The VA: “The Greatest Story Never Told”
Published January 11, 2009 @ 07:19PM PT
I owe new reader Rose Adwell (welcome Rose!) a big thank you. She asks this question in the intro post on health care issues: “The VA, isn't that a very poorly run system? It would be a tragedy if we ended up with that kind of care.”
I owe her this thank you because I’ve been dying to talk about the health care system for America’s veterans, as administered by VA hospitals, clinics and nursing homes around the country. Perhaps 20 years ago, the answer to Rose’s question would have been yes. But today, after a complete overhaul in the mid 1990s, the VA is far from a very poorly run system. It represents, with no exaggeration, the best health care system currently operating in the United States of America.
That statement may be shocking to some because usually veterans affairs only gets talked about when gross injustice occurs – like the transitional housing situation at Walter Reed. It may be shocking for others because you just haven’t heard anything about it – after all the VA only treats 5.5 million people, including veterans and their dependents, nationwide. But behind many of the principles of progressive health care reform, you’ll find a successful case study as implanted in the VA reforms. We would be lucky if we ended up with that kind of care.
Let me be clear – having the best system doesn’t mean that each hospital automatically is the equivalent of the Mayo Clinic. There are variances in care from hospital to hospital, just as not every doctor is guaranteed to be a medical super-genius.
Call me old-fashioned, but I think you determine the best system by the best health outcomes – does it make patients better, and does it do so efficiently? In 2003, the New England Journal of Medicine crunched the numbers, comparing Medicare and the VA on a broad range of health indicators, from preventative care to chronic care to inpatient care to outpatient care. By 2000, the VA had better indicators than Medicare in 12 of 13 categories.
But that statement doesn’t do the results justice. In 10 of 13 categories, 80% or more of the patients surveyed had the appropriate care from the VA, and 90% or more in 8 of 13 categories. For Medicare, 80% or more of patients had appropriate care in only 2 of 13 categories, and none above 90%. Granted, the VA and the Medicare systems’ patient profiles are not identical – but not in a way that makes the job easier for the VA. As the NEJM reported, “However, as compared with Medicare enrollees, users of VA health care are more likely to be in poor health; to have a low level of education, disability, or a low income; to be black; and to have higher rates of psychiatric illness.” In short, better care for sicker patients.
Well, OK, we’re comparing government-run health care to government-run health care. The Big Story we’ve always been told from the defenders of our patchwork system of private sector care is that government health care is an inherently yucky experience. Wait times. Bureaucracy. Pain-in-the-butt-ness. The medical equivalent of going to a DMV. So obviously, patients at the VA must be exasperated with the great care they receive compared to those of us who have private insurance, right? Not even close. The American Customer Satisfaction Index ranks the VA ahead of any private-sector health care or insurance company, for both inpatient and outpatient services. This isn’t a one-year triumph, either. Look up the same rankings for seven consecutive years (2000-2007 with the 2008 data still pending), and you’ll see the same story.
Former Secretary of Veterans Affairs Jim Nicholson calls it, “the greatest story never told.”
How did the VA do it? And how can the 294.5 million of us who aren’t in the VA system get in on some of that action?
The VA embarked upon some major reforms in 1994 and 1995. NEJM laid out the full battle plan in an article published in 1996. Some of this was in reaction to a system that was consistently underperforming and inadequately serving the needs of its patients. But what made these reforms politically possible (let’s face it – the VA was a patronage Pez dispenser at the time, and so potentially resistant to change) was that these reforms neatly fit in “as a part of government-wide efforts to shrink the federal government and reduce the budget deficit.” In short, they were done to save money and improve care. Gosh, doesn’t that sound like our mission statement for reforming health care today?
Here are some highlights of the reforms:
- Shifting resources from inpatient to outpatient care, including capacity at hospitals, accordingly.
- Investing in primary care and prevention. The most dramatic split between the VA and Medicare health outcomes is that 62% of patients got the smoking cessation care they needed at the VA, compared to 38% in Medicare. And that’s one of the indicators that the VA performed poorly on!
- Better coordinated care and case management for long-term care.
- Prioritizing quality mental health care.
- Decisions based on performance metrics. The VA constantly compiles and analyzes data on service and health outcomes to improve care. As the American College of Physicians notes, “Comparisons of VA patients with a national sample show that VA patients receive higher quality of care, with highest quality in areas where the VA actively monitors performance.” Well, fancy that!
