Atul Gawande Talks about Measurement, Accountability and the VA

“What we need is Not health insurance,” Dr, Atul Gawande declared at the Families USA conference in Washington D.C. earlier today. “What we need is health care.”

Gawande, who is the author of Complications: A Surgeon’s Notes On An Imperfect Science, went on to make the point that, “even if a person is on Medicare, that doesn’t mean that he is getting healthier.”

What is fundamentally flawed about our system, he added, is that no one is responsible for making sure that healthcare will be better next year than it is this year. “In 1996,”  he pointed  out, “Americans underwent some 60 million surgeries. In 2008, that number rose  to 100 million. Does that mean that Americans are healthier?” he asked. Or does it simply mean that we are paying for more unnecessary surgeries?  “No one knows,” said Gawande, “because we never measure how well our healthcare system is performing.

“We need a Federal Health Board,” Gawande observed, and it should be measuring our system every three months. “Are people in Springfield, Massachusetts getting healthier? We need to know so that
we can experiment and innovate” in an effort to improve the way we deliver care. If  we don’t  measure, we can’t know if we are making progress. 

Gawande argues that health care reform will be meaningful only if we develop a system that holds health care providers responsible for making care better, safer, and less costly. 

How do we make healthcare less expensive?  “The levers are ugly,” Gawande admitted when talking to a small group following his speech. “We can pay doctors and hospitals less; or we can get them to reduce waste”—i.e . eliminating some of those unnecessary surgeries.

“If someone had arthritis in their hip, we used to treat it with aspirin,” Gawande noted. “Now we do hip replacement surgery” that can cost tens of thousands of dollars.

Is the patient better off?  Recovery from hip replacement surgery is not easy. In some cases, probably a combination of aspirin and physical therapy might be a equally effective.  How often are these surgeries necessary? No one knows (.Though we do know that  when patients are given full information about the side-effects, risks and benefits of joint replacement, and a chance to share in the decision-making  processpatients decide against the elective procedure 20 percent to 30 percent of the time.)

This is why “we need a Federal Health Board”, says Gawande, “to hold us [hospitals and doctors] responsible for what we do. It doesn’t have to be a board structured like the Federal Reserve,” he adds. It could be the Secretary of Health and Human Services. Or it could be a National Institute of Health Delivery. However it is structured, we need someone measuring productivity in our health care system.

As I explained in an earlier post, we know that productivity in our healthcare system is very low because we over-use advanced medical technologies (a  category which includes cutting-edge drugs, devices, tests,, treatments and surgical procedures.) In other industries, advanced technologies usually improve productivity. But, too often, we use new and expensive medical technologies on a broad swathe of patients when only a few, who fit a very specific profile, actually benefit.  .

Errors also reduce productivity. And here, Gawande notes, something as simple as a checklist can reduce complications following surgery by as much as 30 percent. He pointed to a research done by the World Health Organization’s Safe Surgery Saves Lives program. Gawande is a member of the reserach group  and the study, which was published in the most recent issue of the New England Journal of Medicine , focused  at non-cardiac surgery in a diverse group of hospitals and revealed that when surgical teams used the 19-item checklist , mortalities fell from 1.5% to 0.8% while  inpatient complications dropped from 11.0% to 7.0%.

From now on the checklist will be used in a relatively small group of U.S. hospitals and surgeons that choose to use it .In the UK and Ireland, by contrast, the checklist will now be in every hospital,” Gawande observes.  The UK has a “health board”: the National Health Service sets guidelines. By contrast, our laissez faire health care system leaves every hospital and every doctor to practice medicine as they see fit.

In the  U.S., only well-organized integrated multi-specialty health care centers like Kaiser or the Mayo Clinic can move quickly to put a checklist in place, Gawande observes. When physicians work for Kaiser on salary, they follow its evidence- based rules.

Gawande points out that Kaiser became the first health care system in the world to reduce deaths from cardiac disease to a point that this disease is longer the #1 killer among its patients .  How did Kaiser do it? By instituting a system that guarantees  that every cardiac patient is offered the care or drugs that he needs. Checklists work.

