Anyone looking for a solution to physician quality or availability can find it through direct primary care / concierge care. Personally I pay $60/month to have unlimited access to my physician in Austin.
The physician, in turn, rather than having 40% overhead, has no overhead from billing or insurance. They have simple monthly cashflow that they can allocate to cover rent and wages for their practice. This means that the physician can choose how many patients they have relative to their expenses, and decide how much time they have available on average for each patient.
The result is great for the patient, great for the provider, and the sort of thing that will help increase availability of doctors, and their satisfaction with their work.
I've been experiencing this exact issue in the US. Lately a medical issue of mine has been getting worse, and the earliest I can see a new PCP is in May 2025. I managed to get a referral to a specialist by visiting urgent care, but they referred me to a different specialist, and I won't be able to see the latter until late January 2025. Meanwhile my medical issue is continuing to get worse, and I have no one I can talk to about it. I'm looking into alternative options but things are looking bleak. I'm probably going to have to go out-of-network and drive 2 hours to find a doctor that has wait times on the order of weeks (as opposed to the in-network providers, that have wait times on the order of months).
If you think it’s worth it, you can fly to a few places in East Asia or Southeast Asia where you can see a medical specialist in private hospitals on the same day, especially if arranged a couple of days in advance.
These include Singapore, Thailand, Malaysia, Hong Kong, Taiwan, etc.
The quality of care in these private hospitals is usually high as well.
For some cases, the costs in more affordable locations among the above—even after including economy flights—could be cheaper than treatment in the US.
> I won't be able to see the latter until late January 2025
Where are you? This is unusual.
In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1]. In Canada, the "median national wait time 1 was 78 days," with wait ime "defined as the period between a patient’s referral by a family physician to a specialist and the visit with said specialist" [2].
Broadly speaking, American medical wait times are quite good, particularly for specialists [3]. But PCPs/capita vary greatly from state to state [4].
I've seen this too, in the northeast US. I didn't go to our family doctor of 10+ years for 18 months during COVID-19. When I called for a new appointment, they said I had was no longer a patient and had to wait at least 90 days for an appointment to address a painful condition. I still haven't gone back, and now I just use urgent care if needed.
I had similar problems with a specialist. Their appointments are typically six months out, and if you need something more urgent, the answer is "sorry that's all we can do." My last actual appointment, after the ~six-month wait, was a simple 15-minute telehealth visit. It's insane.
I have great insurance and I've never had any problem paying. It's amazing to me that doctors seem to really push back against having patients, or their patients having appointments. Isn't this how they make money? What kind of weird market effect incentivizes this behavior?
It's interesting that dentists and oral surgeons seem to be the opposite. I've never had a problem finding one and they usually seem welcoming, happy to help, and glad to have the business.
It is really frustrating but I've found that most doctors and hospitals have two systems. One for new or very infrequent patients. One for established or regular patients. The latter gets appointments fairly quickly in most cases.
It is rather messed up but One Medical (now owned by Amazon) and a few other services can be worth the money because they have access to the fast track appointment line.
I only know this because after many many months of searching for a primarily care doctor and waiting for an appointment I was told about this. New patient scheduling for my doc is months out. If I email and ask if I can come in next week they always say how about tomorrow/the next day?
Every doctor I personally know is double booked at least a substantial portion of every single day. They count on last minute cancellations and no shows just like airlines do in order to maintain their schedules.
Making friends with folks in the medical field is eye opening to say the least. The system is operating redlined and has been since before Covid. Covid just caused the fractures to finally start showing to the average person.
The real thing coming for us is that every doctor I know other than some specialists are simply counting down the days until they can leave the field of direct patient care entirely. Whether this be early retirement, paying off student debt and bouncing, or making a lateral move to research or a tech firm. The field has gotten to be untenable for many, typically the ones who actually care. The profession as a whole has lost its personal agency to the administrative class. It’s not idle talk either - plenty have actually already executed on these plans.
I think it's likely simply gotten worse since those studies.
A friend of mine needed a specialist. She called multiple offices across two different states, and the soonest appointment available was about 4 months out.
Four or five years ago, we didn't typically see wait times like that.
OP is correct in my anecdotal experience. I live in a large urban area and wait time for PCP is several months out. Even longer for Women's health as I hear from my partner.
I don't remember it being this bad in the past. Perhaps things have changed in the several years since those publications were published.
> I don't remember it being this bad in the past. Perhaps things have changed in the several years since those publications were published.
There's an analogous pattern happening in clinical trials that I suspect is related: there has been a consolidation by private equity[0].
There are several reasons for this, but the gist of it is that pharmas have moved much of the actual work of running large clinical trials to contract research orgs (CROs) and the cost of recruiting patients for trials, training staff, records keeping, and administering the trial becomes out of reach for small independent sites where clinical trials are executed. It's also more efficient on the sponsor side to interface with one large entity rather than several small entities.
I suspect that the increasing demands of technology and burden of records keeping in both clinical trials and health insurance makes it difficult for small independent sites to operate profitably. So what happens is that many small, independent offices end up joining a larger entity that can consolidate some of the "system level complexity" more efficiently. The tradeoff is that it's no longer about the doctor-patient relationship; it's about efficiency and profits.
I also suspect that part of it is that PE realizes that consolidation lets them control prices. If they can control a network of trial sites, then they have more power to negotiate rates with sponsors and CROs for each patient they sign up to the trial. The bigger the network, the greater their leverage. I think this probably also holds true for healthcare and insurance providers in general.
I live just outside a large urban area, and my wait time for a PCP is weeks if I agree to see their PA (the PCP will review all findings anyway), or days if I put myself on their cancellation list. Maybe try calling around just outside of your urban area.
Is it? That's pretty normal in my part of the US, and that's assuming you already have a PCP. If you don't, then finding one that's accepting patients can take much, much longer.
> Is it? That's pretty normal in my part of the US
Are you in a state with a shortage of PCPs [1]? If so, yes. But most Americans aren't in those states, and in at least a few of them the harm is closer to a political choice than an oversight.
I have heard the same comments from people in states all across the nation. It may very well be that it's a minority of states (I don't know), but it's certainly a very substantial portion of the population that's affected.
I'm not asserting that what I've experienced, seen, and heard represents the majority experience. As I mentioned, I don't know. But it's not exactly a rare experience.
In my experience it depends on the speciality you need.
If you need to see an Otolaryngologist (ENT), you might be able to get an appointment within a few weeks. If you need to see an Endocrinologist, it might be 4-6 months.
Connecticut. Everything is like this here. I have genuinely considered moving because of this. My current employer has another location in California, and as much as I hate the idea of moving back there, it might be necessary for my own physical well-being.
> In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1].
I want to point out the important missing fact there that the "America average" time tells you nothing about variance across geography, specialty, or patient population, and you really need to at the very least look further down at the charts where they talk about shortest and longest times in the different cities and specialties.
For instance I see Boston's longest 2022 time for family medicine is 136 days, average 40 days. And Massachusetts is one of the top states on your list for PCPs per capita. At least that's better than 2017 where the longest time was "fuck you, get rekt, lmao".
Sometimes a doctor is available but crappy scheduling software hides that.
I got a small scratch from a squirrel and since it did cause a little blood to appear I figured better safe than sorry and went to Kaiser's site to make an appointment with my PCP.
They had nothing for a few weeks.
So I changed to requesting an appointment with any doctor at the same facility. It then gave me an appointment with my PCP for the next day at 9 am.
I've seen similar problems with vaccine scheduling using their web site. It will sometimes only show appointments at a bigger Kaiser facility in the next town, or an even bigger one 30 minutes away.
But if I actually go in and talk to the people at the front desk at the Kaiser office in my town they can often make me an appointment at that facility.
I had this issue due the consolidation of medical networks.
Luckily I have a BlueCross PPO. So I’ll get fast access to a specialist in NYC in Boston then transfer the records back to the local dude if needed. My wife had an issue with a complication, and I found a doctor who was a contributor to a major study on it and we got treated by him. Epic makes managing this trivial.
It’s the best of both worlds, but only if you have the privilege of legacy insurance and PTO.
10 years ago I could see my doctor when I was sick. Like, the same day. Now if it can't be done at the Target or CVS, it's the emergency room. I didn't even get an annual checkup last year because my doctor had to cancel, and the earliest I can be seen again is this summer. I'm now at the age where this is probably starting to matter.
And I pay like... $30,000 a year minimum for this?
I sort of find telemedicine to a be a scam. I’m sure it has its use case, but most of the time it feels like they are trying to limit liability so they just tell you to go see a doctor in person.
I pulled insurance quotes for my wife and I recently. Both of us are young and with no known health issues. Our monthly premiums for the cheapest plan was around $800 per month, but that was with very limited coverage and a deductible of around $15,000 before they would cover any major expenses.
The premiums would be $9,600 a year but all in we could spend around $25,000. We had options for higher premiums and lower deductibles as well, but the total max out of pocket was almost identical.
Make sure you are fully aware of federal subsidies for your insurance premiums.
It's a bit complicated to explain the details, but basically you won't pay more than about 8.3% of your AGI for insurance, no matter what your income level is.
Alas, these subsidies may expire next year if Congress does not renew them (they don't actually vanish, they are just income-capped at 400% of the federal poverty level).
An annoying aspect of the subsidies is that they have an abrupt drop as you cross 400% FPL.
From 133% (if you are below 133% you are supposed to use extended Medicaid instead of a subsidized marketplace plan) to 400% the amount of the subsidy goes down bit is still substantial at 400%.
This can result in a situation where if your income is a little over 400% FPL you might come out ahead by taking a pay cat to get under.
My employer pays $3,575.49 per month for my HDHP ($12,000 deductible). Family of 3. It's Aetna, through one of the large small-business payroll providers. Are we getting ripped off?
You're probably not getting ripped off (relatively speaking). When I quit my job to take some time off 3 years ago, and signed up for COBRA, the out of pocket expense for 2 adults came to around $2000 per month, also for an HDHP plan.
Kaiser's "platinum-level" (90% average coverage, no deductibles) plan for a young nonsmoking adult runs about $450/mo in my state marketplace, and most of that is further subsidized for someone who isn't making middle class wages. The medium-deductible, 70%-average-coinsurance "Silver-level" plan is about half that.
I don't even understand the concept of a $12,000 deductible when the ACA established maximum out of pocket at:
> "For the 2024 plan year: The out-of-pocket limit for a Marketplace plan can't be more than $9,450 for an individual and $18,900 for a family."
The individual marketplace plans seem to exist in a totally different world from employer-provided plans. When I went from my old employer's COBRA to an MD Health Connection plan, my premium dropped nearly fourfold even with no subsidies.
I mean my wife and I pay $700/mo premium, we both hit our $2500 deductible this year already, my physical therapy is out of network and costs me $800/mo
That's $23k already before prescriptions and we are in our 30s with no major health issues.
I think Taiwan is worth adding to the list of healthcare systems that folks study. I believe it may be similar to the Swiss system.
Everyone has national health insurance, but you also get to choose where to go, and some doctors also offer non-insured services that you can pay for out of pocket.
The result is universal coverage combined with a competitive market that drives prices down and encourages innovation.
I know this is just anecdata, but having held an insurance card there for a while, our family was always able to see our family doctor the same day we called. And the one or two times a specialist or emergency room was needed, there was minimal hassle.
I'm sure there are problems with it, too -- I just don't know what they are. As a customer/patient, it seemed to work far better than the American system I'm used to.
Most of Europe has a similar model to what you've described: some form of mandatory state-backed insurance combined with a mix of private and public healthcare providers. In many countries, however, the biggest hospitals in Europe are owned by the government.
Unfortunately the healthcare systems are in the process of collapsing across the UK and the majority of the continent too.
My pet theory is I don't think it's actually anything to do with the overall funding model. I think it's to do with our inability to adapt to an increasingly elderly population. People's kids here are scattered around the country, often many hours of travel away, living in small apartments, and can't easily look after their elderly relatives in a way that's much more common in East Asia. As a consequence, we are offload that responsibility onto the healthcare system, which treats them as patients with medical issues, when often they are just old people with broadly normal age-related disease. Our systems were never designed to be capable of handling millions of elderly people, and it's not an efficient way of providing the required care, so it's falling apart.
