VA hospital system: best in the US

[Jason McCullough]

http://www.washingtonmonthly.com/features/2005/0501.longman.html

So if you measure the outcomes of the Veteran's Department health care system, they actually blow the private health care system out of the water. Apparently they've been doing tons of shit there.

Outside experts agree that the VHA has become an industry leader in its safety and quality measures. Dr. Donald M. Berwick, president of the Institute for Health Care Improvement and one of the nation's top health-care quality experts, praises the VHA's information technology as “spectacular.” The venerable Institute of Medicine notes that the VHA's “integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation.”

If this gives you cognitive dissonance, it should. The story of how and why the VHA became the benchmark for quality medicine in the United States suggests that much of what we think we know about health care and medical economics is just wrong. It's natural to believe that more competition and consumer choice in health care would lead to greater quality and lower costs, because in almost every other realm, it does. That's why the Bush administration—which has been promoting greater use of information technology and other quality improvement in health care—also wants to give individuals new tax-free “health savings accounts” and high-deductible insurance plans. Together, these measures are supposed to encourage patients to do more comparison shopping and haggling with their doctors; therefore, they create more market discipline in the system.

But when it comes to health care, it's a government bureaucracy that's setting the standard for maintaining best practices while reducing costs, and it's the private sector that's lagging in quality. That unexpected reality needs examining if we're to have any hope of understanding what's wrong with America's health-care system and how to fix it. It turns out that precisely because the VHA is a big, government-run system that has nearly a lifetime relationship with its patients, it has incentives for investing in quality and keeping its patients well—incentives that are lacking in for-profit medicine.

To understand the larger lessons of the VHA's turnaround, it's necessary to pause for a moment to think about what comprises quality health care. The first criterion likely to come to mind is the presence of doctors who are highly trained, committed professionals. They should know a lot about biochemistry, anatomy, cellular and molecular immunology, and other details about how the human body works—and have the academic credentials to prove it. As it happens, the VHA has long had many doctors who answer to that description. Indeed, most VHA doctors have faculty appointments with academic hospitals.

But when you get seriously sick, it's not just one doctor who will be involved in your care. These days, chances are you'll see many doctors, including different specialists. Therefore, how well these doctors communicate with one another and work as a team matters a lot. “Forgetfulness is such a constant problem in the system,” says Berwick of the Institute for Health Care Improvement. “It doesn't remember you. Doesn't remember that you were here and here and then there. It doesn't remember your story.”

Are all your doctors working from the same medical record and making entries that are clearly legible? Do they have a reliable system to ensure that no doctor will prescribe drugs that will interact harmfully with medications prescribed by another doctor? Is any one of them going to take responsibility for coordinating your care so that, for example, you don't leave the hospital without the right follow-up medication or knowing how and when to take it? Just about anyone who's had a serious illness, or tried to be an advocate for a sick loved one, knows that all too often the answer is no.

So they found the free money laying on the floor in health care through boring process-control reform, basically. Lots of managment of business tech, too.

Interesting thoughts how the drive for profits at hospitals & HMOs directly conflicts with improved care, too, in a "lack of long-run investment" way.

First, unlike virtually all other health-care systems in the United States, VHA has a near lifetime relationship with its patients. Its customers don't jump from one health plan to the next every few years. They start a relationship with the VHA as early as their teens, and it endures. That means that the VHA actually has an incentive to invest in prevention and more effective disease management. When it does so, it isn't just saving money for somebody else. It's maximizing its own resources.

The system's doctors are salaried, which also makes a difference. Most could make more money doing something else, so their commitment to their profession most often derives from a higher-than-usual dose of idealism. Moreover, because they are not profit maximizers, they have no need to be fearful of new technologies or new protocols that keep people well. Nor do they have an incentive to clamor for high-tech devices that don't improve the system's quality or effectiveness of care.

And, because it is a well-defined system, the VHA can act like one. It can systematically attack patient safety issues. It can systematically manage information using standard platforms and interfaces. It can systematically develop and implement evidence-based standards of care. It can systematically discover where its care needs improvement and take corrective measures. In short, it can do what the rest of the health-care sector can't seem to, which is to pursue quality systematically without threatening its own financial viability.