At this point, I asked Gawande a question: “You point out that the VA practices evidence-based medicine and, as a result, achieves better outcomes than fee-for-service Medicare, while costing 30% less than Medicare. Yet, when people talking about setting up a public sector health care plan, they speak of creating “Medicare for All”.  Why not open up the VA to everyone?  We have good evidence that patients would be getting better care. The only downside,” I added, “is that patients would be confined to the VA network of doctors.  But is it really worth spending 30 percent more so that people are free to choose doctors and hospitals that don’t practice evidence-based medicine?”

Gawande agreed: the VA –for- all might well be an excellent idea. But how could it be implemented? For one, not everyone lives close to a VA hospital.

I suggested that a National Health Plan might make the VA one option, alongside “Medicare for All” and tightly regulated private insurance plans. Patients could choose whichever model they preferred. But since the VA can offer better care for less, the premiums, deductibles and co-pays under the VA system would be lower—encouraging patients to choose the VA model if it were convenient. Gawande, who has practiced medicine within the VA as well as in the private sector, liked the idea. “Most people don’t realize how successful the VA is,” the Harvard-trained surgeon observed.

“Giving people more choices is a good idea. Then we’ll have a chance to see which delivery system works best. When I was practicing in a VA hospital,” Gawande added,  I was performing surgeries in Boston and our catchman extended all the way to Northern Maine. Vets had a choice; they could go to a private hospital in Maine, or talk the bus all the way down to Boston. Many chose to take the bus.”  Vets know how good VA care can be. And, if the VA were fully funded—the way it was under the Clinton administration—and expanded to accommodate non-veterans, it might indeed be a very good public sector option.

If the insurance industry doesn’t persuade Congressional conservatives to block a public-section health care plan.  In my next post I will explain why Families USA Director Ron Pollack believes that, at this point, the biggest, and most intractable difference between the for-profit insurance industry and progressive reformers revolves around the question of whether private insurers should  be forced to compete with a public sector health plan.


20 thoughts on “Atul Gawande Talks about Measurement, Accountability and the VA

  1. This posting today from the NY Times Economix blog seems apropos:
    A More Rational Approach to Hospital Pricing
    By Uwe E. Reinhardt
    I didn’t comment, but pricing by the condition seems as broad brush as does pricing at the micro level as is done now.
    If we are going to have government determine the level of payment then why not just go all the way and make doctors salaried employees? This is one of the aspects of the VA system that doesn’t get talked about, but I think it accounts for a lot of its efficiencies.
    Doctors no longer have any conflict of interests, not the need to boost their income, not the need to cut care to boost the bottom line in an HMO situation nor the need to juggle care against what the patient (or their insurance) will pay.

  2. Robert–
    I agree: having doctors work on salary is good for everyone in many ways.
    Doctors are no longer forced to see as many patients as possible in a given hour — and they-re not being given financial incentives to “do” as much as possible– to those patients, just in order to keep the lights on.
    Patients are less likely to be exposed to all of the risks of overtreatment.
    But if those salaried doctors are working for the Mayo Clinic or Kaiser, both Medicare and private insurers have to decide how to pay them.
    At the moment,we haven’t yet entirely figured out how to “bundle” payments to doctors and hospital–and how they could/should divide the payments.
    So we are still likely to pay fee-for-servcie.
    But at the Mayo Clinic, doctors don’t know how much Medicare or insurers pay for their various services. (Thus there is no pressure on them to “sell” certain very lucrative services.) The back office deals with how much the Mayo Clinic is paid for varoius services and DRGS. The doctors just worry about what treatments the patient really needs.
    For the time being, this seems to me the perfect system. (See my blog on Mayo

  3. It is clear to me that, overall, physicians will be paid less as a group. Yet primary care physicians need to be paid more. So the only way to accomplish this is to reduce the high-end salaries to bring up the low-end ones. I despair of turf-conscious subspecialty societies ever accepting this, however.
    Most of us chose medicine because we like doing it. Likewise, most procedural subspecialists I know fundamentally chose what they do because they like it. So in a real sense the work is its own reward. If the work environment for physicians is improved substantially — the bureaucratic burdens that sometimes become overwhelming, the malpractice issues — I’m fully confident that we will find enough neurosurgeons or whatever who would be happy to be left alone to do what they do best for far less money than they get now. Within a decade or two, that would be come the culture, as it is in other countries.
    Some have said (on your blog, for example) that money is the only thing that will keep physicians from slacking off, so fee-for-service is the only fair system. I think that viewpoint is wrong. We can change physician culture to give other kinds of rewards, such as time. Frankly, I don’t want anyone operating on my brain or my heart who is substantially influenced by the fees.