It used to be that doctors were running their own small medical offices a lot. Unfortunately, due to insurance overhead it's no longer profitable for individual doctors to do that, especially without existing patients, so the remaining offices are mostly from doctors near retirement age.
So as doctors retire and new doctors don't want to start their own practices those practices have been getting bought out by large medical networks or private equity. Some offices are also going out of network with insurance companies. It doesn't help that PE is willing to pay a ton more than any new doctor could for the practice.
I'd recommend picking medical plans with out referral requirements and with good out-of-network coverage.
I wrote a more detailed post elsewhere in this thread, but I also think this is the case and you can see an analogue with consolidation of clinical trial sites by private equity.
> Private equity dollars are flowing toward clinical trial sites as industry conditions demand larger site networks, PitchBook's analysis of first quarter 2024 deal activity shows.
>
> For CROs, scooping up trial sites is one aspect of a greater movement toward vertical and horizontal consolidation, a long-standing trend that is still playing out in the space, the PitchBook report confirmed. CROs continue to combine with contract development and manufacturing organizations to establish end-to-end drug development capabilities under a single roof, making them more competitive in the outsourcing market.
My brother was a Family Medicine doctor and he got burned out and retired early and is now a potter lol. His ex gf was a doctor and did the same. I suspect this sort of thing is behind a lot of the issues this article is explaining. After Covid, a large portion of the world that could retire did so and never came back. Those that are left and stuck in that world working or trying to use it, are not happy about it.
> Before the pandemic, she says, she might have done two disability tax credit forms; last year, she did twenty
Did Covid cause massive disability? Did legislation change to make claiming a disability easier or more lucrative? Are people claiming disability in response to inability to get jobs that meet their expectations?
It's not the point of the article, but a 10x increase in requests for "disability tax credit forms" seems like a very significant sign of something deeply concerning.
I wonder how many people seeking disability are more accurately described as disenfranchised. If people are looking at bleak prospects of low-paid jobs with limited possibilities for advancement, alongside soaring housing and other costs, how many people with previously manageable impairments are throwing in the towel and using a disability designation to escape the rat race.
Yes, Covid did cause massive disability. The colloquial term for it is Long Covid. I know at least three people suffering from it —- along a spectrum from slight to severe impairment of daily functioning.
> Covid did cause massive disability. The colloquial term for it is Long Covid
I know a previously-healthy guy who got an early variant that went for his pancreas. He now has Type 1 diabetes, a condition one is normally born with and for which there is no cure, just chronic, expensive and time-consuming treatment.
> He now has Type 1 diabetes, a condition one is normally born with
Type 1 Diabetes isn't something someone is born with. Rather, it's something that you generally get when young (and, in fact, it used to be called Juvenile Diabetes, vs Adult Onset, which is what Type 2 used to be called), but it can happen later in line, all the way into the 20s (or later, I believe).
There is a genetic component, but it's also completely possible to get it with no family history.
Didn't realise it was autoimmune. Nevertheless, in his case it was directly caused by Covid attacking the pancreas. That said, he got it in 2020. The virus got milder over successive generations. (Intrinsically and due to broader vaccination and antiviral administration.)
There's actually a couple different "types" of Type 1 Diabetes. For example, you can get it during pregnancy (Gestational Diabetes), etc. So it doesn't surprise me that it's possible to get it from Covid. I seem to recall someone getting it from an injury that damaged the Pancreas enough to prevent it from generating insulin. I don't know if that still "counts" as Type 1; but it certainly has the same effects.
Even for the first person described in the story, her search for a doctor is not primarily described a search for medical care, but a search for someone who can create a paper trail to ensure her child's eligibility for benefits.
A lot of the problems in medical care have nothing to do with the system (Canada vs US) and everything to do with doctor supply.
It’s simply not a great career choice anymore. You start work very late in life, and make only OK money. Some specialists make a lot but they start even later. Some GPs make a lot but they run patient mills. For most GPs, it’s an extreme slog without extreme reward.
The same career issue goes triple for nurses. Young nurses are quitting in droves.
In the US, because of employer insurance, the cost of insurance is mostly hidden from patients. The cost of medical care is similarly opaque -- consumers expect routine checkups to be essentially free, and sick visits to cost next to nothing. Insurance companies are always trying to drive down their costs, and control access for a huge set of patients.
It's a broken system. Years of training, very selective, highly expensive... only for a lot of it to be telling people common sense things like eat less and excercise more.
I know it would be political suicide, but I do believe that we could still have a very good medical system if the level of education we demand of doctors was reserved for surgeons and leadership and the front-line work of GP-style treatment was 100% left to people who were qualified by a normal nurse-style process of undergrad + apprenticeship + test.
That's kind of how it works outside of North America. Students go into medical school right out of high school, and medical school is about 6 years - maybe including residency. They graduate with a degree that allows them to practice general and family medicine. If they want to become specialists, they keep studying and more residency.
North America seems to be alone in requiring a 4 year degree before letting a student anywhere near a medical school.
Also "rest of the world" the medical professionals do not get into massive debt and hence do not need massive compensation upon graduation to offset. One issue of getting more supply of doctor would, I believe, be the resistance from the current system since more supply means lower prices...
Additionally since a lot of our healthcare is managed by Private Equity or other forms of investors that are looking for a profit, I suspect with cheaper staff they will just keep prices the same and increase their profits.
I’ve heard what the article describes about specializing being the way to go. In the US, insurance is also a huge pain in the ass; doctors have to fight to get paid as often as we have to fight to have things covered. There’s also the overhead of insurance for their practice, the costs of running a clinic or being part of a clinic group, maintaining compliance with everything, paying Epic’s extortionate fees, etc.
The last two doctors I’ve had have gone to “concierge” services to help mitigate this. They stabilize their income with annual membership fees that sidestep the insurance company horseshit. They constrain their roster a bit. They can see people more quickly. But you have to be a member.
It’s sad for me, but I get it from their perspective. “Retail” healthcare in the US is by all accounts a nightmare.
There is too much "medical students syndrome" - you learn about some symptoms and they decide you have the issue because the symptoms match even though they don't match in the right way.
There are also a lot of rare things that need expensive procedures that shouldn't be done on a whim. Many medical tests increase your odds of cancer for instance - if you really need that test done to figure out your issue it is worth it, but those tests shouldn't just be done - it is often better to treat the most common causes without verifying that is really the root cause and then only if those treatments fail do the tests to see what you really have.
An interesting thing I'm seeing happening in primary care is that doctors are being replaced by doctor adjacent professions like Nurse Practitioner, Physician Assistant, etc.
A doctor spends a decade working 60 to 80 hour weeks studying medicine whereas an NP is a Master degree, I think which can be obtained online.
There doesn't appear to be clear results yet in studies on the outcomes of NP's vs MD's (see reference).
Another argument is that maybe all that medical school training is overkill in Primary Care and this is perfect setting for NP's or PA's. And also maybe most doctors are not ambitious and forget most of the training they're not using on a daily basis anyway.
I think it would be pretty funny if after more studies NP's showed no different outcomes than MD's.
>If family doctors’ compensation is going to be the lowest of all physicians’, they at least want to rein in their hours and responsibilities. And they want to be able to take a vacation.
The article is relevant, but it is a case of "you get what you pay for".
It's so frustrating. We signed up for a pediatric practice in Atlanta that has 8 doctors.
We saw a great doctor on our first visit, then our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse... So on our way out when scheduling we asked if we could see the same Dr next time.
"Oh sorry she only works Tuesdays"
"Okay weird but this is 2 months out though so that should be fine"
"Actually Tuesday would put you over a week away from when the appointment was requested I can schedule you with ..."
3 visits later and we still haven't seen a doctor once. Not even a 30 second pop in the room to say hi.
We've gotten like 20 immunizations from nurses and can't ask doctors about any of it..
Like cool cool all for these peopl advancing their careers without med school but like
... Usually you want your doctor's to have gone through medical school
I live in Atlanta and I wonder if it's due to the influx of out of state families moving in. It didn't use to be like this. My child was sick recently and we couldn't get an appointment for a sick visit for several days. This too is an office with a dozen docs/NP.
We ended up going to another one of their offices 30 minutes away which had availability (i.e. lower population density?).
For the receptionist that said "it would put you a week away"...that's when you should just push back and say that's fine. There are very few appointments that need to be exact. And you know what, if you're not sure and you're there, ask the doctor if it's ok :)
Also because I'm trying to spread awareness and you'll likely encounter this: Be aware of "hospital/facility fees".
For a baby you have regularly scheduled appointments through the first year to make sure developmental milestones and for the correct immunization schedule.
The amount of bad and actually hazardous parenting advice I've gotten from nurses and PA's is staggering.
When we were discharged from the hospital, the pediatric nurse actually told us it was safe to feed him in the car seat on the drive home.
> a baby you have regularly scheduled appointments through the first year to make sure developmental milestones and for the correct immunization schedule
Sure. None of this requires a doctor, though.
> pediatric nurse actually told us it was safe to feed him in the car seat on the drive home
This is bad advice. But I'm failing to find studies that quantify the risk. You're correct that they shouldn't have said this. But I'm not convinced no doctor would advise similarly.
If everyone wants their kid to be seen by a doctor, we either need to lower the standards of doctor or normalise perfectly-well kids being seen by NPs. (That or a higher billing code if a patient demands a doctor for routine care.)
I find this to be true also. But how can this be? Either feeding a baby in a car is not that big of a deal, or something about the cars or carseats changed? I think it's more like the former.
I'm sure you can get all kinds of dated advice from board-certified physicians too.
I thought socialism was supposed to solve all of this? At least in America we're told that Canada is a clearly superior system, yet I hear over and over again, even first-hand from people in the UK that it sucks for really quite basic things.
At least part of it seems to be that the price system is completely screwed up, the doctors need to be payed more and it's obvious that the institutionalized insurance system is a root cause. When government (or their heavily regulated proxies, or any third-party for that matter) sets prices, expect services and products to deteriorate in quality.
Everyday non-emergency care should be a transaction directly between a doctor and patient. That WWII screwed up the whole system through price controls on wages and locked us in, path-dependency style, to forever paying a useless third party is nothing short of infuriating.
I see the same issues here in the states. I think no matter what the economic model, we need to take a long hard look at the overhead and complexity of healthcare. And by and large, I suspect the insurance companies will be found to be at the root of it.
I can't believe I of all people am calling for less regulation, but the amount of bullshit it seems like doctors have to go through to provide basic service seems counterproductive.
I think people will hit a breaking point and it will be undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life.
It's hard not to see the parallel between healthcare and education where the parasitic overhead has been completely unchecked and enabled by federal subsidies. There's a similar deal with food, housing and other areas. It's absurd the amount of money that has been spent by the federal government in these areas with so little to show, the average person feels not only a lack of progress but decline.
Much of the regulation you’re saying is to blame was written in blood.
Want to know what food and housing was like before regulation? Read the jungle.
Do you think we have deteriorated since then?
Maybe the prosperity you think has deteriorated was not due to lack of regulation, but due to black swan events like… i dunno conquering and industrializing the entire North American continent, all peer nations blowing each other to bits in two world wars, etc?
I agree that all regulation is written in blood. But at the same time, regulation can result in bleeding, and we don't always carefully weigh the costs and benefits of regulation. There may be a law that saves 100 lives a year, but that indirectly causes 150 deaths due to knock-on effects.
It's not easy to inject nuance into a discussion that feels like you have millions of people on each side of a tug-of-war rope that goes from "MORE REGULATION" to "LESS REGULATION".
I think housing, which you mention, is an excellent example. Yes, we need regulation in housing because without it, people will die from shoddy structures collapsing on them, electrocution, gas leaks, etc. But at the same time, in the USA there are absolutely regulations in housing with very little benefit and absolutely massive costs, where we have examples of first-world countries without those regulations that do just fine. I'm talking about things like the requirement that all apartments have 2 stairwells. Or mandatory setbacks and minimum lot sizes and parking requirements. edit -- and of course zoning codes, where we've shifted the market toward building housing that's so big that people can only afford to share it with strangers. And while people used to live in crowded, cramped tenements, driving housing prices up by restricting supply leads to people living on the street.
