The Emergency Room

We often hear that one of the reasons health care "reform" is necesary in the US is because the uninsured overwhelm emergency rooms.  We hear horror stories of overcrowded emergency rooms with long wait times, which would only be better if we had a national health care system like Canada.

A couple of interesting facts:

Average US emergency room wait time:  4.05 hours

Average Canada emergency room wait time:  8.9 to 23 hours

I confess the numbers are not apples-apples, but they are certainly in the ballpark and highly illustrative.   Have any commenters seen a direct comparison?

Update: OK, the numbers are more apples-apples than I thought.  The US 4 hour number is total time from coming in the door to leaving or getting a bed, the same as the Canadian numbers.  The CNN report linked above got their data from here.


  1. Mallard:

    They say that the recession is a chief cause for the increase in average wait times in 2008. Yet this is going back from 2002. From the actual report that they get this info from, there is apparently a decrease in average wait times from 2007.

    Now, correct me if I'm wrong, but wasn't the "official" start of the recession in December 2007?

  2. Bob Smith:

    They say that the recession is a chief cause for the increase in average wait times in 2008. Yet this is going back from 2002.

    Would a totalitarian statist lie to you in order to get their way? Perish the thought.

  3. Fred from Canuckistan . . .:

    A real story from a real Canadian. It is more than the wait times, it is the lousy service.

    Whatever you do, don't follow our pattern. The Euros & Aussies have a much better model.

  4. Fred Z:

    I'm another Fred from Canuckistan, and Fred 1 is wrong. The service is not 'lousy'.

    It is much, much, much,... ... much worse than that.

    Did you know we use artificial hip implants that are out of date in the USA and no longer used by you? Neither did I until my mother in law got one, and it failed. She is now on a 2 year waiting list to replace the replacement. Probably with something made with pride in Bulgaria. But it's all good as she's 78 and may not last the 2 years anyway, why waste the resources?

  5. Paul:

    One thing that popped into my head: given the clear superiority of the state run system in Canada dealing with the day to day health issues of their subjects, emergency rooms should generally not be where one goes when one has the sniffles, like the uninsured in the US might.

    So that 8 hour wait is possibly for more serious health issues.

    Which is why I'm putting myself in a position financially to not need the state. I suggest everyone do the same.

  6. Fred Z:

    "given the clear superiority of the state run system in Canada dealing with the day to day health issues of their subjects"


    "emergency rooms should generally not be where one goes when one has the sniffles"


    complete wrongness, at an awesome level.

    I once took my elderly father to his doctor with a minor ailment. That doctor told me and dad that he could not get dad the required tests and treatment in good time. He told us that we could go to the local hospital emergency room and fake an emergency. He coached us on what to say to get the tests done right away. We did, he got the tests the next day. The advice was based on the theory that a retired guy, my dad, could out wait the emergency room delays. We waited 8 hours, but got he tests. Much better than the 6 weeks otherwise required.

    To be clear: there is no systemic assistance in Canada in dealing with 'day to day health issues'. None, de nada, zero, zip, zilch. The system is completely overpowered by the genuine demands of an aging populace and the inevitable waste from whiners, free-loaders, socializers, bullshit artists, morons and fools that abuse 'free' services.

    My doctor tells me he thinks a full 1/3 of his day is spent with people who have no business whatever coming to see him.

    Any American who thinks Canada has a good system is deluded. Badly deluded. Perhaps to the point of insanity. Worse than Duranty.

  7. Allen:

    Fred Z, I'm sorry to hear about your mother in law. The sad thing is at 78, she very well could live another decade or more these days.

    Your example about going to the emergency room for tests is classic "for every action, there is an equal or greater reaction".

    What frustrates me the most about addressing health care is that very few of the solutions out there such as single payer have better outcomes than what we're doing now. Yet instead of taking the time to look at the problem(s) at hand and come up with new solutions, too many folks turn to outdated "solutions" that we know are just as bad if not worse.

    I guess I shouldn't be surprised, often times the same crowd pushing for single payer is the same one touting 18th century rail technology as being a transportation solution.

  8. Fred Z:

    The longer I sit here, the more I stew and the angrier I get.

    What is the matter with you Americans? Have you lost your marbles completely? You had discovered the secret to one one of mankind's enduring mysteries, the secret of wealth. You were rich and getting more rich every day.