  4. Maggie,
    I wonder how much excess capacity is in the VA system now, and how many patients could be accommodated if the VA system were opened up to non-veterans. Excess capacity, to the extent that it exists, probably varies enormously by geographic region.
    If the VA had to expand its network of hospitals to handle a significantly higher caseload, construction costs may well be higher than in the commercial world even if the facilities are less elaborate because of the need to comply with federal Davis-Bacon Act prevailing wage laws. I’m also curious as to the current salary scale for VA physicians, both primary care doctors and specialists. Is the pay high enough to attract enough new doctors to handle an increased caseload? If not, by how much would pay have to be increased, not just for the newcomers but for the existing staff as well? Nurses, which are also in short supply, might also have to be paid more. With 47 million uninsured people needing healthcare, we are probably not likely to see many healthcare professionals laid off from private sector hospitals who would then be available to staff an expanded VA system. The bottom line is that the VA’s supposed cost advantage may well be a lot less than it appears.
    As I understand it, HMO’s currently have about a 20% share of the employer based health insurance market. It’s not encouraging that Kaiser, Mayo and others have not been able to expand their market share and footprint beyond what they’ve had for years now. By and large, people don’t like HMO’s, though, in theory, if the price difference between HMO’s and PPO’s were high enough, more people might be expected to choose them. I have no idea how great that price difference would need to be to materially move market share.
    Finally, I wonder if and to what extent veterans’ perception of the VA system might change if it were opened to non-veterans. I was struck by your comment on an earlier post that vets didn’t want to go to Dartmouth-Hitchcock instead of the nearby VA hospital that they were used to going to. If VA hospitals were opened to non-veterans, veterans might (irrationally, I think) start to view them as just another hospital and not “their” hospital. It’s an intangible, cultural issue, but I think it’s something that policymakers should be mindful of.

  5. Our healthcare system is certainly in need of overhaul but I think we have to first attempt to answer a few critical questions in order to set a more realistic tone when mulling over the current swarm of healthcare reform proposals (I recently wrote a blog post about this).
    What is our goal exactly? Is it to reduce healthcare costs? Is it to improve quality of care? Is it to prolong life or increase quality of life? How do you measure quality anyway?
    I think answering the above questions requires a little soul searching and introspection for patients, policy experts, and healthcare providers.
    The realists are beginning to realize that there may be no perfect solution that can make everyone happy but for some, to quote Neil Peart, “the future does not have to contain any flaws until it becomes the present.”

  6. I don’t mind the idea that doctors should be salaried. However, we’ll need incentives for quality and productivity. Also something to finance some of the cost of medical school.
    Lastly, we need patent reform. When a single drug/year costs more than the average and median income in the U.S. and a single imaging study if over $5000/test it means drug and technology companies are taking advantage of the monopoly granted by government issued patents. We do need a Health Board or something like the British NICE committed. Patents could be managed with a market driven approach that shortens patent length if pricing is not reasonable (determined by the above health board).

  7. Sean Khozin wrote: “What is our goal exactly? Is it to reduce healthcare costs? Is it to improve quality of care? Is it to prolong life or increase quality of life? How do you measure quality anyway?”
    I also think you could add a few other options such as creating jobs and maybe re-distributing wealth!
    In a caveat emptor, market driven system of anything, individuals usually pay from their own funds to protect other people’s (pooled) funds from being usurped and wasted. Therefore, one might better re-phrase this above question to something like: “how in the world could such huge sums of pooled money get involved in paying for healthcare up to now without having first answers these questions?” In other words, what assumptions (false maybe) have already been incorporated (or overlooked) when forming our current system paradigm that allowed so much pooled funding to be wasted as bad as it seems to be currently wasted???
    What do most folks currently think are the answers to these above questions, and how accurate would these assumptions really be at this time to the knowledgeable folks around here????

