Patients = Patience

You hear at all the time: the problem with socialized healthcare is that it leads to waiting lists, people waiting too long for operations. Months, I hear, people have to wait months for operations you shouldn’t have to wait for, and sometimes they even die before the operation can happen.

Well, I say that’s crap.

Let’s start with some mathematics. Let’s say that we have a population P, and D, the rate occurrence of a particular condition that requires treatment.

Now let’s, for the sake of argument, assume that P is large enough – major city size,> 1,000,000 – to provide some constancy in statistics. So you can tell right away that we’re dismissing rural medicine. Stupid hillbillies who still live out in the boondocks, what the hell do we care about them anyway? All decent people live in slums cities with at least that number of people in it.

A P that large means that the rate of D is basically fairly constant, with the daily rate of Dd having a standard distribution around the mean D, and an approximate Standard Deviation of √D.

Look, these are rough statistics, and you know the drill: lies, lies, and statistics. But if I had a polished statistician go over this stuff, instead of the weird Health IT Nerd, the picture wouldn’t change that much.

So we have this condition occurring Dd number of times per day in the city. Now let’s say that this condition requires treatment on the same day. If this treatment is not provided, the patient will die. Perhaps the condition is extreme exhaustion from exposure to the political shenanigans associated with the bail-out, and the treatment is to be forced to read the War Nerd. Or we could try taking life seriously and posit that the condition is a renal stone, and the treatment is ultrasonic destruction of the stone. (Not that this is generally highly successful, but I’ve always though it’s the perfect procedure: we’ve got a problem – a real painful one, so what we’re going to do is have a good scream at it for a little while, and see if it goes away all by itself.)

Whatever, there’s a rate T, the number of treatments for the condition that can be provided in a day. Unlike D, this number is not subject to a normal statistical variation. Instead, it’s influenced by the availability of staff and long term institutional policies (which often produce unexpected results on the value of T). So for the sake of argument, let’s assume that T is a fixed constant.

If T is less than D, then this is a disastrous outcome - the queue for services will rapidly grow longer and people will die. The queue will get shorter on some days, but in general it will grow longer. However the length of the queue is limited by the number of people who die before they get to the front of the queue. So eventually the queue will stop growing. (So next time you hear of a long queue, understand: the people waiting aren't dying like flies while they're waiting...)

If T = D, then the queue will quickly reach a steady state – but roughly 50% of people will still have to wait until the next day. (Actually, it starts out much lower than that – a small number miss out on some days, say when Dd = D + 1 * √D. And they get carried over to the next day, where they compete with Dd for that day. The eventual outcome of this, what the average carry over is, depends on a variety of modeling and simulation assumptions, but as a rule of thumb, about 50% get carried over the next iteration.)

So when T = D, only 50% of the target is met. Note that like the previous case, the actual length of the queue depends on the number of people who die before treatment.

As T > D, and the gap increases, the percentage chance that a patient will have to wait until the next day drops – but T has to be quite a bit bigger than D before it approaches 0. (How much bigger depends on the value of D, given that the standard deviation of D was posited to be √D, but a useful rule of thumb is T = D + (3 x √D) gives 1% missed targets)

This is well and good, but what does it mean?

If you want to have immediate treatment available, you have to build considerably more than the average required treatment capacity into the system.

This is true for almost all kinds of treatment, whether obstetrics, oncology, cardiology, or what. You just plug different numbers in, and different requirements, but the same basic principles are in play.

Note that it’s mostly not as bad as it sounds because many treatments share a common set of resources, particularly facilities and staff. By pooling these things, the overall size of D increases, and the ratio of D/√D goes up, and the built in waste is ameliorated.

Nevertheless, you need to have excess capacity built into the system. Now this is hardly a radical conclusion – it arises in other industries all the time, particularly in telecommunications and transportation, and it’s a pretty well understood problem.

But people seem to forget this when they start talking about health, and we have these stupid debates about resources and waiting lists. In these, people not only ignore the simple principles above, they also ignore the fact that no society on earth can afford to pay for unlimited healthcare, let alone have excess capacity in the system.