    Did you not understand you could piss away umpteen percent of your GDP on foolish 'health care' like cosmetic surgery, liposuction and whatever BECAUSE YOU HAD THE MONEY, BECAUSE YOU WERE WEALTHY BEYOND MEASURE, BECAUSE IT WAS PEANUTS, BECAUSE ALL YOUR BASIC NEEDS AND MOST LUXURIES HAD ALREADY BEEN BOUGHT AND PAID FOR?

    Pardon me for shouting, but what you have done in electing Obama and the Democrats was very bad, very stupid.

  9. Fred Z:

    Still stewing. Read NRO and mark Steyn to calm down. Didn't work.

    Steyn's father "is currently ill, and the health "system" is doing its best to ensure it's fatal. When an ambulance has to be called, they take him to a different hospital according to the determinations of the bed-availability bureaucrats and which one hasn't had to be quarantined for an infection outbreak. At the first hospital, he picked up C Difficile. At the second, MRSA. At the third, like the lady above, he got septicaemia. He's lying there now, enjoying the socialized healthcare jackpot - C Diff, MRSA, septicaemia. None of these ailments are what he went in to be treated for. They were given to him by the medical system."

    Wealthy successful columnist, pundit, author and the best his father can get is crap. I expect Steyn the elder will soon be in the USA, although my own father frequently refused to go there for treatment. That's part of the trap - as we age we hate and fear travel more and more. My father, my mother in law and no doubt Steyn's dad have the money to go to the USA for treatment, but it's a damn hard thing for an old person to do.

    Just wait my American friends, until some civil servant tells you that your fathers and mothers must go to a facility you know is dirty and incompetent, and any attempt to do otherwise is a criminal offense. Coming at ya, baby.

  10. frankania:

    Problem with US health system? Too few doctors and too many lawyers.
    Here in Mexico there are too many doctors so office visits are as low as $2 (I am not exagerating); there are clinic "price wars" here, and NONE of this is govt. progam--pure private competition.
    Too few lawyers? lawsuits are almost unheard of here; thus doctors don't add legal insurance nor unnecessary tests, etc.
    USA answer? Open the borders to any qualified physician to compete with AMA doctors and limit lawsuits to actual cost and work-time lost.
    What do you think?

  11. Fred Z:

    frankania, you must be nuts, proposing such a solution which is entirely correct, perfect and proper. Don't you know that everyone from the Democratic Party to the American Medical Union, I mean Association, will fight your idea to the death?

    Be careful frankania, I expect there are black CIA helicopters coming for you right now.

    I was in Mexico in 1994 with two sick kids and received fabulous medical service. That experience was probably the start of my ever increasing hatred for the Canadian system. Before then I was a young guy in good health - never needed the system much and when I did it was minor and being young I was naive, stupid, pig-ignorant and silly. God forgive me I voted for the local liberal party.

    Then marriage and two kids, which involves lots of interaction with the medical system. It was bad but until Mexico, I had no idea there was anything different.

  12. Matt:

    Oakwood Hospital in SE Michigan has been advertising for years that you can see one of their ER docs in less than 30 minutes. Now, they're claiming "zero wait":

  13. iceberg:

    "We often hear that one of the reasons health care “reform” is necesary in the US is because the uninsured overwhelm emergency rooms. We hear horror stories of overcrowded emergency rooms with long wait times, which would only be better if we had a national health care system like Canada"

    Why are the emergency rooms crowded, and why would that improve under universal healthcare? Isn't it likely that it will lead to even more usage, not less?

  14. gadfly:

    Much like "free" valet parking finds its way into patient fees, the staff required to accomplish "zero wait time" at the Emergency Room also has to be in the fees. For a lesser fee, I would wait. Unfortunately, the American third-party insurance system has stripped US patients of the God-given right to choose "level of service."

  15. dave smith:

    Canada's e-rooms must also be jammed up with illegal immigrants.

  16. Dr. T:

    ER wait time numbers don't mean much without knowing the reasons for the ER visits. When I did my medical student ER rotation, I was on the 'trauma' side. I expected to see fractures, lacerations, sprains and strains, gunshot and stab wounds, and burns. However, on my first evening I was handed a book on evaluation of chronic back pain. That was the most common problem we saw. The triage nurses gave these patients lowest priority since they had no acute problem. These patients would wait much longer than minor trauma patients. Severe trauma patients had no wait time regardless of how many other patients were waiting.

