Another VA lesson — Healthcare needs to stop being like flying business class

The VA healthcare story has me thinking about the good aspects of delays in medical therapy.

Typical American intuitive thinking holds that healthcare waiting lists are a bad thing. The two central tenets of this mindset are that healthcare brings health, and most of medicine is as time sensitive as cardiac arrest or heart attack.

Yet, when we engage our slow thinking minds it’s easy to see the flaws in such an early-intervention shortcut (heuristic). The business about healthcare not bringing health has been addressed here many times over. The short story is that in general we do best when treating the very sick, not so good with the worried well, and terribly with those near end of life.

What I want to use this essay to focus on is the early-intervention mis-thinking and truth-denial aspects of the VA story. The reason is that there is an important lesson about the way we (should) think about healthcare—a mindset or framework.

(Before beginning, let’s set out a given: there is no defense of quality care variations described in the WSJ today, in which some VA hospitals have 10-fold higher rates of hospital infections than other VAs. That needs to be fixed in the same way private hospitals fixed it a decade ago.)

Let’s begin the wait-list/truth-denial story with the fact that studies show that outcomes in the VA healthcare system compare favorably to those in the private sector. Many people do not believe such data because, to them, it seems implausible. They have pre-conceived notions: Veterans couldn’t possibly being doing well because they have to wait so long to get care.

This, I strongly believe, is wrong thinking. I believe it is entirely likely that the data showing good outcomes at the VA are not only true but also expected.

To make my case, I will use examples laid out in this front-page Sunday NY Times piece, Many Veterans Praise Care, but All Hate the Wait.

Experienced health care reporter Abby Goodnough begins her piece with the story of a 67-year-old veteran who has a hernia. The VA’s offense was making him wait too long for repair. The man had to use his second form of government-supplied care (Medicare) to get the surgery. At the risk of sounding insensitive, it is important to make clear that there are a lot of people in the queue. Waiting for a hernia repair is called triage—and it is the truth of delivering care to the many.

The next case in the piece described a veteran who had to wait for an elective CT scan to evaluate a lung nodule. The VA asked him to wait two months; the private sector did the scan the next day. Of course it is easy to get a CT or MRI in the private system. That is part of the problem. Although we can argue about what is a reasonable number of weeks to wait for a CT scan, the evaluation of lung nodules are not next-day urgent. What’s more, overuse of expensive scans is a major impediment to equal and just public health.

Another veteran in the piece was said to have had a recurrence of his prostate cancer. His VA appointment was three months away. So, yes, this is a long time to go with a scary diagnosis. But we are not told the details of the case, which are important for making judgments on the timing of appointments. Perhaps this recurrence was just a slight rise in a blood test that warranted another check in a couple of months. In prostate cancer, details matter because patients can incur as much harm from treatment as they do from the disease itself. Delaying, or avoiding, prostate cancer treatment may indeed be far from terrible. Ask the (treated) men who now have breasts, leaking urine, impotence, or holes (fistula) from rectum to bladder, whether they might have wished for less rapid or robust care of their prostate cancer.

Yet another veteran complained about “standing room only” in the waiting room at his clinic, and that the doctors seemed “more tired or wiped out than normal.”

Really? Young doctors looking tired. Good, I say. Maybe they are learning. Crowded waiting rooms and tired-looking doctors are hardly a reason to impugn the VA.

Can you see the message?

The VA healthcare system is not perfect. I’m certain that 100% of people who work there could think of things to improve—as can all of us who work in the imperfect private sector.

And of course there are veterans who have suffered from mistakes of omission and commission—just like patients in the private sector.

What I want to show in these examples is a different framework for thinking about how we consume healthcare.

My thesis is that outcome measures at the VA are comparable to the private sector because they take care of the needy, the sick. That triage is not only necessary, but appropriate. That good medical care is often Spartan and uncoddled, which does not mean devoid of empathy or compassion. That if we didn’t have the excesses of CT scans and hernia repair on demand, we’d have more time and resources to educate people and help them make medical decisions most consistent with their goals. We’d have time for minimally-disruptive medicine, good medicine.

