Waiting times
= mismatch between supply and demand with demand > supply (may be caused by / built in/ the design of a health care system. For instance by leaving demand free, but restricting supply of care
Welfare loss
= we are providing things for people at the cost of society that is not made up for by the valuation of those people for the thing
An Aside
- people low on demand curve can have high objective ‘need’ and people high on demand curve can have low objective need
- having a person low on the curve use care for which WTP<MC may still be socially desirebale (still as a society we say it is desirable for them to consume healhtcare)
Waiting list positive aspects
- Reduces need to use other rationing mechanisms; This may signal unnecessary treatments.
- Waiting time functions as a price - longer waiting induces lower demand
- In principle, this mechanism should work similar for the rich and the poor (a price that could be ‘equally limiting’ for the rich and the poor); Having to wait is not different for the rich or the poor. They both have to wait. Treat people based on their need.
- Therefore, no socio-economic differences need to occur due to this rationing mechanism; This is what the NHS system tries to do. No differences in the public system.
- Especially unnecessary care should be restricted (given the professional judgement of necessity); This is done by referrals of the GP.
- Existing waiting times and waiting lists can reduce the flow of referrals (more restrictive referrals; e.g. Stoddard & Tavakoli); of the GP.
- Waiting lists can help to use available capacity optimally (planning device)
- Prioritisation on waiting lists possible based on medical need, so that negative medical side-effects of waiting may be minimised
Waiting list negative aspects
- Loss of quality of life during waiting
- Health state may worsen during waiting time (even causing unnecessary deaths)
- Recovery time may increase with waiting time
- Treatment may sometime be less successful after waiting times (e.g. psychotherapy, cancer treatment)
- Higher medical costs due to “worse cases” and lower success rates
- Uncertainty in patients about when they will be treated; At the dentist, you usually plan an appointment. This is also waiting, but because you know when you will be treated, it doesn’t feel like waiting.
- Dissatisfaction in society with health care systems when waiting times are perceived as too high
- Costs in other economic sectors due to absence of waiting employees (next week); People who are not able to work due to their disabilities.
- Higher risk of becoming permanently disabled when waiting keeps you away from work for longer period
- Differences in waiting times between countries (or regions) may induce cross-border care, which has specific problems
balance
- If a country opts for waiting lists/times as rationing device, then optimal waiting times could be searched for
- This waiting time is long enough to discourage demand, but short enough to limit negative aspects from waiting
- Optimal waiting time in systems without financial barriers to care are not zero (OECD, 2004)
- It should not be zero and there are no other restrictions, you whole systems is unrestriced —> costs of health care will be extremely high. Iedereen wordt altijd behandeld met alles, niet mogelijk en willen we niet. Je wil toch iets van limitatie in wat je aanbied voor de samenleving. Want anders behandel je iedereen met ook een hele lage medical need.
- If you have no waiting times, you should have other rationing mechanisms. Also the other way around: if you have no other rationing mechanisms, you should have waiting lists.
- Problem: optimal waiting time differs per disease, per situation, per individual etc. and may not be only based on medical need!
What works to reduce waiting times?
- supply-side expansion (if capacity considered too low): reducing budgetary/capacity contraints, rewarding productivity
- Demand side reduction (if capacity is deemed adequate): less referrals, less demand (e.g., co-payments); system meer efficient maken
- Process / regulations: improving utilization facilities, maximum waiting time guarantees, choice (given variation in waiting times)
‘Hidden demand’
becomes visible when waiting time reduces (or the ‘price’ of care is lowering)
–> It is like digging in the sand on the beach: the hole will fill itself with sand while you are digging (Smethurst & Williams, Nature, 2001)
Martin and Smith (1999) performed a cross-regional study in the UK
Demand increased with supply, but increase in demand relatively small: ‘The policy implications of these results are therefore important. They suggest that increased NHS resources can bring about reductions in waiting times, and that the associated stimulation of demand is relatively trivial’.
Siciliani & Hurst (2003)
- Among the group of countries with waiting times, it is the availability of doctors that has the most significant negative association with waiting times. Econometric estimates suggest that a marginal increase of 0.1 practising physicians and specialists (per 1,000 population) is associated respectively with a marginal reduction of mean waiting times of 8.3 and 6.4 days (at the sample mean) and a marginal reduction of median waiting times of 7.6 and 8.9 days, across all procedures included in the study.
