Long Waits for Doctors’ Appointments Have Become the Norm - The New York Times

Long Waits for Doctors’ Appointments Have Become the Norm - The New York Times: "The Commonwealth Fund, a New York-based foundation that focuses on health care, compared wait times in the United States to those in 10 other countries last year. “We were smug and we had the impression that the United States had no wait times — but it turns out that’s not true,” said Robin Osborn, a researcher for the foundation. “It’s the primary care where we’re really behind, with many people waiting six days or more” to get an appointment when they were “sick or needed care.”

The study found that 26 percent of 2,002 American adults surveyed said they waited six days or more for appointments, better only than Canada (33 percent) and Norway (28 percent), and much worse than in other countries with national health systems like the Netherlands (14 percent) or Britain (16 percent). When it came to appointments with specialists, patients in Britain and Switzerland reported shorter waits than those in the United States, but the United States did rank better than the other eight countries.

So it turns out that America has its own waiting problem. But we tend to wait for different types of medical interventions. And that is mainly a result of payment incentives, experts say."



'via Blog this'

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The Waiting Times Myth

The Incidental Economist Blog started talking about wait times this past week, and has several interesting posts on the topic here, here, and here. I won't reiterate them, they speak (well) for themselves. The bottom line is that we aren't really any great shakes with our wait times and access to care, we spend way too much time and money and use too much of our work force doing expensive procedures when we should be concentrating on primary care and reducing the need for all of those heroics. The US supply of physicians vs. specialists is inverted from high performing health systems where most doctors provide primary care.

Given this background, here's my take.

When I discuss health care reform with friends, families, colleagues, or in public, the two most pervasive myths about health care outside the US are that in every other country, care is inferior and rationing is accomplished by intolerable waiting times. As I endeavor to dispel these myths, I am invariably told an anecdote about a person who died in Canada or England awaiting some procedure or other.

Dispelling these myths is two-fold: first, pointing out the rationing that occurs in America either by private health insurers or by lack of wherewithal to afford services, and second, by pointing out that there are more health care systems than “ours” and “theirs.”

Given that an estimated 45,000 Americans are estimated to die every year due to lack of access to health care services , rationing in America is particularly troublesome, and oddly overlooked. There are many reasons for this, but mostly it is the lack of drama and, paradoxically, the pervasiveness of this experience, especially to those of us in health care. Anecdotes are powerful things, and so I have to always tell a few of my own to counter the horror stories they’ve heard about other countries. So, a few cases of my own: a man who puts off seeing a doctor (for what he knows is diabetes), ends up in the ICU critically ill, because he is trying to get on a health insurance plan and hopes he won’t be found out; a down-sized engineer with a year long persistent cough and weeks of coughing up blood, who waits until he is near death to come to the hospital because he can’t afford to see a doctor; and finally a young man with a seizure disorder admitted twice to the ICU for unremitting seizures in just a few months because his neurologist won’t see him because he’s been underemployed and couldn’t pay his last bill. Multiply my stories by nearly a million physicians in America and you see the magnitude and pervasiveness of the problem.

Beyond anecdotes, there is actual data, such as the Commonwealth Fund study showing that "U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the ER, see a specialist, and have elective surgery.” Additionally, Americans are less likely to have a regular doctor, less likely to get prescriptions filled, less likely to get follow-up care, less likely to keep a doctor long-term, and have a harder time getting taken care of nights and weekends. In another report, the Commonwealth Fund has shown the US ranks 19th out of 19 countries evaluated on preventing deaths that are amenable to adequate health care, an excellent measure of the overall performance of a country’s health care system.

That there is more than one country outside the US with a unique health system, might surprise some whose rhetoric suggests a vast wasteland of a series of Soviet style medical gulags. OECD data shows (Siciliani, 2003) that waiting times are a problem in some countries, but only about half of those in the OECD. The others are like the United States in lack of significant waiting times, but unlike us they manage to do this with their entire population covered, and at significantly lower costs.

Now, let's do a little thought experiment. Say you are in a country that has relatively high waiting times for elective procedures, say Canada (but not England so much any more!). Take one sixth of your population and deny them access to care because, oh, they don't deserve it. What do your waiting times look like now? Take another sixth or so, and tell them they have to choose among school, dental care, glasses, food OR preventive health care. Or even life saving health care. OK, now how are your queues?

Americans ration, all right. It is unbecoming, to say the least. It is leaving people to slowly die, to be more blunt. It is under the radar for most, but not for us, not for the millions of care givers and social workers and nurses and parents and children who have to bear witness.

