PNHP

Physicians: Independent professional practitioners or employees controlled by health care’s big players?

Physicians: Independent professional practitioners or employees controlled by health care’s big players?

By Edgar A. Lopez, M.D., F.A.C.S.
Louisville Medicine, Letters, June 2014 

In the New York Times issue of February 14, 2014, an article written by Elisabeth Rosenthal and titled, “Apprehensive, many doctors shift to jobs with salaries,” the following information caught my attention:

Today, accordingly to the AMA statistics, in the USA:

  • 60 percent of family doctors and pediatricians are employees 
  • 50 percent of general surgeons are employees
  • 25 percent of surgical specialists including ENT, ophthalmologists and others are employees

In 2007, 24 percent of cardiologists were employed; it jumped to 35 percent in 2012.

Local hospitals in the state of New Jersey bought, just recently, 22 private cardiology practices.

These statistics reflect the rapid demise of the concept of the private delivery of medical care that has fallen in this country into the tentacles of the private health insurance companies that continue to siphon off, in a macabre way, the tax money that is supposed to be used for health care. Instead the funding of private health care in the USA, the richest industrialized country in the world, is all about profiteering and the Wall Street dance of the stock market as it relates to escalating health care costs for everybody.

In the meantime, the Affordable Care Act has only brought more sophistication to the profiteering process of the private health insurance companies while still more than 45,000 citizens a year die because of lack of health insurance. Believe you me these victims are hard-working middle-class citizens; they are not the immigrants (documented or otherwise), they are not the veterans of war, they are not from the top 1 percent, they are not from below the poverty line, they are hard-working individuals, low-level executives and college graduates, adjunct professors, low-level employees of the same private health insurance companies, etc., who carry exorbitant deductibles in the newly baptized Platinum, Gold, Silver, Bronze plans that, in my opinion, rather than precious metals’ names, should be called “chatarra” (which in Spanish means: scrap metal).

The concept of incremental health care reform sponsored traditionally and continuously by serious institutions like the AMA and the American College of Surgeons is another clear manifestation of a non-viable, non-sustainable system for funding and delivery of health care. It just doesn’t work, and the price for the ones left behind the affordability wagon is: death, debt, despair and mental illness plaguing the streets.

When you have an acute catastrophic illness and you are, for whatever reason, underinsured or even worse uninsured (don’t know which one is worse) there is absolutely no time to wait for incremental shenanigans.

My dear colleagues, the only viable solution to save the private practice of medical care (funding and delivery) in this country, and at the same time serve Everybody In and Nobody Out, is a single-payer system based on the bill introduced in the U.S. Congress on repeated occasions through the years by Rep. John Conyers: H.R. 676. We can call it also: Improved-Expanded Medicare for All, from birth to death and without the participation of the private health insurance industry. That bill will save at least $400 billion a year, to begin with. H.R. 676 is properly explained on the Web. Just google H.R. 676 and read the bill. Everybody’s back is covered, including the low-level employees of the private health insurance companies.

I want to respectfully invite the current president of the GLMS [Greater Louisville Medical Society] and the president-elect to a public conversation including members of GLMS to discuss why H.R. 676 doesn’t have the support of certain medical organizations. It is not even discussed. You bring your team of experts and I will bring mine.

Logistics and details can be properly planned.

Dr. Edgar Lopez is a member of Physicians for a National Health Program (PNHP) and a founding member of the Kentucky chapter of PNHP.

https://www.glms.org/Content/User/Documents/Publications/LouisvilleMedicineJune2014.pdf

VA Care: Still the Best Care Anywhere?

By Phillip Longman
Washington Monthly, June 3, 2014

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title “Best Care Anywhere, Why VA Health Care would be Better for Everyone,” it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominate media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of the health care delivery system reform.

I don’t mean just the fulminations of the right-wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is senior editor of the Washington Monthly. This article, the first of a series, appeared at the Washington Monthly’s “Political Animal” blog.

http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_still_the_best_care_an050598.php

*****

Veterans aren’t the only ones waiting for health care

By Ezra Klein
Vox, May 23, 2014

In 2005, Phillip Longman, a senior fellow at the New America Foundation, published an article entitled “Best Care Anywhere” in the Washington Monthly. The article, which later became a book (which I blurbed), made an unexpected argument: the Veterans’ Administration’s health-care system had quietly become one of the best — if not the best — health systems anywhere.

Longman’s evidence was expansive. A 2003 New England Journal of Medicine compared the VA with Medicare on 11 measures of quality. “On all 11 measures, the quality of care in veterans facilities proved to be ‘significantly better.’“ The Annals of Internal Medicine published a study that compared VA facilities with private managed-care systems in their treatment of diabetes patients. “In seven out of seven measures of quality, the VA provided better care.” The National Committee for Quality Assurance ranks health-care plans on 17 different performance measures. “In every single category,” Longman wrote, “the VHA system outperforms the highest rated non-VHA hospitals.”

Then there was the testimony of the veterans themselves. “The quality of care is outstanding,” Peter Gayton, deputy director for veterans affairs and rehabilitation at the American Legion, told Longman. A survey found that 81 percent of VA hospital patients were satisfied with the care they received compared to 77 percent of Medicare and Medicaid patients.