  8. Chris–
    You wrote that if we are gong to raise the incomes of primary care physicians we care going to have to pay some very well compensated physicians less. There will be , as you say, great resistance to this.
    But you add: “I’m fully confident that we will find enough neurosurgeons or whatever who would be happy to be left alone to do what they do best for far less money than they get now. Within a decade or two, that would become the culture, as it is in other countries.”
    I think you are entirely right. Certainly, some people, who go into medicine with an eye on the money, would not go into medicine. That would be all to the good. There are a sufficient number of very bright, dedicated,hard-working young people in this country to fill those slots–and most likely, they would achieve the better outcomes that we see in countries where the highest paid doctors Don’t make $450,000–$1 milion..
    Paying our doctors so much more has not lead to better care So perhaps we should rethink how we attract doctors (more loan forgiveness and scholarships) and how we select them, probing values, looking for signs of professinalism, maturity, and a willingness to sacrifice.
    You continue:”Some have said (on your blog, for example) that money is the only thing that will keep physicians from slacking off, so fee-for-service is the only fair system. I think that viewpoint is wrong. We can change physician culture to give other kinds of rewards, such as time. Frankly, I don’t want anyone operating on my brain or my heart who is substantially influenced by the fees.”
    Chris, I agree completely. And like you, I have known many professionals (doctors, academics and even lawyers and law professors) who were Not working for the money. How much they made was not the primary motivator.
    Is should come as no surprise that they are usually the people at the top of their field–the most creative, and the most intelligent people who found the work its own reward.
    Friday, when I was interviewing Dr. Atul Gawande, a Harvard trained surgeon who practices at Brigman & Women’s, he mentioned that he would be perfectly happy to work at the VA– where, as you know, he would be on salary, at a much lower salary than he makes now.
    (He has worked at the VA in the past, and liked it.)
    Essentially, he enjoys performing surgery, caring for patients, and writing. As long as he can do what he does, he would be happy.
    Finally, I agree, I don’t want someone operating on me who is substantially influenced by the fees.
    I already answered your question about Kaiser expanding its footprint in other regions just a few days ago in another thread.
    I’m afraid someone gave you misinformation. Kaiser has expanded successfully into 18 states and D.C. All of Mayo’s outposts show better outcomes at a lower price than most American hospitals (See the most recent Dartmouth Atlas on Mayo)
    There is no excess capacity at the VA. Because President Bush decided to “starve the beast” the VA has been underfunded for much of the last 8 years– too little staff, long waiting lines. (Google testimony before Congress.)
    You are right that Vets like the culture of VA hospitals. But they didn’t want to go to Dartmouth Hitchcock because they saw it as a fancier hospital where they would be vying with wealthier patients for attention.
    They know that docs who work in VA hospitals care about them.
    I’m not at all sure that Vets would object to their hopsitals being opened to others–as long as their hospital is fully staffed and funded. This is very important.
    But if anything, if we opened VA hospitals to others, it’s likely that there would be more interest– in the media, and in Congress–about making sure that paitents in VA hospitals are getting what they need.
    Right now, vets are a sadly neglected group.
    At one time, nearly everyone in America knew someone who had been in the military (in WW II). But now, our “volunteer army” is drawn from a very small subset of society. In many regions of this country, few middle-class, upper-middle-class or upper-class Americans know anyone who served in Iraq the Gulf War, or, even in Vietnam.
    With all of the talk about government investment in neglected areas of our economy (infrastructure, schools) etc, I’ve been surpised by how little has been said about the Vets.
    Jenga– Actually, we now know that we are not going to increase average life expectancy by that much.
    It appears that mid-eighties will the average life expectancy. (See Christine Cassel’s book Medicare Matters–she’s a geriatriciian and Presidentof the American Board of Internal medicine.)
    What we can do is make those last 15 or 20 years better.
    In some cases that means hip replacement surgery; in other cases it does not.