[magnet]

Some unrelated features of VA hospitals that may contribute to their success:

1) Many of them are affiliated with university teaching hospitals, and benefit from their expertise. Academic medical centers usually give better (if less personal) care than community hospitals.

2) It's almost impossible to win a malpractice case against the VA or its docs, and everyone knows it.

3) The VA was among the first the adopt a fully electronic medical record.

[Alan Au]

In addition, the VA system is more or less centrally administered, which is one of the reasons *why* they can effectively roll out an EMR system. Being affiliated with the university teaching system certainly doesn't hurt either. Contrast this with the private care system, which is a fairly uncoordinate collection of service providers.

On the subject of EMRs, there's currently a federal initiative to develop a standardized national EMR system. Of course, for an example of failed EMR systems, look for a report on the Cedars-Sinai EMR fiasco.

- Alan

[Jason McCullough]

A lot of it does look like incentives. "The VA systems strongest incentive is to keep people from coming back by making sure they're healthy" is quite a bit different from "hospital incentives are to sell services." One's the insurance company and the provider combined, one has them seperate.

Is there any evidence that malpractice claims actually affect the cost of health care? Kevin Drum digs up numbers on this occasionally, and it seems to be a rounding error.

[graller]

My employer is the provider of the databases used throughout the VA. They do have a powerful, unified view of the electronic record. We just finished a rollout that upgraded every server in every hospital to our latest version and the latest version of VMS. All the VA sites run on Compaq AlphaVMS clusters running Cache - our database product. Most of the applications run in the VA are home grown or implemented by consultants to the VA's design specifications.

[Derek Meister]

It certainly doesn't hurt in attracting doctors.

[magnet]

A lot of it does look like incentives. "The VA systems strongest incentive is to keep people from coming back by making sure they're healthy" is quite a bit different from "hospital incentives are to sell services." One's the insurance company and the provider combined, one has them seperate.

Is there any evidence that malpractice claims actually affect the cost of health care? Kevin Drum digs up numbers on this occasionally, and it seems to be a rounding error.
I'd be interested in seeing his analysis. Do you have a link?

There's several components to this issue. Malpractice premiums are probably a negligible factor in the rising costs of health care.

However, the threat of a lawsuit changes the way health care is distributed, and leads to a lot of waste. On the other hand, lawsuits may decrease the likelihood of costly errors. Anecdotally, there are plenty of VA doctors faced with a possible errors who shrugged them off, saying "Don't worry, this is the VA."

I'm not sure how you could determine the size of the net effect, since so much of it occurs at the margins. For example, if expensive drug X is slightly better than cheap drug Y, is prescribing Y an error? If you are 90% confident of a diagnosis, should you order an expensive test that will bring your confidence level to 99%? In private practice, the standard of care often does not take costs into account. Cost-benefit analyses are rare; in their absence using the cheaper drug and skipping the test are considered errors. Maybe they shouldn't be.

[Jason McCullough]

Well, how do you know it's such a big problem then if it's so hard to measure? With the insurance industry's history of astroturf PR in this area I suspect the whole thing is made up.

http://www.washingtonmonthly.com/archives/individual/2005_01/005402.php

http://www.washingtonmonthly.com/archives/individual/2005_01/005402.php

[magnet]

Well, how do you know it's such a big problem then if it's so hard to measure? With the insurance industry's history of astroturf PR in this area I suspect the whole thing is made up.

http://www.washingtonmonthly.com/archives/individual/2005_01/005402.php

http://www.washingtonmonthly.com/archives/individual/2005_01/005402.php
I think most analyses of the growing costs of health care in the US pin the blame on technology, not malpractice premiums. New drugs and tests cost a lot, and deliver a small incremental benefit.

Health care providers are taught to always opt for the best proven technology - that's practically the definition of "Standard of Care." Oftentimes they don't even know how much a drug or test costs, especially if a third party is paying. Fear of malpractice and moral hazard both probably contribute to this effect.

I didn't say this was a problem. It's not, any more than buying a Rolls-Royce is a "problem". It's simply an expensive solution.

[Nick Walter]

<RANT>

I'll go ahead and say healthcare costs are a fucking problem, but then I get pissed at this sort of things and the incredible waste and the incredibly poor cost/benefit ratio that modern healthcare is providing.

