16. Abelson R. Heart procedure is off the charts in an Ohio city. New York Times, August 18, 2006, Business Desk. http://www.nytimes.com/2006/08/18/business/18stent.html?ex=1156996800&en=9a672c108ed8640c&ei=5070.
17. Gagnet K. Lourdes to pay $3.8M: hospital admits no fault in Patel-related matter. Daily Advertiser (Lafayette, La.), August 18, 2006.
18. Ellwood P. Does managed care need to be replaced? Presentation to the Graduate School of Management, University of California, Irvine, October 2, 2001. http://www.medscape.com/viewarticle/408185.
19. Enthoven A. Review of The Rise and Fall of HMOs: An American Health Care Revolution, by Jan Gregoire Coombs. CommonWealth Fall 2005. http://www.massinc.org/index.php?id=481&pub_id=1697&bypass=1.
20. Gruenberg EM. The failures of success. Paper presented as the Rema Lapouse lecture at the annual meeting of the American Public Health Association. Miami, Florida, October 19, 1976. reprinted in the Milbank Memorial Fund Quarterly 1977;55(1):3–24. http://www.milbank.org/quarterly/830424gruenberg.pdf.
21. White K. The ecology of medical care: origins and implications for population-based healthcare. Health Services Research 1997;32(1):11–21.
Chapter 9
1. Video News: Midland Memorial’s David Whiles on OpenVista. ModernHealthcare.com. April 14, 2009. http://www.modernhealthcare.com/article/20090414/VIDEO/304149945#ixzz1WGlUnUnz?trk=tynt.
2. Han YY, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116:6 (December 1, 2005):1506–1512.
3. Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA Begins Process to Create Open Source Electronic Health Record, press release, April 1, 2011. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2075; Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. VA Begins Implementation of Open Source Program, press release, June 30, 2011. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2124.
4. Information on this new community should be available at the Web site of the so-called Open Source Electronic Health Record Agent (OSEHRA), which is being launched through a VA contractor, The Informatics Applications Group (TIAG). http://www.osehra.org/.
5. Kohl H, Johnson R, Baldwin T, Ryan P, Kind R, letter to the Hon. Roger W. Baker, Assistant Secretary of Veterans Affairs for Information and Technology, and Dr. George Peach Taylor Jr., Deputy Assistant Secretary of Defense for Force Health Protection and Readiness, February 7, 2011. http://www.govexec.com/pdfs/032211bb1.pdf.
6. Brewin B. Wisconsin reps try to derail VA/Defense open source health records system. Nextgov, March 22, 2011. http://www.nextgov.com/nextgov/ng_20110322_3673.php.
7. Zakaria S, Meyerson DA. How to fix health IT. Washington Post online, September 17, 2009. http://www.washingtonpost.com/wp-dyn/content/article/2009/09/17/AR2009091703734.html.
Chapter 10
1. Text of Clinton Statement on Veterans-Related Bills, Washington, U.S. Newswire Oct. 9, 1996: “The second bill—H.R. 3118, the Veterans’ Health Care Eligibility Reform Act of 1996—includes many elements of the proposal that the National Performance Review, led by Vice President Gore, recommended to establish a modern, integrated health care system that will improve access to, and care for, the Nation’s veterans. The bill, for instance, authorizes the Department of Veterans Affairs to furnish comprehensive medical services to all veterans, expanding the array of services that it now provides. Eligibility reform has been a high priority of veterans for many years, and I am pleased that we finally could enact it.” http://veterans.house.gov/hearings/schedule106/july99/7-15/gao.htm.
2. Physicians for a National Health Plan. Over 2,200 veterans died in 2008 due to lack of health insurance. press release, November 10, 2009.
3. Personal communication.
4. Vandenberg P, Assistant Deputy Under Secretary for Health for Policy and Planning. VHA’s Future Horizon: Evolving Trends. Presentation to the National Leadership Board Summit. April 13, 2011.
5. Personal communication.
6. Veteran Population Model/VetPop2007. Office of the Assistant Secretary for Policy and Planning, Department of Veterans Affairs. January 2008. http://www.va.gov/VETDATA/docs/Demographics/VetPop07-ES-final.pdf.
