MedCity Influencers

Quality healthcare? It’s the Veterans Administration

Journalist Phil Longman at the New American Foundation recently updated his book “Best Care Anywhere,” […]

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 of medical outcomes for its patients? How about in other measures of quality?

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 the leading edge of medical research, due to its close affiliation with the nation’s leading 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 and charismatic leadership of Dr. Ken Kizer, who took control of the Veterans Health Administration under President Clinton. The key to making it all work was the VA’s near lifelong relationship with its patients, which means it has incentives as an institution for investing in prevention, disease management, and other protocols that keep patients well-incentives that are sadly lacking elsewhere in the U.S. health care system.

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

As the VA has shown, digital medicine, when properly implemented, vastly improves the quality of medicine. That’s great for the VA, whose institutional incentives 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 do they experience fewer complications. This is very costly to hospitals and doctors who earn their money by performing procedures, as opposed to keeping people well. Why invest it electronic medical records if its means that ultimately you’ll have fewer heart attack patients to bill, or will earn less from treating diabetic patients because you have properly managed their disease?

Health care reform passed without creating a public care option, a loss many 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 also contains provisions, which few people know about, that could provide the ground work for something like a civilian VA health system. Whether this actually 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 funding adequate?

There is at least $12 billion available for anyone who wants to set up what the bill calls an “Accountable Health Care Organization.” That means an organization that is willing to accept getting paid for keeping its patients well, and that is willing to adapt and integrate health care information technologies of the kind the VA has pioneered. The barriers to entry are remarkably low. The VA’s software, for example, is free to any health care provider who wants to use it, because was written by VA doctors on government time. It’s also “open source,” which means that health care providers 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 more Americans have access to the VA model of care, the lower health care costs will 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 enough resources to pay for tax cuts, or to start making serious down payments on our national debt.

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

It’s estimated that one-third of all health care spending outside VA goes for over-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 would lose the freedom to decide which treatments and medications they wanted to use?

Most Americans have very little choice of doctors right now. Just try finding a primary care physician who is still taking patients. Every VA patient has a primary care physician who coordinates their care among specialists. Unlike most other health care providers, the VA does extensive research on what works and doesn’t in medicine, including by using the outcomes data available from its own electronic medical records. This, ironically, provides its patients with insurance against one of the leading health hazards in the United 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 rare to find a vet who has been treated there recently who isn’t a big fan. Then start questioning your health care providers about why they can’t deliver the same quality of care. People all over the world, including the people in Uganda, 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 information technology. 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 if what they say at first seems counterintuitive or contrary to conventional wisdom.

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

Several years ago, Fortune magazine asked me find out who was providing the most innovative and effective health care in the U.S. Having lost my first wife, 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 in 20 years?

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


Merrill Goozner

Merrill Goozner is an award-winning journalist and author of "The $800 Million Pill: The Truth Behind the Cost of New Drugs" who writes regularly at Gooznews.com.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

Shares0
Shares0