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VA vs. Medicare

Previously I linked to this article comparing the VA and Medicare, to VA's advantage. I'd only skimmed a bit into the article before; reading it properly now, I feel it could use some quotes. A lot of it is about the wonders of electronic data systems. It's embarrassing, at least for the $6000/capita, "best in the world" private side of US health care. But it's also about systematic market failure: most US doctors and insurance companies don't have an incentive to keep you health, especially over the long term.


VA does better

An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be "significantly better."

Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.

It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals. ...

The venerable Institute of Medicine notes that the VHA's "integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation." ...

Errors kill

Doctors aren't the only ones who define the quality of your health care. There are also many other people involved--nurses, pharmacists, lab technicians, orderlies, even custodians. Any one of these people could kill you if they were to do their jobs wrong. Even a job as lowly as changing a bedpan, if not done right, can spread a deadly infection throughout a hospital. Each of these people is part of an overall system of care, and if the system lacks cohesion and quality control, many people will be injured and many will die.

Just how many? In 1999, the Institute of Medicine issued a groundbreaking study, titled To Err is Human, that still haunts health care professionals. It found that up to 98,000 people die of medical errors in American hospitals each year. This means that as many as 4 percent of all deaths in the United States are caused by such lapses as improperly filled or administered prescription drugs--a death toll that exceeds that of AIDS, breast cancer, or even motor vehicle accidents. ...

Worse, even when strong scientific consensus emerges about appropriate protocols and treatments, the health-care industry is extremely slow to implement them. For example, there is little controversy over the best way to treat diabetes; it starts with keeping close track of a patient's blood sugar levels. Yet if you have diabetes, your chances are only one-out-four that your health care system will actually monitor your blood sugar levels or teach you how to do it. According to a recent RAND Corp. study, this oversight causes an estimated 2,600 diabetics to go blind every year, and anther 29,000 to experience kidney failure.

All told, according to the same RAND study, Americans receive appropriate care from their doctors only about half of the time. The results are deadly. On top of the 98,000 killed by medical errors, another 126,000 die from their doctor's failure to observe evidence-based protocols for just four common conditions: hypertension, heart attacks, pneumonia, and colorectal cancer. ...

Indeed, airlines, even when in bankruptcy, continuously improve their safety records. By contrast, the death toll from medical errors alone is equivalent to a fully loaded jumbo-jet crashing each day. ...

Electronic records

Craddock cracks a smile when she recalls how nurses reacted when they first were ordered to use the system. "One nurse tried to get the computer to accept her giving an IV, and when it wouldn't let her, she said, 'you see, I told you this thing is never going to work.' Then she looked down at the bag." She had mixed it up with another, and the computer had saved her from a career-ending mistake. Today, says Craddock, some nurses still insist on getting paper printouts of their orders, but nearly all applaud the computer system and its protocols. "It keeps them from having to run back and forth to the nursing station to get the information they need, and, by keeping them from making mistakes, it helps them to protect their license." The VHA has now virtually eliminated dispensing errors.

In speaking with several of the young residents at the VA Medical Center, I realized that the computer system is also a great aid to efficiency. At the university hospitals where they had also trained, said the residents, they constantly had to run around trying to retrieve records--first upstairs to get X-rays from the radiology department, then downstairs to pick up lab results. By contrast, when making their rounds at the VA Medical Center, they just flip open their laptops when they enter a patient's room. In an instant, they can see not only all of the patient's latest data, but also a complete medical record going back as far as the mid-1980s, including records of care performed in any other VHA hospital or clinic. ...

Quick response and research

The same system reminds doctors to prescribe appropriate care for patients when they leave the hospital, such as beta blockers for heart attack victims, or eye exams for diabetics. It also keeps track of which vets are due for a flu shot, a breast cancer screen, or other follow-up care--a task virtually impossible to pull off using paper records. Another benefit of electronic records became apparent last September when the drug-maker Merck announced a recall of its popular arthritis medication, Vioxx. The VHA was able to identify which of its patients were on the drug within minutes, and to switch them to less dangerous substitutes within days.

Similarly, in the midst of a nationwide shortage of flu vaccine, the system has also allowed the VHA to identify, almost instantly, those veterans who are in greatest need of a flu shot and to make sure those patients have priority. One aging relative of mine--a man who has had cancer and had been in and out of nursing homes--wryly reports that he beat out 5,000 other veterans in the New London, Conn., area for a flu shot. He's happy that his local veterans hospital called him up to tell him he qualified, but somewhat alarmed by what this implies about his health.

The VistA system also helps to put more science into the practice of medicine. For example, electronic medical records collectively form a powerful database that enables researchers to look back and see which procedures work best without having to assemble and rifle through innumerable paper records. This database also makes it possible to discover emerging disease vectors quickly and effectively. For example, when a veterans hospital in Kansas City noticed an outbreak of a rare form of pneumonia among its patients, its computer system quickly spotted the problem: All the patients had been treated with what turned out to be the same bad batch of nasal spray.

But not adopted by private doctors

Developed at taxpayer expense, the VistA program is available for free to anyone who cares to download it off the Internet. The link is to a demo, but the complete software is nonetheless available. You can try it out yourself by going to http://www1.va.gov/CPRSdemo/ . Not surprisingly, it is currently being used by public health care systems in Finland, Germany, and Nigeria. There is even an Arabic language version up and running in Egypt. Yet VHA officials say they are unaware of any private health care system in the United States that uses the software. Instead, most systems are still drowning in paper, or else just starting to experiment with far more primitive information technologies.