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A reality check on that Canadian "Brain Tumor" story

A reality check on a reality check:

Still, I found Holmes tale both compelling and troubling. So I decided to check a little further. On the Mayo Clinic's website, Shona Holmes is a success story. But it's somewhat different story than all the headlines might have implied. Holmes' 'brain tumour' was actually a Rathke's Cleft Cyst on her pituitary gland. To quote an American source, the John Wayne Cancer Center, 'Rathke's Cleft Cysts are not true tumors or neoplasms; instead they are benign cysts.'
There's no doubt Holmes had a problem that needed treatment, and she was given appointments with the appropriate specialists in Ontario. She chose not to wait the few months to see them. But it's a far cry from the life-or-death picture portrayed by Holmes on the TV ads or by McConnell in his attacks.
In Senator McConnell's home state of Kentucky, one out of three people under age 65 do not have any health insurance. They don't have to worry about wait times for hip or knee replacement or cancer surgery -- they can't get care. The median household income in Kentucky is $37,186 -- not quite enough for the $97,000 bill at the Mayo Clinic. CNN didn't mention that in its 'Reality Check.'"

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What do other countries do? - Kansas City Star

What do other countries do? - Kansas City Star:

"In Britain, famously, they wait.

"To replace a hip, for instance, means months before surgery.

"Spaniards and Italians have single-payer health care systems, but they leave it to the cities and villages, not the capitals, to run things. The Greeks demand all medical bills be covered by universal insurance, but let doctors hit up patients for more.

"The Swiss are required to buy health insurance, and virtually all do.
Health care systems around the world vary like cuisine, reflecting customs and history. Some ingredients travel better than others."

Bravo to writer Scott Canon of the KC Star for doing a piece on international health care systems.

I quibble with some of it, particularly the first line, and wrote Canon about it:

Thanks, Mr. Canon for your piece "A Universal Pain", which appeared in my Pittsburgh Post-Gazette today. This kind of reporting is in very short supply and should be front and center in our ongoing discussions on health care, not relegated to the disparaging remarks hurled at Canada by conservatives.

But, I am curious about where you got some of your information. Some seems more up to date than mine, and some less so.

The most glaring one is in the first paragraph regarding waiting times in the UK. Here is more recent news:
http://cmhmd.blogspot.com/2009/05/exclusive-nhs-hospital-waiting-times.html


Further, there are countries with universal health care unlike us, but without significant waiting times, and with better quality outcomes than our own (and I know you praised Germany's system, which is my favorite model):
http://cmhmd.blogspot.com/2009/05/oecd-waiting-times-study-executive.html

A final point, although health care is pushing budgets to the brink internationally, it is very important to remind the public that increasing expenditure from 8 or 9 or 10% of GDP by one or two percent, compared to our 17 or 18 or 19% in our system is a big difference.

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QUALITY: Waiting for ...the Cardiologist. And the Orthopedist. And the Dermatologist... | New America Blogs

QUALITY: Waiting for ...the Cardiologist. And the Orthopedist. And the Dermatologist... New America Blogs:



"Health care consultants Merritt Hawkins and Associates...looked at waiting times in 15 American cities for nonemergency care.


Overall, the average wait was three weeks—up from 8.6 days since the last survey of this type in 2004 -for a routine heart checkup from a cardiologist, a checkup for skin cancer from a dermatologist, a painful or injured knee from an orthopedic surgeon, a 'well woman' exam from an OB/GYN and a routine physical from a family practitioner. But there was a huge variety in wait times, anything from one day to an entire year."



Going to the actual document is interesting.

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OECD Waiting Times Study Executive Summary

I realized that while I have a link to this study elsewhere, it is rather a pain to get to the information because the document is in pdf.

Now, this is from 2003, and so the UK/NHS data is now happily out of date. And leaders in Canada have seen the results in the UK and are pushing to end the bloc financing of hospitals that helped so much in the UK. But anyway, here is the summary:

• Waiting times for elective surgery are a significant health policy concern in approximately half of all OECD countries.
• This report is devoted to [analyzing waiting times]. An interesting feature of OECD countries is that while some countries report significant waiting, others do not.
• Waiting times are a serious health policy issue in the 12 countries involved in this project (Australia, Canada, Denmark, Finland, Ireland, Italy, Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom).
• Waiting times are not recorded administratively in a second group of countries (Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and the United States) but are anecdotally (informally) reported to be low.
  
• This paper contains a comparative analysis of these two groups of countries and addresses what factors may explain the absence of waiting times in the second group. It suggests that there is a clear negative association between waiting times and capacity, either measured in terms of number of beds or number of practising physicians. Analogously, a higher level of health spending is also systematically associated with lower waiting times, all other things equal.
  
