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September 07, 2009
Note to Ezra Klein: "It's the Bureaucracy, Stupid"
Via Glenn Reynolds, Ezra Klein seems to think he has schooled Bruce McQuain on the problems with the military health care system. Klein, in a rather peevish post entitled "The Smackdown that Wasn't", snarks:
Bruce McQuain writes:
Dale and I once interviewed Ezra Klein about health care on our podcast. Klein held the VA system up as a shining example of good government health care. Of course that was before the shameful condition of Walter Reed had been discovered.Walter Reed is an army hospital, not a veteran's hospital. The two systems have nothing to do with one another. That's why the problems at Walter Reed led to the resignation of the Secretary of the Army and not the Secretary of Veterans Affairs.
Klein's drive-by "analysis" blithely ignores Bruce's point, which was not (as it was inaccurately summarized) that the VA and the Army hospital system are one and the same. The idea that McQ, a Vietnam vet and long-time patron of both the Army and the VA systems, thinks they're under the same management is unsupported nonsense of the first order. But hey - it's always so much easier to knock down a straw man than to refute a point that requires more than casual sniping. A careful reading of Bruce's post might have prevented Klein from making an ass of himself:
Klein held the VA system up as a shining example of good government health care. Of course that was before the shameful condition of Walter Reed had been discovered. Since then other problems (for instance, contaminated colonoscopy equipment in various locations) have been discovered.A commenter once asked “if VA is good enough for our veterans, why isn’t it good enough for us.” My answer was “it isn’t good enough for our veterans, it is instead what they’re stuck with.”
Today brings another example of the problems this sort of medicine is bound to have. It is a bureaucratic nightmare, even at the relatively small size of VA.
In other words, the VA (a relatively small government health program which serves a small, well defined population) is not a terribly good proxy for a nationwide single payer health system that would have to provide universal health care to everyone. Bruce's point, which Klein missed entirely in his haste to commence chest thumping, is that if two much smaller government health care programs (the VA and Army medical system) are riddled with inefficiency, waste, and bureaucratic bungling, what on earth makes Klein think a system many times larger is a good idea? Since I'm piling on, there's a reason military families call TRICARE, "Try to get care". To paraphrase the last president who tried to foist national health care on the American public, "It's the Bureaucracy, Stupid".
The type of medical mistake in the article Bruce linked to is not limited to government health care. But then that wasn't the point. The point was that government oversight failed - utterly and repeatedly:
That as they say, was the tip of the iceberg. No one reported the problem because there was no peer review. And, this was one of many mistakes made by this doctor that apparently no one knew about:Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records.
The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show.
Six years and no one had a clue. In fact, if you read the article in full, as you should, you’ll see that the discovery of this was essentially an accident.
The Internet makes people lazy. They don't bother to read posts carefully, nor do they read the supporting links in their entirety. We've all been guilty of doing that. I've done it on occasion. And when that was pointed out to me, I acknowledged it. Is Klein big enough to do that?
What Klein and many others who commented on these posts also don't consider is an inconvenient little fact that blows his suggestion that the VA is an appropriate example for how national single payer might work right out of the water. Sometimes, a picture really is worth a thousand words:
What does this chart tell us?
Well for one thing, no single class of VA eligible veterans receives most of their health care through the VA. In other words, the bulk of their health care needs are met outside the VA system. As you can see from the following chart, which broadly summarizes data reported here, the VA is NOT the primary health care delivery system for most vets:
Note that vets who have the ability to go outside the system (middle and high income vets and vets with no service related disability) go somewhere else to get care 75% of the time. Do you think there might be a reason for that? Here is the distribution of non-VA health plans by VA Priority class:
This critical fact was echoed in a 2008 report on the quality of VA health care:
Nearly 80 percent of enrolled veterans have access to other health care coverage, and data from VHA indicate that most enrollees with other coverage rely on VHA for only part of their medical care. Veterans are particularly likely to turn to VHA for outpatient care and for certain services—such as mental health and substance abuse counseling—on which VHA has put particular emphasis and for which many veterans may not have private coverage. Most enrollees rely on other providers for emergency services and inpatient hospital care. Enrollees may choose one provider over another for various reasons, including travel time, out-of-pocket costs, and perceived quality of care for a particular type of service.
Also, care is not free to all comers:
VA provides treatment for service-connected conditions free of charge to all enrolled veterans. Veterans in the highest priority groups generally do not pay inpatient or outpatient copayments even for care unrelated to their service. Copayments for outpatient services for veterans in the lower priority groups are $15 for a primary care visit or $50 for a visit to a specialist. The copayment for inpatient services for the first 90 days of care during a 365-day period is $992 and $496 for each additional 90 days of care during a 365-day period. The per diem charge for inpatient services is $10. Those copayment rates may be reduced by 80 percent for veterans with income and/or net worth below HUD’s geographic index.Copayments for medications are waived for veterans with very low income and those with SCD ratings of 50 percent or higher. Those copayments are also waived for veterans in priority groups 2 through 6 after they reach an annual cap of $960. Veterans in priority group 6 pay copayments only for services that are not related to their exposures or experience. Veterans in the lowest priority groups—7 and 8—pay copayments for all care that is not related to a service-connected condition. Even under the various circumstances in which copayments are waived, a veteran’s third-party insurer may be billed for treatment for conditions unrelated to his or her service.
