There must be some econ literature on this one . . .
Joseph Delaney writes that telehealth has been proposed as a solution to ER wait times, but it hasn’t worked so well in practice. Among other things, there are problems with call-center culture:
It made me [Delaney] think of the time this month that there were reports of the 911 number in Toronto asking for call back numbers after a medical emergency. Even if overstated, it really does bring to light the key problem with telehealth—that call center culture is famously customer-hostile.
A number of years back I had a problem with my cable company. Like many foolish persons, I called the cable company and spent 2 hours on hold. After I was told that nothing could be done, I asked if there was anybody I could speak with that had more authority to deal with the issues. I was then placed on hold again. Several hours later a message played saying that the call center was closing and disconnected me. This was an infuriating experience and there was simply no accountability even possible. So the next day I made the long trek to the customer service center, waited in line for about an hour, and then had the problem actually fixed. No part of this experience made me like the company more, but the call experience was terrible.
Recently, I have been constantly hearing “call volumes are unexpectedly high” recordings every time I call a place like a bank or the University travel agent. As a person who once worked in customer service telemarketing call volume forecasting, I even tried times and days that are notoriously light for call volume. No luck.
So the central challenge of telehealth is how to break with the cost-cutting culture that values customer wait times at zero (or even seems to see them as a good thing). You can only redirect from the Emergency Room via telehealth triage if it is relatively quick (let us say an hour, maximum). Because you get no triage credit at the ER for having called telehealth, so if the answer is “go to the ER” but you have lost 4 hours on the phone then that is going to quickly teach everyone not to call telehealth lines.
With pediatric ERs reporting wait times as long as 15 hours, you can see the value of telehealth if it can keep children out of the queue and free up capacity. But that really requires that it be agile (why wait 4 hours as a prelude to waiting 15) and able to do things like prescribe. I know that RSV is an atypically severe phase, but at some point the default needs to be that there are a lot of respiratory viruses running around and we should plan around that.
That gets me to my last pet peeve about telemedicine, which that you need to be able to provide helpful interventions. In a recent covid burst, I had a family member use a telemedicine provider to ask about paxlovid only to be told that it could not be prescribed by phone but that it required an in-person visit. Yes, the plan really was for the infectious person to sit in the waiting room of a walk-in clinic for hours so that the prescription could be written by a person able to see the patient. Now, whether or not treating covid with paxlovid was a good idea is a different question but the issue was that these policies make calling first seem like a bad plan, as you waited hours for an appointment making it much less likely that you can successfully get seen at a walk-in clinic with a time-sensitive health issue.
Which is the opposite of what you want people to do, frankly.
Without solving these cultural issues of how we treat in-calls and how we treat patients, we are not going to be able to really move the demand side for ERs.
Beyond the special difficulties of medicine, this all reminded me of a well-known problem with parole and probation. Given modern technology, these should be more effective than prison and much much cheaper, but they get such low funding that parole and probation officers are overwhelmed. It’s a disturbing paradox that when an alternative solution is cheaper, it gets underfunded so as to not be effective.
That all said, my own health plan’s telehealth system has been working well for me. So I think it can work well if the financial incentives are in the right place.
With the prison thing, I guess the problem is that there are political incentives to spend lots of $ on prisons, not such incentives for parole/probation. Also there may be legal reasons why it’s easy to lock people up but not so easy to implement effective parole/probation.
What do economists say about this?
So here’s my question. Is this a general thing? The idea that when there’s a cheaper and more effective solution out there, it gets done too cheaply and then it’s no longer effective? This would seem to violate some Pareto-like principles of economics, but it happens often enough that I’m thinking there must be some general explanation for it?
I don’t get Delaney’s post at all. I can probably think of some relevant econ literature and the prison situation deserves its own extended discussion, but let me just deal with telehealth for now. I’ve had a number of telehealth visits and they have been nothing like call centers. The biggest problem has been that the normal medical practice of overbooking and delays can leave you waiting in a virtual conference for quite a while – but it is still better than waiting in the waiting room with masks and sick people. The problem is that the medical system has not yet adapted its normal business model to making telehealth a regular part of its delivery process – partially a result of funding issues (e.g., will Medicare continue to cover these visits?), partially a result of technological choices (the systems don’t seem as user friendly as zoom, webex, etc.), and partially a lack of training and experience.
