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For quality, it’s hard to top veterans’ care

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June 2, 2010

For quality, it’s hard to top veterans’ health care

By Kristen Gerencher, MarketWatch

SAN FRANCISCO (MarketWatch) — Where can you find the highest quality health care in the U.S.? There isn’t one single answer, but believe it or not, many studies and independent experts point to the Veterans Health Administration as among the best.

The VA has its own system-wide electronic health record, sophisticated quality-measurement tools, a coordinated approach to care, long relationships with patients and close ties to teaching hospitals, which supply a steady stream of medical residents.

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Some other health systems also provide excellent patient care, and every place has it weaknesses, but the VA generally stands out on quality, said Elizabeth McGlynn, associate director of Rand Health, a division of the Rand Corp., in Santa Monica, Calif.

"You’re much better off in the VA than in a lot of the rest of the U.S. health-care system," she said. "You’ve got a fighting chance there’s going to be some organized, thoughtful, evidence-based response to dealing effectively with the health problem that somebody brings to them."

The combination of its information system and support tools, routine performance reporting and financial incentives for managers who hit quality targets gives it an edge, said McGlynn, who co-authored a comparative study published in the Annals of Internal Medicine in 2004 that found the VA outperformed its community health-care counterparts by 20 percentage points in preventive care. It also performed significantly better on chronic disease care and in overall quality.

As the U.S. enters a new era with the passage of the health-reform law that takes full effect in 2014, experts say the VA’s evolution offers lessons because many of the pilot projects and quality-improvement initiatives the new law calls for are similar to the VA’s approach.

Why it’s different

The VA expects to treat 5.5 million veterans in the U.S., Puerto Rico, U.S. Virgin Islands and Guam this year, the majority of whom have medical problems related to their military service. Financed by taxpayer dollars, it has a current health-care budget of $50 billion and operates more than 1,400 care sites, including 950 outpatient clinics, 153 hospitals and 134 nursing homes.

Health-care providers practice in teams and doctors are salaried as opposed to being paid a fee for service. That helps remove an incentive to order tests and procedures that aren’t necessary, a key problem in the broader U.S. health system when physicians practice defensive medicine or try to maximize their income, said Phillip Longman, senior fellow at the New America Foundation and author of a book about the VA called "Best Care Anywhere."

"The rest of the health-care system doesn’t have a business case for quality," Longman said. "Quality usually costs them money because they get paid to perform procedures on sick people.

"There are many idealistic people in medicine trying to do the right thing, but in our system no good deed goes unpunished," he said, citing diabetes care as an example.

"The big money is in letting diabetics decline to the point they need an amputation, need dialysis, become blind. That’s where you make your big money, not in keeping them well. Once you know a little about how this world works, it stands to reason the VA’s the best care," Longman said.

Dr. Ashish Jha, associate professor of health policy at Harvard School of Public Health and a general internist at the Boston VA, won’t go as far as to say the VA is superior to other medical stand-outs in the broader health-care system.

"What I do know is that the care in the VA is consistently very good and certainly much better than average," Jha said.

It has imposed market-based reforms such as pay for performance and value-based purchasing that have paid off, he said.

"They have in some ways brought the rules of supply and demand to bear in assuring the care they deliver is much more efficient," Jha said. "I do think there’s something ironic about that, that a government agency was doing it before the private sector was."

The VA isn’t a likely candidate for achieving such gains given that it’s run by a sprawling federal agency, has five public-sector labor unions and a patient population that tends to be older, sicker and poorer than average, Longman said. But its success is more commonly accepted now than even a few years ago.

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"You’re seeing a lot of people who may have served in Vietnam and had very bad images of the VA," Longman said. "They never went to it or they went to it once and had a bad experience and are now coming back in their 50s, 60s, and 70s [saying] ‘This place is great. The drugs are cheap. There’s a whole team looking at me. Their computers remind me every year I’m due for a flu shot and it’s kind of one-stop shopping.’"

Longman estimates the rest of the health-care system is about 15 years behind not just in health-information-technology implementation but also in moving toward a patient-centered care model.

To be sure, the VA has had its share of scandals and lapses over the years. Last year, two VA centers in Florida and Tennessee contacted thousands of veterans to alert them that they may have been exposed to contaminated colonoscopy equipment that could put them at risk for hepatitis or HIV.

But despite such sporadic problems, many experts credit the VA with staging a remarkable turnaround in the mid-1990s that now puts it among the highest-performing systems on many measures of quality ranging from the effective treatment of diabetes to the reduction of medication-dispensing errors.

Meeting new challenges

A key challenge is how the VA will continue to adapt as health care increasingly moves away from hospital-based settings and becomes more outpatient-oriented.

And even with its electronic health record called VistA, it too will have to hustle to meet younger veterans’ expectations for customer service and technological capacity, Jha said.

"These are folks who grew up in the Facebook generation, and they expect a level of use of technology and responsiveness that’s going to be tough for any agency to meet," he said.

Among the most pressing concerns is how the VA can keep pace with the needs of women veterans, a growing subgroup of its patients.

At many VA facilities, women still can’t receive comprehensive primary care at one site, according to a March report from the Government Accountability Office, an independent body that advises Congress. The report found the VA is having trouble recruiting mental-health care providers who can treat military sexual trauma specific to women, and needs to better address the privacy and safety needs of female veterans.

Denise Williams, 33, is familiar with the VA’s strengths and shortcomings. Having served in the army in a noncombat role for seven years until 2003, she now goes to the VA Medical Center in Washington three or four times a year for routine health care and once a year for well-woman checkups.

"There’s still staff members that need to be trained to realize women are veterans," she said. "Sometimes a female veteran is mistaken for the spouse."

Overall, Williams said she’s satisfied with the VA care she receives. "There are still gaps that need to be filled and they still have a way to go, but I think it’s a very good health-care system."

As is customary, she was assigned a primary-care doctor as part of her health-care team and is happy enough with that relationship that she hasn’t requested a physician switch. She also likes how flexible the pharmacy options are.

"You can call for your refills and they’ll mail it in," Williams said. "They’re very reliable. If you don’t have the time to wait and pick it up yourself, you can request it gets mailed to your home."

She said paperless health records make for more seamless care than when she was in the military, and she currently pays no copays. But if she’s seeking care for a health problem that’s not service-connected, it can take a few weeks to be seen.

Kristen Gerencher is a reporter for MarketWatch in San Francisco.