How long should the wait be to see a doctor?

by on July 24, 2007 at 7:17 am in Medicine | Permalink

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.

barbadkatte July 24, 2007 at 7:25 am

May be the supply of doctors is low.

Cormac July 24, 2007 at 7:32 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.

Gong Tao July 24, 2007 at 7:59 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.

Jason July 24, 2007 at 8:13 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.

John Wilson July 24, 2007 at 8:29 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.

Pup, MD July 24, 2007 at 8:32 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.

Max July 24, 2007 at 8:39 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…

GordonD July 24, 2007 at 8:55 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)

Alejandro Gonzalez July 24, 2007 at 8:58 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.

Mike July 24, 2007 at 9:11 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.

Yancey Ward July 24, 2007 at 9:34 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.

pinus July 24, 2007 at 10:12 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.

Ana July 24, 2007 at 10:33 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.

DaveL July 24, 2007 at 11:00 am

My experience is that businesses that are basically selling time are generally going to try to be as heavily booked as possible.

This includes doctors, restaurants, lawyers, airplane flights, hotels, resorts, sports teams, building contractors, etc.

Once the clock ticks past a given time, it can no longer be sold. Their incentive is to make sure that time isn’t empty, because empty time is worthless, and the result is generally going to be overbooking, even when very intensive modeling of the product allows almost infinite price variation (e.g., airline tickets).

This is why you sometimes have to wait for an appointment, and also why you wait once you are at the doctor’s office.

Whit Stevens July 24, 2007 at 11:32 am

Strange, my managed care organization has almost no lines. I spend on average about 1 minute in the waiting room. The longest I’ve ever waited was about 5 minutes. I can always schedule an appointment for the same day if I don’t mind seeing somebody other than my normal doctor. And most times I can schedule an appointment for my normal doctor in a day’s time, sometimes the same day. More hospitals need to study the Toyota lean manufacturing model.

robertdfeinman July 24, 2007 at 12:27 pm

The reasons for waiting vary and trying to squeeze this into a one-size-fits-all is an oversimplification.

This week the NY Times had an article on the shortage of doctors in upstate NY (and small towns elsewhere). Obviously waiting there is a supply and demand issue. As for those who say that there is a shortage of doctors, this is also an oversimplification. There is a maldistribution of doctors. In my upscale town you can’t turn around without stumbling over a doctor’s office.

Doctors move where their earnings potential is higher, or the social life is better or to see more interesting cases. (The bigger the pool the higher the chances that an usual case will present itself.)

Some doctors overbook to maximize their time. In addition many doctors don’t use a single queue. They have multiple consultation rooms and patients are in various stages of their visit simultaneously. The use of nurses and other medical specialists also means that doctors no longer do the routine operations.

We are also insourcing doctors (and nurses) from elsewhere, so the shortage of medical schools is not as big an issue as some make it to be. Think of the efficiency – India gets to spend the $100,000 training the doctor and we get a trained expert for free. Many countries in Africa are now complaining about a doctor/nurse drain. Yet another example of “free trade”.

Christina July 24, 2007 at 12:40 pm

What if insurance companies tiered doctors they way they do prescription drugs? If a doctor raises his rates, then the insurance can raise the co-pay accordingly. The worst and cheapest doctors would have the lowest co-pay, and the most famous and most expensive doctors would have the highest. It seems to me that would eliminate some of the queuing problem.

alkali July 24, 2007 at 1:07 pm

Slightly off-topic:

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.

This is just wrong. Seating at El Bulli (or the French Laundry, or Alinea) is limited for the same reason that only one new Stephen King novel comes out each year. You’re buying the work of a particular person (or group of persons) who can only create so much product in limited time.

Pup, MD July 24, 2007 at 1:22 pm

If a doctor raises his rates, then the insurance can raise the co-pay accordingly. The worst and cheapest doctors would have the lowest co-pay, and the most famous and most expensive doctors would have the highest.

Given that the ability to pay has a moderate inverse relationship with complexity of patient needs, that would be a pretty disastrous scenario.

It might fix the queueing problem, since patients who would have been going to the doctor will just do the libertarian heath economists a favor and die already in the hallway of their local ER.