    Your numbers on patient satisfiaction come from the people who make and sell the devices and suregeons who implant them (in some cases, taking kick-backs from device makers to use their hip implant.)
    If you look at shared-decision-making research you will find that IF dcotors give patients full information about risks and benefits of hip replacement 20% to 30% of patients will decide not to do it.
    If they don’t get full information, quite a few are surprised by how hard rehab can be. (Particuarly if you haven’t tried physical therapy first.)
    But once you’ve gone through the ordeal, the cost, the time, etc., you are probably not going to say “I wish I hadn’t done it.” People will do almost anything to avoid regret.
    In other countries, where medicine is not driven by profits, less invasive techniques (physical therapy and drugs) often produce equal patient satisfaction.
    Jenga– You add: “I want someone who is accessable, worried about their reputation and wants MORE patients, not LESS. A salaried physician would rather have less because the fewer patients they see, the less they have to work. There is absolutely no incentive to work in a new patient rather than tell someone to go to the ER, no incentive to return a phone call, no incentive to be on time and every incentive to spend 1 hour treating an ankle sprain or talking about the local football team for 45 minutes. You lose fee for service, you also lose customer service. They go hand in hand.”
    Jenga: I hope you are not a doctor–if you are, you can’t be very happy.
    Most doctors don’t think of their patients as “customers. They don’t return phone class, or work in a patient in need for the money.
    Chris: You write: “continual hustle to see more patients, something you offer as a good thing, easily translates into a propensity to do more things on those patients you do see, which is not necessarily a good thing. It is the principal engine driving our high costs.”
    I’m afrid that this is all true.
    Barry– You write: “Any restructuring of our healthcare system needs to be an American solution that reflects our culture and values even if it turns out to be somewhat more expensive”
    What values? When it comes to structuring a healthcare system, America’s “values” have been marked by inequality, greed, lack of respect for the patient . . .
    Despite many hard-working, well-intended doctors, nurses and other healthcare workers, they are working in what Don Berwick, head of the Institute of Healthcare Improvement rightly calls a “stupid system” — a system designed to serve the intersts of the healthcare industry rather than the interests of the patient.
    Many people have given a lot of thought to those questions, and have provided some very good answers.
    See Dr. Donald Berwick’s book, Escape Fire–for a very good start.
    People who have studied health care and health care delivery are in pretty wide agreement about our goals: We want to improve quality and reduce costs. In fact, the two go hand in hand. Healthcare in the U.S. is more expensive than in other advantaged countires–and not as effective (in terms of outcomes and patient satisfaction) because it is so wasteful.
    We perform a great many unncessary, ineffective and sometimes unproven tests, treatments and procedures, using over-priced sometims risky drugs and devices that have not been fully tested.
    There are more errors in our hospitals.
    It turns out that “more care” is not necessarily better care. And, the most expensive, aggressive, intensive care is not the best care.
    We know that higher quality and lower spending in a less profit-driven system is the goal. The debate is over how to get there.
    I agree about the need for patent reform–and a Health Board. But it will be very difficult to insulate it from Congress and lobbyists .
    NG– I don’t think that the goal of healthcare reform is to create jobs.
    In too many cases, the desire to create–or keep jobs– has caused us to build too many hospitals, to keep unsafe hospitals open, too hire too many people to make to many MRI units . . .
    All of this excess capacity has been bad for our health, leading to overtreatment which exposes patients to risk without benefit.
    It would be nice to create more jobs for primary care physicians, but few people want those jobs, not just because pay is relatively low, but because working conditions are so poor.
    So the supply just isn’t there–and won’t be until we redesign the system.
    How did we get the system we have? We “let the market decide.” And letting “the market” create our health care system gave us a system that stresses competition rather than collaboration, and profits over than patients.