- VistA – the VA’s Electronic Health Records system. Yup, they’ve got it – and it works well, if not perfectly. (Of course, being in a closed, single-payer system helped the implementation and start-up of this vital system.) Niko Karvounis of Health Beat Blog sums it up thus, “VistA has quite a lot going for it: the VA has improved productivity by 6 percent a year since it was implemented in VA hospitals nation-wide; VistA has helped the VA cut its health care costs by 32 percent since 1996; and the VistA computerized prescription system is incredibly accurate, correctly matching patients and medication 99.997 percent of the time.”
- Honest-to-gosh negotiation on prescription drugs, particularly compared to the Medicare Part D plans. Families USA has the gory details: “We found that for all of the top 20 drugs prescribed to seniors, VA prices are substantially lower than the lowest prices charged by the largest Part D insurers. The median difference was 58 percent. In other words, for half of the 20 drugs, the lowest price charged by the largest Part D insurers is at least 58 percent higher.” So if you actually bother to negotiate for the best prices, you get them. Interesting. File that away for future reflection.
Who would have thought that the best health care in terms of cost, efficiency, coverage and health outcomes would be a single-payer system? Not only that, it’s a closed system – with it’s own hospitals, doctors, staff and decisions on which prescription drugs it will or will not disperse. If this were a wrestling match, you’d be hearing the “socialized medicine” theme music as the VA system entered the ring.
For all the lavish attention I’m paying to it, it’s clearly not perfect.
One of the problems highlighted during the presidential election by Bill Richardson and John McCain (and may I just say, “Whoa, that’s a weird pairing!”) was concern over convenient access, particularly for veterans in rural areas or those who otherwise live far away from the 153 VA hospitals or 711 outpatient clinics. For a country this size, that’s not actually enough to cover the veteran population conveniently.
Another is that the appropriation for VA funding is constantly in doubt each year. It’s bizarre that an institution that serves such an honorable population with essential services in a way that is already efficient and becoming more efficient each year would be in such a situation. When more service members are returning home from Iraq and Afghanistan and into the VA system, that seems like sacrilege. But “V.A. never knows what its level of funding will be for the next year,” said Senator Akala of Hawaii, a fact that raises concerns about how much politics would impair the full funding of a national single-payer system, were we to create one.
Finally, the interoperability that plagues the various Health IT initiatives is on full display. VistA and the Department of Defense electronic health records system for active service members don’t talk to each other and operate in completely different ways. The inefficiency in the handover of records from the DOD to the VA is beyond stupid.
But at the end of the day, the VA system is better than Medicare, better than Medicaid and better than the private insurance industry. As Americans, we’re sometimes loath to look to solutions and models outside our borders. But if we’re looking for a successful model of health care reform, we don’t need to look beyond what the VA accomplished over a few years in the 1990s.
It would be a dream come true if the rest of us ended up with that quality of care.
(Photo credit: 60 in 3 on Flickr.)
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Comments (18)
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Tim has been an online organizer and blogger on health care policy for the Obama for America campaign (during the primaries) and currently for the Committee of Interns and Residents/SEIU Healthcare, a labor union for intern and resident doctors. Views expressed here are Tim's, and don't represent the positions of CIR or SEIU.
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Great post - I never knew any of this about the VA either. So helpful to know!
Posted by Leigh Graham on 01/11/2009 @ 08:05PM PT
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i have been a part of the v.a. healthcare system since 1971. i've seen it go through many, many changes. 100% of my healthcare is now provided by the v.a. i only wish every citizen could have the same quality of care that i receive.
i have been working as an activist in promoting h.r. 676, a single payer health plan. maybe the v.a. works so well because the greed factor is removed.
Posted by tom bell on 01/11/2009 @ 08:10PM PT
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I see 20 to 40 patients per day as a Nurse Practitioner in an Urgent Care. It keeps people from using the hospital ER as their Primary Care. Many of my patients don't have insurance and they just pay the visit fees. Most only need a physician once every 2 years so this saves them a monthly insurance premium. However, if they need surgery or extensive tests they could loose everything in today's economy. They are so afraid. If we had a per person catastrophic subsidy from the government it would cut down on ER costs for the hospitals. The VA's and Tricare clinics could be opened up to the general public for fee for service. Minute Clinics run by Nurse Practitioners in pharmacy's could be given more authority to order labs and xrays. A not for profit government HMO is what we need.
Posted by CAROL BUTLER on 01/11/2009 @ 10:41PM PT
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Nice post. <3
Posted by M N on 01/12/2009 @ 05:27AM PT
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Thumbs up. As a social worker who went to school down the street from a VA hospital, I was pleasantly surprised at the quality of care available at the place and the quality of people working there.
Posted by MInute Man Pete on 01/12/2009 @ 09:17AM PT
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Walter Reed is an Army Medical Hospital and not part of the VA (another mistake often made by those who would slam the VA).
