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Does Socialized Medical Care Provide Higher Quality Than Private Care?

Discussion in 'General Discussion' started by In Love With Medicine, Jan 23, 2020.

  1. In Love With Medicine

    In Love With Medicine Golden Member

    Jan 18, 2020
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    Americans are not fans of socialized medicine. Sure, some people want socialized health care payment, including many people who are fans of Medicare for all. But even most Bernie Sanders supporters probably aren’t in favor of socializing the entire U.S. health care system, thereby making hospitals and medical clinics into government property. Americans are proud of the high quality of care offered by non-government providers, from their local community hospitals to places like the Mayo Clinic. Many are afraid that if doctors and nurses become government employees, the quality of their care would erode.
    But a recent study of patients with kidney failure highlights the possibility that, at least for some people, socialized medical care is higher quality than private care.

    The study looked at military veterans whose kidneys were failing, so much so that they might soon need dialysis. The research team, out of Stanford University, looked at how these veterans fared based on whether they received care in the VA system or at private clinics and hospitals.

    An important factor: The VA system is socialized. When veterans receive care in the VA, their doctors and nurses are employed by the federal government, and the hospitals and clinics where they receive their care are typically owned and operated by that same government. By contrast, even though Medicare is a federal program, it pays for people to get medical care at practically any hospital or clinic in the U.S., whether public or private, for-profit or nonprofit.

    If socialized medical care is bad for patients, then you’d expect people within the VA system to fare worse than veterans who, instead, pay for their medical care with Medicare.

    Instead, the study provided fairly compelling evidence that the VA offered better care than the typical private provider. The study results are complicated, and I’m sure I won’t do them full justice. But here’s why I find them compelling.

    For starters, the researchers recognize that veterans who receive care in the VA are different than those who receive care outside the system. In comparing these two groups, therefore, they made great efforts to account for these differences, with a statistical technique called propensity matching. In addition, the researchers got hold of data on more than 11,000 patients, making it unlikely their findings were influenced by a few outliers.

    What did they find?
    People receiving care outside the VA were way more likely to get dialysis than those in the VA. Remember, all the patients in the study had kidney problems at the beginning, but weren’t yet on dialysis. Good management of their kidney failure could potentially slow down the progression of their disease, thus staving off the need for dialysis. Yet, 82 percent of non-VA patients ended up getting dialysis, versus only 53 percent of patients receiving care at the VA. That’s a huge difference.

    Now you might wonder whether private practitioners are right to offer more dialysis care to these patients and whether, by that same logic, VA providers were refusing to dialyze patients who needed such treatment. Such suspicion of the VA is understandable, given recent publicity surrounding horrendous delays in providing veterans with access to timely care. However, the Stanford team didn’t find evidence that the VA refused to give dialysis to patients who needed it. In fact, they couldn’t find any difference in survival rates of people who received care in or outside of the VA. In other words, all that extra dialysis didn’t prolong people’s lives.

    How could dialysis not save someone’s life? Two ways. First, people might get dialyzed before they need it. Second, they might get dialyzed even though they’re too sick to benefit from such treatment. The researchers found evidence of both practices in private practice settings. Some people got dialysis too early. Others got it even though they had other advanced, life-threatening illnesses like dementia or metastatic cancer.

    Here’s a picture showing the researchers’ results. It shows that the chance of progressing from “kidneys-failing” to “your-doctor-thinks-you-need-dialysis” is greater for Medicare enrollees being cared for by private physicians (versus patients receiving care in the VA). Take two 80 year olds with weak kidneys, for example; the one receiving care outside the VA will be WAY more likely to be dialyzed (relative risk of about 1.8). Have metastatic cancer? A VA doctor might recognize you are too sick to benefit from dialysis but the private clinic doctors–for financial reasons?–will dialyze you anyway:

    Relative risk of dialysis treatment within two years of incident kidney failure among patients

    My take on this study and on VA care more generally?
    1. We have a problem getting newly retired veterans into the VA system, a problem we need to fix ASAP. When we expand the military and involve men and women in long tours of combat duty, we owe it to them to expand the VA system accordingly.

    2. That’s because once people get into the VA system, they usually receive excellent care. I practiced medicine in the VA for almost two decades, and was proud of the quality of care the system offered to our patients.

    3. Financial incentives sometimes undermine health care quality. Private practitioners often don’t get well paid to care for patients with chronic kidney disease; managing their illness in ways that hold off the need for dialysis takes lots of poorly-paid time. VA clinicians are paid salaries and face different incentives than most private practitioners. Similarly, nephrologists in private practice may sometimes have a financial incentive to transition patients to dialysis; VA physicians face no such incentive.

    The high quality of kidney care in the VA health care system does not prove that socialized health care systems are better than alternatives. But it does prove that socialized systems can provide better care than privatized systems. That should be enough to change the nature of health care debates in the U.S.

    Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel. He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes.


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