
The US health care wait times myth - gronkie
http://theincidentaleconomist.com/wordpress/enough-with-the-wait-times-already/
======
CWuestefeld
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.

~~~
maxharris
_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._

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...](http://4.bp.blogspot.com/_otfwl2zc6Qc/S8p3XotZRpI/AAAAAAAANQ4/9Bn63-6lmgs/s1600/medschool.jpg)

(from [http://mjperry.blogspot.com/2010/04/medical-school-grads-
hav...](http://mjperry.blogspot.com/2010/04/medical-school-grads-have-been-
flat.html))

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.

~~~
leot

      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).

------
klochner
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/...](http://www.colorado.edu/Economics/courses/econ2020/section6/gifs/fig62.gif)

~~~
CWuestefeld
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
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.

------
zaidf
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.

~~~
maxharris
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.

~~~
leot
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.

------
raganwald
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.

~~~
gamble
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.

~~~
leot
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.

~~~
gamble
Possibly. I have to believe that Donna Dubinsky is pretty well off, and she
still had complaints about American healthcare.

The minute number of people who are able to chance paying seven-figure medical
bills out of pocket might enjoy the US system, but I doubt that group
encompasses even a majority of 'rich' Americans, by any reasonable definition.

------
jbooth
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?

~~~
yummyfajitas
_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...](http://www.statcan.gc.ca/pub/75-001-x/2007109/article/4096885-eng.htm)

~~~
jbooth
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.

~~~
yummyfajitas
Ok, fine. So we are in agreement that health outcomes are roughly even.

Insurance companies don't make much in the way of profits. Those greedy pigs
have profit margins roughly the same as home improvement stores, textile-
apparel clothing and slightly less than packaging and containers. (And keep in
mind, this was a good year for them. They all raised prices significantly in
anticipation of Obamacare.)

<http://biz.yahoo.com/p/sum_qpmd.html>

You simply won't get much money by soaking insurance companies.

The main thing you need to do to reduce spending is to get people to consume
less medicine. That was the conclusion of another (very good) series of
articles on the same blog - we spend more on health care because we consume
more (in particular, outpatient care).

[http://theincidentaleconomist.com/wordpress/what-makes-
the-u...](http://theincidentaleconomist.com/wordpress/what-makes-the-us-
health-care-system-so-expensive-%E2%80%93-conclusion/)

~~~
jbooth
>Those greedy pigs have profit margins roughly the same as home improvement
stores, textile-apparel clothing and slightly less than packaging and
containers.

Except all of those things involve _moving stuff around_. Insurance is just
bit flipping in the banks when you get down to it, paperwork at the absolute
worst. They should be able to manage way lower margins, they're moving money
on paper instead of goods. But they don't, because they're an entrenched
industry which puts less competitive pressure on them.

However you're right in that soaking the insurance companies won't make up the
gap. We need to get smarter and be more efficient. As a first step, why don't
we just the other 6 members of the G7, since they deliver equivalent outcomes
for much cheaper? I'm not a healthcare expert but the topline numbers say it
all. Healthcare's killing us on all aspects of everyone's budget. There could
still be a role for insurance companies, there is in europe.. let's just do
what works.

~~~
yummyfajitas
Profit margins are not generally dependent on the weight of the stuff you are
moving around. It is mostly based on risk and competitiveness. Risk increases
profit margin (see: software companies, drug companies), while competitiveness
reduces it (see: retail).

If there were no competitive pressure, why didn't insurance companies raise
prices a lot higher? That's what ISPs did, resulting in a profit margin of
28%.

As for copying the G7, which of the other 6 members of the G7 do you propose
copying? And how will imposing their system in the US prevent the overuse of
medical services?

Do you think that Americans will say "our health care system is now just like
France, maybe I better act like a Frenchman and not run to the doctor because
I have the sniffles?"

------
dean
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
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.

------
Groxx
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.

~~~
Qz
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.

------
jedbrown
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.

~~~
georgieporgie
> 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.

~~~
jedbrown
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
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.