Posted by bart woolery on 01/19/2009 @ 07:47PM PT
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I went to my first VA appointment last week. Was very pleasantly surprised. Questions like: "Did you get a flu shot?" No. "Want one?" Yes, thanks. "When was the last time you had a tetanus shot?" Uh, more then 10 years I think. "Want one?" Yes, thanks. Better then I am getting with TRICARE based on 20 years of service (28 total, some in the reserves). I wish I knew where to put in the suggestion that we expand the Public Health service to care for those who need health care, or two branches, public health and personal health. Require hospitals, including the VA, to provide the support services at cost. Hospitals can hire more people and pass the cost off to the Health Service. People that want to be a Dr. and get accepted to Med School can join, get paid as an enlisted grad 5 till they graduate and do five years. Some will stay, some will leave, and the bonus for staying is advanced training and the 20 year retirement. Some people will leave the military service and use their time toward a Public Health retirement (bonus is no more over seas deployments and their previous time counts). Put the offices near the hospitals for routine lab work when possible, run them 16 hrs or the ones that can support it 24 hrs and that will clear the ER for real ER cases. People that want to pay and can pay for private can do so. Following a transition period we will have a system that people can move in and out of should their personal situation change and staffed with decent Docs that are there for their personal benefit too.
Posted by Ron Kellis on 01/20/2009 @ 05:53PM PT
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Perhaps I'm one of the 20%, because I'm a veteran rated at 100% disability, service-connected. I'm wheelchair bound, one arm paralyzed, yet still working full time. I find the VA system is great if you're retired, but incredibly poor for those who have a job. Many times I have to take time off to deal with VA red tape, deficiencies and misunderstanding, and I get paid hourly, so it comes out of my pocket.
Posted by James Hamp on 01/24/2009 @ 07:50AM PT
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james, i don't understand. you say you're rated at 100% disability. the v.a. pays $2700 a month, tax free, if you single, and provides all your medical care at no charge. also, if you're rated at 100%, you are entitled to social security disability.
these are benefits that you, and all other disabled vets are entitled to. you earned them. you gave your time, and your body, and they give back. have you not checked with the v.a. lately?
Posted by tom bell on 01/24/2009 @ 02:12PM PT
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Tom, I get that $2700/mo. I work, so I'm not entitled to Social Security, as the SS rating system isn't the same as the VA. I'm saying those medical benefits aren't free for the working man, because they cost me whatever hourly I would make. $2700 may seem a lot, but I pay my ex $1800 of that in alimony.
Posted by James Hamp on 01/24/2009 @ 02:41PM PT
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I am a Vietnam Vet, and three years ago I went to my local VA Hospital (Harbor facility in Brooklyn NYC) and applied for services. I put this off all these many years because when I first returned from the war, and visited the VA here in NY (the Bronx), it was the most disgusting facility on earth. Vermin, peeling paint, crowded clinics, and a bad attitude on the part of the staff.
Due to financial constraints, I was forced to revisit. Was I pleasantly surprised; shocked actually at the vast improvements made over these past decades.
I have been receiving long-overdue health care for three years now. The care, atmosphere, and professionalism is the best I have ever received. It is what I would like to see every citizen have access to. The coordination is also fantastic, from social work, to GP, from psychiatry, to podiatry, from dental to vision, the care is top-shelf. Oh, and the generic drugs sent to me by mail are (for me) free and effective.
In the past, during my working life, I used HIP, GHI, private health insurance, and out of pocket health care. The VA surpassed all my previous experiences by leaps and bounds. It is total care, the way it should be. Their computerised (totally paper-free) system makes it efficient as well. I rarely wait for a clinic visit, the doctors are professional, and go the extra mile. The thoroughness is incredible as well.
The VA system should be made the model for universal health care in America. It's already invented, and it WORKS! I can not give enough to praise about VA system, it is simply the best health care available in America. I am healthier than I have been in years, and feel I have a real careing partner, truely concerned about me as a person. Kudos to the VA!
Bob
Posted by Bob Richards on 01/28/2009 @ 12:05PM PT
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Thank you for your post, Tim, and everyone's comments.
The greatest story never told should be bedside reading for everyone in Congress.
What's the difference between the care providers in VA and private facilities?
Posted by Andrew Chow on 03/27/2009 @ 09:11PM PT
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For one thing, with the economic downturn, VA hospital jobs are now top of the list for graduating resident physicians. It's not a great time to go into private practice for the first time, many hospitals may be facing layoffs of their attendings (or have already begun doing so), but the VA is as stable as it gets.
