Examining the Quality and Cost of VA Health Care | The American Legion
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As a result, the priority of persons with disabilities for life-saving interventions is substantially reduced.
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Because it employed such discounting, the Oregon Health Care Plan to set priorities for Medicaid-funded procedures was found to discriminate against people with disabilities Bodenheimer Although some objectionable features of the discounting methodology have been modified Saloman and Murraythe Global Burden of Disease frameworks continue to adopt procedures that result in strikingly low quality-of-life estimates for many disabilities.
Many mainstream philosophers and bioethicists question the use of summary health measures in priority setting Harris ; Brock But many still defend the general assumptions about disability and quality of life that informed those measures Brock Other philosophers and disability scholars have challenged these assumptions Bickenbach Some have gone even further, questioning whether quality-of-life assessments place an exaggerated premium on the prevention or correction of impairments that do not, in hospitable environments, preclude rich and rewarding lives Barnes a; Asch and Wasserman Disability and Health People appear to regard health as one of the most important goods, more important than wealth, status, or professional success.
Health is seen as special in part for instrumental reasons, because it is thought to be a prerequisite for many or most other goods. So the relationship of health to disability is an issue of central concern for those who seek to replace or supplement a medical model of disability Bickenbach ; Shakespeare The social model of disability, which informs the Americans with Disabilities Act and kindred legislation, may appear to move disability away from health policy and toward civil rights.
Yet movement in one direction does not preclude movement in the other. People with disabilities have significant health care needs, and their needs may depend to some extent upon their disabilities. For philosophers as well as policy makers, the challenge posed by the social model is to acknowledge the importance of health and health care for people with disabilities without assuming that all people with disabilities are unhealthy just because they are disabled, and without overemphasizing the correction or mitigation of impairments.
This requires a careful examination of the relationship between health and disability.
Do all disabilities result from, or in, a loss of health? To answer such questions, we need a serviceable theory, concept, or definition of health. There are a variety of competing philosophical accounts of health see SEP entry on concepts of health and disease. They can be distinguished in several ways: These distinctions are not independent of each other. Non-normative accounts of health tend to treat health as the absence of disease, dysfunction, or deformity.
These accounts also tend to be instrumental: On the other hand, instrumental accounts that define health in terms of the pursuit of an individually, culturally, or other variable range of goals will tend to weaken the connection of health to bodily, cognitive, or affective functioning. If health is defined simply as the absence of disease, then a person can be disabled but healthy if and only if he can be disabled but not diseased.
If, however, health is a state of psychophysical flourishing or vitality, then an individual can be healthy, although perhaps not perfectly healthy, even if disabled or diseased, and unhealthy even if free of disability or disease. Two notable exceptions are Christopher Boorse and Robert Wachbroit, who offer biomedical definitions that are value-neutral, or as Boorse claims, as value-neutral as biology itself Boorse They define health in terms of normal or species-typical physical and mental functioning, so that disabilities are by definition unhealthy.
But such value-neutral accounts do not assume that disabilities are therefore bad or undesirable, merely atypical. Still, the core intuition, concerning the enormous practical value of species-typical functioning, can be accepted without accepting medical normalization as the preferred or default response to atypicality; indeed, without accepting the claim that species have functions with species- typical levels defined in biological terms see Amundson Further, the claim that species-typical functioning is instrumentally valuable leaves open the question of why departures from species-typical functioning are instrumentally disvaluable: Yet most people have a strong conviction that practical advantages do not exhaust the value of health, nor practical disadvantages its disvalue.
To accommodate this conviction, those accepting a narrow definition of health as the absence of disease may want to acknowledge that disease, or its usual symptoms or consequences, has inherent disvalue, while distinguishing disability from the other symptoms or consequences of disease, particularly pain and death.
Those adopting a broader definition of health as an aspect of well-being or flourishing may also want to claim that being unhealthy has inherent disvalue, while distinguishing disability from a lack of health.Which Countries Have The Best Healthcare? - NowThis World
Distinguishing Disability from Disease The distinction between disease and disability has received surprisingly little attention in the philosophical literature. One of the few detailed analyses of the relationship between disease and disability was offered by Ron Amundson, who proposed that disability should be understood as one of the three general consequences of disease, along with pain and death Amundson Amundson contended that it was both clearer and closer to common usage to treat disease as an atypical process that tended to result in disability, pain, or death.
