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General Medicine

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National Health Expenditures: The Past, Present, Future and Solutions
Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative
   Case Study of Physician-Faculty Perspectives
Special Article: Physician Burnout-The Experience of Three Physicians
Brief Review: Dangers of the Electronic Medical Record
Finding a Mentor: The Complete Examination of an Online Academic 
Matchmaking Tool for Physician-Faculty
Make Your Own Mistakes
Professionalism: Capacity, Empathy, Humility and Overall Attitude
Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
Comparisons between Medicare Mortality, Readmission and 
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
   Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
   the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
Hospital Performance Measures And Outcomes 


Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.


Entries in costs (2)


National Health Expenditures: The Past, Present, Future and Solutions

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

"[T]he US health care system … defies the laws of economics, and of gravity. Once the price is high, it just stays there."- Dr. Naoki Ikegami


The costs of health care in the US have been increasing for many years and the US now spends more on health care than other developed country. The cost of health care is higher in the US in nearly every category. However, the dramatic rise in health care costs over the past 35 years occurs during the time when pharmaceutical costs and administrative costs have also dramatically risen. It seems likely that these costs may account for much of the increase in health care. However, neither is dealt with by the Affordable Care Act (ACA). Until a system of oversight is enacted on medical costs, it seems likely that US health care costs will continue to rise.

The Past

In comparison to other economically developed countries health care costs have risen dramatically in the US over the past 35 years (Figure 1) (1).

Figure 1. Rise in health care spending in the US and selected other countries.

Myths. The reasons for this rise in spending have been shrouded in myths and accusations. It has been argued that high costs is the price for the best health-care system in the world. However, patient outcomes in the US are mixed. In a 2011 report by the Organization for Economic Co-operation and Development (OECD), the United States ranked 25th in life expectancy (1). Although we do better in cancer survival rates, we are more likely to die of heart disease and we do not have a good track record on treating chronic diseases such as asthma.

Health care rationing. An argument has been made that because health care is heavily rationed in other countries, Americans use more health-care services in comparison. We do rank high in the use of some expensive tests and procedures (more on this later), but overall the OECD reports that the US is well below other developed countries in number of average doctor visits per year, hospitalizations and hospital length of stay (1). Americans have better-than-average access to specialists, but we lag compared to other countries in getting immediate access to a primary care doctor when we're sick and we are much more likely forgo heath care because of costs (2).

Bad patients. Some have claimed that the US has to spend more on health care because we are fat and lazy. Although this may be true, it does not explain the gap in health care spending between the US and other countries. Obesity rates are higher in the US but the US compares well to other countries in smoking and drinking (1). We also have a younger population compared to many other OECD countries which should actually lower costs (1).

Tort reform. The US has more lawyers and more lawsuits of doctors but this does not seem to be a major factor in health care costs. Tort reform would probably not go far in bringing down US health-care costs. A 2009 study by the nonpartisan Congressional Budget Office (CBO) found that implementing tort reform would reduce US health care spending by only 2 percent (3).

Government inefficiency. There is also speculation that US Government inefficiency and spending that drives up health care costs. Health care administrative costs in the Veterans Administration (VA) are estimated to be lower than private insurance according to the CBO (4). However, as recently discovered in the patient wait times scandal, VA data may be suspect. The Centers for Medicare and Medicaid Service's (CMS) administrative costs are reported to be about 2 percent of claims costs, while private insurance companies’ administrative costs are in the 20 to 25 percent range. The argument is that private industry with costs for advertising, collection, and profit are eliminated by CMS resulting in lower costs. However, this concept has also been challenged. CMS’s administrative costs are often hidden or completely ignored by the complex and bureaucratic reporting and tracking systems used by CMS (5). Furthermore, the estimates completely ignore the inefficiencies created by CMS's mandates requiring an increasingly heavy paperwork burden for physicians and hospitals.

