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How long should the wait be to see a doctor?
Matt Yglesias notes that seeing a doctor in the U.S. involves waiting. I've never had this experience (not going to the doctor is my trick) but I've heard the same from other people. My question is a simple one: in market equilibrium, should we expect two- or three month-long waits to see a doctor? Or is this somehow an artifact of government intervention?
I understand why I might have to wait to get an iPhone (though I didn't) or Harry Potter (though Yana didn't). I understand why I can't just call up El Bulli and get a reservation; they want the highest status people eating there, plus the air of exclusivity creates positive publicity for spin-off products. But I wouldn't expect those mechanisms to matter for medicine, at least not at the GP level ("he won't transplant a heart for just anyone, he's promoting his personal line of stents", etc.).
Why might one have to wait for a doctor?
1. There are big gains to sticking with your previous doctor, and demand is uncertain each period so the lines add up. But I would expect the law of large numbers to kick in, plus sometimes the wait should be very short.
2. Waiting lists are a form of price discrimination. Some patients "hoard time" (just as dept. chairs in a university "hoard space") by making lots of appointments, many of which are unnecessary ex post. Indirectly they are charged for this privilege but they get immediacy when they need it. Matt (maybe) didn't need immediacy and wasn't willing to pay for it.
3. The President is always the last person to enter the room and that policy maximizes the value of his time. Maybe doctors have lots of "drop out" appointments (patients get better or perhaps they die), and so doctors maximize the value of their time by keeping a long queue. But for this to maximize profits, must the queue be longer than a week or so?
4. Some constraint -- legal or otherwise -- prevents doctors from raising their prices. (This hypothesis, by the way, suggests that American medical care is even more expensive than it looks.)
Readers, why is the wait often as long as it is? I'm not interested in debating health care policy today, I'd just like an answer to this question.
Addendum: Jane Galt adds commentary and analysis.
Posted by Tyler Cowen on July 24, 2007 at 07:17 AM in Medicine | Permalink
Comments
May be the supply of doctors is low.
Posted by: barbadkatte at Jul 24, 2007 7:25:08 AM
The wait will be longer at physicians' offices that see a lot of hmo patients. The physicians are paid monthly by the head, from what I understand, for each patient, and they are reimbursed much less per patient for actual visits and treatments. HMO patients tend to use the physician more often, due to having low copayments, and the doctors are scheduling patients every 10-15 minutes versus 20-30 minutes in the old days. Thus, they are booked up months in advance. The more hmo patients they have, the more they are paid by the hmo. If however, you are a "private insurance" or cash patient... that wait usually becomes very short (which happens in Canada too, if I remember correctly).
Posted by: William at Jul 24, 2007 7:26:46 AM
I'm not familiar with the details of US private healthcare, but in other countries, most medical insurance policies have price caps on various types of treatment ($X per ENT specialist visit; $Y per CT scan), above which the patient pays 100% of the excess, but below which they pay the first (say) $50.
If, for the typical policy level available to "normal" employees, the caps don't vary much between insurance providers, then that's your constraint. And incidentally, since I gather in the US the uninsured almost certainly can't afford specialist treatment, it will also bid up fees that might otherwise have been lower.
Posted by: Cormac at Jul 24, 2007 7:32:16 AM
In this part of the world (Montana) doctors are distributed according to money-making potential: there are many doctors who do cosmetic surgery, but too few who do dermatology though the need in this high harsh country where many work outside is very high.
Posted by: Mary Scriver at Jul 24, 2007 7:46:53 AM
My physician and my kids' pediatrician can fit us in within 24 hours when we need to be seen. When I worked at Kaiser we could see people the same day that they called for an appointment. Wait time for a routine physical exam is much longer.
Unsurprisingly, the minute clinic model, where patients pay cash, allows you to be seen within a few minutes of arrival with no appointment.
Posted by: Gong Tao at Jul 24, 2007 7:59:01 AM
I think the first comment had it right: a supply shortage of doctors. A shortage which is perpetuated in part, by the medical educational system.
Posted by: Eric Robertson at Jul 24, 2007 8:05:30 AM
Having run the front desk of my wife's dental office on more than one occasion, I came to a better understanding of why this occurs. In clinics, downtime is wasted time. They want to be as busy as possible. Therefore, they will do their best to schedule a full block of patients ahead of time. Being able to roughly "fix" your schedule and not accept emergencies/walk-ins makes for better staff, doctor and patient (if you are lucky enough to have an appointment) experiences - there is a greater ability to see all the patients on time without generating high wait-times, scrambling to handle new patients is at a minimum, downtime (=wasted time) is reduced.