For another, because the doctors are salaried, their incentives are different. The VA rewards care coordination and quality of care, and has a system-wide electronic records system that's as good a system out there as we've seen.
Posted by Timothy Foley on 03/27/2009 @ 09:35PM PT
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So you are saying VA providers' pay is based on electronic records that measure more than just the number of patients and amount of procedures performed or prescriptions assigned. That's another benefit of electronic record keeping: when more qualitative and accurate measures of the quality of care provided by the various providers at each stage, and for each patient.
Is it possible to replicate or duplicate the experience learned from the best in the VA system? Can this Best Practice be codified into a set of guidelines for or public and private hospitals?
Posted by Andrew Chow on 03/27/2009 @ 10:22PM PT
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The biggest difference is that the atmosphere is one of a team working together completely for the patients' good, as opposed to a corporation working mainly for the bottom line ($). The providers generally try to do their best, but the institutional attitude makes all the difference. At the VA, it's not about profit, it's about the care.
It is time to take the greed of the insurance companies out of our health care system once & for all!!! The VA has it right for sure. Let the governement run the system for everyone, to benefit from low drug costs (free to us), uniform portable electronic medical records, simpler billing (invisible to us), & so many other efficiencies.
We can't afford NOT to do it this way now given our current recession! Businesses would no longer have to pay for employees' health care coverage! If each of us had a card & could go anywhere, but the government just paid all the bills, it would save lives & money. It would be a higher quality of care & convenience, too.
Speak up to your Congresspersons & get active now to make it happen. The insurance companies don't want reform, they are in business to make money. In America, we are already paying enough for health care that we can get rid of the insurance companies all together & get everyone covered. There is no room for profit in universal health care.
Posted by Beth Hubert Rothermel on 05/24/2009 @ 08:52AM PT
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It is a shame the rest of the V. A. is not run as efficiently. Countless vets are waiting to get medical / mental care due to the abuse, negligence with-in the regional offices, loss of records, records that are shredded, employees that are rude and do not care. The claims process takes years and there is a backlog of over 600,000 claims. Many vets become homeless and some have died waiting for the claims process. A lot give up the fight out of frustration and stress the process causes. I have been fighting since 2004 with a previous claim that I gave up on in 95. I am cared for at the Philadelphia VA and my current Dr's are all VA , they concur with my claim and yet I am still fighting. There are also many other problems that are not being told, the prescription drug program has a great deal of problems such as meds that are not delivered on time or not at all, most meds are mail order and some (popular) meds are not available at all. This is totally unacceptable and must be stopped, please do not be fooled by these reports all is not well at the VA. There are countless Veterans that are suffering at the hands of the V.A.
Posted by Joseph Simpson on 05/31/2009 @ 07:07PM PT
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I am a disabled Veteran, rated at 50% now and yes we have an outpatiant clinic here in Charlotte that I have used at times to be seen for an anual physical, this place is beautiful and well kept and clean and effieciant.
But my beef with the VA is not that the treatment is good, because it is, my issue is availability of treatment when I need it. At 50% I am intitled to medical treatment for any condition regardless of origin. (below 50% if condition is not service related, then you pay a co-pay for treatment)
But the local outpatiant clinic does not have the facilities to treat me in an emergancy situation, nor if today I wake up and feel like I have the Flu and want to see a doctor. For anything I need any type of Urgent Care for, I am requared to drive an hour or more away to be seen at the nearest VA hospital in the emergancy waiting area. This is not even close to being logical becaise Charlotte NC is the largest city in the State of NC, why do I have to drive an hour to be seen or use my Free Medical benifits through the VA ?
Another question is why is the VA rating system not tied to your primary care physician ? why do I have to request a re-evaluation and be seen by someone who does not know my medical history and who does not have access to my records just to try to be determined weather or not I can get an increase in my rating for a peticular issue.
Some very hard questions..... But overall the improvment has been good.
Posted by RICHARD DAVIS on 07/16/2009 @ 08:59AM PT
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hi, i have been in the va system for several years. i have seen it improve so much in these yeare. if i rated 1-10, ten being the best, i would vote 10+. the care is so excellent. why cant the government do as the va. is doing. have our own hospitals and our own employees. the doctors i have seen say it is so much better than private practice. the government makes things so difficult. we would own our equipment etc. would not care if insurance would pay or not. insurance is billed for every aspirin and bed pan. plus, they mark these items up so much. example, $5.00 for a aspirin. get it at store for pennies. thanks for reading this. i am for this type of system.
Posted by charles garrett on 10/08/2009 @ 07:29AM PT
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