Physician income. Some think that greedy physicians making too much money explain the rising costs in health care. Physician compensation varies widely between specialty, health care setting and region. Laugesen and Glied (6) concluded that higher physician fees were the main drivers of higher US spending. However, in 1970, the average inflation-adjusted income of general practitioners was $185,000. In 2010, it was $161,000, despite a near doubling of the number of patients that doctors see a day. Furthermore, during the boom years of the 1990's physician incomes remained relatively stagnant with an actual decline in the early 2000's (7-9). Although physician income is higher in the US than other countries, it would not appear to explain increasing health care costs since physician income was predominately stagnant or decreasing while health care costs rose.

Drug costs. Pharmaceutical costs have been increasing in the US (Figure 2) (10).



Figure 2. Total prescription drug spending 1980-2012.

Some have blamed these costs in increasing health care costs in the US. Although the rate of growth appears to be leveling off when adjusted for inflation (Figure 2), pharmaceutical costs remain high in the US.

Administrative costs. In ground-breaking work published in 1991 Woolhandler and Himmelstein (11) found that US administrative health care costs increased 37% between 1983 and 1987. They estimated these costs accounted for nearly a quarter of all health care expenditures. In Canada the administrative costs were about half as much and declined over the same period. They followed their 83-87 report by examining data from 1999 (12). US administrative costs had risen to 31% of US health care expenditures.

The trend is perhaps best illustrated by the graph below (Figure 3) (13).  

Figure 3. Growth in administrators and physicians 1970-2010 (used with permission of David Himmelstein).

The growth in administrative costs may not limited to the private sector. CMS' administrative costs are very difficult to determine. Similarly, the VA also has hidden costs. However, during my 30 years at the VA, I saw a disturbing growth in the front office. New assistant directors were continually hired, sometimes during a hiring freeze when needed doctors and nurses were not hired (Robbins RA, unpublished observations). The growth in VA administration has been staggering at some levels. Regional Veterans Integrated Service Network (VISN) offices were founded in the mid 1990's. However, these VISNs provide no healthcare and now number nearly 5000 employees (14). VA central office in Washington grew from about 800 employees to 11,000 in the last 15 years (14). This represents a staggering 20-fold increase over the past 15 years.

The Present

High Costs. Nearly everyone agrees that health care costs are too high and have continued to rise albeit more slowly during the Obama administration (1,15). At $8713 per person the US outspent every other OECD country for a number of years including 2015 (Figure 4) (1,15).

Figure 4. Current expenditure on health, per capita, US$ purchasing power parities. OECD average in green and United States in red.

The next closest was Switzerland at $6325. The US is a very rich country, but even so, it has devoted an increasing percentage of its gross domestic product (GDP) to health than any other country for a number of years including 2015 (Figure 5).

Figure 5. Current expenditure on health as a % of gross domestic product (GDP). OECD average in green and United States in red.

Switzerland is the next highest, at 11.1% of GDP, and the average among economically developed countries was almost half that of the US, at 8.9%.

High Numbers of Expensive Procedures. There is plenty of blame to spread for the increased cost of health care in the US. Spending on almost every area of health care is higher (Figure 6) (1,2).

Figure 6. Health spending by category in US dollars 2010 or latest year available.    

Because the spending is higher in nearly every category, the reasons for the high costs in the US are likely multifactorial. US health care has a long-standing reputation for excessive numbers of procedures at high costs. The data would seem to back that impression. The numbers of some expensive procedures or operations appear to be higher in the US compared to other countries (Table 1) (1).

Table 1. Numbers of exams or procedures in the US with OECD rank and average.

High Cost per Procedure. Furthermore, the costs of procedures in the US are high compared to other countries (1,16). (Table 2).

Table 2. Cost of common procedures. Highest cost in red.

The average price for a wide range of both medical and surgical services in the US is 85 percent higher than other OECD countries (16). Both the numbers of expensive procedures and the high cost of procedures undoubtedly contribute to the high cost of health care in the US.