My wife has probably racked up $15000 in doctors bill (largely covered by insurance) in the last 2 years. None of that medical care provided her ANY benefit, no conditions were cured or alleviated, no forward progress was made on her health. Lots and lots of very expensive and arcane tests were ordered by doctors apparently afraid to leave any bizarre probability unexplored, lots of time and money was wasted. All for zero net benefit. Both of the (minor) health problems my wife had 2 years ago she still has.

</RANT>

[Jason McCullough]

Oh, obviously tech is driving increasing costs. I just think malpractice claims are a snow job.

Sorry to here about your wife, Nick. Um, and if they're minor problems why did you order the tests?

[magnet]

Oh, obviously tech is driving increasing costs. I just think malpractice claims are a snow job.

Sorry to here about your wife, Nick. Um, and if they're minor problems why did you order the tests?
Exactly.

He didn't order the test - his wife's doctor did.

Consider that other countries have access to the same technology we do, but they manage to keep costs down. Why?

Part of the reason is that doctors order tests that they know in advance are unnecessary. I interpret some of these tests for a living, and I'd estimate at last half the calls I get from doctors begin, "Look, we know it's going to be negative, but we need to get a [insert test] before we send the patient home." Because if they don't and something goes wrong, they fear getting sued. Besides, insurance will pay (mostly), right? Likewise, doctors prescribe expensive medicines with very little marginal utility, e.g. Plavix instead of aspirin for stroke prevention.

And you're right, tort reform isn't going to change that - it's a question of attitudes. We have to ask ourselves as a nation whether we are better served by an expensive Rolls-Royce of a health care system, or a Honda which does almost exactly the same job, but costs a lot less.

[Jason McCullough]

.....and going back to the linked article, that kind of fits in with "the private health care system has the wrong incentives." When you think about it, doctors getting paid per-procedure is rather strange.

[magnet]

.....and going back to the linked article, that kind of fits in with "the private health care system has the wrong incentives." When you think about it, doctors getting paid per-procedure is rather strange.
I agree that incentives in health-care are a cause of the problem of increasing costs.

I don't know how you avoid paying a doctor per-procedure, though. Capitated systems, in which a physician gets a salary based on patient load, might work for primary care docs, but their salaries aren't driving costs - they're just the gatekeepers.

Bear in mind that there are laws against docs getting reimbursed for tests they order - someone else is supposed to do the job. In fact the largest costs get incurred when a patient is referred to a specialist. But if specialists doesn't get paid per-procedure, why should they accept complicated referrals? If an HMO is serious about cutting costs, they can refuse to refer patients to a non-capitated specialist. But since the non-capitated specialists are usually the most popular, patients will inevitably complain about not being able to choose their own doctor.

[Kevin McGuire]

Being in the trenches, I have to say that defensive medicine (ie ordering a bunch of tests that will be low yield in order to avoid a potential lawsuit if you miss something) is one of the major factors driving health care costs. Its not the malpractice premium, but the threat of lawsuit behind it that drives doctors to order more tests.

The downside if you're sued is catastrophic - sure, you're likely covered by insurance, but even if you win the case (and the vast majority of malpractice cases go to the defendant) you face the misery of court time, the risk of losing your job/reputation, and the time away from your practice.

The downside of ordering more labs or tests is minimal. A few more lines of orders. Maybe an extra form to fill out. And the satisfaction that even if this is a zebra case (the aphorism is that when you hear hoofbeats, you should think about horses, not zebras) you'll have ruled it out or caught it.

The recent example that sticks in my mind is of an internist who was sued for not ordering a PSA on a comparatively young male patient who later turned out to have prostate cancer (he had even discussed not ordering the test with the patient, and they both agreed that it was not needed). The various national guidelines (which the internist followed) recommend against ordering PSA's on younger men, since the false positive rate is so high and the risk of disease is quite low. This leads to follow up tests (needle biopsies, etc) which are unpleasant and since the yield is so low, generally considered uneccessary. However, since many of the other docs in the area (northern VA, IIRC) were ordering PSA's on anyone with a prostate older than 40, he lost the lawsuit.

[Nick Walter]

Oh, obviously tech is driving increasing costs. I just think malpractice claims are a snow job.

Sorry to here about your wife, Nick. Um, and if they're minor problems why did you order the tests?

The tests got done because the doctor used strongarm scare tactics on my wife, frightening her with a litany of things that could be wrong. I think it should be legal to beat doctors for this behavior.