Bruce July 24, 2007 at 1:27 pm

Looking at my insurance statement, the doctor billed $100 for my visit. I paid a $10 copay and the doctor billed the insurance company the remaining $90. According to the statement, in accordance with their previously negotiated agreement, my doctor was only paid $10 for this visit. So the insurance company paid him nothing.

If he was only going to get my copay, why did he even bill the insurance company? He has to pay the expense of his office personnel processing the paperwork, which is a total financial loss.

Doug July 24, 2007 at 1:34 pm

I have a question: In Canada (everywhere I have been anyway) our clinics have a certain number of doctors that are On or Off – this is like a standard job. They can book the days they are in or not in, and when you make advance appointments for doctors you are booking into these slots.

But also each clinic has an on-call doctor. The doctor that is on-call rotates every day and they cannot have appointments booked for them when they are on-call; they can only take walk-ins. Now, when you have minor emergency things like: Flu, Ear-infection, minor stitches, sprained ankle, etc. you can just walk into any clinic and book with the on-call doctor. I usually see wait-times in Saskatoon between 30minutes and an hour and 30 (depending on the season/that day/where the office is located). Also, when a wait is kinda long it is sometimes best just to goto a clinic in another part of the city.

I have also seen these on-call doctors rotate between clinics within the city but am unsure of the details behind this.

So, my question is, in the US do you have similar things? Can you walk into any clinic and get in-queue for the on-call doctor without any prior appointment?

Robert A. Book July 24, 2007 at 1:55 pm

Previous commenters have come up with a lot of very creative and complicated answers for what is really a simple problem. There is a main reason and a secondary reason why doctors don’t raise prices to shorten their queues — and why the best doctors aren’t spending more time in patient care.

1) The main reason is that doctors basically can’t raise their prices. Almost all visits are paid for by Medicare or private insurance; Medicare pays set rates for particular services, and private insurance generally pays a set percentage (90-120%) of Medicare’s payment (thus free-riding off Medicare’s delineation of services and determination of relative values). Most importantly, both Medicare rules and most private insurance contracts do NOT allow doctors to charge more and have patients pay the difference out of pocket. Unlike Cormac’s description of some other countries’ systems, it’s not that they pay $X and the patient pays the excess — they pay $X, and to get the $X the doctor has to agree not to charge any excess. (There can be copays, but the total charge can’t exceed $X.)

The result is: Long lines, short doctor visits, and a quality cut-off that preserves the low end of the spectrum.

2) The supply of doctors is artificially limited by regulation. The AMA and state licensing boards limit the number of licensed physicians, and the federal government limits the number of residencies in each specialty. There is also a complex system limiting the number of foreign doctors who can practice in the U.S.

BigJimInDC July 24, 2007 at 2:00 pm

Having just been discussing this issue with my fiance, including some economic angles spurred by reading your blog, in the end my issue isn’t so much with the wait, but the lack of respect for MY time. I know I make more money than that doctor, at least on an hourly rate, yet he expects me to sit in his office for up to 2 hours to see him for just 5-10 minutes. In the mean time, I’ve already taken off of work an hour or two early, while his office staff team of over 10 people surely could have called me before I was leaving the city to inform me that the doctor was running 1-2 hours behind, and to “take my time”. And people think software developers are always late on delivering their projects!

hdr July 24, 2007 at 3:25 pm

Medical education is expensive because the medical profession wants it to be. A big debt justifies big fees. Medicine is as much a business as a “profession.”

Medical scientists pay virtually nothing for their graduate educations and are actually paid stipends.

Kat July 25, 2007 at 1:20 am

Looking at my insurance statement, the doctor billed $100 for my visit. I paid a $10 copay and the doctor billed the insurance company the remaining $90. According to the statement, in accordance with their previously negotiated agreement, my doctor was only paid $10 for this visit. So the insurance company paid him nothing.

This reminds me of something I recently discovered.

A friend worked for a doctor. The doctor performed a particular procedure for which he charged the insurance company $100. The Doctor was paid $43 by the insurance company. So, he knew that to be paid $43, he had to bill $100. If he billed less than $100, he would be paid less than $43.

If a patient wanted to pay out of pocket, the doctor couldn’t charge him the $43 he got from the insurance company, he had to charge him the $100 he billed the insurance company. If he charged the out of pocket patient less than that he would be charged with insurance fraud.

Every state creates its own insurance fiefdom but this is the law in at least Virginia and Illinois, but it’s probably widespread.