On a separate note, you would not believe how much work is involved in setting up a new patient at offices that are not completely electronic. Here is my experience:
- Get them to fill out paperwork: 10 minutes
- Create a patient chart (e.g. building all the specific papers that the doctor needs into a file folder): 10 minutes
- Calling insurance to get benefits and eligibility (because their electronic systems are useless at times): 10 minutes
- Entering the patient and insurance information into the computer to allow better treatment estimates (because all insurances pay different rates in different ways): 10 minutes.
While some of these steps can be done in parallel, and while I am probably slower than the usual front desk staff at paper shuffling, I found this amount of "work" to be upsetting.
Posted by: Jason at Jul 24, 2007 8:13:20 AM
Not sure why prices don't rise. But supply cannot rise due to the cognitive requirements of doctors, only a small proportion of the population have the requisite IQ's.
Posted by: adrian at Jul 24, 2007 8:25:25 AM
1. How good is your doctor? I've lived in various parts of the country, and I've found that in general, the better the doctor, the longer the wait time to see him or her. I'll speculate this is because the good doctors (and clinics) get referrals from their existing patients, which drives up wait times. If you have an intuition that a doctor isn't any good on the first visit, are you going to go back?
2. Did you get referred to see a specialist by your doctor, or did you make an appointment on your own initiative? The difference in wait time between those cases can be weeks or months; I suspect but cannot prove that there is some punitive aspect to the scheduling here at work. In my non-cynical moments I suspect the specialists keep time slots open for referrals or emergencies.
3. Is this a pre-existing condition? Sometimes it can take a couple months to see the dermatologist, but if she finds something suspicious and wants to see you back in a couple days, it's amazing how that space suddenly frees itself on the calendar.
4. Where do you live? Certain kinds of medical care is going to be more expensive in certain parts of the country. I stopped seeing my previous dermatologist (who practiced out in the upper-middle class suburbs) when the wait times for appointments climbed to over 6 months. My new dermatologist works in a lower-middle class city and the wait time is now down to about a month and a half.
Posted by: John Wilson at Jul 24, 2007 8:29:19 AM
The rejoinder to Yglesias's point is that, in America, if the wait is too long for your taste you can find another doctor. In Europe, not so much.
Posted by: jb at Jul 24, 2007 8:31:35 AM
There are only a finite number of intellectually qualified English-speaking people who are willing to take on 200k worth of debt and 11 years worth of rigorous post-graduate education only to be able to start working when they are 30 at the primary care level to only make 140k a year, while there similarly qualified-at-graduation buddies either a) become engineers at 22, b) start practicing law at 25, c) get their ph.d at 27 while never having to take a night of call, d) get their MBA at 28 after making bank for four years already, etc...
Whether that finite number is greater than or less than a)the number of students admitted to medical school, and b) the number of culturally qualified foreigners allowed to practice medicine in the United States, is probably the greatest source of discussion.
Posted by: Pup, MD at Jul 24, 2007 8:32:12 AM
Three main factors I've noticed:
1) triage -- as Gong Tao says, my GP schedules physicals 3-4 weeks out, but there are slots reserved for same day urgent cases. Likewise, specialists often make you wait when they're paged to the hospital.
2) training lags -- as Mary Scriver says, dermatologists are the slowest. That's b/c skin cancer has increased but the multiyear training cycle hasn't yet increased dermatology supply. This effect vanishes in the long run, but in practice, some specialty will always be oversupplied and some undersupplied as needs change.
3) Personality -- Don't underestimate the effect of being one's own boss. Medical training selects many doctors for whom the marginal value of a challenging case or a deeper focus is higher than the marginal value of squeezing in another patient, and these doctors often let early appointments run late. My best doctor is often interrupted by nurses telling him to hurry up. I compensate for this by trying to get the 1st appointment of the day.
Posted by: DK at Jul 24, 2007 8:34:55 AM
Is it really that long? I mean, with specialized medicine it is the high demand contra few doctors. However, I never had to wait when it comes to general medicine (however, you have to wait in the waiting room despite having an appointment!). Also, old people and hypochondriacs clog practices by going there way to often (or even have to go due to prescription issues).
Also, in germany, demand is artificially raised by insurance companies advocating that the insured sees a doctor at least once a year (in dental medicine even twice a year). Perhaps this also adds to the waiting list.
Also, a general shortage of doctors could be the problem, because studying medicine is expensive and hard compared to other venues...
Posted by: Max at Jul 24, 2007 8:39:25 AM
Queueing Theory would have us believe that the expected wait time for the medical system is determined by the following factors: the number of doctors, the average processing time, the variance of the processing time, and the interarrival times of the patients. All of these variables stack the deck against efficient operations in the medical field. Note: I have excluded a lot of economic arguments. I assume that if you're sick, you pay the price for a doctor. I don't assume, though, that doctors will do the same work for less.