  9. It somewhat puzzles me why there is so much talk on paying doctors less. Physicians collectively take home less than 10% of our healthcare dollars (after spending years in training and entering the workforce in their 30’s with $200,000 of debt). The bulk of the money is going somewhere else and, in a very well orchestrated move, special interests have managed to point fingers at the hard working physician, who is the only person you would want to have on your side when you’re in need of medical care.
    Our healthcare system is convoluted and fragmented by design. A great many are diverting billions their way behind the scenes holding up an old broken canvas where experts, academics, and the public paint their lofty visions for a better tomorrow. Although valid ideas do often emerge, we are in serious need for a band new canvas, a new paradigm that respects the doctor-patient relationship as the foundation of delivering effective care. Everything else is really just noise.

  10. I notice that a lot of providers are stressing the provider-patient relationship as the key to reform. Well in a continuation of my most recent thread, I think that if huge sums of pooled funds (public and private) are going to pay these providers and their related facilities, accountability for something hopefully socially (and maybe even healthwise) beneficial better be in the mix at a lot higher level than as of today and the past!

  11. “What values?”
    When I think about healthcare reform, I look at universal coverage as a given that just about everyone agrees we should have. I believe the overall system needs to be looked at in three pieces.
    The first is the healthcare delivery system that hospitals, doctors and other health professionals work in. The changes that I think are needed here include incentives for doctors to migrate from solo and small group practices to larger multi-specialty group practices or, at least, virtual group practices. We need interoperable electronic records so that medical information is available where and when it’s needed and so duplicate testing and adverse drug interactions, especially in hospitals, can be sharply reduced. Tort reform that would protect doctors and hospitals from lawsuits based on a failure to diagnose a disease or condition as long as national evidence based standards were followed is also an important component.
    The second piece is payment and coverage reform. We need to move away from fee for service payment which simply rewards resource utilization and not value. Episode pricing for expensive surgeries or a course of cancer treatment should be part of this. Capitation arrangements to manage the care of diabetics and others with chronic conditions would be another piece as would drug price negotiation coupled with limited and/or tiered formularies. Evidence based medicine, along with comparative effectiveness and cost-effectiveness research can help us to determine what we should and should not pay for. Patients who want services, tests or procedures that are not paid for would have to self-pay. Robust price and quality transparency tools would also be helpful.
    The final piece, which seems to be so divisive, is how to finance health insurance. The single payer advocates have their viewpoint while those (including myself) prefer choice and competition (with appropriate federal regulation and standardized benefit packages) and a strong role for private insurers. This is the part where values and culture come in. To me, its choice and competition vs. a monolithic one size fits all approach. Even with complete taxpayer financing, we can still have plenty of choice through the use of vouchers and risk adjustment payments.
    For the first two pieces, there will probably be lots of resistance from doctors, hospitals and, drug companies who fear lower income and/or profit, less freedom to practice as they see fit without any oversight, and more economic risk that would come with both capitation, episode pricing and limited drug formularies. Health insurance financing will be more of a liberal vs. conservative ideological battle. At the very least, every stakeholder group, especially doctors and hospitals, need to be challenged to articulate what they are prepared to give up to create the better, higher value for money system that we all say we want.

  12. Barry-
    I agree with much of waht you say–but it has little to do with the American values of American-style capitalism (individiualism, every many for himself, charge whatever the market will bear) that have formed the health care system that we have today.
    Finally, when you do write about American values you say: “This is the part where values and culture come in. To me, its choice and competition vs. a monolithic one size fits all approach.”
    You are right that traditional American values empahsize “choice and competion”.
    When it comes to healthcare, this means a tiered system where care is rationed based on income: Americans are free to chocse–indeed forced to choose–the level fo care that they can afford.
    As for competition–yes, competiton rules. Hospitals don’t want to s share infomation about techinques that save lives with other hospitals–and in the U.S. this is perfeclty legal. (It would not be in Europe). See my book on this point– a quote form Donald Berwick.
    U.S. drug-makers refuse to share resrach infromatoin with other U.S. drug-makers: they all claim the info they have on Alzheimer’s is properietary information.
    Some hospitals don’t want information IT that would open patient records to other hosptials–they want captive cusomters. (See my recent post on Irrational Exuberance over Healthcare IT)
    Cmmpetition is fine in certain areas of the economy. But when it comes to healthcare, we need collaboration –to save lives. There is no such thing (or should not be) as “proprietary” life-saving information.
    We have decades of experience showing that when it comes to healthcare, competition does not bring prices down (or improve quality).
    See Health Affairs: when there are more hospitals in a city prices for hospital care go up and outcomes are no better, often worse (Dartmouth Atlas)
    Ditto for more specailists.
    In most industires, the price of cutting edge technolgoy comes down over time as rivals entire the marketplace. Not so in healthcare.
    AS for one-size-fits all healthcare. Bary, have you ever been to France, Germany, Denmark, Sweden, Canda . . and received healthcare there? Do you have famly members receiving healthcare there?
    Or are you merely repeating the progagada spread by cosnervative ideologoues?
    I have read extensively about healthcare in these coutnires, interviewed patients and doctors in these countires and have relatives who have recieved healthcare in Canada and Germany for years.
    Nothing “one-size-fit-sll” about it. My step-son, hiw wife and baby have gotten better care in Germany for the past 7 years then he ever received in Manhattan (Ann they are not even German).
    When his wife had trouble in delivery (under public-sector insurance at a public-sector hospital), the hospital, the doctor, the midesives were all superb. When her baby had to stay in the hospital for two weeks longer, they let her stay too–in a room on the same hall-at no charge. (Imagine that happening in the U.S.)’
    Talk to any woman who has delivered a baby in a Manhattan hospital recently and see what percentage rave about how wonderful the experience was. (Or just read any of the many current books about what you need to know when pregnant– hospitals forcing women into unncessary C-sections (more lucrative and more convenient for the hospital); babies placed in intensive care ICUs when it’s not medically ncessary (Health Affairs has published reserach on how this endangers the baby’s health and delays attachment with the mother.)
    But in the “competiton” for well-heeled patients more and more hospitals have built very expensive ICU units for new-borns. How do they pay for them?
    By using them.
    Why do you think these other countires have better outocmes while spendingd so much less? Different values. They put patients ahead of profits.
    Becuae they haven’t tried to turn healthcare into a for-profit enterprise.

