A Naval Approach to Healthcare

USS John C. Stennis (CVN 74), Flight Deck Operations – credit: mt-milcom.blogspot.com

Most Americans find the notion of “socialized medicine” to be abhorrent. In most citizens the concept evokes visions of a moribund, inefficient bureaucracy more concerned with paperwork than in attending to the complexities of health problems. However, I would like to observe that the United States has “socialized defense” that works quite well. The armed forces are comprised of linked government agencies strictly regulated by massive bureaucracies. What if our army, navy and air force operated like our healthcare system does? What if individual commanders were allowed to innovate at will, set their own rules, procure and contract for materials and equipment at the unit level, and let the best units win, as hospitals do? That would, I submit, be a disaster.

Six years ago, a Navy doctor was alarmed by a 1999 Institute Of Medicine report about medical errors, a report that said,

” . . . between 44,000 to 98,000 people die each year as a result of preventable medical errors. For comparison, fewer than 50,000 people died of Alzheimer’s disease and 17,000 died of illicit drug use in the same year.”

The doctor decided to compare how Naval Aviation handled errors and accidents with how our healthcare system handles them. In his paper (emphasis mine) he said,

“In 1953 alone, there were 2,266 major aircraft accidents involving 5% of the 14,051 operating Naval aircraft and claiming the lives of 423 Naval aviation personnel.”

What has happened since 1953? Dr. Harmon’s report says,

“(in 2005), Naval aviation has drastically decreased its incidence of Class A mishaps (an accident involving a fatality, a major injury, or destruction of the aircraft) over the past 50 years to a current rate of 11 per 183,000 flight hours.”

To put that in perspective, 183,000 flight hours is more than 20 cumulative years of flight time.

When I look up commentary on this situation the language I find is mostly purged of political opinion. Few experts want to advocate the Public Option or a socialized system outright because, I submit, they well know the prejudice against it. But that would be the most direct way to adopt a  systems approach for healthcare like the U.S. Navy’s for aviation.  What is a systems approach?  It would mean standards for medical procedures, checklists, medicines, monitoring, sanitation, equipment sterilization, personnel training, etc.  Look, doctors and naval aviators have some things in common.  They’re smart, well educated, and like being in charge.  But they’re both confronted by complex situations, sometimes fast-moving, and they’re not gods  The systems concept works for Naval Aviators who fly on and off carriers in all kind of weather the world over, so why can’t it work for medicine too?

Our present healthcare system has profit as its primary goal. If we had a socialized system purposed for optimum patient care, both preventive and acute, there is no doubt in my mind that the system would not only be vastly improved but doubled in financial efficiency. Indeed, it is well known that socialized medical systems in numerous countries deliver comparable results to ours with fewer errors and for less than half the cost.

My latest AARP bulletin has an editorial on page 3 advocating, “Let’s Launch a War on Waste”, and it’s about this same issue. It quotes the most recent IOM study:

“The U.S. health care system now is characterized by more to do, more to know, and more to manage than at any time in history . . . The result is a paradox: advances in science and technology have improved the ability of the health care system to treat diseases, yet the sheer volume of new discoveries stresses the capabilities of the system to effectively generate and manage knowledge and apply it to regular care.”

AARP’s message is not so much about waste, really, despite the title.  Carelessness or poor character aren’t the reasons for the problem.  No, the problem is that we have the wrong kind of system.  We haven’t made much progress since 1999 because the present system is outmoded.  A true systems approach is needed to remedy both the medical error problem and the financial problem and AARP ought to be telling us we need some form of government medicine – socialized medicine. Let’s get over our prejudice against the concept, and let’s get over

House Republican Press Conference on Health Ca...

House Republican Press Conference on Health Care Reform (Photo credit: House GOP Leader)

the illusion that healthcare is a commodity like farm produce where one shops for the best value. When you’re sick you commit to a supplier and you’re pretty-much stuck there.  Congressional Republicans tried to make Obamacare a dirty word – it’s not.  It in fact contains the seeds of reform, but because of Conservative opposition and lobbying by the medical industry it was shorn of what it should have been.  It’s way past time for America to get a healthcare system that puts patient welfare above profit. If the medical error rate doesn’t convince, the fiscal cliff should because medical costs are the prime driver of that problem.