Finally (and perhaps most importantly) there is the issue of wait times and customer satisfaction. On wait times, though single payer proponents just LOVE to tout the VA's patient satisfaction rates as "proof" of the high quality of VA care, studies that compare the actual quality of care received by patients to their perceived satisfaction found no correlation between the two measures:
Patients' ratings of their medical care do not substitute for evaluations of the technical quality of that care, according to a study issued today by researchers from the RAND Corporation, UCLA and the U.S. Department of Veterans Affairs Healthcare System.The study is the first to compare patients' own reports about the quality of their medical care with a comprehensive evaluation of their medical records.
Researchers studying vulnerable older patients found that while patients on average rated the quality of their medical care a 9 on a 10-point scale, comprehensive reviews of their medical records found they received recommended care just 55 percent of the time.
“Patients' ratings of health care are easy to obtain and report, but our findings suggest they do not accurately measure the technical quality of medical care,” said Dr. John T. Chang, a UCLA physician and lead author of the study. “If we want to understand the technical quality of health care, then we need to look at medical records.”
On wait times, several sources have reported that somewhere between 96 and 98 percent of vets receive a VA appointment within 30 days of their desired appointment date. But the VA's own interim report states that this data is unreliable and undercounts unsatisfactory wait times:
VA also tracks measures of access to care, particularly, waiting times for appointments or procedures. VA reported that, in 2006, 96 percent of all veterans seeking primary medical care and 95 percent of all veterans seeking specialty care were seen within 30 days of their desired dates.15 However, according to a 2005 report by the VA Inspector General (IG), the department’s data on waiting times were not accurate, and, in fact, many fewer patients were receiving appointments within the 30-day window than the figures cited by the department in its official reports.16 In September 2007, in a follow-up audit, the VA IG found that established procedures were still not being followed and that, as a result, data on waiting times could not be relied upon.
So, despite the fact that:
* Ezra Klein has exactly zero experience navigating the bureaucracy at the VA or trying to get care there;
*the VA isn't the primary health care provider for the vast majority of vets
* it isn't free of charge for many vets
* patient satisfaction and wait time data cannot be relied upon
Despite his lack of personal experience dealing with government health care and not knowing much about the VA, Ezra Klein can confidently assert that a far larger system that would be the primary provider for far more patients than the VA has ever had to treat will work just as well as the VA!
And anyone who dares suggest otherwise is just plain stupid.
Posted by Cassandra at September 7, 2009 08:41 AM
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Comments
Klein is a foolhard.
One of my "check off the blocks" items for retirement was to report to the VA clinic at Ft. Dix, and, after a 15-minute discussion, I determined that the sole function of this operation is to provide veterans with a strip map and directions to the VA hospital in Philadelphia.
I had *that* figured out within a minute, but it took an additional fourteen minutes of discussion to get the guy to reach into his file cabinet and actually produce the map. And that episode was the *high* point of my off-and-on jousting with the VA.
Most vets consider the VA a more insidious enemy than any we faced on the battlefield...
Posted by: BillT at September 7, 2009 12:02 PM
Well, you might find these links useful as to the political shenanigans which go on in VA hospitals.
http://theeprovocateur.blogspot.com/2009/09/clout-scandal-at-pittsburgh-va.html
http://theeprovocateur.blogspot.com/2009/09/clout-scandal-at-pittsburgh-va.html
These links detail a story about how a congressman from North Carolina pulled strings to get an incompetent doctor back on the payroll at the Pittsburg PA VA facility. Single payer means institutionalizing government graft.
Posted by: Dantes at September 7, 2009 01:27 PM
I'm a physician and trained in three different VA hospitals in my career. I like the vets -- good people. I liked a number of the staff -- they were trying.
Hated the system. Hated the bureaucracy. Hated the fact that just about every administrator there had a reason why the ordinary things that we did at the university hospital couldn't be done at the VA.
I've only dealt with TRICARE and the military hospitals indirectly but I have no reason to think they're any different from the VA experience.
If the VA system is the "public option", no thanks.
Posted by: Steve White at September 7, 2009 01:30 PM
Spent several weeks at a VA while in medical school. My favorite anecdote: Nice old vet had a biopsy. Mid-afternoon he and his family were waiting for the results. I went down to the lab, spoke with the pathologist who had the slides on his bench but hadn't looked at them yet, and he was packing up his things up to leave for the day. I asked him if he would just look at the slides, since the family was waiting on tenterhooks. The pathologist looked at me and said, "Well, if it's cancer today it will be cancer tomorrow." And with that, he left.
