I've really only been to the doctor a handful of times as an adult. Each time it's happened, though, I'm left to wonder about the view that the problem with a national health care system would be that it would lead to waiting times. I always seem to need to wait to see a doctor. At any rate, Business Week writes this up a bit and Kevin Drum has more.
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Waiting in America
11 Jul 2007 01:03 pm
Comments (35)
But...but...blah blah blah Canadian hip replacement blah blah blah anecdote!
My wife wanted to change primary care doctor: two months' wait for a first appointment. It seems as if the first appointment is the one with the biggest wait: once you're on the books, you're a potential cash-cow for them because there's an incentive not to look elsewhere.
My NHS surgery allocated a certain amount of time for same-day appointments, filled to those calling after 8.45am.
Wait times are a frequent complaint about the Canadian system (of which I am a consumer). It isn't an illegitimate complaint - although the bulk of the problem is with elective procedures, which can best absorb delays, and where one would hope that to the extent wait times are necessary, they would fall here.
Nevertheless...
1. The point has often been made that it's easy to reduce wait times by lopping off between 1/5 and 1/6 of your population (a la US).
2. The disincentives to make use of the US system for preventative medicine/maintenance/checkups also reduces consumption, so as to reduce waiting time. In Canada, where a doctor's appointment is at no cost, people don't feel constrained about going to the doctor, even for routine stuff or checkups. Hence, there's a longer wait to see a doctor (although it ain't that bad - it really is the specialists where it's a problem). Contrast the US, where I would guess that a lot of people, even the insured, are heavily dissuaded from consuming health care in a similar fashion. Certainly after seeing SiCKO, if I had health insurance/HMO, I would be loathe to do anything to bring attention to myself and risk terminating my coverage by going to the doctor for anything but the most essential things.
I once bought a car from a Saturn dealership that offered free car washes for the first year. They had to discontinue the program when some clowns insisted on bringing their car in for a free wash EVERY SINGLE DAY.
I'm curious how national health care systems handle analogous conduct. Most people only go to the doctor when necessary, of course, but surely there are some people who would drop by every week because hey, it's free. And there are hypochondriac types who would feel it's "necessary" to see the doctor all the damn time. Without even a co-pay for office visits, how do systems like Canada and Britain keep this sort of behavior in check?
To follow up, now that I've read the linked article:
The Commonwealth study did find one area where the U.S. was first by a wide margin: 51% of sick Americans surveyed did not visit a doctor, get a needed test, or fill a prescription within the past two years because of cost. No other country came close.
So I guess my hypothesis was right...
Having said that, and having read the other comments...
There really is a problem in Canada with wait times for elective procedures. Hip replacements are ridiculously long. I'm a lawyer, and my colleagues who practice civil litigation tell me that it can be a 9 month wait to have an orthopedic specialist assess a client for the purpose of their civil claim (in cases of broken bones and accidents).
It is interesting to see this in Business Week.
The sooner businesses wake up and realize - that a government run nationalized system lifts a massive burden from employers - the better.
From what I understand, wait times are vital for keeping the hypocondriacts under control.
Take your typical hypocondriact with the flu. Instead of staying in bed, drinking clear liquids, and waiting to get better. They roll themselves out of bed and drag themselves to the Doctors office. Once their they will demand either antibiotics (totally useless against a VIRUS) or Tamiflu.
Tamiflu "those who took TAMIFLU within 48 hours of the first appearance of symptoms felt better 30 percent (1.3 days) faster than flu patients who did not take TAMIFLU. "
If they had just stayed in bed the end result would have been the same. Whatever they gained from the tamiflu is lost due to spending the day at the doctors office and waiting in line at the pharmacy - rather than in bed.
Never understood the complaint that patients in other countries wait to see a doctor. Who doesn't wait to see a doctor?
I was diagnosed with a serious health issue 8 years ago, and the wait to see a specialist was 6-8 weeks, during which there was a distinct possibility I was going to get a lot worse. I had good health insurance so payment was not a factor.