In medicine, there are diminishing marginal returns to making doctors go through more schooling, and the cost is simply that fewer people choose to be doctors, and people just go without health care. And even within that simple dilemma of "should we make it harder or easier to be a doctor", i'm sure there is a universe of alternate ways to move the needle in different dimensions. Requiring more or less schooling, more or less time in residency, changing limits on the number of hours doctors and nurses can be scheduled in a week, tightening or loosening malpractice law in different ways, etc. Each of these has some positive and negative effects, and I'm sure we have a ways to go before we hit the optimal point. And even then, you have to choose how to balance quality of patient care against doctors and nurses quality of life!
Or take drug approvals. There are drugs in development that show lots of promise, that probably should be made available to people who are dying anyway and want to try them. The FDA does not allow that. We have to balance against companies trying to scam people with fake medicine. No policy is 100% without harm. I believe that, even for policies I strongly advocate.
Or laws that were originally targeted at local environmental protection, that are now being used by nearby residents to stop solar farms from being built, stopping us from reducing fossil fuel usage. Those regulations were written in the blood of wildlife -- and now they're cause much more harm than good to wildlife all across the world.
So if you are asking if we've deteriorated since The Jungle, in many ways, no, of course we've improved safety of working conditions massively, and lots of other things. But in other, important ways, we've gone somewhat backwards. I believe it's absolutely possible to improve our society by removing some regulations, but I think it takes a lot of careful, small, targeted tweaks, where we've carefully weighed the costs and benefits. Though in rare cases, like as in parking minimums, the evidence is that they are so harmful that just scrapping the regulation entirely is the way to go.*
> Want to know what food and housing was like before regulation? Read the jungle.
Not convincing since you're reducing the entire time period to The Jungle which was sensationalized fiction, effectively political propaganda.
But to your broader point, things improved directly from capitalism and markets. My reading recommendation? Deirdre McCloskey "Why Liberalism Works" on the absurd increase in living standards brought about through innovation enabled by capitalism, we're talking some 3,000% in average income over the course of time you're referring to.
> And by and large, I suspect the insurance companies will be found to be at the root of it.
At least in the US, this is true. The pervasiveness of interaction with insurance and the power they wield turns them into a rent-seeking layer with the massively negative economic effects of socialism.
Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.
> Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.
The problem with this model is that often very catastrophic things can be caught during routine care, so it actually makes a lot of sense for insurance to pay for a yearly physical. Otherwise a lot of people are going to wait until their spine is blown out and their knees need replacement to seek any kind of care at all, at which point their care is 100x more expensive than if they did a yearly.
Any other kind of care like going to the doctor because you're sick is entirely the point of insurance. It covers your medical care for unanticipated problems.
Getting sick is not an unanticipated problem. A major illness or injury is.
Insurance has no business paying out for you going in for strep throat or the Flu or an annual checkup. These are normal things everyone gets multiple times throughout your lifetime, and should easily be taken care of via market forces for a very reasonable fee.
The problem with US healthcare can be entirely boiled down to a principle agent problem. Someone else is always paying, so no one actually really cares that much about the cost of things and the incentives always are to increase costs and use more services since there is no actual market competition.
Worse than that, nobody gets a choice anyway. If don't have to take the insurance my boss offers me - but if I don't I'm throwing away more than ten thousand dollars in subsidies they offer. It is really hard for anyone to compete with that deal - there are things I don't like about my insurance but it isn't worth shopping around as nobody can come close to the price/service they are giving me.
I have long wanted to get rid of the insurance/employer tie, but I'm a minority and so nothing gets done.
People say this a lot but it feels unlikely to me. I think the biggest causes of the problem love the idea that insurance is to blame.
Hospital admin, doctors orgs, pharmacy benefit managers are all much more interested in things being overly complex, under-staffed, etc. Insurance companies just want to sell insurance with the % profit that is typical of insurance (eg Cigna's profit margin is the same as Allstate).
Besides, if insurance was to blame, it would work better in Canada and other countries that rely on private insurance less. But Canadians don't seem very pleased with their longer waits.
We need more doctors and nurses [1], full stop. Anything that prevents an aggressive increase in supply of these workers is something that needs to be actioned against.
Healthcare is a utility masquerading as a profit based industry. Squeeze the profit and inefficiency out, any comp should be going directly to systems and people providing care. Insurance companies? Gone [2]. Pharmacy benefit managers? Gone [3]. Lock private equity out of owning anything healthcare related [4] [5] [6]. I don’t want to knee jerk “union” for individual contributors, but you need some sort of governance mechanism so the CEO of a non profit hospital isn’t taking home $1M/year [7] [8] [9] while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios, which are used to increase labor load without increasing labor costs or hiring more practitioners [10]).
> We need more doctors and nurses, full stop. Anything that prevents that is what needs to be actioned against.
I agree we have a shortage, but to offer a counter-argument:
We shouldn't need a 100% full-blown doctor for everything doctors do today. We could also help address the shortage by splitting out some responsibilities that are restricted to just doctors among professionals that only have 80% (or 60%, or 50%) of the training / certifications of an MD.
We've already presumably been doing this in the US with physician assistants and nurse practitioners. It hasn't solved it, but the problem would undoubtedly be many times worse without them.
Great call out, I agree. NPs [1] are the NCOs (non commissioned officers) of the medical field. Where applicable, level up folks with the desire and aptitude from RN->NP. This specific pain point is a talent pipeline health and structure challenge. MD feelings around this are going to be something to consider, to note when preparing for the opposition [2].
If you said "Where applicable, level up folks with the desire and aptitude from IT support->senior engineer. This specific pain point is a talent pipeline health and structure challenge. SWE feelings around this are going to be something to consider, to note when preparing for the opposition" people would go wait, maybe the occasional fresh bootcamp grad or ITsupport technician has the potential to do strong work or manage a team, but in general their education has not prepared them. Of course if you ask a doctor "could the RN or NP run this floor" there's a conflict of interest when they tell you "no", but they're also correct.
Having a nurse is probably better than no medical care at all, so a tiered system where poor people get nurses without realizing they're worse than doctors would have that advantage, but the right overhaul imo would be reducing the years of schooling required to become a real doctor (undergrad, med school, residency, maybe fellowship, finally attending). If doctors skipped undergrad and cut out some med school or fellowship requirements, they'd start working earlier and could afford to choose specialties that pay less. As well as expanding residency slots and moving insurance compensation to family medicine and pediatrics.
edit - here's a good example, https://old.reddit.com/r/medicine/comments/1f6m5i9/its_scary... the good news is they'd agree with you that midlevels do have a role, the problem with scope creep is defining what that role is, and the assumption that the training is 80% or even 50% there
> the CEO of a non profit hospital isn’t taking home $1M/year while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios).
In Houston, the renowned Texas Children's Hospital did layoffs — after paying millions to their CEO and other executives. FTA: "Over a seven-year period from 2016 – the earliest year of data published by the Internal Revenue Service – to 2022, the average pay for Texas Children’s 10 highest-paid leaders ballooned from $963,971 to nearly $2.2 million, an increase of 125%. (The latest tax filings do not reflect how much leaders at Texas Children’s earned this year, after the hospital reported major financial losses.)" [0]
The usual response defending such high compensation is something like, "We have to pay our execs so much because we're competing for talent with the for-profit hospitals." OK, one possible solution might be returning marginal income tax rates — across the board — to what they were in the 1950s. That would help neutralize the constant craving for more money as one of the main ways that execs judge their personal career success. "The top income tax rate reached above 90% from 1944 through 1963 ...." [1]
I'm fairly certain a large chunk of the problem is demographic shift. healthcare is one of those industries most used by the elderly, and the proportion of the population in that demographic has skyrocketed
Also I would guess that there is more healthcare, more options, more procedures, more drugs. Length of stays in hospitals might have shortened due to less invasive procedures, but if more procedures are done and there is not increase in staffing, time is spread over larger number of patients.
I think there are things that could do with less regulation in Canada that would be easy wins.
Like for people with recurring prescription meds, maybe don't require them to make an appointment every month to get their meds? Even if we consider extreme examples like opiates, it's not like cutting off drug abusers or people selling their meds does anything to curb the opiate crisis. Opiates are already available everywhere and the supply is much more dubious and dangerous.
My best friend since high school is a doctor. Hearing all the bullshit that she had to go through, the different selection processes, abuse (scheduling), etc; it's crazy.
It doesn't weed out people who will be bad doctors, it weeds out people that can't handle the abuse.
I had a prescription for 1 20mg pill a day. Pharmacy didn't have 20mg but they had 10mg. They couldn't give me 2 10s instead of 1 20 because regulations didn't allow that. Yeah, we need less regulations.
The American system is too expensive and leaves too many people without coverage. Not very many people would argue that.
The Canadian system is suffering from doctor shortages and other problems and the article lists a lot of reasons why (at least for Alberta).
What countries are the shining examples of how to do it? How is access to excellent, modern healthcare in Japan? Sweden? Spain? Ireland? Australia? It's all about tradeoffs, what countries do you think make the best tradeoffs?
As with many things the best model to look at is Singapore, which spends far less than most of the OECD with outsized results. They spend half as much on healthcare than the UK and far, far less than the US with results that often put them in the top 5 for healthcare outcomes.
Funny enough, I actually live in Alberta. My personal experience with the healthcare here is actually amazing.
But I’m in Calgary. There’s still a big, expensive challenge in providing care in the tiny towns. Alberta is pretty much infinitely large compared to Singapore.
Another aspect is that some of Alberta’s money goes to subsidize other provinces which is something else Singapore doesn’t have.
They also do many things so radically different that it is always worth looking at how they handle it, especially given that 70 years ago they essentially had nothing but the remains of a post-war colonial city.
It’s certainly always worth learning from others; just making a point about statistical comparisons.
Just because the US, Norway, and Singapore are all categorized as countries doesn’t mean you can compare their stats directly without adding some asterisks for further context each time you do it.
I have a co-worker that moved to the US from the DR last year. She's shocked at how involved and expensive the system is for the most routine visits. It's interesting to hear someone speak with first hand experience in multiple systems.
Canada has a worst of both worlds system. Most wealthy Canadians come to the US for procedures because they can afford it and there is no waitlist, and so they don't care how bad the Canadian healthcare system gets.
Yep, discussions of capitalism as contrasted with socialism are largely pointless as all western countries operate different flavors of mixed economies. Keynes won. You have to have both— if you stray too far in either direction your economy topples.
But accepting "Have government involved in the economy, not too much. Mostly markets" means you have to actually know about the specific industry and surrounding economic factors and that makes discussions boring. It's way more fun to have Cage Match: Capitalism vs Socialism, this Saturday on pay-per-view.
I'm not sure why you're bringing up the Canadian and UK systems after launching an opening salvo at socialism. Surely it makes more sense to take a look at access to healthcare in socialist countries like China or Vietnam?
Every healthcare system rations care. In the U.S. that rationing is largely based on quality of employment or how much wealth you have. To some this is a largely immoral way to ration care.
As with all healthcare systems if there is a shortage of workers or it is not properly funded it will deteriorate. The U.S. healthcare system sucks for people who have no real access to it. The wait time of someone with no access to the system is effectively infinity.
Socialism, capitalism, communism, fascism, etc. are merely economic systems and all of them suck if not properly administered.
What argument? I’m not making an argument. I’m pointing out what I think are facts. Apparently you don’t have enough wealth provided you are in the U.S.
USA here, I think we need to pay them less. It's basically become a game of how little can they do and how much can they charge. Many already don't care about your symptoms, or bother to do any research. They just prescribe stuff as it's pushed. If they aren't already, I'm sure your doctor will soon just be entering your symptoms into ChatGPT.
One reason doctors have so little time for each patient is because 1) demand is through the roof due to artificial constraints on doctor supply, 2) they spend tons of their time dealing with insurance paperwork, and 3) they don't actually get paid that much which means they need tons of volume to stay in business.
(2) and (3) are related since "dealing with insurance companies" == arguing for reimbursement from those companies, which means they're losing time arguing and losing money when they lose those arguments.
You know it's okay simply not to have an opinion on something if you can't spend more than 5 minutes or so thinking about it.
What I noticed is that to not lose money, they need lots of brief visits. Do the checkup, come in later to review the test results, then schedule a follow-up to decide on a referral (or not). Everything after the first visit could have been done with a (voice-only) phone call.
Maybe video visits were supposed to make it easier to generate billing with less driving, but it didn't work out that way.
Ultimately I went with an HMO, where the doctors can provide the same minimal amount of care but not jump through hoops to do it.
