Wednesday, July 9, 2014

On Boston, Waiting Lists, and Whistle Blowing

Whistling in the dark.

Idiom, to be confident something good will happen when it is not likely to occur

Merritt Hawkins, the big Irving, Texas, physician recruiting firm, each year publishes a survey of waiting times for physician appointments in 15 major U.S. cities. Its list of waiting times includes these specialties: dermatology, family medicine, cardiology, obstetrics/gynecology, and orthopedic.

The cities surveyed are: Boston, Minneapolis, Philadelphia, Denver, Seattle, Portland (Oregon), New York City, Detriot, Houston, Dallas-Fort Worth, Washington, Miami, Atlanta, Los Angelos, and San Diego.

I have taken the liberty of averaging the waiting times for these 5 specialties for these 15 cities.

Here they are, from the longest average waiting times to the shortest waiting times.
1. Seattle Boston, 55.5 days

2. Denver, 23.6 days

3. Portland, 23.0 days

4. San Diego, 20.2 days

5. Philadelphia, 20.1 days

6. Minneapolis, 19.2 days

7. Washington, 17.8 days

8. Detroit, 17.6 days

9. New York City, 16.8 days

10. Seattle, 16.0 days

11. Los Angelos, 13.6 days

12. Atlanta, 14.0 days

13. Houston, 14.0 days

14. Miami, 13.6 days

15. Dallas- Fort Worth, 10.2 days

On the list, Boston stands out like a sore thumb , with nearly 2 ½ longer waits than 2nd place Denver and 5 ½ times longer waits than 15th place, Dallas-Fort Worth.

What specialties account for Boston’s long waiting times?

Boston Waiting Times, Rank, Length of Waiting Times

Dermatology, 1

Obstetrics, 1

Family practices, 1

Cardiology, 4

Orthopedics, 3

Why the longer waiting times in Boston, which many, including most Bostonians, consider the Mecca of American Medicine and the model for ObamaCare?

It is a good question, and I have no solid answer.

I know this: a common complaint among patients is long waiting times, not only to get an appointment, but while fiddling one’s thumbs ans staring at the ceiling while waiting in the reception or exam room.

And, as we all know, waiting while dying in VA facilities, is a hot issue at the moment, and VA whistle blowers, many of whom are VA physicians, blame the VA’s bureaucracy, with its bonus rewards for manipulating the data, for the waiting list problems.

Could it be because health care in Boston is bureaucratic and over-regulated, that it occurs in an overly liberal state that believes government is the solution and not the problem?

I do not know. but I know that Boston has more physicians per capita than any other state so a physician shortage is not the source of the problem. The conservative Texas cities, Houston and Dallas-Fort Worth, have doctor shortages and embrace market-based solutions, and have the first and third lowest rating times.

The answer may reside in two opposed philosophies of health care.

The Boston and the ObamaCare philosophies are : if one has enough databases and matrixes and methodologies for systematically understanding the intentions and capabilities of the limitation of the system one can improve it. That approach involves a lot of studies, data-gathering, meeting, and bureaucratic-rule making. It is above all, rational, and does not depend on intuitive decision making. But it takes time and deliberation to weigh all the variables.

The Texas approach is more market-based, seat-of-the-pants, market-based decision-making at the point of care. It involves people making sophisticated decisions at the spur of the moment. It assumes that health care is not always rational, and that indeed it may be messy, unpredictable, nonlinear, and decentralized, detached in many instances from centralized authorities with their computer arsenals.

Bostonians, by overwhelming margins, like their system, even with its long waiting times. Texans swear by their system.

These different philosophies are what make for political horse-racing, which we shall see played out in the November mid-terms.

In his book, Blink: The Power of Thinking Without Thinking (Little Brown and Company, 2005), Malcolm Gladwell reveals that the great decision makers, including those in health care, are not necessarily those who process the most information or spend the most time deliberating but those who have perfected the art of filtering the few factors that matter from too much information at the point of care.

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