Still see a specialist twice a year and if I need to change my appointment, I have to settle for a delay of 4-6 weeks to see my doc.
Pretty much the same thing with my primary care doc, but less of a wait. Least amount of waiting time is at an immediate care center.
The clinics that Wal-Mart/Walgreens are opening are a great idea. Cheap places that can handle the types of illnesses that show up unnecessarily in ER's now. That's the real problem.
As a Canadian, I offer a few data points.
1) many years ago, I had lower abdominal pain, (OK, more like groin area) burning and swelling which got worse over many months. I finally decided to see a doctor at a walk-in clinic who told me I had a hernia and sent me off to a surgeon. I see the surgeon 6 weeks later and he examines me and confirms the diagnosis and schedules surgery, again 6 weeks later. During this time, the discomfort was fairly mild (I was still riding my bike, playing tennis, etc.). I had my surgery, spent one night in the hospital and then went home. The total out of pocket expense was a few bucks for a prescription of tylenol 3s they gave me when I went home (which my supplemental insurance through work would have covered if I'd been bothered to fill out the paperwork)
2) My pregnant wife had significant pain and went to the urgent care facility at the Women's College hospital in Toronto (which focuses on women's health). Their urgent care section is a notch below Emergency in terms of case severity. She was at the hospital for about 4 hours, during which time she had blood tests and an ultrasound done and was seen by a specialist several times. happily nothing was wrong. Out of pocket cost to us - zero.
3) my wife is seeing a midwife during her pregnancy. She goes about once a month and has had a couple of ultrasounds. Cost - zero
4) My dad had an enlarged prostate which caused quite a bit of pain. Surgery took a few weeks to happen, during which time he experienced serious pain and discomfort. My doctor relatives in the US were astounded that they didn't operate right away.
In three out of the four situations, I though our health care system works or worked fantastically (my wife's pregnancy is ongoing). In my dad's case, I was fairly unhappy, though he did eventually receive the needed care. I wonder how much better our system would be if we spent the same as the US per capita?
I wonder how much better our system would be if we spent the same as the US per capita?
Not only that-- imagine how much shorter the waits would be if you simply dropped 15% of your population off the national insurance program.
Prediction: CVS, Walmart, etc. limit their clinics or eventually close them down due to liability issues.
I doubt the money they make will be enough to justify the risk, especially if these clinics get large enough to attract the plaintiff's bar.
On the issue of waiting times, they are predictable in that, given the cost of a medical education (7-10 years of post-college training) in this country and the level of intelligence required to complete it, newly minted doctors for the most part won't be satisfied with the level of pay. Britain's doctors (primary care rather than specialists) earn about the same for far less working hours, no liability costs, less years of youth lost to training and no educational debt. There is a reason why every one of my classmates in medical school who had the chance chose to specialize rather than do primary care...
Even the specialist waiting times are ridiculous. I am still waiting for my dermatologist appointment after 3 months and this situation has been happening to patients for a very long time. The govt. caps the number of residency spots (the true bottleneck in the system) because it is unwilling to fund more or even the present ones adequately. This is a consequence of govt. control of the system and to those enamored of national health care it should serve as a warning about what will happen. Our govt. has made a hash of medical education (too expensive, too long, too bureaucratic, too litigation obsessed) and I am skeptical about its chances with the rest of the system...
*Before the AMA haters come out of the woodwork, please research ACGME and AAMC, the govt. influenced boards that are the real problem...
I doubt the money they make will be enough to justify the risk, especially if these clinics get large enough to attract the plaintiff's bar.
If only Wal-Mart employed some lawyers who could have advised them of this risk in advance. Sadly, it seems they never realized that medical malpractice lawsuits exist.