The VA’s reputation isn’t nearly as good right now. Secret waiting lists in Phoenix are alleged to have contributed to the deaths of 40 veterans. VA hospitals across the country are under investigation for similar malpractice. Some are calling for Department of Veterans’ Affairs Secretary Eric Shinseki’s resignation. (Read Vox’s explainer on the VA scandals here.) So I asked Longman: was he wrong about the VA then? Or are we getting the story wrong now? A lightly edited transcript of our interview follows.

Ezra Klein: You titled your book on the Veteran’s Health Administration “The Best Care Anywhere.” Do you still believe that’s true?

Phil Longman: To the specific issue at hand on whether or not there were secret waiting lists at Phoenix and possibly other hospitals, we just don’t know. There’s strong evidence that employees at those facilities engaged in some kind of gaming of their performance metrics. But we’re still waiting for the investigation to finish.

But the big question with these stories about the VA is, “compared to what?” This scandal wouldn’t exist if the VA didn’t have performance metrics on its employees. If it didn’t measure or care whether veterans get prompt appointments it could just do what the rest of the health-care system has done and not hold people responsible for these metrics. Now, certain people seem to have cheated on this metric. But that’s far better than what goes on in the rest of the health-care system where no one is accountable for this at all.

EK: What’s the metric the VA is using here?

PL: The metric here is they tried to get vets in for non-urgent appointments for care within 14 days. Compare that to a survey done in 2009 on average wait times outside the VA to see a family physician. In Los Angeles, people waited an average of 59 days. In Boston, they waited an average of 63 days. In Washington DC, they waited an average of 30 days. The average wait time in major metropolitan areas is about 20 days. The VA is attempting to create a performance metric by which it would be substantially superior to the rest of the health-care system. It might have missed that mark and some employees might have been cheating.

EK: A point you made in testimony before the Senate Committee on Veteran’s Affairs is that this is a problem of access to care rather than quality of care. What do you mean by that?

PL: When you hear the Veteran’s Service Organization testify, as they all did last week, that the quality of care at the VA is excellent but access is a real problem, they don’t mean access the way most people think of it. They mean how long it takes to qualify for VA benefits generally. And that is a problem.

We have a system that reflects a deep ambivalence among the American people about what vets are owed. On the one hand there’s a consensus that any vet hurt in the line of duty should be put back together by the VA for free. But we’re conflicted about whether everyone in the military should get health care for free. So the way it stands now is most veterans have to prove is that the health-care complaints they have are the direct result of military service. And so if you look at what the bureaucracy at the VA is doing most of the time, it is trying to adjudicate questions like whether someone who’s 58 years old is losing their hearing because of the artillery fire they heard while deployed in Vietnam or because of all the Who concerts they went to in 1968. That’s a real example, by the way.

Another typical case would be someone in Vietnam in 1972 and who worked on a base with lots of Agent Orange and has now come down with Parkinson’s disease. There’s been some evidence in recent years that Agent Orange might be related to early-onset Parkinson’s. And we spend enormous amounts of effort trying to litigate questions like that.

The current administration has made progress in lowering the VA backlog but the largest single cause is not that we have all these guys coming back shot up from Iraq and Afghanistan and no one is around to do the paperwork. It’s that we have all these aging veterans with chronic problems and we can’t decide whether we want to give them health care or not. With Parkinson’s disease they recently decided to just assume that anyone in Vietnam was exposed to Agent Orange and so that’s brought in a whole new group of people.

EK: One thing that frustrates me a bit about this conversation is that there’s a selectivity to when people become outraged over access issues in health care. What’s happened in Phoenix is, if it holds together, a scandal. But we have millions of people who are eligible for federal Medicaid benefits but live in states that refuse to accept the Medicaid expansion. And a lot of those people, well over 40, will die or face serious medical consequences because they’re uninsured. And both before and after Obamacare there will still be millions of people who can’t afford health insurance and no one will make sure they get timely appointments and there’ll be no headlines when they suffer.

PL: The VA puts ideological and political positions in play. People think it proves their worldview is right and other people’s worldview is wrong. And there are allegations of criminality. The lack of Medicaid coverage for huge portions of the population is horrible and it is, ultimately, a much bigger scandal, but it is not illegal.

EK: An interesting point you made in your congressional testimony was that publicly run health-care systems have a dilemma in which they actually track these quality measures and, when they fall short, it’s a scandal. But when private systems fall short, no one even knows. The result is an asymmetry in public perceptions of how well different systems actually work.

PL: Put yourself in the position of these veterans service organizations. They are simultaneously charged with pointing out the defects of the VA when and where they occur and defending the VA from its ideological enemies. Those two aspects of their mission are often in conflict. If the American Legion, which has spent the last 15 years extolling the quality of VA health care and pressing to get more vets into the system, now has to call for the resignation of the head of the VA, that plays into the hands of those who want to torpedo the whole system.

There’s this section in my book about the VA’s pioneering effort to really show how many medical errors there were. They created these registries patterned on things the FAA did for pilots. They allowed people in the VA to report medical errors anonymously and tried to create a no-blame culture that looks for structural reasons for errors and leads to a real safety culture in the VA. That meant publishing statistics on how many medical errors occurred at the VA.

When they first did that the press pounced on those reports. It led to all these headlines like second-rate medicine for first-rate men and the perils of socialized medicine and all this. But the VA was actually admitting there was a problem and they were trying to fix it. The rest of the health-care system was doing nothing.