I don’t think that call centers are a reasonable comparison at all. They are almost universally terrible – I can echo Delaney’s complaints and offer many of my own frustrations. However, the primary reason for these issues is that the companies you are dealing with really don’t care enough to improve service. It isn’t worth their time. Even if the customer gives them bad ratings on social media, it appears that they don’t care (I expect chipmunk will weigh in to tell us how no company can survive if it treats its customers this way, but I’ll disagree in advance with that view). Most call centers are outsourced and funded poorly – intentionally since the company doesn’t deem it worthwhile for customer complaints/issues to be dealt with any better. I think it is a mistake to label this as “call center culture.” The culture is corporate culture – the same culture that thrives on stupidity and herd behavior from its customers. Call centers are merely one tool used to reduce costs with little perceived loss in future revenues.
Also, I don’t expect to see much relevant economic literature. To properly address the issue would require some data on quality of call center services, and I’m not aware of any good data on that (although there is probably some poor survey data that could be used). Economists don’t like dealing with poorly measured quality data, at least compared with more easily measured cost data.
This comment confuses me because I’m pretty sure all or most telehealth calls are handled by call centers. Fifteen years ago I was part of a research project to analyze data from a call center. The call center was staffed by nurses and they would do the usual telehealth stuff. Perhaps there are some telehealth setups in which you get forwarded to a small doctor’s office somewhere or something, but I suspect those are rare.
I dunno, I suppose it’s possible that since COVID the nurses are working some home or something. But that’s true of some call centers too: twice in 2020 I called customer service numbers and the ‘on hold’ message said that employees were working from home and that there might be unusual background noise or other issues.
Perhaps we need to clarify the terminology. I was thinking of telehealth visits – those are directly arranged with my medical providers and there is no call center involved. I was not aware of ER calls going to call centers – if they do, then I have no knowledge about these. I find it very strange if an ER visit would be a telehealth visit in any case. Perhaps there are calls for screening whether or not to go to the ER, but I would be shocked if these were handled by 3rd party call centers.
The specific issue mentioned above – of ER visits – needs further clarification of what role telehealth would play in such circumstances. The other issue – of 15 hour waits for pediatricians – also needs some clarification. I’ve not heard of such waits. But as I indicated, I have had to wait on telehealth visits, just like I have to wait in a doctor’s office, but the former is somewhat more pleasant (although it could/should be done better since there was minimal communication regarding what was going on, how long I would wait, etc.).
It sounds like your experience was with telehealth services provided by nurses through a call center. I have not had experience with such a situation – and, I would try to avoid that if possible. It makes me wonder about what type of health provider this was – it sounds somewhat like an HMO or some other highly managed health care organization – which I try to avoid if I can. It sounds like it was done to reduce costs, but with inadequate attention to quality of care (I am speculating here). In any case, perhaps we are talking about very different things under the label “telelhealth.”
Yeah, maybe terminology is part of the problem.
At the health call center that I’m familiar with, they had two types of employees: nurses and non-nurses. The non-nurses would do things like set up appointments and other administrative tasks. The nurses would answer questions like “my kid has had a 102-degree fever ever since yesterday afternoon, do I need to take him to the ER?” and “I have an eye infection that seems like the same thing I had last year, I still have some erythromycin left from that, can I go ahead and try that for a few days or do I need to see a doctor”, and all of the other zillions of questions that people have that are related to health and that don’t necessarily require an in-person visit anywhere. I have always assumed that when people refer to “telehealth” they are talking about the things those nurses were doing, but maybe that’s not the case.
I think part of the confusion and differing perspectives is that I believe the original post describes the situation in Canada. The post mentions Toronto and I googled a Joseph Delaney and it appears there’s someone by that name in the Epidemiology department of a Canadian university. Although I’m in Canada, I don’t have any experience with telehealth, but I imagine it operates very differently than in the US. Also, I believe that wait times are much longer in Canada than in the US, currently.
