HOSPITALS: VA perfection revisited By Eric Novack

THCB contributor Dr. Eric Novack has been following the unfolding scandal at Walter Reed Medical Center very closely. Eric feels the problems discovered by the Washington Post are indicative of deeper institutional problems at the VA. And deeper problems with government run healthcare systems in general. And as usual, he’s got something provocative to say about it.

When the topic of quality health care has come up at THCB, the 2006 study from Harvard touting the VA as providing the ‘best quality’ care in America gets regularly mentioned.

Reality, however, has finally reached the MSM and the public. This is not a Republican problem.  This is not a Democrat problem.  It is a non-partisan problem.  It is a bipartisan problem.  The problems have existed through Republican and Democratic Congresses and Administrations. And legislators and bureaucrats have been made aware of some of these problems for years and years. 

And yet, nothing significant has changed. The missing interpretation: the absolute fundamental inability for government-run organizations to escape convoluted, bureaucratic, non-meritorious based hierarchies. Anyone still for VA care for all of the USA now?

CODA: From Matthew Holt While I believe that the VA still has its issues, apparently those in the private sector appeared to be convinced by the turnaround in its clincal quality indicators. Or at least Managed Care Magazine has been fooled into thinking that, if of course things are as bad as the WaPo’s collection of anecdotes tells us.

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  1. http://www.ajmc.com/files/articlefiles/AJMCnovPrt2Perlin828to836.pdf
    Please follow the link to read; I find the commentary insightful into the recent history of changes made in the VHA system and the fact that it is able to provide some indicator comparisons to non-government health organizations. I believe it also illustrates how other health orgs in our country are not immune to the problems VHA faces.
    Additionally, if anyone would like access to some of the articles cited in the AJMC commentary I am able to immediately access some of them.

  2. That is incorrect. Medicare contracts with private non-profit administrative companies, like WPS here in Wisconsin, to handle all administrative tasks including the payment of claims. It also contracts with private companies to provide Medicare Advantage programs, for which it costs them 12.5% more than if they just provided the services themselves. So much for private industry being less expensive than the government.

  3. The one key difference between Medicare and the “private sector” is that the overhead in the private sector runs up to 31% vs less than 5% in the other programs.
    This is an often quoted figure, but I have yet to see any proof to substantiate it.
    I have yet to see any carrier with overhead retention charges for administering health claims anywhere close to the 31% figure.
    And what does the federal govt do to administer Medicare, Medicaid, et al?
    They don’t pay claims.
    That is farmed out to carrier.
    You know, the ones who supposedly charge 31% to adjudicate & pay claims.

  4. Of course the current VA model is not perfect, because it must compete with a private market in which physicians can make well over $500K if they are creative. Thus the VA gets the newbies and they aren’t always the best.
    But that doesn’t destroy the model. If all we had was a VA system with all of todays physicians folded into it and paid a progressive P4P salary, it would be a hell of a lot better than the current free-market system that is on the verge of being taken over by the CEOs.
    So Eric, have you applied for your plumbers license yet? If you think the government is bad, wait until medicine is controlled by CEOs and their shareholders.

  5. People seem to miss the most important point though about the VA and the supposed higher levels of care.
    The real interesting question – Is the VA performing better on certain quality (really process) indicators due to a comprehensive EMR system and HIT investments or because of the more hierarchical nature of the VA medical structure compared to private practice?
    I tend to think it is a little of both and that the EMR system overshadows some other important unique factors in the way the VA physicians practice medicine.
    The really scary thing is if the VA is really performing that much better or if the VA is just much better at documenting care that their patients receive.

  6. “Walter Reed is probably an outlier.”
    Sadly it is an outlier on the upper end of the scale. Sweep away the smoke and mirrors and beware of what you may find.

  7. Exactly. Given the “anecdotes” we’ve heard about the provider community killing people, performing unnecessary procedures to make more money, etc., someone with Eric’s intellectual integrity could make a great argument for a healthcare system without Doctors! Sign me up.

  8. Walter Reed is probably an outlier. It is certainly not “much ado about nothing”…this much should be obvious to anybody who cares about the welfare of the patients who were staying on the neglected wards.
    But whether outlier performance reflects on the system as a whole is a different matter. You need data to decide this question. If there have been large-scale quality studies of military hospitals, I’d be interested in hearing about them.
    Generalizing to “any large government bureaucracy” is foolish in the absence of data. But it does make fun (if uninformative) conversation. Everybody has an anecdote…and I’d be shocked if every single commentator on this blog couldn’t come up with some instance, somewhere, in which they or a friend got poor quality care from a privately-administered system. I wouldn’t draw any big picture conclusions from those anecdotes either.