Healthcare needs to stop being like flying business class. Buying extras doesn’t necessarily lead to better outcomes. There’s more room in the plane for all if a few aren’t over-consuming.

The VA is teaching us that. And it’s a good thing.

JMM

Comments

  1. Doctorsh says

    DrJohn

    Are you really doubling down on your argument that delaying care is a good thing?

    Ok, so outcomes AFTER the treatment or testing was completed are comparable. How about the 6 month wait time that the veteran suffered with a hernia or a bad hip and was unable to function, hold a job, live his or her life without being a burden?

    Are we dealing with QALY here?

    Is the patients morbidity and quality of life the same when waiting for care the VA or any health care system that is unable to provide worth anything other than a sorry we don’t have the resources argument.

    Should it really be the govt or other 3rd party health care intruder denying a veteran the freedom to get his medical care in a timely fashion?

    This debate really should not be going on.

    Without our veterans we would not be a free country, nor would many other countries we call. Our friends. It is time we stop this debate about delayed care being the right thing to do, and allow our veterans the freedom to obtain their care in a timely fashion, commensurate with the service they gave to our country!

    • Pete says

      Veterans aren’t being protected from growing breasts with the delays, they are being ignored for things we with health plans can get screened and treated for in a timely fashion by simply going to a different “in plan” doctor. Veterans are even being dropped off waiting lists. It’s being covered up . So it isn’t about flying first class, it’s about just being able to get on the plane.

  2. says

    You are looking at it from a medical standpoint. You aren’t the veteran who sustained a torn rotator cuff while deployed and has waited 3 years to have surgery because it’s elective surgery and PT should be tried first. Three years of PT failure is a long time to go with that injury. This isn’t the exception. This is pretty much how everyone is treated.

  3. Joe says

    Here’s the thing – as a county we’re paying for business class….no…first class health care. Even at the VA.

    That’s the scandal. If we’re happy with bureaucratically imposed waiting and European style single payer care, we should also be happy that we’re paying half of what we pay now. I would take that bargain. Charging first class prices and insisting that coach service should be fine for us since it’s fine for Canada or England or France (all fine systems, in my view) is ignoring the price we pay in the US.

    We in the US are like a rich family arguing about who should be eating ramen for Thanksgiving. We’re paying more than enough for everyone to have a full holiday spread with all the trimmings, but we’re being told there isn’t enough turkey and stuffing to go around.

    We’ve all seen the number 18% of GDP spent on health care. That’s staggering, but it masks the full extent of the problem. The per capita number is worse since our GDP is strong. We spend, per capita ($8500), around twice what is spent in Canada ($4500), France ($4100), and the UK ($3400). Numbers at the VA aren’t as easy to tease out (since VA patients get some care outside the system, are on average older and less healthy than the general population, and so on…) but even the low end of estimates I see ($7500-$12500) are much higher than they should be for the level of care reported.

    Cost matters. It does. If we want a health care system in the model of Canada, France, or the UK, let’s start by cutting everyone’s health care costs in half.

    There would be some grousing, and the cable news people would go nuts, but I think many people would embrace it once they feel the cost savings.

    Instead, everyone I know is paying more each year for less and less care. Telling us it’s good for us rings hollow.

  4. says

    Dr. John:

    Based on your essay and your justification for such a crappy health care system the VA has, I have a feeling you’re an ObamaCare supporter too.

    Sadly, what we see going on with the VA is just a glimmer of what we’ll see in our national healthcare system in the years to come thanks to ObamaCare…except it will be much worse as we’ll be dealing with the entire population of the U.S.

    I’ve said it a million times…government should have a limited roll in health care. The more government is involved, the worse the system gets.

    It’s sad, but we have a better insurance system for our pets and automobiles than we do for our vets and our own citizens. Why is that? Because they are primarily free-market systems with very little government intrusion.

    We wouldn’t tolerate a veterinarian telling us our pet has to wait 3 months for a test or that our car can’t be repaired for another 3 months, but when it comes to our vets or our citizens, we get essays like this that delays in treatment and care are a good thing! It’s an upside down world we live in these days.

