled visit to a specialist in the US for the same condition.

Sure, it's only one data point, so take it with a grain of salt. But I've noticed that those of us who have experienced more than one system tend toward the same conclusions.

I think mind has a point about doing it at the state level, although I'd think that those states with small populations (and thus small risk pools) might be getting the raw deal under that system.

Posted by josephdietrich | July 24, 2007 4:29 AM

Re small populations and small risk pools: Yes, this would definitely be a problem for some states. My parents live in a Midwestern state with a population of less than 1 million, a high percentage of which is elderly. Dealing w/ health care issues at the state level would be very difficult in such areas. More generally, health problems are not randomly distributed across states; neither do they occur most in high-income areas, where the ability to address them would be, presumably, better than it low-income areas.

A state-based approach would just extend the state-based inequities (or differences, if you like) in health care (and other things) that we already have. Differences in lifespan , as well as other health-related disparities, are related to income, although other factors play a role too.

Posted by THS | July 24, 2007 5:37 AM

Did you notice that the ad Matt linked to refers to "the horrors of a government-run health care system". Nothing like a reasoned argument.

Serial catowner recommends memorizing the facts and learning how to deliver them effectively, but I'm not so confident that boring aggregate statistics will be as compelling as colorful anecdotes about the aforementioned "horrors".

Posted by THS | July 24, 2007 5:43 AM

Although the VA may deserve criticism in some domains, it's important to point out that it leads in others. In particular, the VA has been a leader in the field of patient safety, which is a major issue in the U.S. healthcare system (and may be elsewhere too; I don't know the international data).

Posted by THS | July 24, 2007 5:52 AM

Krugman has been hitting it out of the park lately (as he always does anyway) with his two recent health-care columns, perhaps jumping off of the momentum generated from 'Sicko'. I think the worm is definitely turning in this debate as regards public perception, my only fear is that the vast gulf that clearly exists beteen general public sentiment and the policies of our government (on a whole host of issues) is so great that our politicians will just find a way to ignore or side-step the popular will. I get the distinct impression that we have the greatest discrepancy between what the majority of the people say they want in terms of public policy and what we actually get in said policy of any Western democracy. Maybe something dysfunctional here in our democratic process?

Posted by Warren | July 24, 2007 6:38 AM

Why couldn't we have a hybrid system that pulls the best parts from the government-run and private insurance systems?

Have a government-run or single-payer system for routine, preventive, and emergency care. Everyone is entitled to yearly check-ups, mammograms after 50, colonoscopies after 60, heart medication, diabetes counseling, etc. I think this kind of care would be be relatively cheap to provide. A lot could be provided by low-cost clinics and could use nurse practioners, physician assistants or techs, and wouldn't need to involve the doctor in all cases. Something like the Minute Clinics in Target or the Readi Clinics in CVS. Ideally they would have a set of evidence-based criteria that could tell when care needed to be escalated.

Then for more serious or complicated care, where physicians' expertise and intelligence makes the most difference, you could have private insurance or even a free market. We would have to stop controlling the supply of specialists and physicians who are trained each year. And it would force people to decide where they draw the line when it comes to expensive treatments that will not do much good, which is not something our society is used to.

It seems like there are obvious problems and strengths with each system, so why not combine them rather than choosing one over the other?

Posted by Maddy | July 24, 2007 8:01 AM

You need to switch doctors. I've never had to wait more than a week at the very most, and usually I can get in that day or the next.

Posted by Jacqueline | July 24, 2007 8:27 AM

Most private practices consider the maximum acceptable wait time to be 6 weeks for new patient appointments. After that they start adding more docs. Returns are usually worked in during the week. Since docs get paid by the patient and there seems to be an endless supply of patients with problems both imagined and real it is in every doctors interest to see as many paying patients as possible.
As far as issue of single payer vs. multiple payer, I am curious as to why single payer systems hemorrhage doctors to the US. Also why do so many state funded systems have a double track with state paid care in the day and private (largely cash) at night. And places with only one state funded system usually guard that system by making private pay illegal. The rational given by those who use the private pay systems is that the care is better and the wait is shorter.

But as to Matt, I can only suggest that your doctor doesn't like you and is trying to give you the brush off, just like that girl in college did.

Posted by mike | July 24, 2007 9:46 AM

If you want to look at what government run health care looks like, examine the VA Health Care System.

I honestly have no idea what's the best solution for health care, so take my comments with a grain of salt. But it's worth pointing out that the VA is not a health insurance system. It's a form of payment to veterans in return for their service. The payment may be too low and poorly administered, but the financing of it is not in any sense a model of how to or how not to do health care.

