Editore"s Note
Tilting at Windmills

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Sign up for Free News & Updates

September 14, 2007
By: Kevin Drum

BEST CARE EVERYWHERE....As regular readers may know, Phil Longman thinks the VA model of healthcare is the best around. In the October issue of the Monthly, he takes his admiration to another level, suggesting that the best way to provide healthcare to the 45 million uninsured in America is via — what? I guess you'd call it a franchised version of the VA. Basically, the federal government would offer struggling municipal hospitals a trade: if you adopt the VA's management guidelines, the government will pay you to care for all those uninsured folks currently jamming up your emergency rooms and driving you bankrupt. Deal?

It's an interesting idea, but I have some questions. Let's take this passage first:

How is a supposedly sclerotic government agency with 198,000 employees from five separate unions outperforming the best the private market has to offer? In a word: incentives. Uniquely among U.S. health care providers, the VA has a near-lifetime relationship with its patients. This, in turn, gives it an institutional interest in preventing its patients from getting sick and in managing their long-term chronic illnesses effectively. If the VA doesn't get its pre-diabetic patients to eat right, exercise, and control their blood sugar, for example, it's on the hook down the road for the cost of their dialysis, amputations, blindness, and even possible long-term nursing home costs....The VA model is that rarest of health care beasts: one with a perfect alignment of interest between patients and providers.

OK, but the VA has always had these incentives, and until a few years ago the VA sucked. So why didn't those incentives work in 70s and 80s? International comparisons also call these incentives into question. Britain has a VA-like system, for example, while France and Sweden (and most other countries) have more traditional models like Medicare, in which the state funds healthcare but doesn't employ everyone directly. But Britain, with the same incentives as the VA, doesn't do any better than France and Sweden, and in some areas does worse.

So if it's not the VA's incentives that really make it tick, what does? Answer: "Since its technology-driven transformation in the 1990s...the VA has emerged as the world leader in electronic medical records — and thus in the development of the evidence-based medicine these records make possible." Hospitals that joined Longman's "Vista network" (his name for the VA-like franchise he proposes) would have to install the VA's electronic medical record software and would "also have to shed acute care beds and specialists and invest in more outpatient clinics." By doing this they'd provide better care than any current private network and do it at a lower cost.

Wow! But I think I'd want to see some more evidence for this. Everyone from Newt Gingrich to Hillary Clinton sings the praises of electronic medical records, but is their payoff really that big?

In any case, you may be wondering what the point of all this is. Basically it's the camel's nose. Longman believes that setting up his Vista network would be relative cheap and relatively nonthreatening (it doesn't take business away from current insurers since it only covers the currently uninsured), which makes it politically doable. It would be partially funded by the money we currently spend on the poor, and partly by a mandate that everyone be insured. That means lots of young, healthy people without insurance would have to buy into the system. They'd be pissed, Longman acknowledges, but that's tough. They'd come to like it before long.

In fact, that's the whole plan: over time, the Vista network would prove itself to be so great that everyone would want in. Employers would clamor to be allowed to join. Private insurers would either shape up or go out of business. Healthcare in America would get both better and cheaper for everyone. And all because the federal government imposed a specific set of regulations on hospitals that serve the poor.

I have to admit that it sounds too good to be true. Would a federal program for the poor ever get funded well enough to become a model for the rest of the industry? Are electronic medical records really that great? Can we ever save serious money as long as the private health insurance industry has us all in its grip?

I don't know. What I can say is that I've been skeptical about some of Longman's ideas in the past and eventually come around. Maybe I will this time too. Read the whole piece and decide for yourself.

Kevin Drum 1:40 AM Permalink | Trackbacks | Comments (68)

Bookmark and Share
 
Comments
it doesn't take business away from anyone since it only covers the currently uninsured

What stops people who are currently insured at their own cost from dropping their insurance and using this program? Isn't this one of Bush's complaints with the S-CHIP bill?

Don't get me wrong. I favor single payer for everyone, myself.

Posted by: Rick B on September 14, 2007 at 1:47 AM | PERMALINK

Kaiser Permanente in the Pacific Northwest had electronic patient record-keeping a decade ago. If their cost-effectiveness isn't as good as the VA's, something's the matter.

Posted by: David Martin on September 14, 2007 at 1:53 AM | PERMALINK

There is no function of the government that Bush can't destroy.

Other than that, I think it'd work great. I don't think Clinton some miracle worker. Any president not named George Walker Bush ought not to screw it up.

Posted by: chris on September 14, 2007 at 2:30 AM | PERMALINK

Everyone from Newt Gingrich to Hillary Clinton sings the praises of electronic medical records, but is their payoff really that big?

In a word, yes. The one thing that Americans have figured out how to do is analyze data, bunches of data, and the best way to have that data to analyze is on a computer, in a database, so that correlations can be data-mined. We really are the best people in the world at this, and the sooner that we get standardized medical records, the easier it will be to identify risk factors of disease, to identify programs that help people stay healthy, and warning signs that can allow doctors to treat patients before the disease can make its mark.

And that's not even considering the sheer amount of mistakes that electronic records can help prevent.

Our productivity revolution has been driven, in large part, by IT allowing us to figure out how to do things quicker, faster, and cheaper, and how to figure out how to figure things out quicker, faster, and cheaper. The efficiency gains that are there to reap from electronic records will be astounding.

Posted by: Trickster Paean on September 14, 2007 at 2:34 AM | PERMALINK

But Britain, with the same incentives as the VA, doesn't do any better than France and Sweden, and in some areas does worse.

Part of that is getting what you pay for. France ranks #4 in cost of health care per capita, Sweeden #7, while the United Kingdom is #26. [overall ranking is France #1, Sweeden is #23, and the UK is #18] So, do you want better, but more expensive like France, or do you want cheaper, but not quite as good llike the UK.