Dale:
I just got off the phone with a utility. I’ve had to call a lot of call centers lately on behalf of someone else. The wait time was about 10-15 minutes. The problem was resolved in less than ten minutes with the service rep. The service rep was courteous and knowledgeable.
Across the board this has been my experience in quite a few calls in the last few months and less frequently in the last few years. Call center service is relatively fast – rarely over 20 min wait time – and the reps are knowledgeable and courteous if not downright friendly. That’s for credit cards, financial institutions (brokers, banks), utilities, commercial operations, whatever. Even one call to Comcast went pretty well.
Another point: my utility & telecom services are excellent. They never fail. My most recent call to Comcast was to set up a new cable modem/ethernet hub, not for a service or billing problem. The only occasional service failure I’ve had is a few power outages over the last few years during storms. So aside from call centers, most organizations are providing excellent service. That seems like an obvious thing to consider before complaining about call centers.
And it seems to me that yeah, that’s in direct response to customer demand. Cheers! :)
Your experiences are yours. n=1. I also have n=1 with very different outcomes. However, if you would stop making blanket statements, I think there is more that can be said about these experiences. I also have had good experience with my utility companies and financial institutions. Note that utility companies are highly regulated. Financial institutions are as well, but more importantly they face real competition. I’m not surprised that their call centers work well.
I contest your experiences with Comcast. I’ve had very bad encounters with their call centers – and they have a reputation that more closely matches my experiences than yours. Have you ever tried to call Microsoft for assistance? I have and it has not been pleasant. Cellular carriers are another example: about the only thing their call centers are capable of doing is upselling.
The examples have a point. I actually do believe in competition – more than many people (perhaps it is my economics training). Where I see competition, I find call centers work. But where I see lack of competition, call centers have been a black hole in my experience. We may disagree on where we see effective competition. From past comments, it seems like you see it everywhere. I don’t. In particular, I don’t see cable, broadband, cellular service, and many technology providers as exhibiting much effective competition – and I also experience poor telephone support. I will make one exception to that list – broadband from small regulated telephone companies seems to get good support. But many of those companies are close to their customers (many are co-ops).
More typical for my experience has been long wait times, too frequently with a poor connection (amazing how many telecommunications companies have such bad connectivity), at times with random disconnections, and usually with a person reading from an algorithm that lists all the things that I already tried. And, when I ask for a supervisor (which I often do), they are often not available.
Dale: telecoms are highly regulated! Yet you’re still complaining about their call centers. You’re just cherry-picking examples that suit your anti-business point of view. You don’t see competition everywhere because you only look at whatever’s itching your bum at any given instant. When one thing doesn’t work out exactly how you think it should, you go “oh, there’s no competition, look at all these monopolies”!! You don’t look at the larger picture at all.
I think that call center service is not only reducing wait times, but has much more knowledgeable people than in the past. I suspect this is happening because of a) competition; and b) relatively less load on call centers, as an increasing amount of issues and transactions are completed self-serve on the web, meaning additional resources are available for call centers.
chipmunk
I am sensitive to Andrew’s concerns about this “dialogue” degenerating, but I can’t resist addressing your latest comment. It is you who oversimplify things – you see competition everywhere. I am perfectly capable of distinguishing when there is effective competition and where there is not. Telecom call centers don’t work very well in my experience because there is limited competition and consumers are quite sticky. As for your statement that they are “highly regulated” that is just plain wrong. I’ve spent most of my career engaged in regulatory matters and the regulatory climate for the major carriers – and mobile services especially – has changed drastically over the past 2 decades. The FCC (and to a lesser extent state regulators) have bought the idea that telecommunications services are a competitive industry and have deregulated most things (decisions I have major issues with, but nonetheless it is what they have done). In some ways it mirrors the airline industry – it is “heavily regulated” at least regarding safety (the FAA), but mostly deregulated as far as prices and entry.
I’m not cherry picking industries or examples – but I don’t agree that call centers are generally providing excellent and knowledgeable service. There are examples where this is true and ones where it is not. I happen to think that the individual cases matter and that a blanket endorsement or critique of call centers is a mistake. In fact, this is one thing that most disturbs me about my fellow economists – a tendency to see everything through the same filter and an inability to consider the circumstances that apply to individual cases.