    Travis

  5. Pat says

    Flying business class is over-consuming? So now I’m supposed to feel guilty because an airline chooses to reward my frequent travel with an occasional nicer seat via accumulated miles? Ouch.

  6. Melvin says

    As a Vietnam veteran who was medivaced, I was luck to have barely needed the VA over all these years. The Army fixed me up before discharge.
    I agree w Dr. John’s point on the “value” (my term) of delayed treatment for many, if not all patients.
    And the give-em-what-they-want view of Doctorsh Says (earlier commenter) is a crock. VA care is not an entitlement for most vets. Just having served does not give you the right to VA care for anything for life. Retired (20-year) military get that from DoD. VA gives care to those w rated disabilities, certain relatives of same, and certain in-need classes of vets, e.g., the homeless. There is a lot of BS in the claims process (the vets and the VA), but that is indeed another story.
    Back to waits–when was the last time you heard even an allusion to “productivity” or “cost-effectiveness” or cost-savings–all normal concepts that almost any provider in the medical-industrial complex understands and tries to address? The VA does not study or manage much to productivity benchmarks, but rather resorts to crude LIFO or FIFO staffing tactics. . Ant its many partisans are constantly braying about the need for “more resources.” In the aggregate, VA has more than enough to run a decent system for all entitled (and that is not all vets) to its services. But the deployment of funds and overall management is so putrid that the VA suffers, from its own mismanagement, from the tremendous gaps in outcomes and available staff and facilities. That is why Shinseki, and legions of career executives and tens of thousands of VA managers and supervisors need to be booted out. They don’t care about using our funds efficiently. You can have efficiency and good care together–indeed, there is some relationship between the two.. It happens all the time in many places in our healthcare system. Sometimes it happens because delays are expected and allowed. Veterans should not be allowed to get care any time they want it. Any time those who entitled to care NEED it would be more appropriate, including for preventive care.

  7. John R Willis says

    Dr John M:
    I was in the US Army for 20 years. I understand many of the issues with medical care and with triage. The VA has a little different issue in my opinion. I moved from a paying job in NJ to semiretirement in NC. I went to my local VA Clinic and submitted the paperwork for evaluation of edibility for VA benefits in Dec 2013. After no communication from the VA, on 30 January 2014 I went back to the clinic and was told the request for benefits was rejected. Also on 30 January 2014 I wrote to Mr Shinseki requesting that his office verify the rejection and have the responsible office (Atlanta, GA ?) generate a letter informing me of the decision. After no response to my letter I wrote to the VA IG on 26 March 2014 requesting that the OIG investigate the status of my claim and why the VA cannot seem to generate a simple one page letter rejecting the claim after almost three months and a letter to the reported head of the organization. I still have not yet gotten any written rejection from the VA. On 30 May 2014 I generated Inquiry 140530-000498 on the VA web site. Via Email they instructed me to call 877-222-8387, when I called I was told that no record existed of the 2013 Means Test application in the VA database.

    At many levels and with multiple attempts the VA did not do the job they are paid to do. Neither the Office of the Secretary of the VA and the Office of the VA Inspector General could take the time to generate a generic reply much less evaluate and fix the problem. The person that replied to Inquiry 140530-000498 never looked at my records to see that there was no record.

    The people at the VA that actually treat (put hands on ) vets are the best in the world and work under many constraints. The VA problem is that nobody, at all echelons above the actual care providers, does what they are paid to do; however, they do spend much time working to get out of work and passing the action to someone else.

    What the VA and most private sector facilities (as well as most educational facilities) do well is that the people that actual put hands on patients (students) are the best and they are underpaid and overworked. The real organizational issue is the supervision and management layers that have no function except passing paper and consumption of ever greater resources.

    In the case of the VA I am willing to bet that retired general Shinseki nor his staff ever had to actually use any VA facility in person (as a John Doe) without attaching the flag office rank or the VA Office of the Secretary titles.

    Just another point of view, John R Willis