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About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Independent, tending progressive as the GOP recedes from its Eisenhower roots.
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13 Responses to A Naval Approach to Healthcare

  1. Disclaimer: These are my experiences on ONE health problem, in ONE metropolitan area (Chicago) of the country. My problems may have been caused simply by one bad healthcare plan.
    BUT –
    I noticed, during my intensive diagnosis period (for my headaches) in the late 90s that most doctors were forced to work to a “script” by the insurance I carried. No matter how much input I provided, including previous test results, each new doctor had to do Test A, then Test B, and so on down the list. This is an honest question – how would you propose to make sure that a doctor has both the flexibility to work with an experienced patient (such as myself) while still fulfilling the requirements of insurance to make sure he/she has “covered all the bases”? I’d love to hear anybody’s ideas, especially since I’ve been paying out of pocket for the last 10+ years. Thanks!

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    • Jim Wheeler says:

      John, it seems to me that your frustrating situation is a good example of both the inefficiencies of the present healthcare system and the potential advantages of a government systems approach. Just the use of electronic medical records would have eliminated the redundant testing they subjected you to because all the records would have been instantly accessible. And, if the thing were done properly with an emphasis on long-term preventive care, I would like to assume the system would employ a multi-disciplinary approach similar to that used by the Mayo and Cleveland clinics. That means you would be seen by specialists who would collaborate on your problem. In comparison the inefficiency of the present system is evident in your story.

      It’s worth noting, I think, that ObamaCare has already initiated electronic medical records and hospitals are adopting them.

      I need to say this, however. Getting a single-payer system alone is not enough, it needs to be designed properly and it needs to be incentivized properly. That means setting goals that measure system success long-term, including factors like life span, infant mortality, hospital infection rates, medical errors, and quality of life. Naval aviation succeeded and I’m confident medicine can too.

      Thanks for you input, John. I wish you well. (Incidentally, I note you are not far from Mayo’s and the Cleveland Clinic. One of them might be worth a shot.)

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  2. hlgaskins says:

    Great article! Republicans are aware of the benefits of having a solid universal health care system but ignore it. They know and have known for some time that a universal health care system is not only the humane thing to do but is also the most fiscally smart thing to do. And yet they choose to disregard it while accepting money for favors given to greedy and uncaring health care profiteers. Perhaps the presidential election that sent Obama back to the White House for a second term will once again open the debate because the election was partially a referendum on “Obama Care.” Nixon’s plan for Health Reform made Obama Care seem tame in comparison.

    http://www.kaiserhealthnews.org/stories/2009/september/03/nixon-proposal.aspx

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  3. Jim,

    Applause, applause, applause. Now I don’t mean to give you the clap, but your post here hits the proverbial nail on its proverbial head. Our current health care system, with or without Obamacare, is an abomination.

    I’ve done a little research on the “public option” in the past and concluded that the best replacement for medicare, medicare, and SCHIP, is the Veterans Administration’s Health Care system. Since the 1990’s, the VA health system has done a complete turnaround and is now ranked as one of the best in the world. It’s even better than the private sector in delivering quality health care right here in the U.S. of A. And cheaper!

    Matter of fact, I did my own cost analysis of how the VA model could save us over one trillion dollars and posted it right here on this very blog. See “The Medical Contract,” 03-28-2012. (Just think of how many planes the Navy could buy with a trillion bucks!)

    Of course, the VA is a government operation so most Conservatives view it as socialized medicine. But some Conservatives are beginning to walk that misperception back a little. To that point, here’s an article from the right-leaning Rand Corporation, http://www.rand.org/blog/2012/08/socialized-or-not-we-can-learn-from-the-va.html.

    Maybe the AARP’s message is getting through after all.

    Herb

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  4. Excellent points, clearly written. I’ve thought for some time that simply lowering the age for Medicare would be a big step forward. Maybe a gradual lowering until everyone can get Medicare. I also learn from your commenters. Interesting that Herb says our health care system is an abomination, and yet every day I hear politicians saying that our health care system is the best in the world. Just as I keep hearing that American is the greatest country in the world. And when I hear that, I want to say, In what way? Give me the details? In what way is it the best? Yes, our health care system is a mess, and I’m sorry Obama didn’t go further, but at least he is going in the right direction.

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  5. henrygmorgan says:

    Jim:

    I’m afaid you’ve let the cat our of the bag. When freedom-loving patriots learn that our military has “socialized” medicine, the cries of outrage will discharge upon you, accompanied by cries to “de-Europeanize” the military health system. If only I had known back in those long-ago days when I was in the service that I was aiding and supporting communism. Is there a patriotic confessional that I can turn to?

    Bud

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    • Jim Wheeler says:

      You’re right, Bud, that it’s easy to disparage a bureaucratic system, and no system is going to be perfect. It is my hope that America’s long tradition of transparency, of freedom of speech and press, can make a government healthcare system something of which we can all be proud. Our shared experiences in the armed forces and the examples in this post indicate to me that it’s possible. And besides, we can’t afford the mess we have now. Thanks for your comments.