Administrative Costs. In 1999 the administrative costs of health care were estimated to be about 1/3 of all costs and were rapidly rising. There appears to have been little slow down in the rapid rise of administrative costs. Himmelstein and Woolhandler (17) estimated that administration costs could be as much as 45% of health care costs in 2014. There is no line for administrative costs on a medical bill but these costs are factored into all categories of medical spending.

The Future

As both Niels Bohr and Yogi Berra have said, "it's tough to make predictions, especially about the future". Now that King vs. Burwell has been settled, it is apparent that American health care will be directed by the ACA for the foreseeable future. Each year an official National Health Expenditure Projections for the next 10 years is released by the Centers for Medicare and Medicaid Services (CMS)’ Office of the Actuary. By examining these projections (which may be overly optimistic) as well as some observational studies, a rough prediction for the costs of health care can be made.

Economies of Scale. A principle in medical economics central to the Affordable Care Act (ACA) is economies of scale (18). The theory is that larger insurers will have lower prices because they are more administratively efficient. However, a recent study found that the largest insurer in each of the US states served by raised their prices in 2015 by an average of over 10% compared to smaller competitors in the same market (19). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

Provider-Owned Health Plans. Another principle of the ACA in controlling health care costs is establishment of provider-owned (usually hospital) health plans. The theory is that substitution of provider-owned health plans will lower costs by controlling doctors over charging in a fee-for-service model. Although temptingly simple, a recent study concludes that this theory is not supported by the evidence. Comparing provider-owned to nonprovider-owned plans within twelve counties across the US was on average 12% more expensive compared to traditional insurers (20).

Drug Costs. Although drug prices remain consistently high in the US compared to other economically developed countries, competition to reduce these prices for CMS patients has been limited by Congress. Most health care plans have focused on formularies to control prices. Under this system, contracts with pharmaceutical manufacturers establish preferred drugs for use by their clients and their contracted physician prescribers. Although this strategy has been in place for some time, it appears to be ineffectual in controlling drug costs (Figure 6). Most countries place price controls on drugs, a strategy that seems to lack political will in the US (21). There appears to be little in the ACA that will control drug costs.

Administrative Costs. Himmelstein and Woolhandler (22) calculated new overhead costs from the official National Health Expenditure Projections for 2012-2022 released by the Centers for Medicare and Medicaid Services (CMS)’ Office of the Actuary in July 2014. Between 2014 and 2022, CMS projects $2.757 trillion in spending for private insurance overhead and administering government health programs (mostly Medicare and Medicaid), including $273.6 billion in new administrative costs attributable to the ACA. Nearly two-thirds of this new overhead—$172.2 billion—will go for increased private insurance overhead.

Most of this soaring private insurance overhead is attributable to rising enrollment in private plans which carry high costs for administration and profits. The rest reflects the costs of running the ACA exchanges.

Insuring the 25 million additional Americans, as the ACA is projected to do, is surely worthwhile, but the administrative cost is enormous. The ACA isn’t the first time we’ve seen bloated administrative costs from a federal program that subcontracts for coverage through private insurers. Medicare Advantage plans’ overhead averaged 13.7 percent in 2011, about $1,355 per enrollee. However, both Congress and the White House seem intent on sending more federal dollars to private insurers. Indeed, the House Republican’s initial budget proposal would have "voucherized" Medicare, eventually diverting almost the entire Medicare budget to private insurers. Fortunately, the measure passed by the House on April 30, 2015 dropped the voucher scheme.


The difficulty with the ACA is that it does not appear to control the two major causes of the rise in health care spending - pharmaceutical costs and more importantly administrative costs. Himmelstein and Woolhandler (22) have long advocated a national single-payer system for health care similar to Canada's. They cite the low overhead for Medicare and Medicaid and the VA as demonstrating that such a system can work in the US. Despite the obfuscation of the overhead data by both US government agencies such as CMS and the VA, it seems likely that a single payer system would be more efficient than a private system. As Himmelstein and Woolhandler (22) have stated "public insurance gives much more bang for each buck".

