Many Americans assume that all European health care systems are essentially the same: single-payer, government run systems that were created, from scratch, by wise and benevolent reformers.
Nothing could be further from the truth, as Harvard surgeon and author Dr. Atul Gawande reveals in the most recent issue of The New Yorker.
In virtually every country, accidents of history have provided the foundation for reforms that are unique to each country. “Reform” did not mean sweeping change. Instead, each country used the hand that history dealt it, and built upon the system it already had. Gawande suggests that the U.S. should do the same.
And when he looks at the systems we have in place, the Veterans Administration Hospitals (VA) stands out as a very attractive footprint for a national health system that might include many, if not all, Americans. Let me be clear: Gawande does not explicitly vote for the VA as the best model. He presents it as one of several alternatives, alongside “Medicare for All” and the Federal Employees insurance. But as he describes the VA, one cannot help but think . . .
Gawande observes that the VA offers “low costs, one of the nation’s best technology systems for health care, and quality that (despite what you’ve heard), has, in recent years, come to exceed the private sector’s on numerous measures.”
I can confirm that this is true—I’ve researched the VA and written about it both in my book, Money-Driven Medicine, and on The HealthCare Blog here and here. Admittedly, during the last eight years, the VA has not been fully funded, but if Congress allocates the dollars the VA needs, it could once again provide the care that it offered at the end of the 1990s—what Philip Longman describes in his book on the VA: The Best Care Anywhere. Princeton healthcare economist Uwe Reinhardt agrees. Writing in Forbes, Reinhardt observes: “Your chance of getting . . . the right kind of care for the condition you have is higher at the Veterans Administration (VA) hospitals than in the private sector.”
Setting the VA side by side with Medicare, Gawande points out that “when compared to the VA, Medicare costs about one-third more and has had a hard time getting doctors and hospitals to improve the quality and safety of their care.” As for the Federal Employee plan that is often held up as a model for national health reform, the private insurers in that plan “have done even less [than Medicare] to control costs and most have done little to improve health care.” So why are we talking about Medicare-for-all and the Federal Employees’ plan as the best alternatives for universal coverage? The VA system, which is already up and running, with quality and safety controls in place, might offer a better starting point.
How Events, Not Ideology, Set the Pattern for Health Reform in Europe
But before taking a closer look at the homegrown healthcare models that we might build on, consider Gawande’s brief history of how other countries have gone about reforming their systems.
The U.K. wound up with a government-run single payer plan because, on the eve of WW II, Britain’s ministers realized that they must prepare for air attacks on the U.K.’s cities. With that in mind, they evacuated three and a half million people out of the cities, and into the countryside. They then had to make sure that medical services would be available—both in rural areas that were experiencing a population explosion, and in the cities where they projected they would need to treat up to two million war-injured civilians and returning servicemen.
Thus, the U.K. began a national Emergency Medical Service. It was meant to be temporary, but by the end of the war, the nation’s citizens were accustomed to it, liked it and did not want to see it go. “The private hospitals didn’t either,” Gawande explains; “ they had come to depend on those government payments.” Thus, the National Health Service was born.
Things played out differently in France. “Long before the war,” Gawande explains, “large manufacturers and unions had organized collective insurance funds for their employees, financed through a self-imposed payroll tax, rather than a set premium. This was virtually the only insurance system in place, and it became the scaffolding for French health care. . . .” After the war, the de Gaulle government did not try to create an entirely new healthcare system. Instead, it “built on what it had. . . The system “that de Gaulle inherited upon liberation had no significant public insurance or hospital sector,” Gawande explains. ”Seventy-five per cent of the population paid cash for private medical care, and many people had become too destitute to afford heat, let alone medications or hospital visits.”
The nation needed healthcare, and unlike the UK, France did not have a flourishing public healthcare system. So the government expanded the existing payroll-tax-funded, private insurance system to cover all wage earners, their families, and retirees. The self-employed were added in the nineteen-sixties. And the remainder of uninsured residents were finally included in 2000. “Today,” Gawande points out, “Sécurité Sociale provides payroll-tax-financed insurance to all French residents, primarily through a hundred and forty-four independent, not-for-profit, local insurance funds. . . .The French health-care system has among the highest public-satisfaction levels of any major Western country; and, compared with Americans, the French have a higher life expectancy, lower infant mortality, more physicians, and lower costs. In 2000, the World Health Organization ranked it the best health-care system in the world. (The United States was ranked thirty-seventh.)”