Or keep it like it is where the US is #1 in cost and #37 in overall care.

Posted by: natural cynic on September 14, 2007 at 2:36 AM | PERMALINK

It's that lifetime commitment that makes the difference. That's why private insurance can never be optimal.

Posted by: chris on September 14, 2007 at 3:04 AM | PERMALINK

Doctors who work for these hospitals would no longer be constantly visited by pill salesmen, because decisions on what prescription drugs to use would be made on a scientific basis by the Vista board

Because what could be better than taking away from doctors the ability to determine for themselves what the most appropriate treatment is?

Posted by: nicholas on September 14, 2007 at 3:20 AM | PERMALINK

The VA is also a leader in patient safety. This is important not only for the obvious reason that it's better if people are not made sicker or killed while receiving health care, but also because medical errors are costly.

It's worth noting that data collection and analysis plays an important role in current efforts to improve patient safety. The idea is to examine the process of delivering care, identify points at which certain kinds of errors are likely to occur, and then develop a system or process to obviate that problem. This is in contrast to identifying and punishing people who make errors.

Posted by: THS on September 14, 2007 at 3:57 AM | PERMALINK

Nicholas, you have way too much confidence in the ability of doctors to know what medications in what amounts are likely to be most effective. There's tons of evidence to indicate that doctors of all stripes both over and undermedicate and, in many instances, are not up to date about the latest drugs.

Doctors believe in the wisdom and rightness of their clinical judgment, but there's no reason we have to do so.

Posted by: THS on September 14, 2007 at 4:00 AM | PERMALINK

the fed COULD provide the costs to the publicly funded hospitals just as they do with the VA;
others would come along and join because it would, simply, work, in the "not TOO long run"
the electronic record-keeping IS that great an improvement...Kevin, you could just call a couple of VA admin people and find this all out. Why dont you do these things, instead of "relying" on Longman?

Posted by: rich rauscher on September 14, 2007 at 4:45 AM | PERMALINK

incentives are important, i.e. if the doctor's pay isn't based on number of treatments perhaps the outcomes will become more important than generating fees, but of course they aren't the only important thing. records are very important in the big picture and the VA hasn't always had them in electronic form. if you have a complicated condition try getting sick when you take a trip to rural nebraska and you will quickly learn about records.

electronic records are an essential part of the VA system because:

1) they make evidence-based medicine feasible; it takes statistical analysis to figure out which drugs and/or procedures work the best, which doctors work the best, which facilities are best, etc; it isn't feasible to do this analysis using boxes of paper scattered all over the map (even if you tried it imagine the fun manually entering the data for a million patients for analysis).

2) they mean you can walk into a VA facility anywhere with a complaint and the doctor can immediately have access to your complete history and current treatment regimen instead of you having to give it orally, perhaps while you are lying on the table bleeding

3) they enable electronic checking and records keeping of treatment administration which causes the rate of treatment error to plummet, e.g. the nurse scans the container and the patient before handing over the does and the system can in real time alert the nurse that she is in the wrong room

4) they make it easy to view time series over a single patient, e.g. weight fluctuations vs symptoms, which leads to more accurate diagnoses

one of longman's points about this (in the book) is scale is important. if a single doctor's office tries to do it they may find it convenient but in economic terms it is a cost the competition doesn't have; worse you end up having a parallel paper system because you have to interact with the old the guy next door is using.

well speaking of the medical establishment, I'm off to take the wife in. I'm sure one of the things I will not enjoy about this trip is its efficiency.

Posted by: supersaurus on September 14, 2007 at 6:32 AM | PERMALINK

Kevin: "I have to admit that it sounds too good to be true."

It probably is. But I find it certainly intriguing enough to explore the posibilities and continue the discussion. Mr. Longman deserves props for creativity and innovation.

Hell, why not try it? And if it doesn't work, then let's try something else. But, for God's sake, let's at least try something.

Posted by: Donald from Hawaii on September 14, 2007 at 7:01 AM | PERMALINK

The Federal government will need to jump in with a no-cost/low-cost loan system to help finance the electronic medical records for urban and other hospitals providing care to the uninsured. These hospitals have no - like nada, none, zip - reserves or access to cash to fund these expensive systems. I speak from personal experience since my spouse is involved in putting in an electronic medical record system in an inner-city hospital and it's bankrupting them. Right now, the Fed's have made installing such systems an unfunded mandate and it's driving almost all hospitals who provide extensive uninsured care right into the grave. Everybody wants to talk about how implementing such systems can be the miracle cure for what ails our failing health care system, but nobody wants to address the real issue - who pays and how much. So long as the privileged few can skate off with all of the benefits while leaving everyone else with the tab, we will continue to have this problem.

Posted by: PrahaPartizan on September 14, 2007 at 7:27 AM | PERMALINK

A key overlooked factor is that there is a single coherent interest group - veterans - that keep an eye things and bitch when needed. Nothing similar in the private sector.

Posted by: nonheroicvet on September 14, 2007 at 7:31 AM | PERMALINK

The citizens of socialist countries like Sweden, France and Canada would accept an electronic Big Brother health records system, but Americans are too independant to accept it. We're eagles, not sheep.

Posted by: Al on September 14, 2007 at 7:37 AM | PERMALINK

Harvard Pilgrim Healthcare nee Harvard Community Health Plan in Boston has had online patient medical records since the early 1960's. I believe it almost failed in the early 1990's.

Posted by: Lars on September 14, 2007 at 7:59 AM | PERMALINK

The incentives also apply to the physicians. Unlike private practice where the physician's income comes from the work he generates and thus is increased with extra procedures, Va bonuss are related to patient outcomes. Your hypertension patients must have lower blood pressure, your diabetes patients better hemoglobin A1C.

Posted by: Ruth in NC on September 14, 2007 at 7:59 AM | PERMALINK

We're eagles, not sheep.
Posted by: Al

You seem like more of a chicken than an eagle.