Here are a laundry list of reasons that we have such a long wait time:
-- Increasing the number of doctors is not likely to really help the problem if you consider costs as an issue, though you could calculate exactly how many more doctors are needed so that no one should ever wait. If you assume that supply/demand pricing rules are suspended, this would increase the average cost per customer/patient dramatically. In reality, this would just reduce the income of each doctor, which is not the incentive needed to attract more people to the profession.
-- Most importantly, patients arrive randomly but likely with high clustering. A doctor's office waiting room during flu season is probably much busier and the lines are likely much longer. The same can be said for other causes of doctor's visits: weather, major events (the start of school), etc. If patients got sick in regular and predictable ways, there would be MUCH lower waiting times. So, the odds that you are at the doctor are probably highly correlated with others, so get ready to wait. This is also why doctors have plenty of free time (once established)... they work their tails off half the time and can putt around at the golf course the other half (more like 90/10).
-- There is no threshold for acceptance into the queue or for processing. Since it often takes just as long to diagnose someone as sick as it does to diagnose them as healthy, there's no cutting corners. This increases the variability of the average treatment time, as some patients are clearly just down with a cold while others may have serious cancer. Increased variability of treatment time greatly increases the average wait time. Plus, doctors book in 15-minute increments of time. No one takes exactly 15 minutes to treat. If the treatment takes 30 minutes, the waiting time increases. If the treatment takes 5 minutes, a good doctor will draw it out to 15 minutes (you do want a good bedside manner, right?).
-- Like airlines, many doctors overbook their appointments to cover no-shows. Unlike airlines, doctors don't have sophisticated operations departments and years of data to tell them when this is a good idea and when it isn't. Additionally, no-show frequency is likely not-so-random. Someone is probably more likely to skip an appointment the day before Thanksgiving, for example. Since there is no easily implementable system, over-booking will cause longer wait times in the simple "better safe than sorry" method that most medical offices likely use.
-- A single queue is always better than each server (doctor) having its own queue, but that's not the system we have in place in most scenarios. If no one was allowed to have their own doctor, the system would be a lot more efficient on the surface. This increases, perhaps greatly, the average wait time. (If I was told that my doctor would see me in 3 days or I could see some random doctor today, I'm not sure what I'd do. This model only works in emergency situations, and even then not so well.)
-- Doctors are usually unable to divide their time between patients to prioritize. You may be there with a sore throat that takes two minutes to diagnose and treat, but the person requiring 30 minutes of time (which may not have been expected... high variability, remember) is forcing you to wait. If the doctor could take a look at the queue, make a snap judgement and handle the low-hanging fruit, the line would be much shorter. However, that means that that 30 minute treatment just turned into a day-long endeavor as the serious treatment is preempted by minor problems.
-- Convenient appointment times are very similar amongst people. Want a 5pm appointment at the dentist? Book it now months in advance. Doctors don't want to work early or late. In today's dual-income households, there's less flexibility for appointments. I know doctors that begin their day at 6:30 or 7am to see patients, but they're done by 3pm (or start late and end late), but these are still rare. A lot of inefficiency is just due to the fact that you cannot make their next open appointment and the doctor doesn't want to be at the office all day and night.
Ok, sorry for the long list and somewhat un-proofread nature of this post. In short, this is a highly inefficient system that would make any operations researcher cringe, but it's a system that has adapted fairly well around its faults and imperfections. I had a professor who based his entire research on turning hospitals into Toyota factories, so maybe there is hope.
Posted by: Brian Weisberg at Jul 24, 2007 8:47:34 AM
I suspect other factors in doctors' time management problems are a) lousy predictions on the time a visit will take from the booking staff plus b) a lack of precision from the patient making the appointment.
a) If the patient makes an a appointment (other than a follow-up) the doctor has no way of predicting how long the diagnosis/treatment etc will take and therefor the receptionist defaults to some standard. On a day where more complex issues arrive then delays are inevitable. I am not sure if I have ever experienced a time when the waiting room wasn't full so my guess is the standard is in fact too optimistic and probably represents the minimum any visit might make.
b) when people have difficulty getting in to see a doctor I suspect the "save up" issues and then trot them all out at the first available occasion. As much of health issues is slow to emerge it can be parked until it is convenient - so what what we get is "Oh one more thing . . " sessions. The patient thereby gets the equivalent of multiple visits for only one delay. Probably a good ROT (return on time)
Posted by: GordonD at Jul 24, 2007 8:55:48 AM
Perhaps.
In texas we are finding that after tort reform,doctors are moving their practices there. John Edwards channelling dead babies to make a fortune on junk science has pretty much whipped out medecine for feminine issues in NC. So derive from that what you will.
