Putting patients and taxpayers first

by Donald W. Light

Donald Light, a professor of Comparative Health Care Systems at the University of Medicine and Dentistry of New Jersey, recently gave the John F. McCreary Lecture as part of Health Sciences Week. The following is taken from his lecture.

An example of putting patients and taxpayers last is the erratic and lengthening waiting lists in Canada. As an expert on so-called waiting lists, let me clarify what they are.

First, they usually are not lists. Rather they are pools of patients treading water until someone fishes them out.

Second, there are usually four waiting pools and they are set up so that no one can get a grip on the whole process of waiting.

The first pool consists of patients the primary care doctor refers for investigation, and the second pool consists of patients that the specialist recommends for further investigations or for a procedure.

The third waiting pool consists of patients that primary care physicians would have referred if the waits were not so long. This is a reserve pool from which patients are drawn to fill up the first two waiting pools if extra funding or a special program is carried out to reduce them.

It is this pool that makes it look as if there is no way of reducing waiting lists, as if there is a bottomless pit of medical need. In fact, medical need is not bottomless.

The fourth waiting pool, often ignored but critical, are patients treated right away as urgent or emergency cases.

Why are they a waiting pool? Right away turns out to be not now, but within a few days or several days, so there is a wait.

More important, what specialists define as urgent varies considerably from place to place and from season to season.

Usually the waiting pools are put in the hands of specialists in ways that allow them to reap benefits from managing them to their advantage.

But waiting pools should be run by the payers or buyers, because who waits for how long and for what is, as they say, a matter of `allocative efficiency.'

And on the whole, waiting lists are a sign of inefficiency, though some waiting plays several clinical functions and saves money.

The length of time and number of patients treading water varies dramatically, even for the patients waiting in the same area for the same procedure.

These variations, again, are the unscientific results of physician autonomy. The recent national review of Canadian waiting lists concludes that "With rare exceptions, waiting lists in Canada are non-standardized, capriciously organized, poorly monitored, and in grave need of retooling."

The waiting pools are organized to maximize physician autonomy and opportunities to profit because the governments want to minimize political heat.

Ironically, private care makes waiting worse, even for private patients.

A study by the Consumers' Association of Canada found that patients wait much less time if they choose surgeons who operate only in the public hospital, while surgeons who practice privately part-time make both their public and private patients wait longer.

The organization and incentives of
Canadian waiting pools ration care in ways that put patients' needs last. They also put taxpayers last by spending their money in inefficient, wasteful ways.

In particular, the Canadian approach to waiting pool management has been dominated by throwing money at the problem.

As the payers, provincial governments need to insist on data that tell them who is in those pools, how they got there, who is managing patient selection, and whether patients are being fished out according to appropriate clinical criteria.

There are several ways to shorten waiting times and save money: but first, the payers or governments need to decide they really want to get the job done.

As payers they need to combine and oversee all phases of waiting, from the moment a primary-care provider decides a referral is advisory to the end of the story. That means establishing criteria for referral for investigations, and further criteria for operations or procedures.

Second, a scale of severity needs to be put into operation, one that balances clinical need with the costs of waiting such as pain, loss of income, impaired function, and responsibilities for children, elderly or other dependents. Such scales already exist and can be quickly adapted.

Third, the payers need to pay hospitals or facilities in ways that reward treating the high-priority patients quickly.

Fourth, within a hospital or facility, multiple inefficiencies, dislocations, and poor information systems, when straightened out, greatly shorten waiting times.

Finally governments can set up programs for enabling patients to share in the decision about whether they want surgery and if so, what kind.

I do not mean informed consent;
I mean shared decision-making.

The time has come for the public to understand how current policies may dismantle the Canadian system and create a more costly and inequitable two-tier system.

The time has come for the Canadian government to make its health insurance system truly universal, comprehensive and equitable, and to make its organizational and financial structure put patients first and thus minimize rationing at the bedside.