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Health Policy

Veterans Administration Wait Lists — What Can We Learn from This?

Brian L. Grant MD

This editorial from the Seattle Times by Roger Stark raises a number of issues worth discussing. The recent controversy about the VA has been long in the making. It is about culture and corruption. But it also allows us an opportunity to look more closely at the fundamentals of the VA, ask tough questions and perhaps make some basic changes.

There is a lack of understanding about the VA and people tend to mix up and confuse issues. And the reverential manner with which it is spoken by most elected officials makes it difficult to have meaningful conversations.

My time in the VA is quite dated, going back to several rotations as a resident physician in the 70’s and 80’s. Back then I was struck by a number of observations:

  • Most admissions and patients were there for conditions that had nothing to do with military service. And a number of them were receiving permanent pensions because their conditions were identified in the course of service. Chronic Schizophrenia comes to mind. We now know that this is a biologic condition, not environmental, coincidentally becoming symptomatic in late adolescence and early adulthood when individuals may be in military service. If one lasted long enough in service, an early discharge and a lifetime of benefits would result, though the disease would have developed irrespective of service. Other medical admissions were often older Veterans with the usual maladies of age and lifestyle that one encounters in any hospital, such as heart and lung diseases, often flowing from lifestyle issues like tobacco use and diet.
  •  These hospitals were large institutions, often in the same vicinity as other facilities and clinics that offer excellent care options.
  • The staff were of high quality and some, like the Seattle VA, were teaching institutions affiliated with an excellent medical school, and helped train medical students and residents. They cared about their patients.

Setting aside the current controversy, we should ask several questions about the VA and where it should fit in the US Healthcare system:

  • What is the social contract between the VA and Veterans? Who should it serve and why? What is the distinction between those injured in the course of duty and those not? Should those who have served but have no injuries from their service be entitled to free health care via the VA system?
  • Does the current VA disability system work and when should an injury translate into economic benefits vs. treatment for the condition?
  •  What are the moral hazard and political implications of tying an injury to compensation? How does compensation muddy diagnoses like PTSD and traumatic brain injury?
  •  Assuming care is owed or committed, is a free-standing government run system the best way to accomplish this? What are the alternatives?

Readers of this blog know that the current healthcare system is not defended in terms of its economics. It is expensive and costs inflate far in excess of other countries with quality systems or the overall US economy. And there are inherent problems in a system where doing and procedures are rewarded while prevention and thinking is not. Furthermore the system is one where the patient is generally ignorant and disengaged on costs and treatment options and believes or acts as if the details and cost of care is an entitlement owed to them by their employer or government. This trend may be changing as cost sharing via copays and deductibles is growing under many policies. Most of us spend more time shopping for a TV set than a medical procedure or hospitalization that will cost 20-50 times as much or more, because with the TV and other personal expenditures, our interests lie in getting the best value for price.

Once we decide which Veterans to serve, could this not be better accomplished without a massive VA treatment bureaucracy? We have perfectly workable if imperfect government payment schemes including Medicare that can easily be ported to the VA and allow eligible Veterans to receive care from the facilities of their choice in the community.

Centers of excellence providing care for conditions unique to combat could be formed in partnership with high quality medical schools and research institutions for conditions such as amputations and combat-related PTSD.

Current VA resources and staff could be re-deployed into the private sector, where shortages exist presently and where demand would increase with Veterans entering the same system.

Is the current system inherently flawed and rather than focusing on current corruption, are bigger questions needing to be asked and answered?

Are Doctor Ratings Misleading?

Have you ever read their on-line ratings before you’ve gone to see a new physician? It seems like a logical thing to do — after all, you’re trusting a stranger to make decisions about your health that are quiet likely to be life-affecting. That is, after all, why you are going to see them in the first place.

Yet just how useful or accurate are on-line ratings? This Atlantic Monthly article explores the question, pointing out some obvious dilemmas: reviewers are often influenced by secondary considerations such as easy access to parking or their waiting room experience, and there’s no guarantee that the reviewer was even seen by the physician being reviewed.

To top it all off, there is evidence that satisfied patients are not the best cared for or healthiest. A March 2012 study in the Archives of Internal Medicine showed that patients with the highest satisfaction scores were more likely to be taking prescription medications, visit doctors’ offices, and enter the hospital. They were also likelier to be in poor health and die in the ensuing years. Read more…

Why Can’t Doctors Identify Killers?

by Brian L. Grant MD

As a forensic psychiatrist, I find myself as pained as the rest of society when a mass murder takes place. But like Dr. Friedman notes in this article,  I am also aware that efforts to accurately identify and intervene with, in advance of a tragedy, those individuals who are going to commit such acts is impossible. For every person who commits such acts, there are many more with similar personality and mental health issues who would find such acts unthinkable, just as there are those who kill and maim with no obvious mental health impairments. One can’t confine those with a psychiatric diagnosis without casting a net that would include millions of productive individuals who pose no harm. A kinder and gentler society that focuses on empathy and kindness might make a difference in some cases, but by no means all. The most attentive parenting and caring communities may still fall short when it comes to troubled individuals with distorted senses of reality.

