The US health care wait times myth

http://theincidentaleconomist.com/wordpress/enough-with-the-wait-times-already/

by gronkie • 15 years ago

56 56 15 years ago

raganwald4• 15 years ago

What I find interesting about the "We beat Canada" idea is how few Canadians move to the USA in search of better health care. Rich Canadians take advantage of the porous border by travelling to the US and paying for certain procedures, but generally when someone permanently moves from Canada to the US, it's always in search of economic improvement.

I would like to see statistics showing that Canadians would happily take a job with the same or worse pay just to get access to US health care. If the US system was superior in ways that mattered to people, we should be able to measure this effect by looking at immigration.

Maciek416• 15 years ago

I agree, it would be nice to see some data on that.

A few days ago we had a discussion here on HN about the viability of Montreal as a startup hub, and when I raised the question of what Canadian cities in general could do to counter the higher pay and better climate down south, I somehow completely forgot (as did any responders) about the potential advantage of our kinder (if at times sluggish) healthcare system, especially in light of medical tourism options.

jdminhbg2• 15 years ago

Immigration requires a whole lot of push. Given how many Canadians already live within easy driving distance of the US border, even gigantic differences in efficiency and quality wouldn't drive much actual transnational immigration.

You move across a border for a better job, not to potentially shave 45 minutes off your wait time after a putative future cycling accident.

raganwald4• 15 years ago

If we were confident that the friction of immigration exceeds the allure of better wait times, then we can say with some confidence that better wait times simply aren't that important to people. Or at least, not as important as making more money, or retiring to a warm place, or hanging out where the action is.

If it doesn't rank next to those other reasons for immigration that all exceed the friction, I would suggest that people stop defending the US system by saying it's better than Canada's system. It isn't better enough. If you like it, fine. If you don't like it, fix what you don't like. But arguments that it's better than Canada should be accompanied by evidence that it exceeds what is actually an incredibly small amount of friction.

I mean, come on, it's not like you have to learn a new language or give up your love of Hockey to move from Canada to the US. If you have a university degree the whole thing is fairly painless.

p.s. On second reading, I see you talking about driving across the border for "Medical Tourism." To my understanding, this is inconvenient for seeing a GP or a specialist, and while some people consider it worthwhile for an MRI, it is not possible to buy into US medical insurance that would cover anything really expensive.

So effectively, medical tourism is equivalent to being completely uninsured in the USA. I don't think anyone argues with a straight face that being uninsured in the US is superior to being subject to the horrors of Canadian medical care. My understanding is that people argue that being insured in the US is more convenient than being a Canadian. If I thought that being insured in the US was superior to Canadian health care, I wouldn't reason that driving across the border for an MRI somehow gives me the best of both worlds, I'd want US insurance so that I could drive across the border for a heart transplant.

And for that, I'd have to move to the US and suffer the same slings and arrows of outrageous deniability fortune suffered by Ms Drabinsky when she tried to insure her family.

Qz2• 15 years ago

I think that's part of the point of the graph. Yes 'we beat Canada' but not by enough that it matters at all.

gamble2• 15 years ago

Public healthcare is a cornerstone of Canadian national identity, in part because we recognize how bad the American system is. There are always ideologues who are inspired to emulate the American system, but they never get any traction with the electorate because healthcare privatization is the third rail of Canadian politics.

If Canadians move to the US it's in spite of the American healthcare system. I've never heard of anyone emigrating because they thought it was an attraction.

leot4• 15 years ago

In fairness, as a Canadian living in the US, if I were really rich I might move here because of the quality of healthcare I could get. This doesn't mean the system does the greatest good for the greatest number (by any stretch).

The US is easily the best country in the world in which to be rich.

Groxx• 15 years ago

Interesting article, but can I nominate that last line chart for a worst-graph-colors-of-the-year award? Even after finding out that they are, in fact, different colors it's hard to find any country in it, much less with confidence.

