I was thus interested to learn that the Congressional Budget Office had issued a report on the VA's quality initiatives. I've been meaning to get around to reading it for weeks, but I've been sidetracked by other things. (To judge by an internet search, I'm not alone; few people seem to have blogged or linked to it.) But I finally have, and I think I can say two things definitively: the report suggests that the VA really has made outstanding improvements in the quality of care they deliver. And the report also suggests that the VA does not represent any sort of workable model for the US health care system.
The advocates of a VA-style system usually have three core arguments:
- The VHA provides better care because it has centralized records (VistA) to coordinate treatment and reduce errors
- The VHA provides better care because it will care for a patient their entire life, and therefore has incentives to manage diseases rather than mindlessly do procedures
- The VHA can reduce costs through administrative efficiency, central procurement, integrated care, and salaried doctors
So what's left? Consider why, ultimately, the veterans health system is such an outlier in its commitment to quality. Partly it's because of timely, charismatic leadership. A quasi-military culture may also facilitate acceptance of new technologies and protocols. But there are also other important, underlying factors.
First, unlike virtually all other health-care systems in the United States, VHA has a near lifetime relationship with its patients. Its customers don't jump from one health plan to the next every few years. They start a relationship with the VHA as early as their teens, and it endures. That means that the VHA actually has an incentive to invest in prevention and more effective disease management. When it does so, it isn't just saving money for somebody else. It's maximizing its own resources.
The system's doctors are salaried, which also makes a difference. Most could make more money doing something else, so their commitment to their profession most often derives from a higher-than-usual dose of idealism. Moreover, because they are not profit maximizers, they have no need to be fearful of new technologies or new protocols that keep people well. Nor do they have an incentive to clamor for high-tech devices that don't improve the system's quality or effectiveness of care.
And, because it is a well-defined system, the VHA can act like one. It can systematically attack patient safety issues. It can systematically manage information using standard platforms and interfaces. It can systematically develop and implement evidence-based standards of care. It can systematically discover where its care needs improvement and take corrective measures. In short, it can do what the rest of the health-care sector can't seem to, which is to pursue quality systematically without threatening its own financial viability.
The analysis is theoretically appealing, but there are a couple of problems for it. First, on the theory side: it's not clear what incentives the VA has to become more cost efficient. Finding ways to save money in a government bureaucracy is not generally rewarded. Finding ways to save money usually means you get your budget cut, while cost growth can provide an argument for a bigger appropriation. And when the VA runs out of money, it can reallocate services between priority levels, cutting some of its customers off in order to cover higher priority patients.
Which brings me to the empirics: the VA does not, in fact, provide lifetime care for its patients practically from kribbe to grav. The VHA works on Priority Groups, which categorizes who is eligible for what treatments. Some of the categories are rather fun:
Veterans in priority group 6 served in World War I or the Mexican Border War, are seeking care solely for disorders associated with exposure in the line of duty to chemical, nuclear, or biological agents (including, for example, Agent Orange), have compensable SCDs [Service Connected Disabilities] rated zero percent disabling1, or are within a five-year period of special eligibility for recent combat veterans.
The footnote goes on to explain that 
this covers a handful of vets receiving payments for tuberculosis, "special monthly compensation under 38 U.S.C. 1114(k)" or other disabilities. And here is 38 USC. 1114(k):
if the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs, or one foot, or one hand, or both buttocks, or blindness of one eye, having only light perception, has suffered complete organic aphonia with constant inability to communicate by speech, or deafness of both ears, having absence of air and bone conduction, or, in the case of a woman veteran, has suffered the anatomical loss of 25 percent or more of tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy) or has received radiation treatment of breast tissue, the rate of compensation therefor shall be $89 per month for each such loss or loss of use independent of any other compensation provided in subsections (a) through (j) or subsection (s) of this section but in no event to exceed $3,075 per month; and in the event the veteran has suffered one or more of the disabilities heretofore specified in this subsection, in addition to the requirement for any of the rates specified in subsections (l) through (n) of this section, the rate of compensation shall be increased by $89 per month for each such loss or loss of use, but in no event to exceed $4,313 per month;
Pardon me for a moment while I meditate on the notion that we must have more government involvement in our health care in order to bring some rational, efficient order to our broken system.
But I digress. The reason I bring all this up is that none of these groups, according to the CBO, gets as much as 50% of its healthcare through the VA:
So the problem you have to contend with is that if your patient population is different from the general population, and your patients almost all use a mix of your services and other providers, most measurements of your quality may well be picking up the quality of the other helath care they have access to. Or the quality of the patients themselves.
In fact the CBO specifically says that this is a problem with Longman's analysis:
Advocates have claimed that because VHA is free from concerns about generating profits from medical services and faces at least part of the long-term costs associated with chronic diseases, the agency has an incentive to invest in preventive care, coordination of services, and quality improvement26. However, data on the way in which veterans use the system make it clear that most enrollees also rely on other sources of care for a significant portion of their health care needs.