They are consistent with health narrowly defined. Yet some philosophers Hausman The disagreement between Amundson and Boorse on the distinction between disease and disability is not just a matter of semantics. Furthermore, the loss of opportunity associated with disabilities can often be prevented or mitigated more effectively and in the long run more economically by modifying the physical and social environment than by medical intervention.
This is true even though environmental measures are likely to fare poorly against medical interventions in the competition for scarce resources, because of the prestige and perceived importance of medical treatment. The failure to distinguish disease and disability, and the tendency to favor a medical response for both, reflects the sway of the medical model, and offers a clear illustration of how it differs from the social model see SEP entry on disability: Such a process is pathological in the sense that: An account along these lines may have the potential to distinguish disease from disability so as to make the former immediately relevant to well-being in a way the latter is not.
Unlike purely non-normative accounts, it only finds a health-decrement where something bad comes from the state of the body. And finally, defining health in terms of bodily dispositions could help to explain why extrinsic factors, like those cited by social models of disability, are irrelevant to health. It could distinguish between harms that come from social responses to the body from harms that come from the body itself; thereby distinguishing between harms that generate claims on health care and harms that generate claims against discrimination or the denial of fair equality of opportunity.
Despite the importance of distinguishing disease from disability, there are at least three reasons why it is difficult to do so. This legal treatment may, however, be justifiable, because some diseases, such as AIDS, are stigmatized as severely as many or most disabilities. Second, many disabilities, such as the inability to walk, may be associated with diseases, such as MS, which have a progressive character, causing pain and further impairment, and sometimes increasing the risk of death Wendell Health as More or Other than the Absence of Disease An alternative approach to the relationship between health and disability involves a broad or positive conception of health as more than, or distinct from, the absence of disease or disability.
This approach has more and less instrumental versions. On such an instrumental account, the relationship of disability to health depends on the goals that are considered vital or central and on the role of typical functions in achieving them.
Some impairments will hinder the pursuit of some goals goal-based accounts of health vary in whether or how they specify the relevant environment s affecting their pursuitother impairments will have no effect, and some will enhance the pursuit of some goals.
Any generalizations about the impact of impairments on health will depend on the assessment of their net effect on the pursuit of the specified goals. Nor does he shirk from the practical implications of this conception: At the same time, he recognizes a narrower conception of health, treating it as one of the more specific capabilities that health in his broader conception encompasses.
Health in this narrow sense is just the capacity to avoid disease and impairment. But it is unclear why even health in this narrow sense should be a constituent of well-being, given the fact of human mortality and vulnerability. Lawrence Becker has proposed a broad but less instrumental conception of health, examining positive conceptions of health in other disciplines, specifically models of positive mental health in psychology, which incorporate notions such as resilience, robustness, developmental maturity, character strength, and subjective well-being Becker Such conceptions go beyond the absence of disease in two ways: As David Crocker observes, this notion has both negative and positive elements.
The negative dimension includes absence of disease, illness, disability, and other impairments. This positive aspect of basic good health, if not the notion as a whole, gives support and structure to the claim that one can be disabled but healthy. It could also promote the development of health interventions for people with disabilities that are not directed at the normalization of their atypical or impaired functions. One challenge for this approach is to limit the scope of positive health, so that it does not encompass all aspects of well-being, but remains anchored in biomedical functioning.
A second challenge for this approach is to explain how cognitive and affective conditions bear on health, and how any adverse effects of such conditions can be mitigated or eliminated without medical normalization. Personal Relations, Family, and Disability Although the connection between disability and interpersonal relationships is a topic worth exploring in its own right, it also has important implications for well-being and health.
Quality and cost in healthcare: a relationship worth examining.
Numerous empirical studies across a number of behavioral science and medical disciplines have shown the importance of close interpersonal relationships for health and well-being Cohen, Gottlieb, and Underwood ; Uchino, Cacioppo and Kiecolt-Glaser ; Cohen and Wills For example, more than empirical studies have shown that on a number of well-being indices, married men and women are generally happier and less stressed than unmarried people Coombs Personal relationships, including love and friendship, are for most people an essential ingredient of the life they want for themselves, something to value for their own sake as well as for the support they provide during stressful times.
However, many people see disability as an obstacle to friendship, romantic love, and rewarding family life. Disability scholars and activists reject this widespread belief, arguing that the obstacles that exist to accessing such relationships are due primarily to features of the social and physical environment. In this section, we discuss the perceived barriers to such relationships.