Qz2• 15 years ago

I imagine the colors were chosen so that the US sticks out. It's not a general information chart. It's a god-look-how-terrible-the-US-is chart.

klochner• 15 years ago

The author stumbled over one of the most important pieces of data - GP's per 100,000 people. The author notes we have the lowest doctor:population ratio, adding:

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

The problem is that we don't let the market decide on the right number of doctors - the training of new doctors is a function of the number of residencies, which is jointly controlled by congress and current physicians.

So we artificially restrict the supply of doctors, which inflates (and I would argue is intended to inflate) the salaries of all doctors, while also shifting the market equilibrium to a lower quantity of medical services provided [1].

[1] here's a graphical example for people new to economics: http://www.colorado.edu/Economics/courses/econ2020/section6/...

CWuestefeld5• 15 years ago

I agree with what you said, but there's another dimension as well (as I mention elsewhere in this thread, see http://news.ycombinator.com/item?id=2263931).

We also enforce MDs being the gatekeeper to various medical stuff. Many things we insist must be done by a doctor could be done without that degree. There are certainly a lot of things that someone with the knowledge of a LPN or Army medic could do just fine (say, checking for a broken bone).

And our obsession with (the war on) drugs makes MDs the gatekeeper to pharmaceuticals. Really, there's no reason why most drugs can't be widely available. I understand the logic behind some (like the overuse of antibiotics breeding resistant bacteria like MRSA), but MDs are doing a bad job of preventing that, and in any case, those could be the exception rather than the norm. There's really no reason I shouldn't be able to go to the store and pick up, say, my Asacol on my own initiative.

So the low population of MDs is one aspect, but the overloading of MDs with responsibilities for which their skills aren't needed is another.

dkarl• 15 years ago

Doctors being the gatekeepers to pharmaceuticals also means that when you seek care for an ailment or symptoms favored by pill tourists, the doctor will make a snap judgment based on your appearance and demeanor and possibly decide not to give you appropriate care. You might just be sent home with a follow-up appointment, or if you're in the emergency room, you might be left on a gurney in a hallway for hours while the nurses ignore you.

SageRaven• 15 years ago

I agree whole-heatedly with your comment on the "gatekeeper" mentality of the medical industry. Armed with a current copy of "The Merck Manual," some internet research, and local feed store antibiotics, I've successfully self-treated for a few infections.

I can only imagine that retired nurses, field medics, and EMTs (you know, people with real training in this stuff) all being able to legally administer rudimentary healthcare to their local communities would provide much-needed care for a great many cases, thereby increasing the quality of life for many more people.

billjings• 15 years ago

That it's general practitioners is the key data point there - it's not talking about physicians in general. We have a far greater ratio of specialty doctors to general practitioners than other countries do.

I don't have the stats handy, but from what I've read I'd be surprised if we didn't have more doctors per 100,000 people than the average country.

edit: Here's the stats - http://www.nationmaster.com/graph/hea_phy_per_1000_peo-physi... - they bear out my statement, but not really my argument. We have more doctors per 1,000 people than Canada; less than Germany.

prewett• 15 years ago

As another commenter mentioned, it's general practitioners that's limited. According to salary.com, in Austin, "general practitioner" and "family practice" make $58k, "family practice physician" makes $73k. I'll assume the salary is about $75k. Compare "surgeon" at $101k, "heart surgeon" at $114k, and "orthopedic surgeon" at $165k. After going $200k in debt for medical school, I'm thinking family practice isn't looking very financially rewarding. (For comparison, $75k - $100k should be easy for an experienced programmer in Austin, and it doesn't take $200k in debt, either)

The economics definitely penalizes family practice.

CWuestefeld5• 15 years ago

Data point: I live in the USA, and I've got Crohn's disease. I take medicine for the chronic condition, which keeps it in remission 99%+ of the time. But when it flares up, I need to see a doctor pretty quick -- not just because it hurts, but also because the pain is an indication of bad things happening to my intestines.

The thing is, I can't get an appointment to my GI doctor right now, or even tomorrow. So I can't get a prescription for the heavy duty drugs necessary to bring it under control, not without a significant wait while I'm in pain and my ileum is turning into scar tissue.

