Shortening the Health-Care Queues:
Better public than private solutions to Medicare wait problem
By Michael Rachlis, MDFrom the CCPA Monitor February 2006
Waits for care are the biggest political issue facing Canadian health care - a priority reflected in the accord reached a few months ago by the federal and provincial health ministers. They agreed to set limits on wait times for major surgeries and treatments, but conceded that these limits would be targets rather than guarantees. This is welcome news for Canadians already on long wait lists - but overlooked in the ministers' program was a plan to reduce wait times by making more efficient use of existing resources and facilities.
In the absence of such administrative improvements of the public health care system, the operators of private clinics and their supporters - buoyed by the Supreme Court's ruling against a Quebec ban on private insurance for Medicare-covered treatments - are aggressively selling services to anyone who has enough cash to jump the public waiting queues.
Before going down this road, however, Canadians would do well to consider public sector solutions to the wait-times problem. Two such reforms are readily available:
- Establish more specialized short-stay surgical clinics within the public sector to provide the efficiencies that private clinics have capitalized on - but without diverting millions of public dollars to private owners.
- Adopt lessons learned from queue- management practices in other sectors. We have only to look at how line-ups have been streamlined at banks, for example, to see how a better coordination and flow of queues can dramatically reduce wait times.
Evidence from both Queensway and Pan-Am suggests that public sector delivery is superior. These clinics achieve the benefits of specialization and innovation normally ascribed exclusively to the private sector, while reducing overall administrative costs and providing broader societal benefits.
The second new public sector approach to health-care waits is the use of applications of queuing theory to manage waits and delays. Queuing theory applications are used to maximize flow in such diverse areas as air traffic control and manufacturing. Rather than thinking of every wait list as a capacity or resource problem, we need to look at delays through the "lens of flow."
Canadians tend to assume that, if there is a wait for health care, there isn't enough of it. But most waiting is not due to lack of resources. For example, many breast patients have to wait for a mammogram, then wait for an ultrasound, and then wait again for a biopsy. The Sault Ste. Marie breast health centre reduced the wait-time from mammogram to breast-cancer diagnosis by 75% by consolidating the previously separate investigations. If a woman has a positive mammogram, she often has the ultrasound, and sometimes the biopsy as well, on the same day.
We could also eliminate waits for doctors' appointments. Family doctors often have delays of up to four weeks for appointments. The wait is typically shorter just before vacation and longer thereafter, but overall it is fairly stable. A doctor's capacity may be close to meeting demand, but he or she is servicing last month's demand today while postponing today's work until next month. If doctors cleared their backlogs - and they could by analyzing and consolidating the different steps in the diagnosis and treatment process, measuring demand and capacity for each, and eliminating bottlenecks - then they could realistically clear the path to same-day servicing. Patients want one-stop shopping.
The Saskatoon Community Clinic serves over 20,000 patients. In 2004, patients faced a four-to-six-week wait for appointments. The centre temporarily increased resources to clear its backlog, re-designed some of the care pathways, and now provides same-day service.
We could also dramatically reduce delays for specialist care. The Hamilton HSO Mental Health Program integrated 90 family physicians with 23 counsel- lors and two psychiatrists. The result: the number of mental health patients treated went up by 900%, while the family doctors made 70% fewer referrals to the psychiatric specialty clinic.
The enemies of Medicare have used the legitimate public concern about delays in the system to peddle ill-advised policies such as for-profit delivery and private finance. But private clinics are aggravating personnel shortages, and siphoning off more public dollars to shareholders and insurance companies.
The public solutions I propose - specialty clinics in the public sector and application of queueing theory to health care wait lists - are but two of many alternatives to private finance and for-profit delivery. Others include increasing surgical capacity in public hospitals and putting greater emphasis on prevention. There is no shortage of such public system solutions if the political will is present.
(Michael Rachlis, MD, MSc, FRCPC is a health policy analyst and the author of three national best-selling books about Canada's health care system. This article was adapted from his recent CCPA paper, Public Solutions to Health Care Wait Lists.)
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