I don't disagree per se, but it seems from reading the article that they're bemoaning the shortage of qualified doctors and how they're all spent cause they have to work within the confines of centrally planned subsidy prices.
Really they should be charging as high as possible directly to consumers until doctors are attracted into the profession. Cut out the middleman, there is no reason that routine expenses like a sick visit that gets routine labwork or medication need to be insured.
It'd be better to reroute the software developers that construct complex systems to SERVE ADS and addict people to scrolling.
Pay them more, sure. But also let's get rid of the artificial limit on how many we can have. They're not being used effectively and we're all worse off for it.
This is already happening, with more and more primary care responsibilities being pushed to physician assistants and nurse practitioners. At your modern urgent care or "doc in a box" primary care clinic, you may never see the doctor, who mostly exists to lend legitimacy to the practice. Not to say that I don't appreciate the hard work that PAs and NPs do, and I think they are certainly qualified to handle most medical issues in their fields, just that the medical industry is trending towards a less personal experience run by lower paid workers and I can't imagine that leading to better health outcomes for the average person.
And I think that is just fine. There's a large amount of things you don't actually need to see a doctor for. Especially things like looking up your nose and prescribing a Z-pak.
I wish doctors would enter my symptoms in ChatGPT. In my experience they have the opposite problem. They think they know everything and when they hear something they don't understand they just brush it off as nothing. Twice in my life doctors have completely screwed up a diagnosis and later upon doing research it turns out my symptoms were basically a dead ringer for the condition it turned out to be. If the doc had just taken a few minutes to Google it, he would have found it. I don't walk into a doctors office today without doing research first.
The UK's problem is that it wants universal healthcare paid for by general taxation, and free at the point of use. However, the previous government wanted that whilst also reducing public expenditure. You can't have both.
It totally can be done, but it's expensive. I, personally, hope to see taxes rise to pay for this system to work as it should.
Private healthcare is already digging in its claws in the UK due to the fall in availability of state-provided care and (from my experience) it's not a good experience; and it's still expensive!
The UK's state provided system is pretty good, but it runs too much on good will right now.
This right here. The system needs funding to work. The problem is conservative politicians repeatedly trying to make the system worse so they can privatize it.
In my experience it works pretty well under progressive governments that are willing to do the necessary tax-and-spend approach to make it work. Alberta's government is radically conservative, far beyond moderate pro-business conservatism.
As much as the media fixates on Prime Minister Justin Trudeau, it's important to remember that Canada's healthcare is administered provincially, and most provinces have Conservative governance.
Publicly-funded healthcare is much less-expensive with respect to public health outcomes compared to the American system, but it's not so cheap that you can cut it to the bone without creating awful negative consequences.
This article doesn’t really implicate socialism, it’s more about staffing rural towns with doctors (the first anecdote is about Elnora, which is a town of 288 people), and about doctors en masse not wanting to be family general practitioners for their careers. The US and other countries all have a hard time keeping doctors in rural places.
You are implicating private for-profit insurance, however. And maybe forgetting about all the top-ranked government socialized medical systems in The Netherlands, Norway, Sweden, Japan, and others - all ranked higher than the US in quality and efficiency of care. There’s contrary evidence refuting the claim that when government sets prices quality will decline.
What does limited supply of doctors even mean? There’s a finite supply of doctors everywhere, regardless of pricing. Where is the evidence of your claim in Norway, Finland, Japan, etc.?
The U.S. has limited supply of doctors in rural areas, and that’s not due to government pricing. So what justification is there for pointing at government pricing at all? Why is that relevant here, and what makes you believe there’s a broad, general, or causal truth here, given the fact that it’s not true everywhere.
The article is about Alberta, the least socialist of the Canadian provinces. Other provinces have similar problems but Alberta seems to have it the worst. The article talks about doctors moving from Alberta to BC, and I indirectly know a couple who moved from Ontario to BC for similar reasons.
The problem is deeper. The entire structure of the industry makes no sense. Doctors need 12 years of training after high school (the first 4 years of which is useless). Then they end up doing a job where 95% of the work is trivial and could be done by almost anyone with a bit of training.
I know a guy training to do lasik surgery. Turns out it's easy. You could easily train a lasik tech to do it, but that's not allowed. We require it to be done by a doctor making $500k a year who has 12 years of higher education, only 1 year of which is focused on lasik surgery. But we insist on continuing this overly broad training when most modern doctors only practice in a single specialized area. It's like if we required the guy at the oil change place to have a PhD in mechanical engineering. Of course it's going to cost a fortune.
The Social healthcare still have a budget and the govt structure wants resources.
So are we "investing" resources in young and people who will still work and pay taxes?
Or do we invest in people who are already retiring or "incurable".
The older you get the less resources you will be available for you on the social healthcare.
Not saying the US system is sane or one option is better than other.
But the best system is the one that gives you option (and govt hates giving option to you).
1. Want social care? Ok. xx% will be deducted from your paycheck.
2. Want private care? No deductions, you are on your own. And If you don't have money and is charged we will generate a federal debp + 10% for processing fees.
But no... That can't happen. because it would expose the govt or private sector failures.
1. the “socialist” system AKA healthcare for everyone has insane waiting times because everyone needs healthcare & there aren’t enough doctors.
2. the “capitalist” system seems better for the people that can afford it because the people that can’t afford it don’t go so they have no waiting time because a part of the people that need healthcare aren’t getting it due to the price.
It’s silly to say / imply that system 2 is the better way of doing it
What policies have been put in place that would cause the problems they are experiencing? If there is a politics issues, the policies can be talked about.
Policies like the ones in the article, the removal of complexity billing codes, drastically reducing GP earnings.
But AFAICT mostly it's their lack of constructive new models. Alberta has been fiddling at the margins with changes like dividing up the province into districts. OTOH BC introduced a wildly successful new physician pay model almost 2 years ago. I indirectly know several doctors who moved from Saskatchewan & Ontario to BC partly because of that.
P.S. I should emphasize that the new BC physician pay model not only attracts new doctors but it also encourages rostering, encouraging doctors to become the single point of generalist GP that is becoming scarce in Alberta according to the article.
My take on it is that ACA set up the insurance companies as essentially a cost-plus system. I forget the actual name for it in the ACA, but the general idea is that insurance needs to spend at least 80% of the premiums on health care. Sounds good at first pass, but there's also no limit to costs in the ACA. So the way an insurance company makes more money is to pay more for service. And the providers are happy to comply. Costs go up, insurance explicitly doesn't fight costs, so that premiums go up and they keep 20% of a bigger pie now.
I've essentially stepped out of the system. I get the cheapest, biggest deductible policy through my employer to cover a big emergency. But for my personal care, I do Direct Primary Care where I pay my doc $175/mo for my family of 4 and any time I need him, he's there "for free" no office visit fees, etc.
If I'm sick, I can always get same-day telehealth or next day in-office visits. For routine care, I may have to book out a week or so. He's never rushed because his incentive is consult me to keep me healthy so that I _don't_ need to see him. His incentives are not to keep me coming back for more visits.
During my last routine yearly visit, we had a hour long conversation about all the little nagging things that were happening has I get older, and we made a good plan on what to do.
I love this model and I could see it scaling like this:
Rather than forcing (individual mandate) ACA-specified insurance purchases, you are "forced" to put that cost into a HSA-like account (government supplemented for if you can't afford it), and then use the HSA to buy the insurance and/or DPC memberships you want and work for you. That would put downward pressure on price since you're making the decisions not the insurance/government. And you adds competition on service since you choose your providers.
Waiting for Doug Ford to short-circuit this even more and allow MAiD drugs to be dispensed by his friends at Shoppers Drug Mart. He already wants them to start playing doctor so much more...
Why are you using PCPs? The urgent care route seems more efficient, scales, and takes advantage of electronic medical records.
I personally have not had a PCP singular doctor or doctor group in years. I use an urgent care franchise as my PCP.
I have a chronic ailment that requires daily medicine and the medical staff at the urgent care has been more than capable of providing care, writing scripts, and providing referrals to specialists.
The idea of an ongoing relationship with a single doctor has always felt to me like a relic of that mythic past when people would spend 40 years working for a single employer before retiring with a pension.
In my life, as a generally healthy person working in the software industry, I have switched health insurance plans almost as many times as I've needed medical attention. What's the point of going through the trouble to establish a relationship with a PCP when you will see them at most twice, likely only once, before you have to start over after taking your next job?
For primary care. I believe that's where the name Primary Care Provider comes from.
The difference from urgent care is long term. Having the same PCP for long periods of time provides an opportunity for deep insight and developing a personal relationship.
Urgent care is often a 1-4 hour wait and insurance tends to have a higher copay. If you have a patient profile at a large health care provider's facility, you can often get appointments same or next day if you're willing to be flexible about the specific provider that sees you, with the normal (~15 minute) wait and lower copay.
Anyone looking for a solution to physician quality or availability can find it through direct primary care / concierge care. Personally I pay $60/month to have unlimited access to my physician in Austin.
The physician, in turn, rather than having 40% overhead, has no overhead from billing or insurance. They have simple monthly cashflow that they can allocate to cover rent and wages for their practice. This means that the physician can choose how many patients they have relative to their expenses, and decide how much time they have available on average for each patient.
The result is great for the patient, great for the provider, and the sort of thing that will help increase availability of doctors, and their satisfaction with their work.
You can find more on this from https://www.dpcare.org. Here's a map of direct primary care practices: https://mapper.dpcfrontier.com.
I've been experiencing this exact issue in the US. Lately a medical issue of mine has been getting worse, and the earliest I can see a new PCP is in May 2025. I managed to get a referral to a specialist by visiting urgent care, but they referred me to a different specialist, and I won't be able to see the latter until late January 2025. Meanwhile my medical issue is continuing to get worse, and I have no one I can talk to about it. I'm looking into alternative options but things are looking bleak. I'm probably going to have to go out-of-network and drive 2 hours to find a doctor that has wait times on the order of weeks (as opposed to the in-network providers, that have wait times on the order of months).
If you think it’s worth it, you can fly to a few places in East Asia or Southeast Asia where you can see a medical specialist in private hospitals on the same day, especially if arranged a couple of days in advance.
These include Singapore, Thailand, Malaysia, Hong Kong, Taiwan, etc.
The quality of care in these private hospitals is usually high as well.
For some cases, the costs in more affordable locations among the above—even after including economy flights—could be cheaper than treatment in the US.
https://chatgpt.com/share/e/671fb198-2a34-8011-a2e8-e0b4aa45...
The city of Merida in Mexico might also be an option.
> I won't be able to see the latter until late January 2025
Where are you? This is unusual.
In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1]. In Canada, the "median national wait time 1 was 78 days," with wait ime "defined as the period between a patient’s referral by a family physician to a specialist and the visit with said specialist" [2].
Broadly speaking, American medical wait times are quite good, particularly for specialists [3]. But PCPs/capita vary greatly from state to state [4].
[1] https://www.wsha.org/wp-content/uploads/mha2022waittimesurve...
[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC7292524/
[3] https://worldpopulationreview.com/country-rankings/health-ca...
[4] https://www.beckershospitalreview.com/rankings-and-ratings/s...
I've seen this too, in the northeast US. I didn't go to our family doctor of 10+ years for 18 months during COVID-19. When I called for a new appointment, they said I had was no longer a patient and had to wait at least 90 days for an appointment to address a painful condition. I still haven't gone back, and now I just use urgent care if needed.
I had similar problems with a specialist. Their appointments are typically six months out, and if you need something more urgent, the answer is "sorry that's all we can do." My last actual appointment, after the ~six-month wait, was a simple 15-minute telehealth visit. It's insane.
I have great insurance and I've never had any problem paying. It's amazing to me that doctors seem to really push back against having patients, or their patients having appointments. Isn't this how they make money? What kind of weird market effect incentivizes this behavior?
It's interesting that dentists and oral surgeons seem to be the opposite. I've never had a problem finding one and they usually seem welcoming, happy to help, and glad to have the business.
It is really frustrating but I've found that most doctors and hospitals have two systems. One for new or very infrequent patients. One for established or regular patients. The latter gets appointments fairly quickly in most cases.
It is rather messed up but One Medical (now owned by Amazon) and a few other services can be worth the money because they have access to the fast track appointment line.
