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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:

reliance on va care.gif

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:

percentofcare.jpg

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:

outside_insurance.jpg

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.

Update: A reader with firsthand knowledge of this incident sent the following article from the LA Times. He/she has asked not to be identified and I'm holding on to the comment until I have explicit permission to publish it. As I noted in the comments section, the problem is the Byzantine layers of bureaucracy needed to administer such a large system:

Twice, the patient told doctors at the West Los Angeles Veterans Affairs Medical Center that he did not want to be a guinea pig. But they went ahead anyway, keeping him on an operating table with an electrophysiology probe inserted in his heart for an extra 45 minutes to collect research data.

Another patient, a veteran so disturbed by mental illness that he was hiding bullets in his hospital room, also had his heart catheterization treatment prolonged for research purposes, though he did not give his legally required permission either.

Then there was Robert Hanson, a stocky World War II veteran who dropped dead of a heart attack in the hospital parking lot after taking an experimental heart drug. Hanson signed consent forms agreeing to be in a study of the drug, but some caregivers and his daughter insist the 71-year-old did not realize he was forgoing standard therapy to be in an experiment, with all the uncertainty and risk that implies.

These cases, involving a top cardiologist at the hospital, are among the most dramatic informed consent problems documented in recent years. Even now, nearly four years later, this conflict of morality and medicine continues to plague cardiology researchers at the nation's largest VA health care facility.

Hard to think of a more ringing endorsement for "the VA model", isn't it?

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

My mother-in-law works at a VA hospital. My husband used to volunteer there (I also did a short volunteer stint at the same hospital). My husband is a veteran, but he won't touch VA. Honestly he'd rather die at home than go there for care, because at least at home somebody would clean up his filth.

Posted by: Wacky Hermit at September 7, 2009 02:38 PM

Kinda like beating a dead horse to those who know the system. Same complaints as others--needed meds not in fomulary. long wait for appointments.
A major gripe is the near impossibility of getting an answer over the phone. My facility was West Palm Beach, 100 miles from home. If you were lucky enough to get thru to the switchboard you would be transferred to the appropriate department. Then the phone would be answered by machine, and you would never hear back, it would just ring and never be answered and my favorite, the gum't civilian employee would simply lift the receiver and hang up, leaving you to start over. It was simply easier to drive the 200 mi round trip.They would do the hang up trick right in front of you. No shame.

Posted by: Brad C at September 7, 2009 02:50 PM

That's precisely what drove me outside the military medical system, Brad.

I paid out of my own pocket for a civilian doctor for my sons. When I wanted an appointment, I could only call between 7 and 8 am and the line was ALWAYS busy.

I never got a post-partum checkup after the birth of our second child and never saw an ob-gyn until I was nearly 5 months pregnant. Navigating the system was so frustrating that I routinely ended up in tears, or on the phone with the hospital ombudsman (not that this did any good).

With my second pregnancy, I never saw the same doctor twice. They told me - literally - that my baby was at high risk or that I was in danger every single month and then lost my tests :p

I'd call to find out where they were and no one knew. They never made it to my medical jacket.

The in-patient care was excellent, but my prenatal care was the worst I've ever experienced. Thank God I'd already had a baby and knew to do some reading on my own.

Posted by: Cassandra at September 7, 2009 02:59 PM

I think it is worth adding to this discussion that the concern over shortage of doctors for care is manifesting itself all over the active duty / dependents health care system. I'm a vet myself married to an active duty officer. We've lived in three 4 different military locations in the past 10 years: Fort Bragg N.C., Washington D.C./Pentagon, Tampa, FL, and San Diego CA (twice). During that time I have received the bulk of my and my kids care OUTSIDE of the military system. I have even had 2 babies in civilian hospitals. At first that was my choice because I was tired of the AD bureaucracy when I got out and so I chose Tricare Standard which allows you to use civilian doctors but pay co-pays and deductibles. But for my our past 2 tours (Tampa and now San Diego) we are actually under the TRICARE Prime system, but REQUIRED to receive all of our basic care (and in Tampa our specialty care as well!) at civilian doctors. Why? Hard to know all the reasons, but the short answer is shortage of doctors. Now some of the blame for this goes to the wars overseas and the pressures they have put on the medical system. But I think it is a cautionary tale for those who think that a completely gov't run system would work. Right now the gov't has a fall back position -- pay the bills through TRICARE and have the families get their care at civilian doctors. But a completely gov't controlled system won't have that fall back. One final thing that often isn't talked about. At our civilian pediatrician in Tampa there were almost always signs posted on the wall about how TRICARE patients could not receive various vaccines at that doctor and would have to either pay out of pocket or go to the health dept. because TRICARE lagged so far behind the actual costs of the vaccines that the health group would have lost money on every vaccine administered. Eventually TRICARE would get around to raising it's payments and the notices would come down, but then a few months later they'd be up again. Once again, the problem was a slow-acting bureaucracy that did not respond to cost changes in the market well. At one point the pediatrician was no longer accepting new TRICARE patients because this payment problem extended to other care as well. Doctors of the future will not be able to run practices if they are losing money on every single piece of care they provide....