Posted by: DJ on September 14, 2007 at 8:04 AM | PERMALINK

I'm not quite sure about that whole "cheap" claim about switching to electronic records. I was hired at the tail end of the Allina system switching to electronic medical records at one of their hospitals. It took them almost 2 years from start up to implementation.

Granted, we're talking about a corporation, not exactly stellar examples of quick change artists. None-the-less, it was a smaller system then the National system suggested here.

Also, I question the over-all effectiveness of the VA system. Having worked with many veterans over the years, what I've discovered is many of the veterans have also been put on state funded health care and are not even in the VA system.

Now, that might be due to Minnesota's Medical Assistance program being more comprehensive in it's coverage than other states. Men that have gotten coverage in Minnesota, are rejected our right in Wisconsin. I couldn't tell you about other states, so it's a perception thing with me, probably.

Posted by: Rook on September 14, 2007 at 8:07 AM | PERMALINK

Electronic record-keeping permits the Dr. to have ready access to a patients medical history. To widen that system, I think HIPAA will need to be modified to allow the patients to take their records with them. Those records belong to the patient but portability is restricted; it would be a real benefit if a new patient could download their history to the hospital they find themselves in because they're traveling, moving etc..

Praha notes that Right now, the Fed's have made installing such systems an unfunded mandate and it's driving almost all hospitals who provide extensive uninsured care right into the grave.

Quite a number of those hospitals should be in the grave. Urban centers in the rust-belt, for example, are seriously overbedded. Philadelphia has 7x more beds than needed but despite Ch. 11 for a major system, sold to Tenet, most of those hospitals are still open.

The conversion to the "Vista" network could help rationalize, i.e. eliminate, those unnecessary costs in the system. The poor and uninsured would end up with better care in a lower cost system. What's not to like?

Posted by: TJM on September 14, 2007 at 8:14 AM | PERMALINK

People are forgetting how different the VA is from most other medical care. The VA does not offer obstetrics, labor and delivery, neonatology, pediatrics, adolescent medicine, sports medicine, offers very little in gynecology. Most VA medical centers do not even have an emergency department.

Remember, the VA’s patient base are adults who were physically fit enough to be in the military. The VA’s patient base is also more educated than the general population.

I also find it odd that the socialize medicine proponents talk about the electronic medical record at the VA but ignore the enormous problems that the DoD Health Affairs has had with their system. Once you go computerized the organization has to constantly update the system. The DoD is stuck with its legacy system which is much more complicated than the VA systems and has been a failure when upgrading.

Posted by: superdestroyer on September 14, 2007 at 8:29 AM | PERMALINK


OK, but the VA has always had these incentives, and until a few years ago the VA sucked. So why didn't those incentives work in 70s and 80s?

What causes you to make this statement? My father is a Korean War Vet and has been going to the VA for a decade now, they've always given him very good care. Further he knows several WWII vets that have told him they've always gotten good care at the VA.

The radical right is always slamming government agencies, we don't need so-called "progressives" doing it also. Jeesh.

Posted by: bobbyk on September 14, 2007 at 8:41 AM | PERMALINK

Is there a perfect health avatar system out there yet? No, but one is coming, and it won't be too soon. There is no good reason to use pen and paper anymore in medicine.

Posted by: Northzax on September 14, 2007 at 8:49 AM | PERMALINK

We're eagles...

...overweight, fearful, seriously stressed, credulous, cheetos-shoveling and viagra-popping... but eagles nonetheless

unlike those tall, strapping, relaxed and virile Teutonic lambs.

Posted by: Let the eagle waddle.... on September 14, 2007 at 8:50 AM | PERMALINK

Kind of impressed viewing the flow chart assigned to me at the VA - Sat with my Primary Care Doc and perused the color graphs showing all of my weight loss since being properly diagnosed for diabetes, which was caught by a very sharp young lady, who had just been assigned as my PC physician. And, what a pleasure to be able to view my records on screen with my physician.

At first, I balked at their new "Self Serve" check-in - However, this past week, I realized how well it worked - When you check in, your medications come up on the screen - You then check off each one as to current status and can add comments - Thus, your assigned doctor has the info before entering the exam room. Plus, it does force the patient to pay more attention to their meds.

But, to add to a comment about Kaiser Permanente in the Northwest - In Portland, there has still been no breakthrough in record sharing among the three largest systems - Kaiser, Legacy and Providence in addition to Oregon Science Health, a teaching facility of the Univ of Oregon Med School.

Yeah, at lot of VA patients were once in very good physical condition. However, after viewing the many sitting around the VA last Monday, do not really think we could form a brigade and charge up San Juan's Hill.

Posted by: thethirdPaul on September 14, 2007 at 9:15 AM | PERMALINK

Cris,

re: your statement "Any president not named George Walker Bush ought not to screw it up."

Remember the source of personnel ANY Republican President has with which to fill the 7,000 political jobs in the Plum book? The Republican Party is filled with people like John Bolton, Wolfowitz, Bremer, and so on. What that don't have is people who think government can work.

Think about 'serial liar' Rudy, with Norm Podhoretz as an advisor? Thompson, (just another 'pretty face') who can't keep staffers even before he starts officially running for office and can't come up with even sound bite Republican-level campaign policies to run on?

There is no modern Republican who can do a significantly better job that Bush has. George has not accomplished his disastrous tour as President by himself. There are a few Republicans who would not be as inherently detestable as George, but none who could or would do a better job.

Unlike the term "corrupt Republican politician," the term "competent Republican politician" is an oxymoron much like "military intelligence. "

Posted by: Rick B on September 14, 2007 at 9:22 AM | PERMALINK

David,

Re" your statement "Kaiser Permanente in the Pacific Northwest had electronic patient record-keeping a decade ago."