If the military could unionize (as I believe some European militaries allow), it would doubtless be extravagantly overfunded. After all, you never hear about the crisis in health care for civil servants.

Posted by Derek Scruggs | July 24, 2007 10:27 AM

The only thing evil is forbidding people, who can afford it, from purchasing their own health-care if they so choose.

Posted by r4d20 | July 24, 2007 10:28 AM

Like the readers from Italy and Germany, I've found that here in England the good old NHS regularly gives same-day appointments, where I often have to wait more than a month to schedule one with my doctor at home in Minnesota. The flip side, I have to say, is that when I wanted my son to be able to see a counselor the GP who evaluated him said a referral would take several months. I haven't been through exactly the same thing at home, but I expect it would be a little quicker.

Posted by Clara | July 24, 2007 10:34 AM

Whoa! Let's clear up one thing right away- learn the facts, not so you can deliver a boring bunch of them, but so you can confidently state the fact- you don't wait any longer in a "socialized" system. Make that- and the truthfulness of the "you will wait" claim- the major or only point in the argument. Hammer it. Let the policy wonks fuss over reams of stats- our job is to be loud and be proud.

Another point to remember here is that most of us already delay seeking treatment for our own personal reasons. Only a tiny fraction of the public rushes to the doctor for every ache or blemish.

The good part about this is that some stuff just goes away, or you can schedule an appointment in the future on a day you know you won't be working. And, who knows, maybe the treatment you would have gotten in July will be proven ineffective by December. It happens.

The bad part is when people wait until their problem has become an emergency. The solution to this is not to make waiting times zero, but to make care universal so people learn what and which are the important symptoms that say "seek help".

Basically the old 'regular physical' system where you go to the doctor every year and describe your health fears and troubles, and the doctor spends a little time explaining which are the crosses we bear and which are problems we can correct.

However you do it, the foundation is universal single-payer.

Posted by serial catowner | July 24, 2007 12:27 PM

My experience is similar to Matt's: my wait for an annual physical is 3-4 months, but I usually can see someone in my doctor's practice that day for acute care. I think this is a reasonable tradeoff: my doctor only schedules so many physicals a week and is available for followup and acute care the rest of the day.

As for Medicare denying claims: my wife used to do Medicare appeals (before a US administrative law judge) as part of her job. All of the cases were about whether Meidcare or Medicaid would cover the claim. Many were about whether a nursing home stay would be covered. If the patient required skilled nursing care, the claim would be covered by Medicare, a stay that was custodial only would not be.

Posted by Jeff R. | July 24, 2007 1:19 PM

HA! Have these people never actually *been* to a doctor in America? The day my doctor arrives _on time_ of an appointment, and I don't spend 30 min waiting in the exam room for them to come in... that'll be the day I withdraw support for national healthcare.

I *ALREADY* wait in line to see the fsking doctor. I might as well not have to pay through the nose to do it!

Posted by Dave! | July 24, 2007 2:46 PM

I'm fascinated as to what planet the maker of this ad lives on. Back in December I called my primary care physician's office to schedule an appointment. I got one in mid-March. Such is life. Waiting times are, obviously, a function of supply and demand.
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You obviously need to get a new PCP. My coverage is through United Health Care. We just moved here to Denver, and I got an appointment for an initial physical and get acquainted meeting with a new PCP in four days.

When we lived in California before we moved, I could go to my PCP within a week or so. Anything that needed to treated right away (flu, colds, minor accidents) we could have treated at the urgent care facility at the same clinic who had our records. I don't ever think I waited as long as an hour there.

Specialists take longer. My wife's PCP referred her to a neuralogist recently, and that was going to be a month. When she had new symptoms, she called the PCP about it and he got her in to the neuralogist in three days.

Posted by Campesino | July 24, 2007 5:07 PM

Not heard about yet is what happens to a cancer survivor? After a lifetime of paying for insurance, I can't get private insurance for my wife for love nor money. I've already paid for her medical bills, maybe twice over, in insurance premiums over my lifetime, yet as soon as I'm out of work its just f**kin' over.

Posted by steve | July 24, 2007 9:30 PM

Having to wait a few weeks to see a new doctor to get a routine physical is an inconvenience.

Having to wait 6 months to get a cardiac operations when your life expectancy is 3 months is significantly more inconvenient. Google 'Canada Healthcare wait time'. And Canadians are fortunate enough to have the US as a safety valve. The Canadian governments latest solution? Mandate what the wait times are allowed to be. Im sure that wont be rife with bad unintended consequences. Also google- 'UK breast cancer wait'.

My question is- whats more important, healthcare availability in a big picture sense, or sharing the pain 'equally'.