Posted by: kbed at September 7, 2009 03:03 PM

The medical care that I received at the VA for epilepsy (service connected, 0%) was excellent. Gifted doctors, superb staff. Horrible bureaucracy kept trying to keep me from getting that care. For some things the VA is just great (if you have the patience to wait.) For others, it's probably better than the Indian Health Service, but not by much.


The thing from the VA that would probably help the country most would be to adopt their (open source?) medical records system.


Using it as an example of how good a public option would be ... shows complete ignorance of TriCare and the woes that it's handed people. I would use the VA as a provider of last resort; both because I think that there are other vets who need their help even more than I, and I can currently afford other care. (Although that pre-existing epilepsy makes things expensive.)

Posted by: htom at September 7, 2009 03:16 PM

Agree with the commenters with VA experience. I'm medically retired and dealt with the Army and Tricare for 20 years and the VA for 5. It's nutty. The people are great. I have no problems with the quality of care I get. However, the bureaucracy is insane. Everything takes four times as long and has 18 more steps than it should. While you're trying to accomplish whatever it is, your paperwork will be lost twice and something will be mis-entered in the computer 3 times.

Last week I saw a new doctor for a routine checkup. He looked at my (disfigured) face and asked "So, did they figure out what caused that?" I was dumbfounded. I was seriously injured in Iraq and have had 20 some-odd reconstructive surgeries. This is the ONLY reason I go to the VA. That's not written down anywhere in my records?

"Well, I'm sure it's in there, I just hadn't seen that part."

Yup, I sure want to put this system in charge of ALL healthcare....

Posted by: Mike at September 7, 2009 03:33 PM

Oh, when I say the people are great, I should qualify that. Medical staff has always been good. Civilian clerks, administration, assistants, etc. is very hit or miss. Some are great and really want to help make it work. However, some are clearly there for the gov't paycheck and benefits and don't seem to like to bothered by actual patients.

Trying to accomplish anything on the phone, even get a reponse, is by far the worst.

Posted by: Mike at September 7, 2009 03:39 PM

I worked as a veteran's advocate for sixteen years. I've lost track of the nightmare scenarios about the VA.

Ask any veteran who has suffered through the VA system and you'll find out the truth of just how good it is.

My bottom line is this simple: My wife and I have agreed that it would be far better to let me die rather than putting me in a VA hospital.

Posted by: Bill at September 7, 2009 03:43 PM

I had a mixed experience with the military medical system.

Sometimes the care was great. Other times, it was either nonexistent or lagged light years beyond the civilian world.

I have severe migraines. My case had to go before a medical board before they would approve me for a daily medication and triptans. This is ridiculous: at the point where you're losing 20-25 days of your life every month to chronic pain, I don't think it takes a "board" to confirm the doctor's judgment that your current regimen isn't working. Oh, and I'd tried literally every major medication available at the time.

When I got Blue Cross, I was able to see a neurologist for the first time. He got my headaches under control in a week. This was after 10 years of suffering and giving the military "another chance".

I paid out of pocket for my children to see civilian doctors but I tried to use the benefits my husband was promised when he signed up. As I've said before, the difference (both in quality and quantity of care) was stunning.

I literally had no idea what I was missing - my boys had never had a major illness, so their civilian care was limited to routine checkups and the odd strep throat or earache office visit.

Posted by: Cassandra at September 7, 2009 03:47 PM

Klein also ignores two other problems with VA care:

1 The inordinate amount of time it takes to be approved for VA care - often requiring the services of a lawyer for the 2-4 year appellate process;

2 The lack of uniformity of quality of care throughout the system. VA hospitals in the vicinity of first class medical schools have a supply of very able young doctors (like Steve White and Leishman) who are completing their residencies. Generally, they are supervised and monitored or mentored by the medical school faculties and their care is excellent. VA hospitals without proximity to such medical schools are often left with career VA docs and volunteers from the local medical community. This results in spotty care at best.