I would like to imagine a world in which the hospital where my late wife was treated for breast cancer had an inspector general looking over that hospital and two committees of congress charged with scrutinizing quality of care in that hospital and there were broad-based citizens groups that had their rank-and-file going to that hospital and reporting on anything that went wrong and making it national news. I think if we had that we would find a lot of dysfunction in that system — but we would also make American health care better.

EK: What would cause you to revise your belief that the VA is still providing excellent care?

PL: The only thing that would cause me to revise that would be if it is proven that people who are enrolled in the VA system are unable to make timely appointments with their doctors on a scale that remotely threatens the performance of the system as a whole. I am sure wait times are an issue. But there’s been no evidence yet that wait times at the VA aren’t shorter than they are outside the VA. We know veterans, when surveyed, have overwhelmingly positive consumer satisfaction with the VA. We know all the major veteran service organizations salute the VA’s quality of care. And we know veterans are piling up at the door because they’ve heard from other veterans that the VA is a great place to get care.

http://www.vox.com/2014/5/23/5745356/veterans-aren-t-the-only-ones-waiting-for-health-care

We need improved Medicare for all

By G. Richard Dundas, M.D.
Bennington (Vt.) Banner, Letters, June 4, 2014

We read in the Banner that as many as 40 veterans may have died in Phoenix because they could not get needed care at the VA hospital. This is truly outrageous (surely an overused adjective but probably better than disgraceful). We must do better for our veterans.

Here is another statistic that you may or may not want to know depending on your political mindset. It is estimated that in 2013 there were over 40,000 Americans (not a misprint) who died because they had no health insurance and could not access health care in a timely manner. This is similarly outrageous.

I long for the day when we Americans are smart enough to elect leaders who can translate outrage into action. The action that we need is improved Medicare for all. Everybody in, nobody out.

Dr. G. Richard Dundas resides in Bennington.

http://www.benningtonbanner.com/opinion/ci_25891663/letters-we-need-improved-medicare-all

Phillip Longman: VA health care is still the best

Poll: Confidence in veterans’ care plummets to new low

By Susan Page
USA TODAY, June 2, 2014

Americans’ confidence in the medical care provided for soldiers returning from Iraq and Afghanistan has plummeted to new lows in the wake of the VA scandal, a USA TODAY Poll finds. Most people see the problem as widespread and systemic.

Just one in five rate the job the government does in providing veterans with medical care as excellent or good, about half the percentage who said that in a Pew Research Center survey in 2011. Then, half rated the care as “only fair” or poor; now seven in 10 do.

42% have little or no confidence that the problems can be fixed.

Eight in 10 worry that the issue is turning into a political battle in which Democrats and Republicans are more interested in scoring points than solving the issue. On that question, there is almost no difference by party affiliation.

http://www.usatoday.com/story/news/politics/2014/06/02/poll-americans-view-of-va-health-care-scandal/9863621/

****

VA Care: Still the Best Care Anywhere?

By Phillip Longman
Washington Monthly, June 3, 2014

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title Best Care Anywhere, Why VA Health Care would be Better for Everyone, it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominate media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of health care delivery system reform.

I don’t mean just the fulminations of the right wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as, Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is senior editor of the Washington Monthly.

http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_still_the_best_care_an050598.php

****

Comment:

By Don McCanne, MD

Phillip Longman, as the author of “Best Care Anywhere, Why VA Health Care would be Better for Everyone,” is a person to whom we can turn to get the full story on the VA health care “scandal” and how representative it is of the system at large. According to him it is not only the right wing attacks claiming that this is proof of the case against socialized medicine, but it is also “hard-working and earnest reporters” who “wind up giving the public a fundamentally false idea of how well the VA is performing as an institution.”

The new USA Today poll confirms that the reporting has caused Americans’ confidence in the VA health system to plummet, with the perception that the problem is widespread and systemic. Americans do recognize that the politicians are more interested in scoring points than they are in solving the issues (Sen. Bernie Sanders being a notable exception). Nevertheless, the poll indicates that they now believe that the government is doing a poor job and 42% have little or no confidence that they can fix the problems.

Longman states, “it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.” When individuals make the claim that the VA “scandal” proves that single payer would not work in the United States, refer them to this series being written by Phillip Longman where they can learn the truth.

Phillip Longman: VA health care is still the best

Poll: Confidence in veterans’ care plummets to new low

By Susan Page
USA TODAY, June 2, 2014

Americans’ confidence in the medical care provided for soldiers returning from Iraq and Afghanistan has plummeted to new lows in the wake of the VA scandal, a USA TODAY Poll finds. Most people see the problem as widespread and systemic.

Just one in five rate the job the government does in providing veterans with medical care as excellent or good, about half the percentage who said that in a Pew Research Center survey in 2011. Then, half rated the care as “only fair” or poor; now seven in 10 do.

42% have little or no confidence that the problems can be fixed.

Eight in 10 worry that the issue is turning into a political battle in which Democrats and Republicans are more interested in scoring points than solving the issue. On that question, there is almost no difference by party affiliation.

http://www.usatoday.com/story/news/politics/2014/06/02/poll-americans-vi…

****

VA Care: Still the Best Care Anywhere?

By Phillip Longman
Washington Monthly, June 3, 2014

Last week, when I accepted an invitation to go on Hugh Hewitt’s nationally syndicated talk show, his first question to me was, “So how does it feel to be the author of a book about the VA that has been thoroughly discredited?”