Here's a true Nick's wife story from just a few months back. She goes in to get a routine physical and some sort of routine female plumbing checks. The doctor does a blood test and notices the white blood count is "a little high". He has her come back in a month to get retested, and she's still "a little high." Keep in mind she has no feeling of illness, no ill health, nothing wrong at all except a white blood count that "a little high."

Next thing you know her doctor is telling her that she could just mabe have leukemia (even though she didn't show positive for it on the blood test) and the doctor persuades her to make several special (expensive) visits to a blood specialist, countless more blood draws/tests and to drink radioactive garbage and get a cat scan. Now of course ALL of tests came back negative and the doctor starts coming up with more elaborate ideas and my wife finally tells him to fuck himself. His leukemia scare tactic was probably good for 6ish doctor visits and about $10,000 pissed away on specialist vists and obscure expensive tests. Mind you, the insurance companies paid the vast majority of that but I can see why they have to keep jacking up rates if doctors keep wasting patients money like that.

Anyway, I'm going to stop posting on health care topics because I'm waaay too angry at the medical profession to be rational on the topic.

[Brian Koontz]

Perhaps you guys can clear up something I'm not understanding.

How can a lawsuit be won when the doctor takes a *reasonable* course of action, even if that action includes the lack of a step that would have resulted in success for the patient?

So if the step is deemed excessive in terms of the cost/benefit ratio, it shouldn't be usable in terms of winning a lawsuit, despite that in some cases it will be the difference between success and failure.

Lawsuits can theoretically only be won for MALpractice, right?, inept practice, not for not doing *everything* possible regardless of cost.

Can anyone with more experience in malpractice cases state what it takes to win a malpractice suit?

The other issue is something I see time and time again, its a big problem. Spending other people's money. "Insurance will take care of it". "Oh, I'll just expense account it to the business".

If you're doing something you feel to be MOSTLY a waste of money that you would never pay for yourself but you do because "insurance will cover it", congratulations, you're stealing small amounts of money from the pockets of many people. This should be a crime, its no different from direct theft in terms of effect.

Who is in charge of the morality of money-use? Apparently doctors and patients don't always do such a good job.

[magnet]

Here's a true Nick's wife story from just a few months back. She goes in to get a routine physical and some sort of routine female plumbing checks. The doctor does a blood test and notices the white blood count is "a little high". Keep in mind she has no feeling of illness, no ill health, nothing wrong at all except a white blood count that "a little high."
To be fair Nick, I don't know what your wife's white count was, possibly it was only slightly elevated (although "a little high" can really mean anything). But if mine crossed a certain level and I was not ill, I would be worried and want another test, too, especially now that the new anti-leukemia drugs have come on line. Leukemia is rare but your white count is your only warning.

Note that if you're feeling sick with a high white count, then it's probably a simple inflammatory reaction and probably would not get much further attention absent a significant medical history.

So if the step is deemed excessive in terms of the cost/benefit ratio, it shouldn't be usable in terms of winning a lawsuit, despite that in some cases it will be the difference between success and failure.
You can lose a malpractice lawsuit if the plaintiff shows that you failed to meet the "standard of care." While there's no formal rules regarding what constitutes the standard of care, nearly any expert witness will agree that it rarely involves a cost analysis, except in cases of shortages (e.g. flu vaccine).

The standard of care really amounts to whatever is available at an average hospital that is most likely to help.
Who is in charge of the morality of money-use?
Apart from the fear of getting sued that was described above, here's the rule of thumb doctors unofficially use when making decisions:
Would you want your own mother to have treatment X in this situation, if money were no object?
Bear in mind doctors underestimate the inconvenience of minor tests like CAT scans.

[Jason McCullough]

Nick, as I said: profit motive.

[magnet]

Nick, as I said: profit motive.
If your mechanic says your car needs a new widget and offers to do the job himself, that's ok.

If your doctor says you need a CT scan, and offers to read it himself, that's illegal.

Profit motive is a factor in pretty much everything, including medicine. But in medicine, there's at least an attempt to curb the excesses.

[shift6]

How can a lawsuit be won when the doctor takes a *reasonable* course of action, even if that action includes the lack of a step that would have resulted in success for the patient?
Welcome to the US of A, baby. Where all you have to do is get 75% of those jurors feeling real bad for ya, and you'll win your civil suit against the big bad profit-clawing hospital who is backed by an evil insurance conglomerate without breaking a sweat.