Posted by: leishman at September 7, 2009 01:46 PM
I'm a VA patient and am quite satisfied with the care I receive from my healthcare provider. She is thorough and caring.
for specialists, I go outside of the system because the wait time for an appointment with a specialist is usually a month or more.
The Va formulary leaves much to be desired. My specialsts have prescribed Coreg CR, Atacand, and Nexium. None of these are available from the VA, probably because of the cost. The VA will prescribe similar, cheaper drugs but that is not what my Docs want. I have also needed Levequin and other high powered antibiotics. These are not in the VA formulary.
I fear that any new government controlled system, will ration who can get these drugs and may make similar cost decisions.
Gary Ikens
Posted by: Gary Ikens at September 7, 2009 02:01 PM
When I was in medical school, one of my classmates was a veteran and carried a "Blue Card" because he had been seen in a VA clinic for some minor problem.
It was common to check for a VA card at the emergency room of the private hospitals in town and ship any vets to the VA for "care."
After one week on service at the VA hospital, he cut up the card so that would not happen to him if he were to be found unconscious somewhere.
Posted by: Dr. Jimmy at September 7, 2009 02:13 PM
I grew up with Navy health care (and have also used Army when we were at certain duty stations). I was born in a Naval hospital and my youngest boy was born in one too.
As a military child and now the wife of a career active duty officer, I've been around the VA all my life. Military folks stay in touch as our friends get out, so even when we're not using the VA, we know many folks who are. So I completely agree about many of the staff working the VA hospitals - they are good people.
It's not so much the people - they are generally professional and caring. But the bureaucracy makes it really hard to fix problems. My brother in law is career Navy medical. He works long hours and is extremely dedicated.
I was remiss in my post for not saying that my problem isn't with the staff at the VA or at military medical facilities. It's with the over arching system that makes it a struggle for them to provide quality care. When I was growing up, the staff routinely found ways for my Dad to get around the system when it didn't provide the basic standard of care. When your staff spend a considerable amount of time trying to circumvent the system, that's a HUGE sign that something is amiss :p
Like Gary, I couldn't get Imitrex even though I had severe migraines and was ending up in the emergency room at least once a month (this after 3 days of solid throwing up, and only when I got dehydrated b/c I couldn't keep liquids down). In 50 years, my Navy medical jacket is the size of someone who has only been using Navy medical for about 5 years.
As soon as I got the chance, I bailed and started using Blue Cross/BS. It's amazing and I'll never go back voluntarily.
Posted by: Cassandra at September 7, 2009 02:13 PM
I am also a VA outpatient (in PHX AZ) and quite satisfied with my treatment. From scheduling to prescriptions, quality of the staff, etc.
Do I think they could scale up to serve the whole US? No way.
Posted by: Joelo A at September 7, 2009 02:13 PM
My father lives in North Dakota. He had a spot on his lung. He was 88 years and was supposed to get on a bus and go down to Fargo, ND (about 200 miles away) to a strange clinic that he had never been to for a CT scan. (He has the beginning of Alzheimer's or age-related dementia). Then they would bring him back to Bismarck on the bus and if anything further needed to be done, he would have to go back down to Fargo again where he had no support system whatsoever. Bismarck has two of the best hospitals in the upper midwest and we were supposed to take him to Fargo. I told them NO...he was going to be seen by someone in Bismarck. They would have to take this under advisement and have someone from the VA make a decision on this. After I called the VA in Fargo, this was approved after we had the testing done in Bismarck where they found cancer and part of his lung was removed; only done at his age because he has the body of a 60-year-old. This was all taken care of before he was even scheduled to be down in Fargo. VA also keeps the elderly on oral diabetes meds when they should be on insulin. They also didn't want to pay for Lantus. What happens to those people who don't have someone to speak up for them?
Posted by: Peeved at September 7, 2009 02:22 PM
I quit my job with UPS in 2006, losing my company insurance and finally, eleven years after I retired, had to sign up with TriCare. My physician of 11 years did not take TriCare and I was forced to find a new doctor.
I sign up with a doctor on the TriCare list of local physicians; three times.
Every time I went to see him TriCare informed me that I hadn't designated a physician and assigned me to some unknown doctor in Dallas, 20 miles from my home.
This circus happen three times even though I'd designated a physician and the system initially accepted that physician until I went to see him. Then the system went back on the automatic selecting of the same unknown doctor in Dallas. Phone call after phone call finally resolved the issue.
Just in time to be dis-enrolled because TriCare incorrectly said I hadn’t paid my quarterly bill. This happened twice and I had to fax some minor bureaucrat a copy of the credit card record proving that I’d paid.
Incompetence is rampant and now we are facing the specter of a new provider replacing Humana. To say that military retirees dependent on TriCare are worried would be an understatement. To have won the contract the new provider had to underbid Humana. What will that mean for the beneficiaries??
Nothing good I suspect.
Posted by: RetiredE9 at September 7, 2009 02:25 PM