Posted by: vnjagvet at September 7, 2009 05:05 PM

Klein is insane. Anyone who wants to implement the VA system nationwide is insane. I work for VA on the benefits side, and in my capacity I review dozens of veterans' VA treatment records every week. I've a got a small bird's eye view, so to speak, on VA care. My concerns about instituting VA-style care nation-wide are twofold. 1) Your choices, particularly with respect to medication, are limited by policies which the individual provider has little ability, and less incentive, to fight, and 2) The idea that the centralized electronic medical records system used by VA might be implemented nation-wide is simply frightening.

One poster already mentioned the formulary issue. VA formulary is limited, and you will not get certain medications which are widely prescribed on the outside. Now most vets can, and do, go private where this is an issue. This will not be possible when the faceless bureaucrats are making decisions for the entire country. And there are strict conditions placed on the prescription of certain medications, particularly narcotic pain meds. If you have a chronic pain issue, your prescription is contingent upon 1) signing a contract stipulating that you will not obtain pain medication from any other source, and 2) periodic drug testing. This is to ensure you are not doctor-shopping, and are taking the meds rather than selling them. They do not, however, restrict their testing just to opoids, and if you turn up positive for, say, cannibinoids, you face being cut off. For those of you liberal types who think your personal choices will remain personal in a VA-style universal plan, think again.

But what really frightens me is the potential for establishing a national electronic medical records database similar to VA's CAPRI system. A certain former Speaker of the House thinks this is wonderfully innovative and should be implemented nation-wide. Really? Do you really want every intimate detail of your medical history stored on a central server somewhere where you have no control over who has access to it? Where a faceless GS nothing like me checking for evidence on your claim for a right knee condition gets to know everything about you from your penile implant to your alcoholism? Did you know that medical professionals are not always professional, and sometimes leave little notes in the file which may affect impressions, and by extension, future decisions made for you by other doctors? Now, if you and your doctor disagree, you move on. In a centralized records system, you can never really walk away.

And did you know that medical record-sharing is already permitted between Federal agencies? VA does not need a HIPAA consent form from you to obtain your Social Security records. What are the implications for your medical privacy when there is a massive central electronic database potentially accessible to all Federal agencies? Is it conceivable that one day your treatment records may even be available to Federal law enforcement entities? VA is already required to report vets with incompetency determinations to the NICS so that their 2nd Amendment rights can be revoked. What could happen if you come up positive on your afore-mentioned drug test?

Think this is just a paranoid fantasy? I've been around the bureaucracy long enough to know that there is no good policy that cannot be slowly and methodically subverted. Politicians answer to voters. Bureaucrats, not so much. That's why politicians move their agendas forward through attaching arcane amendments to popular bills which change key wording in the laws which govern the bureacratic processes. Once you establish a national electronic medical records database, you simply cannot defend your privacy against the relentless encroachment of government do-gooders. No, VA care is not the route we need to take. No government-driven system is. We need tort reform and insurance deregulation. Do not give this government any more power.

Posted by: debbie at September 7, 2009 05:30 PM

If you really want to see government medical care, try going to one of the hospitals of the IHS, Indian Health service. I've seen exactly one article on their problems since the health care debate started...

And don't visit a hospital or clinic that the tribe runs or subsidizes with casino money, but some of the other, more isolated ones that only get into the news when the tribe has a riot after someone dying.

Posted by: Nancy Reyes at September 7, 2009 05:58 PM

Would you guys please come out of your shells!

Posted by: RIslander at September 7, 2009 06:27 PM

(When I was advocating the use of the VA's medical record system, I did not mean to advocate a national health care database, just a common language and coding for conditions and treatments, so that it would be possible for one health care payer to understand -- without translation -- other health care payer's records; I've seen several times when we changed that things didn't get translated correctly.)

Posted by: htom at September 7, 2009 06:48 PM

I know, RIslander, they seem to have a hard time with sharing.

heh.

IAMC, MAMC, GLWAH, names that will live in infamy.

We had BC/BS...I loved it.

Posted by: Cricket at September 7, 2009 06:54 PM

I've got to be honest, with the exception of a few very junior admin types, military and civilian, I and the family have never had a problem. As for the admin types, those problems were resolved before I jumped over the counters.

Posted by: RIslander at September 7, 2009 07:21 PM

My two exposures to VA medicine:

In February 1973 I went to the VA hospital in Augusta, Georgia. After that day long visit in hell I vowed never to darken the door of a VA facility again. So far I have kept that vow.

