Tuesday, March 8, 2016

One Asshole's (Informed) Opinion: "All good things arrive unto those who wait - and don't die in the meantime"

- Mark Twain, from a time long before the invention of wait-times targets

Why do we need to wait for health care? If we allow "two-tiered" or partial privatization of health insurance, would that make wait times worse or better? Or better for rich people and worse for poor people? Why did all those billions not make the wait times go down?

This post isn't going to answer those questions directly. What I hope to do is convince you of the folly in focusing so much public policy on wait times.

The most obvious question, "which wait time are you talking about?" is actually the least important, because anything you wait for, whether in health care, McDonald's, or a restroom, operates under the same general rule:

Anytime the number of people seeking service exceeds the system's capacity, a wait is incurred.

That's it. No great mystery. If you need to pee and there's no free urinal at halftime of a game, you're going to wait. If you need a cataract removed and the ophthalmologist's OR time is fully booked, you're going to wait.

If the planners of a system are smart, they use a field of math called Queuing Theory to figure out what system capacity is needed to keep the wait under a set amount of time. This is used in fast food restaurants, for example, to determine staffing needs at different hours of the day. McDonald's knows that, on average, X customers come in each day for lunch. Serving each customer takes an average of Y minutes. If a person has to wait more than Z minutes to be served, they will leave and the restaurant loses money. Queuing Theory allows you to plug numbers into the various model formulas, and voila...the manager knows how many staff are needed to serve all customers without going past the Z minute mark. There are even ways to factor in triage, to prioritize some customers over others.

Great! So why don't we use these kinds of calculations to figure out how to solve wait times problems in health care? All it takes is simple math!

Um, no. The math in health care, in fact, is very, very fuzzy.

For starters, some parts of the health care system have a very fluid capacity and others don't. Your family doctor can step on the gas to clear an overstuffed waiting room. She just cuts out the chit-chat, guzzles some extra coffee, and goes. On the flipside, there are only so many operating tables, OR hours, post-op beds, and Anesthesiologists to go around. It takes a ton of investment to expand surgical capacity.

The second problem is that health care utilization is a lot like building a new lane of highway--the added capacity gets eaten up quickly, and before long you're back to waiting. As an example, let's say a hospital adds a second MRI scanner. Initially, the wait for an MRI will plummet. After a while, however, doctors who wouldn't have bothered referring patients with a non-urgent problem like a bum shoulder will start referring. Before long, everyone's back to waiting. We have decades of experience demonstrating that this is exactly what happens in health care. This is before you factor in things like increasing demand from the aging population and so on.

Third, health care service has no alternative. If the line at the Burger King is too long, I turn around and leave. If the radio reports that the highway is bumper-to-bumper, I don't bother. You can't "not bother" to get your cataract removed or heart valve replaced.

Most importantly, the fuss over wait times has turned into a bludgeon by politicians and administrators. It's one thing for putting incentives in place to keep a waiting list small. It's another thing entirely to tie department funding and job security to often-arbitrary targets, when everyone is doing their damnedest to provide safe and proper care. The more money gets pissed away on stopwatch-wielding consultants and wait-times-oversight bureaucrats, the less is spent on front line caregivers, and the more morale suffers. There needs to be some degree of accountability in health care, but never at the cost of burning out providers. Unfortunately, this is exactly what's happening everywhere in health care, with devastating consequences on dedicated, conscientious health care workers.

So what to do about unacceptable waits for surgery or consultations? Push the politicians to pay for patient care, not scorekeeping.

And bring a book to your appointments. Some days you're waiting because someone else is crashing, and one day the person in crisis might be you.

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