I'm curious how national health care systems handle analogous conduct. Most people only go to the doctor when necessary, of course, but surely there are some people who would drop by every week because hey, it's free. And there are hypochondriac types who would feel it's "necessary" to see the doctor all the damn time. Without even a co-pay for office visits, how do systems like Canada and Britain keep this sort of behavior in check?
have you been to the doctor's recently? it's a pain in the ass, even if you're lucky enough to get an appointment when you want.
if a few people go to the doctor's office a bit too often, it's a small price to pay (literally, i'm sure someone could dig up some research that shows that the costs are actually quite small, percentagewise) compared to all the people who skip regular checkups, or avoid going to the doctor for things that seem small today. those people impose much bigger costs onthe system overall.
now, admittedly canada and the UK and other countries haven't solved that problem. even with single payer health insurance or nationalized health care, some people still don't go to the doctor when they need to, because it's a pain in the ass.
Pediatric allergist: five months wait, leaving our son without milk for almost half of his second year until that could be excluded as the problem. Not an emergency but not optinal provision of helathcare either. In metropolitan Philadelphia, although the wait was even longer here so we drove thirty miles to Wilmington.
However, I got in for my kidney transplant (not on the donor waiting list; my wife had an extra) inside of a month from the date it became necessary. So go figure.
My wife and I have been living in the UK for several years. She's Canadian and I'm American. We both very much appreciate that we can see our GP here for free on short notice and that prescriptions cost around £7 ($14 US). As a result, I'm much more likely to get regular health checks compared with when I lived in the States.
There are a couple drawbacks. If you're referred to a specialist, it can take many months depending on the urgency. Want to see an ear specialist about that earache? You might get a slot in 6 months, when you've forgotten that your ear ever felt bad. Of course, you can always go the private route and pay a great deal for expedited service.
The drawback that is less commented-on is that you often feel rushed in your appointments, I suppose because the doctors and nurses are just spread very thin. You always feel like they're trying to push you out the door.
For me I much prefer the healthcare here, because I just wouldn't be able to afford going regularly in the US, but in an emergency I might feel otherwise.
Yawn. Same old same old. As I've said many times before, on many different forums, any attempt at reforming the American health care system is just rearranging the deck chairs on the Titanic unless and until we're willing to do something about our monstrous levels of spending on end-of-life care. Spending hundreds of thousands of dollars keeping a dying person alive for a few more weeks, when the patient's chances of long-term survival and quality of life are both zero, is both a huge waste of resources and an utterly meaningless measure. The Canadians and Europeans are much more likely to let a dying person in this predicament peacefully fade away, and that hasn't turned them into heartless barbarians. And it certainly hasn't hurt their countries' life expectancies either.
The drawback that is less commented-on is that you often feel rushed in your appointments, I suppose because the doctors and nurses are just spread very thin. You always feel like they're trying to push you out the door.
The alternative, of course, is that you show up for your 4:00 appointment and end up waiting until 5:45, because the doctor is so behind from everyone overstaying their time slot throughout the day. The flip side of a rushed office is that you at least get to see the doctor before you die of old age.
I'm a medical student at U. of Maryland that rotates through a number of hospitals in inner city Baltimore and the surrounding suburban areas. We also cover the VA hospital (= government run healthcare)
Our hospital, and other suburban hospitals, have very short wait times for elective surgeries for those with insurance - the cost of the surgery will pay not only the surgeon but the cost of keeping the OR open -nurses, techs, cleaning crew, etc. who are on an hourly wage.
Those who don't have insurance have an impossibly long wait for elective procedures, as they have to wait to be scheduled at a time convienent for the surgeon and that there aren't a lot of cases on the OR schedules.
At the VA hospital there is a VERY long wait for elective procedures - the hernia repair wait list is approximately 15 months right now. This is because no one wants to pay the overtime to keep the ORs running and the surgeons are getting paid the same amount of money (they are surgeons from our home institution who rotate for 2 week blocks at the VA) and thus draw a 2 week "salary" no matter how many procedures - or the complexity they do. The nurses frequently don't want to work any overtime (who can blame them) and thus, afernoon surgeries routinely get cancelled if morning cases run long.
I guess the solution in the government run national healthcare would to have a sliding scale for surgeons, but you'd also have to find a way to keep the ORs open to do the necessary procedures.