I’m happy for you that you have had such good experiences, but I don’t share your experiences and I believe there is evidence that your experience is not generally what people experience (and I won’t bother to search for evidence, so let’s just leave it that neither you nor I have clear evidence to support our positions – of others want to provide such evidence, I’ll be happy to look at it).
“and mobile services especially”
Yes, I realized after I made that comment that landline services are heavily regulated but mobile services probably aren’t. Fair enough.
“Telecom call centers don’t work very well in my experience because there is limited competition and consumers are quite sticky. ”
This is good example of how you incorrectly assess competition.
Businesses don’t compete on their call centers – they compete on the overall value of their goods and services. Call centers are one component of those services – and likely a very small one at that. For wireless, price, phone features and bandwidth are probably the primary bands of competition. Did you switch your provider because of the service at call centers? Do you ditch your Microsoft products? If you answer “no”, then you’ve already proven its a small portion of the competitive equation and demonstrated why call centers would be on the lower tier of investment choices for the company: because ultimately customers don’t care. You claim “consumers are sticky” – another way of saying that is that they don’t care that much in the end about call center services!
Dale, you attack competition the same way evolution deniers attack evolution: they subdivide and subdivide (e.g., “cherry pick”) and even reword evolutionary theory until they find one feature that it isn’t immediately explicable – according to their rewording – then jump on that to “disprove” evolution. You divide up company goods and services, which are actually offered as a whole package, then pick which ones don’t suit you and attack them as “not competitive”. This is the same technique used by the guy who wrote the book about debt mentioned by “somebody” – he redefined “barter economy” to a narrow, obscure definition, then claimed that no barter economy ever existed, using the bait and switch with the common definition of “barter economy”.
Again, though, despite the modest importance of call centers to customers overall, I think they’ve improved because the demand on them has declined as web services have become better and better, and more customers can self-serve on the web. That leaves more resources for a relatively – relatively – smaller volume of calls.
“I won’t bother to search for evidence, so let’s just leave it that neither you nor I have clear evidence to support our positions”
Finally! Excellent. Thank you. You have presented anecdotes about call centers – the entire content of this thread is anecdotes. They are no more, or less, valid than mine.
chipmunk says:
“Businesses don’t compete on their call centers – they compete on the overall value of their goods and services. Call centers are one component of those services – and likely a very small one at that. For wireless, price, phone features and bandwidth are probably the primary bands of competition. Did you switch your provider because of the service at call centers? Do you ditch your Microsoft products? If you answer “no”, then you’ve already proven its a small portion of the competitive equation and demonstrated why call centers would be on the lower tier of investment choices for the company: because ultimately customers don’t care. You claim “consumers are sticky” – another way of saying that is that they don’t care that much in the end about call center services!”
I agree 100%. In fact, this is my point. Somehow, you interpret this fact as evidence supporting your notion that call centers have improved generally – given that in some of these cases (e.g. wireless services, Microsoft products) call centers matter little to consumer decisions, I believe the correct economic reasoning should lead you to believe that these call center services would receive little investment and providers would care little about the quality of the services they provide. Yet you somehow believe the opposite. Whatever – I’ll go with the economic logic that if there is little incentive to provide high quality call center services, then there will be little quality provided (and, the reverse).
I’m not going near your evolution tirade as I’ve said nothing about evolution.
Ah yes, Dale should absolutely have considered that you have had good experiences lately with call centers, and inferred from that that most organizations are providing excellent service. But then again, maybe he did consider that, but also considered that I have had bad experiences lately with call centers, so they cancelled out.
Awe! You couldn’t find anything legit to criticize in my comment, but you still wanted to say something to show you care! Awe! Flattering!
Chipmunk:
This particular thread is degenerating into what Phil calls “garbage time.” Please do your part to maintain the level of discourse in our comments. Thanks!
