Understanding Waiting Times for Health Care

In Sunday’s New York Times, Elizabeth Rosenthal discusses evidence that waiting times for medical care in the U.S. do not always compare favorably with those of other developed countries:

“I fully expect wait times to be going up this year for Medicaid and Medicare and private insurance because we are expanding access to care, but we’re not really expanding the system of providers,” said Steven D. Pizer, a health care economist at Northeastern University in Boston.

Unfortunately, the article evolves into an apologetic for waiting times as a good thing. I would also quibble with Ms. Rosenthal’s description of U.S. health care as “market-based” which it certainly is not. I don’t think I’ve met anyone, pro- or anti-ObamaCare, who does not expect waiting times to increase as long as ObamaCare exists. So, we better get used to them. How to explain them?

First, it is surely the case that a little waiting might be beneficial. This is often alluded to in articles like Ms. Rosenthal’s, but only conceptually. Seldom do surveys actually compare experienced waiting times with medically appropriate waiting times. One that does is the Fraser Institute’s survey of waiting times in Canada, which finds that experienced waiting times do, indeed, exceed medically appropriate waiting times in that single-payer system. The Fraser Institute has also detected a negative effect on mortality.

Second, patient surveys are somewhat perilous. The Fraser Institute surveys doctors, not patients. There are a few disadvantages to surveying patients: Their recall may be faulty, their expectations vary, and their definition of “waiting time” may not be consistent. For example, a patient in Canada may not bother to seek an appointment with a specialist immediately when his family doctor recommends one, because he knows it is hopeless. Instead, he and his family doctor will use their networking skills to identify a likely opportunity. For example, a friend of mine in Toronto helped a friend of his get an appointment with a specialist, because my friend’s daughter and the specialist’s daughter attend the same private school. So, he can short circuit the “system” to help his friend. His friend will not report a long wait when surveyed. His family doctor, however, will report a long wait.

Third, even if patients report accurately, they may actually be demanding too much health care relative to the supply, but the supply may more than adequate for actual medical needs. This may explain what is happening in the Boston area, where waiting times are much longer than elsewhere in the U.S. Obviously, there is no shortage of excellent physicians and hospitals in Boston. However, Massachusetts has had mandatory health insurance for a few years now, so the state has artificially stimulated demand. Under Governor Patrick, the state has begun an exercise in seeking to control costs by artificially constraining supply.

One thing we can say for certain about waiting lists is that we will be talking about them a lot more in the years to come.

Comments (7)

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  1. Frank says:

    It’s not all gloomy. The market is responding appropriately in that we are seeing the arrival of more urgent care centers or places like One Medical Group which have low costs and are able to see patients almost immediately.

    • John R. Graham says:

      The rise of urgent-care centers is very interesting. I have read some good articles about them but not yet discussed on the blog.

      They are clearly responding to demand. And yet, they appear to be the opposite of what the government wants: Integrated care delivered in so-called accountable care organizations.

      An increasing number of patients appear not to want to become dependent on such a system but be free to get the treatment they need at a transparent price.

      • Devon Herrick says:

        John,

        About seven years ago I was invited to speak at a conference on retail clinics. As you know, I am a fan of retail medicine in all its forms. Most of the speakers were industry advocates.

        I was asked to speak on the regulatory and political climate for retail clinics after Obama took office. I basically explained that the party in power thought primary care should be provided at ones “medical home.” Thus, I didn’t believe public health advocates within the Obama Administration really liked the idea (at that time) because retail clinics represented fragmented care. As evidence of this, I used the example of Boston, where the local board of health actively blocked some clinics because they didn’t represent its idea of what a clinic should be.

        At the time I (inadvertently) ruffled some feathers of industry advocates. (the speaker who followed me denounced me as completely wrong). Yet, during lunch with the attendees, all I spoke to were afraid I was right. Luckily my predictions were proven wrong during the intervening years and opposition to retail clinics has softened. But you’re correct that urgent care clinics don’t fit neatly with the idea that we should all have a “Medical Home” where our doctor (Marcus Welby) knows us by name, delivered us as babies, treated us as kids, grants same-day 30 minute office visits, and doesn’t make us pay if he knows money is tight. Of course, the concept of a medical home like that is pure fantasy.

  2. Devon Herrick says:

    I read an article several years ago about how some dermatologists have a longer wait time for Medicare than for privately insured patients. Also, Botox requires only a few days wait; a skin cancer check was more like a month. Indeed, a New York Times article said some dermatologists even had a separate door and phone lines for cash paying (cosmetic) patients.

  3. SPM says:

    Wait times are an interesting topic to study, as you have pointed out. Your example points out that patient behavior in seeking out appointments with certain providers can be influenced by their previous experience and expectations, thus not always offering a true reflection of wait times. This seems like a problem similar to the one described in a previous blog here regarding the inaccuracy of certain metrics used to rank nation’s healthcare systems.
    http://healthblog.ncpa.org/ignoring-the-obvious-choosing-suitable-metrics-in-evaluating-health-care/

  4. Big Truck Joe says:

    Case in point is myself. I have a PCP located 30 mins away who I see for preventive care twice a year to review chronic issues. He is busy so it may take several days to see him if I’m currently sick. I also have an urgent care center 5 mins away who see me immediately and have a pharmacy in house. It costs $25 more per visit at the urgent care center but it’s worth it so I don’t have to wait several days in pain. In my 40’s I can pretty much self diagnose and know what I need so why should I wait on my PCP just so I don’t get “fragmented” care? I doubt I’m alone in this thinking.

    • John R. Graham says:

      Exactly. When you shop for groceries, does the government encourage you to go to one and only one supermarket? You are free to go wherever you want. And nobody complains that the market for groceries is “fragmented”.