I only know this because after many many months of searching for a primarily care doctor and waiting for an appointment I was told about this. New patient scheduling for my doc is months out. If I email and ask if I can come in next week they always say how about tomorrow/the next day?
Every doctor I personally know is double booked at least a substantial portion of every single day. They count on last minute cancellations and no shows just like airlines do in order to maintain their schedules.
Making friends with folks in the medical field is eye opening to say the least. The system is operating redlined and has been since before Covid. Covid just caused the fractures to finally start showing to the average person.
The real thing coming for us is that every doctor I know other than some specialists are simply counting down the days until they can leave the field of direct patient care entirely. Whether this be early retirement, paying off student debt and bouncing, or making a lateral move to research or a tech firm. The field has gotten to be untenable for many, typically the ones who actually care. The profession as a whole has lost its personal agency to the administrative class. It’s not idle talk either - plenty have actually already executed on these plans.
Maybe there are simply not enough doctors, so their waiting list is exactly that, months long?
I think it's likely simply gotten worse since those studies.
A friend of mine needed a specialist. She called multiple offices across two different states, and the soonest appointment available was about 4 months out.
Four or five years ago, we didn't typically see wait times like that.
Could this be a result of HDHP plans that allow "direct to specialist" appointments, as opposed to triage through a PCP?
OP is correct in my anecdotal experience. I live in a large urban area and wait time for PCP is several months out. Even longer for Women's health as I hear from my partner.
I don't remember it being this bad in the past. Perhaps things have changed in the several years since those publications were published.
There are several reasons for this, but the gist of it is that pharmas have moved much of the actual work of running large clinical trials to contract research orgs (CROs) and the cost of recruiting patients for trials, training staff, records keeping, and administering the trial becomes out of reach for small independent sites where clinical trials are executed. It's also more efficient on the sponsor side to interface with one large entity rather than several small entities.
I suspect that the increasing demands of technology and burden of records keeping in both clinical trials and health insurance makes it difficult for small independent sites to operate profitably. So what happens is that many small, independent offices end up joining a larger entity that can consolidate some of the "system level complexity" more efficiently. The tradeoff is that it's no longer about the doctor-patient relationship; it's about efficiency and profits.
I also suspect that part of it is that PE realizes that consolidation lets them control prices. If they can control a network of trial sites, then they have more power to negotiate rates with sponsors and CROs for each patient they sign up to the trial. The bigger the network, the greater their leverage. I think this probably also holds true for healthcare and insurance providers in general.
[0] https://www.fiercebiotech.com/cro/private-equity-invests-tri...
I live just outside a large urban area, and my wait time for a PCP is weeks if I agree to see their PA (the PCP will review all findings anyway), or days if I put myself on their cancellation list. Maybe try calling around just outside of your urban area.
> This is unusual.
Is it? That's pretty normal in my part of the US, and that's assuming you already have a PCP. If you don't, then finding one that's accepting patients can take much, much longer.
> Is it? That's pretty normal in my part of the US
Are you in a state with a shortage of PCPs [1]? If so, yes. But most Americans aren't in those states, and in at least a few of them the harm is closer to a political choice than an oversight.
[1] https://www.beckershospitalreview.com/rankings-and-ratings/s...
I have heard the same comments from people in states all across the nation. It may very well be that it's a minority of states (I don't know), but it's certainly a very substantial portion of the population that's affected.
I'm not asserting that what I've experienced, seen, and heard represents the majority experience. As I mentioned, I don't know. But it's not exactly a rare experience.
In FL. Been to 2 different PCP over the past decade. Was 90+ days before I could get my first appointment at both locations.
I’m in Southern California and it also is a bit of a wait
IME (SoCal) the 1st visit can take 2-3 months. After that you can get back in with only a 2-3 week wait, shorter if it’s urgent.
They seem to rate limit new patients so current patients can get in.
USA/Bay Area here.
My surgery took months of specialist appointments and months to get an OR slot. There was a conflict and it was delayed again.
I changed networks and when searching for a new PCP I had to wait over a month for the first appointment.
In my experience it depends on the speciality you need.
If you need to see an Otolaryngologist (ENT), you might be able to get an appointment within a few weeks. If you need to see an Endocrinologist, it might be 4-6 months.
There is a specialist shortage. Refs I've sent to Endros take months. I've even had to refer patients to places nearly 150 miles away.
Connecticut. Everything is like this here. I have genuinely considered moving because of this. My current employer has another location in California, and as much as I hate the idea of moving back there, it might be necessary for my own physical well-being.
> This is unusual.
> In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1].
I want to point out the important missing fact there that the "America average" time tells you nothing about variance across geography, specialty, or patient population, and you really need to at the very least look further down at the charts where they talk about shortest and longest times in the different cities and specialties.
For instance I see Boston's longest 2022 time for family medicine is 136 days, average 40 days. And Massachusetts is one of the top states on your list for PCPs per capita. At least that's better than 2017 where the longest time was "fuck you, get rekt, lmao".
Sometimes a doctor is available but crappy scheduling software hides that.
I got a small scratch from a squirrel and since it did cause a little blood to appear I figured better safe than sorry and went to Kaiser's site to make an appointment with my PCP.
They had nothing for a few weeks.
So I changed to requesting an appointment with any doctor at the same facility. It then gave me an appointment with my PCP for the next day at 9 am.
I've seen similar problems with vaccine scheduling using their web site. It will sometimes only show appointments at a bigger Kaiser facility in the next town, or an even bigger one 30 minutes away.
But if I actually go in and talk to the people at the front desk at the Kaiser office in my town they can often make me an appointment at that facility.
It's also much faster to get in front of a NP than a doctor.
I had this issue due the consolidation of medical networks.
Luckily I have a BlueCross PPO. So I’ll get fast access to a specialist in NYC in Boston then transfer the records back to the local dude if needed. My wife had an issue with a complication, and I found a doctor who was a contributor to a major study on it and we got treated by him. Epic makes managing this trivial.
It’s the best of both worlds, but only if you have the privilege of legacy insurance and PTO.
10 years ago I could see my doctor when I was sick. Like, the same day. Now if it can't be done at the Target or CVS, it's the emergency room. I didn't even get an annual checkup last year because my doctor had to cancel, and the earliest I can be seen again is this summer. I'm now at the age where this is probably starting to matter.
And I pay like... $30,000 a year minimum for this?
> 10 years ago I could see my doctor when I was sick. Like, the same day
Have you tried telemedicine? I've done it through One Medical, and it's a charm for little things that require a quick check-up.
I sort of find telemedicine to a be a scam. I’m sure it has its use case, but most of the time it feels like they are trying to limit liability so they just tell you to go see a doctor in person.
I know insurance can be pricey, but $2500/month? Who's your provider? Do you have a family of 6 or something?
I pulled insurance quotes for my wife and I recently. Both of us are young and with no known health issues. Our monthly premiums for the cheapest plan was around $800 per month, but that was with very limited coverage and a deductible of around $15,000 before they would cover any major expenses.
The premiums would be $9,600 a year but all in we could spend around $25,000. We had options for higher premiums and lower deductibles as well, but the total max out of pocket was almost identical.
Make sure you are fully aware of federal subsidies for your insurance premiums.
It's a bit complicated to explain the details, but basically you won't pay more than about 8.3% of your AGI for insurance, no matter what your income level is.
Alas, these subsidies may expire next year if Congress does not renew them (they don't actually vanish, they are just income-capped at 400% of the federal poverty level).
To save people a lookup, 400% of the federal poverty level in 2025:
An annoying aspect of the subsidies is that they have an abrupt drop as you cross 400% FPL.From 133% (if you are below 133% you are supposed to use extended Medicaid instead of a subsidized marketplace plan) to 400% the amount of the subsidy goes down bit is still substantial at 400%.
This can result in a situation where if your income is a little over 400% FPL you might come out ahead by taking a pay cat to get under.
My employer pays $3,575.49 per month for my HDHP ($12,000 deductible). Family of 3. It's Aetna, through one of the large small-business payroll providers. Are we getting ripped off?
That seems high. Family of 4 and I pay $447, employer pays $1,342 (so total $1,789).
My plan is Anthem Silver Preferred Blue PPO 4000/10%/7250 w/HSA - in other words $4000/person deductible (or 8k for whole family).
This is through Gusto, company is in New Hampshire.
You're probably not getting ripped off (relatively speaking). When I quit my job to take some time off 3 years ago, and signed up for COBRA, the out of pocket expense for 2 adults came to around $2000 per month, also for an HDHP plan.
Kaiser's "platinum-level" (90% average coverage, no deductibles) plan for a young nonsmoking adult runs about $450/mo in my state marketplace, and most of that is further subsidized for someone who isn't making middle class wages. The medium-deductible, 70%-average-coinsurance "Silver-level" plan is about half that.
I don't even understand the concept of a $12,000 deductible when the ACA established maximum out of pocket at:
> "For the 2024 plan year: The out-of-pocket limit for a Marketplace plan can't be more than $9,450 for an individual and $18,900 for a family."
What are you even paying for?
The individual marketplace plans seem to exist in a totally different world from employer-provided plans. When I went from my old employer's COBRA to an MD Health Connection plan, my premium dropped nearly fourfold even with no subsidies.
Yes, I have a family of 6.
Premium + deductible + prescriptions + out of network care
I believe 30k is possible for a healthy single American.
I didn't think so back when I was in a startup insurance program where it literally covered stuff.
But i've been on a "normal" health plan through my wife's job for the last 5 years.
The American health system is experienced totally differently by different classes of people.
Just because it's possible, doesn't mean it's typical, or even common.
I mean my wife and I pay $700/mo premium, we both hit our $2500 deductible this year already, my physical therapy is out of network and costs me $800/mo
That's $23k already before prescriptions and we are in our 30s with no major health issues.
I think Taiwan is worth adding to the list of healthcare systems that folks study. I believe it may be similar to the Swiss system.
Everyone has national health insurance, but you also get to choose where to go, and some doctors also offer non-insured services that you can pay for out of pocket.
The result is universal coverage combined with a competitive market that drives prices down and encourages innovation.
I know this is just anecdata, but having held an insurance card there for a while, our family was always able to see our family doctor the same day we called. And the one or two times a specialist or emergency room was needed, there was minimal hassle.
I'm sure there are problems with it, too -- I just don't know what they are. As a customer/patient, it seemed to work far better than the American system I'm used to.
Most of Europe has a similar model to what you've described: some form of mandatory state-backed insurance combined with a mix of private and public healthcare providers. In many countries, however, the biggest hospitals in Europe are owned by the government.
Unfortunately the healthcare systems are in the process of collapsing across the UK and the majority of the continent too.
My pet theory is I don't think it's actually anything to do with the overall funding model. I think it's to do with our inability to adapt to an increasingly elderly population. People's kids here are scattered around the country, often many hours of travel away, living in small apartments, and can't easily look after their elderly relatives in a way that's much more common in East Asia. As a consequence, we are offload that responsibility onto the healthcare system, which treats them as patients with medical issues, when often they are just old people with broadly normal age-related disease. Our systems were never designed to be capable of handling millions of elderly people, and it's not an efficient way of providing the required care, so it's falling apart.
This is my understanding of the US situation.
It used to be that doctors were running their own small medical offices a lot. Unfortunately, due to insurance overhead it's no longer profitable for individual doctors to do that, especially without existing patients, so the remaining offices are mostly from doctors near retirement age.
So as doctors retire and new doctors don't want to start their own practices those practices have been getting bought out by large medical networks or private equity. Some offices are also going out of network with insurance companies. It doesn't help that PE is willing to pay a ton more than any new doctor could for the practice.
I'd recommend picking medical plans with out referral requirements and with good out-of-network coverage.
I wrote a more detailed post elsewhere in this thread, but I also think this is the case and you can see an analogue with consolidation of clinical trial sites by private equity.
https://www.fiercebiotech.com/cro/private-equity-invests-tri...
My brother was a Family Medicine doctor and he got burned out and retired early and is now a potter lol. His ex gf was a doctor and did the same. I suspect this sort of thing is behind a lot of the issues this article is explaining. After Covid, a large portion of the world that could retire did so and never came back. Those that are left and stuck in that world working or trying to use it, are not happy about it.