So, how do you limit the resources available without creating waiting queues? Want a hint?

You can’t.

Well, actually, I lie. You can. But only if you deny some people access to the queue at all. Then they turn into a “totally negative healthcare outcome” instead of screwing up your statistics (i.e. they screw someone else’s stats up. Since funding is linked to statistics in most jurisdictions, this is just a way of externalizing the costs).

So, you choose: the immoral or the distasteful? Which is it to be?

Though there’s a third option. The way this works is simple: You know that a queue has to exist, but you personally don’t want to wait. So you create a two-tier system that ensures you don’t have to wait when you need the treatment, that someone else will wait. Or miss out altogether.

This only really works well if you can arrange that everyone who matters is in the top tier, and people in the second tier are such losers that they either don’t have representation (e.g. communist paradises)  or don’t have the wit or leverage to be heard anyway (say, UAW members ;-). Note that this can only work if the second-tier people fund the first tier some way or other (kind of socialism in reverse).

I’ll leave it to you to decide for yourself how well your country manages this issue, whether you’re happy with the way the case-by-case decision is made, whether it’s going to be the immoral or the distasteful for you and your loved ones.§

But next time you hear someone discussing the disgraceful state of waiting lists in [country/system/state] as compared to [other country/system/state], ask yourself: how are the statistics lying this time? How many people had a totally negative outcome before the possibly positive outcome got counted? And who were they?

§ The correct answer to the question above is ‘no, I’m not happy’. It doesn’t matter which country you live in. Tricky huh?

p.s. Here’s an excellent example of this stuff in practice, quoted from
http://tedstumor.blogspot.com/2009/03/natasha-richardson-epidural-hemorrhage.html

“It's important to ask this question, because this is precisely the situation where the Canadian-type health care system -- much touted by reform advocates -- tends to fail Canadians.”

Yes, the Canadian government makes one set of decisions. These weight some situations preferentially over others. And then:

“In the United States if someone falls and hits her head and then an hour later is rushed to the emergency room you can bet she will get a STAT CT scan and immediate neurosurgical attention.”

This is another set of decisions. Because there’s a word or two missing from this paragraph – this doesn’t apply to all citizens, only to those with “coverage” – a number steadily decreasing at this time. Both of these are two-tier systems. The Canadians just outsource their first tier to USA – works well for everything but emergency medicine.

All I want for Christmas

It’s Christmas time. [Well, okay, it’s not anymore. This was written before Christmas, but the one friend I do have reviews these posts first, and he disappeared on holiday beforehand, so I’m only getting to post it now].

It’s a hard time of year for everyone, especially if you have any sense of the ridiculous. After all, what’s the basis for Christmas? The Son of God came to the world, and told everyone that God was angry because of everyone’s injustice and greed. So naturally, we remember Jesus by giving gifts to anyone who’ll give us stuff back, and by eating and drinking far too much. We can’t even get the time of year right – though maybe it’s best that Christmas is just a pagan feast at heart.

Of course, when I’m stupid enough to say something like this to my friends, they tell me that the best part of Christmas – what it’s really all about – is spending time with my family. Well, they’re quite welcome to spend time with my family. Though if they think that’ll be fun, they don’t know my family as well as I do. So I’m back hiding in my hovel, thinking about healthcare and IT (and not before time too. Apologies for the long delay between posts – apparently our customers expected me to get some actual work done before they got to go on their family fun-time holidays).

And what I’m thinking about right now is, what will you and your loved ones – if you have any – what will you be talking about this Christmas once you’ve had too much to eat and drink, and all the presents are opened? Well, I can’t think of anything better than to talk about healthcare system reform. 

“Umm, yeah,” you’re saying, “right. What else would we talk about?”

Well, don’t blame me. Instead, you can blame Senator Tom Daschle:

Daschle wants Americans to host “holiday-season house parties to brainstorm over how best to overhaul the U.S. health-care system,” the WSJ reports.

Don’t believe me? Check out the WSJ for the whole outrage. And thanks to my spies in the USA who alerted me to this gem.

