Saturday, June 7, 2014

Long Waits

Everybody is exercised about long wait times at VA facilities. I'm not sure why you would expect anything else. See a City Journal article on the topic.

Rationing care by making people wait is a classical system response to people's overuse of what is, from their perspective, a "free good." That is, something which is prepaid at a flat rate. Ask any economist.

I first encountered this phenomenon as a student patient at two different university health services in the 1960s. I met it again at Kaiser clinics in 1970s Northern California.

Clinic phones were so overloaded I'd sometimes wait most of an hour just to get to talk to an appointment clerk. Hours-long stays in the appropriately named doctor's "waiting room" were common too.

The reasons I waited so long to see a doctor are exactly the same reasons Soviet citizens spent half their lives waiting in long lines to buy bread or meat or ... whatever. Overuse of resources priced below a market clearing price.

Basic microeconomics tells us goods are scarce. They can be rationed by price or by long waits or even by formal systems of rationing as the US experienced in wartime.

The VA is forced to "ration" by wait times as its clients are deemed to have earned "free" care by military service. VA care isn't free, of course, it is paid for with our taxes.

Like the UK's National Health Service, waiting is how we disincentivize VA system overuse. Veterans want more health care than we're willing to pay for in taxes.

Simple "cueing" is a crude system that fails to do the effective triage which would identify those in need of urgent attention. Properly done, triage gets heart, stroke, and cancer sufferers seen soonest, while making people wait months or years for a new knee or hip - conditions that are painful but non-life-threatening in the short run.

Mental problems are more difficult to triage. Will a depressed or PTSD patient suicide? Most won't, a few will. What is an acceptable triage error rate? If you are the patient's spouse or parent the answer is zero, an error rate taxpayers are unwilling to fund.