GeorgeTheK: 15 months for a hernia! I wasn't to perturbed by 3 months but I'd have been pretty damn cranky by 15.
Gabriel: Visits with your doctor in Canada also seem pretty rushed but we have a pretty interesting contrast here. My wife's a naturopathic doctor (regulated by the province, requires a 4 year ND degree after a BSc, followed by board exams). NDs practice botanic medicine, acupuncture, homeopathy, etc. NDs are NOT covered by OHIP (the provincial health insurance program) so people pay out of pocket, unless your supplemental insurance through your job covers it (mine does to the tune of $500/year/person). NDs set their rates and operate completely privately. A key benefit of this kind of treatment is that they tend to spend much more time than MDs actually talking to patients before treating them. It's much more personal and that's a big reason why people like it. The funny thing is, I suspect that would stop being the case if it was covered by OHIP.
Peter: I've heard this many times but do you know of any data that actually shows the cost of extreme end-of-life care compared to overall medical expenditures?
Peter,
"Spending hundreds of thousands of dollars keeping a dying person alive for a few more weeks, when the patient's chances of long-term survival and quality of life are both zero, is both a huge waste of resources and an utterly meaningless measure."
Your comment brings to mind this WSJ essay: How Faith Saved the Athiest: Why did the doctors stop asking me to pull the plug? I showed it to my father a few weeks before he passed away, and he had a hospital staff member make copies for him so he could share it. One point of the essay is that there is sometimes pressure in the U.S. as well to let dying patients "fade away".
More specifically though, in response to your comment, predicting survival times for terminal patients is often difficult (many physicians refuse to offer estimates) and quality of life varies and is, to some extent, subjective. In my father's case, after he was diagnosed with terminal lymphoma (after having beaten back the disease twice over the preceding 20 years), he survived another 14 months with treatment, and most of that time was with a relatively high quality of life: living independently at home, being treated as an outpatient. Those fourteen months were certainly meaningful to my father, his family and friends.
They also weren't a "waste of resources". As a long-term cancer survivor, my father's private health insurance premiums for the last 20 years of his life were expensive: the insurance company actuaries knew what level of care my father might need in the future, and they priced their premiums accordingly. My father gladly paid those premiums every month, and he got the care he paid for.
GeorgieTheK: in a single-payer system, the would be resolved by the fact that physicians would be paid by procedure, just as they are now, but they would be reimbursed by a single insurance-provider, not a multitude of them (speaking of hernias, I believe that the most successful hernia center in North America is actually in Canada).
The VA seems to act similar to the NHS, where the doctors are just paid-on-contract/salaried employees.
Echoing Fred, the problem with saying "we spend too much money on the last weeks of a patient's life" is that we don't know those are going to be the last weeks of a patient's life until the patient dies. And if the patient doesn't die, his last weeks will be at some point off in the future, in which thousands of dollars will be spent THEN. Certainly plenty of people are hoping that a heroic medical intervention will help them make it to a milestone they wouldn't want to miss (eg, Christmas, a grandchild's graduation, etc.)
Re: Most people only go to the doctor when necessary, of course, but surely there are some people who would drop by every week because hey, it's free.
who the hell has time to drop by the doctor's all the time? Certainly no one with a job and/or a family. That leaves the family-less poor and the elderly, many of whom already have "socialized medicine" in the form of Medicare or Medicaid. Now more than a few people that group have serious health issues that require frequent doctor visits, but as for the ones who are healthy, how often do they go to the doctor?
Re: There really is a problem in Canada with wait times for elective procedures
Given that we have a perfectly adequete supply of orthopedic surgeons, an of surigcal facilities, I don't see how we would have such long wait times. I suspect Canada's problem in this regard is related to it low population density and small population overall.
Re: Pretty much the same thing with my primary care doc,
I've never had a ridiculous wait for a primary care doctor. Same day appointments are not always possible (often they aren't) but I've never had to wait more than one business day for an appointment, unless for reasons of my own I needed to delay a few days. To be sure, when changing doctors I've called one or two who seem to avoid new patients by imposing a three month wait, but there's plenty of other doctors in the PPO registry and I've always found one who is more eager for business than that.