      Like

  6. ansonburlingame says:

    To all,

    I start by reading “…the system would not only be vastly improved….”, meaning the delivery of HC across the board in America with a “Naval aviation approach…” to HC. I suppose you use current single payer systems in Europe as the basis for such a claim. Dirty word or not, all of you are calling for some form of socialized HC delivery and payment, or so it seems to me.

    In the ideal world, HC decicions must be between patients and providers, mostly doctors and forget payment for the moment. A patient is “hurting” and a doctor’s help is sought, just like a broken car is taken to the “car hospital”. Good mechanics “heal” the car or good doctors heal patients. But of course some cars cannot be “healed” and they are sent immediately to the “junk yard”. Try doing that with a patient!!! Decisions related to “stuff” are Cost/Benefit decisions, even pilots, who are immediately “grounded” if they fail to measure up. How often does anyone “ground” a doctor and who exactly, other than courts have such power?

    Medical care is today NOT just between patients and doctors unless the patients are very wealthy and can pay for HC despite what any “insurance” (private or government) might dictate. .

    Here is just one very small example. Consider a person addicted to drugs or alcohol, a disease. Betty Ford is the pre-eminent treatment facility for such a disease and it costs about $30K for a 30 day period of rehab. Medicare and Medicaid do NOT pay for such treatment but he local Ozark Center (New Directions) does so. Then go look at New Directions and compare it to Betty Ford. Based on my own observations, I would not send my “dog” to the Ozark Center. It is a “machine” taking in addicts and spitting out addicts with a short stop alone the way for “rehab”. Maybe a 5% success rate for that facility and almost every patient therein is funded by government sources. And that short stop costs around $15-$20K right out of taxpayer pockets.

    Americans today are seeking real equality in HC for all Americans. Socialism is a form of government that by and large strives to deliver equality (as does communism to a degree as well). Democracies also demand equality today, by and large.

    Great, go for it, equality. But then confront the economic reality, not just “demands or wishes” and PAY FOR IT. My wife “demanded” (doctor ordered it) a CAT scan. Hospital charge was $1780. “Government” paid a total of $66. Now show me a supply and demand curve that finds an equilibrium for such supply (at $66) and demand (no matter what it costs).

    Start “small” if possbile. Just PAY FOR MEDICARE as we know it today before you leap to even greater “socialized HC” for all Americans. You will note if you look that I have blogged on the subject.

    Anson

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  7. In case you missed last night’s 60 Minutes, here’s part of the reason our health care insurance is so damn high: http://www.cbsnews.com/video/watch/?id=50136261n

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    • Jim Wheeler says:

      Well, wordpress just ate my reply. I think. So I’ll try again.

      Thanks Herb for a valuable addition to this post. I finally had time to watch the 60 Minutes clip about the manipulation of Medicare and Medicaid by the for-profit hospital company, HCA. It is an excellent example of how the profit motive can corrupt the process. I have some experience with similar manipulation of laws and rules by management. It does not and usually is not explicit. Managers (and doctors) are smart – they observe and listen. Hiring, firing, placement, all are ways to get the message through as to what is expected, and quotas masquerade as statistical goals. I just hope other readers will make sure not to miss the clip. If profit is the goal, patient care will be secondary.

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  8. ansonburlingame says:

    Herb,

    I saw the 60 Minutes show and yes, therein is a problem. I found a few years ago that following the rules of Medicare can in fact be a burden. I had pneumonia in Hawaii and went to the ER. They kept me for about 5 hours and tried hard to find a way to admit me to the hospital. But my condition did NOT meet Medicare criteria for hospitalization and I was subsequently released to return to my hotel to continue my recovery. All worked out fine though I was “sick as a dog” in a hotel room, cared for by my wife for about 3 days. All I needed was lots of hydration and anti-biotic medication prescribed by the ER doctor. So in fact I did NOT need hospital care, after all.

    So how that HC company can admit patients, legally, for profit only is beside me and shows ME at least lack of enforcement by Medicare or their own rules.

    Go back to the $66 paid for a procedure charged at $1780. If Medicare paid what it really costs (plus a reasonable profit) for that procedure, then such tricks pulled by the HC company would not be needed. But Medicare FORCES HC providers to rely on volumn only to stay in business, forget quality of care.