[Jason McCullough]

Nick, as I said: profit motive.
If your mechanic says your car needs a new widget and offers to do the job himself, that's ok.

If your doctor says you need a CT scan, and offers to read it himself, that's illegal.

Profit motive is a factor in pretty much everything, including medicine. But in medicine, there's at least an attempt to curb the excesses.

Except the medical system is pretty much defined by "someone else will pay for almost everything else that's done to me".

Doctors obviously aren't rubbing their hands together and fabricating illnesses, but as the article points out, you get when you have incentives for. If there's no financial incentive for doctors to engage in cheap preventive care like the examples mentioned, they don't focus on it.

[Jason McCullough]

Longman has expanded that this article (http://www.washingtonmonthly.com/features/2005/0501.longman.html) into a very interesting full-length book (http://www.amazon.com/Best-Care-Anywhere-Health-Better/dp/0977825302). Recommended reading for the upcoming debates about what to do on health care in the next administration.

The surprising thing is how simple the technical fixes to half the cost of health care, while covering everyone, would be. Health care is using a 19th-century management and delivery system attached to 21st century technology.

[Chris]

Ok, personal experience here but the VA system schedules my father for surgeries but doesn't know what floor he is on, what day he is supposed to be there, what he is in for, what medication he is on or what room he is in. He never sees the same doctor twice, gets his medication switched around every other visit and is made to take an ambulance 30 miles because they don't want the local civilian emergency room determining how to treat chest pains. I will give them this, they were not responsible for said ambulance running out of gas on the way but I wouldn't be surprised if they were.

At least they drove my father to take Medicare treatment and go to a civilian hospital for the majority of his care.

Maybe that is just our experience.....

[Euri]

Private healthcare continues to fail because there is no way to opt-out. In any profit driven system, we can opt out completely. Doing that with healthcare can mean death. We're forced to pay in to a system that is trying to make as much money as possible. It's bullshit. Healthcare should not be for profit.

[StGabe]

Healthcare is a subject that I'm surprised I don't know more about. It interests me a lot and I've a lot of opinions about what is wrong with it but I'm forced to admit that I don't really have the knowledge or data to back them up.

So with that disclaimer, it seems to me also that the key issue is offering incentives for long-term health. Secondary to that is some centralized method for keeping doctors accountable.

My healthcare nightmare:

I have GERD (acid reflux). When I was first figuring this out I was looking for doctors to help me with the extremely fucked up sore throats and bronchitis I was getting as a result. I.e. ear, nose throat guys. I had recently moved to west LA and didn't know any doctors so I just used my insurance's system for locating doctors. I picked one at random and I made an appointment. I got there and to find out: it's actually a plastic surgery clinic specializing in boob jobs, being run by a guy who initially specialized in ear/nose/throat. He sees me for about 3 minutes, takes one look at my throat, prescribes some antibiotics and chucks me out. Ok, whatever. A waste of my time, certainly, but I figure I'll just pick another doc and try that. Well a month later I get the $400 bill that my insurance decides it won't cover detailing some set of procedures that apparently occurred during my 3 minute meeting with the doctor. I guess he was doing something highly technical with that tongue depressor that I didn't understand. Yay.

...

I've since decided to try out an HMO (Kaiser) figuring that HMO's at least do offer a more centralized medical care system and have to be more concerned about long-term health. I was a bit wary of the "lack of choice" issue but got drawn in by the extremely low deductibles, etc. So far I'm very happy. I've had one bad experience (was told to go to urgent care only to be told at the urgent care that I needed to see my real doc to get any real sorts of care) but that has been balanced out by a lot of good experiences. It does seem pretty clear to me that there is a significant efficiency gain to centralizing the entire enterprise and I do feel like I get more comprehensive care.

Anyway, enough anecdotal stuff. I'm curious if anyone knows of actual data comparing HMO's to PPO's, et al? I'd be curious to look at some numbers.

[Chris]

Health care is a tough nut to crack, a lot of it is lifestyle and the trend towards encouraging preventative checkups and charging more for high-risk patients is probably going to increase. I would not be surprised to see smokers and morbidly obese patients be asked to pay more as long as our current system stays in place. The other part of the issue is the system is pretty entrenched, it will take a lot of effort to fight off the lobbyists for something that will work evenly across the board. I"m no fan of socialization but I think elements of it may need to be considered. I don't know what the answer is though.