Somebody, I’ll let Dale make the point from intended in my previous comment:
“neither you nor I have clear evidence to support our positions”
Sorry, I guess my point wasn’t clear enough. It was that your evidence for call centers providing excellent service is an anecdote that Dale certainly didn’t have access to; yet you said it was something to have taken into consideration before complaining about them. Even if he took into account your anecdote about good experiences, he could also take into account my anecdote about having terrible call center experiences recently (which is true). If we want to go beyond anecdotes though, all I can find is this:
https://www.bloomberg.com/news/articles/2022-06-07/customer-service-wait-times-triple-as-vacancies-vex-call-centers
which accords with the “due to unprecedented call volumes” blip I hear from every call center these days.
Isn’t this simply industries charging as much as possible for as little as possible? Ie, profit maximization.
If hospitals could charge the same for telehealth as they do for ER visits, then you’d see them make that option more attractive. Actually, they would prefer to get rid of the hospital altogether and just be a call center. Then eventually not even the call center, it would just be people working from home answering the calls.
The only counterforce is competition with other options.
Let us not overlook a secret sauce solution. Last year or so, I tried to reach Delta Airlines customer service several times and was on hold to the point I kept giving up. Then, somehow via the Web, I discovered an emergency number and got through so quickly that I almost forgot what I was calling about. The person I reached at this number usually deals with genuine emergencies such as hijackings, explosions, etc., and he was stunned that I was calling about altering my seat selection. And it took him time to do the adjustment because that was not what he customarily did.
My guess is that every airline has such a special phone number to deal with genuine crises and this phone number is known to at least some of the employees.
I’ve seen some of those emergency numbers, but never thought to call them, even in a (personal) emergency of my own (missed connection, etc). I thought (correctly, I suppose) they were intended for real emergencies involving potential loss of life and not just time/money. But then I wonder: why do those numbers exist? If an explosion or hijacking were to occur, I would call 911, but I would never think to call some obscure airline number.
Maybe the numbers exist so the 911 people have someone to call. Suppose you’re working at a 911 desk and you get a threat that there’s a bomb on Xray Air Flight 802. What to you do?
I’m just speculating, but I’d guess these numbers are not primarily for the public at all, they’re for higher-level communications.
These are just examples of economic rents, are they not?
With cable companies in the US, I don’t think the issue is zero value assigned to the customer’s time, it is negative value assigned to the customer being able to get through and actually cancel a contract or similar. So 2-hour wait times make sense from their perspective.
I wonder why hospitals actually make those children wait on the premises for 15h. When 50+ people are before someone in a queue, they should be offered the option to go home and have someone call them when their expected wait times are below 1h. All of this could be automated pretty easily. It’s not like they physically need to form a queue to be in one.
This sometimes helps reach a real person: https://gethuman.com/
When I get good call center help (which does happen from time to time) I always ask to talk to the helper’s supervisor to say so.,
I should probably do this too, but usually even if I’ve had great service I’ve had to sit on hold for a while to get it, so by the time I’m done with the call I am very eager to move on to something else.
But all of the calls are recorded, or at least I’m warned that they might be. When I have good or great service I always say so at the end, something like “You have been extremely helpful and efficient, thanks very much for that!” It would be nice if the person at the other end could flag such calls for their supervisor to listen to.
Like Andrew, I have had good experience with my workplace group health plan phone line. Having participated on employee-employer benefits committees, I’ve seen that for such companies getting a new client is difficult and losing an old one implies a big cost.
So, on both extremes call centre culture is corporate culture. Good service is provided when it pays off, otherwise not. It isn’t a matter of certain companies being nice.
It’s important to remember that the health care industry in the US (as well as most other countries) is heavily regulated and otherwise influenced by government entities, like Medicare. Oftentimes if you ask the question, “why are things being done this way?” the answer is that the behavior is optimal given the incentives shaped by government intervention.
For years, telehealth was incredibly limited. Why? Because regulations limited it.
Why isn’t telehealth better now? I’m not an expert and don’t know for sure, but the first thing I would check is how much people can earn doing it. For instance, “call volumes are high” isn’t really meaningful. What matters is call volumes relative to the amount of staff that you have to field said calls. If the wages of people doing telehealth are lower than other alternatives, then you are going to struggle to maintain your staff. There can also be a compensating differential whereby people prefer working with others face-to-face than being on the phone (there could be many drivers of this, including the higher intensity of work and diminished bargaining power). If they pay the same amount, then people might prefer to work in-person. This leads to staff not being high enough to meet the call volumes. So why not raise the wages? Well, the government and health insurance companies are likely determining it.