Well, yes, as the author of the title Best Care Anywhere, Why VA Health Care would be Better for Everyone, it’s been dispiriting to have it confirmed by a preliminary inspector general’s report that some frontline VA employees in Phoenix and elsewhere have been gaming a key performance metric regarding wait times. But what’s really has me enervated is how the dominate media narrative of the VA “scandal” has become so essentially misleading and damaging to the cause of health care delivery system reform.

I don’t mean just the fulminations of the right wing press. It’s nothing new when Fox rolls out Ollie North to proclaim that any real or reported failure of the VA is proof of the case against socialized medicine.

I’m also talking about the work of hard-working and earnest reporters, who due to a combination insufficient background knowledge and the conventions of Washington scandal coverage, wind up giving the public a fundamentally false idea of how well the VA is performing as an institution. Over the next several days, I plan to make a series of posts here at Political Animal that I hope will be helpful to those covering the story, or for those who are just trying to get the full context for forming an opinion.

Today, let’s just start by scrutinizing the now almost universal assumption that there is a “systemic” problem at VA hospitals with excessive wait times. Even progressives, including the likes of Jon Stewart and Bill Maher, seem predisposed to believe this for their different reasons. Some voices, like my former colleague Brian Beutler of The New Republic, even speculate that the scandal may ultimately bounce in a way that harms the Republicans more than it does the Democrats.

But before we go there, can we get clear on just what the underlying reality is? There is, to be sure, a systemic backlog of vets of all ages trying to establish eligibility for VA health care. This is due to absurd laws passed by Congress, which reflect on all us, that make veterans essentially prove that they are “worthy” of VA treatment (about which more later). But this backlog often gets confused with the entirely separate issue of whether those who get into system face wait times that are longer than what Americans enrolled in non-VA health care plans generally must endure.

Just what do we know about how crowded VA hospitals are generally? Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply (pdf). Nationwide, their number fell by 17 percent between 2000 and 2014, primarily due to the passing of the huge cohorts of World War II- and Korea War-era vets. The decline has been particularly steep in California and throughout much of New England, the Mid-Atlantic and industrial Midwest, where the fall off has ranged between 21 percent and 36.7 percent.

Reflecting this decline, as well a general trend toward more outpatient services, many VA hospitals in these areas, including flagship facilities, want for nothing except sufficient numbers of patients to maintain their long-term viability. I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as, Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

Once you have this background, it becomes easy to understand certain anomalies in this scandal. If care is really so bad, for example, why did all the major veterans services remain unanimous in recent testimony before Congress in their long-stranding praise for the quality of VA health care? And why have they remained stalwart in defending the VA against its many ideological enemies who want to see it privatized? It’s because, by and large, VA care is as good, if not better than what vets can find outside the system, including by such metrics as wait times.

Similarly, if VA care were not generally very good, the VA would not continue to rank extraordinarily high in independent surveys of patient satisfaction. Recently discharged VA hospital patients for example, rate their experience 4 points higher than the average (pdf) for the health care industry as a whole. Fully 96 percent say they would turn to VA inpatient care again.

Now if you go out looking for vets who say they have been victimized by the VA, you will have no trouble finding them, and many will be justified in their complaints. But as I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Phillip Longman is senior editor of the Washington Monthly.

http://www.washingtonmonthly.com/political-animal-a/2014_06/va_care_stil…

Phillip Longman, as the author of “Best Care Anywhere, Why VA Health Care would be Better for Everyone,” is a person to whom we can turn to get the full story on the VA health care “scandal” and how representative it is of the system at large. According to him it is not only the right wing attacks claiming that this is proof of the case against socialized medicine, but it is also “hard-working and earnest reporters” who “wind up giving the public a fundamentally false idea of how well the VA is performing as an institution.”

The new USA Today poll confirms that the reporting has caused Americans’ confidence in the VA health system to plummet, with the perception that the problem is widespread and systemic. Americans do recognize that the politicians are more interested in scoring points than they are in solving the issues (Sen. Bernie Sanders being a notable exception). Nevertheless, the poll indicates that they now believe that the government is doing a poor job and 42% have little or no confidence that they can fix the problems.

Longman states, “it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.” When individuals make the claim that the VA “scandal” proves that single payer would not work in the United States, refer them to this series being written by Phillip Longman where they can learn the truth.

Single-payer would fix health care

By Bob Fischer
Register Guard (Eugene, Ore.), Letters, June 2, 2014

In his May 24 letter Roger Russell said the serious problems at Veterans Affairs hospitals have to do with allegations of veterans waiting weeks or months to see a doctor, malpractice, fraud and even unnecessary deaths.

Those are symptoms of serious problems related to the VA’s size and financing. It’s too small to handle the enormous need, and it doesn’t receive the resources it needs to do the job.

Russell said having a single-payer system would mean the federal government would take over and control the nation’s health care system. That’s wrong, too, with the error due to confusing health care financing with health care delivery.

Single-payer is about financing health care. It’s like Medicare. Under a single-payer system, the government pays the bills and health care delivery is left in the hands of doctors, nurses and other health care professionals, a matter between patients and their doctors. Unlike private insurance companies, the government doesn’t intrude or interfere.

Single-payer means the for-profit insurance industry is taken out of the health care equation. Private insurance companies are the reason Americans pay twice as much for health care as people of other industrialized nations, and they’re the reason we get worse health care outcomes.

If we want to fix our health care system, single-payer is the only way to do it.