Today I have employees who are retired Army and Navy. A simple follow-up visit with a doctor at VA means a day off work. I asked why and was told "we spend a long time sitting around."

Posted by: GLT at September 7, 2009 07:32 PM

I am a military dependent with 2 small children. One of my children was referred to a specialist for a minor problem. After a couple of weeks without receiving any paperwork about the referral I contacted the pediatricians office. My child could not receive a referral because according to the computer database she was not enrolled in Tricare for the area in which we had moved a few months prior. I had a copy of the paperwork showing that yes indeed we had properly enrolled my child. I visited the pediatric clinic, the Tricare office, the DEERS office and still it could not be resolved. I called Tricare, my husband visited all the offices and still no luck. We continued this round robin for a couple of weeks. The pediatric clinic told me it was a known computer glitch but they had the IT people 'working on it.' I spoke to the Tricare patient advocate and we tried faxing the proper paperwork to Tricare. Still no luck. After 12 weeks her status was properly updated and her referral finally came through. This referral was for a minor problem that had actually cleared up by the time her referral went through. I didn't dare cancel the referral though as I was concerned that if she needed an urgent referral we would have to start the whole process over again.
I agree that anyone who puts forth the VA or Tricare as a shiny example on which to build a national health care system should have to experience it for themselves before they force it on others.

Posted by: BunnyMomRocks at September 7, 2009 08:32 PM

Just my $0.05 on the VA, Tri (to get) Care and Military Medicine. First, remember they call it "PRACTICING" for a reason.

I wound up in a VA facility in Roanoke, VA because my civ doc said I could get my scripts filled for free....well, not quite, plus I wasted days seeing their docs to validate what my civilian doc had written up and provided xrays for. *sigh*

Tricare, last time on active duty was OK, except that they were slow to pay - so slow in fact that my bills (for the bride) went to collection and I was hounded for a short while till I called my congresscritter. Still was getting tricare crap nearly a year after tour.

Active duty medical for full timers used to be OK. Can't comment about now, but I was doing my 2 weeks in VA and needed some care. I had to enroll in tricare to get looked at and a flight physical was out of the question. I thought about it and then....

I took my Cigna medical card into town and got what I needed in a couple of hours, to include a USNR doctor's autograph. Amazing. Just amazing.

In 2002, I had to go in for some surgery - really serious surgery - at U of Miami/Jackson Memorial Hospital. It's right across the street from the VA Med Center, so there is a lot of cross pollination of Drs. My lead surgeon had privileges at the VA hospital and he wanted to know why I came to UM/JMH. I told him my civilian doc sent me there, He said I was lucky because the VA would have just sent me home to die. It really was that serious, but I recovered thanks to some great docs and nurses in Miami. It's no fun having a Priest stand over you and give you last rites as you are laying on a stainless steel table with IVs in both arms. BTDT.

TTFN. Long tour is percolating. Back to the CoE!!!

KP

Posted by: Kbob in Katy at September 7, 2009 10:56 PM

My dad retired before Tricare, I guess. My parents always took us to the doctors on base, even when we were stateside. Only issue I recall is the OB/GYN my mom saw when she was pregnant with my youngest sister wanted her to have extra tests down to make sure the baby was okay, but my mom declined because it didn't matter what the tests said, she wasn't terminating the pregnancy. Then, after said sister was born, when she was still a newborn, one of the doctors was convinced she had some dread illness (don't recall what) and she had to get all kinds of tests (that required lots of poking), and never found anything, and my sister is fine....

Dad doesn't use VA. He has medical through his teaching job, and that's what they've been using. He should probably check into VA to cover his hearing problems (which he's in denial about) and get a hearing aid, but so far he hasn't done that, either, even though it could be service related (though proving that, 18 years after retirement might be difficult).

Posted by: Miss Ladybug at September 7, 2009 11:15 PM

I would not assume Klein is arguing in good faith - in fact, I cannot assume that of anyone on the left today. I used to do so, but they have run through several times the normal amount of trust I would extend to anyone. Liars, cheats, thieves, and that's just for warmup.

Now wait for the Micah Wright/Jesse MacBeth "veterans" to show up and call us names. You know the guys, they served in the Eleventy-Twelfth Marine Ranger SEAL Squadron Brigade and were really in the shit, man. Can't talk about much because it's all, like, still totally classified.

But those guys all love the VA and think everyone should have it. Plus, they'll point out that everyone on Medicare loves that, too. And for a clincher, the US is the only industrialized nation that doesn't give everyone free cradle to grave medical care. Oh, and as for rationing, the free market does that already: case in point, flying cars. No flying cars. Call that fair?