    If an ER's patient mix is mostly nonsense such as chronic back pain plus minor trauma and minor illnesses, then wait times can be long without endangering patients. However, if the mix of illnesses and injuries is more severe, then long wait times definitely endanger patients.

    The problem in both Canada and the USA is that hospital ERs are being used for routine care instead of true emergencies. There are a handful of 'urgicare' centers that try to fill this need, but government and private health insurers many not reimburse for getting 'urgicare.' ER visits always are covered, even when they were not needed.

  17. Dr. T:

    Frankania, Mexican doctors rarely deserve the title. Almost none could pass the qualifying exams and get through a US residency program. Also, we aren't "AMA doctors." The AMA represents less than 25% of physicians, and the AMA has no control over licensing (states), board exams (dozens of specialty boards), medical schools (federal government plus a private accrediting board), etc.

    I do favor letting in many more qualified physicians. England, Canada, Germany, France, Spain, Italy, Israel, Australia, and a few other countries have equivalent medical training. Most US clinicians work 60-80 hours a week, and many of them won't mind losing some patients (to immigrant MDs) and gaining some free time.

  18. Noumenon:

    Thanks very much for providing your sources. I don't agree that it is apples to apples. The 4 hour figure is from page 6 of the Press Ganey report and is for "time spent in the emergency department." The 23.8 hour figure is from page 9 of the Canada report and represents "time until admitted into an inpatient bed."

    Why these two figures are different is partly explained on page 7 of the Canada report:

    acceptable length of stay. For example a higher acuity patient i.e. multiple injury car accident may be seen quicker but ultimately is waiting longer to get into an inpatient bed in the hospital. These higher acuity patients usually require a barrage of medical interventions to stabilize them before they are
    admitted to an inpatient bed (that has to be available or
    found) in the hospital, which is when their measured wait stops. This is why the maximum length of stay is longer for higher acuity patients.

    In short, I believe the four hour figure includes all the chronic back pain patients who are sent home immediately, while the 24 hour figure includes only the very severe cases who are actually admitted into an inpatient bed.

    I have been to the ER twice for stitches. My wait time was about six hours and three hours, but I was never admitted into the hospital. So I would count in the Press Ganey average, but not the Canadian average.

  19. Me:

    Anecdotal evidence: the two times that I had to take advantage of emergency care in Germany, I saw a doctor within 10 minutes of arriving at the hospital and got treated right away. (Abscess in the elbow bone, needed opening, draining, suturing, intravenous antibiotics, 3 day hospital stay; fixing and setting a broken clavicle).

    The one time I drove myself to an ER in Seattle, I had to make a detour to a private parking lot because the hospitals lot was closed due to construction, walk 5 minutes back to the ER, got my blood pressure taken by a nurse, sat in the waiting room with 3 other people from 10PM until 4AM, all the time doubled over with pain, saw a doctor at 4, got some painkillers, went into surgery at 11AM the next day. I had to wonder if someone in Administration had pointed out that burst appendices can generate an order of magnitude more income than an ordinary appendectomy.

    I saw the bills to my insurance in all cases; cost of care was 3600 and 1200 Euro for the procedures in Germany and 46000 USD for the appendicitis in the US. Off the net and for a more current comparison, the maximum cost for an appendectomy in Germany was up to 2740 Euro in 2005 (state run system with a master list for max cost). Germans tend to complain a lot about the unreasonably high cost of these procedures, so clearly nobody is ever real happy with the cost of healthcare, but there's a marked difference here.

    While in my case, both quality and cost of care were atrocious compared in the US compared to a European socialized system, I realize that it's a rather small sample base.

    My personal impression derived from these and many Dr visits is that the US healthcare system is neither particularly great on waiting times, quality of care, efficiency or cost of care. I'd be interested in opinions about why that is - how do the costs typically break down on the hospitals side?

    My layman view of things is that I believe that emergency care represents a problem where the typical interplay of market forces is concerned - by the time a patient has made it to an ER, their bargaining power is rather limited ("Ha - you want to charge me what? I'll take my broken leg to a hospital in Florida instead unless you give me at least a 10% discount" (limps out)). There is no backpressure in the system - the parties in the system administer cost based on standard rates and don't mind those creeping higher because the cost is passed on.