We will focus on relationships typically understood as enduring and in some way intimate: In that respect, our conception of personal relationships is narrower than the broad conception of a relationship that figures in some of the literature on relational egalitarian theories of justice see, for example, Anderson ; though for a principle of relational egalitarianism that is derived from consideration of what spouses owe one another, see Scheffler The close relationships we have in mind—whether of friendship, partnership, or family—involve some degree of mutual regard, personal disclosure, and particularized knowledge.
They also involve material and emotional mutuality, but need not involve equal exchanges between the parties. Philosophers have often treated equality of some kind as a prerequisite of friendship see SEP entry on friendship.
In the Nicomachean Ethics, Aristotle distinguished among three kinds of friendship: The last, the highest or truest form, required similarity of character. Philosophers since Aristotle have rejected some of his prerequisites for friendship, such as equality of social or economic status, but they have shared his view that friendship must be a relationship among equals.
The debate has largely focused on the kind of equality that is required. Thus, Aristotle denied that parents and their children could ever be true friends, since the inequality between them could never be overcome no matter how much the child does for his parents. This position is rejected by English and Kristjansson Generally, contemporary accounts of friendship place less emphasis on equality or similarity of specific traits and more on equality of respect, investment, and commitment.
Given the vast range of differences among close friends in talents, interests, and tangible contributions, it would not seem that disabilities pose any general barrier to intimacy. Nevertheless, philosophers and bioethicists have tended to look skeptically on the possibility that a person with a disability could offer the mutuality and equality required for a satisfying relationship with a nondisabled friend, romantic partner, or family member.
The disability is perceived as creating an uncomfortable degree of inequality and dissimilarity; parents have difficulty picturing the child growing into a productive adult and parent, fulfilling some of the goals people have for undertaking childrearing Ruddick Similarly, when the bioethics literature considers people with disabilities as parents, it is largely to assess whether it will be harmful for children to be raised by disabled parents Coleman ; Robertson ; or whether adult children will have to give up their other life projects to care for their newly-disabled parents Callahan In this literature, relationships involving disabled people are chiefly viewed from the perspective of those without disabilities.
Whether the topic is end-of-life decision making Hardwigtreatment decisions for low birth weight, premature or otherwise disabled newborns Stackthe rehabilitation of persons after traumatic brain injury Nelson and Fraderor selection for or against disabling traits in embryos or fetuses Botkin ; Ruddick ; Greenthe focus is on how nondisabled people are affected by a potential relationship with someone who has a disability.
What is largely missing from these accounts is serious consideration of the perspective of the person with a disability; of how her life will be affected, for good or ill, by the family or friendship relationships in which she is embedded.
In addition, little attention is paid to relationships in which all involved parties have disabilities. As Chappell has noted, writers assume that it is in the interest of people with disabilities to aspire to relationships with nondisabled people, even if it is not is the interest of the latter. It seems clear that if the consequences of personal relationships for the flourishing of persons with disabilities were given the same weight as the consequences for nondisabled persons, it would encourage a deeper and fuller appreciation of the goods of personal relationships.
The type of inequality and its explanation are not always made explicit. Does it result from the perceived inability of people with disabilities to participate in activities that are important to some, most, or all friendships?
Or does it arise from the perceived need on the part of the person with a disability for technological or human assistance to manage typical life tasks? Does it stem from a belief that the person with a disability does not possess the social or psychological resources to prove a stimulating and rewarding friend? The influence of a dichotomous conception of disability, that is, of a conception of disability as a personal attribute one either has or lacks, is evident even in the way questions about disability and personal relationships are framed.
If, instead, we adopted the human variation model of disability see SEP entry on disability: That model conceives of an impairment as an arbitrary range on the continuum of variation for a human attribute. Moreover, the model sees disability as an interaction between atypical functioning or embodiment and an unaccommodating environment. The model also suggests that a disability, like an impairment, ought to be considered as a graduated characteristic: Although this is largely an empirical question and cannot be answered by philosophical reflection alone, philosophy can clarify the concepts that figure in the question: One reason having or acquiring a physical, intellectual, or emotional disability lessens the chances that relationships will move beyond acquaintanceship is that the disability looms so large in the minds of the nondisabled person and perhaps the disabled person as well that it obscures or eclipses other features on which an intimate relationship can be solidly grounded.
Most people do not yet see disability as one among many characteristics with respect to which humans can vary. This aspect of romantic leave can amplify the concerns of people already skeptical about the ability of persons with disabilities to contribute to thriving friendships.
