Best Care Anywhere, part 5: "patient for life"

I started this series a month ago. The most recent post, about the "Hard Hat" code hackers, was here. I finished the book two weeks ago, and on Monday 10/27 I met the author. It's a short, easy read, packed with information and well written - and a great story. I've had a busy two weeks (more on that later)

On the e-patient blog there's a discussion about referrals and second opinions and the difficulties they cause. A whole bunch of patients are really irked at how they're being treated, and I think this is a good thing; I think in the coming year or two we'll see an eruption of people saying how poorly the system works, which could be the start of a long-overdue revolution.

The discussion led me to add a comment based on something important that I found in the book. For your consideration:

-----------
Christine,

I think the time has come to shift the focus for a moment.

A couple of weeks ago I spoke at a dinner along with Phillip Longman, author of Best Care Anywhere: Why VA Health Care Is Better Than Yours. It's a gripping story spanning thirty years, in a book that's just 136 pages long and could be read on a Saturday. I've been "synposizing" it on my blog, starting here.

There are many factors in the VA's success in quality measures and patient safety, but a central one is that they had a patient for life, so there was every incentive for early detection and no incentive to hope the problem would move to a different insurer. So the VA got very good at it, resulting in far less critical care, more effective automation, fewer errors and better care.

I say "had" a patient for life because under the Bush administration, for some insane reason, they changed that rule, totally dissing our veterans by making them prove a problem was service-related.

One might think this was to cut government costs, but the insane thing is that veterans in this bind are then forced to move to Medicare (private medicine), where care is worse and government costs are higher!

The inevitable result is a lengthy appeals process and lawsuits as veterans try to get their case covered, further increasing costs and stressing the veterans and their families. Insane.

Anyway: if our insurers "had us for life," I think they might have greater interest in catching things early and being sure they had the right diagnosis in the first place.
-----------

Thoughts, anyone?

Best Care Anywhere, part 4 - the Hard Hats

Last time I finished recounting the "where we are today" stats, about how remarkably the VA has been outperforming other systems on measures of care quality and safety, all while maintaining costs. As I've continued reading I've been quite surprised at how they got there. It's not by any process anyone would design, and yet the methods have tremendous implications.

In the post-Vietnam years the VA health system was in lockjaw. The combination of politics and change-resistant bureaucrats made improvement all but impossible, just as predicted by the observers in the previous installment who felt any government operation was doomed to end up this way.

But for years, way under the radar, operating in basements (literally) and often going directly against orders from upstairs, a loose federation of geeks and medicos were hand-coding computer systems, largely out of self-defense - they were desperate to find ways to handle their impossible workload. They wrote programs that automated admissions and discharge, handled prescriptions electronically, maintained patient records to sniff out potential problems.

They wrote it all in open source: nobody owned the code, and anyone could check it for accuracy or contribute improvements. (For those who aren't familiar with the idea of Open Source software, which anyone can edit, try this: Wikipedia is an open source encyclopedia: anyone who knows how can go in and edit any page they want.) (Of course, someone else might edit it back. Such communities find ways of being civilized, and progress usually happens.)

Unlike today's sickening morass of systems that won't talk to each other, these people wrote programs specifically with the intent that the data should be shareable. Most important, since the programs were written solely to help the users (e.g. pharmacists), the only features that got programmed were ones that the users wanted, and the features worked the way the users wanted.

Mind you, this was before PCs. And to keep their work secret, these people, who came to be known as the Hard Hats, couldn't even write their software on computers - the requisitions would have been too conspicuous. So they often wrote their lines of code on primitive 1970s word processors, so there was no error-checking or system assistance at all. They'd type in the code and then carry the disks to a computer somewhere else, and only then find out if there was a typo or a logic error. (Writing software is much much easier today, but these guys did it blind.)

Management, the "high priests" of computers in those days, hated it. One of the Hard Hat leaders had his DEC (Digital Equipment Corp) computer piled with paper and set on fire; his car engine was rebuilt several times because someone repeatedly put sand or salt in the tank. Computers found to be used for this work were confiscated.

Meanwhile, in a great irony, the people who were squelching this competence-centered programming were incapable of getting anything done themselves, so the gulf between what worked and what was authorized grew wider and wider. In 1979 the VA's computer office removed more systems than it installed. (I had no idea this was going on!)

In 1981 it came to a head, when a broad rebellion arose, finally getting the attention of a top VA manager. Long story short, the situation was turned on its head: hundreds of high priests were fired and the Hard Hats were empowered. With the restraints removed, all the different disconnected programs the Hard Hats had written could be brought together into one big system - and the book says it took less than a week.

Most astounding of all, that combined system came to be called VistA - and it's still in use today. Where's the software anyone else was using in 1981?

---

What do we see here? I'll start, but I'd really like to hear what you see.

First: great systems are built specifically and only for the people who will use them. They're created by asking the users what they need, not by sitting in a conference room trying to anticipate what the user might like.

And the users are brought in early, to see the earliest prototype, which gets modified to work the way the user wants.

Second, extreme need can be a powerful creative force as resources become so overtaxed that people will do anything to relieve the pressure. If you look at how many boomers are about to enter the high-consumption phase of their healthcare "careers," you can read the handwriting on the wall.

Third, the advent of microcomputers and then PCs meant that power (computing power in this case, and power to create) got into the hands of the people, who could then do anything they wanted with that power. Look what happens when access to tools is unlocked, instead of being under centralized control.

It's power to the people, isn't it?