John,
I’ve had crummy experiences on plenty of non-health-related calls. It’s true that these tend to be worse in monopoly or near-monopoly situations like the cable company and the electric company, but even in competitive markets. Up above, paul alper recounts a story involving an airline, that’s a good example. So I don’t think we can blame this phenomenon on government regulations.
I think the reason we have enormous in-person medicine system is that telehealth was not viable under regulation though. And furthermore that the doctors lobbies most likely lobbied to prevent regulations that would create widespread telehealth. People who have invested heavily in offices and equipment don’t want 50% of their patients moving to someone else’s practice via phone calls, even if that’s the best outcome for the patient.
I don’t dispute that you can have a bad experience on non-health care related calls. I think the question is whether some industries have particularly bad experiences versus others and what factors may be driving it. As Daniel said previously, monopoly or near-monopoly situations could result in an underinvestment in customer service. Such a monopoly may or may not be related to government regulations. I don’t dispute that more competitive industries could have an underinvestment in call center support for reasons both related and unrelated to government regulations (an unrelated reason might be that companies are fighting on costs and the low cost provider might be reducing investment in customer service [in this case you would need to find another provider who does], a related reason might be that minimum wage regulations price out workers who could otherwise work in a call center, reducing the supply of labor). Health care stands out, however, as a particularly regulated industry in the US.
I can think of a few general rules. One is that capacity invites traffic, which is a lesson from roads: that if you build more road, you build more usage of the road, both because that taps current need and allows expansion of need. Since you have university coverage, have you experienced what most people do, which is a tremendous under-serving of their medical needs? As in, if you look at the desire to build greater equity in health outcomes, then where is the capacity to do that? Most places don’t have anywhere near sufficient medical infrastructure now.
I’m not sure anywhere has sufficient infrastructure because Boston, for example, draws people from many places – regional, national, international – while large sections of the local and regional population are not well covered. In other places, there is not even a pretense of having sufficient care. One reason, IMO, the expense of our medical education system makes it uneconomic for doctors and nurses to work in many markets. And of course the hospital chains are now run by bean counters and HR. Doctors now tell stories of hospital chains buying practices to close them so they can drive patient traffic to their existing practices and facilities. This literally deprives areas of care in a number of specialties.
Telehealth is almost like a prayer that maybe this will work on a scale past things like the poison control hotline.
Another is that some things don’t work as people think, as in probation/parole is not set up at all the way you likely imagine. The best candidates for parole are people who have served serious time and who society doesn’t want to let out, while the people who actually get parole tend to be younger and more involved with criminal behavior. They are released because they didn’t commit super serious crimes and the prisons need the space. Parole is a way to shorten sentences because we need the space, which means the people don’t really fit the naive conception.
And, as an aside, parole has tried to shift to the telehealth equivalent: they monitor electronically and require phone call and other virtual check-ins. Otherwise, the job is that of a social worker: too many cases, huge amounts of wasted time chasing people around, vast paperwork, lots of bad things happening.
The second general rule would be that a poorly constructed system will find ‘whatever’ solutions because those are the best that fit, even though they’re not good solutions and they don’t fit very well. Like the stuff you write about.
Jk:
I don’t have university health coverage. I buy health insurance through the university but then I chose a doctor through a big practice (Weill Cornell Medicine) which happens to be well run.
Regarding probation and parole: My issue for the purpose of the above post is just that it’s a lot cheaper than prison, but then it gets underfunded so that the officers get overwhelmed. The “too many cases” problem could be handled by hiring more officers (which would be much cheaper than sticking more people in prison), but somehow there’s never enough budget for that.
On probation and parole: I’m not at all sure that this has much in common with the telehealth situation. I once taught in a college program for prisoners (2 year program at Attica Correctional Facility). There was probably no real evidence at that point in time whether such programs were cost effective – but there were issues affecting the program’s success (or lack thereof) that had nothing to do with evidence or costs. The prison administration and employees (guards) were openly hostile to the program – they objected (with some justification, in my mind) to offering “free” college education to convicted felons while their own children were ineligible for financial support for college. As a result, they did everything they could to impede the success of the program.