Worse, some are even tearing out their electronic information systems. That's what happened at Cedars-Sinai Medical Center in Los Angeles, which in 2003 turned off its brand-new, computerized physician order entry system after doctors objected that it was too cumbersome. At least six other hospitals have done the same in recent years. Another example of the resistance to information technology among private practice doctors comes from the Hawaii Independent Physicians Association, which recently cancelled a program that offered its members $3,000 if they would adopt electronic medical records. In nine months, there were only two takers out of its 728 member doctors.

Simple checklists

So-called "wrong site" surgery happens in about one out of 15,000 operations, with those performing foot and hand surgeries particularly likely to make the mistake. Most hospitals try to minimize this risk by having someone use a magic marker to show the surgeon where to cut. But about a third of time, the VHA has found, the root problem isn't that someone mixed up left with right; it's that the surgeon is not operating on the patient he thinks he is. How do you prevent that?

Obviously, in the VHA system, scanning the patient's ID bracelet and the surgical orders helps, but even that isn't foolproof. Drawing on his previous experience as a NASA astronaut and accident investigator, the VHA's safety director, Dr. James Bagian, has developed a five-step process that VHA surgical teams now use to verify both the identity of the patient and where they are supposed to operate. Though it's similar to the check lists astronauts go through before blast off, it is hardly rocket science. The most effective part of the drill, says Bagian, is simply to ask the patient, in language he can understand, who he is and what he's in for. Yet the efficacy of this and other simple quality-control measures adopted by the VHA makes one wonder all the more why the rest of the health-care system is so slow to follow.

No one gets paid for your long term health

The same problem exists across all health-care markets, and its one main reason in explaining why the VHA has a quality performance record that exceeds that of private-sector providers. Suppose a private managed-care plan follows the VHA example and invests in a computer program to identify diabetics and keep track of whether they are getting appropriate follow-up care. The costs are all upfront, but the benefits may take 20 years to materialize. And by then, unlike in the VHA system, the patient will likely have moved on to some new health-care plan. As the chief financial officer of one health plan told Casalino: "Why should I spend our money to save money for our competitors?"

Or suppose an HMO decides to invest in improving the quality of its diabetic care anyway. Then not only will it risk seeing the return on that investment go to a competitor, but it will also face another danger as well. What happens if word gets out that this HMO is the best place to go if you have diabetes? Then more and more costly diabetic patients will enroll there, requiring more premium increases, while its competitors enjoy a comparatively large supply of low-cost, healthier patients. That's why, Casalino says, you never see a billboard with an HMO advertising how good it is at treating one disease or another. Instead, HMO advertisements generally show only healthy families. ...

But projections show that, between 2001 and 2008, the initiative will cost the local hospital $7.7 million in lost revenue, and reduce the income of the county's medical specialists by $1.6 million. An idealistic commitment to best practices in medicine doesn't pay the bills. Today, the initiative survives only by attracting philanthropic support, and, more recently, a $500,000 grant from Congress. ...

Consortiums of large employers may have the staff and the market power necessary to evaluate the quality of health-care plans and to bargain for greater commitments to patient safety and evidence-based medicine. And a few actually do so. But most employers are not equipped for this. Moreover, in these days of rapid turnover and vanishing post-retirement health-care benefits, few employers have any significant financial interest in their workers' long-term health.

That's why you don't see many employers buying insurance that covers smoking cessation programs or the various expensive drugs that can help people to quit the habit. If they did, they'd be being buying more years of healthy life per dollar than just about any other way they could use their money. But most of the savings resulting from reduced lung cancer, stroke, and heart attacks would go to future employers of their workers, and so such a move makes little financial sense.




Summary

The article finishes by musing that rather than closing VA hospitals as veteran populations fall, we should open them to the general public in return for public service of some kind.

For my part, I've generally assumed that Medicare For All would be the best and simplest way out for the US. Probably is simplest, but now I wonder if it's best. Canada's Medicare seems to do better than UK's NHS -- well, Canadians live longer -- but the VA's own history shows quality of a centralized system can vary widely. Wish I knew more about France and Sweden's systems.

One difference is arbitrary legalism -- the VA is allowed to negotiate drug prices down, Medicare isn't.

But this goes to show how the current US system is almost optimized for poor outcomes overall. Employer-tied insurance and adverse selection of individuals means depression of entrepreneurship, self-employment, and small businesses; it also leads to employer and insurer unconcern for long-term outcomes, since you'll likely have left them; for the really long term, everyone switches over to Medicare, so there's really a disincentive to care about your long term health. And of course per-service for-profit care gives an incentive to the doctors to do as many tests and procedures as they can get away with, which when it comes down to tests and surgery for microtumors that would kill you by the time you were 130, are likely harmful for your health.

Comments

( 3 comments — Leave a comment )
mmegaera
Jul. 2nd, 2009 05:52 am (UTC)
I don't know who everybody else's insurance is, but my HMO has had computerized records for years and years, and a PC in every examining room. I can look at my records from my home computer if I want to, too, and communicate with my doctor, etc., via email. It always floors me when I read articles like this where it's assumed that's not the standard for health insurance records.

I do wish it could be that way for everyone, though [sigh].
mindstalk
Jul. 2nd, 2009 06:05 am (UTC)
Is yours Kaiser Permanente? They've been cropping up recently as pioneers -- integrated care in the Gawande article, second-best in this one.
mmegaera
Jul. 2nd, 2009 06:15 am (UTC)
edited, sorry
No, Group Health, a Pacific NW HMO.

I had Kaiser when I lived in California, and if they're supposed to be second best they've improved drastically in the last 30 years. They were gawdawful back then. The ratio of bureaucracy to care was about 100 to 1 on a good day.
( 3 comments — Leave a comment )

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