Switzerland also had no experience with public-sector insurance. In 1994, when the Swiss decided it was time to pass a universal coverage law, most of its citizens had private, commercial health insurance. So in Switzerland, reform meant passing a law requiring everyone to buy private commercial insurance, while providing government subsidies to insure that health insurance would cost no more than 10 percent of income.
Gawande’s point is that, in each country, national health insurance “has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual and untidy.” Here, I am reminded of an anecdote told by Congressman Barney Frank and quoted in a recent New Yorker profile “When someone asked Harold MacMillan ‘what has the most impact on political decisions,’ he said ‘Events, dear boy, events.’” Events—these are the unplanned historical realities that provide the building blocks for reformers.
Frank added that recently, “events have just totally repudiated [the conservatives and we are now in a position to take advantage of that.”
Some might think that this means we are in a position to nationalize the hospitals, put doctors on the government payroll, abolish employer-based insurance and roll out the far more perfect system that you and I dream about.
Siren Songs
Gawande disagrees. He is quick to acknowledge that the system we have is “an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat.”
And yet, and yet: “Hundreds of millions of people depend on it,” says Gawande. “The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our econo
my. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it.”
At the same time, Gawande understands why, from a progressive point of view, a single-payer system might seem the ideal solution. From a conservative point of view, a pure, market-based system would represent the most rational fix. But, Gawande declares, “these are siren songs. . . . Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.”
If we want a chance to learn from mistakes and failures, we cannot pour billions of dollars all at once, into a plan that looks good on paper. Gawande points to the 2003 prescription-drug program for America’s elderly as an example of what can go wrong :
“This legislation aimed to expand the Medicare insurance program in order to provide drug coverage for some ten million elderly Americans who lacked it, averaging fifteen hundred dollars per person annually. The White House, congressional Republicans, and the pharmaceutical industry opposed providing this coverage through the existing Medicare public-insurance program. Instead, they created an entirely new, market-oriented program that offered the elderly an online choice of competing, partially subsidized commercial drug-insurance plans. It was, in theory, a reasonable approach. But it meant that twenty-five million Americans got new drug plans, and that all sixty thousand retail pharmacies in the United States had to establish contracts and billing systems for those plans.
“On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.”
And the retail drug business represents only about 11 percent of U.S. health care. Imagine what would happen if we tried to roll out an entirely new health care system. We should have offered prescription drugs through the traditional Medicare program. But the Bush administration was bent on throwing the business to private sector insurers, so it tried to create a market-based drug program with a single stroke of the pen.
When it comes to universal coverage we need to proceed in a way that allows for continuous learning from mistakes, constant tinkering with reform.
Gwande acknowledges that this will take time. He envisions national health reform that begins on “say, January 1, 2011” and involves “no noticeable change for Americans who have dependable coverage and decent health care. But we can construct a kind of life boat alongside it.” He suggests, for instance, that if we want to use Medicare and/or the Federal Employees private insurance plans and/or the VA system as a model for national health insurance, we might begin by offering “any of these programs . . . to a starting group of Americans—the uninsured under twenty-five years of age, say—the chance to join within weeks.”
Why begin with Americans under 25? Because all children would have access to care, and young adults would receive the preventive care and counseling that can set the stage for a healthy middle-age. Finally, as a group, Americans under 25 are healthier than the rest of us, and so by starting there, we could cover the maximum number of people at the lowest cost.
An Approach that Allows Us to Learn From Mistakes and Failures
“With time and experience” Gawande writes, “the programs could be made available to everyone who lacks coverage. The current discussion between the Obama Administration and congressional leaders seems to center on opening up the federal workers’ insurance options and Medicare (or the equivalent) . . . with subsidized premiums for those with low incomes..
“The costs have to be dealt with,” Gawande continues. “The leading proposals would try to hold down health-care spending in various ways (by, for example, requiring better management of patients with expensive chronic diseases); employers would have to pay some additional amount in taxes if they didn’t provide health insurance for their employees. There’s nothing easy about any of this. But, if we accept it, we’ll all have a lifeboat when we need one.”