LikeThatOnly July 25, 2007 at 8:50 am

Here in India many private clinics follow a price discrimination system – the queue is long, but you can jump to the start of the line by paying extra. Also, sometimes the good doctors have a nurse screen you before deciding how urgently you need to see the doctor.

Daniel Stone, MD July 25, 2007 at 10:43 am

As a doctor, I’d suggest that there is more than one answer to this question and that the reality of waiting times varies greatly from practice to practice. The best single answer would involve the nature of queueing. As the need for medical services varies somewhat randomly, the timing of visits will inevitably be subject to “clumping” and spacing. When patients get “clumped” waiting time goes up. I have periods when patients wait an hour and other times (fewer) when it seems like I’m just sitting around.

As there’s only one doctor at the head of the queue for most patients (unlike, say, a line for multiple phone operators) waiting time builds rapidly with queueing. As mentioned above, there are psychic and other benefits to seeing a doctor who knows you and understands your particular medical history. So, people do find value in waiting, as opposed to just seeing the next available person with a white coat. And, of course, when a patient waits once, they generalize that experience to that doctor, the system, etc. As an example of that, I take about four weeks vacation per year. I notice that if I’m away for a three day weekend, the next week I’ll get several comments about how I’m “always on vacation.”

Paul D July 25, 2007 at 11:08 am

“The supply of doctors is artificially limited by regulation. The AMA and state licensing boards limit the number of licensed physicians, and the federal government limits the number of residencies in each specialty. There is also a complex system limiting the number of foreign doctors who can practice in the U.S.”

I certainly agree with this statement. I would add that the supply of medical providers is severely limited by the requirement that providers be licensed physicians. I suspect that many of the tasks performed by MD’s could for the vast majority of patients be handled by someone with far less training than an MD. If the market for automobiles were regulated in the same way as the medical profession, anyone who wanted a car would be required to purchase a BMW–economy cars would not be an option.

Barkley Rosser July 25, 2007 at 12:49 pm

dsquared,

Of course it is much more efficient to have all these sick people dragging
their sorry behinds out of bed to go cluster together and cough all over each
other in the doctor’s waiting room, given that, after all, (s)he is such an
expensive piece of human capital. So, go the NHS or move to France…

TW July 26, 2007 at 2:56 am

I have gone to a primary care guy that has experimented with various forms of boutique medicine, with different levels of success. Overall, I think it is a good approach.

However, the thing I have found perplexing is that certain specialists seem to be very difficult to see, or aren’t accepting new patients (for chronic types of illness). I am surprised that they don’t simply charge more or, at the least, reserve some of their time for patients willing to pay a higher price. It is possible that they do this, but don’t advertise it. Or, perhaps people with some sort of influence can jump the queue, but it I just don’t know the right people. I suspect that there is some sort of vague distaste for seeming overly commercial at work.

As far as the comments on limits to supply, I would recommend that people read the original Flexner report. I suspect that people tend to rely on secondary sources rather than reading the actual report. As much as markets are attractive in the abstract, this is a ‘Jungle’ sort of document that makes the evils of regulation seem like a desirable evil.

Jose July 26, 2007 at 6:44 pm

There exist two main factors:
1) A shortage of doctors as already stated
2) “No shows.” Not all patients who make appointments actually show up.

The second point is what causes the wait times to be either longer or shorter. General Practice Physicians tend to over book their time slots because on average they have some number of “no shows” patients. The time allotted for each individual visit per patient is also random. When everyone shows up to their appointments and/or takes more than the average amount of time during the visit they impose a cost of waiting on those patients behind them.

The patient who is waiting has essentially two choices: wait or search for another doctor with shorter waiting times. The second option is often very costly so patients wait it out.

Perhaps a better solution would be to charge individuals for not showing up to their scheduled appointments. Individuals would then actually show up to their scheduled appointments and doctors would not need to over book time slots.

Pedro Stewart June 28, 2008 at 12:23 pm

Because, due to a political intervention(Government decides how many doctors will graduate each year)the offer of doctors doesn’t fill the demand. If you want to become a doctor there are a lot of barriers because the price is high and the admissions are limited.(If you want to create a medical school(which is a very lucrative business) you’ll have a lot of problems(burocracies that will make impossible your project)
Because in USA the free commerce and free competition only exists when it’s convenient.

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