Footnote 26 goes to Longman's book, which was based on the 2005 article.
This is also a problem with analysis of cost control. The VHA controls its costs in a number of ways, but one of them is managing its priority lists--making it harder for those who are lower priority to get care. For example, thanks to the influx of war veterans, the VA in 2003 closed its lists to many higher-income people who didn't have service-connected disabilities--AKA Priority Group 8, which as you can see, isn't getting much of its health care from the VHA.
So in some sense, you are trivially controlling cost per enrollee, but you're not necessarily doing it by delivering better care at a better price; you may just be providing less care for some enrollees. But that doesnt mean that total national healthcare spending on those people goes down. By contrast, most people with private insurance do most of that spending through their insurance.
Furthermore, the changing mix of the priority groups can dramatically effect how much you need to spend. Much has been made of the VA's ability to control costs, but according to the CBO:
Some proponents of the veterans' health system have suggested that VistA has helped the Veterans Health Administration hold down cost growth when compared with other federal health programs, such as Medicare. But such comparisons are difficult to make. The substantial changes in the VHA's structure and in eligibility for care make it particularly difficult to interpret usch metrics as cost per enrollee when enrollment was rising dramatically from 1999 through 2002. In this assessment, the Congressional Budget Office (CBO) adjusted enrollment data to account for changes in the mix of enrollees adn found that VHA's spending per enrollee was relatively flat from 1999 through 2002, but since that date it has risen about as rapidly as spending per enrollee in the Medicare program.
This cuts both ways, of course--I imagine the influx of new vets is quite expensive. The point is, you can't compare a system that manages its costs by allocating a set budget among a shifting group of people, few of whom actually depend on the VA for all their healthcare, with any other system.
We can't do anything like what the VA does on a national scale--not to manage our costs, not to deliver our services. A system in which people got 20-50% of their care from the government, and the rest from some other provider, would not be a good system--especially because while applauding VistA, the CBO also points out that it can make data sharing between systems very difficult.
That's not to say there are not lessons we can learn from the VHA. Just for starters, the conversion to electronic medical records is long overdue, and we ought to be using the Medicare payment system to herd doctors and hospitals faster towards adopting systems that are interoperable and meet certain broad standards. But whatever the merits of the system, it simply doesn't tell us much about how to design some sort of comprehensive government health care system.
the conversion to electronic medical records is long overdue,
But those records have to be HIPPA compliant, which means that some hacker who breaks into a health provider's or insurance company's systems can't get at the unencrypted data. So these systems will need better security than the banks (read Brian Krebs stuff at his Security Fix blog at the WaPo) and credit card companies have been able to put in place.
Yes, veterans as a group are healthier when drafted than their 4-H bretheren. OTOH, a large proportion of them have experienced wounds and living conditions that non-veterans have never had to endure.
Few of us, thankfully, had to survive living exposed to the elements at Chosin, Guadalcanal, the Ardennes, just about anywhere in Vietnam or Iraq, etc. Not many of us have to live with the long term effects of routine operations at high altitude or deep water dives, the concussion of artillery, or 12 months of battlefield stress and sleep deprivation.
And who can say how any of these factors affects the long term health of the people who have experienced them?
Is the fact that veterans start off healthier offet by the fact that many of them experience more physical adversity than non-veterans ever will?
There's no aggregated data on this at all, which only adds to Megan's point: you can't compare them to the general population, even if the VHA was their only caregiver.
Yeah, I'd tend to guess that the benefits of a healthier initial pool vs the drawbacks of being exposed to anti-personnel mines, traumatic stress, and Agent Orange are, at best, a wash. Many of the conditions that disqualify 18-year-olds from military service (flat feet, homosexuality) don't bear much on long-term health problems. Though some are surely excluded for things like asthma, diabetes, obesity and anemia that are significant in the long run. The populations are different, but it's possible to compare different populations, just harder.
I meant to write 4F and not 4H, but there is no edit here. Pretty funny mistake, actually...
In any case, I wanted to comment on flat feet, being the recipient of two of them.
I thought the same thing when I was 18. I had done well in High School Football, and basic training wouldn't have scared me.
By the time I was 30 I realized that my flat feet were causing problems with my knees, and on up to my hips and back. Crippling? No - but I'm not marching, climbing, running, or even just standing watch on a deck all day. I can absolutely appreciate why flat feet are a 4F issue.
As for homosexuality, the issue there is order in the ranks and logistics.
If you believe that people have a right to reproductive privacy, then you believe that men and women shouldn't share public bathrooms or barracks. You should be able to relieve yourself without being concerned that someone is eyeing your "equipment." Perhaps you personally don't mind if people see you naked, and that's your right, but surely you don't deny people their right to modesty and privacy?
And therein lies the root issue with homosexuality in the military. If I don't want to be viewed sexually while I use the bathroom, then I don't want women in there with me. Or homosexual men. Or bisexual men or women.