As we experiment, we will learn: “It won’t necessarily be clear what the final system will look like. Maybe employers will continue to slough off benefits, and that lifeboat will grow to become the entire system. Or maybe employers will decide to strengthen their benefits programs to attract employees, and American health care will emerge as a mixture of the new and the old. . . . The system will undoubtedly be messier than anything an idealist would devise. But the results would almost certainly be better.”
Gawande does not pick one model that he thinks will work best. This is something that will have to play out over time: Events that we cannot foresee will tell reformers what is possible and what is not.
Nevertheless, Gawande stresses that we have options: “our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems . The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s).
“These are all established programs,” he notes, “each with advantages and disadvantages.“ The VA offers effective care at a low cost, meeting the two goals that President Obama stressed during his Inauguration address. But, Gawande acknowledges. “it has a tightly limited choice of clinicians—you can’t go to see any doctor you want, and the nearest facility may be far away from where you live.”
By contrast, “Medicare allows you to go to almost any private doctor or hospital you like, and has been enormously popular among its beneficiaries, but” as noted, “it costs about a third more per person and has had a hard time getting doctors and hospitals to improve quality and safety” As Obama describes the federal employees insurance , it sound least attractive: while it offers a range of subsidized private-insurance choices, “insurance companies have done even less than Medicare to contain costs and most have done little to improve health care (although there are some striking exceptions.)”
There is no question but what Americans value being able to choose their own doctor. Granted, many stay “within network” because co-pays are lower, but they might resist being limited to VA doctors . Though, in fact, VA medical centers are affiliated with medical schools, and are known for practicing cutting-edge “evidence-based medicine” based on what the newest medical research tells us about risks and benefits. When Merck finally was forced to withdraw Vioxx from the market, the VA, along with the Mayo Clinic and Kaiser already had stopped giving the potentially dangerous drug to most patients.
And while Medicare patients have a choice of doctors, doctors also have the choice not to take Medicare patients. Citing low fees, more and more doctors are shutting their doors to new Medicare patients. One wonders how many previously uninsured patients would be able to find a doctor who would take them under “Medicare for All.”
To my mind, effective care at a lower cost trumps everything else; opening the VA to all seems a superb idea. The VA would need addition funding and staff; but I think we would get a better bang for taxpayer dollar investing in the VA rather than in Medicare or private insurance. Nevertheless, many uninsured Americans do live too far away from a VA center, and so they would need other choices.
We might open all three alternatives to the public, letting Americans choose between the VA, a public-sector Medicare for all plan, and a menu of private insurance plans modeled on the federal workers’ program. Since the VA is the most efficient of the three (defining efficiency as better outcomes at lower costs) premiums for individuals who chose the VA would be lower. And the government subsidies for those who could not afford the premiums also would be lower—good news for taxpayers.
The VA system offers another example of how lower-cost care often is better care. The VA is more efficient, makes fewer errors, and does a better job of managing chronic diseases, in part because it has the VistA Electronic Health Record, a health IT system designed by the VA itself. Over at the Healthcare Blog, Scott Shreeve recently described VistA as by far the most successful” system when it come to achieving clinical transformation through the use of information technology, adding that the VA’s “should seriously be considered as a potential solution for government-based health care information technology.”
What We Can Learn From Massachusetts
Gawande ends his story by looking at reform in the state where he lives and works: Massachusetts. He applauds the state’s effort, noting that “surveys have found that at least two-thirds of the state’s residents support the reform.” Gawande cites just one major problem: “The Massachusetts plan didn’t do anything about medical costs . . . , and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance . . .” [Though the Swiss pay 10 percent of their income for healthcare before getting a government subsidy, proving that even in a relatively efficient system, medical care is not cheap. ] Gawande concludes: “The experience [in Massachusetts] has shown national policymakers that they will have to be serious about reducing costs.”
Massachusetts, like the rest of the country, also suffers from a serious shortage of primary care providers and family doctors. Loan-forgiveness programs that allow medical students who choose these specialties to graduate debt-free could go a long way toward solving the problem –but it will take years for these students to make it through the pipeline and into the marketplace. This is another reality to keep in mind: universal coverage will create demand, but it will not create supply.
Keep this in mind when someone tells you that “True reform requires transformation at a stroke.” Gawande reminds us that this is not the way healthcare reform has occurred in other countries. For those interested in “reality-based reform,” the truth about how health reform has come about elsewhere is, as Gawande says, “both surprising and instructive.”