Bob Fischer resides in Bandon, Ore.

http://registerguard.com/rg/opinion/31640663-78/care-health-eugene-system-payer.html.csp

Wake-up call for reform

By Arthur J. Sutherland III, M.D.
The Commercial Appeal (Memphis, Tenn.), Letters, May 31, 2014

Your May 18 article “City health plan: Changes could cost retirees, employees” shows just how broken our health care delivery system has become. Employer-based commercial health insurance is not working. This way of financing access to health care has persisted in spite of the evidence that the U.S. has the most complex, chaotic and costly health care system in the developed world. We do not cover everyone in America and most people with insurance are underinsured. Your article gave dramatic examples of gaps in coverage for both active city employees and retirees.

The sad part of this story is that America spends twice as much per capita on health care as other countries, but gets inadequate results. We are the only developed country in the world not to provide universal coverage, and the World Health Organization ranks the U.S. 37th in overall health status compared to other nations.

The 2010 Patient Protection and Affordable Care Act was just “health insurance reform.” We are already seeing that this law will not cover everyone in America or control long-term costs. In essence, it is not sustainable because it added more cost and complexity, plus reduced the patients’ choice of providers and hospitals to narrow networks controlled by the insurance industry.

What we need is a public single-payer national health insurance system — a “Medicare for all” model. We were never able to get this debate on the table during the health care reform debate because of the excessive corporate influence that rendered our government incapable of making policy on the basis of evidence and the public good.

Your story should be our early warning, and a wake-up call to restructure our health care payment and delivery system.

Dr. Arthur J. Sutherland III resides in Memphis.

http://www.commercialappeal.com/news/2014/may/31/letter-wake–call-reform/

VA: Do we awfulize, or do we fix it?

Chairman Sanders Lays Out Legislative Action Plan for Veterans

Senator Bernie Sanders, June 1, 2014

Senate Veterans’ Affairs Committee Chairman Bernie Sanders (I-Vt.) today outlined a comprehensive legislative package to address “reprehensible” behavior by VA officials and to correct underlying problems in access to medical care.

“There must be a culture of honesty and accountability within the VA and people who have lied or manipulated data must be punished. But we also have to get to the root causes of the problems that have been exposed. The simple truth is that with 2 million more veterans coming into the system in recent years there are many facilities within the VA that do not have the doctors, nurses and other personnel that they need to provide quality care in a timely way.”

Sanders said a Thursday hearing of the veterans committee will consider the Restoring Veterans’ Trust Act of 2014. The measure then could be put on a fast track for consideration by the full Senate. It would give the VA authority to immediately remove senior executives based on poor job performance while preventing wholesale political firings. It would provide veterans who can’t get timely appointments with VA doctors the option of going to community health centers, military hospitals or private doctors. It would authorize VA to lease 27 new health facilities in 18 states. It would authorize emergency funding to hire new doctors, nurses and other providers in order to address system-wide health care provider shortages and to take other steps necessary to ensure timely access to care.  To address primary care doctor shortage for the long-term, the bill would authorize the National Health Service Corps to award scholarships to medical school students and to forgive college loans for doctors and nurses who go to work at the VA.

Altogether, the bill would provide education, retirement security and other benefits for millions of veterans and their families. Virtually all of the provisions already have been approved by the Senate committee, many of them by unanimous votes, during previous legislative markup sessions.

Sanders said the need for congressional action was underscored last Wednesday when the VA’s independent Office of Inspector General found that officials had lied about wait times for appointments at the Phoenix VA and other medical facilities. A separate audit delivered to President Barack Obama on Friday disclosed attempts by VA employees at two-thirds of VA hospitals and clinics to cover up delays in providing patient care.

http://www.sanders.senate.gov/newsroom/press-releases/chairman-sanders-lays-out-legislative-action-plan-for-veterans

THE RESTORING VETERANS’ TRUST ACT OF 2014: http://www.sanders.senate.gov/download/restoringveteranstrustact2014?inline=file

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VA Scandal Gives Single-Payer Opponents Ammunition

By Brianna Ehley
The Fiscal Times, May 27, 2014

The ongoing scandal at the Veterans Affairs Department has forced the idea of government-managed health care into the spotlight, with opponents pointing to the VA’s failures as an example of what could happen if the country were to adopt government run health care or a single payer insurance policy on a larger scale.

Larry Kudlow of the Kudlow Report was quick to pounce on the VA scandal as testament to what goes wrong when you adopt socialized medicine. “This VA scandal is a reminder that government-run single-payer health care does not work.”

However, single payer advocates say what’s happening at the VA isn’t relevant to single payer at all, since the VA is completely government-run and in a single- payer system, the delivery of care would remain largely in the private sector’s hands.

Sen. Bernie Sanders, the independent Senator from Vermont and potential 2016 presidential contender, has been a leading advocate of a single-payer health care system for years. Last week, Sanders led a panel discussion on Capitol Hill over the future of single payer, since his home state of Vermont is expected to serve as a single payer guinea pig for other states.

http://www.thefiscaltimes.com/Articles/2014/05/27/VA-Scandal-Gives-Single-Payer-Opponents-Ammunition

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Comment:

By Don McCanne, MD

To no surprise, opponents of government involvement in health care have jumped on the malfeasance exposed at the Veterans Health Administration as proof that the government can’t do anything right. Many have expanded that by saying that this is proof that a single payer health care system cannot work – a non sequitur if there ever was one. This nonproductive awfulizing that is taking place (imagining horrific situations and outcomes that don’t yet exist) is a totally inappropriate response when what we need is intervention to correct the deficiencies. Fortunately Sen. Bernie Sanders understands that.

