The US health care wait times myth
theincidentaleconomist.com
theincidentaleconomist.com
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.
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.
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.
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).
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.
Here's an article on the same guy, Jasper Lawrence: http://blogs.discovermagazine.com/discoblog/2009/07/22/are-h...
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.
http://medicalmarijuana.procon.org/view.answers.php?question...
"And that’s after spending way, way, way more money than anyone else"
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/...
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.
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.
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.
The economics definitely penalizes family practice.
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.
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.
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.
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.
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.
For example, defensive medicine can be traced to the way our legal system works.
It's a healthcare and ____ problem(insert IP, legal etc.)
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.
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.
The US is easily the best country in the world in which to be rich.
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.
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.
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.
That's fine. I assume the reverse, asserting that the Canadian (and European, and ...) systems are better is also a no-go, given rates of immigration there from the US?
I just don't think anyone's going to move anywhere for health care systems unless they're already sick and they're going for medical tourism purposes. Use of the health care system is a nebulous future possibility, whereas a job or the weather or the cultural environment is an everyday reality. Immigration rates aren't going to tell us much about any health care system.
(edit: specifying the final object)
Very true. Since very few people move from one industrialized nation to another for the health care, we should conclude that they all provide very similar services.
I wouldn't assume that there's no difference for someone who is older, uneducated, or unemployed, because the cross-border friction is WAY higher for them.
And of course, all we are talking about is perceived benefit. If one system costs a lot more than the other, we can make all sorts of statements about that. Is the Canadian system more expensive? Is the American system more expensive? I've seen both arguments given, and it looks an awful lot like you can juggle figures at will to justify either claim.
You might be right, but I don't think you can simply assume it.
For example, a well-educated, professionally employed person old enough to have an established family is highly immobile for those very reasons. Their jobs and their family ties are holding them in place. Who knows how these factors all net out.
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.
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?
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...
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.
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...
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.
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?"
And, their total profit plus executive salaries is a small fraction of the amount of admitted Medicare fraud.
I mention medicare because it's supposedly more efficient, but that's based solely comparing their cost to cut a check to the "overhead" of private health insurance companies.
Note that folks who have disputes with medicare are less likely to win than folks who have disputes with private health insurance companies.
Do you have a citation for this? It doesn't sound implausible, but a citation would be nice.
http://abcnews.go.com/Nightline/medicare-fraud-costs-taxpaye... says that the govt admits to $60B/year in medicare fraud.
http://issa.house.gov/index.php?option=com_content&task=... says that the number is closer to $150B .
Meanwhile, the govt recovered $4B in 2010. http://www.publicbroadcasting.net/kwgs/news.newsmain/article... .
IIRC, the total profit by private healthcare companies was less than $10B in 2009 and the executive salaries total was under $1B. You've said that the 2010 numbers are somewhat better.
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.
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?
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.
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.
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.
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.
The resulting marketplace, including availability of treatment, is correspondingly skewed. We pay for crisis management, not health management.