7. Ibid.
Chapter 11
1. National Committee to Preserve Social Security and Medicare. Price Negotiation for the Medicare Drug Program: It Is Time to Lower Costs for Seniors, Data Analysis Brief. October 2009. http://www.ncpssm.org/pdf/price_negotiation_part_d.pdf.
2. Blake M. Dirty medicine: how medical supply behemoths stick it to the little guy, making America’s health care system more dangerous and expensive. Washington Monthly, July/August 2010. http://www.washingtonmonthly.com/features/2010/1007.blake.html.
3. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Healthcare. New York: McGraw-Hill Books; 2009. See also Christensen’s May 13, 2008, lecture at the Massachusetts Institute of Technology, available online at http://mitworld.mit.edu/video/594.
4. Wennberg JE, et al. Improving quality and curbing health care spending: Opportunities for the Congress and the Obama administration. The Dartmouth Institute for Health Policy and Clinical Practice. December 2008.
Acknowledgments
I am grateful to the many people who agreed to lend their time, expertise, and support as I set out to find a model for health-care delivery-system reform and absorb its paradoxical lessons. I am particularly indebted to Dr. Donald Berwick, formerly of the Institute for Health Care Improvement and Dr. Elliott S. Fisher of Dartmouth Medical School for teaching me new ways to look at health care. Dr. Kenneth Dickie, formerly of the VA, not only sat with me for an extensive interview but also provided me with invaluable access to his personal archive of material related to the VA’s early and tumultuous experiments with digitalized health care. Dr. Scott Shreeve, founder of Medsphere—a company committed to bringing the VA model of care to the private sector—was also very generous with his time, insights, and archives, as has been Dr. Ken Kizer, who is now Medsphere’s chair. I am also grateful to the many current and former VA employees who continue to share their insights, including Tom Munnecke, a pioneering VistA Hardhat who has now rejoined the cause of Health IT; Rick Marshall of the VistA Expertise Network; Dr. Ross Fletcher of the Washington VA Medical Center; and others who would prefer not to be mentioned.
My colleague Shannon Brownlee and I have deeply influenced each other’s thinking on health care over the years as we reported on—and tried to make sense of—the actual practice patterns of American medicine. For those interested in a deeper look at what’s wrong with American medicine outside the VA, I recommend her book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (Bloomsbury 2007).
Thanks go as well to Paul Glastris, editor in chief of the Washington Monthly, for his help in formulating many of the ideas in this book and for having the courage to publish my 2005 cover story on the VA. Len Nichols and Sherle Schwenninger provided useful early comments and challenges. Brian Beutler provided invaluable research help, and Jeannette Warren provided essential editing of the early manuscripts. Deep thanks go to Bernard L. Schwartz, whose generous support of the foundation provided me with the time and intellectual freedom I needed to research and write this book. Finally, I am most grateful to my wife, Sandy, without whose thoughts, encouragement, and forbearance I could not have completed this book.