Many nondisabled people may doubt that people with disabilities can be fulfilling partners in any loving adult relationship. Many nondisabled people may find it hard to imagine seeing their reflection in a disabled partner. According to LaFollettelove, at least ideally, brings out the best in the participants. For nondisabled people, it may be hard to see past the impairment to imagine that a partner with a disability can bring out their best, be similar enough to understand them, enhance their self-worth, or meet their deepest needs.
Disability creates a number of challenges to forging intimate physical and emotional relationships. People with sensory-motor impairments who were disabled beginning in early life often report that they were socially segregated from other children, either directly because they were tracked into different classes or different schools, or indirectly because other students avoided them.
Consequently, many disabled children have not been socialized about sex in the way other children have been: To make matters worse, many disabled children do not receive sex education until a much later age than their able-bodied peers if at alla reflection of the pervasive stereotype that disabled people are infantile and asexual Shakespeare These challenges persist into adulthood.
Others addressed issues of quality. For still others, it was a matter of inequality of treatment. If this is a microcosm of current concerns and suggested solutions, does it bode well for the formation of a consensus, political or otherwise, leading to progress? But a number of respondents raised the question of whether the most feasible solution may lie primarily in the free market, with perhaps some help from government. Suggestions of causes of the current challenge of rapidly rising costs in relation to quality of outcomes, at least by the imperfect measure of life expectancy, included waste in the system Julie Maire, Edward Hare, and Jack Flanagan as well as fraud Kate McClellandrisk avoidance on the part of physicians, a litigious society, and inadequate protection from it for physicians Rowland Freeman"defensive" medicine leading to unnecessary tests and treatments, an insurance system that is costly and inadequate for those who really need it Amar Sahay and David Albert Newmanthe high cost of new technology, artificial restrictions on the supply of drugs Sergey Mirkiin and healthcare providers David Stahl and Michael Robbinsthe size and complexity of the problem itself James Sullivangovernment involvement Paul Jacksonand uninformed or unnecessarily needy consumers Hakan Hillerstrom.
In addition to these issues, Elizabeth Benbrooks reminds us that healthcare "comes freighted with a host of fundamental moral, ethical, and emotional issues that simply don't exist for other industries.
Paul Jackson suggests that "The only thing the government should be involved with is controlling the drug, insurance, and medical industry advertising spending which would bring down costs. Sergey Merkin asks, "Why not open the country to foreign medications?
And Hakan Hillerstrom implied that consumer education and choice may be an important response to many of these challenges. Keith Butler believes that it could come in the form of a two-tiered system of private treatment at personal expense layered on a service free to all with protections for healthcare givers and the elimination of third party insurance. Are these the free market answers we've been waiting for?
What do you think? Original Article Healthcare will grab more and more headlines in the U. We believe that this direction is the most promising avenue for future research: Such knowledge could provide a blueprint for improvement. These research findings have several potential implications for public policy in health care.
Public policy might be directed at informing consumers and referring physicians about the nature of the relationship between volume and outcome or at improving outcomes, or both. Data on volume of procedures by hospital are publicly accessible in many states through hospital discharge abstract databases. Many of these databases also permit identification of treating physicians.
Making these data widely available is one potential way of informing consumers and clinicians. Some of the challenges such efforts would face are the difficulties of explaining what the data mean and what they do notthe technical challenges of carefully identifying conditions and procedures for which research is conclusive that higher volume is associated with better outcomes and at what thresholdand the need to update the data regularly. Page 29 Share Cite Suggested Citation: A Systematic Review of the Research Literature?.
The National Academies Press. Recent actions by private employers suggest that some purchasers may be prepared to take an active role in steering patients toward high-volume hospitals, using incentives directed either at managed care plans or at employees themselves.
What Is the Government’s Role in US Health Care?
No data exist on which to base predictions of the impact of such efforts. Available data suggest that significant numbers of patients do not use data on outcomes or volume where they exist to choose where to receive care.
We believe that the most promising use of the research findings linking volume and outcome is to fuel quality improvement. To the extent ongoing research is successful in demonstrating what specific clinical and organizational processes of care are associated with improved outcomes, this knowledge can be put to direct and immediate use to improve hospital and physician care.
Public policy can accelerate this improvement by supporting the necessary research, by fostering and evaluating demonstration programs to implement it, and by disseminating successful models. This report must be made out and published by each hospital in a uniform manner, so that comparison will be possible. A set of statistics had been prepared comparing the mortality at a certain semi-private hospital of beds with that of four of the best general hospitals in America, having a total of 1, beds.
