VA Hospitals ** The Best

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Sunday, Aug. 27, 2006

 

How VA Hospitals Became The Best

 

No longer a nation's shame, veteran care is acing competitors

 

By DOUGLAS WALLER

 

Most private hospitals can only dream of the futuristic medicine Dr.

Divya Shroff practices today. Outside an elderly patient's room, the

attending physician gathers her residents around a wireless laptop

propped on a mobile cart. Shroff accesses the patient's entire medical

history--a stack of paper in most private hospitals. And instead of

trekking to the radiology lab to view the latest X-ray, she brings it up

on her computer screen. While Shroff is visiting the patient, a resident

types in a request for pain medication, then punches the SEND button.

Seconds later, the printer in the hospital pharmacy spits out the order.

The druggist stuffs a plastic bag of pills into what looks like a tiny

space capsule, then shoots it up to the ward in a vacuum tube. By the

time Shroff wheels away her computer, a nurse walks up with the drugs.

 

Life in a big-name institution like the Mayo Clinic? Not hardly. Shroff,

31, a specialist in internal medicine, works at the Veterans Affairs

hospital in Washington, where the vets who come for the cutting-edge

treatment are mostly poor.

 

If you're surprised, that's understandable. Until the early 1990s, care

at VA hospitals was so substandard that Congress considered shutting

down the entire system and giving ex-G.I.s vouchers for treatment at

private facilities. Today it's a very different story. The VA runs the

largest integrated health-care system in the country, with more than

1,400 hospitals, clinics and nursing homes employing 14,800 doctors and

61,000 nurses. And by a number of measures, this government-managed

health-care program--socialized medicine on a small scale--is beating

the marketplace. For the sixth year in a row, VA hospitals last year

scored higher than private facilities on the University of Michigan's

American Customer Satisfaction Index, based on patient surveys on the

quality of care received. The VA scored 83 out of 100; private

institutions, 71. Males 65 years and older receiving VA care had about a

40% lower risk of death than those enrolled in Medicare Advantage, whose

care is provided through private health plans or HMOs, according to a

study published in the April edition of Medical Care. Harvard University

just gave the VA its Innovations in American Government Award for the

agency's work in computerizing patient records.

 

And all that was achieved at a relatively low cost. In the past 10

years, the number of veterans receiving treatment from the VA has more

than doubled, from 2.5 million to 5.3 million, but the agency has cared

for them with 10,000 fewer employees. The VA's cost per patient has

remained steady during the past 10 years. The cost of private care has

jumped about 40% in that same period.

 

Vets still gripe about wading through red tape for treatment. Some

11,000 have been waiting 30 days or more for their first appointment.

The Iraq and Afghanistan wars could stress the system, although for the

moment VA officials say the agency can accommodate the new patients.

That's because older vets, especially those from the World War II and

Korean War eras, are dying of natural causes at the rate of about

600,000 a year, whereas the Iraq and Afghanistan wars have so far

created a little more than 550,000 new vets.

 

On the other hand, because advances in body armor and field medicine

have enabled soldiers to survive battlefield injuries that in earlier

conflicts meant death, many of the new patients are arriving at VA

hospitals with severe wounds. In response, the VA has set up four

polytrauma centers around the country. Dawn Halfaker, a former Army

captain who lost her right arm in Iraq, says negotiating the bureaucracy

to get treatment for all her medical needs has been frustrating at

times. She had to wait eight months for an appointment at the Washington

hospital to get her teeth cleaned. Even so, she says, the care " is not

as bad as I thought it would be. "

 

The roots of the VA's reformation go back to 1994, when Bill Clinton

appointed Kenneth Kizer, a hard-charging doctor and former Navy diver,

as the VA's under secretary for health. Kizer decentralized the VA's

cumbersome health bureaucracy and held regional managers more

accountable. Patient records were transferred to a system-wide computer

network, which has made its way into only 3% of private hospitals. When

a veteran is treated, the doctor has the vet's complete medical history

on a laptop. In the private sector, 20% of all lab tests are needlessly

repeated because the doctor doesn't have handy the results of the same

test performed earlier, according to a 2004 report by the President's

information technology advisory committee.

 

Another innovation at the VA was a bar-code system, as in the

supermarket, for prescriptions--a system used in fewer than 5% of

private hospitals. With a hand-held laser reader, a nurse scans the bar

code on a patient's wristband, then the one on the bottle of pills. If

the pills don't match the prescription the doctor typed into the

computer, the laptop alerts the nurse. The Institute of Medicine

estimates that 1.5 million patients are harmed each year by medication

errors, but computer records and bar-code scanners have virtually

eliminated those problems in VA hospitals.

 

Private hospitals, which make their money treating people who come to

them sick, don't profit from heavy investments in preventive care, which

keeps patients healthy. But the VA, which is funded by tax dollars, " has

its patients for life, " notes Kizer, who served in his post until 1999.

So to keep government spending down, " it makes economic sense to keep

them healthy and out of the hospital. " Kizer eliminated more than half

the system's 52,000 hospital beds and plowed the money saved into

opening 300 new community clinics so vets could have easier access to

family-practice-style doctors. He set strict performance standards that

graded physicians on health promotion.

 

As the reforms produced results, veterans began " voting with their

feet, " says Dr. Jonathan Perlin, who just resigned as the VA's health

under secretary. Hundreds of thousands abandoned private physicians and

enrolled in the lower-cost and higher-quality VA care. But that created

a new problem. The VA's budget from Congress (currently about $30

billion annually) couldn't cover the influx. By January 2003, with

hundreds of thousands waiting six months or more for their first

appointment, the VA began limiting access to only vets with

service-related injuries or illness or those with low income.

 

Veterans' groups understandably want the health-care system expanded to

accommodate vets with higher incomes and no service-related ailments.

Tom Bock, commander of the American Legion, has another idea: allow

elderly vets not in the system who are drawing Medicare payments to

spend those benefits at a VA facility instead of going to a private

doctor, as is now required by Medicare. " It's a win-win-win situation, "

he argues. Medicare, which pays more than $6,500 per patient annually

for care by private doctors, could save with the VA's less expensive

care, which costs about $5,000 per patient. The vets would receive

better service at the VA's facilities, which could treat millions more

patients with Medicare's cash infusion.

 

But conservatives fear such an arrangement would be a Trojan horse,

setting up an even larger national health-care program and taking more

business from the private sector. Congress has no plans to enlarge the

scope of veterans' health care--much less consider it a model for, say,

a government-run system serving nonvets. But it's becoming more and more

" ideologically inconvenient for some to have such a stellar

health-delivery system being run by the government, " says Margaret

O'Kane, president of the National Committee for Quality Assurance, which

rates health plans for businesses and individuals. If VA health care

continues to be the industry leader, it may become more difficult to

argue that the market can do better.

 

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