Healthcare Efficiency

The VA is, was, or has been all of these.  (Continuing the reading of Phillip Longman’s book.)  One key distinction that Longman (PL) fails to make clearly is that the VA is a system.  It cares for a defined population, employs the providers, and owns the hospitals.  This vertical integration defines the VA and a few smaller systems in the US as well as national healthcare systems in some other countries.  It is thus unfair to compare the VA system with “fee for service Medicare patients.”  One certainly can compare VA hospitals, as isolated units, with other hospitals.  And, when you do so, the VA does really well.  They wrote the book on patient safety and have done well on many studies of quality in healthcare.  Be careful, tho, to look carefully at the measures of “quality.”  Make sure they are relevant to “healthcare”  (life expectancy is not) and to the setting being examined.  Compare hospitals to hospitals and primary care practice to primary care practice.  You can’t compare primary care in the VA to Medicare patients or to any other insurance company’s population.  

The VA also has low costs per patient--they have to.  Congress keeps cutting their budget.  That, of course, is the strongest argument against government control of healthcare--the money in the system is determined by political whim, not by need  or by how well a facility is managed.  There’s a reason why there are more MRI machines in Detroit than in all of Canada.    

PL mentions (chapter two) the NCQA.  A fine organization, but remember, they exist to advise employers on which HMO to select for their employees.  Their standards do not look at providers from the patient’s point of view.  Remember also that doing poorly on a given measure may not mean you do poorly on that measure.  It may mean you don’t have a good system to document how well you are doing.  It costs more to document that you gave an aspirin to the patient with chest pain than it does to give the aspirin.  

None of this should detract from the good job the VA is doing.  Their patients are older, sicker, smoke more, etc., etc., that the average US population, yet the VA does an excellent job taking care of them at a cost below that of any other HMO.  Surprising then that the Republican Congress severely limited access to the VA to the point of denying previously promised access.  One other fact not mentioned is that the VA bargains hard for drugs.  Congress will not allow Medicare to do that.  

All this good news may not continue.  Current veterans are getting older and sicker and fatter, and going to need more healthcare.  In addition, many Iraq war veterans are returning with injuries that would have killed them in prior wars.  Their needs for care will go on forever.  Congress seems disinclined to provide a budget for the VA that is related to the needs of their patients.  (No government ever does.)  So we’ll probably see care deteriorate, followed by news reports of poor care, followed by a flurry of activity pretending to address the problems.  Been to Walter Reed lately?