Is it possible that there are elements in the criminal justice administration that object to the technological approaches to probation/parole that account for it being underfunded?
I wonder if this is a version of the Jevons paradox that hinges on quality instead of quantity?
The Jevons “paradox” is that when technology (in his case, the steam engine) increases the efficiency with which people use a resource (coal), the market can end up consuming more of the resource than it did before the efficiency gains.
The issue comes up in markets with price elastic demand e.g., you halve the price of gas and people double their usage.
In the cases in this post though, instead of a competitive market we are looking at the technology change from the perspective of budget-constrained organizations. It seems like these organizations have highly elastic budgets with respect to quality of the particular service (health consultation and parole/probation). As technology improves the quality of the service, funds flow away to other parts of the budget until the service’s quality declines to a level of cruddiness similar to the experience before the innovation.
Maybe there is some nice way to model this with ideal points for quality of service provided?
https://en.wikipedia.org/wiki/Jevons_paradox
The original post by Delaney raises very different issues for me. Reading the post that Andrew quoted from, it is a curious mixture of different situations and various data sources. I discount almost entirely the Twitter streams regarding ER wait times. The situation that has given rise to this media attention is the recent RSV/COVID/FLU perfect storm that has overwhelmed hospital facilities. That is an important issue – what capacity should be available for demand fluctuations and who should pay for it? I’m not sure I see telehealth as an important piece of that puzzle. And, to the extent that it is, I’m not sure the issues have much to do with telehealth in general or prisons or call centers. An emergency situation arising from extreme demands does not necessarily share much with these other situations. If it does, I would need a much clearer description to make sense out of whether there is some underlying common cause or phenomenon (such as Jevons paradox).
Also, the news stories that Delaney cites involve long waits to see a “doctor” with unspecified (presumably shorter) waits to see a nurse, and also distinctions between emergency cases and not-so-emergency cases. Surely there is triage going on in these hospitals. Would telehealth really help under these circumstances? Perhaps – but if there are obstacles to telehealth solutions under these circumstances, I think the underlying causes are similar to why the system capacity was inadequate to begin with. That is, I don’t see the impediments as having much to do with technology or call centers at all. It seems more a matter of a market/business failure to provide adequate service for random demand (a situation in which “option value” has been the subject of some attention – how (and who) do you pay for backup capacity under random demand?
It seems to me that if you want to solve the problem of long wait times at emergency rooms, you should deal with the reality that many people, some with many health problems, use emergency rooms for primary care. If you could address that, say with universal health insurance, then emergency rooms would be freed up to deal with emergencies.
Trying to think of Andrew’s question of whether some broader law governs the tendency to starve ostensibly cost-effective options to the point where they fail. I certainly don’t have any special data on this, but to me the common denominator between tele-health and parole (tele-incarceration?) is just Newton’s first law:
(a) Lots of inertia (status quo funding channels, capital assets, institutional practice, and human training) meets
(b) Little force for change (highly regulated markets where consumer choice isn’t a strong enough factor to exert much influence on policy priorities)
When conditions (a) and (b) both hold, a change to something more “efficient” can’t be expected to spontaneously sprout and organically flourish from the seed of a better idea. It’s natural to think, as the OP did, that somehow getting the customer time-tax to register correctly would help. I agree that would help, but register to whom? How? I don’t think these questions go anywhere because the current system is just so far from being set up to care about that. If so-called “out-come-based healthcare” really took off, then at least we’d have a place to put that time-tax cost, but as it is, it just seems like that cost lives in an entirely different universe that Epic Systems software knows nothing about.
As for the anecdotes about (some) great employer health plans/systems having useful tele-health, I think those are just cases where condition (b) doesn’t hold. A large institutional client like Columbia U or IBM actually might actually care about customer experiences because those customers are its employees, and they have reason to care about huge time sucks for their employees.
