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

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

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

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

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

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

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

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

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

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

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

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

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

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

Can you see the message?

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

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

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

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

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

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

JMM