The problem provoking the current furor is the tolerance and mismanagement of excessive queues. It is well within our capabilities to reduce queues to acceptable levels. More attention should be given to queue management (the process that reduced long lines at airports after 9/11). Capacities within the system need to be adjusted. Often small expenditures directed to increasing capacity can dramatically reduce queues. Reinforcing primary care has long been recognized as a priority, yet members of Congress sit on their duffs. Perhaps this will awaken some members to the need to fulfill their responsibilities to the people.

In February, Sen. Sanders submitted a bill to Congress designed to improve the functioning of the VA health system. It was blocked by the Republican Senators. Sen. Sanders is now using the political capital created by this mismanagement in an effort to enact The Restoring Veterans’ Trust Act of 2014. It not only addresses the queues, but it also establishes other important policies designed to improve the functioning of the VA health system. Although he may be able to gain enough Republican support to pass this bill in the Senate, some Republican members of the House this weekend said that we do not have the money required to implement the proposals. Of course that is nonsense. With midterm elections around the corner, the Republicans are going to have to decide whether they want to take the blame for refusing to act on behalf of our veterans.

This really is about what we are as a country. Do we take care of our veterans, or do we move forward with efforts to defund the government so it will drown in a bathtub? We have our choice of politicians who will align themselves with one side or the other. In a democracy, it is up to the voters to decide which politicians we want representing us. So, what do we support, social solidarity or trashing of our revered government institutions?

Simpler, better

By George Dyck, M.D.
The Wichita Eagle, Letters, May 20, 2014

As we still hear about confusion surrounding the Affordable Care Act, I think about how different it is in Canada. I go there to work in the summer and see how much simpler things can be for the person who needs medical care. Residents of Canada can go to the Manitoba Health website and see the following:

“Medicare has become culturally and politically important to Canadians as a reflection of, and as a defining influence on, our national identity. Shared principles of equity, fairness and compassion are embodied in the health care system, and the services it provides are now regarded as a basic right.

“In order to receive medical attention, Canadians need only go to the physician or clinic of their choice and present the health insurance card issued to all eligible residents of a province or territory. There are no charges, deductibles or dollar limits for insured medical services (physician, hospital and surgical-dental), and there are no forms for patients to fill out.”

What is it that prevents Americans from embracing this kind of system? We hear voices saying we do not want to give up our freedoms. But what kind of freedom is this for those who cannot figure out how to get their medical care?

I do not hear people in Manitoba complaining about lost freedom. They shake their heads in disbelief about how complicated it is south of the border. And statistics show they have better health and greater longevity, as well as better overall satisfaction with their health care.

Dr. George Dyck resides in North Newton, Kan.

http://www.kansas.com/2014/05/20/3464064/letters-to-the-editor-on-rps-promoting.html#storylink=cpy

The VA scandal, and the ones beyond

By Inge De Becker, M.D.
Star Tribune (Minneapolis), May 31, 2014

True, the VA has waiting lists, real and fake. We spend fortunes to send youngsters to war, yet underfund their care when they come home. They suffer for no good reason.

That is unacceptable.

Here’s what else is unacceptable. Even with the Affordable Care Act, 30 million U.S. people will remain uninsured. No one keeps their waiting lists, but each year tens of thousands will die because they lack adequate access to medical care. Nearly half of the states refuse to expand Medicaid, effectively condemning more than 7,000 uninsured each year to preventable deaths. Medical bills remain the leading cause of bankruptcy. We don’t have enough primary care physicians, both inside and outside the VA.

Even the best programs could be better, and doctoring waiting lists must stop, but patient surveys still make the VA the highest-rated health care program in the country. Let’s face it. The VA is a public, single-payer health care program. The day the United States and Minnesota choose an adequately funded, public single-payer system, everyone will have access to timely care, and everyone will be protected from financial disaster in time of illness.

Now that is acceptable.

Dr. Inge De Becker resides in St. Paul.

http://www.startribune.com/opinion/letters/261324261.html

VA: Do we awfulize, or do we fix it?

Chairman Sanders Lays Out Legislative Action Plan for Veterans

Senator Bernie Sanders, June 1, 2014

Senate Veterans’ Affairs Committee Chairman Bernie Sanders (I-Vt.) today outlined a comprehensive legislative package to address “reprehensible” behavior by VA officials and to correct underlying problems in access to medical care.

“There must be a culture of honesty and accountability within the VA and people who have lied or manipulated data must be punished. But we also have to get to the root causes of the problems that have been exposed. The simple truth is that with 2 million more veterans coming into the system in recent years there are many facilities within the VA that do not have the doctors, nurses and other personnel that they need to provide quality care in a timely way.”

Sanders said a Thursday hearing of the veterans committee will consider the Restoring Veterans’ Trust Act of 2014. The measure then could be put on a fast track for consideration by the full Senate. It would give the VA authority to immediately remove senior executives based on poor job performance while preventing wholesale political firings. It would provide veterans who can’t get timely appointments with VA doctors the option of going to community health centers, military hospitals or private doctors. It would authorize VA to lease 27 new health facilities in 18 states. It would authorize emergency funding to hire new doctors, nurses and other providers in order to address system-wide health care provider shortages and to take other steps necessary to ensure timely access to care.  To address primary care doctor shortage for the long-term, the bill would authorize the National Health Service Corps to award scholarships to medical school students and to forgive college loans for doctors and nurses who go to work at the VA.