• Among the group of countries with waiting times, it is the availability of doctors that has the most significant negative association with waiting times. Econometric estimates suggest that a marginal increase of 0.1 practising physicians and specialists (per 1 000 population) is associated respectively with a marginal reduction of mean waiting times of 8.3 and 6.4 days (at the sample mean) and a marginal reduction of median waiting times of 7.6 and 8.9 days, across all procedures included in the study.
  
• Analogously, an increase in total health expenditure per capita of $100 is associated with a reduction of mean waiting times of 6.6 days and of median waiting times of 6.1 days.
  
• In the comparison between countries with and without waiting times, low availability of acute care beds is significantly associated with the presence of waiting times. Also, evidence from this and other studies suggests that fee-for-service remuneration for specialists, as opposed to salaried remuneration, is negatively associated with the presence of waiting times. Fee-for-service systems may induce specialists to increase productivity and may also discourage the formation of visible queues because of competitive pressures. In addition, evidence from this and other studies suggests that activity-based funding for hospitals may also help reduce waiting times.

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Exclusive: NHS hospital waiting times are the lowest since records began - mirror.co.uk

Exclusive: NHS hospital waiting times are the lowest since records began - mirror.co.uk:

"Hospital waiting times are the lowest since records began, Health Secretary Alan Johnson will say today as he rounds on critics of the NHS.

"Mr Johnson aims to hit back at the doom and gloom-mongers by showing how the nation's health service has been transformed for the better in the 12 years since 1997.

"He will highlight figures showing delays for treatment have fallen in many areas."

Some of the numbers are quite impressive. I don't think these numbers are significantly different than US (and by that, I mean these are not intolerable waits by most standards). And remember, they hae health care for their entire population, not just those who can afford it.

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EzraKlein Archive | The American Prospect

EzraKlein Archive The American Prospect

This is just too fun. Fraser Institute puts on prominent Canadian physician to dis Canadian health care, which he does, mildly IMHO, but then proceeds to dis the American system even more!

And Dr. Day (former CMA President) makes some great points:

1. Waiting times are a function of the way Canada funds hospitals, by bloc grants to hospitals rather than having money follow the patients as in the rest of the world.

2. Waiting times cost more, particualarly in terms of patients illness progression and economic costs of lost work, wages, productivity, etc.

3. Britain has essentially fixed its waiting time issues by dispensing with the bloc system.

4. “I think this is what people tend to forget. They equate alternatives to the Canadian health care system with ‘Americanization,’ which is not what we’re talking about. We’re talking about countries like Belgium, and Switzerland, and France, and Austria.”

5. One should be able to buy private health insurance (in Canada) to supplement the Candian Medicare system.

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Shortage of Doctors Proves Obstacle to Obama Goals - NYTimes.com

Shortage of Doctors Proves Obstacle to Obama Goals - NYTimes.com:

"Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

"“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

"The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

"Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

"“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”"

So, do we have the beginnings of class war in medicine? Our spending is unsutainable, we spend it in the wrong places quite often, and the specialties with something to lose ( high reimbursement rates) are not going to take this lying down.

The article also goes on to point out that as we bring more people into the ranks of the insured, waiting times will go up. Gee, where have I heard that before?

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Candian Medical Association Looks to Europe to Improve Health System

Letter to members kicks off CMA debate:

The Canadian Medical Association is looking at European health systems for ways to improve.

The CMA won't launch its online consultation about transforming Canada's health care system until April 6, but if the initial response to President Robert Ouellet's March 6 letter announcing the endeavour is any indication, the consultation website should be a busy place.

Within five days of emailing the letter to members and posting it on cma.ca, the CMA had received 149 emails, many containing lengthy comments.

In his letter, entitled Status quo, or transformation?, Ouellet suggested that if Canada wants 'a sustainable, universal health care system, we have to transform the one we have.' It was first emailed to 45,000 members and posted on cma.ca, and then sent by regular mail to a further 25,000 members.

The link the the letter is at their website, and a few choice comments are there, and here:

• "I kindly disagree with you. The problems in our system will not be solved by privatizing the most lucrative parts of it. Canadian doctors want to practise medicine, not run businesses."
• "I was delighted with your comments. The constant arguments that any changes in our system will make us like the US have been misleading and frustrating."
• "It is about time care and money be patient based. Bring on the new system you suggest - it cannot come soon enough for me."
• "I'm baffled how we are like sheep and accept the wait times in our country when other countries far surpass our achievements."