Maggie:
Your usual stellar on-point work..A compelling discussion and major league food for thought, IMJ.
Talk about unrealized efficiencies of existing (and yes, in some respect under-utilized) infrastructure…
Yes, some investment will be required, but talk about return on investment!
Tweeted this today..
http://www.twitter.com/2healthguru
Great post Maggie,
Giving people options and the educational materials to weigh the options makes a lot of sense.
Having worked at a VA, I was impressed how quickly things changed when a visionary leader (Ken Kizer) took the helm. He created a safe environment for learning, and the electronic health record shows what can happen when reform is presented as an iterative journey rather than the need to get everything right the first time.
This post truly gives me hope. Thank you for all you do to gather and synthesize data into coherent posts.
Maggie says “To my mind, effective care at a lower cost trumps everything else; opening the VA to all seems a superb idea”
Gawande or Mahar don’t talk enough here about the economic tsunami that David Walker and Peter Orszag predict?? Or did I miss it?
But I agree it is a helluva start and the premise that unique events drive the shape of our unique form of health care reform is a good realistic one
It’t tough for me too, Maggie, to give up my idealized dream for a perfect system
Dr. Rick Lippin
Southampton,Pa
there is no perfect system… yet, the false choice of single payor vs. universal coverage, over simplifies the health reform debate.
why not take existing infrastructure and tweak in such a way to leverage its “constituent ingredient value”? a blending of the Medicare for all model, with the VA health care system backbone and creating a floor for basic benefit plan design as the starting point for insurance coverage, not to mention pricing benchmarks, would be an enormous and positive step forward, on the road to health reform.
We have so much redundant and dormant capacity coupled with a mal-distribution of assets (both institutional and people), not to mention wide variations of medical practice patterns, that to not think in terms of such a master inventory before a reform overlay, is a missed opportunity, imj.
Maybe I am taking this proposal too literally, but does anyone else think it’s dis-respectful to throw the “un-insured” in with folks who risked their lives for our country?
Veterans have earned their coverage by serving their country. I think that you don’t have to look very far for less favorable opinions about VA care, but that is another matter.
I might accept a similar system for the uninsured, but I reject the idea of mixing Veteran’s in with the uninsured because I think it diminishes what they sacrificed to earn that care.
As a VA physician (and computer scientist) I must express a cautionary note about considering the VA’s current computerized medical record as a paragon of design. It does have a number of advantages, the chief being integration: the remote data feature (when it’s working) allows me to view records from VAs across the country. The system is also a good deal more reliable than it used to be, and there is very little downtime or lost work these days.
However: the system is slow (trying loading all 1500 progress notes from a lengthy chart — time to go out for coffee), the user interface is littered with infelicities (template windows pop up and lock out access to the rest of the chart), and it generally mimics an old paper chart rather than using any kind of sophisticated database to structure the information. Gems of useful data are hidden in the plethora of excessive charting (mostly by nursing). Searching is very primitive (exact text strings only, no wild cards or fuzzy matching). It’s very hard to compare sets of medications to reconcile outpatient and inpatient meds. While it is a huge improvement over what existed before, which as has already been noted is mostly due to Ken Kizer, and I have no quibble with the fact that the VA is meeting or exceeding many quality measures, the current system cannot be said to occupy any kind of vanguard position in informatics by virtue of its current properties. I hope this will change, but there’s good reason to believe that the current system will be the future system for years to come. Somehow that message gets lost in the Pollyanna-ish accolades that I see so often.
The VA system currently excludes millions of veterans (including myself) from coverage because (1) we do not have a service connected disability and (2) we make too much money. I agree with GingerB that non-veterans should not be included in the VA system until all veterans are whether they have alternative medical coverage or not.
While integrated healthcare is better able to control costs than the more widespread fragmented model, Kaiser, for one, has not been able to replicate its model in very many places. A Kaiser executive told me a few months ago that it tried contracting with doctors and hospitals elsewhere, but it didn’t work. It would be enormously expensive to build the infrastructure, including hospitals, to expand Kaiser to other markets and too many people seem to reject the limited range of choices that a staff model HMO implies.
I also agree with Dr. Gawande that it makes more sense to build on what we have which is employer based insurance plus Medicare and Medicaid. The individual market is broken except for the young and healthy while we need to find a way to cover the uninsured. The tax preference currently afforded to employer provided health insurance is an accident of history related to efforts to get around World War II era wage and price controls, and we are still paying for those government produced unintended consequences over six decades later.