I'm intrigued by this line from the article:
> Before the pandemic, she says, she might have done two disability tax credit forms; last year, she did twenty
Did Covid cause massive disability? Did legislation change to make claiming a disability easier or more lucrative? Are people claiming disability in response to inability to get jobs that meet their expectations?
It's not the point of the article, but a 10x increase in requests for "disability tax credit forms" seems like a very significant sign of something deeply concerning.
I wonder how many people seeking disability are more accurately described as disenfranchised. If people are looking at bleak prospects of low-paid jobs with limited possibilities for advancement, alongside soaring housing and other costs, how many people with previously manageable impairments are throwing in the towel and using a disability designation to escape the rat race.
Yes, Covid did cause massive disability. The colloquial term for it is Long Covid. I know at least three people suffering from it —- along a spectrum from slight to severe impairment of daily functioning.
> Covid did cause massive disability. The colloquial term for it is Long Covid
I know a previously-healthy guy who got an early variant that went for his pancreas. He now has Type 1 diabetes, a condition one is normally born with and for which there is no cure, just chronic, expensive and time-consuming treatment.
> He now has Type 1 diabetes, a condition one is normally born with
Type 1 Diabetes isn't something someone is born with. Rather, it's something that you generally get when young (and, in fact, it used to be called Juvenile Diabetes, vs Adult Onset, which is what Type 2 used to be called), but it can happen later in line, all the way into the 20s (or later, I believe).
There is a genetic component, but it's also completely possible to get it with no family history.
Didn't realise it was autoimmune. Nevertheless, in his case it was directly caused by Covid attacking the pancreas. That said, he got it in 2020. The virus got milder over successive generations. (Intrinsically and due to broader vaccination and antiviral administration.)
There's actually a couple different "types" of Type 1 Diabetes. For example, you can get it during pregnancy (Gestational Diabetes), etc. So it doesn't surprise me that it's possible to get it from Covid. I seem to recall someone getting it from an injury that damaged the Pancreas enough to prevent it from generating insulin. I don't know if that still "counts" as Type 1; but it certainly has the same effects.
> an injury that damaged the Pancreas enough to prevent it from generating insulin. I don't know if that still "counts" as Type 1
It does. Type 1 is fundamentally about an inability to produce insuline. Type 2, an inability to respond to it.
> He now has Type 1 diabetes, a condition one is normally born with
This is simply untrue. You can be born with it, but it's certainly not the common type of type 1.
How old is he? Type 1 can show up in your 20s-30s, it's not always the case that you're born with it
I think it's a combination of long covid and the effect covid had on people's mental health.
Being "disenfranchised" can very easily lead to major depressive disorder, anxiety disorders, etc.
Even for the first person described in the story, her search for a doctor is not primarily described a search for medical care, but a search for someone who can create a paper trail to ensure her child's eligibility for benefits.
A lot of the problems in medical care have nothing to do with the system (Canada vs US) and everything to do with doctor supply.
It’s simply not a great career choice anymore. You start work very late in life, and make only OK money. Some specialists make a lot but they start even later. Some GPs make a lot but they run patient mills. For most GPs, it’s an extreme slog without extreme reward.
The same career issue goes triple for nurses. Young nurses are quitting in droves.
> and make only OK money
Sounds like it has a lot to do with the system.
In the US, because of employer insurance, the cost of insurance is mostly hidden from patients. The cost of medical care is similarly opaque -- consumers expect routine checkups to be essentially free, and sick visits to cost next to nothing. Insurance companies are always trying to drive down their costs, and control access for a huge set of patients.
It's a broken system. Years of training, very selective, highly expensive... only for a lot of it to be telling people common sense things like eat less and excercise more.
I know it would be political suicide, but I do believe that we could still have a very good medical system if the level of education we demand of doctors was reserved for surgeons and leadership and the front-line work of GP-style treatment was 100% left to people who were qualified by a normal nurse-style process of undergrad + apprenticeship + test.
That's kind of how it works outside of North America. Students go into medical school right out of high school, and medical school is about 6 years - maybe including residency. They graduate with a degree that allows them to practice general and family medicine. If they want to become specialists, they keep studying and more residency.
North America seems to be alone in requiring a 4 year degree before letting a student anywhere near a medical school.
Also "rest of the world" the medical professionals do not get into massive debt and hence do not need massive compensation upon graduation to offset. One issue of getting more supply of doctor would, I believe, be the resistance from the current system since more supply means lower prices...
Additionally since a lot of our healthcare is managed by Private Equity or other forms of investors that are looking for a profit, I suspect with cheaper staff they will just keep prices the same and increase their profits.
I’ve heard what the article describes about specializing being the way to go. In the US, insurance is also a huge pain in the ass; doctors have to fight to get paid as often as we have to fight to have things covered. There’s also the overhead of insurance for their practice, the costs of running a clinic or being part of a clinic group, maintaining compliance with everything, paying Epic’s extortionate fees, etc.
The last two doctors I’ve had have gone to “concierge” services to help mitigate this. They stabilize their income with annual membership fees that sidestep the insurance company horseshit. They constrain their roster a bit. They can see people more quickly. But you have to be a member.
It’s sad for me, but I get it from their perspective. “Retail” healthcare in the US is by all accounts a nightmare.
I wonder what percentage of medical issues we could tackle by better analyzing and categorizing the existing medical studies that are out there.
And then attaching a user interface to the data that guides the user through a step-by-step self-diagnose process.
There is too much "medical students syndrome" - you learn about some symptoms and they decide you have the issue because the symptoms match even though they don't match in the right way.
There are also a lot of rare things that need expensive procedures that shouldn't be done on a whim. Many medical tests increase your odds of cancer for instance - if you really need that test done to figure out your issue it is worth it, but those tests shouldn't just be done - it is often better to treat the most common causes without verifying that is really the root cause and then only if those treatments fail do the tests to see what you really have.
An interesting thing I'm seeing happening in primary care is that doctors are being replaced by doctor adjacent professions like Nurse Practitioner, Physician Assistant, etc.
A doctor spends a decade working 60 to 80 hour weeks studying medicine whereas an NP is a Master degree, I think which can be obtained online.
There doesn't appear to be clear results yet in studies on the outcomes of NP's vs MD's (see reference).
Another argument is that maybe all that medical school training is overkill in Primary Care and this is perfect setting for NP's or PA's. And also maybe most doctors are not ambitious and forget most of the training they're not using on a daily basis anyway.
I think it would be pretty funny if after more studies NP's showed no different outcomes than MD's.
Interesting write up on NP outcomes.
https://pubmed.ncbi.nlm.nih.gov/18766097/
>If family doctors’ compensation is going to be the lowest of all physicians’, they at least want to rein in their hours and responsibilities. And they want to be able to take a vacation.
The article is relevant, but it is a case of "you get what you pay for".
It's so frustrating. We signed up for a pediatric practice in Atlanta that has 8 doctors.
We saw a great doctor on our first visit, then our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse... So on our way out when scheduling we asked if we could see the same Dr next time.
"Oh sorry she only works Tuesdays"
"Okay weird but this is 2 months out though so that should be fine"
"Actually Tuesday would put you over a week away from when the appointment was requested I can schedule you with ..."
3 visits later and we still haven't seen a doctor once. Not even a 30 second pop in the room to say hi.
We've gotten like 20 immunizations from nurses and can't ask doctors about any of it..
Like cool cool all for these peopl advancing their careers without med school but like ... Usually you want your doctor's to have gone through medical school
I live in Atlanta and I wonder if it's due to the influx of out of state families moving in. It didn't use to be like this. My child was sick recently and we couldn't get an appointment for a sick visit for several days. This too is an office with a dozen docs/NP.
We ended up going to another one of their offices 30 minutes away which had availability (i.e. lower population density?).
For the receptionist that said "it would put you a week away"...that's when you should just push back and say that's fine. There are very few appointments that need to be exact. And you know what, if you're not sure and you're there, ask the doctor if it's ok :)
Also because I'm trying to spread awareness and you'll likely encounter this: Be aware of "hospital/facility fees".
https://www.theguardian.com/us-news/article/2024/jun/09/pati...
This happened to us, with a Northside Imaging center in a shopping plaza. A chest x-ray that's normally $50 at a regular center is costing us $500.
> our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse
Is your kid sick? If not, you don't need a doctor.
For a baby you have regularly scheduled appointments through the first year to make sure developmental milestones and for the correct immunization schedule.
The amount of bad and actually hazardous parenting advice I've gotten from nurses and PA's is staggering.
When we were discharged from the hospital, the pediatric nurse actually told us it was safe to feed him in the car seat on the drive home.
> a baby you have regularly scheduled appointments through the first year to make sure developmental milestones and for the correct immunization schedule
Sure. None of this requires a doctor, though.
> pediatric nurse actually told us it was safe to feed him in the car seat on the drive home
This is bad advice. But I'm failing to find studies that quantify the risk. You're correct that they shouldn't have said this. But I'm not convinced no doctor would advise similarly.
If everyone wants their kid to be seen by a doctor, we either need to lower the standards of doctor or normalise perfectly-well kids being seen by NPs. (That or a higher billing code if a patient demands a doctor for routine care.)
By the way I'm curious how long ago you had your children, as I'm finding that advice from previous generation parents does not age well at all.
I find this to be true also. But how can this be? Either feeding a baby in a car is not that big of a deal, or something about the cars or carseats changed? I think it's more like the former.
I'm sure you can get all kinds of dated advice from board-certified physicians too.
>Sure. None of this requires a doctor, though.
When literally googling your question is more reliable than asking your 'doctor', something is in need of fixing.
> When literally googling your question is more reliable than asking your 'doctor', something is in need of fixing
Google can't administer vaccines. It also can't fill out a chart that might be important in an emergency.
I thought socialism was supposed to solve all of this? At least in America we're told that Canada is a clearly superior system, yet I hear over and over again, even first-hand from people in the UK that it sucks for really quite basic things.
At least part of it seems to be that the price system is completely screwed up, the doctors need to be payed more and it's obvious that the institutionalized insurance system is a root cause. When government (or their heavily regulated proxies, or any third-party for that matter) sets prices, expect services and products to deteriorate in quality.
Everyday non-emergency care should be a transaction directly between a doctor and patient. That WWII screwed up the whole system through price controls on wages and locked us in, path-dependency style, to forever paying a useless third party is nothing short of infuriating.
I see the same issues here in the states. I think no matter what the economic model, we need to take a long hard look at the overhead and complexity of healthcare. And by and large, I suspect the insurance companies will be found to be at the root of it.
I can't believe I of all people am calling for less regulation, but the amount of bullshit it seems like doctors have to go through to provide basic service seems counterproductive.
I think people will hit a breaking point and it will be undeniable that heavy regulation and subsidization is the root of dysfunction and deterioration of most important aspects of life.
It's hard not to see the parallel between healthcare and education where the parasitic overhead has been completely unchecked and enabled by federal subsidies. There's a similar deal with food, housing and other areas. It's absurd the amount of money that has been spent by the federal government in these areas with so little to show, the average person feels not only a lack of progress but decline.
You don't have to deregulate to move away from demand side subsidies as your main intervention.
Much of the regulation you’re saying is to blame was written in blood.
Want to know what food and housing was like before regulation? Read the jungle.
Do you think we have deteriorated since then?
Maybe the prosperity you think has deteriorated was not due to lack of regulation, but due to black swan events like… i dunno conquering and industrializing the entire North American continent, all peer nations blowing each other to bits in two world wars, etc?
I agree that all regulation is written in blood. But at the same time, regulation can result in bleeding, and we don't always carefully weigh the costs and benefits of regulation. There may be a law that saves 100 lives a year, but that indirectly causes 150 deaths due to knock-on effects.
It's not easy to inject nuance into a discussion that feels like you have millions of people on each side of a tug-of-war rope that goes from "MORE REGULATION" to "LESS REGULATION".
I think housing, which you mention, is an excellent example. Yes, we need regulation in housing because without it, people will die from shoddy structures collapsing on them, electrocution, gas leaks, etc. But at the same time, in the USA there are absolutely regulations in housing with very little benefit and absolutely massive costs, where we have examples of first-world countries without those regulations that do just fine. I'm talking about things like the requirement that all apartments have 2 stairwells. Or mandatory setbacks and minimum lot sizes and parking requirements. edit -- and of course zoning codes, where we've shifted the market toward building housing that's so big that people can only afford to share it with strangers. And while people used to live in crowded, cramped tenements, driving housing prices up by restricting supply leads to people living on the street.