Index
accountable care organizations (ACOs), xxi–xxii
Affordable Care Act. See Obamacare; Patient Protection and Affordable Care Act of 2010
Agent Orange, 19, 125, 129, 131–32
lessons of, 128–34
Agent Orange Act, 128–29
Algood, Terry, 43
Alzheimer’s, 105
American Legion, x
Bagian, James P., 64, 66
Baker, Nicole Johnson, 75
Baltimore VA Medical Center, 10
Bauman, Robert E., 2
Berwick, Donald M., xxii, 6, 59, 69
“Best Care Anywhere,” xi
Beth Israel Medical Center (New York City), 75–76
Board of Veterans’ Appeals, 132
Bradley, Omar, 16
Brown, Jesse, 63
Bunker, John P., xxxix
Bush, George H. W., 128, 129
Bush, George W., 118
cancer care, 4
cardiologists, overpaying, xix
Carlson, Russ, 67
Carvey, Dana, 65
Casalino, Lawrence P., 73–75
Cedars-Sinai Medical Center (Los Angeles), 25
Cerner Corporation, 113, 118
Children’s Hospital of Pittsburgh, 112–14
cholesterol drugs, 85
Christensen, Clayton, 141
Cleland, Max, 21
Clinton, Bill, 48
Clinton, Hillary, ix, 47
Cogan, Richard, 46
computerized medical records. See electronic medical records
consumer satisfaction, VA and, 5–6
cost containment, VA and, 7
Costa Rica, xli
Court of Appeals for Veterans’ Claims, 132
Craddock, Kay J., 36–37, 39
Curtis, Donald L., 29, 30
Cutler, David M., xxxix
Davis, Richard, 27, 31
“death panels,” xx–xxi
Department of Defense (DOD), viii, 119, 120
Department of Veterans Affairs (VA). See also Veterans Health Administration (VHA); veterans hospitals
affiliation with medical schools, 16–18
as benchmark of quality, 9–12
consumer satisfaction and, 5–6
cost containment and, 7
early history of, 13–17
full disclosure of medical errors and, 62–64
as the Honda of health care, 7–9
medical efficiency and, 7–9
population served by, 8
quality of care and, 2–6, 9
safety and, 6, 64–70
VA model of care, 140
Vietnam veterans and, 18–21
Deukmejian, George, 50
Deutsch, Albert, 15–16
Dickie, Kenneth, 23, 27, 30, 32–33
dispensing errors, 38
doctors, selecting, 87–89
Dole, Bob, 17
drug-dispensing software, 65–67
Duke Medical Center, 76
electronic medical records, 31–33. See also VistA software program
benefits of, 40
investing in, 79
VA doctors and, in 1970s, 31–34
Ellwood, Paul, 104
employers, U.S. health-care system and, 80–86
Epic Systems Corporation of Wisconsin, 117
errors. See dispensing errors; medical errors; omission, errors of
evidence-based medicine, 52
family medicine, VA and, 134–37
Fisher, Elliott S., xx, 93
Fletcher, Ross, 36–37, 42
Forbes, Charles R., 13–14
Fort, Wally, 27
Gavazzi, A. A., 30
Gayton, Peter, 5
Germany, electronic medical records in, 79
Gittlesohn, Alan, 91–92
group health insurance, 81
Grove, Andrew, xxvii
Gruenberg, Ernest M., 105
Hagel, Chuck, 30
Hardhats, 22, 23, 28. See also VistA software program
“underground railroad” period, 29–31
Harding, Warren G., 13
Hawthorne effect, 106–7
health care. See also specific topics
declining pace of progress of, xxxiii–xli
rising cost of, xxxii
health-care benefits, VA
access to, 124–27, 132–33
family medicine and, 134–37
health-care monopoly power, 82–83, 86
health-care providers, consolidation among, 82–83
health-care reform, xiv. See also Obamacare; Patient Protection and Affordable Care Act of 2010
eligibility rules and, 133
family medicine and, 134–37
health-care spending
projected increases in, xvi, xxxii
wasteful, xiv, xxiii–xxiv
health-care system, U.S., xli–xlv
employers and, 80–86
expenditures on, xl
market forces and, 80
“Health for Life” network. See Vista Health Network
health information technology (IT), 10, 79
market failure, 121–22
open-source, 116, 118, 120–21
proprietary, 114–23
wants to be free, 115–18
health maintenance organizations (HMOs), 140
shortcomings, 103–9
health records. See electronic medical records
health savings accounts, 11
Healthcare Information and Management Systems Society (HIMSS), 120–22
