The VA: “The Greatest Story Never Told”

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.)