Large employers are good natural pools and the administrative costs for large self-funded plans are quite low – in the mid to high single digits as a percentage of the total spend. If we could find a way to cover the currently uninsured and those who become uninsured when they lose their job or retire before the age of Medicare eligibility, that would bring peace of mind to everyone who feels locked into a job because of health insurance. To drive costs down or at least bend the medical cost growth curve, we need payment reform including episode pricing for expensive surgical procedures, and payments based on evidence based medicine, comparative effectiveness and cost-effectiveness. Electronic medical records and sensible tort reform would also be helpful. Subsidies to purchase health insurance should be based on the Swiss premise that paying 10% of income for health insurance is reasonable for the middle class and above.
Gawande used a top down model of looking at healthcare building without looking at building from the foundations up.
So what is already present to some degree at the foundations of primary care, preventive care, public healthcare and patient participative care?
Community health centers, office-based physician practices, ambulatory clinics – hospital and commercial-based, public health agencies, home care agencies, and occupational and school health services.
The scope of services provided by providers at these venues practice disease surveillance, containment and prevention, perform well screening and health teaching, provide basic diagnostic testing and treatment for acute and chronic illnesses, injuries and diseases, practice healthcare coordination and case management, and provide chronic disease management and end of life care.
The also use professional nurses more fully as patient case managers and health educators/coordinators, and so can maximize the effectiveness of primary care physicians and mid-level providers to focus on diagnosis and direct treatment.
Instead of deciding at this juncture, to adopt the VA or a hybrid government/private model of providing tertiary care which is high tech, high complexity and high cost, why not focus on building and strengthening the foundation so that rationing isn’t practiced at the front end.
And for Gawande to conclude that the MA plan is working because his patients don’t complain is absurdity in action. Of COURSE his patients don’t complain. They’ve already jumped through multiple hurdles to see the good doctor in his specialty practice on his tertiary care referral center campus. it’s the mobs of those who can’t even find a primary care provider and who now have used all of their discretionary income paying for a worthless insurance policy instead of using the money to pay for actual health – you know – CARE.
Yikes! I forgot to state the rationale for using a foundation first model:
Provides care in the most local manner, so increases care accessibility
Provides care to the most people
Is lower tech
Is lower cost per patient encounter
maximizes the role of professional nurses (baccalaureate educated with community health didactic and clinical exposure)
Prevents morbidity and mortality leading to higher hospitalization rates and usage
Is congruent with emergency preparedness initiatives and goals around pandemic flu and other large scale health emergencies
Improves ability to study populations for critical health indicators (epidemiology more accurate)
Improves provider satisfaction with being able to maintain therapeutic relationships
Can liaise with schools of medicine, nursing, public health and allied health to improve bench to bedside research application, increase the number of students in health professions programs, address provider shortages and improve care
Gregg, Ken, Ginger, Barry,Steve, Dr.Rick, Barry and Annie
Thanks for your comments.
Gregg– thanks for the kind words. Yes, I think the VA infrastructure (Health IT, data-base that they use to practice evidence-based medicine–
could serve as the foundation for good public-sector healthcare for many Americans.
Ken– Yes, Kizer did a marvelous job of transforming the VA in the 1990s–and he did it with relatively little money.
After 2000, the Bush administration began starving the beast-the VA and some in Congress fought hard for funding but they still are underfunded. But I’m quite certain that this will change under the Obama administration.
Gregg– You wrote: “have so much redundant and dormant capacity coupled with a mal-distribution of assets (both institutional and people), not to mention wide variations of medical practice patterns, that to not think in terms of such a master inventory before a reform overlay, is a missed opportunity, imj. ”
I agree–if some of the excess capacity of MRI units etc. in regions where we over-treat could be redistributed that would be good for everyone.
Ginger G–
There’s nothing wrong with the uninsured. It’s true that many are poor and many are black or Latino. But many veterans are poor and many are black or Latino.
One good thing about the modern U.S. army is that it has done a pretty good job of fighting racial prejudice. . .
(Also many uninsured Americans are self-employed and just cannot afford to pay $13,000 (average family premium) without help from an employer. )
So I’m not sure how we are “diminishing” Vets by “mixing them in with the uninsured.”
