long waits for medical consults

ONE small consolation of our high-priced health care system — our $2.7 trillion collective medical bill — has been the notion that at least we get medical attention quickly.

Americans look down on national health systems like Canada’s and Britain’s because of their notorious waiting lists. In recent weeks, the Veterans Affairs hospitals have been pilloried for long patient wait times, with top officials losing their jobs.

Yet there is emerging evidence that lengthy waits to get a doctor’s appointment have become the norm in many parts of American medicine, particularly for general doctors but also for specialists. And that includes patients with private insurance as well as those with Medicaid or Medicare.

Merritt Hawkins, a physician staffing firm, found long waits last year when itpolled five types of doctors’ offices about several types of nonemergency appointments including heart checkups, visits for knee pain and routine gynecologic exams. The waits varied greatly by market and specialty. For example, patients waited an average of 29 days nationally to see a dermatologist for a skin exam, 66 days to have a physical in Boston and 32 days for a heart evaluation by a cardiologist in Washington.

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.

Americans are more likely to wait for office-based medical appointments that are not good sources of revenue for hospitals and doctors. In other countries, people tend to wait longest for expensive elective care — four to six months for a knee replacement and over a month for follow-up radiation therapy after cancer surgery in Canada, for example.

In our market-based system, patients can get lucrative procedures rapidly, even when there is no urgent medical need: Need a new knee, or an M.R.I., or a Botox injection? You’ll probably be on the schedule within days. But what if you’re an asthmatic whose breathing is deteriorating, or a diabetic whose medicines need adjustment, or an elderly patient who has unusual chest pain and needs a cardiology consultation? In much of the country, you can wait a week or weeks for such office appointments — or longer if you need to find a doctor who accepts your insurance plan or Medicare.

And those waits are likely to get longer as the Affordable Care Act brings tens of millions of newly insured patients into a system that is often already poorly equipped to provide basic care. “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.

The Department of Veterans Affairs, which is reeling from revelations of long patient wait times at its hospitals, is actually one of the only health care systems in the nation that openly tracks waiting times and has standards for what they should be. “The V.A. does have some deficiencies which are being exposed right now, but compared to what?” said Dave A. Chokshi, a former White House Fellow with the Veterans Affairs Department and a professor at NYU Langone Medical Center. “There aren’t really accepted benchmarks for what’s reasonable in the private sector.”

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Waiting … and Waiting …

A look at the average time to get five kinds of appointments for new patients in 2013, from a survey of 15 metropolitan areas.



Like the V.A. system, many national health programs abroad are required to keep track of wait times because they are spending government money. But such systems also have medical and financial incentives to curb wait times and dispense preventive care in a timely manner: If people with relatively routine problems can’t see a doctor or a specialist for an office visit, their problems often fester and require more expensive hospital treatment.

For that reason, Britain’s National Health Service stipulates a standard that patients should wait in an emergency room no more than four hours if they are to be admitted to a hospital. The organization also tracks how many patients wait more than six weeks for needed diagnostic tests (1 percent recently). Canada, for its part, tracks wait times province by province and procedure by procedure.

And as the Department of Veterans Affairs discovered, when wait times are public, there is often heavy pressure for improvement. “The U.K. puts a lot of effort into reducing wait times because it’s a huge political issue — it wins or loses elections,” Dr. Osborn of the Commonwealth Fund said. “In the U.S., compared to other countries, wait times have been less of a national conversation.”

To reduce waits, countries have tried various interventions, such as assigning more medical staff members to trouble spots, redesigning scheduling algorithms to prioritize certain appointments and requiring at least one medical office in a given region to be open nights and weekends so patients don’t have to visit emergency rooms. In the Commonwealth Fund report, 39 percent of insured Americans and 48 percent of the uninsured had visited an emergency room in the past two years, compared with less than 25 percent of Germans and Dutch.

In the United States, Dr. Pizer said, shorter waits could be achieved by allowing nurses and physician assistants more leeway to open their own practices and perform simple diagnoses and procedures. Medical schools could be better motivated to turn out doctors in needed fields like primary care. The Merritt Hawkins survey found that Boston, the city with the most doctors per capita, had some of the longest wait times, because the city is flush with specialists.

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English: Barack Obama signing the Patient Prot...

English: Barack Obama signing the Patient Protection and Affordable Care Act at the White House (Photo credit: Wikipedia)

Finally, it’s worth remembering that waiting for medical care can be either harmful or beneficial, depending on circumstances, doctors say.

Wait times for office visits are certainly “bad for the old and frail who have conditions that require frequent monitoring” like heart problems and diabetes, Dr. Chokshi said. And they can be deadly if a depressed person waits months for a first therapist’s appointment.

But patience can pay off for many other conditions, like joint pain and viral infections, where — given a little time — the body often heals on its own.

There is widespread agreement that Americans receive unnecessary treatment when it is profitable to do so. For example, they are far more likely to get steroid injections or surgery for back pain than people in other countries, even though medical guidelines suggest six weeks of conservative treatment before other interventions are tried; backs often heal on their own, and there are risks to the procedures.

Sometimes, it would seem, a little more waiting would do us some good.

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