How do I accommodate that in an armored fighting vehicle, or a submarine? Whose rights do I trample?
The initial pool excludes a whole lot of expensive chronic conditions like asthma, type 1 diabetes, schizophrenia, joint problems, etc. Absolutely, combat vets are expensive to treat--but combat veterans of lengthy wars are a small minority of the total veteran population. Annual fitness tests also slow the development of various other chronic conditions.
Booosh is a war criminal and should be sent UP THE RIVER along with Flush Limpballs!
"The conversion to electronic medical records is long overdue". Megan, I work on exactly this kind of thing at Johns Hopkins, which is as electronic as anywhere you're likely to find. We have every kind of electronic records, and every kind of inter-system data transmission.
And now there is Stimulus money available for changing over to electronic medical records. Therefore: We are supposed to build some kind of plan to get this much converted by this date, that much by that date.
Result: As my supervisor told me, the inmates are now running the asylum. And he's a big liberal. Darn it, we have been trying to convert everything to consistent electronic medical records. For forty years now. Succeeding in some things, doing complex conversions between systems in other things. In some places, thankfully growing fewer, we haven't been able to move away from just paper. Believe me, we don't want paper. But it's really a hard process, and giving us federal regulations on how it has to be done is just adding a lot of confusion into the mix.
If I understand correctly, No Child Left Behind did about the same thing to the American educational system.
Good points. Furthermore, the impact of EMR's is questionable, at best.
Remember that medical records are currently handled by some of the lowest paid resources in the whole healthcare chain (typically the person manning the front desk), and it's not as if they're not already using computers to enter and retrieve patient information. The marginal benefit of harmonzing the systems and equipping them with what amounts to a Shopper's Loyalty Card can't possibly deliver on the expectations.
Several countries already have extensive EMR's and, like all computerized systems - SURPRISE! - it now takes extensive resources to maintain these systems and their data. Info Tech people don't work cheap...
it is hard but why could the VA do it and not JH?
MikeR is correct about the difficulty of electronic medical records systems - I wrote software for medical lab automation. A friend worked on an electronic medical record system for a certain space station program. It took 5 years to design and implement an electronic system for the crew of the station. And that is for a system that will only deal with a subset of medical information, because the space station only has a few medical instruments and usually has no medical doctor onboard. Now, take that and amplify this by several orders of magnitude to account for all the kinds of data that are generated and the problem is not one that can addressed in a few years.
For example, there are standards for HTML, CSS and other technologies used in web pages. The standards are well known and have test suites available for use by developers. The best browsers for the PC are at best 92% compliant with HTML. It's even worse for CSS compliance.
So, to have a medical records system that can exchange data among your primary care doc, hospitals, specialists, labs, etc. a standard will need to be hammered out, which will take a couple of years to draft, comment, revise and publish. Then someone has to build a test suite and make sure it is correct. Finally, you can write the software and test it. Then hope it works and you don't kill someone when your system sends the data incorrectly or accepts data and mangles it. It also has to be secure and meet HIPPA standards. (In fact, the network that exchanges the data among providers should not be the internet and the computers should be isolated from it. It should be a private, strongly encrypted network like the bank funds network.)
Oh, and there will be a huge cost in getting the hardware and software, installing it and servicing it. And the fact that one of Obama's Chicago buddies runs an electronic medical records company has nothing to do with the enthusiasm for these proposals.
And the fact that one of Obama's Chicago buddies runs an electronic medical records company has nothing to do with the enthusiasm for these proposals.
And where were you when Bush/Cheney were doing favors for their buddies? Haliburton for starters.
Maybe he voted for 'hope and change'.
Maybe Obama can run in 2012 with a new slogan: Bush screwed things up for 8 years. I've only had 4.
Derek
The major Halliburton contract for military support was an IDIQ contract let during the Clinton administration as I recall.
If setting up a medical electronic records system is so fiendishly difficult, we'd better get started now. Because when it's done, it will save everyone loads of expense, time, and medical error. Which is the point, right?
Why you and MikeR think it is interesting or relevant to gas on about how hard your job is, I have no idea.
I find it very interesting to hear from the people involved, regarding how soon such a system can be practically implemented and what hurdles will be faced. We can decide that we want systems implemented instantly, but that doesn't mean it can happen. [Sometimes I wonder if Obama understands this. As someone who's never really done much himself except to try to pressure others to take action, he seems to believe that simply setting goals is a major accomplishment for which he deserves a lot of credit.]
Why you and MikeR think it is interesting or relevant to gas on about how hard your job is, I have no idea.
Well, it's not my job now.
However, if you listen to the administration supporters and members pushing electronic medical records as if it was a silver bullet that will kill the vampire of high administrative costs in medicine, you would think that we can do it nearly overnight. Add in that stimulus money has been dedicated in the current budget to buying these magical systems that don't exist and you have a recipe for waste of a lot of money. (Note: there are current electronic medical records systems out there right now, but they don't talk to each other, which is the major benefit being touted for them.) It's an example of some executives being sold a bill of goods by overenthusiastic salesmen.