But I do think we would have to make sure that we provided the full funding and staffing needed so that Vets wouldn’t find themselves waiting in long lines.
We might begin by opening the VA system to uninsured
and self-emplooyed people ages 55-65 since the VA already treats many people in that age group (veterans of Vietnam) and it set up to handle that population.
Steve–
I’m well aware that the VA system is far from perfect. You’re right, VistA can be exaspeating–I’ve visited a vA hospital where doctors showed me the problems– long notes, ec.
That’s why I’m not sure it would be worth trying to adapt VistA for use in the private sector.
But, like you, these VA doctors also find the system very useful.
And if you talk to docs outside the VA using other systems–many of them are at least as disgruntled.
Some hospitals and medical have simply thrown out systems after spending millions on them.
Health IT experts tell me that you don’t hear the worst stories becaues a)
doctors and hopsitals hate to admit, publicly, that they have wasted milllions on something that didn’t work out and b)the health IT industry doesn’t want the word to get out.
So you only hear the success stories.
I’m also told that VistA could be improved; and their is an argument for really investing in it, and turning it into The Health IT system for all government healthcare.
(The Bush administration brought in a private contractor to do Health IT for the Defense dept. and that turned out to be a disaster. We’ve written about it here on HealthBeat . . .)
I’d love to see the Obama administration spending some of the money it plans to spend on Health IT to improve VistA, rather than starting from scratch . . .
It would be hard (though not impossible) to adapt the VA’s Health IT for the private sector, but it works well within its own closed system. So if we expanded that closed system so that a) Vets no longer had long waits for appts. and b) uninsured and self-employed Americans could be included, we wouldn’t have to invest billions in a new
Health IT system for that group.
If the VA were opened up to, say, uninsured and self-employed people 55-65, they might well bring federal dollars needed to improve VistA now. Otherwise, you’re right, given the economy, it won’t happen for a long time.
In the meantime, the fact that “the VA meets or exceeds quality measures in many areas” ,despite less than optimal IT, is impressive. As you know most of American healthcare does not meet or exceed those standards–even when it is much more expensive than the VA.
Dr. Rick– I didn’t mention the meltdown because at this point, I take it as a given. We are heading into a deep, long recession that could resemble the 1930s (Great Depression).
I fully expect 10% unemployment.
I expect the stock market to continue to fall– probably won’t hit bottom until sometime in 2010. And then, it’s anybody’s guess when it will begin to grow again.
We could be in for a long period (like 1974-1982) when it was almost impossible to make money in the S&P 500 (In the late 1980s, Business Week ran a cover story saying that no one is buying stocks anymore–just “old fogies.”
We have so much debt-it’s going to be very hard to get this economy up and running again.
That’s why we have to make sure that we invest in healthcare in a way that is going to give us the biggest bang for our buck.
Barry– If your illness is not related to your military service and you earn over a certain amount,
you’re right, you’re not covered. (Since you are a money manager, I imagine you earn much more than the average veteran.
Here is the question: should a single mother living in poverty stand behind you in line–when you can easily afford health insurance?
In an ideal world you and she would both be covered. But given the eocnomic situtiona, I would say taxpayers should pay for her first..
Moreover, it is not clear to me that taxpapyers should pay the medical bills for 40 years for someone who served in the military for a few years–unless he or she was wounded. That’s a huge amount of money–especially if the ex-soldier is well off.
If you were earning median income, or were suffering from a war injury, that would be another story . .
As for Kaiser, I don’t know where you get your information (hearsay, apparently)- . .
Kaiser operates successfully in 8 states plus D.C. (Denver, Ohio, Georgia, Oregon & Washington, Hawii, among others. . .)
It’s true that it had to close its operation in Texas where a very conservative medical culture fought hard to push it out–and it didn’t succeed in the Northeast where solo-practioners and patients accustomed to solo-practioners rejected the model.
It’s worth noting that for decades, the same conservative medical cutlure fought hard to close down the Mayo Clinic.
Many doctors don’t like the idea of doctors working together cooperatively, on sslary.
Meanwhile, the Northeast (from Masschusetts south) is generally considered to be the least efficient part of the country when it comes to healthcare– much higher costs, outcomes generally poorer than in other regions; much less collaboration and less evidence-based care.
