Saturday, August 1. 2009
Phillip Longman: The Best Care Anywhere. This is actually an article from 2005, back in the dark (Bush) ages when nobody even considered the possibility of trying to do something to reform our mess of a health care system, but it's worth taking another look at now. It's about how a government agency carved off a single-payer population and provided them with a health care system with virtually no private sector participation. Free from the influence of private interests, the government only had to balance costs and benefits off. The result is the best quality, lowest cost health care system in America. That's what the Veterans Administration did. Longman went on to expand this article into a book, Best Care Anywhere: Why VA Health Care Is Better Than Yours (paperback, 2007, Polipoint Press).
This came about basically because of two moves by Bill Clinton: in 1994 he appointed Kenneth W. Kizer VHA undersecretary of health, and in 1996 he signed a bill to expand eligibility to all veterans, not just combat casualties.
A lot of details follow on just how this works, but much of it shouldn't be surprising. Most problems are easier (less expensive and more successful) to deal with when you catch them early, which became a focus. And health care is a team activity, so having one set of common electronic records both eliminates extra work and errors and lets everyone work on the same plan. They also took a look at evidence, identifying problems and checking what worked and what didn't. This is almost common sense when you're trying to provide quality health care, but it isn't always followed in the private health care system, where there's an overriding concern for profits.
Doctors write their orders into the electronic records system, and nurses check off every time they administer a drug or procedure. The system, by checking the patient ID and the drug/procedure, has virtually eliminated routine mistakes.
Of course, you don't automatically get superior health care by turning it over to the government. It also takes management skill, professional dedication, adequate funding, enough time to review cases and refine and improve methods. You could duplicate many of these methods with private health care providers, especially if you can develop a portable system of records and a system of reviews and accountability that can be shared everywhere. You also need to do as much as you can to isolate medical decisions from the profit machinations that inevitably come with private sector companies. (No one denies that profits are powerful motivators, but nothing is clearer than the fact that optimal health outcomes and optimal profit outcomes have nothing in common.) Public financing of as much shared infrastructure as possible would help -- indeed, would be essential -- with private providers. Open source software is one key element here: it makes adoption practically free, while keeping all of the technology transparent so it can be critiqued and improved by users all over the world. Freely published academic research is another. A single-payer insurance system would also help to push best practices throughout a private provider system.
Lots of lessons here, but the most important one is that the pursuit of best practices and quality outcomes also works best as a cost containment system. In fact, it's the only cost containment methodology that doesn't sacrifice quality. Moreover, by focusing on quality first, we have an answer to everyone worried more that reform will diminish quality, as well as an answer to the bean counters.
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