Altogether, the bill would provide education, retirement security and other benefits for millions of veterans and their families. Virtually all of the provisions already have been approved by the Senate committee, many of them by unanimous votes, during previous legislative markup sessions.

Sanders said the need for congressional action was underscored last Wednesday when the VA’s independent Office of Inspector General found that officials had lied about wait times for appointments at the Phoenix VA and other medical facilities. A separate audit delivered to President Barack Obama on Friday disclosed attempts by VA employees at two-thirds of VA hospitals and clinics to cover up delays in providing patient care.

http://www.sanders.senate.gov/newsroom/press-releases/chairman-sanders-l…

THE RESTORING VETERANS’ TRUST ACT OF 2014:http://www.sanders.senate.gov/download/restoringveteranstrustact2014?inl…

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VA Scandal Gives Single-Payer Opponents Ammunition

By Brianna Ehley
The Fiscal Times, May 27, 2014

The ongoing scandal at the Veterans Affairs Department has forced the idea of government-managed health care into the spotlight, with opponents pointing to the VA’s failures as an example of what could happen if the country were to adopt government run health care or a single payer insurance policy on a larger scale.

Larry Kudlow of the Kudlow Report was quick to pounce on the VA scandal as testament to what goes wrong when you adopt socialized medicine. “This VA scandal is a reminder that government-run single-payer health care does not work.”

However, single payer advocates say what’s happening at the VA isn’t relevant to single payer at all, since the VA is completely government-run and in a single- payer system, the delivery of care would remain largely in the private sector’s hands.

Sen. Bernie Sanders, the independent Senator from Vermont and potential 2016 presidential contender, has been a leading advocate of a single-payer health care system for years. Last week, Sanders led a panel discussion on Capitol Hill over the future of single payer, since his home state of Vermont is expected to serve as a single payer guinea pig for other states.

http://www.thefiscaltimes.com/Articles/2014/05/27/VA-Scandal-Gives-Singl…

To no surprise, opponents of government involvement in health care have jumped on the malfeasance exposed at the Veterans Health Administration as proof that the government can’t do anything right. Many have expanded that by saying that this is proof that a single payer health care system cannot work – a non sequitur if there ever was one. This nonproductive awfulizing that is taking place (imagining horrific situations and outcomes that don’t yet exist) is a totally inappropriate response when what we need is intervention to correct the deficiencies. Fortunately Sen. Bernie Sanders understands that.

The problem provoking the current furor is the tolerance and mismanagement of excessive queues. It is well within our capabilities to reduce queues to acceptable levels. More attention should be given to queue management (the process that reduced long lines at airports after 9/11). Capacities within the system need to be adjusted. Often small expenditures directed to increasing capacity can dramatically reduce queues. Reinforcing primary care has long been recognized as a priority, yet members of Congress sit on their duffs. Perhaps this will awaken some members to the need to fulfill their responsibilities to the people.

In February, Sen. Sanders submitted a bill to Congress designed to improve the functioning of the VA health system. It was blocked by the Republican Senators. Sen. Sanders is now using the political capital created by this mismanagement in an effort to enact The Restoring Veterans’ Trust Act of 2014. It not only addresses the queues, but it also establishes other important policies designed to improve the functioning of the VA health system. Although he may be able to gain enough Republican support to pass this bill in the Senate, some Republican members of the House this weekend said that we do not have the money required to implement the proposals. Of course that is nonsense. With midterm elections around the corner, the Republicans are going to have to decide whether they want to take the blame for refusing to act on behalf of our veterans.

This really is about what we are as a country. Do we take care of our veterans, or do we move forward with efforts to defund the government so it will drown in a bathtub? We have our choice of politicians who will align themselves with one side or the other. In a democracy, it is up to the voters to decide which politicians we want representing us. So, what do we support, social solidarity or trashing of our revered government institutions?

Health policy experts versus everyone else: Why do the experts believe themselves?

Unnecessary Tests and Procedures In the Health Care System: What Physicians Say About The Problem, the Causes, and the Solutions: Results from a National Survey of Physicians

ABIM Foundation, May 1, 2014

Nearly three-quarters (73 percent) of physicians say the frequency of unnecessary tests and procedures in the health care system is a very (29 percent) or somewhat (44 percent) serious problem. ….

The top reasons physicians say they order unnecessary tests and procedures are concern about malpractice issues (52 percent say a major reason), just to be safe (36 percent), and wanting more information for reassurance (30 percent). …

The second-tier influences are patients’ insistence (28 percent) and wanting to keep patients happy (23 percent). Third-tier reasons include other factors such as … the fee-for-service system (5 percent)…. [p 5]

http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf

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Phasing out fee-for-service payment

By William Frist and Steven Schroeder
New England Journal of Medicine, 2013; 368:2029-2032

The fee-for-service mechanism of paying physicians is the major driver of higher health care costs in the United States [citation omitted] ….. The long-range solution is [to] shift from a payment system based on a fee-for-service model to one based on value through mechanisms such as bundled payment, capitation, and increased financial risk sharing.

http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

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Comment:

By Kip Sullivan, JD

There is an enormous gap between the opinions of the health policy elite in this country and those of the public, including physicians. The health policy elite find this gap too boring to analyze. They know why this gap exists. The problem is not them, it’s the hoi polloi and the doctors. Patients are bewitched by “technology” and think “more is better,” and doctors’ minds are warped by the incentives of the fee-for-service system. It does not occur to health policy experts that there might be something very wrong with their culture. The idea that there is even a “culture” within the health policy establishment would strike the establishment as at best uninteresting and at worst silly. That this culture might be dysfunctional is unthinkable. In their view, the only “culture” that needs analysis is that of the medical profession and of the unwashed masses.