Meta comment: I’ve noticed not much systems thinking happens around here (stocks and flows). Individual commenters identify their (single) bad actor/input/parameter to tweak. Yet reading all the comments helps me build up a better systems view.
Dana Meadows, Thinking in Systems:
“No one intends to produce a society with rampant drug addiction and crime, but consider the combined purposes and consequent actions of the actors involved:
• desperate people who want quick relief from psychological pain
• farmers, dealers, and bankers who want to earn money
• pushers who are less bound by civil law than are the police who oppose them
• governments that make harmful substances illegal and use police power to interdict them
• wealthy people living in close proximity to poor people
• nonaddicts who are more interested in protecting themselves than in encouraging recovery of addicts
Altogether, these make up a system from which it is extremely difficult to eradicate drug addiction and crime.”
“this all reminded me of a well-known problem with parole and probation. Given modern technology, these should be more effective than prison and much much cheaper, but they get such low funding that parole and probation officers are overwhelmed. ”
Is this really a “well known” problem? If it’s never been effective anywhere, how could it be “well known” that it would be effective with proper funding? I have no knowledge of the problem, but if there was ever a time when states and local governments would have jumped on this opportunity surely the last two years would have been it – the political winds for letting people out of prison were at gale force.
My guess is that most things that seem like they should work but aren’t happening are probably not happening because they actually don’t work.
As long as you define “work” as “make big money for for profit prison operators”
There is no paradox here if the caller isn’t the customer. In health care the caller is not the customer unless it’s concierge medicine, in which case the telehealth works pretty well.
In Australia during Covid telehealth was released from purgatory and given a Medicare Shedule # allowing GP’s, medico’s and psych’s to consult via the phone. Telehealth. A boon
They are restictrcting access again. First to go were psychological services last December requring $250 per consult niw plus if in a remote location, access to video conferencing facilities. Yeh. Weird.
Worse the RDVSA – Rape & Domestic Violence Australia who had started shelters way back for rape victims and abused women ended up with the premier trauma hotline. They had the intelectual property of what and hiw to do it.
They asked for $1m in funding to cover unanswered calls to go from 85% answer rate to 95+%.
Instead, the Australian Government had one if the Big 4 acct firms do a report. The report – never seen – refommended $5m and to replicate service. It was given to Medibank Private. A for profit. NOT Medicare out public health service.
As you can read in this and many other articles, safety and privacy werecompromised. And trauma via tele now a profit centre… ” Earlier this year Medibank healthcare and strategy group executive Andrew Wilson told The Australian that the services offered, which include BeyondBlue, Nurses on Call and After-hours GP as well as 1800 RESPECT, are an active part of their business.
“We have put a stake in the ground and said we’d like to double the operating profit of this part of the business in the next three years.”
“Medibank Health Service rejects what it calls “offensive claims” it is profiting from violence, saying: “We aren’t not-for-profit, but we have specialist expertise in delivering important 24-hour care and mental health phone support.”…
https://www.smh.com.au/politics/federal/counselling-service-walks-away-from-national-assault-hotline-1800-respect-over-privacy-concerns-20170901-gy8vx6.html
The kicker is the hotline 1800RESPECT is now advertised by the Australian Government and everywhere without a byline “for profit”. Galling in extremis.
I love your work Andrew and seeking knowledge re economics, Pareto, Jason’s paradox etc.
But really it just boils down to greed and control, and that horrid phrase “profit motive”.
Philosophy of neoliberals more than economics.
*
And bravo to:
“theCamel” for bringing up Systems Dynamics.
“Meta comment: I’ve noticed not much systems thinking happens around here (stocks and flows). Individual commenters identify their (single) bad actor/input/parameter to tweak. Yet reading all the comments helps me build up a better systems view.
“Dana Meadows, Thinking in Systems:”
Had the public via sortion been allowed to do the analysis, build a systems dynamics model, run a few scenarios, instead of an accounting firm, we would have included rape trauma and health, not just call volume and redundency vs capital cost and profit. And shown the takeover for what it was. A for profit power grab.
Do you have any stats to show above?
A sad episode of ‘tele’ trauma health in Australia.
And I’m still hoping you will seek what outliers dumped before QALY & LSV developed.