Hines, Frank T., 15–16
hospitals. See veterans hospitals; individual hospitals by name
Hurricane Katrina, 43
Hurricane Rita, 43
iatrogenic medicine, xiv–xv, xviii, xxiii, xli. See also overtreatment
Independent Payment Advisory Board (IPAB), xx–xxi
information technology. See health information technology (IT)
Institute of Medicine (IOM), 128–30
insurance, health, xiii, xv–xvi, 133, 134. See also group health insurance
Intermountain Healthcare, 77
Johnson, Martin E., 27, 28, 30
Kesey, Ken, 17, 157n9
Kingsbridge VA hospital (New York City), 20
Kinnick, Sue, 67, 68
Kizer, Kenneth W., 62–63, 67–68, 133
appointment of, 47–53
drug review process and, 56–58
transformation of VHA and, 53–58
Klein, Robert, 20
Kleinke, J. D., 71, 73
Kolodner, Robert M., 39
Korchik, William, 58
Kovic, Ron, 19
Krasnow, Steven, 37
Kreis, Greg, 34
Laine, Erick, 78
Leape, Lucian, 69
Leshner, Alan, 102
Lovell, Vic, 17
Lushene, Bob, 27
Madrona Medical Group (Bellingham, Washington), 78
managed-care organizations, 144
Meadows, Oliver, 20
medical efficiency, VA and, 7–9
medical errors, xi–xii, xiv–xv, xviii, xxx, 59–63, 65–66, 68–69. See also iatrogenic medicine
VA’s full disclosure of, 62–64
VistA software for preventing, 37–38 (see also VistA software program)
medical records. See electronic medical records
Medicare, 132, 133
future of, xvii–xix, 143–48
turning it into a voucher program, xiii, xviii, xix, 146
Medicare providers, cutting reimbursement rates for, xix–xxii
Medicare retirement age, raising, xviii–xix
medications costing more than the medical costs they save, 84–85
Merck, 40
Meyerson, David A., 123
Midland Memorial Hospital (Texas), 79, 111–13
mistakes, medical. See medical errors
monopolies, 82–83, 86
Montgomery, G. V. (Sonny), 30–31, 129
Moreshead, Gordon, 27
National Surgical Quality Improvement Program, 4
Nickel, Gary, 124–26, 130, 132
Nickel, Terry, 124–26
Nimmo, Robert P., 30, 128
Noah, Tim, 90
Oates, Alan B., 131
Obama, Barack, ix, xi
Medicare and, xvii
Obamacare, vii, xii, xx, 4–5, 145. See also Patient Protection and Affordable Care Act of 2010
after, vii–xxv
Office of Data Management and Telecommunications (ODM&T), 26
omission, errors of, 61
O’Neill, Joseph (Ted), 27, 28
open-source health IT, 116, 118, 120–21
“open-source” software, 113–17. See also VistA software program
Orszag, Peter, ix
Our Lady of Lourdes Regional Medical Center (Lafayette, Louisiana), 101–2
overtreatment, xxxix–xl, 140
insurance against, 94–96
Parkinson’s disease (PD), 124–25, 130
Patel, Mehmood, 101–2
patient-centered health care, 49, 51, 159n5
Patient Protection and Affordable Care Act of 2010 (PPACA), xii, xx, 4–5. See also Obamacare
Patient Safety Event Registry, 63
Pear, Robert, 64
placebo effect, 106, 107
pneumonia, 105
posttraumatic stress disorder (PTSD), 8, 19, 124
preventive care, 84, 96
proprietary health IT systems, 114–23
quality of care, 71–73
finances of, 75–79
VA and, 2–6, 9
radiation, medical, 95–96
radiologists, overpaying, xix
reimbursement rates. See Medicare providers
Reinecke, Ian, 80
Rockefeller, John D., IV, 54–55
Roemer, Milton I., 97–98
Roemer’s law, 97–103
Ryan, Paul, xiii
safety. See also medical errors
VA and, 6, 64–70
Scully, Thomas, 25
Shafer, Paul, 30
Shalley, Andrew V., 17
Shinesky, Eric K., 130
Simpson, Alan K., 46
single-payer system, 152n7
smoking, 83, 84
socialized medicine, xi
statin drugs, 85
sulfa drugs, 105
surgery at wrong site, 65–66
Tatarczuk, Joe, 27
technology, investing in, 78–79
Timson, George, 28–29, 33
treatments, determinants of, 92–97
Tucker, Chris, 67
undertreatment, 140
“upcoding,” xx, 92
VA. See Department of Veterans Affairs (VA)
value equation, 52
Veterans Health Administration (VHA), 9–10, 47. See also Department of Veterans Affairs (VA); specific topics
Kizer’s transformation of, 53–58
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