Although the gap between public and expert opinion was documented by the early 1990s, the health policy community has shown no interest in understanding its cause. For the health policy elite, there is nothing to explain: The public is wrong and they are right. Pollster Daniel Yankelovich articulated the establishment point of view in a 1995 paper on the muddled debate about the Clintons’ Health Security Act. “The nation’s leadership and the public are carrying out a bizarre dialogue of the deaf,” Yankelovich wrote. “The nation’s elites have little trouble conversing with one another, but when it comes to engaging the public, there is an astonishing lack of dialogue.” [p. 8]

http://content.healthaffairs.org/content/14/1/7.full.pdf+html?sid=fa42b84d-5f51-458f-bde1-d42bcbd15855  

The problem, said Yankelovich, is the public does not agree with the experts’ diagnosis of the health care crisis. Virtually the entire health policy establishment thinks US expenditures are high because the volume of health care is excessive. But the public disagrees. As Yankelovich put it, “[M]ost Americans attribute the rising costs of health care to waste, fraud, greed, and inefficiency, [and] they assume that whatever is wrong can be fixed by cracking down on these expressions of venality….” [p. 14] The public, Yankelovich concluded, is “on a collision course with the majority of experts”. [p. 14] Yankelovich’s explanation for this standoff was “lack of realism” and “wishful thinking” by the masses. The elite couldn’t possibly be wrong.

The health policy cognoscenti treat the gap between physician and expert opinion with the same incuriosity and arrogance. The latest evidence of how drastically physician opinion departs from that of the establishment appeared in a poll published by the ABIM Foundation (created by the American Board of Internal Medicine) on May 1. The poll found that only 5 percent of physicians believe the fee-for-service payment method is a major cause of overuse of medical care. The three most common explanations doctors offered were variations on the same theme: Reducing uncertainty. Other polls report similar results http://www.unitedhealthgroup.com/~/media/UHG/PDF/2012/UNH-Working-Paper-8.ashx (see p. 8) http://jama.jamanetwork.com/article.aspx?articleid=1719740 (see Table 3).

The health policy elite emphatically disagrees. “The fee-for-service model is like asking a butcher how much steak you should eat,” Jonathan Gruber, a prominent advisor to the Obama administration, “explained” to NPR.

http://www.npr.org/templates/story/story.php?storyId=106859968

According to former Senator William Frist and Steven Schroeder (see article quoted above), the “fee-for-service mechanism is the major driver of higher health care costs.”

How do we explain this divergence of opinion? I propose a modest hypothesis: That the health policy community is as deeply influenced by incentives peculiar to their profession as physicians are by incentives peculiar to their profession. I propose that researchers both inside and outside the health policy community begin their analysis of my hypothesis by documenting the pattern I have outlined above – the experts’ habit of issuing pronouncements on the allegedly irresponsible behavior of doctors as the chief cause of the health care crisis – and comparing that pattern with analogous patterns in physician explanations. Investigators would then examine the evidence behind the different world views.

Let me offer an illustration.  The paper from the New England Journal of Medicine quoted above – “Phasing out fee-for-service payment” – contained one of those extremely rare instances in which proponents of the FFS-is-to-blame diagnosis tried to document their claim. The authors, Frist and Schroeder, cited one and only one paper – a paper published in 2011 by Laugeson and Glied entitled, “Higher fees paid to US physicians drive higher spending for physician services compared to other countries.” http://content.healthaffairs.org/content/30/9/1647.abstract The paper didn’t merely fail to support Frist and Schroeder’s claim, it contradicted it. It demonstrated that volume of services (in other words, overuse) could not explain why expenditures on physicians are so much higher in the US than in other countries that also rely primarily on the FFS method, and that higher physician fees in the US explained the difference. To paraphrase Gerard Anderson et al. http://content.healthaffairs.org/content/22/3/89.full.pdf+html, it’s the prices stupid, not FFS.

Researchers investigating my hypothesis might ask, What incentives are Frist and Schroeder exposed to that would incline them to make such a sloppy mistake? Do proponents of the FFS-is-to-blame mantra and managed care in general make more money, publish more often, advance faster within the ranks of politics and academia, have greater access to the media, or have more luck raising money from foundations than, say, single-payer advocates or observers who are less passionate about their criticism of doctors and patients?

I’m not proposing to exempt doctors and patients from similar scrutiny. I’m proposing that the scrutiny, at long last, become even-handed. I have little doubt even-handed scrutiny would either force the health policy illuminati to honor the rules of scientific discourse and stop promoting diagnoses and solutions with little or no evidence, or it would lower the credibility of the illuminati in the eyes of the public and the media. In either event, the decks would be cleared for a real debate about single payer. Then the most profound gap between the public (including physicians) and the experts would become more visible: By large majorities the public supports single-payer. https://www.pnhp.org/sites/default/files/docs/2011/Kip-Sullivan-Two-thirds-support-medicare-for-all.pdf