A decade ago the computer technology was not adequate to support the data requirements, collection requirements, processing needs and display requirenemnts that an effective computer medical records system requires. What data there was entered into the computer would have been processed by a single, especially trained computer technician who had little medical knowledge. Sorting and search procedures were slooooowwwww. Effective display of processed was nonexistent. The computers had too little storage space and were too unreliable.

Effective security techniques required by individual medical data did not exist in those days.

The effort by Kaiser Permanente a decade ago was simply too far ahead of the technology to be comparable to what the VA has done.

Posted by: Rick B on September 14, 2007 at 9:33 AM | PERMALINK

As a VA employee (but not directly involved in healthcare or health delivery), I am amazed that the VA could be doing anything well. The VA system overall is weighted down by oversight and investigation of EVERYTHING, from trivial to important matters. Obviously oversight is very important, but the bean counters seem unable to recognize what is truly important. Every time some oversight people from DC show up, they suck the energy out of the place by demanding enormous amounts of paperwork and time from the local VA employees, such that it is impossible for them to do their real jobs.

Posted by: machiado on September 14, 2007 at 9:33 AM | PERMALINK

We'd never in a gazillion years think of running our financial industries via paper any more. The efficiencies, reduction of errors, ability to mine the current data for trends and to look at past data...huge. All of those benefits could be brought to bear on medical. Just thinking off the top of my head, if someone was to take an existing drug and propose to use it for an alternative purpose, some queries and number crunching could immediately reveal its efficacy based on past histories already in the data.

It'd be A Big Deal. The main difficulty would seem to be privacy and HIPAA.

Posted by: SJRSM on September 14, 2007 at 9:34 AM | PERMALINK

Don't forget that a core problem in health care is the mirror-image economics of it: doctors are piece workers. Highly-paid, but it's still piece work. So if you reduce the fees for what they do, they simply do MORE: as the fees go down, quality declines cuz doctors see more patients in the same amount of time.

Nor do more doctors reduce costs: a health care analyst explained this baffling fact to me once. You don't get more general practitioners, you get more and more niche specialists, which also makes the cost go up through the proliferation of specializations.

Competition itself has the unintended effect of decreasing quality; so does managed care.

I know somebody who just had an emergency appendectomy, despite having had the same HMO doctor for a dozen years. She had complained quite specifically about abdominal pain on her right side for years, but the HMO never did the blood test for appendicitis -- in fact, never said the word. When it became acute and she happened to see a company doctor (who was there for unrelated reasons), he told her to get to an emergency room: but the help line at the HMO simply told her to literally take two aspirin and call again in the morning.
The surgeon told her that her appendix was scarred, that she'd had acute appendicitis before, that it was chronic and recurring -- but it was NOT in the HMO's interest to find this out.
From the MBA business model of an HMO, unless she had actually died (precipitating an expensive malpractice suit), it all works out: sure, they will negotiate a higher price for the emergency surgery, but they don't pay the overhead for the emergency room. Putting a patient at risk was more cost-effective than encouraging doctors to do tests that MIGHT not be positive: it's not a case of 'better safe than sorry', it's 'which financial risk is more profitable'.

Maybe massive amounts of data (the Moneyball approach to medicine? you heard it here first: it's MY phrase, you can't have it) can resolve the perverse economic incentives of care rationed by the demographics of profit: nothing else seems to work.

Posted by: theAmericanist on September 14, 2007 at 9:43 AM | PERMALINK

Al,

If Americans are "eagles, not sheep" why do we keep spraying DDT around to make our eggs too brittle to carry eaglets to term?

Inadequate medical record-keeping, poor statistics and no analysis, perhaps? Sounds like a problem best solved by an electronic medical records system to me.

Hey, it works for Wal-Mart's logistics system. Why shouldn't it be applied to the provision of medical services?

Posted by: Rick B on September 14, 2007 at 9:47 AM | PERMALINK

Orwell: actually, the IRS, the US Mail, and social security are reasonably efficient organizations. Local governments run k-12, and YMMV. FEMA was extremely effective under Clinton, but turned into a turkey in the tender hands of the Bush administration.

My question: why do we think the VA is so great? Almost all direct comments I've heard from friends with direct experience suggest that it's terrible...

Posted by: CFG in IL on September 14, 2007 at 10:00 AM | PERMALINK

People are forgetting how different the VA is from most other medical care. The VA does not offer obstetrics, labor and delivery, neonatology, pediatrics, adolescent medicine, sports medicine, offers very little in gynecology. Most VA medical centers do not even have an emergency department.

Remember, the VA’s patient base are adults who were physically fit enough to be in the military. The VA’s patient base is also more educated than the general population.

Except for neonatology, the specialty services you mention aren't particularly costly ones. It's true that vets aren't representative of the population more broadly. If anything, they're sicker, something that will become worse as the polytrauma survivors of our current wars transition to the VA system, to say nothing of those with less severe physical injuries, but the lingering effects of post-traumatic stress disorder and other mental health sequelae of combat.

Posted by: chinois on September 14, 2007 at 10:02 AM | PERMALINK

I work in a healthcare software company, although not one that has electronic medical records (EMR) for a product. We do interface with EMRs to pull staffing needs data based on the condition and number of patients in each unit. I have also recently had two family members admitted to hospitals; my father admitted twice and my niece admitted twice with a third ER visit.

A couple of points to make, first from the technology side: EMR implementations can take a couple of years or more, depending on the size of the healthcare organization and the number of EMR modules the organization decides to implement. That's not unusual due to the complexity of the information and number of systems that must be provided. However, the software can be transformative in the delivery of patient care. It can save time, reduce human error along several parts of the care delivery chain, and alert caregivers to potential complications for the patient (allergies, contraindications, or previous visits/issues impacting the current visit).