  13. Sean & NG
    Thanks for your comments.
    NG– I agree . .
    Sean– See the post that goes up tomorrow titled “The Disease: Exorbitant . . ” and my explanation of why the amounts we pay doctors at the top of the income ladder are a problem.
    The biggest problem is that when we make certain services too lucrative, volume rises, and unnecessary procedures hurt patients. These perveres financial incentives also help drive healthcare inflation.

  14. “And like you, I have known many professionals (doctors, academics and even lawyers and law professors) who were Not working for the money. How much they made was not the primary motivator.Is should come as no surprise that they are usually the people at the top of their field–the most creative, and the most intelligent people who found the work its own reward. ”
    is that last part a fact or an opinion? i don’t know how you separate out motivations? it makes a nice sound bite to say the works is its own reward, but it doesn’t necessarily make it true. i certainly see lots of really successful people who love their work who might make more if say they switched from academic medicine to private practice, but the jobs are different and then they wouldn’t love it so much. they make enough doing their current job that they choose to continue. that doesn’t mean they value having ‘enough’ money any less than the next guy.
    i think chris johnson’s statement that he is surrounded by people who wouldn’t work harder if they were fee for service not likely to be applicable at the majority of institutions in the country. likely the call burden at mayo is lighter because of the housestaff. the number of people helping them get through their day is simply not available anywhere else, for unknown reasons (financially viable only there?) and yes i have some experience as i am a frequent referral source to mayo and go to watch procedures on my patients.
    as to his final comment about who he would want operating on him, if i were him i would worry about not only the physician but hospital resources supporting the physicians-do they have enough nurses to help you recover, are they spending enough to keep their equipment updated? i can assure you whatever the motivations of the physicians may be, the hospital executives are much more financially minded than the physicians.

  15. I think the outcomes charted by the VA are laudable, but not entirely due to the efforts of a “closed system”. I worked at the VA for about three years in primary care. Most of my patients who had any outside payor source (private insurance thru a spouse, Medicare, etc.) actually had what we called “dual care”. This was especially prominent prior to the passge of Medicare Part D and the availability of subsidized medication coverage. Our Medicare eligible veterans came to the VA almost solely for the purpose of subsidized medications. They often did not get their specialty care thru the VA, preferring instead to utilized more easily available (non-rationed) care nearer to their homes.
    As their assigned primary care physician, I encouraged them to get the care that made the most sense for them. At the VA, a patient with signs very suggestive of angina would require a cardiology referral to get appropriate further risk stratification (stress test, etc.). This could take months. If the same patient went back to his home town primary care doctor and asked for a cardiology referral, he would have his appropriate testing within the week. I generally try to treat my patients how I would want my family members treated, and I often had to admit to myself that the delays we were asked to present to our VA patients as appropriate (i.e. saving the system money) would not be delays that I would find appropriate for myself or my family.
    I always read the studies of purported VA outcomes data for a particular disease and wonder if the people who do the data mining of VA charts to publish those studies have a clue that the patients are likely also seen by a cadre of specialists in their home towns, and the better outcomes are because they had a better access to their medications thru the VA, not necessarily because of any superiority of “managed care”. The information about collaborative care is not available generally in the VA record, and even a structured interview is not likely to unearth it reliably because the patients fear that if they admit that they are really getting most of their care outside of the VA, they will be disenrolled (there really used to be a policy where that was a possibility).

