The Doc's In, but It'll Be a While
Despite spending lots more per capita on health care, the U.S. is often as bad or worse than other industrialized nations in wait times
by Catherine Arnst
Susan M., a 54-year-old human resources executive in New York City, faithfully schedules a mammogram every year, calling each April because she knows it will take at least six weeks to get an appointment. She went in for her routine screening at the end of May, and a few days later learned she would need a second mammogram because the first wasn't clear enough. First date available: July 3. After complaining to a supervisor, Susan (who didn't want her last name used) got an appointment for a week later, and that's when the real waiting started.
A doctor immediately reviewed the second mammogram and told her it showed an abnormality and that she would need a so-called stereotactic biopsy, an outpatient procedure in which a needle is inserted into the breast. But she couldn't get an appointment for the procedure until mid-August. "I completely freaked out," she says. "I couldn't imagine spending the summer with this hanging over my head!" After many calls to five different facilities, Susan found a clinic that would read her existing mammograms on June 25. They would also schedule a follow-up MRI and a biopsy, if needed, within 10 days. That's a full month after her first, suspicious mammogram. "We are constantly told that early detection of cancer is key," she says. "The system is clearly broken."
Sicko Release May Spark Debate
One of the most repeated truisms about the U.S. health-care system is that, for all its other problems, American patients at least don't have to endure the long waits for medical care that are considered endemic under single-payer systems such as those in Canada and Britain. But as several surveys and numerous anecdotes show, waiting times in the U.S. are often as bad or worse as those in other industrialized nations—despite the fact that the U.S. spends considerably more per capita on health care than any other country. In addition, 48 million people without insurance do not have ready access to the system.
The issue of health-care reform in the U.S. is likely to receive even more attention with the June 29 release of Michael Moore's latest film, Sicko. The sharp-edged film calls for dramatic reform of the U.S. health-care system (see BusinessWeek.com, 6/4/07, "Michael Moore Wants to Reform Health Care").
While Moore doesn't focus specifically on wait times, delays are becoming a bigger issue. One disturbing study published last year by researchers at the University of California at San Francisco found average waits of 38.2 days to get an appointment with a dermatologist to check out a possibly cancerous mole. "Waiting is definitely a problem in the U.S., especially for basic care," says Karen Davis, president of the nonprofit Commonwealth Fund, which studies health-care policy. She attributes the delays to a number of factors. Only one-third of U.S. doctors are general or family practitioners, she notes, compared with half in most European countries. Also, only some 40% of doctors have arrangements for after-hours care, making it difficult to see a physician on nights and weekends. As a result, emergency rooms have become fallback systems for routine care.
Several Factors at Work
Changing demographics are only worsening the problem. Patients are getting older and sicker and requiring more care. But a new generation of doctors, half or more of them women, is no longer interested in working long, grueling hours. Low insurance reimbursements and heavy paperwork loads also limit physicians' willingness to see any patient any time. And tightening immigration rules have limited the number of foreign-born doctors entering the U.S. "There are restrictions on the supply side and growing demand, so longer waits are going to be inevitable," says David Williams, a consultant with MedPharma Partners in Boston.
There is no systemized, nationwide collection of data on wait times in the U.S., making it difficult to compare delays to those in countries with national health systems, who typically track and publish data on wait times. But a 2005 survey conducted by the Commonwealth Fund of sicker adults in six highly industrialized countries found that only Canada was worse than the U.S. when it came to waiting six days or longer to schedule a doctor's appointment for a medical problem.
Of the countries surveyed, 81% of patients in New Zealand got a same or next-day appointment for a nonroutine visit, 71% in Britain, 69% in Germany, 66% in Australia, 47% in the U.S., and 36% in Canada. Those lengthy wait times in the U.S. explain why 26% of Americans reported going to an emergency room for a condition that could have been treated by a regular doctor if available, higher than every other country surveyed.
No. 1 in Foregone Care
The Commonwealth survey did find that patients in the U.S. had shorter wait times than every country except Germany when it came to getting an appointment with a specialist for nonemergency elective surgery, such as hip replacements, cataract surgery, or knee repair. But Gerard Anderson, a health-policy expert at Johns Hopkins University, says most doctors know how to "game the system" in those countries where there are queues for elective surgery, by putting at-risk patients on the list long before their need is critical. "Their wait might be uncomfortable, but it makes very little clinical difference."
The Commonwealth survey found one area in which the U.S. assumed first place—by a wide margin: 51% of U.S. adults surveyed did not visit a doctor, get a needed test, or fill a prescription within the past two years because of cost. No other country came close to that percentage.
The Commonwealth study was one of very few to compare wait times in the U.S. to other nations, but several other surveys have compared the difficulty in getting to see a specialist in different regions in the U.S., and found that some cities perform very poorly on that score. For example, a 2004 survey by medical recruitment firm Merritt Hawkins & Assoc. looked at wait times for appointments with four different specialists in 15 metropolitan areas. The researchers found that average waits for a heart checkup with a cardiologist can range from 37 days in Boston to nine days in Seattle, while patients with a knee injury who want to see an orthopedic surgeon can wait an average of 43 days in Los Angeles, or eight days in Atlanta.
Minute Clinics
In the UCSF study published last year, the researchers set out to determine how long it would take to get an appointment in 12 cities to examine a face mole that had changed color, a common warning sign of skin cancer. They found a range of mean wait times according to geography, from 20 days in Little Rock to 73 days in Boston. The researchers pointed out that the wait in rural areas, where dermatologists are scarcer, are likely much longer.
Few solutions have been posited for wait times, in part, say policy experts, because the problem is rarely acknowledged in the U.S. But the health-care market itself is beginning to address the issue, with the rise of walk-in medical clinics situated in retail stores. Hundreds of these clinics have sprung up in stores like CVS/Caremark (CVS), Wal-Mart Stores (WMT), and Pathmark Stores (PTMK), and they are rapidly growing. Usually staffed by nurse practitioners, they promise rapid care for minor medical problems, usually getting patients in and out in 30 minutes. The slogan for CVS's Minute Clinics says it all: "You're sick, we're quick." Those are comforting words for patients who'd rather not wait 10 weeks for a routine medical screening.
Arnst is a senior writer for BusinessWeek in New York. |