In medicine, there are diminishing marginal returns to making doctors go through more schooling, and the cost is simply that fewer people choose to be doctors, and people just go without health care. And even within that simple dilemma of "should we make it harder or easier to be a doctor", i'm sure there is a universe of alternate ways to move the needle in different dimensions. Requiring more or less schooling, more or less time in residency, changing limits on the number of hours doctors and nurses can be scheduled in a week, tightening or loosening malpractice law in different ways, etc. Each of these has some positive and negative effects, and I'm sure we have a ways to go before we hit the optimal point. And even then, you have to choose how to balance quality of patient care against doctors and nurses quality of life!
Or take drug approvals. There are drugs in development that show lots of promise, that probably should be made available to people who are dying anyway and want to try them. The FDA does not allow that. We have to balance against companies trying to scam people with fake medicine. No policy is 100% without harm. I believe that, even for policies I strongly advocate.
Or laws that were originally targeted at local environmental protection, that are now being used by nearby residents to stop solar farms from being built, stopping us from reducing fossil fuel usage. Those regulations were written in the blood of wildlife -- and now they're cause much more harm than good to wildlife all across the world.
So if you are asking if we've deteriorated since The Jungle, in many ways, no, of course we've improved safety of working conditions massively, and lots of other things. But in other, important ways, we've gone somewhat backwards. I believe it's absolutely possible to improve our society by removing some regulations, but I think it takes a lot of careful, small, targeted tweaks, where we've carefully weighed the costs and benefits. Though in rare cases, like as in parking minimums, the evidence is that they are so harmful that just scrapping the regulation entirely is the way to go.*
> Want to know what food and housing was like before regulation? Read the jungle.
Not convincing since you're reducing the entire time period to The Jungle which was sensationalized fiction, effectively political propaganda.
But to your broader point, things improved directly from capitalism and markets. My reading recommendation? Deirdre McCloskey "Why Liberalism Works" on the absurd increase in living standards brought about through innovation enabled by capitalism, we're talking some 3,000% in average income over the course of time you're referring to.
> And by and large, I suspect the insurance companies will be found to be at the root of it.
At least in the US, this is true. The pervasiveness of interaction with insurance and the power they wield turns them into a rent-seeking layer with the massively negative economic effects of socialism.
Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.
> Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.
The problem with this model is that often very catastrophic things can be caught during routine care, so it actually makes a lot of sense for insurance to pay for a yearly physical. Otherwise a lot of people are going to wait until their spine is blown out and their knees need replacement to seek any kind of care at all, at which point their care is 100x more expensive than if they did a yearly.
Any other kind of care like going to the doctor because you're sick is entirely the point of insurance. It covers your medical care for unanticipated problems.
Getting sick is not an unanticipated problem. A major illness or injury is.
Insurance has no business paying out for you going in for strep throat or the Flu or an annual checkup. These are normal things everyone gets multiple times throughout your lifetime, and should easily be taken care of via market forces for a very reasonable fee.
The problem with US healthcare can be entirely boiled down to a principle agent problem. Someone else is always paying, so no one actually really cares that much about the cost of things and the incentives always are to increase costs and use more services since there is no actual market competition.
Worse than that, nobody gets a choice anyway. If don't have to take the insurance my boss offers me - but if I don't I'm throwing away more than ten thousand dollars in subsidies they offer. It is really hard for anyone to compete with that deal - there are things I don't like about my insurance but it isn't worth shopping around as nobody can come close to the price/service they are giving me.
I have long wanted to get rid of the insurance/employer tie, but I'm a minority and so nothing gets done.
It is valid for insurance to give you a discount if you get your yearly checkup. They can even calculate how much discount you should get for this.
People say this a lot but it feels unlikely to me. I think the biggest causes of the problem love the idea that insurance is to blame.
Hospital admin, doctors orgs, pharmacy benefit managers are all much more interested in things being overly complex, under-staffed, etc. Insurance companies just want to sell insurance with the % profit that is typical of insurance (eg Cigna's profit margin is the same as Allstate).
Besides, if insurance was to blame, it would work better in Canada and other countries that rely on private insurance less. But Canadians don't seem very pleased with their longer waits.
We need more doctors and nurses [1], full stop. Anything that prevents an aggressive increase in supply of these workers is something that needs to be actioned against.
Healthcare is a utility masquerading as a profit based industry. Squeeze the profit and inefficiency out, any comp should be going directly to systems and people providing care. Insurance companies? Gone [2]. Pharmacy benefit managers? Gone [3]. Lock private equity out of owning anything healthcare related [4] [5] [6]. I don’t want to knee jerk “union” for individual contributors, but you need some sort of governance mechanism so the CEO of a non profit hospital isn’t taking home $1M/year [7] [8] [9] while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios, which are used to increase labor load without increasing labor costs or hiring more practitioners [10]).
[1] https://thehill.com/changing-america/well-being/prevention-c...
[2] https://penncapital-star.com/uncategorized/americans-suffer-...
[3] https://www.ftc.gov/news-events/news/press-releases/2024/07/...
[4] https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltex...
[5] https://www.washingtonpost.com/business/2024/10/17/private-e...
[6] https://www.theguardian.com/business/2024/oct/10/slash-and-b...
[7] https://www.npr.org/sections/shots-health-news/2024/08/19/nx...
[8] https://www.audacy.com/wwjnewsradio/news/national/revealed-c...
[9] https://arstechnica.com/health/2023/10/nonprofit-hospitals-s...
[10] https://healthjournalism.org/blog/2023/09/a-primer-for-cover...
> We need more doctors and nurses, full stop. Anything that prevents that is what needs to be actioned against.
I agree we have a shortage, but to offer a counter-argument:
We shouldn't need a 100% full-blown doctor for everything doctors do today. We could also help address the shortage by splitting out some responsibilities that are restricted to just doctors among professionals that only have 80% (or 60%, or 50%) of the training / certifications of an MD.
We've already presumably been doing this in the US with physician assistants and nurse practitioners. It hasn't solved it, but the problem would undoubtedly be many times worse without them.
Great call out, I agree. NPs [1] are the NCOs (non commissioned officers) of the medical field. Where applicable, level up folks with the desire and aptitude from RN->NP. This specific pain point is a talent pipeline health and structure challenge. MD feelings around this are going to be something to consider, to note when preparing for the opposition [2].
[1] https://en.wikipedia.org/wiki/Nurse_practitioner
[2] https://www.ama-assn.org/practice-management/scope-practice/...
If you said "Where applicable, level up folks with the desire and aptitude from IT support->senior engineer. This specific pain point is a talent pipeline health and structure challenge. SWE feelings around this are going to be something to consider, to note when preparing for the opposition" people would go wait, maybe the occasional fresh bootcamp grad or ITsupport technician has the potential to do strong work or manage a team, but in general their education has not prepared them. Of course if you ask a doctor "could the RN or NP run this floor" there's a conflict of interest when they tell you "no", but they're also correct.
Having a nurse is probably better than no medical care at all, so a tiered system where poor people get nurses without realizing they're worse than doctors would have that advantage, but the right overhaul imo would be reducing the years of schooling required to become a real doctor (undergrad, med school, residency, maybe fellowship, finally attending). If doctors skipped undergrad and cut out some med school or fellowship requirements, they'd start working earlier and could afford to choose specialties that pay less. As well as expanding residency slots and moving insurance compensation to family medicine and pediatrics.
edit - here's a good example, https://old.reddit.com/r/medicine/comments/1f6m5i9/its_scary... the good news is they'd agree with you that midlevels do have a role, the problem with scope creep is defining what that role is, and the assumption that the training is 80% or even 50% there
> the CEO of a non profit hospital isn’t taking home $1M/year while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios).
In Houston, the renowned Texas Children's Hospital did layoffs — after paying millions to their CEO and other executives. FTA: "Over a seven-year period from 2016 – the earliest year of data published by the Internal Revenue Service – to 2022, the average pay for Texas Children’s 10 highest-paid leaders ballooned from $963,971 to nearly $2.2 million, an increase of 125%. (The latest tax filings do not reflect how much leaders at Texas Children’s earned this year, after the hospital reported major financial losses.)" [0]
The usual response defending such high compensation is something like, "We have to pay our execs so much because we're competing for talent with the for-profit hospitals." OK, one possible solution might be returning marginal income tax rates — across the board — to what they were in the 1950s. That would help neutralize the constant craving for more money as one of the main ways that execs judge their personal career success. "The top income tax rate reached above 90% from 1944 through 1963 ...." [1]
[0] https://www.houstonchronicle.com/projects/2024/texas-childre...
[1] https://www.wolterskluwer.com/en/expert-insights/whole-ball-...
I'm fairly certain a large chunk of the problem is demographic shift. healthcare is one of those industries most used by the elderly, and the proportion of the population in that demographic has skyrocketed
Also I would guess that there is more healthcare, more options, more procedures, more drugs. Length of stays in hospitals might have shortened due to less invasive procedures, but if more procedures are done and there is not increase in staffing, time is spread over larger number of patients.
I think there are things that could do with less regulation in Canada that would be easy wins.
Like for people with recurring prescription meds, maybe don't require them to make an appointment every month to get their meds? Even if we consider extreme examples like opiates, it's not like cutting off drug abusers or people selling their meds does anything to curb the opiate crisis. Opiates are already available everywhere and the supply is much more dubious and dangerous.
My best friend since high school is a doctor. Hearing all the bullshit that she had to go through, the different selection processes, abuse (scheduling), etc; it's crazy.
It doesn't weed out people who will be bad doctors, it weeds out people that can't handle the abuse.
I had a prescription for 1 20mg pill a day. Pharmacy didn't have 20mg but they had 10mg. They couldn't give me 2 10s instead of 1 20 because regulations didn't allow that. Yeah, we need less regulations.
There is likely no regulation that says this. Doctors and pharmacists have very broad legal authority to prescribe whatever they see fit.
It’s almost assuredly an insurance/PBM billing issue, not a regulatory thing.
The American system is too expensive and leaves too many people without coverage. Not very many people would argue that.
The Canadian system is suffering from doctor shortages and other problems and the article lists a lot of reasons why (at least for Alberta).
What countries are the shining examples of how to do it? How is access to excellent, modern healthcare in Japan? Sweden? Spain? Ireland? Australia? It's all about tradeoffs, what countries do you think make the best tradeoffs?
> what countries do you think make the best tradeoffs?
In the western hemisphere? Cuba.
As with many things the best model to look at is Singapore, which spends far less than most of the OECD with outsized results. They spend half as much on healthcare than the UK and far, far less than the US with results that often put them in the top 5 for healthcare outcomes.
Yes but it’s also the size of a medium-sized city.
It’s easy to imagine a small, rich region in the US / Canada / UK running its own system and doing well at it.
The scale of caring for an entire country is a challenge onto itself.
Alberta is the richest province in Canada and has a population half the size of Singapore. That doesn't seem to be helping them.
Funny enough, I actually live in Alberta. My personal experience with the healthcare here is actually amazing.
But I’m in Calgary. There’s still a big, expensive challenge in providing care in the tiny towns. Alberta is pretty much infinitely large compared to Singapore.
Another aspect is that some of Alberta’s money goes to subsidize other provinces which is something else Singapore doesn’t have.
They also do many things so radically different that it is always worth looking at how they handle it, especially given that 70 years ago they essentially had nothing but the remains of a post-war colonial city.
It’s certainly always worth learning from others; just making a point about statistical comparisons.
Just because the US, Norway, and Singapore are all categorized as countries doesn’t mean you can compare their stats directly without adding some asterisks for further context each time you do it.
I have a co-worker that moved to the US from the DR last year. She's shocked at how involved and expensive the system is for the most routine visits. It's interesting to hear someone speak with first hand experience in multiple systems.
Canada has a worst of both worlds system. Most wealthy Canadians come to the US for procedures because they can afford it and there is no waitlist, and so they don't care how bad the Canadian healthcare system gets.
> Socialism ... Canada ... UK
I would hardly describe any of the governments of Canada or the UK in the past, what, 50(?) or so years as being socialist...
Yep, discussions of capitalism as contrasted with socialism are largely pointless as all western countries operate different flavors of mixed economies. Keynes won. You have to have both— if you stray too far in either direction your economy topples.