It's funny, isn't it? Canada has the sense to look past the end of its collective nose for solutions, while we continue to try to tweak our system as it continues on its glide-path into the mountain.

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Thomson Reuters Survey Finds Cancer Patients Forgoing Treatment

Thomson Reuters Survey Finds Cancer Patients Forgoing Treatment: "cancer treatment decisions of individuals.

Entitled “The Cost of Cancer,” the report aggregates survey responses from 1,767 adults currently being treated for cancer. It finds a clear link between patients’ annual income and their decisions to curb cancer treatments due to cost — even among patients with late-stage cancers.

The report notes that among the 569 survey respondents with late-stage cancer, 12.3 percent said they have passed up recommended treatment because it was too expensive. This figure varies dramatically by patient income level. Twenty-five percent of late-stage cancer patients who earn less than $40,000 a year said they have chosen not to undergo a recommended treatment due to cost — compared with 11.2 percent of those earning between $40,000 and $80,000 per year and 4.8 percent of those earning more than $80,000 annually.

Similarly, 65 percent of all respondents with late-stage cancer said the out-of-pocket cost of treating their cancer has caused them distress. Among all cancer patients earning under $40,000 per year, that number jumps to 77 percent.

“The physical and emotional burden of illness is not the only challenge cancer patients face,” said Bill Marder, PhD, senior vice president and general manager for the Healthcare business of Thomson Reuters. “Many also struggle to cope with medical costs. This survey shows that the cost of cancer treatment is affecting patients’ ability to get the care they need.”"

I think this research speaks volumes about the American healthcare system. This is why I have it categorized under so many topics (see links below and to right). It speaks to the de facto rationing by income in the US, it speaks to how consumers "drive" healthcare (i.e., decision making is not rational), how our waiting times are trimmed by not including those who don't seek care due to financial concerns, and how those who love to try to compare anecdote horror stories just don't geet how bad our system is for so many people.

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International Comparison: Access & Timeliness

From the Commonwealth Fund:
International Comparison: Access & Timeliness:

"U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the ER, see a specialist, and have elective surgery. Specifically:

The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.

Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.

U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department.

U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%–60%) or to wait four months or longer for elective surgery (8% v. 19%–41%) (Schoen et al. 2005)."

Additionally, Americans are less likey to have a regular doctor, less likely to get prescriptions filled, less likely to get follow-up care, less likely to keep a doctor long-term, and have a harder time getting taken care of nights and weekends.

It speaks for itself.

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CITY HEALTH CLINICS NEED A BOOSTER SHOT | Philadelphia Daily News | 04/04/2008

CITY HEALTH CLINICS NEED A BOOSTER SHOT Philadelphia Daily News 04/04/2008:

"How they don't work: The system is far from perfect. According to a report released by the Philadelphia Unemployment Project last year, it can take up to five months to schedule an appointment with a doctor at a health center. Advocates say the centers need to extend evening hours and add staff to shorten waiting times. The mayor's proposed funding increase is supposed to deal with some of these issues.
One of the biggest challenges that health centers face is offering competitive salaries to attract qualified staff.

The salaries offered by the city for three critical positions - pharmacists, dentists and physicians - are relatively low when compared to industry averages.

The highest-paid pharmacist working for the city makes $77,013 - well below the national median of $103,000. The same is true for dentists who work for the city. A typical dentist makes $130,000 a year. That's significantly more than the $95,630 made by the highest-paid dentists at city health centers.

The largest discrepancy can found in the salary paid to doctors. The average physician working in a family practice makes $204,000. The highest-paid physician working for the city makes $109,820 - a difference of more that $94,000."

Just had to post this for all of those who insist we don't have to wait for healthcare in America and that "everyoine in America has access to health care."

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AlterNet: 10 Myths About Canadian Health Care, Busted

AlterNet: 10 Myths About Canadian Health Care, Busted:

"2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning -- and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I'm both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I'm in a unique position to address the pros and cons of both systems first-hand. If we're going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here's the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they're made of."

Read on...

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The Doc's In, but It'll Be a While (Business Week)

The Doc's In, but It'll Be a While:

"The Doc's In, but It'll Be a While Despite spending lots more per capita on health care, the U.S. is often as bad or worse than other industrialized nations in wait times "

h/t to Marc Brown

It is from June '07, but it was new to me...