However, a caveat must be added. A lesson that should be learned from the recent VA scandal is that public officials are no more honest that private companies in reporting data. Any system devised will need close oversight by knowledgeable patient care advocates. If not, the dollars intended for health care will be diverted into administrative pockets. It seems most likely that this should be on a local level by health care providers not employed or appointed by the administrators they oversee. Otherwise, there would be no real oversight. The ACA seems to encourage "provider-owned" health plans. These plans should be overseen not by the business cronies or administratively appointed physicians and nurses, but by independent health care providers who will look at administrative costs with a suspicious eye and question the costs at a local level. Otherwise the present system of less care at higher prices will persist.


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  2. Stokes B. Health affairs: among 11 nations, American seniors struggle more with health costs. Pew Research Center. December 3, 2014. Available at: (accessed 8/4/15).
  3. Congressional Budget Office. October 9, 2009. Available at: (accessed 8/4/15).
  4. Congressional Budget Office. Comparing the costs of the veterans’ health care system with private-sector costs. December, 2014. Available at: care_Costs.pdf (accessed 8/4/15).
  5. Mathews M. Medicare’s hidden administrative costs: a comparison of Medicare and the private sector. The Council for Affordable Health Insurance. January 10, 2006. Available at: (accessed 8/4/15).
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Cite as: Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. doi: PDF


Correlation between Patient Outcomes and Clinical Costs in the VA Healthcare System

Richard A. Robbins, M.D.1

Richard Gerkin, M.D.2

Clement U. Singarajah, M.D.1

1Phoenix Pulmonary and Critical Care Medicine Research and Education Foundation and 2Banner Good Samaritan Medical Center, Phoenix, AZ



Introduction: Increased nursing staffing levels have previously been associated with improved patient outcomes.  However, the effects of physician staffing and other clinical care costs on clinical outcomes are unknown.

Methods: Databases from the Department of Veterans Affairs were searched for clinical outcome data including 30-day standardized mortality rate (SMR), observed minus expected length of stay (OMELOS) and readmission rate. These were correlated with costs including total, drug, lab, radiology, physician (MD), and registered nurse (RN), other clinical personnel costs and non-direct care costs.

Results: Relevant data were obtained from 105 medical centers. Higher total costs correlated with lower intensive care unit (ICU) SMR (r=-0.2779, p<0.05) but not acute care (hospital) SMR. Higher costs for lab, radiology, MD and other direct care staff costs and total direct care costs correlated with lower ICU and acute care SMR (p<0.05, all comparisons). Higher RN costs correlated only with ICU SMR. None of the clinical care costs correlated with ICU or acute care OMELOS with the exception of higher MD costs correlating with longer OMELOS. Higher clinical costs correlated with higher readmission rates (p<0.05, all comparisons). Nonclinical care costs (total costs minus direct clinical care costs) did not correlate with any outcome.

Conclusions: Monies spent on clinical care generally improve SMR. Monies spent on nonclinical care generally do not correlate with outcomes.


Previous studies have demonstrated that decreased nurse staffing adversely affects patient outcomes including mortality in some studies (1-5). However, these studies have been criticized because studies are typically cross-sectional in design and do not account for differences in patients’ requirements for nursing care. Other observers have asked whether differences in mortality are linked not to nursing but to unmeasured variables correlated with nurse staffing (6-9). In this context, we correlate mortality with costs associated with other clinical expenditures including drug, lab, radiology, physician (MD), and other clinical personnel costs.

The observed minus the expected length of stay (OMELOS) and readmission rates are two outcome measures that are thought to measure quality of care. It is often assumed that increased OMELOS or readmission rates are associated with increased expenditures (10,11). However, data demonstrating this association are scant. Therefore, we also examined clinical care costs with OMELOS and readmission rates.


The study was approved by the Western IRB.  