But accepting "Have government involved in the economy, not too much. Mostly markets" means you have to actually know about the specific industry and surrounding economic factors and that makes discussions boring. It's way more fun to have Cage Match: Capitalism vs Socialism, this Saturday on pay-per-view.
Get outta here with your fair-minded, reasonable comments.
I'm not sure why you're bringing up the Canadian and UK systems after launching an opening salvo at socialism. Surely it makes more sense to take a look at access to healthcare in socialist countries like China or Vietnam?
Every healthcare system rations care. In the U.S. that rationing is largely based on quality of employment or how much wealth you have. To some this is a largely immoral way to ration care.
As with all healthcare systems if there is a shortage of workers or it is not properly funded it will deteriorate. The U.S. healthcare system sucks for people who have no real access to it. The wait time of someone with no access to the system is effectively infinity.
Socialism, capitalism, communism, fascism, etc. are merely economic systems and all of them suck if not properly administered.
These arguments sound about 15-20 years too old. I have wealth but I can't see a doctor. What the hell happened?
What argument? I’m not making an argument. I’m pointing out what I think are facts. Apparently you don’t have enough wealth provided you are in the U.S.
> the doctors need to be payed more
USA here, I think we need to pay them less. It's basically become a game of how little can they do and how much can they charge. Many already don't care about your symptoms, or bother to do any research. They just prescribe stuff as it's pushed. If they aren't already, I'm sure your doctor will soon just be entering your symptoms into ChatGPT.
One reason doctors have so little time for each patient is because 1) demand is through the roof due to artificial constraints on doctor supply, 2) they spend tons of their time dealing with insurance paperwork, and 3) they don't actually get paid that much which means they need tons of volume to stay in business.
(2) and (3) are related since "dealing with insurance companies" == arguing for reimbursement from those companies, which means they're losing time arguing and losing money when they lose those arguments.
You know it's okay simply not to have an opinion on something if you can't spend more than 5 minutes or so thinking about it.
Doctors don't deal with insurance companies and billing. They have people for that.
1) Yes they do, especially at smaller practices (another reason for the mass extinction of independent medical practices)
2) When they do have other people for it (which yes, is very often to your point), they're paying those people
3) When you pay other people, you need to make more money to pay them with
4) To make more money, you need more volume
5) To get more volume, you need to spend less time with each patient
You've changed nothing about the core dynamic of the system, just interjected with a meaningless and not-even-totally-true detail.
What I noticed is that to not lose money, they need lots of brief visits. Do the checkup, come in later to review the test results, then schedule a follow-up to decide on a referral (or not). Everything after the first visit could have been done with a (voice-only) phone call.
Maybe video visits were supposed to make it easier to generate billing with less driving, but it didn't work out that way.
Ultimately I went with an HMO, where the doctors can provide the same minimal amount of care but not jump through hoops to do it.
I don't disagree per se, but it seems from reading the article that they're bemoaning the shortage of qualified doctors and how they're all spent cause they have to work within the confines of centrally planned subsidy prices.
Really they should be charging as high as possible directly to consumers until doctors are attracted into the profession. Cut out the middleman, there is no reason that routine expenses like a sick visit that gets routine labwork or medication need to be insured.
It'd be better to reroute the software developers that construct complex systems to SERVE ADS and addict people to scrolling.
Pay them more, sure. But also let's get rid of the artificial limit on how many we can have. They're not being used effectively and we're all worse off for it.
No disagreement from me regarding that.
This is already happening, with more and more primary care responsibilities being pushed to physician assistants and nurse practitioners. At your modern urgent care or "doc in a box" primary care clinic, you may never see the doctor, who mostly exists to lend legitimacy to the practice. Not to say that I don't appreciate the hard work that PAs and NPs do, and I think they are certainly qualified to handle most medical issues in their fields, just that the medical industry is trending towards a less personal experience run by lower paid workers and I can't imagine that leading to better health outcomes for the average person.
And I think that is just fine. There's a large amount of things you don't actually need to see a doctor for. Especially things like looking up your nose and prescribing a Z-pak.
I wish doctors would enter my symptoms in ChatGPT. In my experience they have the opposite problem. They think they know everything and when they hear something they don't understand they just brush it off as nothing. Twice in my life doctors have completely screwed up a diagnosis and later upon doing research it turns out my symptoms were basically a dead ringer for the condition it turned out to be. If the doc had just taken a few minutes to Google it, he would have found it. I don't walk into a doctors office today without doing research first.
Both Canada and UK are beginning to see more and more private involvment in healthcare so I don't know if it is socialism's fault here.
The UK's problem is that it wants universal healthcare paid for by general taxation, and free at the point of use. However, the previous government wanted that whilst also reducing public expenditure. You can't have both.
It totally can be done, but it's expensive. I, personally, hope to see taxes rise to pay for this system to work as it should.
Private healthcare is already digging in its claws in the UK due to the fall in availability of state-provided care and (from my experience) it's not a good experience; and it's still expensive!
The UK's state provided system is pretty good, but it runs too much on good will right now.
This right here. The system needs funding to work. The problem is conservative politicians repeatedly trying to make the system worse so they can privatize it.
Just going to take the time to indicate that this is a conspiracy theory, since conservatives are always lambasted with that term.
In my experience it works pretty well under progressive governments that are willing to do the necessary tax-and-spend approach to make it work. Alberta's government is radically conservative, far beyond moderate pro-business conservatism.
As much as the media fixates on Prime Minister Justin Trudeau, it's important to remember that Canada's healthcare is administered provincially, and most provinces have Conservative governance.
Publicly-funded healthcare is much less-expensive with respect to public health outcomes compared to the American system, but it's not so cheap that you can cut it to the bone without creating awful negative consequences.
This article doesn’t really implicate socialism, it’s more about staffing rural towns with doctors (the first anecdote is about Elnora, which is a town of 288 people), and about doctors en masse not wanting to be family general practitioners for their careers. The US and other countries all have a hard time keeping doctors in rural places.
You are implicating private for-profit insurance, however. And maybe forgetting about all the top-ranked government socialized medical systems in The Netherlands, Norway, Sweden, Japan, and others - all ranked higher than the US in quality and efficiency of care. There’s contrary evidence refuting the claim that when government sets prices quality will decline.
When government sets prices quality won’t always decline right away, but supply will be limited.
This is what happens every time a Canadian doctor moves to the US for the money.
What does limited supply of doctors even mean? There’s a finite supply of doctors everywhere, regardless of pricing. Where is the evidence of your claim in Norway, Finland, Japan, etc.?
The U.S. has limited supply of doctors in rural areas, and that’s not due to government pricing. So what justification is there for pointing at government pricing at all? Why is that relevant here, and what makes you believe there’s a broad, general, or causal truth here, given the fact that it’s not true everywhere.
The article is about Alberta, the least socialist of the Canadian provinces. Other provinces have similar problems but Alberta seems to have it the worst. The article talks about doctors moving from Alberta to BC, and I indirectly know a couple who moved from Ontario to BC for similar reasons.
The problem is deeper. The entire structure of the industry makes no sense. Doctors need 12 years of training after high school (the first 4 years of which is useless). Then they end up doing a job where 95% of the work is trivial and could be done by almost anyone with a bit of training.
I know a guy training to do lasik surgery. Turns out it's easy. You could easily train a lasik tech to do it, but that's not allowed. We require it to be done by a doctor making $500k a year who has 12 years of higher education, only 1 year of which is focused on lasik surgery. But we insist on continuing this overly broad training when most modern doctors only practice in a single specialized area. It's like if we required the guy at the oil change place to have a PhD in mechanical engineering. Of course it's going to cost a fortune.
The Social healthcare still have a budget and the govt structure wants resources.
So are we "investing" resources in young and people who will still work and pay taxes?
Or do we invest in people who are already retiring or "incurable".
The older you get the less resources you will be available for you on the social healthcare.
Not saying the US system is sane or one option is better than other.
But the best system is the one that gives you option (and govt hates giving option to you).
1. Want social care? Ok. xx% will be deducted from your paycheck.
2. Want private care? No deductions, you are on your own. And If you don't have money and is charged we will generate a federal debp + 10% for processing fees.
But no... That can't happen. because it would expose the govt or private sector failures.
yeah… both systems suck ass.
1. the “socialist” system AKA healthcare for everyone has insane waiting times because everyone needs healthcare & there aren’t enough doctors.
2. the “capitalist” system seems better for the people that can afford it because the people that can’t afford it don’t go so they have no waiting time because a part of the people that need healthcare aren’t getting it due to the price.
It’s silly to say / imply that system 2 is the better way of doing it
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What policies have been put in place that would cause the problems they are experiencing? If there is a politics issues, the policies can be talked about.
Policies like the ones in the article, the removal of complexity billing codes, drastically reducing GP earnings.
But AFAICT mostly it's their lack of constructive new models. Alberta has been fiddling at the margins with changes like dividing up the province into districts. OTOH BC introduced a wildly successful new physician pay model almost 2 years ago. I indirectly know several doctors who moved from Saskatchewan & Ontario to BC partly because of that.
P.S. I should emphasize that the new BC physician pay model not only attracts new doctors but it also encourages rostering, encouraging doctors to become the single point of generalist GP that is becoming scarce in Alberta according to the article.
My take on it is that ACA set up the insurance companies as essentially a cost-plus system. I forget the actual name for it in the ACA, but the general idea is that insurance needs to spend at least 80% of the premiums on health care. Sounds good at first pass, but there's also no limit to costs in the ACA. So the way an insurance company makes more money is to pay more for service. And the providers are happy to comply. Costs go up, insurance explicitly doesn't fight costs, so that premiums go up and they keep 20% of a bigger pie now.
I've essentially stepped out of the system. I get the cheapest, biggest deductible policy through my employer to cover a big emergency. But for my personal care, I do Direct Primary Care where I pay my doc $175/mo for my family of 4 and any time I need him, he's there "for free" no office visit fees, etc.
If I'm sick, I can always get same-day telehealth or next day in-office visits. For routine care, I may have to book out a week or so. He's never rushed because his incentive is consult me to keep me healthy so that I _don't_ need to see him. His incentives are not to keep me coming back for more visits.
During my last routine yearly visit, we had a hour long conversation about all the little nagging things that were happening has I get older, and we made a good plan on what to do.
I love this model and I could see it scaling like this:
Rather than forcing (individual mandate) ACA-specified insurance purchases, you are "forced" to put that cost into a HSA-like account (government supplemented for if you can't afford it), and then use the HSA to buy the insurance and/or DPC memberships you want and work for you. That would put downward pressure on price since you're making the decisions not the insurance/government. And you adds competition on service since you choose your providers.
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Waiting for Doug Ford to short-circuit this even more and allow MAiD drugs to be dispensed by his friends at Shoppers Drug Mart. He already wants them to start playing doctor so much more...
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Nah, a physician assistant is sufficient to escort you to a pod and press a button.
I prefer self checkout.
Yeah, that will make it much less awkward that nobody showed up on my final hour.
I want an AI doctor so at least there is some information I can get between the months delay it takes to get an appointment.
Why are you using PCPs? The urgent care route seems more efficient, scales, and takes advantage of electronic medical records.
I personally have not had a PCP singular doctor or doctor group in years. I use an urgent care franchise as my PCP.
I have a chronic ailment that requires daily medicine and the medical staff at the urgent care has been more than capable of providing care, writing scripts, and providing referrals to specialists.
The idea of an ongoing relationship with a single doctor has always felt to me like a relic of that mythic past when people would spend 40 years working for a single employer before retiring with a pension.
In my life, as a generally healthy person working in the software industry, I have switched health insurance plans almost as many times as I've needed medical attention. What's the point of going through the trouble to establish a relationship with a PCP when you will see them at most twice, likely only once, before you have to start over after taking your next job?
Urgent care is much easier.
> Why are you using PCPs?
For primary care. I believe that's where the name Primary Care Provider comes from.
The difference from urgent care is long term. Having the same PCP for long periods of time provides an opportunity for deep insight and developing a personal relationship.
Urgent care is often a 1-4 hour wait and insurance tends to have a higher copay. If you have a patient profile at a large health care provider's facility, you can often get appointments same or next day if you're willing to be flexible about the specific provider that sees you, with the normal (~15 minute) wait and lower copay.