The academic medical centers in this region do some great reserach, and of course there are always individual doctors who are excellent, but on the whole, reserach, rather than patient care, is the focus here. At least this is what doctors at academic medical centers in this area tell me.
Annie–
I think probably you should read teh article itslef (see link in post) rather than just my quotes.
“Community health centers, office-based physician practices, ambulatory clinics – hospital and commercial-based, public health agencies, home care agencies, and occupational and school health services.”
are akk fine — in particular, I’m all in favor of community clinics. The VA
has clinics. It also has nurses.
But Gawande is talking about the larger over-arching structure of an INTEGRATED delivery system.
One major problem with our health care system is that it is so fragmented. Office-based physician practices of 1 to 5 physicians are an impractical model in most cities because the overhead is too high. Look at rents, the cost of utilities and the cost of labor.
Meanwhile, in order to make a go of it, too many of those small practices are buying their own diagnostic equipment–creating redundances and over-treatment that we simply cannot afford.
Ambulatory care centers need to be intergrated into a system that includes hospitals and after-hours clinics. School programs and home health care need to be integrated.
The hodge podge that we have now means that one hand doesn’t know what the other is doing. Providers cannot look at patient records from the ambulatory center or the clinic or the hospital–which leads to waste, duplicate tests, and medication errors.
A doctor at a VA hospital can look at a patient’s record throughout the system. IF he moves, if he becomes sick while on vacation–everyone is looking at the same record.
This is major.
And this is why so many medical journal articles that compare outcomes at the the Va to outcomes in the private sector–for diabetics and patients suffering from many other conditions– find that the VA consistently outperforms the private sector–and does so at a lower cost.
My brother-in-law had a hearing problem for years. He had gone to hearing specialists here in Manhattan. He had seen various doctors and nurses; had his hearing tested, etc.
Finally, a couple of years ago, a PCP at the VA noticed his hearing problem and came up with a solution (I think it was an implant–I know he no longer wears a hearing aid.)
He can now hear very well; he’s a different person at parties and dinners.
This is merely an anecdote, but it fits with
what the medical journals say. Fully funded VA care is often excellent.
I wasn’t clear on my first two at bats, so let me try one more time:
I agree that as they are now, the infrastructure and services are mostly a hodgepodge. They certainly need to be integrated and systematized. However, I think that it’s imperative to fund at the local community level first as the highest priority. Every single person must have accessible and affordable primary/preventive/public and participative health services immediately.
No hospital, payer or inpatient system is going to be able to provide for that in the near future – even if we waved a magic wand over the VA or Medicare.
I think the most viable way to tackle this is by creating a national oversight system – Daschle’s Fed Board, perhaps, or CMS, or the VA oversight board – some body that’s able to provide oversight on a large scale.
Concomitantly, fund regions based on a formula of capitation, existing local primary care infrastructure, predicted usage of that infrastructure, predicted need of services and infrastructure and allow regional (to be defined) geographic areas allocate the funds.
This should bypass for-profit third party payers, and it should put dollars directly toward services, providers and healthcare settings.
The second phase would be to create more formal integrated healthcare systems by linking hospitals, skilled nursing facilities, rehabilitation centers, labs, diagnostic treatment centers, etc. within each region to assure that everyone has access to tertiary care, women’s health (I don’t recall that the VA performs deliveries and neonatal care – does it?), and specialized services.
But if the big fish are always skimming the food off the top, the little fish will never be funded and will always be starved of vital resources.
I’m advocating feeding the many schools of little fish first, getting them established, and then linking them up systematically with the big guys who serve as referral centers.
I think one of the problems is that when people are self-denying health care, they remain invisible, and the dire problems aren’t known. That’s when you find someone frozen to death in his home, for having the heat turned off.
We must stop thinking in terms of by cardiac surgery and dialysis and start thinking in terms of influenza prevention and blood pressure management when we discuss healthcare access and rationing.
Annie-
Thanks for your perseverane.
You write: “We must stop thinking in terms of cardiac surgery and dialysis and start thinking in terms of influenza prevention and blood pressure management when we discuss healthcare access and rationing.”
I agree absolutely. I think
we need a huge investment in public health, community clinics, etc.
Before she left the Senate, Hillary Clinton had put forward a very interseting bill that would have the governmetn really take over preventive services– a huge investment in public health.