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delawareonline ¦ The News Journal, Wilmington, Del. ¦ Patient increase, limited medical school slots make seeing doctor tougher to do

delawareonline ¦ The News Journal, Wilmington, Del. ¦ Patient increase, limited medical school slots make seeing doctor tougher to do:

"Some doctors say the problem lies not with a doctor shortage, but with an uneven distribution of MDs. New doctors gravitate toward more lucrative specialties, such as sports medicine. Specialties that require surgery, such as ophthalmology, also attract doctors because Medicare and insurers reimburse surgical procedures at a far higher rate than evaluations. Cooper said young doctors are turning to these profitable specialties at the expense of Medicare patients, who largely suffer from diabetes and arthritis and are in need of endocrinologists and rheumatologists. Medical school students also may be dissuaded from primary care. Dr. David Krasner, who works at Family Practice Associates in Wilmington, said the existing reimbursement system pays too little for cognitive evaluations by primary care physicians. 'For physicians to go into primary care in this day and age, it's akin to committing financial suicide,' he said. 'The shortage in my opinion won't get better until Medicare changes the way it reimburses.'"

Please click on some of the tags below: physician income, in particular to learn more about this topic...

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The Reality-Based Community: Rationing health care

The Reality-Based Community: Rationing health care:
Rationing health care
Posted by Mark Kleiman

"All this, let's recall, with the Chancellor breathing down the neck of the boss of the medical area on behalf of a full professor at the university that owns the hospital. So my experience with the system was probably about as good as it gets except for corporate executives using places like the Mayo Clinic or family members of people on the boards of directors of hospitals. (Apparently it's generally understood that if you stump up enough in the way of contributions to get on the board of the hospital, you're entitled to priority care; that's how not-for-profit hospitals raise capital.) It was only later that I discovered why the insurance company was stalling; I had an option, which I didn't know I had, to avoid all the approvals by going to 'Tier II,' which would have meant higher co-payments. The process is designed to get very sick or prosperous patients to pay to jump the queue. I don't know how many people my insurance company waited to death that year, but I'm certain the number wasn't zero. "

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The Doctor Will See You—In Three Months

The Doctor Will See You—In Three Months: "It's not just broken for breast exams. If you find a suspicious-looking mole and want to see a dermatologist, you can expect an average wait of 38 days in the U.S., and up to 73 days if you live in Boston, according to researchers at the University of California at San Francisco who studied the matter. Got a knee injury? A 2004 survey by medical recruitment firm Merritt, Hawkins & Associates found the average time needed to see an orthopedic surgeon ranges from 8 days in Atlanta to 43 days in Los Angeles. Nationwide, the average is 17 days. 'Waiting is definitely a problem in the U.S., especially for basic care,' says Karen Davis, president of the nonprofit Commonwealth Fund, which studies health-care policy. All this time spent 'queuing,' as other nations call it, stems from too much demand and too little supply. Only one-third of U.S. doctors are general practitioners, compared with half in most European countries. On top of that, only 40% of U.S. doctors have arrangements for after-hours care, vs. 75% in the rest of the industrialized world. Consequently, some 26% of U.S. adults in one survey went to an emergency room in the past two years because they couldn't get in to see their regular doctor, a significantly higher rate than in other countries."

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Waiting Times for Care? Try Looking at the U.S. - Nurses, Doctors Say It's Time to Debunk the Myths

Waiting Times for Care? Try Looking at the U.S. - Nurses, Doctors Say It's Time to Debunk the Myths: "'There’s been a lot of clamor lately about delays in care in some other countries. But if you want to see some really unsightly waiting times, look at U.S. medical facilities,' said Deborah Burger, RN, president of the 75,000-member CNA/NNOC. While the problem has been largely overlooked by the major media, it was quietly exposed by the chief medical officer of Aetna, Inc. late in Aetna’s Investor Conference 2007 in March. In his talk, Troy Brennan conceded that 'the (U.S.) healthcare system is not timely.' He cited 'recent statistics from the Institution of Healthcare Improvement… that people are waiting an average of about 70 days to try to see a provider. And in many circumstances people initially diagnosed with cancer are waiting over a month, which is intolerable,' Brennan said. Brennan also recalled that he had formerly spent much of his time as an administrator and head of a physicians' organization trying 'to find appointments for people with doctors.' While Brennan's "

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Angry Bear on OECD Waiting Times Study

Angry Bear:

"The data shows that many countries with 'nationalized' health care systems have little or no waits for elective medical procedures. A 2003 OECD working paper entitled 'Explaining Waiting Times Variations for Elective Surgery across OECD Countries' by Luigi Siciliani and Jeremy Hurst provides some survey evidence of actual waiting times in various OECD countries. The results of that survey are presented below."

Two nice tables here explain a lot...

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