"I have no idea". Then I'll repeat it. We in the Health Care IT community have been working on electronic medical records for forty years, we at Hopkins for almost all that time. By now most systems are electronic; the problem is communication between them. We are very motivated; we don't like paper. It is very hard. We are doing it as fast as we can. We cannot do it faster just because someone in Washington throws money at us. We certainly can't do it faster if the one in Washington decides to fine-tune our work by setting up goals that must be met and that have little to do with the actual issues we are dealing with.
Oy. Broken record time: The VA is entirely electronic. What are the reasons VA could do this and private healthcare cannot? There are plenty of reasons and it is certainly true that migrating to electronic records is wrenching (the VA took a decade to do it), but we know it can be done and that it provides enormous benefits.
BTW, ask any med student returning to the school hospital after 3 weeks at the VA what she thinks about having to spend 1/2 her time finding missing medical records.
A couple of minor quibbles: the military weeds out young people with congenital conditions or early onset health problems. It cannot weed out people who are healthy in their youth but who will develop serious health problems later in life, which is the vast majority of people after all. The military does also weed out youth with behavioral and addiction problems but, again, cannot weed out those who will develop those problem years later (the military is not prescient). And as far as I know the military does not weed out smokers.
Also, the kids who go into the army are not necessarily the smartest folks in society. Those kids go straight to college after high school (usually). The military recruitment pool consists mainly of the average achievers.
Right, but it does not consist of the kids I know who can't get into the military because they have major impulse control problems, couldn't finish high school, and mostly like to spend their time on smoking pot and petty pilfering.
Agreed Meagan, and I mentioned these sorts of issues under the category of "behavioral problems". My point is that the military population is pretty average all in all, and excludes the extremes at either end of the spectrum. As such "people who have served in the military" approaches the US norm for the population as a whole, with a narrower distribution.
But the distribution it excludes is the one with the worst health and behavior problems. Since there's skew in cost distribution--you can't spend less than $0 on a patient--this will shift the mean.
My daughter is diabetic and we interface regularly with other parents of diabetic kids. The quality of compliance varies by a HUGE amount even though we all have the same doctor (and this says nothing about those that do not see an endocrinologist regularly).
Some of these parents border on negligent - but assuming that this is because they weren't taught correctly is absurd.
This being the Internet, I knew the systems implementation guys would show up. Here's EMR from an end-user perspective: it's awful.
I've used the VA's VistA system, and I've used GE's Centricity anesthesiology module. (My anesthesia group uses Centricity, and I used VistA during training.) VistA was not an evil thing - actually I liked it better than most other EMRs I have seen - except that using it is too often like finding a needle in a haystack - all notes, from dietary to physical therapy to physician to nurse to pharmacist, are in one unsorted blob. It's almost impossible to find what you want when someone has 300 notes attached to their record. As for GE's Centricity, I'll be the first to stipulate that anesthesiology is unlike any other branch of medicine - even stranger than radiology. We are not paid in the same way as other physicians, we use drugs most physicians have heard of only in passing (if at all), and our idea of a medical record is so heavily specialized that when the VA decided to implement computerized anesthesia records the solution was to buy scanners and scan the preoperative assessment and anesthetic records into the imaging system. The GE Centricity system automatically records vital signs, and it is fairly easy to use intraoperatively. Unfortunately, the preoperative assessment and plan - the thing that gets done over and over for people having multiple surgeries, and one of the most important pieces of paperwork we use, as it is a one-page medical history - is a nightmare to read (although copying the data from the last preop assessment is easy). And the anesthetic record itself is hard to read. For all the failings of paper, it was easy to comprehend at a glance exactly what went on.
And that gets to the heart of it: most physicians really, really appreciate dictated histories, discharge summaries, and operative notes, because they are always totally legible. BUT, those critical moments aside, it is infinitely quicker to grab a chart, squiggle in a few lines, and move on than to sit down, log in, choose a patient, select the proper form, and start to enter information. (Example: although the use of TAB to navigate between fields is one of the most universal paradigms in computers, the GE Centricity program requires you to click with the mouse on the next field. The VA, different but no better.) And there is no incentive to change it, because the physicians get no individual benefit from computerized records despite the significant increase in workload.
When businesses implement cost-saving measures like automation, they trade a large up-front investment in technology for a larger long-term payoff in higher productivity and lower personnel costs. But when doctors improved their efficiency and reaped the financial rewards in the early days of capitation, those rewards had to be returned (in part, at least) to the insurance company in terms of lower capitation payments the next year. The incessant chatter about lowering physician salaries (because they're "too high") in the health-care debate has proven that government would be no different. So where is the incentive for individual providers to go out, purchase a system, learn it, and implement it practice-wide, if the payout goes to someone else?