  20. HS:

    Would you spend all of you and your families' money and property if your dad could live (and wanted to) another year? That is the hard question I dreaded but did not have to answer. At the same time, I don't want someone else answering it for my dad or the family.

    Medicare is a lost cause because the ratio of sick to healthy is high. IMO, the quickest way to change that is to bring more healthy people into the pool at the expense of quality. I would and have paid for my dad's health but I don't want to pay for yours.

  21. Me:

    Honestly, part of the answer (following a strictly economical line of argument, not involving ethics) would be to create a much simpler licensing system for professionals charged with treating bacterial infections, simple flesh wounds, burns and abrasions, backpain, the common cold, sinusitis, measels, mumps and rubella and fractures. Add another line of simplified certification for the 10 most frequent surgeries. You'll get less qualified and more specialized people trained on the common medical activities at a substantially lowered cost and swamp the system with them, which should lower the price and increase availability of the most commonly required care. For anything further reaching, yes, you'll continue to have to see more specialized professionals at a higher cost; and yes, there'll be a few cases where something more severe is misdiagnosed as a simple common case by less trained personnel. I'd guess that the numbers here will be in favor of the most common cases, especially if taking into account that misdiagnoses of uncommon causes as frequently occuring illnesses with similar symptoms is probably already a common occurence because of the reinforcement effect.

    It's likely that you could replace 90% of the work of today's practicioners with a simple computerized decision tree (with a few nodes reading 'go fetch a specialist') and a nurse.

  22. Me:

    Hm - the system just ate a long comment of mine. Apologies if this is more brief or turns up twice...

    In a nutshell, the one feasible way to achieve significant savings in medical care in the US I can think of is to create a separate group of practioners with less strict licensing requirements who get to specialize in the most common aspects of a general doctors or surgeons work: hand out antibiotics and painkillers, fix major fractures and suture/bandage flesh wounds, forward to more specialized care if the patient is showing no improvement or the symptoms are outside of typical bounds.

    Swamp the market with cheap and plentiful specialists who routinely take care of the 80% cases, idemnify them against anything but criminal charges in cases of death and dismemberment (we've got great insurance to take care of personal health and disability claims) and you'll have both higher availability and lower cost.

    Yes, there's going to be the occasional case of something complex being misdiagnosed as a common disease, but I'd bet we'd not see much higher percentages of that are happening now already, and the higher availability of care might offset that entirely.

    As a privately practicing practicioner of that sort, I might even chose not to elect the hospital that just added a $50M ward and a $800M administrative wing with marble offices but a smaller facility that meets my needs.

  23. Andy:

    Anecdotal, but this is what I know for the Canadian system (southern Ontario, as each province manages it's own, and you cannot make blanket statements about a Canadian system, as there is not one).

    My mother-in-law went for colonoscopy on a Friday morning, they found cancer, gave her a cat scan and two blood transfusions, had surgery by noon the next day, and also removed a hernia.

    My Dad had leukemia, had my aunt in the UK tested, discovered she had a blood disorder, found a match in germany, flew the bone marrow stem cells over, and cured my Dad. Sure, he has ongoing issues (it's been 5 years) but he is alive.

    Never saw a bill, have no clue on the cost for either of these.

    Just two of many shining examples of what the Ontario Health Insurance Plan health care can do.

    As a side note, I broke my hand early in the year, waited two hours in emergency (they were busy) and my issue was less severe than some of the later arrivals who (rightly) were looke at first.

  24. Sandy:

    The problem with uninsured people in emergency rooms is that emergency care is more expensive than an office visit. It has nothing to do with crowded ERs. If hospitals can reduce unpaid ER costs, then they won't have to recover those costs in other areas. Reduced costs will be passed on to insurance, which will reduce premiums.

    Of course, a really easy solution is to require non-profits to have a clinic where they will see all patients, and then make sure there's a non-profit within 20 miles of every citizen.

    As to waiting times. People complain about the waiting times in Canada, then say that's what would happen here if everyone had health coverage.

    What they're really saying is they think people without health insurance shouldn't be able to get medical care. Even if the reason the person doesn't have health insurance is because the employer doesn't pay for it, and even if their own employer pays theirs.