[VictoriaWong]

He didn't order the test - his wife's doctor did.
Consider that other countries have access to the same technology we do, but they manage to keep costs down. Why?
Part of the reason is that doctors order tests that they know in advance are unnecessary. I interpret some of these tests for a living, and I'd estimate at last half the calls I get from doctors begin, "Look, we know it's going to be negative, but we need to get a before we send the patient home." Because if they don't and something goes wrong, they fear getting sued. Besides, insurance will pay (mostly), right? Likewise, doctors prescribe expensive medicines with very little marginal utility, e.g. Plavix instead of aspirin for stroke prevention.

That's the nature of evidence-based medicine. The insurance companies are demanding proof before they'll pay for treatment, and the methods of proving that are getting increasingly expensive. Defensive medicine drives up costs too, but someone else already addressed that.
Also, sometimes healthcare providers in an organization have care guidelines they absolutely must follow. For example, I'm a volunteer in a hospital. Since I was born in a British colony, I got the BCG vaccine for TB: standard care, back then. So my skin tests are positive every time I've taken them- twice, since they're good for 4 years. I needed to get a TB clearance this year, since my x-ray clearance was almost over: so I went over to occupational health to see about getting that.
Apparently, in order to order x-rays, they have to have a positive skin test reaction first. Okay, well, I've got documentation of two positive skin tests and clear lungs, why don't you just save the Hospital money and just have me take the x-rays? Nope, they've got to do the skin test first.
So I'll be heading into the hospital on Friday to get x-rayed- my skin test was marginally positive. The entirely unnecessary skin test. And my x-rays will be clear. *shrug*

Perhaps you guys can clear up something I'm not understanding.
How can a lawsuit be won when the doctor takes a *reasonable* course of action, even if that action includes the lack of a step that would have resulted in success for the patient?
So if the step is deemed excessive in terms of the cost/benefit ratio, it shouldn't be usable in terms of winning a lawsuit, despite that in some cases it will be the difference between success and failure.
Lawsuits can theoretically only be won for MALpractice, right?, inept practice, not for not doing *everything* possible regardless of cost.
Can anyone with more experience in malpractice cases state what it takes to win a malpractice suit?
The other issue is something I see time and time again, its a big problem. Spending other people's money. "Insurance will take care of it". "Oh, I'll just expense account it to the business".
Who is in charge of the morality of money-use? Apparently doctors and patients don't always do such a good job.
Welcome to the US of A, baby. Where all you have to do is get 75% of those jurors feeling real bad for ya, and you'll win your civil suit against the [I]big bad profit-clawing hospital who is backed by an evil insurance conglomerate without breaking a sweat.
QFT. The people in charge of the morality of money-use is currently the insurance company. Although Congress tried to step in with Schiavo.


Doctors obviously aren't rubbing their hands together and fabricating illnesses, but as the article points out, you get when you have incentives for. If there's no financial incentive for doctors to engage in cheap preventive care like the examples mentioned, they don't focus on it.
Also, sometimes the patients won't. For example, I have relatives with hypertension and high cholesterol and all that. They continue to eat high-salt and high-fat foods. So at some point, their doctors are going to have to make the choice between prescribing meds or letting them fall apart.

It's bullshit. Healthcare should not be for profit.

Can you agree that healthcare providers should get salaries? If not, we can go back to the home care system developed before modern hospitals developed, and you can see how much better a job untrained people can do. :-[
Health care is a tough nut to crack, a lot of it is lifestyle and the trend towards encouraging preventative checkups and charging more for high-risk patients is probably going to increase. I would not be surprised to see smokers and morbidly obese patients be asked to pay more as long as our current system stays in place. The other part of the issue is the system is pretty entrenched, it will take a lot of effort to fight off the lobbyists for something that will work evenly across the board. I"m no fan of socialization but I think elements of it may need to be considered. I don't know what the answer is though.
Close. There are too many lobbies that would be against increasing costs for smokers and morbidly obese patients that that would never happen.

In the interest of full disclosure:
I'm a pre-med student working in biological research and studying public health policy and implementation at one of the leading US institutions for the above.