From the patient and family member's perspective, I've accompanied my family members to four of the five admissions processes they've encountered in the past few weeks. My father was admitted twice to a facility that does not have a fully implemented EMR. My niece was admitted twice and had a third ER visit to a facility with an EMR. Both hospitals are part of the same health system but the EMR is not yet fully implemented at my father's hospital. The difference is striking. The caregivers for my father were able to access some of his medical records electronically for his previous stay, but mostly relied on his paper chart and the fact that the previous stay had ended just four days prior to his readmission. He had a serious complication for a type of medication, and we needed to research what similar medicine he had used 5 years ago during a visit to one of their other system hospitals. Had we been in a fully implemented EMR hospital and healthcare system, we could have quickly accessed that information, figured out the medicine that needed to be halted, and then discontinued it. We relied first and foremost on my memory, as my father's was not the most reliable given that he was simply trying to draw enough breath to sustain himself. Had we been admitted to a different hospital outside of the city, we would have been in serious trouble.

For my niece, she has been in the hospital three times in the past week, and six times in the past four months due to a difficult pregnancy. I accompanied her on the most recent visits, and was asked many details about her previous visits that I did not know. However, we were able to quickly retrieve all of the details: high blood pressure, bladder infection, migraines, etc., through the EMR. That provided caregivers with all of her information, history, allergies and the details they needed to understand how best to treat her.

EMRs are a significant component for success, but not the only reason. A properly implemented EMR can be a contributor to financial health for the organization. There are many other contributors that have been discussed here before - insurance reimbursements, staff utilization, medical supply costs are other significant factors. Those are also components of the VA system that help it be so successful.
I encourage other readers to look more broadly for a multifaceted solution instead of focusing on whether or not EMR's can serve as the end-all, be-all to solve the problems.

Posted by: MR421 on September 14, 2007 at 10:08 AM | PERMALINK

I'm sorry. Your not in the system. We can't treat you.

Cherry picking insurance companies want to be able to exclude your pre-existing condition or deny you coverage using a national comprehensive database.

I see you had a strep infection when you were two. We can't pay for the treatment of your damaged heart valve that occurred at that time. It's a pre-existing condition.

Posted by: deejaayss on September 14, 2007 at 10:08 AM | PERMALINK

My question: why do we think the VA is so great? Almost all direct comments I've heard from friends with direct experience suggest that it's terrible...

Anecdotal evidence isn't so useful when evaluating healthcare. You can always find someone to complain about something. Several surveys done in the last 10 years have found the VA system to have higher patient satisfaction, lower error rate, and better patient outcomes than either private insurance or Medicare.

Posted by: me2i81 on September 14, 2007 at 10:16 AM | PERMALINK

People are forgetting how different the VA is from most other medical care. The VA does not offer obstetrics, labor and delivery, neonatology, pediatrics, adolescent medicine, sports medicine, offers very little in gynecology. Most VA medical centers do not even have an emergency department.

Correct. The VA operates in a relatively proscribed area of medical service.

Remember, the VA’s patient base are adults who were physically fit enough to be in the military. The VA’s patient base is also more educated than the general population.

Actually, the VA probably spends more time and money treating retired or former military than it does active duty. I would guess the ratio must be 4 to 1 if not 5 to 1. And, historically, the only service people who continued to use VA medical services (as applicable) were people who did not have jobs that included sufficient health care coverage. If the data is a available, I believe you would find that most vets weren't relying on VA medical services, at least from the late 1970s through the 1990s.

I also find it odd that the socialize medicine proponents talk about the electronic medical record at the VA but ignore the enormous problems that the DoD Health Affairs has had with their system. Once you go computerized the organization has to constantly update the system. The DoD is stuck with its legacy system which is much more complicated than the VA systems and has been a failure when upgrading. Posted by: superdestroyer

The health systems we use in Seattle (Virginia Mason, Swedish Medical Center, and Seattle Children's Hospital) all have electronic data systems. Every exam room is now equipped with a monitor and keyboard. It was obviously an tremendous expense, but the hardware and even software are better and cheaper than they were just five years ago.

Posted by: JeffII on September 14, 2007 at 10:35 AM | PERMALINK

"...it doesn't take business away from current insurers since it only covers the currently uninsured..."

I had to stop here. This is the point in which all economic science is tossed out the window and massively incorrect statement justifies a potential result.

Anyone who believes the Dem candidates are doing anything but politicing this issue should look at this statement and ask, "do I really beleive these idiots?"

Posted by: Matt on September 14, 2007 at 10:39 AM | PERMALINK
Because what could be better than taking away from doctors the ability to determine for themselves what the most appropriate treatment is?

Obviously, the answer to that is to remove tchotchkes, golf junkets, and other forms of bribery, and require them to solely use scientific data. Which, through the miracles of economy of scale, will be available to them with negligible costs in time or expense from the advisory board!

Would you like your pony now?

Posted by: kenga on September 14, 2007 at 10:43 AM | PERMALINK

If I hadn't heard so much reported in the mainstream media about how much veterans love the VA and think the care it provides them is so superior to what they got as civilians, I might be skeptical of Longman's plan.

Posted by: Swan on September 14, 2007 at 10:51 AM | PERMALINK

I actually know next to nothing about the health care issue, and maybe some specific proposals of Longman's would help out for all I know, but it sounds like he's making some pretty extraordinary claims.

Posted by: Swan on September 14, 2007 at 10:53 AM | PERMALINK
I had to stop here. This is the point in which all economic science is tossed out the window and massively incorrect statement justifies a potential result.

Please explain - are you saying that uninsured people DO in fact pay insurers, so by providing them coverage, business will be taken away from the insurers?
If not, I'd appreciate it if you would make your point in words that make sense instead of asserting an obviously false condition.

Posted by: kenga on September 14, 2007 at 11:01 AM | PERMALINK

I'm sorry. Your not in the system. We can't treat you.

