In surveying the UHC systems in various countries back in 1999, the one that impressed me the most was Finland’s. It was initiated later than those in other western European countries, the UK, and Japan. Costs per capita and as percentage of GDP are comparable to those in Japan and the UK NHS. And the results have been dramatic for a population, small as it is, not keen on exercise with high rates of diabetes, overweight, and heart attacks. Life expectancy was significantly lower than that in other northern European countries. That disparity in life expectancy has been eliminated since Finland adopted a UHC system. Infant and maternal mortality is now rare.
What seemed notable to me is that Finland’s system is predominately controlled at the local level. A modular, “bubble-up” model that informs the federal health board of health outcomes, ideas to consider, and resource requirements. The inverse of the original, one-size fits all, “trickle-down” UK NHS model. In a country as small as Finland, the UK model would likely have delivered equally good results. Why they chose to go with the local-centric and more experimental model is unknown to me, but it does seem consistent with their less rigid and rule bound educational system that is currently impressing many US educators.
Modular systems tend to lose a bit in efficiency over a single, “our way” system. However, what is lost in efficiency is often made up for by being less rigid and more robust. Distributed versus centralized. Modular can also be more easily replicated not that that would have been a major concern when Finland was considering its UHC system options. Or perhaps their system was modified in the early 1980s when their hospitals adopted the US Veterans Administration VistA (Veterans Health Information Systems and Technology Architecture ), an electronic health records system.
Who knew that the US Government through the Veterans Administration built an award winning information technology system? To service a socialized medical system.
For its development of VistA, the United States Department of Veterans Affairs (VA) / Veterans Health Administration (VHA) was named the recipient of the prestigious Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University in July, 2006. The VistA electronic medical records system is estimated to improve efficiency by 6% per year, and the monthly cost of the EHR is offset by eliminating the cost of even a few unnecessary tests or admissions.
A modular system, originally named in 1981 the Decentralized Hospital Computer Program (DHCP)*, so freaking good that it has been or is being considered for installation by WHO around the world and numerous private medical institutions. (The DOD had “better” ideas and after early cooperation with the VA, reinvented half the wheel – probably at ten times the cost and works half as well as VistA.)
One of the VistA modules is MyHealthVet,
… a web portal that allows veterans to access and update their personal health record, refill prescriptions, and schedule appointments. This also allows veterans to port their health records to institutions outside the VA health system or keep a personal copy of their health records, a Personal Health Record
Hmm. VA medical appointments are scheduled through VistA. Shouldn’t matter if the veteran uses the MyHealthVet portal or calls a VA office and the clerk enters the data. VistA has the capacity to issue reports on the wait times and monitor for compliance with VA standards for wait times. If those standards can’t be met due to inadequate medical staff resources, why would any VA medical center director want that information subverted or repressed? So much so that staff at the Phoenix VA Medical Center were directed not to enter the data in the system but maintain a log of requested but yet to be scheduled appointments.
As luck would have it, last week I met a career VA medical center contracting officer and had the opportunity yesterday to pick his brain. Will refer to him as Avery to avoid any possible negative repercussions for him. Avery is a veteran and thirty plus year federal employee. Through thick and thin (the sequester took a heavy toll on him and his colleagues) and good and bad. Shinseki, according to Avery, has been a good and should not resign. The Phoenix VA medical center director is the one who should resign, again according to Avery, and she’s not a scapegoat.
As to why those secret, offline wait list logs were set up, Avery pointed out several reasons. One of which has been publicly disclosed and apparently how the Phoenix VA medical center director became exposed. Not only was there subversion of VistA appointment scheduling but she also disabled the ability of veterans to get authorization to use non-VA facilities due to the excessive wait time, a standard right for veterans. On paper the director looked good as to timely delivery of medical services and limited use and cost of non-VA medical services. Factors that likely boosted the annual bonuses for the director and staff.
Excessively long wait times could also be a function of the outside contractors the director and her senior associates hired. Apparently there is a revolving door between VA medical contractors and senior VA medical administrators. Not uncommon for work to be outsourced at a higher cost than retaining it in-house. (Audits checking on this along with cronyism and nepotism would be a good idea.)
Avery also mentioned that there are a large number of VA medical center senior and mid-level administrators that are “deadwood” and are Republicans that resent the Obama administration. He and colleagues had hoped that Shinseki would do some house cleaning and acknowledged that like Obama, he hasn’t.
Finally, Avery said that there’s lots of money sloshing around in the VA medical system that gets spent but not effectively. And easy enough for rightwingers and Fox to find when they look for it:
The records also show hundreds of thousands in taxpayer dollars were spent on work that had little to do with health care. The hospital’s 2013 gardening budget was more than $180,000. The hospital’s interior design bills over the past three years surpassed $211,000.
From that it’s easy to conclude that even when the US does socialized medicine, which is exactly what the VA medical system is, it does it poorly. The per capita cost of the VA system is expensive. A multiple of Finland’s per capita cost. Some of that higher per capita cost is justified as chronic service connected health issues. But not all of it. Perhaps it’s time for the VA to check out and import some operating procedures from Finland.
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*In the early 1980s systems managers and programmers at a mid-sized company told me that building a large application in modules wasn’t how they did things. Don’t know if that was an equipment or programmer skill limitation, but it frustrated me because it meant that the application would take longer to deliver anything and would have more bug
