Friday, October 29, 2010

The Waiting Is The Hardest Part

(Thomas Eakins, The Gross Clinic, 1875)

A common objection to single-payer health care systems is the supposedly lengthy amount of time patients wait to get an appointment. Actually, this depends on the reason for the appointment.

Medical care divides into three tiers: primary, secondary, and tertiary. In America, primary care refers to the family doctor, pediatrician, or gynecologist who meet most medical needs. In most other wealthy countries, primary care begins and ends with the family doctor, and indeed some do not offer pediatric care as we understand it. Secondary care refers to hospitalization and outpatient services involving surgery or another significant intervention such as chemotherapy. Tertiary care involves a rare condition requiring a highly specialized intervention.

When a country makes a decision to offer universal access to health care to citizens, residents, and visitors regardless of their income, policy implementation inevitably focuses on the health of the overall population as opposed to marketing health care to individuals. Population-based health policy leads to an emphasis on preventive care both at the public health level and at the provider level. At the provider level, that means getting people into the system before problems develop, which in turn means emphasizing primary care over secondary and tertiary care. Primary care is also less expensive than secondary care, so the more that health needs can be met at that level, the lower the overall bill to taxpayers and the more affordable the system becomes.

In practice, then, countries that offer universal coverage -- i.e., all wealthy nations except for the United States -- have a high ratio of primary care physicians to secondary care doctors. And while this can result in a wait for treatment of nonacute conditions, well-off citizens in these countries can generally purchase supplemental insurance for reducing waits or buy into a national program. And note the distinction: Longer waits for nonacute secondary care are a function of policies that follow from universal coverage, not a supposed single-payer health care government bureaucracy or lack of supply created by a disincentive to become a physician. (Single-payer countries have no more or less doctors than any other developed nation.)

So, there is a tradeoff: In a universal health care system, individual patients with nonacute conditions either wait longer for treatment or purchase a place in line in exchange for universal coverage, cheaper health care, a longer life expectancy, and wide array of services for the population as a whole.

Is it a tradeoff worth making?...


Darlene said...

As everyone's insurance rates, co-pays, and prescription drug prices are due to go up next year the Single Payer system looks better and better.

With the Republicans poised to wield power after Nov. 2 it will never happen. In fact, they are going to try to eliminate what few real reforms have occurred. Blast them all to h---.

sussah said...

Hi K, It's in the physicians' interest to let individual patients with nonacute conditions wait a while to get an appointment. It makes their job easier since nature makes a good start on healing the person before the appointment comes. The appointment still happens, the money is exchanged, pills are purchased, everyone except the frustrated patient has been made happy. sp

paula said...

Many people in the US have had long waits for care--primary and secondary--years before health care reform.
In rural areas, including where I live, specialists are limited in number, and primary care docs are stretched thin. We have 0-2 physicians per specialty per county, in this end of Massachusetts. In Vermont and New Hampshire, I would guess it would be closer to every 2-3 counties. Just because there's a cardiologist in your area doesn't mean he/she is close by. You may have to drive an hour for an appointment for which you've waited anywhere from three weeks to three months. Community hospitals carry a big burden and, sometimes, paramedics on volunteer ambulances are heroes. In my experience, our tertiary care is good, but it's just for emergencies.
Does that mean people are less healthy here in rural counties than those in metropolitan areas? I don't think you could find data to support that opinion, at least not in the Northeast. Might be a different story in other parts of the country. By necessity, people in this region are generally resourceful and accustomed to keeping themselves healthy. Plus, the cold weather kills off bacteria and makes you move faster :)
All in all, I don't think health care reform will affect the quantity of resources here very much. Numbers have always been low, in spite of USPHS and other federal programs. On the other hand, quality has been good. Let's hope it stays that way.

K. said...

"Does that mean people are less healthy here in rural counties than those in metropolitan areas? I don't think you could find data to support that opinion, at least not in the Northeast."

I doubt that the data will ever support that opinion. For one thing, rural areas have many fewer violent death per capita and probably fewer by traffic accident as well. Moreover, the lifestyle -- better opportunities to walk and bike -- is likely more conducive to preventive care.

Since they are designed to move auto traffic, American suburbs and exurbs can be nightmares of public health. Hemmed in by arterials, it's virtually impossible to do things like walk to dinner or the store. Bike paths help some, but practically speaking they are designed for recreation and not for an alternate mode of transportation. Then of course the 'burbs have high concentrations of fast food and chain restaurants, neither or which are noted for healthy choices. Inner cities are also plagued with fast food restaurants, plus residents there usually have less choice in grocery shopping.

Suzan said...

Great writing! I so agree with everything you've written.

And music! Thanks so much for the Vedder singing with my fave Tom P.

I'm a fan of yours now.

May I blogroll you?

(And thanks for the comment on my blog.)


K. said...

Suzan, thanks and blogroll me away! I think you'll like the music on the Citizen K. jukebox.

Suzan said...


Did someone say "jukebox?"

Thanks, sweetie.

I'm sure I will.


P.S. You're on my blogroll.

K. said...

Hey, thanks for the shout out!

Steven said...

None of my initial appointments with doc's around here have been under 8 weeks. I'm currently waiting to see a doc and it will be 10 weeks gone by the time I see him. So much for health care in the USA...