The high cost of waiting

As a nation, our collective attention is increasingly drawn to the way in which health care costs are crippling the economy. The Center for Medicare and Medicaid Services projects this cost, if unchecked, could rise to $3.4 trillion in 2015, a whopping 18.3 percent of the U.S. gross domestic product.

Acknowledging this escalation, policymakers have rolled up their sleeves in search of cost-cutting measures to improve efficiency without adversely affecting quality, including more extensive use of health information technology, a reduction in unneeded and unnecessary testing, and a focus on disease prevention rather than cure.

But does $3.4 trillion capture everything we spend on health care?

In the past two months, I underwent the tribulation of four encounters with our health care system: two appointments with a dental surgeon following a recent implant surgery, plus a visit to my primary care physician, then an orthopedist for a leg injury.

Each of the four visits unfolded in an uncannily identical way.

I arrived 10 minutes before each scheduled appointment time to complete any required paperwork and "check in." So far, so good. But 30 minutes past the "scheduled" appointment time, I was still waiting to be called to see the doctor. I was told in each case: "The doctor is running late — he/she had to deal with an unexpected emergency this morning."

I endured the delay in three of the cases. But in the fourth, I simply left after a 50-minute wait. The appointments ranged from 8 a.m. to 12:45 p.m. Apparently, "unexpected" events occur throughout the day and, it would seem, on a daily basis. This was a trifle hard to swallow.

A physician's time is perhaps the scarcest resource in our health care system and needs to be utilized optimally. Doctors play a noble role in our society — they save lives and relieve pain. Their time is valuable. And it is preferable if the patient waits rather than the doctor.

But what about my time? I concede my work is unlikely to produce a cure for cancer, but I like to think I also contribute to society, as educating young people and engaging in research produces some social benefit. And while I sit in the doctor's waiting room looking through a three-month-old copy of Food and Wine, I am not producing any useful output.

My experience is not unique. Every day, hundreds of thousands of patients sit in hundreds of hospitals and clinics across America, waiting — 23 minutes on average in 2010 — to see the doctor. But averages can be misleading and meaningless for the patient who waits more than an hour.

Economists like to brag about the productivity of American workers. In September 2011, the average hourly wage rate for nonfarm workers was $23.16. That's about $8.90 in 23 minutes. Let's do some quick back-of-the-envelope calculation. The total of outpatient visits across the United States in 2010 was 110.5 million, according to medical data aggregator Stratasan. Assuming the "productive" workforce is individuals ages 25 to 65, this number is approximately 61 million. Multiply that by the time spent in the doctor's waiting room: a national expenditure of more than half a billion dollars. And this does not include the "mental anguish" costs of waiting, the frustration and sense of helplessness.

Half a billion may seem like a drop in the ocean when juxtaposed with $3.4 trillion, but it is not chump change. And this is conservative. The real estimate of lost productivity is probably much higher.

How can we address this? Much is made about the role information technology can play in reducing costs and improving quality. How about using some of these tools to alleviate the waiting game and help patients feel more in control of their time? Here are some examples:

•¿If the "doctor is running late," send me an instant message with an approximate anticipated delay (keep a margin so the doctor does not have to wait). Maybe I can quickly do my grocery run or not interrupt the preparation for my class.

•¿Maintain a Web page listing all appointments for the day (with patient identities masked). Update the finish time of the appointment.

•¿Provide data on typical wait times, number of patients handled per week, etc. The power and beauty of data is that it can be used to generate predictions and facilitate better decisions. In the long run, these data will give patients useful information about what days of the week and times of the day to schedule an appointment.

•¿Help patients spend their wait time productively. Offer free wireless Internet access. That may well become a competitive differentiator.

Recently, I noticed some physicians offering "no-wait guarantees" — for an additional fee, of course. I welcome this move but also worry we are moving toward a service differentiation model in health care, much as we have in the airline and banking industries. Surely every patient deserves equal treatment, regardless of their ability and willingness to pay.

Ritu Agarwal is a professor and dean's chair of information systems at the University of Maryland's Robert H. Smith School of Business. She directs the Center for Health Information and Decision Systems. Her email is

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