Hospital level of care. For descriptive purposes, hospitals were grouped into levels of care. These are classified into 4 levels: highly complex (level 1); complex (level 2); moderate (level 3), and basic (level 4). In general, level 1 facilities and some level 2 facilities represent large urban, academic teaching medical centers.

Clinical outcomes. SMR and OMELOS were obtained from the Inpatient Evaluation Center (IPEC) for fiscal year 2009 (12). Because this is a restricted website, the data for publication were obtained by a Freedom of Information Act (FOIA) request. SMR was calculated as the observed number of patients admitted to an acute care ward or ICU who died within 30 days divided by the number of predicted deaths for the acute care ward or ICU. Admissions to a VA nursing home, rehabilitation or psychiatry ward were excluded. Observed minus expected length of stay (OMELOS) was determined by subtracting the observed length of stay minus the predicted length of stay for the acute care ward or ICU from the risk adjusted length of stay model (12). Readmission rate was expressed as a percentage of patients readmitted within 30 days.

Financial data. Financial data were obtained from the VSSC menu formerly known as the klf menu.  Because this is also a restricted website, the data for publication were also obtained by a Freedom of Information Act (FOIA) request. In each case, data were expressed as costs per unique in order to compare expenditures between groups. MD and RN costs reported on the VSSC menu were not expressed per unique but only per full time equivalent employee (FTE). To convert to MD or RN cost per unique, the costs per FTE were converted to MD or RN cost per unique as below (MD illustrated):

Similarly, all other direct care personnel costs/unique was calculated as below:

Direct care costs were calculated as the sum of drug, lab, x-ray, MD, RN, and other direct care personnel costs. Non-direct care costs were calculated as total costs minus direct care costs.

Correlation of Outcomes with Costs. Pearson correlation coefficient was used to determine the relationship between outcomes and costs. Significance was defined as p<0.05.


Costs: The average cost per unique was $6058. Direct care costs accounted for 53% of the costs while non-direct costs accounted for 47% of the costs (Table 1 and Appendix 1).

Table 1. Average and percent of total costs/unique.

Hospital level. Data were available from 105 VA medical centers with acute care wards and 98 with ICUs. Consistent with previous data showing improved outcomes with larger medical centers, hospitals with higher levels of care (i.e. hospitals with lower level numbers) had decreased ICU SMR (Table 2). Higher levels of care also correlated with decreased ICU OMELOS and readmission rates (Table 2). For full data and other correlations see Appendix 1.

Table 2. Hospital level of care compared to outcomes. Lower hospital level numbers represent hospitals with higher levels of care.



SMR. Increased total costs correlated with decreased intensive care unit (ICU) SMR (Table 3, r=-0.2779, p<0.05) but not acute care (hospital) SMR. Increased costs for lab, radiology, MD and other direct care staff costs and total direct care costs also correlated with decreased SMR for both ICU and acute care SMR (p<0.05, all comparisons). However, drug costs did not correlate with either acute care or ICU SMR. Increased RN costs correlated with improved ICU SMR but not acute care SMR. For full data and other correlations see Appendix 1.

Table 3. Correlation of SMR and costs.


OMELOS. There was no correlation between SMR and OMELOS for either acute care (r= -0.0670) or ICU (r= -0.1553). There was no correlation between acute care or ICU OMELOS and clinical expenditures other than higher MD costs positively correlated with increased OMELOS (Table 4, p<0.05, both comparisons).

Table 4. Correlation of OMELOS and costs


Readmission rate. There was no correlation between readmission rates and acute care SMR (r= -0.0074) or ICU SMR (r= 0.0463).Total and all clinical care costs directly correlated with readmission rates while non-direct clinical care costs did not (Table 5).

Table 5.Correlation of readmission rates and costs.



The data in this manuscript demonstrate that most clinical costs are correlated with a decreased or improved SMR Only MD costs correlate with OMELOS but all clinical costs directly correlate with increased readmission rates. However, non-direct care costs do not correlate with any clinical outcome.

