Waiting Times in the Health Sector: What Works?

By Luigi Siciliani, Michael Borowitz and Valerie Moran
Organisation for Economic Development and Co-operation (OECD), OECD Health Policy Studies, February 2013

The book first provides a framework to understand the role of waiting times in health systems in Chapter 1. It then discusses variation and best practice in defining and measuring waiting times across OECD countries in Chapter 2. The book summarises and discusses the effectiveness of the most common policies to address long waiting times in 13 OECD countries in Chapter 3. Chapters 4-16 provide detailed country case studies respectively in Australia, Canada, Denmark, Finland, Ireland, Italy, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, and the United Kingdom. They describe current policy developments and assess the effectiveness of policies in the last ten years.

Table 3.1 – (Policies and their potential effect on waiting times)

Supply-side policies

1. Increased production in the public sector by funding extra activity – WEAK
2. Contracting with private sector – WEAK
3. Sending patients abroad – WEAK
4. Increased productivity by introducing activity-based financing (DRGs) – MEDUIM
5. Increased choice of providers – MEDIUM
6. Improved management of waiting lists – MEDIUM

Demand-side policies

1. Explicit guidelines to prioritise patients – MEDIUM
2. Subsidise private insurance – WEAK

Combined policies

1. Waiting-time guarantees – WEAK
2. With sanctions – STRONG
3. With choice and competition – STRONG

Chapter 5 – Canada

This chapter outlines the main characteristics of the Canadian health care delivery system, traces the development of unacceptably long patient waiting times for care and examines public concern about the viability of Canadian Medicare. While individual jurisdictions addressed the problem of waiting times with limited success, federal provincial and territorial leaders collaborated in the development of a pan-Canadian approach to reduce waiting times in the context of the 2004 10-Year Plan to Strengthen Health Care. Reductions in waiting times are presented as are the results of statutory parliamentary reviews of progress.

In response to their 2004 commitment and given the funding to support it, Canadian jurisdictions have delivered measurable improvement in patient waiting times in the priority clinical areas. There has been improvement in the infrastructure required to collect data and to compare and report on performance. This improvement, across the country, would not have been possible without the federal, provincial and territorial collaboration and commitment set out in the 10-Year Plan to Strengthen Health Care. Nor could it have been documented without similar collaboration on data, definitions and reporting methodologies.

The accomplishments of the past eight years were necessary and have been beneficial but not sufficient according to the most recent Parliamentary Review. It calls for investment in dealing with the root causes of waiting and investment in better management practices along the continuum of care.

The full 328 page report can be read online at this link:

A well designed single payer national health program uses equitable public financing to ensure that health care is universal, administratively efficient, and reasonably comprehensive. The opponents of single payer cannot deny these well documented benefits, so they usually resort to the claim that single payer systems cause rationing. Does this allegation have any basis in fact?

The term “rationing” traditionally has referred to the equitable allocation of a commodity that is in short supply. In health care, the term is more limited. In OECD nations any person experiencing a medical emergency receives essential care. There is no rationing of emergency services.

On the other hand, in many but not all nations a backlog in the scheduling of elective services may develop. Theoretically, everyone would still receive appropriate care, but they might have to wait for it. Rather than labeling this phenomenon “rationing,” we should call it what it is – “waiting times” or “queues.”

This new OECD report is important because it demonstrates that, with good government stewardship, queues can be reduced to acceptable levels. (Totally eliminating queues by providing instant access to all services, no matter how specialized, is not practical nor desirable.)

The United States was not included in this report. Queues are not as much of a problem for individuals who are well insured, though some excessive delays do occur. Rather, some experts claim that we do “ration” care for those without the ability to pay for that care, with the exception of emergency services provided in an Emergency Department. Yet “ration” may not be the appropriate term since these individuals do not receive an equitable allocation of a limited resource; they are denied care in a system to which others are granted access.

Let’s suppose that we enacted a single payer national health program in the United States. It is true that if we later elected leaders who were opposed to government programs, their inattentiveness to needs could result in the development of excessive queues. That is why it is important to understand what does and what does not work.

In the list in Table 3.1 (above), you can see that measures that are not particularly effective are those such as sending patients abroad, contracting public patients with the private sector, or subsidizing private insurance plans (like ACA does).

Moderately effective measures include increasing choice of providers (not locking patients into networks), using activity-based financing (DRGs), and improved queue management, with better systems of prioritizing patients.

The strongest measures, according to this report, include establishing waiting time guarantees with sanctions for failing to comply (sanctions combat sloth), and providing more choice and competition. Here choice refers to choice of health care professionals and institutions, selected based on competition on perceived quality and service. Another important measure that was left off of this list is fine-tuning system capacity.

Since Canada’s single payer system is the closest to the PNHP model of reform, it is important to understand what is happening there. We still hear that “single payer would cause rationing like they have in Canada.” But, with federal and provincial collaboration, they have made considerable progress in reducing their queues, and are continuing with efforts toward further improvement.

All we would need to avoid “rationing” under a single payer system is responsible public stewardship. If the people in charge insist that we can’t have single payer because of rationing, then we, in turn, need to insist that they be discharged as our public stewards. There are plenty of well qualified individuals who do care about the health of our people.