[Euri]

Can you agree that healthcare providers should get salaries? If not, we can go back to the home care system developed before modern hospitals developed, and you can see how much better a job untrained people can do. :-[

I can't tell if you're an idiot or you misunderstand.

[VictoriaWong]

The healthcare system must be profit-driven to some extent in order to pay for research and salaries. The only other option is to cut down on both of these, and while I'll cheerfully agree that many private doctors are overpaid, without the incentive of comparatively high pay for skilled healthcare professionals, there'd be a lot fewer in healthcare, and at that point, care might end up switching back to the home care model.

Not healthy for society.

[Euri]

For-profit in this context means that it exists for the pursuit of monetary gain exclusively. That is, a business. Healthcare should not be a business. Doctors, having to do difficult work after a difficult education should be well paid. Research should be funded by private/public sources. But, a hospital should not exist to turn a profit. Nobody should be getting fabulously, hundreds of millions of dollars wealthy off of any of this.

[Lurb]

Can you agree that healthcare providers should get salaries? If not, we can go back to the home care system developed before modern hospitals developed, and you can see how much better a job untrained people can do. :-[

...

In the interest of full disclosure:
I'm a pre-med student working in biological research and studying public health policy and implementation at one of the leading US institutions for the above.

Need to study more. I'll paint it with thick lines.

Non for profit healthcare budgetting:
-Collect taxes&premiums
-Buy hi-tech thingies
-Docs: Pay them
-Nurses: Pay them
-Staff: Pay them
-Lawyers: Fuck them sideways, then legislate them out of the picture
-Shareholders: Try somewhere else kthxbye

[VictoriaWong]

For-profit in this context means that it exists for the pursuit of monetary gain exclusively. That is, a business. Healthcare should not be a business. Doctors, having to do difficult work after a difficult education should be well paid. Research should be funded by private/public sources. But, a hospital should not exist to turn a profit. Nobody should be getting fabulously, hundreds of millions of dollars wealthy off of any of this.


Need to study more. I'll paint it with thick lines.

Non for profit healthcare budgetting:
-Collect taxes&premiums
-Buy hi-tech thingies
-Docs: Pay them
-Nurses: Pay them
-Staff: Pay them
-Lawyers: Fuck them sideways, then legislate them out of the picture
-Shareholders: Try somewhere else kthxbye



Yes, I understand this, but private hospitals would exist in far fewer numbers if it were not for the for-profit system: this would lead not only to less care being provided, but also fewer spaces available for training and other problems associated with packed hospitals.
Also, pharmaceuticals are largely profit-driven because they're comparatively difficult to find. *shrug* Many times they're found at academic institutions and then the discoverers go and found a company to pursue it. I'll agree with you that no one should be getting fabulously wealthy off of healthcare.
The only reason I made that statement earlier was that last year, in my public health policy class, someone seriously argued that doctors should do what they do because they love it and not get paid. No compensation whatsoever. And they weren't arguing this in a "reductio ad absurdum" manner but with a genuine conviction that not only was this truly non-profit, but this was the only real way to run medical care. Under the justification that someone had to be making a profit if money was changing hands, presumably.
Now, I'm fine with being a resident and sleeping in a cot in the hospital breakroom for the rest of my life, and the hospital provides scrubs, but it'd be nice to be able to do things like, you know, eat once in a while. Not necessarily good food, but at least 2000 calories a day.
So I wasn't sure if the poster meant it that way.

[Euri]

The only reason I made that statement earlier was that last year, in my public health policy class, someone seriously argued that doctors should do what they do because they love it and not get paid.

Seriously? I'd have ended the conversation right there. I love what I do but damn if you aren't going to pay me for it. Being a doctor is not easy and deserves good compensation. Even in zomg socialist countries without much of a private sector, doctors get paid fairly well.

[VictoriaWong]

It was less a conversation than it was a "class discussion" moderated by the policy-side Public Health TA, who dismissed attempts to denounce this person by saying "I think he has a valid point of view. Let's listen to what he has to say."
Their idea of fair compensation apparently includes only the satisfaction of saving lives. Sure, it's incredibly satisfying, but it won't last long if the doctors either have to starve to death or pick up another job on the side. (Which is presumably how he figured this would work- he never mentioned that solution.)
Exactly.