I see this as a separate issue from National Health Reform simply because most of the people advocating for Natoinal Health Reform are thinking about acute care –not public heatlh.
It shouldn’t be that way, but it is.
Thus I would like to see someone pick up the ball from Hillary and put forward legislation that would begin to fund public health: community clinics open 18 hours a day, 7 days a week that could keep people out of ERs,
health care in schools (dentists, eye exams and opticians, nurses in the schools doing physical exame that would pick up on and report–kids who are being physically and sexually abused.
Free smoking cessation clinics and nicotine patches.
I could go on.
But these are not the things that most health care reformers are talking about. That’s why I think the “small fish” need a separate push, and separate legislation.
I think there are people in the Obama legislation that would pay attention.
“Here is the question: should a single mother living in poverty stand behind you in line–when you can easily afford health insurance?”
Of course not. I’m just not sure that the single mother would be served all that well by the VA system. I don’t know how much it would cost per member to expand the VA infrastructure to accommodate the currently uninsured either. It may well be more cost-effective to help them acquire conventional insurance while trying to enact payment reforms that could materially increase the cost-effectiveness of the rest of the system.
Regarding Kaiser, 8 states plus DC is not 50 states. Moreover, my understanding is that its reputation among its members is higher in Northern CA than in its other markets. Nationwide, the staff model HMO just hasn’t gained much traction even though it should be able to beat the fragmented rest of the system on both costs and cost-effectiveness. Rightly or wrongly, too many people just bristle at the inherent limitations on provider choice and won’t accept it if they don’t have to. Doctors, for the most part, haven’t exactly embraced it either.
I think we agree that every stakeholder group is going to have to give something up in order to achieve meaningful reform that expands coverage and improves value. I know that I’m willing to do my share as I’ve said numerous times. I haven’t seen much evidence yet that doctors and hospitals are willing to do theirs. I’ll be most interested to read what the members of your working group ultimately have to say about that.
Barry–
Thanks for your reply.
If you have time, do read “The Best Car Anywhere” about the VA. I suspect you would find it very interesting.
The VA definitely could offer quality care at a more affordable price than the private sector. (At the VA–Docs on salary– no fee-for service incentive to overtreat– formularies based on medical evidence in their own databases; no money wasted on hospital amenitites like waterfalls-
VA hospitals tend to be older, not glarmous, but many Vets like them.
There was talk of closing the VA hospital in New Hampshire that is very close to Dartmouth-and sending the Vets to the Dartmouth-Hitchock Medical Center– a much more attractive hopital (and also very good.)
The Vets did not want to go there.
Re: the fact that Kaiser is only in 8 states plus D.C.–not 50 states.
I can’t thnk of another health care system that
has done as well. Kaiser has been particularly successful in Denver and DC–and well as other lcoations..
But you are right–both patients and doctors in many parts of the U.S. resist the idea of healthcare based on medical research (evidence -based medicine–which is how Kaiser, the Mayo Clinic, and the VA try to “manage” care.
But I think you and I agree that we need evidence-based medicine.
We need to educate the public on this subject–and we need to train doctors differently.
The Working Group on Reform agrees that we definitely need to reform medical education. While talking about reforming our health care system, we continue to train doctors to work in an old, dysfunctional system.
The Working Group also is in agreement that large, multi-specialty groups where docs are on salary proivde the most efficient care (better outoomes And lower costs).
The key is that these are
organized, collaborative systems.
They are rarely found in the for-profit world. Typically they are non profit systems which, in many ways, operate like the VA.
I don’t understand why one would propose an underfunded hospital-based system to provide cost-effective care. Cost per person are highest in the VA system and although one could argue a high level of acuity, one must consider if it is proportionate.
There already exists a network o f federally funded/subsidized clinics in the ambulatory space that are generally efficient and associate with behavioral, dental and social services.
These community health centers (CHC) are distinguished from other non-profits by having a board consisting of community users. The disadvantage is that inexperienced boards can mitigate the effectiveness of CHCs, as has been the case in my recent experience. Although CHC’s have grown in importance during the Bush administration, capacity remains an important problem and given the poor quality of management I have seen, they may have difficulty recruiting anything but PHS and IMG candidates. Perhaps expanding to other non-profit health systems (not all) based on strict performance requirements may help.
The VA can only be part of the solution, but a public system of VA/CHC/service-oriented non-profits may do the trick.
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