    Socialized medicine tries to manage HC like an assembly line, complete with every rule possible for safety, etc. Only doctors and patients can cost effectively manage HC in my view. Each car coming off the assembly line is thus “hand made” and expensive, maybe. But many times I found that doctors did not charge “flat rates for hang nails”. Instead they adjusted fees according to the patient’s ability to pay as an individual. The local hospital in my home town did the same when the “poor” were admitted as well.

    But no the world has changed and now we expect government to dictate compassion and professionalism by all concerned and fix the prices as well. That means we move to lower paid “robots” to deliver HC at wages akin to that of a garage mechanic fixing a car!!! That is MY vision of how HC worked in the Soviet Union long ago and to a degree in Europe today.

    Anson

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  9. Anson,

    I don’t understand the apparent hysteria from the far right over “socialized medicine.” As I pointed out above, we already have it through the VA health care system. It is generally acknowledged that the VA model works better than what we now have because it has better health outcomes than the private sector, has a much lower cost per patient, and those who participate prefer it over the system we have now. I haven’t heard any complaints about “assembly line” treatment.

    Even though the right wing outliers don’t want to hear it, the performance of socialized health care systems in Europe, Canada, Australia, and Japan are very similar to that of the VA. We would do well to learn from their experience.

    I would much rather have a government run hospital concerned about its budget than a private hospital more concerned with squeezing as much profit as it can out of each patient rather than providing cost-effective health care.

    At the end of the day, it seems clear to me that many Republicans are merely deluding themselves that health care should be treated as profit oriented free enterprise. It most assuredly is not. There are no 2 for 1 sales, no holiday specials, no discount coupons. It is this fantasy that, over the decades following the end of WWII, has resulted in Americans having to endure the most expensive health care in the world while receiving comparatively mediocre health outcomes. Sadly, there are way too many who want to keep it that way.

    To me there is something immoral about making a profit off of human pain and suffering. But that’s just me.

    Herb

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  10. ansonburlingame says:

    Herb,

    I am not against socialized medicine per se. What I am against is medicine that becomes mediocre. And yes, I had (long ago) experience with such medical practices while in the Navy, particularly as it related to my family.

    First, as a healthy 23-46 year old man, I never had need for really intense medical care. Annual physicals, a broken bone or two along the way, etc. were my only medical needs. Almost all of my routine medical care could easily and effectively be provided by a well trained corpsman stationed aboard any ship to which I was assigned.

    Now for the family. Again, other than child birth there was hardly ever a need for high end medical care. But, for example, when a 3 year old had a high fever, etc. and “home care” was not enough, a 4 hour wait in an ER with MANY waiting patients for a throat culture and some anti-biotic prescription was certainly inefficient to say the least, A 3 year old in a waiting line behind auto crash victims is…….?

    I also saw, but never experienced for my own family, that when something really serious came up, invariably the care was “farmed out” to civilian HC providers. Even a simple tonselectomy (spl) for my two sons was conducted within the civilian HC community rather than a military hospital. As well rarely did such military hospitals/doctors deal with cancer, severe heart disease, etc. In short, military medicine was limited to routine care for normal, healthy younger folks by and large.

    Consider for example, obesity, diabetes, early onset heart disease, cancer, etc., the far more dibilitating medical concerns of the much larger civilian population in both numbers of patients and severity of the disease. Throw all of that at a typical militiary medical institution and watch out. For sure they are not trained, equiped or staffed for such an onslaught and the ramp-up in staffing alone would be unbelievable, in my view.

    As well, don’t forget the training pipeline for providers of such care. Do you propose that government take over the bulk of medical education? Almost all military doctors came from civilian educational facilities, sometimes paid for by government. The staff then served some period of obligated service then bolted for the door to the much higher pay of civilian practice. Sure some doctors, etc. remained in the military but most left as soon as possible.

    One counter to such views is the remarkable ability of military medicine to care for today’s combat injuries. How that has been achieved is beyond me for sure today. But again that is a very limited set of patients, thousands, certainly not millions and as well, other than the injuries themselves, those patients are normal, healthy men and women. Try multiple amputations on a basically unhealthy person and see how long they “last” as only an example.

    The CONCEPT of superb HC for ALL Americans is a great concept for sure and I would love to see it happen. But how to staff such a system, manage such a system, and PAY FOR such a system is beyond me.

    As for the last point, paying for such a system, I again challenge anyone to simply figure out a way to pay for Medicare today. If or when that is achieved, by itself, and Medicare becomes sustainable, fiscally, then I will start to listen seriously to proposals for a much greater form of socialized medicine in America. But not until then, at least for me. I will remain convinced that it is a pipe dream, not something that is really achievable and acceptable to most Americans.

    Anson

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