The VA's vaunted low physician costs? Go check the staff roster at your nearest VA. Notice how many are immigrants. Physicians can get a green card by doing a residency in the US and then working for a certain number of years in an underserved area... or in a VA. Most are working at half the market wage (or less) in order to get green cards. (The rest are a mix of those who are in need of govt-employee benefits, the semi-retired who don't want a demanding job, and those who couldn't get hired anywhere else - the same reasons anyone else would take a job that had awful pay.)
"So where is the incentive for individual providers to go out, purchase a system, learn it, and implement it practice-wide, if the payout goes to someone else?"
The same argument holds for computer companies that get more efficient at making better computers, only to see the price of computers fall. The incentive? If your competitor does it and you don't, you go out of business. In a private industry-based universal health insurance plan like the one we're about to get, the same logic will apply. And in the case of an information technology like EMR the issue of network efficiencies comes into play: as everybody else starts using it, you either adopt it too, or you start to find that your newly hired doctors are protesting they can't do their jobs because they trained as interns on EMR systems and you don't have them; you find your data can't be handled by any other organization that needs to look at your data, be it insurers or what have you; etc.
Your comments on how hard these systems are to use and what the relative advantages/disadvantages are are quite interesting, though.
You referred to EMR systems, plural, and that is part of the problem. It's inefficient as practitioners move from job to job because of the time lost getting oriented to the system. I harbor no hope of a national standard, but a benefit of having one would be that the curricula of every medical, nursing, dental, medical social work, physician therapy, respiratory therapy, and other relevant program could include EMR. Any system updates could be made part of relicensing requirements.
It's also inefficient, and potentially dangerous, to move back and forth among systems over the course of a work day or weekend on call. It's not unusual for physicians to work in several hospitals over those time frames. The differences across systems are a setup for errors.
From what I've seen, the gap between the end-users and the people designing the system seems unusually wide. My hospital is killing us designing the system in-house, incrementally. There has been little effort to get input broadly. So we have a system that's optimized for a few users (reminiscent of Devilbunny's dissatisfaction of EMR for anesthesiology), but awful for everyone else. Or at least this week; next week, they'll change a few things and once again you won't be able to find the button that pulls up your schedule or takes you to your unsigned notes or whatever. This has been going on for several years and there is not even an estimate as to when the EMR will be some approximation of completed.
Additionally, we have Mesozoic workstations, not enough of them despite their slowness, and a temperamental computer network. There's no convincing IT that "only 5-10 seconds" per click, multiplied by hundreds of clicks over a day isn't workable when clinic is backed up or it's nursing shift-change on the ward. And there's certainly no sympathy from them when the system crashes when the note for the ill, complicated patient that you have just spent 45 minutes meticulously crafting goes into the ether because saving interim versions takes a half-dozen clicks and the computer froze. That was a weekly or greater occurrence until I devised a workaround, one that requires using a couple of different computers.
Buying something off the shelf can be fraught with trouble, too. A hospital across town spent jillions on a system, drove its medical and IT staff crazy with it for 2+ years, decided it was a wash and is starting over.
Well, yes, you'd go out of business if you didn't keep up with the trends. But every business has an incentive to lower costs - you can lower prices (and thus gain market share) while making the same profit per unit. Total profit thus goes up. In medicine, we have Baumol's cost disease, so the number of patients that can be seen per day has an absolute maximum. A computerized medical record is more work than a paper chart if the entries are brief and frequent - a surgeon, for example, will visit patients in the hospital and write three- or four-line notes updating the charts of all of them.
If EMR is implemented, however, this becomes slower. The efficiencies of the system (and there are plenty) benefit the hospital, or the insurer, or the government, but not the physician. As a result there is strong resistance to EMR - why should you work harder to save someone else money, when you won't see any of it?
The free-form nature of medical notes is very valuable. When any system starts to try to turn free-form into drop-down lists, radio buttons, and the like, it gains systemic efficiency (if "diabetic" is clicked, make sure that a hemoglobin A1C is drawn yearly) but loses accuracy and becomes much more cumbersome to use. So if you implement an electronic version of the current beast, the only gain is that all handwriting becomes legible. On the other hand, if you use a lot of drop-downs, you end up with notes written by a computer using canned phrases.
As a quick point, I think the risks involved are often a deterrent. A typo or mis-submitted/received information can result in disastrous consequences for the patient. Thus until a competitor does implement a system perfect enough to avoid these types of mistakes and that can simultaneously increase efficiency, no practice has the motivation to compete that you reference. I think this is part of why medicine is behind in EMR, but so incredibly up to date in instruments (CT, X-ray, etc.)
I would take issue with this:
The staff at the local VA in my city are faculty at a top 10 medical school and include the physician widely accepted as the consummate clinician across three large and well-regarded hospitals. Some people accept the "awful pay" of the VA because it affords the opportunity to provide care for people who have served the nation, to teach, to do research, or some combination of those.I would be curious as to whether Kaiser has come up with a workable EHR solution for anesthesiology. Most VA docs I know like their EHR, although I have met a few who do not. I have yet to meet a Kaiser doc who doesn't love their system. But I haven't spoken to any anesthesiologists there.