Posted by: Steve Skubinna at September 7, 2009 11:59 PM

Thanks. I have been hearing so much praise for the VA system that I was starting to doubt myself.



My father was a 100% disabled WWII vet. The closest VA facility was, and is, 70 miles away. He avoided going unless he was very, very ill. I think that facility contributed to his fear of doctors when he got in his 70's.



He got into rough shape because he was blind, had osteoporosis so bad that his chin had worn a hole in his chest. My brother took him up to the VA over his objections. They admitted him and the next day he was dead. They said that he was disruptive and pulled his IV lines out and that contributed to his death. They were never clear about the cause of death. They put complication from COPD but I have my doubts. I suspect that he pulled his IV's at the bag end which allowed him to basically bleed out through the tubes.



But I was in Germany at the time and didn't push it.



Now I am retired military and have a small hearing disability. After about a year of fighting with them I finally got hearing aids. The problem with them is, I can't stand them.



Now I'm waiting for my next hearing exam and I'm hoping to get the kind of HA that I want. But I called for an appointment in June and now I have one, in September.



If it weren't for the fact that my medical insurance doesn't cover hearing aids I wouldn't go anywhere near the place.

Posted by: John Dunshee at September 8, 2009 03:06 AM

Pardon my ignorance, and that is exactly what it is, but I am retired military, and since getting out, I have been in a VA hospital exactly once. My youngest daughter is still on Tricare. She goes to any doctor who accepts the program, and that seems to be most.

All my children were born in civilian hospitals. At the time of her birth, we nearly lost the youngest, but things turned out quite well. As for Walter Reed, the vast majority of soldiers going through it have nothing but praise for their treatment and the medical staff. As for myself, I am, admittedly, not the best patient in the world. I have, because I wanted to "keep up with the boys," been released from the hospital after having been treated for some injuries, and back in the same hospital in less than two weeks with major injuries. Again, aside from having a bird Colonel MD reaming me out about my intellectual capabilities, had great treatment.

This, believe me, is not an endorsement for national health of any type - I am totally against it - but somewhere along the way, I missed the horror stories about medical coverage for the active duty and retired military.

Posted by: RIslander at September 8, 2009 11:45 AM

My youngest daughter is still on Tricare. She goes to any doctor who accepts the program, and that seems to be most.

That may well depend on where you live, RIslander.

Many doctors here in the DC area don't accept Tricare. Just last month Congress heard testimony about this problem:

Sgt. Maj. of the Army Kenneth O. Preston and the top NCOs from other services appeared before the House Armed Services Military Personnel Subcommittee to share the successes and problems of military family support programs.

Preston said military families are experiencing problems finding TRICARE providers off installations, especially in more rural areas.

"One of the major accessibility challenges to getting quality medical care is finding sufficient health-care providers outside our military installations who accept TRICARE payment," Preston said.

TRICARE brings together health-care resources of the military and civilian medical professionals, Preston said. It serves active, Guard, and Reserve members, retirees, families, survivors and certain former spouses worldwide.

The limited number of health-care providers who accept the plan is a result of negative past experiences with the program, Preston said.

"Many of them were left with a bad taste in their mouth from dealing with TRICARE before because of the length of time it took to get reimbursement," Preston explained.

One health-care provider he spoke with accepts TRICARE patients out of charity to help the military, Preston said.

http://www.army.mil/-news/2009/07/23/24823-sma-calls-for-review-of-tricare-standards/

I have been astounded at how many former military doctors who now have civilian practices won't take TRICARE. When asked why not (and I always do ask) they say the same thing: the slow reimbursement and lower compensation rates cause so many problems for them that it's not worth it.

Posted by: Cassandra at September 8, 2009 12:06 PM

We are facing a TRICARE issue now. I got a referral for physical therapy to a facility in our area that accepts TRICARE. So far, so good.

Dr.'s name (he was a past CO of the facility in here in GA) is known at the PT facility. Dr. also takes TRICARE. TRICARE approved therapy through their 'point of service' option, which means we had to pay out of pocket. The kicker is, they had paid this facility in full during the first three weeks prior to the renewal, and the Engineer was on active duty at the time.

We are STILL going the rounds with this after FIVE YEARS.

Posted by: Cricket at September 8, 2009 01:48 PM

Nice post.........

Posted by: Los Angeles Colonoscopy at September 17, 2009 07:00 AM

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