Specialists of course are another matter. Generally two or more weeks seems to be the rule in non-emergency situations
Re: The drawback that is less commented-on is that you often feel rushed in your appointments
Very much a feature of many US doctor practices too.
Re: we're willing to do something about our monstrous levels of spending on end-of-life care.
And what do you suggest? Having Dr Kevorkian train a legion of executioners? I am often curious about the claims I see on this matter because I have never known anyone (as in elderly relatives) who had "heroic" end of life care. In every case it was simply palliative and supportive care, with Hospice handling the final denouement, not wild experimental procedures with six digit price tags and a single digit chances of success. And most of my kin had either living wills (in one case her daughters had to press the hospital to "pull the plug") or at least DNR orders. So who are these people with gold-plated terminal illness care? None of my family that's for sure!
Yea, 15 months for a hernia. (Incidentally, there was a paper that came out last year that showed that "watchful waiting" for elective hernias - i.e. for those that weren't strangulating bowel - was better than surgery in the long run due to the relatively high rate of complications in hernia repair.)
In any case, I think this sort of waiting is the sort of thing the people - rightly - fear. For the vast majority of Americans who do have insurance, a wait of 15 months for repair of a hernia would seem absurd. Ditto with other elective procedures.
I'm not totally convinced that a fee for service for surgeons would necessarily solve the long wait problems. The fee that comes from a single payer system has to make it WORTH the doctor's/nurse's/tech's/hospital's time to spend doing a procedure. If the reimbursement is low enough, plenty of people are going to say "screw it, i'd rather spend these extra hours with my family" than make only a small increase in their salary.
That's the other hang-up with a single payer system - you must adequately compensate the people who are doing the work. Right now, as it stands, there would be some major winners and losers in the game of a single payer system. The losers would be the big money professions - cardiology, dermatology, plastic surgery, anesthesiology - who would take a MASSIVE pay cut. The winners would be the GP and the pediatricians who tend not to make a lot of money now, and would likely see incomes rise.
As a future physician, I'd love to see a single payer system (full disclosure: i'm headed into Emergency Medicine who, from all estimates I've seen, would see about the same in compensation but probably improved working conditions) but can't help think how impossible it will be to get by my girlfriend's parents who are cardiologists and each earn around $750,000/yr. I find it hard to believe that a single payer system will ever pay them more than around $350,000-400,00k/yr (currently VA cardiologist on staff - meaning employed full time make around $250,000-350,000) - essentially cutting their income in half. The outcry - and propaganda from them - will sink the enterprise.
"I find it hard to believe that a single payer system will ever pay them more than around $350,000-400,00k/yr"
Poor bastards. I have my doubts that "After national healthcare, my income has dropped to 400K!" would be an effective propaganda slogan. I believe you when you say they'd bitch, but would anyone respond with anything other than offering them a frothy cup of Shut the Fuck Up?
my girlfriend's parents who are cardiologists and each earn around $750,000/yr.
Damn, marry her!
Re: we're willing to do something about our monstrous levels of spending on end-of-life care.
And what do you suggest? Having Dr Kevorkian train a legion of executioners?
The Canadians and Europeans seem to have figured it out.
Re: The Canadians and Europeans seem to have figured it out.
No they haven't. Even in those countries a lot of healthcare spending is concentrated at the end of life-- which makes sense as that's when a person is usually sickest and needs the most attention (and as another person mentioned it is usually not obvious that the patient has only six months to live). Europe and Canada have cheaper healthcare systems all around, so of course their end of life care is cheaper too. But the elderly and the dying still account for a disproportionate share of their bill.