A number of studies have examined nurse staffing.  Increased nurse staffing levels are associated with improved outcomes, including mortality in some studies (1-5). The data in the present manuscript confirm those observations in the ICU but not for acute care (hospital). However, these data also demonstrate that higher lab, X-ray and MD costs also correlate with improved SMR. Interestingly, the strongest correlation with both acute care and ICU mortality was MD costs. We speculate that these observations are potentially explained that with rare exception, nearly all physicians see patients in the VA system. The same is not true for nurses. A number of nurses are employed in non-patient care roles such as administration, billing, quality assurance, etc. It is unclear to what extent nurses without patient care responsibilities were included in the RN costs.

These data support that readmission rates are associated with higher costs but do not support that increased OMELOS is associated with higher costs implying that efforts to decrease OMELOS may be largely wasted since they do not correlate with costs or mortality. It is unclear whether the increased costs with readmissions are because readmissions lead to higher costs or the higher clinical care costs cause the higher readmissions, although the former seem more likely.

These data are derived from the VA, the Nation’s largest healthcare system. The VA system has unique features and actual amounts spent on direct and non-direct clinical care may differ from other healthcare systems. There may be aspects of administrative costs that are unique to the VA system, although it is very likely there is applicability of these findings to other healthcare systems. 

A major weakness of these data is that it is self reported. Data reported to central reporting agencies may be confusing with overlapping cost centers. Furthermore, personnel or other costs might be assigned to inappropriate cost centers in order to meet certain administrative goals. For example, 5 nurses and 1 PhD scientist were assigned to the pulmonary clinic at the Phoenix VA Medical Center while none performed any services in that clinic (Robbins RA, unpublished observations). These types of errors could lead to inaccurate or inappropriate conclusions after data analysis.

A second weakness is that the observational data reported in this manuscript are analyzed by correlation.  Correlation of decreased clinical care spending with increased mortality does not necessarily imply causation (13). For example, clinical costs are increased with readmission rates. However, readmission rates may also be higher with sicker patients who require readmission more frequently. The increased costs could simply represent the higher costs of caring for sicker patients.

A third weakness is that non-direct care costs are poorly defined by these databases. These costs likely include such essential services as support service personnel, building maintenance, food preparation, utilities, etc. but also include administrative costs. Which of these services account for variation in non-direct clinical costs is unknown. However, administrative efficiency is known to be poor and declining in the US, with increasing numbers of administrators leading to increasing administrative costs (14).

A number of strategies to control medical expenditures have been initiated, although these have almost invariably been directed at clinical costs. Programs designed to limit clinical expenditures such as utilization reviews of lab or X-ray expenditures or decreasing clinical MD or RN personnel have become frequent.  Even if costs are reduced, the present data imply that these programs may adversely affect patient mortality, suggesting that caution in limiting clinical expenses are needed. In addition, programs have been initiated to reduce both OMELOS and readmission rates. Since neither costs nor mortality correlate with OMELOS, these data imply that programs focusing on reducing OMELOS are unlikely to be successful in improving mortality or in reducing costs.

Non-direct patient care costs accounted for nearly half of the total healthcare costs in this study. It is unknown which cost centers account for variability in non-clinical areas. Since non-direct care costs do not correlate with outcomes, focus on administrative efficiency could be a reasonable performance measure to reduce costs. Such a performance measure has been developed by the Inpatient and Evaluation Center at the VA (15). This or similar measures should be available to policymakers to provide better care at lower costs and to incentivize administrators to adopt practices that lead to increased efficiency.


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  15. Gao J, Moran E, Almenoff PL, Render ML, Campbell J, Jha AK. Variations in efficiency and the relationship to quality of care in the Veterans health system. Health Aff (Millwood) 2011;30:655-63.

Click here for Appendix 1.

Reference as: Robbins RA, Gerkin R, Singarajah CU. Correlation between patient outcomes and clinical costs in the va healthcare system. Southwest J Pulm Crit Care 2012;4:94-100. (Click here for a PDF version)