Thursday, October 16, 2008

Best Care Anywhere, part 3

Last time I said "Could it be that the principal principle at fault is the idea of letting people say 'Not me' to a part of the problem?" But it didn't quite sit right, and I just edited it to "letting care providers, or insurers, say 'Not me' to particular parts of the problem".

Chapter 1

When people read "veterans hospital" what comes to mind is the much-publicized stories of neglect. By the first Clinton administration conservatives pointed to them as proof positive that any move toward "socialized medicine" was doomed. Here's Jarret Wollstein on Hillary's plan, 1994:
"To see the future of health care in America for you and your children under Clinton's plan, just visit any VA hospital. You'll find filthy conditions, shortages of everything, and treatment bordering on barbarism."
Phillip Longman, author of this book, says he made the same argument in a book in the mid-90s. But then he says "Here's a curious fact: who do you think receives better health care? Medicare patients who are free to pick their own doctors and specialists? Or aging vets, stuck in those presumably filthy VA hospitals, with their antiquated equipment, uncaring administrators, and incompetent staff?"

The answer has emerged from serious research completed since 2000, and published in respected journals.
  • NEJM* 2003: 11 quality measures compared veterans' facilities with fee-for-service Medicare. On all measures the VA was "significantly better."
  • AIM* 2004: VA facilities were compared with commercial managed-care systems in care of diabetics. The VA provided better care on 7 out of 7 measures.
  • In the same issue, a RAND Corp study said the VA outperforms everyone else in 294 measures of quality.
  • A 2006 article in Medical Care compared life expectancy of elderly VA patients with those in Medicare Advantage. Death rates were significantly lower in the VA.
  • The National Committee for Quality Assurance ranks health care plans on many performance measures, such as how well they manage high blood pressure and adhere to various best practices. Highest ranking system: Partners (Mass General)? Mayo? Johns Hopkins? No, the VA.
  • In 2005 JAMA* called the VA system "a bright star in the constellation of safety practices."
  • In 2001 a JAMA paper said the VA does a much better job than others of keeping African American patients alive.
Or heck, let's ask the patients, whose butts are on the line.
  • Are patients clamoring to get out of the VA system? To the contrary - in 2006 the American Legion fought for a bill to let veterans trade in their Medicare benefits so they could get into the VA.
  • For six straight years in surveys by the National Quality Research Center, the highest ratings went to the VA.
  • One factor: the system runs well. 69% report being seen within 20 minutes of scheduled time, and 93% report being able to get to a specialist within 30 days of their requested date.
So, what's the deal here? What was Wollstein missing when he slurred the VA, ten years before those studies were done?

He might have a kneejerk pre-judgment against anything government - in 2006 he wrote Democracy vs Freedom, arguing that "to have a free and peaceful world ... the powers of government must be strictly limited." (I wonder what he'll think when his turn comes. Perhaps his understandable desire for freedom will lead him to want the freedom to get into the VA system.)

Anyway, doesn't this just make you itch to know what's going on here? It reminds me of how in the 1960s American auto executives testified before Congress, with great sincerity, about how it simply wasn't possible to make a more reliable car. Then along came Toyota.

Funny you should mention that, because the next thing Longman mentions does is call the VA "the Toyota of health care." (Toyota is known for its combination of reducing defects and controlling costs, by continuously and intentionally improving their processes, identifying and removing the sources of recurring problems.)

In 2006 Harvard's Kennedy School of Government cited the VA for innovation in government: "While the costs of healthcare continue to rise for most Americans, the VA is reducing costs and reducing errors, and becoming the model..." [emphasis added]

From 1995 to 2004 the US Medical Consumer Price Index rose 39.4%. At the VA it went up 0.8% - while producing all those quality results.

There's more, but you get the picture. Doesn't it just make ya itch to know how they do it? Don't you want your healthcare to work that well? There's something at stake here, isn't there?

Next: Part 4

*NEJM = New England Journal of Medicine; AIM = Annals of Internal Medicine; JAMA = Journal of the American Medical Association

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