At first I laughed at this. I was pretty disappointed too. I was certainly hoping for more from the incoming administration. After eight years of the Bush power slide, we’re in desperate need of a responsible approach to prevent the inevitable, though a quick survey shows that the Democrats have quite happy competed with the Republicans to see who offers worse government (it’s a US thing: governments are bad, so we vote for bad governments). Nevertheless, I found myself hoping that “Change we can believe in” didn’t mean that kind of change the Health IT Nerd believes in, the kind that I usually see in the healthcare system – namely, just a different kind of stupid.

As I said, I thought, who’d be stupid enough to talk about healthcare policy over a Christmas meal? But the more I thought about it, the more I realized that we always talk about healthcare policy when my family gets together. It starts easily enough, talking about our family’s latest encounter with the healthcare system. What with the many little accidents of life – backyard, kitchen, and bedroom - and getting old (also accidental; at least, it certainly seems to happen while you’re looking the other way), the extended families of the Health IT Nerd and his suffering wife have regular encounters with the healthcare systems across the world, and whichever side of the family we have the “luck” to spend the festive season with, the subject is sure to come up.

And once the subject does come up, you can be sure of one thing: everyone is going to start complaining about how terrible the healthcare system is. After all, it’s never our fault that we needed healthcare. Actually, it’s not our fault. Since the only thing that’s sure in life is death and hospitals, it’s just because we were born. So the fact that we need healthcare is our parent’s fault – it’s important to know who to blame for all life’s ills. For this reason, the best time to talk about how to reform the healthcare system is when you get together with those whose fault it is. 

It doesn’t matter what country you’re in, either. You can be sure that everyone’s going to be complaining about the quality of the healthcare system. And also how much we have to pay for it. Again, it doesn’t matter how it gets paid for, directly, indirectly through insurance, or indirectly through taxation. We pay too much, and the quality of service sucks. 

So, this year, when you get together as families, do your patriotic duty, and brainstorm how to overhaul the U.S. health-care system, because, as Daschle points out:

There is no question that the economic health of this country is directly related to our ability to reform our health-care system

For a start, you can tell by looking at the way we celebrate Christmas, you can tell for sure that it would be a waste of time asking us to consider the healthcare system from some altruistic perspective about what would actually be good for our health. No, we definitely need to talk about money. And since there’s a war or two to fight, and the worst financial crisis this century, we need all the money we can get. 

So this year, instead of simply complaining about how poor the system is, instead, try and figure out how to pay less, either by defrauding someone, or perhaps by setting up some kind of ponzi scheme to raise enough money to pay for it (as if any kind of savings plan isn’t a ponzi scheme in the end). If that doesn’t work out for you, see if you can figure out how to overhaul the US healthcare system. And the best kind of overhaul is one that saves money – in other words, one that makes the system poorer. 

It’s kind of a game, see. Basic level, you get to plan a healthcare system assuming no constraints, like worrying about how much it costs. But anyone can design a pretty good healthcare system that way. At the intermediate level, factor in real world constraints like costs, staffing levels, and inefficiencies like organizational dysfunction. There’s a special advanced level where you also get to make allowances for things like liability funding, and on-going educational resourcing. If your family wins at that level, then you move onto wizard level, where you get to figure out how to overhaul the US healthcare system to make it better, while factoring in unreal world constraints like eating long lunches with friendly lobbyists.

No one wins the wizard level. Ever.

But it’s Christmas, so there’s no harm in hoping for the best. After all, wishes can come true. So what does the Health IT Nerd wish for?

Of course, I wish for world peace, justice for all, the end of famine, an end to bad governments, and that people would stop sponging off their richer neighbors. And in healthcare, I wish that people would stop getting sick, and that everybody would be happy to let their poor sick neighbors sponge off them.

Hmm. This isn’t going well. Though at least Bush the Second is going to be gone. I guess that’s not much a Christmas present though, since it was all organized years ago. 

No, other than a bit more of that river of gold, what I really want for Christmas is that everyone would finally come to really understand: Interoperability – it’s all about the people.

[Belated Christmas note: I sure hope you got what you wanted for Christmas. Because I didn't)