These statistics were obtained from published reports. They clearly showed that the semi-private hospital not only did more operations, but that the mortality was much lower, especially in some of the more difficult branches of surgery.
Among the factors he cited in addition to the volume of operations were the skill of the surgeons, the comorbid conditions of the patients, the financial condition of the hospitals, and the way in which surgical departments were organized to triage particular patients to particular surgeons. Data to answer these questions continue to prove elusive, some 86 years after a Boston surgeon, Ernest Avery Codman, first posed them.
Codman Codman's questions lay dormant for more than 50 years, until the National Halothane Study, undertaken in the s to assess possible hepatotoxic effects of halothane, unexpectedly reported a fold variation in operative mortality among participating U. Moses This finding led to a series of further investigations.
StanfordFloodFlood a, Flood b More recently, beginning with the work of Luft and colleagues LuftBunkerLufta large body of research has focused on measuring and explaining the relationship between patient outcomes and the volume of specific health services provided by hospitals and physicians.
Many studies have documented that higher volume is associated with better outcomes for a variety of different surgical procedures and medical conditions. Flood a, Flood b, Luft Although a few studies have found some indirect evidence that is consistent with either or both of these hypotheses, we believe a reconceptualization is warranted of the model that describes the potential mechanisms by which volume and outcome might be related in health care.
This reconceptualization is prompted both by several inconsistencies in the older hypotheses and by evidence from recent research.
Examining the Quality and Cost of VA Health Care
But we know that such data are not readily available and cannot be the basis for very many patient referrals. Even where they do exist, physicians report that they do not use them to make referrals. SchneiderHannan Nor is there evidence that patients either shun hospitals with well-publicized poor outcomes or flock to those with good ones.
ChassinSchneider Further, both of these hypotheses focus on explaining how particular hospitals or physicians might have achieved high volume and good outcomes over time. Neither offers much help in explaining the causes of differences in outcomes among hospitals or physicians with different volumes or in suggesting how the poorer performers might improve.
Some recent evidence documenting systematic differences among high-and low-volume providers in the use of specific interventions points to a different set of explanatory factors. Thiemann We, therefore, begin this systematic review of the research evidence linking volume and outcome in health care by describing a new conceptual model.
In subsequent sections of this monograph, we describe how we used this model to develop criteria to judge the quality of the published research we reviewed. We then define our literature search strategies, inclusion and exclusion criteria, and methods for reviewing and rating included studies.
We discuss the results of the review separately for each included topic area and then discuss generalizable findings and issues. Finally, we discuss the potential policy implications of the findings.
Conceptual Framework Figure 1 displays the factors we believe are likely to be the most potent explanatory variables in understanding how volume of services is related to health outcomes. Patients are selected to receive surgical or medical services in a variety of ways. Some have little time or choice e.
The opposite is true for many surgical procedures, especially for the vast majority of elective operations.
We know little about the relationship between volume and patient selection. Are patients of high-volume hospitals or physicians likely to be more or less appropriate candidates for surgery than patients of low-volume providers? A single study documented that high-volume surgeons were more likely to perform inappropriate carotid endarterectomies than low-volume surgeons were.
Brook b Few investigations have addressed this important dimension of quality. Page 31 Share Cite Suggested Citation: How Could Volume Affect Quality? More attention has been focused on identifying the key variables that define the severity of patients' presenting illness and the comorbid conditions that also affect the outcomes of treatment.
How well these factors are measured and taken into account i. If high-volume surgeons or hospitals treat patients who are systematically sicker or healthier than their low-volume counterparts, comparisons of their outcomes are not valid without scientifically rigorous risk adjustment.
Once the patient population undergoing treatment is adequately characterized, it is then necessary to consider exactly what treatments the patients receive. Volume of services cannot directly produce better outcomes.
If volume is related to outcome, that association must be expressed by differences in the components of care or in the skill with which treatments are provided.
For some conditions or procedures, specific component treatments processes of care have been demonstrated to improve outcomes. For example, it is essential to know whether patients undergoing treatment for acute myocardial infarction received therapies designed to achieve reperfusion acute angioplasty or thrombolytic drugs in appropriate settings. Other effective processes for this condition include aspirin, beta blockers, and angiotensin converting enzyme ACE inhibitors, each with its own specific indications.
Although data on effectiveness and efficacy for most surgical processes of care are lacking, it is equally essential that researchers investigate the extent to which carotid endarterectomies or coronary bypass operations are performed the same way at high- and low-volume centers and by different surgeons.