Cherry picking insurance companies want to be able to exclude your pre-existing condition or deny you coverage using a national comprehensive database.

I see you had a strep infection when you were two. We can't pay for the treatment of your damaged heart valve that occurred at that time. It's a pre-existing condition.
Posted by: deejaayss on September 14, 2007 at 10:08 AM
--------------
Kevin, in order for this to work you would have to ALSO couple it with single-payer insurance. Private won't work because of this reason. You can regulate the insurers with community rating and can't turn anybody away laws, but if you are going to bother with having to do all that you may as well just have something like the UK's NHS. But then you are going to remove "choices" and everybody is going to howl like hell. MUCH better off just to allow people to opt-in to Medicare and just raise taxes to cover it and you can get the care anyplace. MUCH simpler that way. The biggest thing the VA has going for it is cost-pure and simple. I say do Medicare for everybody and then look at cost afterwards.

Posted by: Doc at the Radar Station on September 14, 2007 at 11:27 AM | PERMALINK

Actually, Seattle is a pretty good example of getting part of it right. Almost all of the hospitals are part of the U of W teaching hospital system. In the one I go to, Harborview, EMR is pretty well implemented. X-rays are absurdly simple- digital images can be reviewed by the x-ray doc wherever he is and a second shot taken if needed, you go to the clinic and your doc has the view on a screen, which he can zoom. This one function alone creates such huge savings it is a tremendous driver for EMR.

In the rural county where I live, the hospital-clinic system is putting in big information pipes. You really have to do this, not only for patient outcomes, but to be able to attract competent people to practice in rural clinics.

Actually, the information age is upon us. Our electric utility is putting in fiberoptics to install real-time meter-reading, so eventually everyone in the county will have broadband. A hospital district not planning to take advantage of this would just be too stupid to live.

Posted by: serial catowner on September 14, 2007 at 11:28 AM | PERMALINK

I think what he meant is that 1) the uninsured are kids, who will eventually get insured by the private sector, or 2) unemployed, who are folks who were once insured by the private sector and will be again when they get another job, OR 3) who are employed by companies that don't offer insurance who are more or less screwed cuz their health care is provided on an emergency basis by the taxpayer.

So the economics are that in the first and second cases, this takes away from POTENTIAL private insurance customers, and in the third case, it eliminates a subsidy.

Posted by: theAmericanist on September 14, 2007 at 11:28 AM | PERMALINK

I have belonged to Kaiser Permanente for 15 years and have seen and appreciated the efficiencies that have resulted from the switch to electronic record keeping over the years.

One aspect that has not been mentioned is renewing medications. All Kaiser patients can sign up to be a member of their website and can renew prescriptions on-line and pay for them by credit card. They usually arrive in the mail one or two days later.

Kaiser has a central pharmacy here in Portland that handles prescription orders. It is so efficient that medical people from other countries have come to observe how it works. Every clinic still has pharmacies on site, so that you can pick up new prescriptions right after you see a doctor, but ordering on-line is so easy for renewing them.

Also, if you go in for a routine blood test, you can view the results on-line, too. It is a good way to see how your cholesterol readings are doing over time.

Posted by: emmarose on September 14, 2007 at 11:45 AM | PERMALINK

One of the unheralded aspects of the Federal public servants is how the VA has made their medical records computer system available to other governments. I don't know the exact numbers of countries involved, but I believe that the VA medical system software has been made available to other countries, who then use it as the base, instead of needing to start the software development from scratch. One country that I believe did this was Mexico, who I believe modified it so the prompts were in Spanish, not English).

I heard about this at a Information Technology conference at least five years ago. I am a former Federal computer specialist.

Posted by: Bill Huddleston on September 14, 2007 at 11:53 AM | PERMALINK

Doctors who work for these hospitals would no longer be constantly visited by pill salesmen, because decisions on what prescription drugs to use would be made on a scientific basis by the Vista board...

I love this idea! In fact, I propose that all major professions be insulated from advertisers, the private sector, and the unpleasant complexity of having to use their own experience and training, by having a government board make all their decisions for them.

According to the article, that would be this board:

Governance of the Vista network would be in the form of a board appointed by the president, whose members would not be subject to Senate confirmation and would serve staggered terms—in effect, a Federal Reserve Board of Medicine.

Posted by: harry on September 14, 2007 at 12:11 PM | PERMALINK

The "Moneyball" approach??????

You must be kidding - As a diehard A's fan since they moved from Philly to KC in 55, Moneyball is vastly overrated.

So, you bring in promising interns, then when they bloom into top notch physicians, you either trade them or lose them to free agency? Kee-Rist, medical systems would be constantly rebuilding. Of course, they would learn to take a lot of pitches.

Screw Billy Beane and Moneyball.

Posted by: thethirdPaul on September 14, 2007 at 12:37 PM | PERMALINK

"Please explain - are you saying that uninsured people DO in fact pay insurers, so by providing them coverage, business will be taken away from the insurers?"

No, the idea I was trying to get across is side effrects, which democrats seem to ignore completely though they have been accepted economic science for over a hundred years.

The idea that the government provides health insuance equivalent to those who pay privately, and nothing will change is just ludicrous.

Democrats in the primary simply ignore sound science, they are just like Mormon or Islamic freaks. Everyone with any college degree have been complaining about this for years. Republicans at least try to fake their agreement with science, but Dems in primaries just say some of the stupidest shit, Hillary and Obama are the worst.

Posted by: Matt on September 14, 2007 at 12:44 PM | PERMALINK

Can attest to the fine UW system at Harborview in Seattle - Was in that system for several years - When I transferred to the VA, the records from Harborview were readily available.

emmarose, yes, Kaiser has implemented on-line ordering - However, I do like the VA phone-in automated system for prescriptions and the drop off by, either the Post Office or, in a rush, by a private service - However, I believe, that there is still a problem in the Portland area in sharing of medical information among Legacy, Providence, OHSU and Kaiser - Unless, this has been worked out.