Posted by: Jacob at Jul 24, 2007 8:56:35 AM
Current med student here.
The AMA limits the supply of doctors. The amount of debt you graduate medical school with discourages becoming a general practitioner. Better to go into a higher paying specialty to pay off that 300,000 debt.
Posted by: Alejandro Gonzalez at Jul 24, 2007 8:58:21 AM
If there is widespread waiting indeed, what you should be asking before attempting to explain 'why' is whether the number of people on the waiting list on any given time has been increasing or falling. Assuming its stable, raising prices would mean that in the new equilibrium there would be excess supply - higher prices would translate to more people joining the queue than leaving it, and soon there would be no queue and the good doctor would start having a lot of spare time in his hands.
Why don’t doctors vary their prices then according to the size of the queue? Perhaps some form of price stickiness, competition, notions of fairness and people not valuing shorter waiting times that much.
You may also be interested in this, in relation to government ran systems:
http://bluematter.blogspot.com/2007/07/queue-for-redistribution.html
Lines in public health care systems are a potent force for redistribution.
Posted by: datacharmer at Jul 24, 2007 9:08:32 AM
I work on a local ambulance squad, and I can attest that the problem is even larger than it appears. A significant fraction of the people we transport are not particularly ill, and could certainly travel safely to the doctor on their own.
Why do they call us at all hours for a $600 trip to the emergency room? First, they are on Medicade (which pays for the ambulance ride), and second, they wish to avoid the wait you have described. An ear infection or a tummy ache will be seen the same day at the emergency room, and this is a powerful incentive.
I think the cause is straightforward - a shortage of GPs. The GPs salary is sharply limited by insurance co-pays and the time-intensive nature of his job. He can only make so much. The shortage that follows is inevitable.
Posted by: Mike at Jul 24, 2007 9:11:01 AM
Kaiser has a triage system for assigning priorities (emergency, urgent, routine)for general medicine. Audiologists and routine mammographies take weeks, Blood tests done in advance, x-rays done on the spot. (This contrasts to some doctors, who have you go to independent testing labs, for which the visit must be also scheduled.)
No doubt most of your responses come from well-doctored areas (which are not necessarily the most healthy). But the NY Times had an article on the problems being faced in upstate NY (Binghamton)--as a declining area, it's not attractive to new doctors or specialists and the remaining doctors are getting old. Finding a doctor at all was taking months.
And that's not to mention problems of care on Indian reservations, etc.
Posted by: Bill Harshaw at Jul 24, 2007 9:12:21 AM
When you can shop around, you don't have to wait. When you can't shop around, you might have to wait. There are severe constraints on the supply of medical services, and not a lot of constraints on the want for such services.
Yglesias may as well complain that you go hungry because you can't get a table at a popular restaraunt on a Friday evening.
Posted by: Yancey Ward at Jul 24, 2007 9:34:20 AM
More thoughts
1.) Unlimited demand with virtually unlimited money
2.) People are unwilling to pay for a second tier service
3.) People are remiss to do without (even to go so far as expect other people to pay)
4.) Shortage of qualified people with little incentive outside of the intangible to become a doctor
5.) Hospitals have to treat everyone regardless of ability to pay
6.) Medicare/Medicaid does not pay the entire bill
7.) Incredibly litigious society using malpractice insurance as a lottery - no liability limitation in what is essentially a best guess service - and now the defensive medicine practices that are a result is also time consuming and expensive, couple this with limited supply
Its basically a problem that is a result of a very broken process that is a boondoggle of problems.
Posted by: Jacob at Jul 24, 2007 9:46:51 AM
"But I would expect the law of large numbers to kick in..." This is a misunderstanding of the law of large numbers. What does it say? As n goes to infinity, the sample average goes to the true mean. However, individual discrepancies from true mean stay the same. The law of large numbers cannot remove individual discrepancies, it just averages them out. Nothing changes for the individual as n increases.
Posted by: pinus at Jul 24, 2007 10:12:46 AM
In my doctor's office employs a nurse practitioner. You can make an appointment to see her substantially quicker than you can to see the doctor(s). This is good for me, because I can self-triage and decide that a matter is minor and get on the appointment book faster.
The wait time at the office is a queueing problem, and the issues with trying to make that efficient were clearly covered in a post above this one. I try to make appointments for early morning or early afternoon to minimize the number in the queue in front of me.
Posted by: RJ at Jul 24, 2007 10:23:32 AM
We found out that our wait was because our doctor chose to work short hours and only 3 1/2 days a week. Ditto for other members of the practice. If we wanted to have consistent care with one practitioner, the was considerable.
Posted by: Ana at Jul 24, 2007 10:33:15 AM