As for the incentive for technology implementation, Medicare is making small bonus payments to providers who use approved e-prescribing systems. I can't recall the specifics, but over the next half-dozen or so years, those bonuses will gradually shade into penalties for providers who still hand-write prescriptions.
Oh, there are some wonderful physicians in the VA, and I don't mean to disparage them. (As in your example, our VA houses a diagnostician par excellence.) But there are not enough of them to keep the place fully staffed, because the pay is so low. There are some who appreciate the time to teach and research, and no doubt we all benefit from that - but not enough to fill the VA, let alone the entire nation's hospital systems. And the VA can be that way because there are other places to pick up the slack - VA's don't see trauma, for example.
You're right, though, that I came off as overly dismissive of the VA. Sorry.
Is Longman aware of the major trends and lessons of the last century? He's blindly repeating all the advantages of planned economies as if they're new and highly persuasive arguments - top people will make all the good decisions, unhampered by any unpleasant incentives that might distract them from doing the right thing. The fact that all decisions are centralized in one and only one body will result in massive efficiencies, unlike those foolish countries that waste energy on competition. Without personal motivations getting in their way, people will work five times as hard on innovation and taking chances and constantly striving to be better.
And the Soviet Union will win the cold war and lead us all to a worker's paradise. Really, this time it will work. Don't even think about all those past failures, because healthcare is 'different'.
You know, funny thing. The quality of the VA system also happens to resemble the vastly superior quality of the centralized health care systems of most of the rest of the industrialized world.
The major trends and lessons of the last century is that free-market health care does not work, and does not produce good or cost-efficient health care.
There are lots of reasons for this. Any health care economist could give you at least six. Judging from your gratuitious invocation of the Soviet Union, my guess is that you wouldn't be interested.
How many of those "vastly superior" systems have you experienced? I have a fair amount of experience with Hong Kong's healthcare system. The people of Hong Kong, in the rankings I've seen, have higher average life expectancy than pretty much all European countries. Would you say that this is because of a superior healthcare system? Then I have to conclude that you have no experience with their system (plus, of course, it's not a centralized system).
If your claims aren't based on life expectancy, then what are they based on? Surely not, say, survival rates for specific diseases or early access to cutting-edge treatments. So what basis do you have for claiming that these centralized health care systems are "vastly superior"?
Muzzybelly, when you compare our stats against the socialized health care of other countries, we're about average. Our higher death rate comes from gun violence (half of which is directly due to our attempt to outlaw some drugs), and from automobile deaths. Our lower WHO score is simply because the WHO score is partly based on "do you have a socialized health care system".
I don't know from what evidence you conclude that free-market health care doesn't work, but SURELY you aren't looking at the US for that evidence, are you? Only a completely deaf, dumb, blind, and stupid person would look at our country and think that it has a free market in health care. First, it's illegal to practice medicine without a government license. Second, a whole parcel of drugs are unavailable to you over the counter. Third, the vast majority of health care is paid-for by proxies who have their own incentives; said proxy system is maintained by government incentives.
The example of the USA simply proves that government health care can be badly run; does that surprise any reader of this blog?
Devilbunny,
You are right that physicians get no individual benefit from computerizing their records. Almost all of the social benefit is provided in the form of a positive externality. This is known as a public good, and it's precisely why the government should be involved. It is textbook economics (even the basic micro kind) that markets, on their own, provide inefficiently low quantitites of public goods. Which is why governments usually have to do things like enforce zoning laws that limit development density, create parks and roads and highways, etc.
As for the quality of existing systems, I can't say from first hand experience. But GE is hardly the only system out there. And the answer to poorly designed systems is better design. Not just to abandon the whole concept.
Well, while there is some public good to be had, most of it is private - lowering insurers' and hospitals' costs without paying any more to the person who does the work in their stead. Physicians - whose time is most efficiently spent seeing patients - are being made to do an $8/hr data entry job. How is that efficient?
Fair enough. We agree that there is a huge positive externality. Whether that is truly a public good is really just terminology ("public goods" can in some instances be provided privately) and where you focus your gaze -- i.e. Medicare/Medicaid, or private insurance.
The point is that someone has to incent doctors, but also that it would be a good idea to do so. Whether that is by means of legislation, bigger payments to doctors by one or more payers who adopt the right system, etc.
I agree that a big problem is standardization. The EMR people need to all get together and create a standard data format so that systems aren't plagued by interoperability.
It's funny how you dance all around the right solution, but you're just afraid to say it: a free market in health care. If electronic record-keeping will really save money, then some doctors will simply do it, and those doctors will be able to charge less money or will earn more money (and in time those excess profits will be competed away).
I don't understand how you came to be so intelligent and wise as to be able to discern a huge positive externality without any evidence. Did you take a pill or something? Vitamins? Exercise? Please, give up your secret method, because I KNOW that I'm nowhere near able to identify huge positive externalities as easily as you can.