  16. Thanks for your comment.
    You are right: many VA patients get care both at the VA (much lower prices for drugs becuase the VA is allowed to negotiate with manufacturers for lower prices) and in the outside world.
    But the studies published in NEJM etc were looking at
    patients who were full-time
    VA patients.
    In many cases the studies were focoused on inpatients cared for at VA hospitals.
    As the care improved at the VA in the 1990s–thanks to a huge overhaul of the system– many more patinents began to use the VA exclusively.
    I don’t know when you worked there, but as I have wirtten on other posts, since 2000 the Bush administration just didn’t give the VA the funding it needed. Meanwhile demand grew as Vets returned from Iraq and Vietnam vets aged. . .
    This is when the lines grew long– and perhaps this is when you were working there

  17. Just finished watching you on Charlie Rose tonight.
    Your concept of health care is stunning to me. Based on your concept, we should spare no amount of expense on keeping a person alive, no matter what the cost or what the quality of life.
    My niece was born last summer with major heart problems. One million dollars and 3 weeks later she passed on. No expense was spared, trust me, I watched. My sister’s out of pocket from her insurance company was $4,000. Where do you think the other $996,000 comes from under your scenario? It comes from all of us.
    The problem with your theory is it looks at health care while ignoring the economy and who has to contribute the money to fix things. Government should take it all over if you had your way. I have news for you, the health care system will be even less efficient once it is owned and run by the government.
    If I am taxed to the point where I make no money but all my services are free, I will not be happy. The United States is a capitalist country. Please look outside your own world. It is a very easy thing to sit there and tell stories on Charlie Rose about how someone was denied healthcare because they did not have insurance or money. It is a very complex thing and unpopular thing to say, OK when is enough health care enough? If my 100 year old grandmother is in a coma and found to have cancer, should we start doing radiation no matter the cost? Is she less important than your college student who could not afford radiation? Please don’t tell me there is a limit on your compassion when my grandmother could live on to 105 with radiation treatment. You see the problem with your plan is that its underlying assumption is that we should “spare no amount of time and money to save one person” even if it means dragging the whole of our society into an economic abyss. Here is a bet, my health care costs under your world start at 10% of my income but they eventually go up to 40% of my income. Have you seen a lot of tax decreases over the years. I live in LA, our sales tax is over 10% now in some jurisdictions. The CA government spends more than they collect every year for other social services like schools, fire, police, etc. Where does it end?
    Try to take the non-popular approach and actually think thru what this could do to medical costs and more importantly who would bear them. By the time my health care costs 40% of my income, I can no longer afford to have just one job so I have to get a second job and the second job is more dangerous and one day I am killed doing my second job. Have you created a better world for my kids at that point? No.
    I am not saying there is a simple solution but let’s not turn the US into Canada or some other 3rd rate country. our government has screwed up more than it has fixed over the past 100 years or more so please don’t give them health care as well. Think big picture – think beyond solving your health system problems by just having an 800 pound gorilla run it. Surely you can come up with something better than this.
    Lastly, I don’t care if people in Springfield are getting healthier. What is your goal ? Do you want us all to live forever. Do you think that will be a good thing?
    Let the market control it – as poorly as it is operating now, it will only get worse if federally run. I promise.

  18. The VA does not do enough to retain the doctors that it does have. Some examples: 1) Office conditions: the office for one new doctor I know is the same place where patients are seen, this is unacceptable.
    2) Doctors are scolded for seeing their patients too often, which supposedly takes away valuable spaces for other patients. Isn’t it good for very sick patients to come in more than a half an hour per year?
    3) Unrealistic performance measures—how many fecal coliform cards returned? This is not necessarily under a doctor’s control. Too much time is spent on such measures.
    I believe there are some serious flaws in terms of making the morale of doctors higher. Pay is not the only part of retaining employees.

  19. “If someone had arthritis in their hip, we used to treat it with aspirin,” Gawande noted. “Now we do hip replacement surgery” that can cost tens of thousands of dollars.
    I know what point this is trying to make, but aspirin does not replace joint replacement surgery. And I’ve seen aspirin kill.
    False dichotomies and oversimplifications do nothing to add to the discussion.