My solution is that when I vacation in Mexico, I buy and bring back a personal supply of prednisone. The downside of this is that prednisone is nasty stuff that I don't want to take, it's not as effective as the real treatments, and it's got much worse side effects. But I don't have a way to get the real stuff.

So I'm pointing the finger, at least in part, at the regulations here in the USA. By artificially controlling the number of doctors, and/or constraining our access to pharmaceuticals, we're creating the situation where I am unable to get the treatment I need. This has nothing to do with economics or even insurance company policies, really. It's all to do with nanny-state government.

maxharris2• 15 years ago

I agree with you! Here's some data about how the supply of doctors is constrained by law:

http://4.bp.blogspot.com/_otfwl2zc6Qc/S8p3XotZRpI/AAAAAAAANQ...

(from http://mjperry.blogspot.com/2010/04/medical-school-grads-hav...)

For the last 30 years, 16,000 new doctors are let through each year, and this is very carefully regulated to keep guild members rich. There's nothing wrong with that, but the problem is that the government is used as a tool to maintain this monopoly. (Unfortunately, it's been this way since the Middle Ages.) Does it have to be this way? Not if you decide that people should be free to choose for themselves which expert they should seek medical help from, and what qualifications they require. If you own your own body (and I say you do), this is your right to decide.

On top of that, new drugs cost somewhere around $1 billion to take to market. When only 300 people in the country have a rare condition, the FDA makes it so that nothing can be done for them because there is no way to recoup a billion dollars from any small group of people.

leot4• 15 years ago

  For the last 30 years, 16,000 new doctors are let through each year, 
  and this is very carefully regulated to keep guild members 
  rich. There's nothing wrong with that, but the problem is 
  that the government is used as a tool to maintain this 
  monopoly.

What? If the AMA is restricting the number of doctors in order to make more money, then there absolutely is something "wrong with that". You're stating as a premise that it is ok for doctors to act selfishly in a way that causes (or aggravates) harm. The sworn responsibility of an MD is to get us and keep us healthy.

Sure, it's also wrong if government is going against the public interest in restricting the number of doctors. But whether someone should be able to claim that they are a certified medical doctor is something I want government to regulate, at least for now. AFAIK, these regulations were put in place in response to quackery (and the like).

dalore• 15 years ago

Wow, I live in the UK and when I need to see the doctor I just drop by with no appointment, wait my turn (depending on number of people in the surgery can take 10-60mins. Then the doctor sees me.

leot4• 15 years ago

Likewise in Canada. I think the wait time numbers are higher because people are waiting to see "their" doctor. But there are lots of drop-in private clinics, and it is always "free" to visit them.

antidaily• 15 years ago

Why don't you go to the ER?

btilly• 15 years ago

Sorry for the digression.

I have a friend with Crohn's disease who read all of the research on hookworm, found a company that would ship it to Canada, went to Canada, and got himself infected. Several months later he has managed to discontinue most of the drugs and he is feeling better than he has in years.

Unfortunately hookworm has been classified as a medication in the USA, and is unpatentable, so will never be approved as a treatment here. But if you're willing to travel abroad, look into it. Seriously.

georgieporgie2• 15 years ago

I heard about this on This American Life. Here's the link, it's in part 3: http://www.thisamericanlife.org/radio-archives/episode/404/e...

Here's an article on the same guy, Jasper Lawrence: http://blogs.discovermagazine.com/discoblog/2009/07/22/are-h...

ronanz• 15 years ago

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http://medicalmarijuana.procon.org/view.answers.php?question...

josto• 15 years ago

Im assuming you're in California? What health plan do you have? I know sometimes you can't get an appointment right away, but it really depends on the condition. I got diagnosed and needed surgery, and I don't go to the ER, but something called Urgent Care. Emergency is a nail in your head... But urgent care is for pain that needs to be dealth with.. ie - you took tylenol and advil, and it didnt work.

You should research Urgent Care centers through your health plan and have their address in your phone. That way, you can get the care you need in a timely manner.