Holy frig, muzzybelly (I have trouble taking argumentation from "muzzybelly" seriously -- if you were serious about your thoughts you'd put your name and reputation behind them). The only reason why EHR is a "social benefit" is because people don't pay for their own health care. Stop interfering in the health care system and you'll rapidly find out if EHR is beneficial or not.
Man, oh, man, ignorance of economics is available at zero cost everywhere, but especially among the commentators here!
Thank you, Devilbunny. That's an important point. We still have a lot of applications where users just can't afford the time to do things electronically. A fair percentage of my electronic records are scans of handwritten reports, and will stay that way till we find a way to input the data that doesn't waste providers' precious time. All that is potentially fixable (hand-helds, better user interfaces), but has to be fixed one piece at a time.
Well, there's the other part of this: you IT guys get little or no credit for the work you've already done. People act like paper charts mean paper everything, and that's not the case - the electronic system my hospital uses, while not terribly fast, does provide easy access to labs, diagnostic reports (radiology, cardiology, etc.), and all dictations.
The chart thoughtfully provided by Ms. McArdle should not be misinterpreted as population octiles. The high priority categories (1-4) are not anywhere near half of the veteran's population. The percent of all eligible veterans who actually choose to use VA is closer to 20 percent. You can call a pig's ear a silk purse, but the VA is at best a health care provider of last resort. Its also easy for VA to ration care as it provides very little access to non-VA providers even when it would be in a patient's physical best interest. And given the deluge of funding provided as each administration strives to out pander the last with the well-heeled Vets, Inc. lobby groups, one would think the quality statistics would be a little less equivocal.
Speaking just from the IT perspective: We tend to speak of the VA as having a really good hospital information system setup - one of the best.
Re: Surely not, say, survival rates for specific diseases
I don't know anything about Hong Kong, but I have seen a study showing that, out of 10 potentially fatal diseases, Canadian survival rates were higher than the US survival rates for five of them, US survival rates were higher for two of the conditions, and for three there was no significant difference. Yes, we see lots of cherry-picked examples of this sort which seem to favor the US (prostate cancer is the most commonly cited) but the overall stats are not so favorable to the US as the Right likes to claim.
I was responding to a claim that all centralized systems are "vastly superior". Findings that one specific system (Canada) is better in terms of survival rates for some specific diseases (but the same or worse for others) might contradict what I said if I had been the one to claim that the US was vastly superior to all. But the claim was very different - that all centralized systems are unambiguously better.
The VA is a good example of how rationing care can skew reportable results. The VA does not see all comers, so vets who seek care elsewhere don't get counted. If the VA had to treat every veteran regardless of priority group, it would be swamped and we would be reading horror stories about patients dying in waiting rooms, as occasionally happens in county hospitals. The vaunted EMR doesn't make the VA better as much as it gives snappy looking results. Who isn't impressed by how a computer generated screen looks compared to hand scrawled notes? But remember the principle of GIGO. If a tired resident is sloppy with orders and notes, plenty of mistakes beyond illegibility are possible. When I was a medical student doing a VA rotation in 1978, I saw a patient die of sepsis from an untreated urinary infection (he had come to the hospital for a pacemaker battery change.)The abnormal lab results were right there in the chart. The problem was, no one acted on them.
You are making some very strong assumption about something that you do not have any information on.
OK, VA patients get a significant portion of their care from other providers.
You are assuming that the care they receive outside the system is more expensive than the care they get inside the system.
That is an extremely heroic assumption.
I can come up with an easy explanation why it is just the opposite.
For example, vets often do not go to the VA system until their problem becomes too expensive for them to afford it in the private sector.
Both my father and my grandfather spent the last few months of their lives in a VA hospital. They went there because they knew getting the care they needed in the private sector would be very expensive and would be a major drain on their budgets and/or their estates.
This is very common and implies that the treatment at the VA is actually more expensive, just the opposite of your heroic assumption.
Megan, your broken record pattern of responses to statistical analysis begins to strain credulity.
Any time government run care or insurance appears to work, it is really just an illusion. Its because the poor insurance companies weren't being treated fairly in the analysis, or because Americans are just too intractably unhealthy to treat effectively....
Just how high do you have to move the bar before it is too high for you to reach?
I am a physician with a practice in a community with a large VA Hospital. Many of my patients with veteran's benefits see both the VA doctors and me. The reason is simple; they get all their medications free at the VA. These patients with complex eye problems (diabetic retinopathy, glaucoma) wouldn't dream of getting the expensive procedures (laser treatments and surgery) they need at the VA where they would be performed by resident physicians (young doctors in training). The low salaries of these young MDs, who provide most of the care at many VAs, hold down costs. The successful treatment of complex diseases with nothing but eye drops creates the illusion of the VA providing excellent low cost care in all these inaccurate statistical studies. Many of the patients are only going to the VA for the free medications. All of their expensive, and effective, procedures are provided outside the system.
