Innovation, influence and business in America's medical cities.

Journalist Phil Longman at the New American Foundation recently updated his book “Best Care Anywhere,” which documents the 1990s rejuvenation of the Veterans Administration’s health care system. Between editions, the wars in Iraq and Afghanistan placed strains on the VA not seen since Vietnam. Here’s his thoughts on the current state of the system, and the lessons its transformation holds for other delivery systems in the U.S.

How does contact with the VA healthcare system compare in terms ofmedical outcomes for its patients? How about in other measures ofquality?

In study after study published in peer-reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost-effectiveness, and patient satisfaction. The VA is also on theleading edge of medical research, due to its close affiliation with the nation’sleading medical schools, where many VA doctors have faculty positions. The VA has its problems, but compared to those found elsewhere in the U.S. health care system, it offers “Best Care Anywhere.”

How has the VA managed to create such a successful model when government bureaucracy, political pressures and limited funding would seem to make it impossible?

During the 1990s, VA health care underwent a quality revolution. It was started by frontline doctors and nurses who simply wanted to do right by America’s veterans. It was later propelled by the enlightened andcharismatic leadership of Dr. Ken Kizer, who took control of the VeteransHealth Administration under President Clinton. The key to making it allwork was the VA’s near lifelong relationship with its patients, which meansit has incentives as an institution for investing in prevention, diseasemanagement, and other protocols that keep patients well-incentives thatare sadly lacking elsewhere in the U.S. health care system.

The VA’s medical records are entirely computerized. Why hasn’t theprivate sector been able to do the same? What are the effects?

As the VA has shown, digital medicine, when properly implemented, vastlyimproves the quality of medicine. That’s great for the VA, whose institutionalincentives are aligned with those of its patients. But elsewhere in the U.S.health care system, the business case for quality is weak or doesn’t exist.Improved quality means that fewer patients get sick, and that when they dothey experience fewer complications. This is very costly to hospitals anddoctors who earn their money by performing procedures, as opposed tokeeping people well. Why invest it electronic medical records if its meansthat ultimately you’ll have fewer heart attack patients to bill, or will earn lessfrom treating diabetic patients because you have properly managed theirdisease?

Health care reform passed without creating a public care option, a lossmany progressives feel dooms the bill to failure. Is that the case?

The Bill does concern itself primarily with expanding insurance coverage,and not directly with reform of the actual practice of medicine. But it alsocontains provisions, which few people know about, that could provide theground work for something like a civilian VA health system. Whether thisactually happens depends heavily on people at the local and state level taking advantage of the opportunity the bill gives them. It’s kind of like getting just the toy you want for Christmas, only it says on the box “some assembly required.”

What are the prospects for that happening, and is the fundingadequate?

There is at least $12 billion available for anyone who wants to set up whatthe bill calls an “Accountable Health Care Organization.” That means anorganization that is willing to accept getting paid for keeping its patientswell, and that is willing to adapt and integrate health care informationtechnologies of the kind the VA has pioneered. The barriers to entry areremarkably low. The VA’s software, for example, is free to any health careprovider who wants to use it, because was written by VA doctors ongovernment time. It’s also “open source,” which means that health careproviders outside the VA can modify it to meet their particular needs.

Would a civilian VA mean more and bigger government?

For those who are concerned about the growth of government, and I am one, the most important single objective is to control the cost of health care,which is driving up spending at all levels of government. The moreAmericans have access to the VA model of care, the lower health care costswill be, while at the same time health care quality will improve. Done right,the widespread adoption of the VA model of care could free up enoughresources to pay for tax cuts, or to start making serious down payments onour national debt.

What effect would such a system have on health insurance costs forAmerican businesses and families?

It’s estimated that one-third of all health care spending outside VA goes forover-treatment, such as redundant testing and unnecessary surgery. Because the VA model gives doctors no financial incentive to perform operations people don’t need, and empowers them with the information technology to keep track of test results and coordinate care, it’s widespread adoption could well cut health care spending by a third. Insurance premiums would fall commensurately.

Would such a healthcare system mean that doctors and patients wouldlose the freedom to decide which treatments and medications theywanted to use?

Most Americans have very little choice of doctors right now. Just try findinga primary care physician who is still taking patients. Every VA patient has aprimary care physician who coordinates their care among specialists. Unlikemost other health care providers, the VA does extensive research on whatworks and doesn’t in medicine, including by using the outcomes dataavailable from its own electronic medical records. This, ironically, providesits patients with insurance against one of the leading health hazards in theUnited States, which is being subjected to unnecessary treatment. Of course, no one is compelled to receive their care from the VA, nor would anyone be compelled to join a health care plan that adopted its model if it didn’t fit their preferences.

What can the average citizen do to make VA quality medical care available for themselves and their communities?

Start by talking to veterans about the care they receive from the VA. It’s rareto find a vet who has been treated there recently who isn’t a big fan. Thenstart questioning your health care providers about why they can’t deliver thesame quality of care. People all over the world, including the people inUganda, enjoy the benefits of electronic medical records, but few in the U.S.do. Demand to know why your doc is still using 19th century informationtechnology. Finally, be open to the many people both in and outside U.S.medicine who are calling for wholesale reform of the delivery system, even ifwhat they say at first seems counterintuitive or contrary to conventionalwisdom.

How did you get interested in the VA and what did you think you wouldfind out when you began your research?

Several years ago, Fortune magazine asked me find out who was providingthe most innovative and effective health care in the U.S. Having lost my firstwife, Robin, to breast cancer, and having seen much of the dysfunction of the U.S. health care system up close during that ordeal, I was eager to take the assignment. No one was ever more surprised than me to find that that the long troubled VA had become the bright star of American Medicine.What would you like to see the American health care system look like in20 years?

If all goes right, we will have a health care system in which the interests ofpatients and providers and aligned, as they are in the VA. Both individualsand policy makers will pay much more attention to prevention, and to theenvironmental and behavioral factors that play by far the greatest role indetermining our health and longevity. We will also come to understand thatmany of the procedures performed by today’s profit-maximizing surgeons and other specialists have no scientific basis and, worse, cause muchneedless death and suffering. And we will wonder why it took us so long toopen minds to these truths.