- Analogously, an increase in total health expenditure per capita of $100 is associated with a reduction of mean waiting times of 6.6 days and of median waiting times of 6.1 days.
treeknormen
= de normen die we hebben gezet voor max wachttijden in NL
Waiting List Fund in 1997
–> to have a waiting list to get money out of the fund
–> perverse incenitives: if you pay hospitals with waiting lists it is profitable to have long waiting lists
Why less wiaiting after 2000?
- System changes (first lifting budget restrictions and later regulated competition) – productivity rewarded
- These decreased waiting time considerably
- They came at a price though: expenditure increased and demand restrictions (from no claim to deductible) more prominent
- This short example from The Netherlands shows complexity of waiting times and policy measures to reduce them
- System and details matter!
Waiting times decreased (especially rapidly after 2000). But expenditures increased.
Different scenarios (koopmanschap et al)
fig 1. people stay the same (je gezondheid blijft hetzelfde terwijl je wacht)
fig 2. while they are waiting the situation gets worse. But once you get treated late, you will get back to the same level as you would have when you would have been treated earlier
fig 3. people deteriorate while waiting and it takes longer to recover. But they will get back to the same level as they would have, when they would have been treated earlier
fig 4. people deteriorate while waiting and they will never get back to the situation, as they would have when they would have been treated earlier –> they never get the same quality of life. (permanent gezondheidsverlies door het wachten)
socio-economic inequity waiting lists
benefit of waiting lists is allocation health care wihtout dpeending on ATP (how much income you have –> ability to pay)
evidence shows sociio-economic inequity nonetheless. Possible explanations include:
- people with higher SES engage more actively with the system and exercise pressure when they experience long delay
- may have better social networks (“know someone”) and use them to gain priority
- may have lower probability of missing scheduled appointments
- may articulate their wishes and needs better and more forcefully
consumer moral hazard
- ex ante
- ex post
ex ante
= less prevention and more risk Before something happens. A person who is fully ensured, will be less engaged in, for instance, prevention. BEFORE.
ex post
= demand more and more expensive care Once you are ill, you want more and more expensive care then you otherwise would have wanted. Not matter the cost I want the best care after falling ill. AFTER.
Solution for consumer moral hazard?
- Through for instance cost-sharing (certain % of costs is borne by patient) the experienced price is raised and the incentive for consumption and moral hazard decreased. By having this incentive, you want to reduce unnecessary care.
Reduce the amount of unnecessary care (push out the demand curve); you hope that the right side of the demand care represents unnecessary care.
Questions about efficiency and equity
effiiency: are people actually capable to see where they should be on the demand curve? is it only unnecessary care that we are putting out of the system or is there also necessary care put out of the system?
equity: are we not pushing more care in people who are actually not so well of relative to people who are relatively well off?
creese (BMJ, 1997)
Poor people are both sicker and more sensitive to healthcare prices than wealthier people. A range of policy options other than user fees exists for dealing with situations of both underfinanc¬ing and rapid growth in expenditure. As an instrument of health policy, user fees have proved to be blunt and of limited success and to have potentially serious side effects in terms of equity. They should be prescribed only after alternative interventions have been considered. lets not go there unless we tried al the other things
What do we know RAND-experiment (USA)
- Largest and most famous source of information: RAND HIE (1974-1977)
- Households randomized to schemes with 0 to 95% co-payment and varying deductible (up to maximum amount) with long follow-up
- Data was collected on expenditures but also on health status
- Shows people are indeed sensitive to prices - mean expenses of those households with free care $982, those with 95% coinsurance $679 (individual price elasticity around -0.20)
- All types of service fell: physician visits, hospital admissions, mental health service.
- The poor more severely restricted use than the rich did
–> Yes, you can reduce healthcare consumption by have a co-payment.
Newhouse et all, 1993) is free health beneficial?
For the average person there were no substantial benefits from free care (Newhouse et al., 1993, p. 201) Exception: “sick poor” (appr. 6% of US population) - people with low incomes with particular illnesses (high blood pressure, vision problems, bad teeth & gums, children with amaenia (=bloedarmoede)). For them free access to care beneficial. For the average person they didn’t find an effect on health.
Policy implications (newhouse et al)
- targeted free beneficts (e.g. vision and dental) or avoid for certain people that they have to pay
-problem: conditions can be difficult to exempt (e.g. high blood pressure), since identification of potential beneficiaries is crucial part of treatment - solution: exempting loew-income people form cost-sharing (but: how to draw poverty line, stigmatization of poor) people don’t like carying the green card if other people can see that they belong to the 6% poorest
- simply accept the negative side-efffects form this rationing device
- what do we value: equal access, equal use, or equal health outcomes