As a physician who actually works with EMRs (not in my practice but in some institutions where I teach) I agree with Devilbunny that their benefits are exaggerated. In my field, ophthalmology, medical records include retinal drawings on every patient with colored pencils, difficult to impossible with current EMR. And with the reams of paper I get from institutions using EMR (especially the VA) it takes forever to find any useful information. The legibility benefit is canceled out by the piles of useless and duplicate information in every EMR. But EMR will be rammed down our throats because there is one institution that will greatly benefit from EMR, the legal profession.
Ms. McArdle: Love your libertarian and intellectually honest (even when wrong) commentary. But on the VA there are a number of factual issues with your commentary that suggest the need for some additional research on your part:
1. Incentives for cost efficiency: VA's health budget is non-mandatory money so VA has to go to Congress every year. The consequence for VA of not keeping its costs under control is not that its budget will be cut so much as that it will have to exclude potentially eligible veterans. That is what happened to the priority 8s. Cutting off veterans makes the VA and, more significantly, its politically powerful constituency of veteran service organizations, very unhappy. Please also note this very important fact: priority 8 veterans are likely the least expensive patients to treat (no service connected condition, higher income). The VA cannot control its costs per patient (only its overall costs) by excluding priority 8s - in fact, cost per patient likely goes up when VA does this.
2. Also, on the "theory side," perhaps the most important question is whether the way the VA delivers health care brings with it as a consequence (not entirely unintended but hardly the main driver) more cost-effective healthcare. The proponents of the VA delivery model and the evidence say that it does.
3. 1 and 2 are part of what seems to be a general lack of information on your part about the VA patient population. That population may have once been the young, strapping warriors that are obviously in your mind's eye (didn't you just get married), but today it is older, sicker, poorer, and has more comorbidities than the general population. These patients are more expensive to treat, not less.
4. When judging the quality of VA healthcare the fact that VA patients also get healthcare elsewhere is, of course, a highly significant fact. However, your treatment of this issue is very misleading (this is not a personal aspersion; I just mean that it overstates by a lot the limits of what we can say about VA quality). One can compare the VA population or a subpopulation with an appropriate non-VA population and draw lots of conclusions about differences in healthcare as long as one controls for differences in non-VA healthcare between the two populations. As long as this factor is properly controlled for, differences in healthcare quality or health outcomes can properly be attributed to differences between VA and non-VA healthcare. This is not to say that the issue of healthcare for VA patients received outside the system is not important, but well-conducted, scientifically rigorous studies comparing VA and non-VA care can be done and in the past 10-15 years, many studies published in peer-reviewed journals from the New England Journal of Medicine on down show that patients in the VA get better treatment and have better health outcomes across the board.
4. The VA is a self-contained healthcare system and obviously that cannot be replicated for the population at large. There are other characteristics of VA that make it unique as well. Two examples: VA's commitment to treating veterans, not just patients, is a very real motivating factor for the organization. Second, VA's research program, which is highly clinically focused, provides substantial benefits for clinical care and private healthcare systems are not able to replicate this capability (although there are ways to address this through NIH, AHRQ, and other research funding entities).
5. There are many aspects of the VA model, however, that are directly relevant to the reform of American healthcare. Changing how healthcare is delivered is the key. Here are some of the lessons of VA that could serve as models:
- Doctors on salary who have no financial incentives for choosing one kind of treatment over another. This point is usually made in the context of numbers of tests, but it matters more generally given that our current private healthcare system incentivizes more expensive over less expensive treatment regimens.
- Doctors are not exposed to personal liability for malpractice.
- Healthcare providers, their supervisors, hospital administrators, and regional administrators are evaluated using highly quantitative healthcare process and outcome measures. If the rate of hospital-acquired infections goes up, the hospital director's performance review suffers. There is plenty of research showing that quantitative healthcare performance measures improve healthcare.
6. The importance of electronic health records cannot be overstated. VA is entirely electronic. I won't go into detail, but offer the following about VA's National Surgical Quality Improvement Program (NSQIP) from the Annals of Surgery May 2007: "NSQIP has become the gold standard for measuring risk-adjusted patient outcomes after surgery; and by doing so, it is the only national database that can offer risk-adjusted statistics for evaluation by the sponsoring hospitals."
In conclusion (whew, you say), I would urge you to take a closer look at the widely available data and studies about the VA patient population and healthcare. Contact the DC VA and ask Dr. Fletcher to give you a dog-and-pony about VistA. He loves to do it. Reform of healthcare in America depends on getting the access to healthcare data that only electronic records provide and VA (and DOD) are going to drive the proliferation of EHR. You watch.
BTW, I do not and have never worked for VA. For 2 years until recently I did oversight of VA on the Hill. I found plenty of things that needed fixing but it is an indisputable fact that, considered as a system, the VA provides the best healthcare in America. Many characteristics of VA are highly relevant to reform and cost control in healthcare.