I am so glad we have such good doctors, pharmacists, etc in California at least... they def are trying their best. It all just depends on the condition. If God forbid you get seriously ill, then you will get all the appointments you need. Yes there is usually some wait, but its not THAT bad.

zaidf3• 15 years ago

My siblings and I take a pill 3x day for life for a genetic condition. The pill(colchicine) cost pennies in its generic form. It isn't a pill that was made in a lab after millions in research. So there were plenty of generic brands available and it'd cost us 5 bucks/mo from Walmart.

That was that.

Last year a company came in and got an exclusive on it on the premise that they spent millions in testing the pill for quality etc. Armed with the exclusive, they killed all generic brands and are selling the same pill for $5/pill.

What cost me $5/mo previously now costs $450/mo.

There is something seriously flawed about some things in our healthcare system.

CWuestefeld5• 15 years ago

Last year a company came in and got an exclusive on it... There is something seriously flawed about some things in our healthcare system.

That doesn't sound like a healthcare problem. That sounds like an IP problem.

Whatever it was that let the new manufacturer take the compound out of the public domain is where you should be directing your ire. Sounds like another indictment of patent law.

zaidf3• 15 years ago

Semantics. Almost all problems related to healthcare have their root cause at something other than healthcare directly.

For example, defensive medicine can be traced to the way our legal system works.

It's a healthcare and ____ problem(insert IP, legal etc.)

mrkurt2• 15 years ago

Stringent FDA requirements that require extremely expensive testing are basically a health care problem. The fact that we have to give people monopolies so they can afford to do what the FDA wants is an unfortunate symptom of the problem.

mrkurt2• 15 years ago

If you don't value the testing Colcrys did (I probably wouldn't, colchicine's been around long enough), consider getting it from a "Canadian" pharmacy online. Generics of otherwise patented/exclusive drugs in the US are frequently legal in other countries. I know of a number of people who order from an online "Canadian" pharmacy for a generic version of Singulair, which is produced in India.

The legality of importing these for personal use is pretty murky. The FDA probably wouldn't like it, but it's not a blatant violation of any laws I'm aware of either.

More generally, I really struggle with patent protections for pharmaceuticals. It's difficult to imagine how they'd justify paying ginormous amounts of money to develop and/or test products to the FDA's standards without patent protection, but I find the idea of patents pricing people out of medication distasteful.

maxharris2• 15 years ago

This is the FDA's fault.

Without the FDA, you would keep buying the generic you had been buying, and the company would keep making it for you. But with the FDA, a company can come in and essentially buy a monopoly on a market that would otherwise be free.

zaidf3• 15 years ago

Is the solution really FDA or no FDA? Without knowing a lot, I doesn't seem too hard to cite goods that have come from the FDA.

leot4• 15 years ago

It sounds like you're saying "government is the problem". But nearly every other developed country doesn't have this problem.

Please, explain why government is the reason for why the US healthcare system is so much poorer than the healthcare system of countries in which there is far more government involvement.

Other countries show us that solution to bad government isn't the elimination of government. The solution is to fix what we've got.

jbooth3• 15 years ago

Yeah, I mean I can understand the philosophical place that one could come from that would make one skeptical of government-run anything.

But every other industrial nation beats the crap out of us both in results and in results per $$, while spending far less money. This isn't a theoretical argument -- we could just copy one of those systems wholesale and get way better results than we're getting.

At one point does the engineering principle of "if it works, it works" kick in?

If you saw a better technique for doing something at your business, and didn't do it because "i don't like to see problems solved in that fashion, regardless of what the metrics tell me", you'd be an idiot, right?

yummyfajitas5• 15 years ago

But every other industrial nation beats the crap out of us both in results and in results per $$...

What results? Please be specific. In particular, if you want to compare health outcomes, please make sure you controlling for factors like demographics, lifestyle, pollution, food quality, etc.