Posted by Mark Buehner | July 25, 2007 12:10 PM

My family and I have been patients of three different HMOs (Aetna, Healthspring, Humana) and Blue Cross/Bue Shield. At no time in the past 20 some odd years have we had to wait more than a week for a primary care appointment, and on many occasions we have been able to get in to see the doctor on the day we called if we were willing to wait a bit once we got there.

In addtion, my wife and son have had to see specialists for rather serious problems and on those occasions (several) they have gotten in to see the doctors within a week or two. Yes, there have been tests that have taken a few weeks to schedule, but none for life-threatening issues and I feel confident had they been life-threatening we would have been seen quickly. Finally, I had to have shoulder surgery and while it took me a month to get the surgery that was only because I wanted to get it done when it was best for me, not because of the doctor's schedule - he could have had me cut open in two days (and he is one of the best in Tennessee).

Dental insurance - we get seen within one week for cleanings and other preventative issues and I was seen on the day I called when I broke a tooth.

Perhaps you guys who are having troubles need to pick better insurance and/or doctors.

Posted by David | July 25, 2007 12:14 PM

Demand management, delay of care and queueing behavior

"The private sector could easily organize an insurance scheme that made it much quicker and easier to get in to see your doctor -- your premiums and/or copayments would just need to be way higher."

It is true that it would cost a health care system more money to expand capacity in primary care. But capacity has nothing direct to do with when care is delivered. Delays in providing primary care do not reduce the amount of capacity needed to meet demand, they simply mean that the demand is met later. You can do today's work today, or you can do it tomorrow, but it's still the same amount of work.

You can theorize that making people wait a few months will discourage at least some of them from seeking care, and thereby actually decrease the care capacity needed. This sort of strategem is called demand management in the trade. But this question has actually been looked at empirically, and it turns out that delay creates more expense than the very modest "gains" it achieves in holding down demand. We know this because military medicine sites that have transitioned from a "system" of chronic delay in obtaining routine care, to one of open access, have consistently seen demand decline. It turns out that patients in a system that uses delay to manage demand learn to game such a system by hoarding appointments. They call the first day the next month's appts come open in order to secure appts they might not really need, because if they wait to see if they will really need to see their doctor, it will be too late, all the appts will have been snatched up. They say that people in the late unlamented Soviet Union would join any queue they saw forming, even if they didn't particularly need the commodity at the end of the line, because you never knew when that commodity would be available again. You simply have to stop the queues, make the commodity predictably available, and the maladaptive (to the system) queueing behavior ends.

But if it would be cheaper to the system to deliver care without building delay into that system, if you could be seen today, rather than in 3 months even if the system had the same medical capacity, then why isn't the system organized that way? Wouldn't the insurance plan that organized to deliver medical care today, rather than 3 months from now, beat the competition hands down? Yes, it would. But the problem for such an insurer is that this competitive edge would work disproportionally on beneficiaries who actually use medical services, but these people, you know, actual patients, are exactly the beneficiaries you need to get rid of, to foist on your competitors, if you wish to survive in the medical insurance business. So the field of competition in indemnity medical insurance is self-limited to providing only crappy solutions in the timeliness with which you get your care. Any good solution would attract discerning consumers, who happen to be the folks with a disproportionate amount of experience with illness that the plans cannot afford to attract.

All of which is just another way of arriving at a conclusion that really has been obvious for over a generation. Medicine has evolved way past the point at which the model of indemnity insurance for medical care makes any sense at all. One universal plan for the one universal risk pool in this country is the only way out of a system in which the many plans we have now that have no choice but to compete to meet the needs of only those beneficiaries who have no need for medical services. People who never see the doctor could care less if you have to wait 3 months to see the doctor, but it's those people, and only those people, that your insurance plan has to keep happy. You, you high utilizer of medical services, you they heartily wish would take a hike over to their competitor across the street.

Posted by Glen Tomkins | July 25, 2007 5:06 PM

The HealthcareAmerica site makes a lot of the standard horror-story claims about socialized medicine. Apart from the obvious generalization that for the increasing fraction of the US population who get their medical care from HMO's, the current system produces precisely the same horrors, does anyone have a link to a site that takes factual issue with any of those claims?

-F.

Posted by Fingal | July 30, 2007 7:44 AM

Wow! It's great to come to a site where people realize that socialism actually worked out great in the USSR, Bulgaria, Hungary, etc., and that today North Korea is one of the most prosperous nations on earth! And, when one sector of the economy is totally fucked from 100+ years of government interventions, the obvious solution is more government intervention. Wow, you "progressives" see clearly!

Posted by Nick Danger | August 3, 2007 12:28 AM