In the absence of the ability to meaningfully predict and intervene before troubled individuals act out, whether they have a psychiatric diagnosis or not, we may wish to look to and study those places where violent deaths are far fewer and consider the differences in place. Are these differences those of demographics, politics, economics, values, or perhaps access to firearms? We make many tradeoffs as a society to achieve certain results and goals. Considering and studying these choices in an open and objective manner may be of great value to all.

What Childhood Asthma Treatment Rates Can Tell Us About Healthcare Reform

As this New York Times opinion piece notes, cost-sharing (e.g. co-payments and deductibles) is used to decrease health spending. Cost-sharing may be effective  in prompting people to think twice before seeking medical care or when selecting among options, but is it helping us reach the end goal of reducing the overall spend in the long run?

Treatment rates for childhood asthma are a particularly useful indicator, as having asthma inherently requires medical care, and preventive care is more effective and cost-efficient than treating someone during an attack. In other words, having to pay a large co-pay or deductible may discourage necessary treatment which only prolongs problems and makes them more expensive and more difficult to treat. A study just released in JAMA (Journal of the American Medical Association) Pediatrics indicates that poor families who have private insurance with higher cost-sharing are more likely to skip recommended care than those with lower cost-sharing or Medicaid. As the piece opinions:

In the United States, we have adopted a system where those who use the most care pay the most out of pocket. That may seem “fair” in some way, but cost-sharing isn’t about fairness. It’s about reducing health care spending without negatively affecting health outcomes. It should be a scalpel. We’re using it like a club.

Read more…

Will Transparency in Cost Help Force Competition?

Washington State lawmakers are hoping so – during the recent legislative session, they approved new transparency rules by January 2016. The belief is that transparency will force providers to be more competitive – cutting unnecessary spending such as ordering diagnostic tests which aren’t needed, or prescribing name brand drugs when generics work as effectively.

Washington’s largest insurance providers initially fought the proposal, objecting to disclosing their negotiated prices. So the database will contain only costs from Medicaid and insurance covering state employees, though supporters hope it eventually will be expanded. The Everett Clinic, north of Seattle, has so far posted prices for imaging services with the on-line encouragement for patients to call and ask for information on other services as well. Read more…

The Cost of Overseeing the Business of Medicine

Overseeing the business of medicine is big business. Per capita annual spending in the U.S. on health care administration is $606, more than double that of France, which has the next highest rate among industrialized nations.

The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor. Administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. Read more…

Spotting Medicare Fraud

Medicare insures 49 million Americans a year, at a cost of about $604 billion annually – and spent another $1.5 billion fighting health-care fraud last year. But a loose system of investigators can’t reliably spot suspicious billing.

Medicare made public the details of $77 billion in payments to doctors, labs, ambulance companies, and other medical providers in an effort to increase transparency and get the public’s help identifying improper payments.Within days of the document dump, Bloomberg News, the New York Times, USA Today, and ProPublica, among others, did just that, uncovering tens of millions of dollars’ worth of questionable billing practices, as well as payments to doctors whose checkered records the federal government may not have been aware of. Read more…

Sixteen years into the vaccination/autism myth

In 1998 Andrew Wakefield published a paper claiming a link between the measles-mumps-rubella (MMR) vaccination and autism – reporting on a total of eight children who developed symptoms of autism within a month of receiving the vaccine.

In the past sixteen years there have been multiple studies – at least 14 worldwide – and books published debunking the paper, which was initially rejected by four of the six reviewers who were asked to judge it. And yet the myth continues to have tragic effects worldwide as more deaths are reported from outbreaks of preventable these diseases here in the United States and abroad. Why? In part thanks to celebrities like Jenny McCarthy, actress, Playboy centerfold, co-host of The View, and since 2005 anti-vaccine activist. Read more…

Choices Being Limited Under Some New Health Care Plans

Since the Affordable Care Act created marketplaces for private health plans last fall, insurers expecting to lure customers with low premiums have fashioned smaller networks of medical providers.

By cutting out expensive hospitals and negotiating favorable rates with doctors in exchange for sending more patients their way, insurers can keep premiums down. In one instance, Blue Shield’s new network includes 43 hospitals in Los Angeles County, about 64 percent of what its standard coverage offers. Read more…

Tracking Patient Data to Reduce Emergency Room Visit Frequency – and Cost

As the Affordable Care Act expands Medicaid to a greater number of patients, the need for states to keep emergency room costs in check will become more pressing.

In a trial program in Washington State, ERs are now required to upload information on patients they’ve treated into a new database.  This allows other ER doctors and providers to research incoming patients, making a big impact on cost savings, with doctors now able to track patients whose situations would be better served by far less expensive office visits.

Patients with multiple visits (those who went to the ER more than four times a year) — suggesting they are using the ER in lieu of visiting primary case visits — made up a fifth of all ER visits paid for by Medicaid.

Data released on March 20 shows that ER visits by Medicaid patients fell 10 percent in the 2013 fiscal year, and the rate of ER visits that resulted in a non-acute diagnosis decreased by more than 14 percent. Database use is credited for a substantial amount of the state’s $33.7 million reduction in 2013 Medicaid costs. Read more…