Also, how do you propose to pay US doctors the same salaries paid to doctors in poorer countries? Some numbers: the top 5% of income earners in Canada earn 40% less than the top 5% of the US. Are you proposing to knock doctors a few rungs down the income ladder?

http://www.statcan.gc.ca/pub/75-001-x/2007109/article/409688...

maxxxxx• 15 years ago

I think reducing doctors' salaries is a good idea.

jbooth3• 15 years ago

A) Call it even for health outcomes if you'd like, we could argue the numbers regarding demographics, lifestyle and all that until the cows come home, but health in Canada/UK/France/Japan definitely isn't materially worse. So for the sake of argument let's just call it even, except we're spending several times as much. (we actually spend more gov't money on healthcare per capita than many companies with socialized medicine, in addition to private sector spending -- that's how broken our system is).

B) Regarding doctors wages, I'm not really talking about "poorer" countries unless you'd call western europe, canada, japan "poorer". If they make significantly less in those countries than here.. sure, fine. Given that we don't offer cheap schooling like those countries there might be a limit to how low we can go, though.

C) Top 5% of income != doctors, necessarily. And the money we're wasting, a tiny percentage of that is going into doctors' pockets. Most of it is just plain pissed away, and a lot goes to insurance company profits. Doctor salaries are pretty far down on that list, so I don't think I was proposing drastically lowering their salaries, no.

CWuestefeld5• 15 years ago

If we have to have this discussion again...

we could just copy one of those systems wholesale

Maybe. But when you do out the demographics, there are plenty of reasons to think that things here are not quite the same. With different sorts of problems, the same solution isn't guaranteed to work.

Maybe. But maybe you're constrained because of what the Board of Directors will allow you to do. By analogy, the Constitution simply doesn't allow the federal government to do many of the things that your solution would require. Even if they're great ideas, it's simply not allowed. So you should be concentrating on changing the Constitutional restrictions that prevent those solutions, rather than getting the Courts to throw out ever larger chunks of the only thing that protects us from tyranny.

dean• 15 years ago

That first graph is interesting. I would like to see their definition of "wait time when sick". Since the article separately mentions waiting to see specialists, and elective surgery, I'm going to assume wait times in the graph do not include these.

When we talk about wait times in Canada, most people mean the amount of time they have to wait when they walk in to a hospital or clinic, without an appointment. In other words, how long do you have to wait to see a doctor now. Not how long do you have to wait for an appointment with your GP. And that time is typically measured in hours, not days.

Frankly, I'm surprised to see that anyone in any of those countries has to wait 6 days to see a doctor when they are sick.

phjohnst• 15 years ago

Yeah, I can't believe that more people above aren't asking this question.

From my experience in the Canadian system, if you're really sick (ie badly injured, have cancer, whatever) you actually get pretty quick service. Sure, if you walk into the ER with your kid that has a flu, you might have to wait a couple hours while they deal with the people that just got in a car accident, but I can live with that. And really, if you're chronically sick enough to still be sick in 6 days (and could wait that long, ie you didnt need to go to the ER) then the 6 day wait to see a GP is likely not going to make a big difference. (Must be noted, I've never had to wait 6 days to see my doctor when I was sick, more like 1-2, and could always just walk in if I needed to)

It really comes down to this: If you need help now you'll get help, free, right now. No questions.

jedbrown2• 15 years ago

The final figure claims less than 0.3 general practitioners per 100,000. That would amount to around 1000 general practitioners in the country which is at least two orders of magnitude low.

georgieporgie2• 15 years ago

> at least two orders of magnitude low.

You're saying there are 100,000 general practitioners in the US? Even that number may be low, as this WSJ article says the US has "352,908 primary-care doctors". The article also says there are around 954,000 total doctors in the US.

jedbrown2• 15 years ago

I said "at least" instead of giving a more precise number exactly because the WSJ's "primary-care" statistic included "general practitioners, internists, family physicians and pediatricians" and I remembered seeing an older statistic claiming only a bit more than 100k general practitioners.

pasbesoin• 15 years ago

The U.S. health care insurance system is term insurance at whole (i.e. life) insurance prices.

The resulting marketplace, including availability of treatment, is correspondingly skewed. We pay for crisis management, not health management.

The US health care wait times myth

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