Posted by: thethirdPaul on September 14, 2007 at 1:17 PM | PERMALINK

Having read the book, I think that a couple of things are being missed here. It is not the electronic records system alone, but the combination of of the electronic records system *and* the incentives to keep people healthy.

The book has at least one example of a clinic that installed the VA systems and found that it cost them money from lost business.

In the mainstream (as opposed to the VA), doctors are paid for treating patients, not for curing them or for keeping them healthy.

Posted by: patrizio on September 14, 2007 at 1:19 PM | PERMALINK

I'm not able to find good statistics (they may or may not be out there, I don't know), but I suspect that a lot of the VA's advantage is due to the comprehensive delivery of health care. The VA functions like a very large, fully integrated, multi-specialty group plus. The VA provides not just medical care, but also provides pharmaceutical management, mental health care, and even social workers. My guess would be that that has a bigger benefit than their admittedly fine EMR. Additionally, the VA benefits from its status as a teaching hospital. The VA supports a lot of cutting edge research which tends to keep all of the providers aware of current medical treatment and allows patient with unusual diseases access to higher quality care.

VA docs are also more efficient because they don't order a bunch of CYA testing. They are insulated from malpractice concerns and it really affects their practice behaviors.

Posted by: J Bean on September 14, 2007 at 1:34 PM | PERMALINK

Anecdotal evidence isn't so useful when evaluating healthcare. You can always find someone to complain about something.

Amen.

Let's all of us take the pledge: when engaging in blogospheric discussions of healthcare reform, I vow to cite statistics, hard data, and reputable studies, and refrain from talking about how my Uncle Joe in London died from a British Hospital superbug or how a colleague with private insurance in Chicago was told they won't pay for her cancer operation.

Posted by: Jasper on September 14, 2007 at 1:36 PM | PERMALINK

Matt says:

The idea that the government provides health insuance equivalent to those who pay privately, and nothing will change is just ludicrous.

I think Longman addressed that:

If this kind of competition were allowed to happen, private health care companies would either lose customers to Vista or be forced to find ways to curb overtreatment, reduce medical errors, and in general provide better, more cost-efficient care. Either way, the competition would lead to dramatic improvements in American health care.

Posted by: kenga on September 14, 2007 at 1:43 PM | PERMALINK

The VA also has nursing homes, geriatricians, and is pretty aggressive about moving people into hospice care all of which helps to improve efficiency and elder care outcomes.

Posted by: J Bean on September 14, 2007 at 1:55 PM | PERMALINK

Electronic records is a very big deal
I drive Grandma to the doctors. Every one asks the same questions about past history, meds allergies, etc etc. One unified record system would eliminate all this paperwork and room for error. (Oh yeah, I forgot about that new drug). The problem is keeping the insurance companies big nose out of the database and using it to turf the non-healthy.

Posted by: bakho on September 14, 2007 at 1:58 PM | PERMALINK

"First, unlike the 1993 Clinton health care plan, the Vista proposal does not directly take on the medical/industrial complex. It would not require any changes to the private insurance market, for instance, or place any costly mandates on employers. At least in the short term, Vista would be focused on customers who aren't now part of the private health insurance market."
::
"Similarly, imagine that Vista is put into place and works as advertised. Over time, word gets out that the quality of treatment in Vista is pretty good—indeed, better than what most people with employer-provided health care receive. Pretty soon, individuals who are not eligible for Vista start clamoring for the right to buy into the system. And employers, realizing that Vista is doing a better job of controlling costs than their own private-sector health providers, start pressuring Washington for permission to contract with Vista to provide health care for their employees."
----------

Ok, so what's to stop employers from dumping their health insurance coverage on their employees and telling them to go get VISTA? Without a mandate on employers, and "not directly taking on the medical/industrial complex", HOW is this going to be FUNDED should this event take place in quick real time? Wouldn't VISTA be just a tad bit overwhelmed here, especially since they are *providing* the health care? I don't think the author has thought out these possible scenarios. It looks to me like an easy way to let employers and private insurers off the hook here.

Posted by: Doc at the Radar Station on September 14, 2007 at 2:22 PM | PERMALINK

Two things on electronic medical records:
First, they work. My husband, an internist, went all-electronic 10 years ago. He has been a member of a research group sponsored through the NIH (although he gets no funding), and has scored as the highest performing medical practitioner in terms of outcomes the entire time. Electronic medical records allow him to monitor patient well-being, ensure preventive care, and be sensitive to problems as they arise, not when they are acute. His patients have better controlled sugar levels, better controlled hyperlipedemia, and hyptertension. They stay out of hospitals and have few complications, despite the fact that Jim's patients comprise a primarily geriatric population.

The second thing about electronic medical records is that they are very costly to install and maintain, there is no way to recoup the costs, and they do not reduce staff time. Since these higher costs are coupled with the fact that cost reimbursement for time spent on preventive care is a fraction of the reimbursement for time spent on acute care, practitioners using electronic records are among the lowest paid physicians. Until this disconnect is fixed, I don't see all-electronic offices sweeping the nation.

One last: a paper office is not a barrier to insurance company intrusiveness. Like everything, it is already far worse than you think.


Posted by: Lenore Wilson on September 14, 2007 at 2:43 PM | PERMALINK

Kevin wonders why, in my article, I say that the VA’s near lifetime relationship with its patients, which it has always had, is a key to its current success.