  9. Talk about it being a problem of funding. NYC columnist Paul Krugman writes today, “For all its cries of ‘support the troops,’ the Bush administration has treated veterans’ medical care the same way it treats everything else: nickel-and-diming the needy, protecting the incompetent and privatizing everything it can.”

  10. harrumph… would you then subscribe to an argument that goes that the problem at Walter Reed is an ‘outlier’ and the uproar is ‘much ado about nothing’?
    fyi– the point is not that the VA and Walter Reed are overseen or run by the same agency, but rather that the problems are endemic to any large government bureaucracy.
    Also, I hope that I can draw a simple equation:
    EMR does not equal high quality care.
    Nor is it a requisite component of a quality health program. It may be nice, but as fomer ONCHIT (office of national coordinator for health info technology) David Brailer told me, electronic records are a tool that can help improve care; the mere presence does not mean better care is being provided or that errors will necessariy be prevented. (see the UPMC study about that, which has been written about by Matthew in the past)

  11. Just two things:
    1. Mark R is right: Walter Reed is not part of the VA system. The VA system is for civilians who are veterans. It is completely separate from the military medical system. But it’s easy to see why even doctors (who should know better due to their VA rotations during residency) can get confused on this point.
    2. Despite various recent studies documenting nice performance on quality measures by the VA system, there is still significant heterogeneity within the VA system. Some VA hospitals are superb and others are downright awful. I’ve worked in one of the awful ones. And within the same VA hospital, you can find good wards and bad wards, good nurses and bad nurses, etc. Bottom line, you can certainly find the low-quality tail of the VA’s quality distribution if you look for it. This performance heterogeneity exists within each and every private-sector system as well. So even if Walter Reed were part of the VA system, it’s a bit of a specious argument to use anecdote as an indicator of anything other than outlier performance. The plural of anecdote is not data. If you have new data on overall system performance, then let’s hear it.

  12. You all (hopefully) appear to be just reading the headlines from Dana Priest from WaPo. Folks at Salon.com and elsewhere have been writing about the problems for many years. Long before we were attacked and find ourselves at war.
    MToubbeh- perhaps you missed the discussion here last week about the real information about the relative overhead costs. please check it out.

  13. Ooops — guess I should have actually followed the link above to the “It’s Not Just Walter Reed” Wash Post story. Matthew’s point about anecdotal evidence is a good one, however.

  14. I think Eric has also missed the point, something has changed, and that is we are at war!
    Health care expenditures, by the VA and the military, have been increasing exponentially, due to the Iraq war, and without a corresponding increase in funding, something had to give.
    It isn’t a problem with government or military run organizations, it is a problem of funding. The VA was doing quite well, until there services started being over run with wounded soldiers returning home.

  15. Nearly 50% of all health care in this country is paid for by federal, state and local government via either the VA, Medicare, Medicaid of government employee health benefits.
    We already have a government run system. The one key difference between Medicare and the “private sector” is that the overhead in the private sector runs up to 31% vs less than 5% in the other programs. VA care (traditional care for the vast majority of vets who are retired not trauma care or PTSD treatment for the new vets) On seven out of seven measures in head to head comparisons hands down better. http://www.washingtonmonthly.com/features/2005/0501.longman.html
    When Katrina hit the VA was the only system that didn’t lose a single record or RX as they are all linked by computers. Patients can even access them from home and put in notes in a patient section.
    If you have heart disease and are in the VA system vs a private HMO guess what the outcomes are better in the VA system. The reason is quite simple actually. When you own your patients for life you invest in preventive measures. So any up front costs that you spend to improve care five or ten years from now comes back to the system.
    Remember the vast majority of the recent press was about the Dept of Defense out-patient care not the VA but there is no question that all out-patient long-term care in this country is a mess. In my own private personal health insurance policy (I pay for it as I am an independent employee) it allows me a total of $5,000 in outpatient rehabilitation coverage.

  16. Apparently Eric Novack isn’t aware that Walter Reed is not operated by the VA but directly by the Army itself. I’m not familiar with the Harvard study, but presumably facilities not actually operated by the VA were not included in the VA’s results. Try again, Eric.

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