Here's something to think about. Today, with blogs, user forums, and all those other "Web 2.0" tools, we all have a shot at using unprecedented tools for finding, sharing, and publishing information. (Look what I'm doing right here, sharing what I see, and look what you're doing by reading it. This blog costs me nothing - you too.)

What else do you see in this story so far? What raises your eyebrows? What will you tell friends?

Final part in the series

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

Best Care Anywhere, part 2a

Updated 10/16... see italics: changed "letting people" to the more-specific "letting providers or insurers," which is much more on point.

In Part 2 I mentioned that one factor in the VA's results is that they're "stuck with" a patient for life. I meant it somewhat glibly, but later I realized I wrote about the same issue from a different angle way back in December, in one of my very first posts: For prettier statistics, omit inconvenient people. It's a long post, and something of a rant, but in short it says that a planner can come up with really nice pricing plans, etc, if you allow excluding the hard parts. I related examples from the health insurance industry from my own experience and friends'.

But isn't it ironic that when you're not allowed to exclude the tricky parts, costs can go down?

This is really interesting, because if you tug at any one part of the system, it seems like a morass (as I commented last week on e-patient). But it appears that if you insist on including the whole puzzle, it becomes solvable!

Preliminary wonderment: could it be that the principal principle (!) at fault is the idea of letting care providers, or insurers, say "Not me" to particular parts of the problem? I don't know. I don't believe in lots of legislative forcing, nor bureaucracy. But I know first-hand (as does the author of this book) that things have not been working out well in healthcare, left to the free market.

Next in the series

Best Care Anywhere, part 2

Part 1 ended with a snip from the introduction:

You don't even have to travel to some far-off foreign country like Sweden, or even Canada, to see it in operation. It's already up and running, right here in America.

Here are some results of this US-based healthcare wonder:

• Most of its doctors have faculty appointments with academic hospitals
• Two have won the Nobel Prize in medicine
• Its innovations include development of the CT scanner, the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, the nicotine patch, and prosthetic devices including hydraulic knees and robotic arms
• Exceptional safety record (more on this later)
• Health promotion and wellness programs
• Pioneering and unparalleled adoption of electronic medical records (instead of the paper too often used by "modern" hospitals and doctors elsewhere)

Costly, eh? No: it's the only healthcare provider in the US where cost per patient has been level in recent years.

I haven't finished the book yet (I'm into chapter 2, and the above is all in the introduction) but so far it seems apparent that one substantial factor in this has been that this provider is "stuck" with the patient for life. (They get no benefit at all from postponing conditions.) It's not that simple, though - if dunderheads were stuck with you for life, they wouldn't necessarily be smart about it, and they certainly wouldn't have necessarily invented all that stuff above. Some smart people are at work here.

Next in the series

Highlighted in Best Care Anywhere - part 1

I'm reading Best Care Anywhere. This book is hot, and I want to share it with you, but I don't want to wait until it's finished. Also, sometimes when I think too much, I talk too much. So I'm going to try something new.

As I read, I'm highlighting like crazy. As I finish each chapter, I'm just going to post the highlighted parts.

Why is it hot? Because a lot of people I know are wandering around (figuratively) wondering what we can do to make healthcare better, and the US Veterans' Administration has been doing (for years) what I think everyone ought to be doing: taking a long-range view of the total patient, not a short-range view of "what costs will we approve and incur this quarter or this year?" When you look at it that way, a lot of other answers fall out pretty easily.

For instance years ago the VA pioneered e-prescribing, vastly reducing medication errors caused by handwriting; most hospitals don't have that yet. The VA invests in early detection, because unlike your average insurance company, they're responsible for that patient for the rest of his/her life. And so on.

This surprises a lot of people because we keep hearing scandals about VA hospital abuse. This will be covered in the notes. One thing to bear in mind: there's a difference between quality of care, and access to that care. Another: sometimes there have been political agendas involved. We'll get to that; for now, just listen for what works.

---

The author's perspective

The book grew out of an assignment by Fortune to document that government-administered healthcare would be a disaster. The author, a pro-market anti-government thinker, fully agreed. But there was a problem: a few years earlier his wife had been through a terminal cancer, and they'd witnessed all too clearly the inefficiencies and gross errors that are too common in US healthcare today ... and he didn't find that in the VA.

To the contrary, he found a system where they actively prioritize eliminating causes of errors, and they do it successfully. Although he expected to find that "socialized" (government-run) healthcare would be bloated and inefficient,

...as I started asking experts for suggestions about who was delivering the highest-quality, most cost-effective, innovative, and scientifically driven health care in America, I kept hearing an answer I could not believe. It contradicted all that I knew about health care and medical economics, indeed, about markets and governments in general. Yet these experts backed up their assertion by pointing me to study after study ... in prestigious, peer-reviewed journals.

And here's the punch line:

I knew the editors of Fortune would never feature it on their cover. And I was right. We agreed on a kill fee with no hard feelings. Business is business.

Ain't that grand? BUT: he pursued the subject, and wrote this book.

A solution to America's health care crisis does exist, I realized. Better than that, you don't have to rely on mere theoretical speculations or econometric simulations to see how it might work, nor do you have to wait around for a revolution in technology. You don't even have to travel to some far-off foreign country like Sweden, or even Canada, to see it in operation. It's already up and running, right here in America.

Stay tuned. (Or just buy the book - this one's worth the $10.17 at Amazon, and you can do your own highlighting.)

Continued in Part 2