In part the answer is that VA never was a bad as portrayed in movies such as “Born on the 4th of July.” As detailed in my book, Best Care Anywhere: Why VA health care is better than yours (Pollipoint 2007) activists long ago admitted to stage setting at least some of the outrageous conditions chronicled in the media during the post-Vietnam era. It’s also true that as a very large, public institution the VA is routinely subject to high levels of scrutiny. Failings that go unreported elsewhere in the health system become instant headlines and the subject of Congressional hearings when they occur at the VA. Opponents of “socialized medicine” also long have had a high stake in pointing to any shortcomings in its only actual example in the U.S. The VA thus has a built in p.r. problem, as do all government run health care systems around the world. Yet even when the VA’s reputation was very low compared to today, veterans groups strongly resisted proposals to replace VA health care with vouchers. Most vets who use VA health care prefer it to private sector health care, and always have.

So the VA never was that bad. Why did it get so much better, both compared to its past performance and to other providers? Partly it’s a matter of inspired leadership. In larger measure, it’s a matter of the changing nature of illness. The improvements the experts are talking about are largely in the realm of preventing and managing long-term chronic disease, which have become the leading causes of death in modern populations. This change is key to understanding the VA’s superior performance. In the treatment of acute care injuries and infections like pneumonia, it doesn’t matter much if there’s a long-term relationship between patient and provider. You either get the right short-term treatment or you don’t, then recover or die. But now that more and more of us are living long enough to suffer from heart disease, cancer and especially diabetes, which by their nature require long-term, highly coordinated care to prevent and manage, it has come to matter a lot if we treated by an institution that has a stake in our health five or twenty years down the road.

Posted by: Phil Longman on September 14, 2007 at 3:49 PM | PERMALINK

Actually, Seattle is a pretty good example of getting part of it right. . . . Posted by: serial catowner

We are blessed here in greater Seattle. We've got six of the best hospitals in the country that, though ostensibly in competition with one another, are pretty damn good at working together. Seattle/King county pretty much invented the aid car with the pioneering Medic One program in the 1970s (still the "best" place in the country to have an heart attack), and now they are testing a program of putting medics on motorcycles to speed accident/emergency response that much more.

Posted by: JeffII on September 14, 2007 at 3:58 PM | PERMALINK

What’s the big deal about the VA’s electronic medical record system? For one, unlike the propietary systems private companies are trying to market, its original code was written by doctors for doctors, as part of an ad hoc, collaborative process. The story, which I chronicle in my book, Best Care Anywhere, is wonderful. It’s one of an underground subculture of geeky doctors and other health care professionals, known as the Hard Hats, that emerged within the VA beginning the late 1970s. Hacking clandestinely on Tandy PCs and DEC mini-computers, they wrote some 18,000 different programs that eventually were integrated to become the VA’s world class VistA system.

Because of this history, VA doctors have long had “buy in” to digitalized medicine that it is still largely lacking in the rest of the health care system. And while there is no one definition of “open source,” the VA’s VistA system is essentially that. From this come all sorts of advantages over the proprietary software programs, including no licensing fees, rapid detection and elimination of bugs, and the ability of end users to improve the code and adapt it to their own medical practices.

Finally, there are the huge networking effects that are unique to VistA. So your doctor carries a lap top around? Big deal. Electronic medical records have some value over paper files, but not much if they cannot be widely shared among the many different specialists, labs, pharmacies and other players typically involved in a patient’s care, either at one time or over time.. Also, the data contained in electronic medical record about what treatments work best is of little use to researchers if they cannot aggregate that data across large populations. The potential for electronic medical records to drive the development of safer, more effective “evidence based medicine is huge, but only if those records are part of a very large, integrated system like the VA’s. It took me a long time to get my head around these realities, but once I did it was easy to see what a big deal the VistA system is.

Posted by: Phil Longman on September 14, 2007 at 4:44 PM | PERMALINK

JeffII, Correct and WhipLash Willie is on his Harley right behind them.

As long as they stay off I-5 and the Mercer Mess.

Posted by: stupid git on September 14, 2007 at 5:46 PM | PERMALINK

JeffII, Correct and WhipLash Willie is on his Harley right behind them.

As long as they stay off I-5 and the Mercer Mess.
Posted by: stupid git

I figure they'll use those big overpowered hybrid bikes that they ride in the Paris-Dakar Rally. That way they can bounce over curbs and dividers at 40MPH.

Posted by: JeffII on September 14, 2007 at 6:10 PM | PERMALINK

The reason the VA does better is not because of electronic health
> records but, rather, because the health records are embedded into a
> health care system grounded in a strong primary-care focus. The
> long-term commitment is characteristic of good primary care. So is
> person-focused care rather than disease-focused care. So is
> comprehensiveness of services---breadth of services provided by
> primary care rather than by a bevy of specialists, but with good
> specialist backup to primary care--and coordination of services when
> they have to be provided by specialists. The major problem with the
> US health-services system, apart from the large number of people who
> are excluded from it---is that people now seek care more from
> specialists than from primary care physicians. There is lots of
> evidence on this point but it never appears on the blogs or in the
> mainstream media. (See the paper by Starfield et al in Milbank Quarterly, 2005).
>

Posted by: barbara starfield on September 14, 2007 at 10:27 PM | PERMALINK

nptemczrv aynedwxgq goacdf nthvlgwpe tphivby ntgbcf nkyc

Posted by: xiwenc qhtwi on January 14, 2008 at 4:41 AM | PERMALINK

idogxbm swzxj ygxorpu drqby xfwejlrpy tgyebzf chnyuxor http://www.atsnzfkjh.shkjlaqoc.com

Posted by: qizyrge dmpg on January 14, 2008 at 4:41 AM | PERMALINK

ensvcdwu aocvfemly inrg zwaijh myjdtqxsv wprdo sojenwuz otejvb lymbzvhk

Posted by: emckib maperkshd on January 14, 2008 at 4:41 AM | PERMALINK




 

 

Read Jonathan Rowe remembrance and articles
Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Sign up for Free News & Updates

Advertise in WM



buy from Amazon and
support the Monthly