The systematic devaluation of primary care
You have to wait to see a primary care provider under our current non-system of paying for medical care because that system consistently undervalues primary care. Markets work! So that undervaluation has succeeded at driving primary care providers out of the market, or discouraged new recruits to primary care, sufficiently that they are in enough demand that the payers cannot force the price of an office visit even lower than it already is. Sadly for you, this process has reached equlibrium at a point that your wait time to see a primary care physician is something that you find undesirable. Tough luck! You're not a payer, so your valuations don't count. The insurers pay the bills. They don't value primary care (except in the sense that it is the type of care in which they have the most leverage at holding down their costs), and their valuations are the only ones that count.
Until either you become rich enough to become a payer, to pay out of pocket for your medical needs, or the electorate decides to become a payer, the single payer, and puts a different, higher, valuation on primary care, you will continue to have to wait to see your doctor.
Make an appointment to see the doc early in the day; then, back to bed.
I think Georgia has just lifted a veil off another reason why US health insurance is so much higher than the rest of the world! Granted I would rather see a cardiologist make $750K/yr than see a pharmaceutical company charge $100/month for some knockoff drug that is not even an improvement over their previous drug that cost $10/month.
Of course she also forgot to mention the potential biggest winners of a single-payer system (naysayers aside), the vast majority of the American people!
Glen Tompkins:
"You have to wait to see a primary care provider under our current non-system of paying for medical care because that system consistently undervalues primary care."
A letter writer to the Wall Street Journal last week, a physician, explained something relevant about the state of primary care today: "family practice" physicians have two fewer years of residency than old-school internists, so they are often less equipped and less confident in making diagnoses; hence, more need to refer patients to specialists (although I'm sure liability is at least as large a factor).
Ricky:
If I had to choose between market incentive for cardiologists and pharmaceutical companies (I'd rather not), I'd want to see the pharma companies retain market incentives. Drug companies (particularly smaller ones) take huge risks and spend years advancing scientific research to come up with new drugs; cardiologists got good enough grades in college to get into med school and then were pushed along with everyone else (there are not a lot of med school dropouts).
Also, the "big winners" of a single payer system here would be people who both: 1) don't have health insurance now; 2) aren't net federal income tax payers and so won't get dinged by the higher taxes to pay for it. The losers will be everyone who likes and can afford their current coverage.
Re. the 750K/year cardiologist...this just confirms the feeling that I've always had that there's just too few doctors and the profession deliberately strangles supply to keep prices (i.e. their salaries) sky high. I bet you could double the number of entrants into medical school without a decrease in quality. Naturally the AMA would have a collective aneurysm at the prospect.
Re: The losers will be everyone who likes and can afford their current coverage.
You assume that people's current coverage will continue (and continue to be affordable) indefinitely, however that is very unlikely to be true. Might as well claim that the losers will be everyone who is healthy today since why would they ever need healthcare anyway?
The current health care fianancing system is not sustainable, and whether people likle it or not it cannot continue forever.
Re: The loser will be everyone who likes and can afford their current coverage.
I currently love my coverage, mainly because I am healthy and don't pay for it directly. That said, I don't have any choice on the plan, not by vote or by proxy, my company tells me to take the insurance offered or leave it. I may some day find the coverage stinks. Also as costs have risen so have my deductibles. At some point my company won't be able to pay for it all then I'll have to start paying some of it out of my paycheck.
Now, I work for a wonderful company that treats its employees very well and I am almost certain that my salary would increase more than any tax increase necessary to set up government-run universal coverage since the money currently being paid to insurance would come back into my pocket. I know other businesses won't be so generous, but the supply and demand of wages would see people's wages raise once their employers are freed of paying health insurance.
I'll take my chances with a government program, so long as it is insulted from right-wing ideologues.
Comments closed July 25, 2007.
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Heads in the Sand
Indeed; about two months ago, I made the earliest available appointment to see my doctor re: my absurd cholesterol levels. Unsurprisingly, two months later the appointment is inconvenient. I try to change it, and the next available appointment is in two months. So I just accept the inconvenience, and the knowledge that I'll have to show up an hour early and sit for an hour after my appointment time before I see the doc.
One thing SiCKO definitely does, it makes you utterly intolerant of this kind of bullshit.
Posted by Rob | July 11, 2007 1:35 PM