- © 2008 Canadian Medical Association
In a country where mere whispers of socialized medicine conjure images of the Red Army marching in to take over hospitals, it is ideologically inconvenient that a system run by the United States government provides the best health care.
Since the late 1990s, the Veterans Health Administration has consistently outperformed commercial providers in quality, efficiency and patient satisfaction. It won Harvard University's 2006 Innovations in American Government award for its health information software and topped all health care systems in a 2004 ranking by the National Committee for Quality Assurance.
These achievements came without rises in cost. From 1996 to 2007, per-patient costs remained stable at about $5800, compared to the $7600 spent on a typical American patient in 2007.
“If the VA [Veterans Administration] were a car company,” writes Phillip Longman, author of Best Care Anywhere: Why VA Health Care is Better Than Yours, “it would be Toyota.”
Still, many experts don't believe the Veterans Administration is a model for government-mandated universal health care. “We have in our political rhetoric the belief that anything that the government runs doesn't work,” says Margaret O'Kane, president of the National Committee for Quality Assurance.
Indeed, the Administration was delivering mediocre care until Dr. Kenneth Kizer was appointed in 1994 to overhaul it. He monitored performance, adopted chronic disease treatment guidelines and assigned veterans their own primary-care doctors. A change in federal law allowed a shift away from acute hospital care. “It literally took an Act of Congress to allow the VA to provide primary care,” says Martin Charns, director of the Veterans Affairs Center for Organization, Leadership and Management Research.
Kizer cut the number of hospital beds by more than half and opened hundreds of community clinics. He streamlined the approved-drug list and bargained with drug companies. These savings allowed Kizer to turn the Veterans Administration into the most wired health system in the country.
Its software links 1400 medical centres, community clinics and nursing homes. Doctors or nurses can instantly pull up patients' medical records. Information once scattered in paper files is electronically organized to show diagnoses, medications, scans and lab reports. Reminders pop up when a patient needs a pneumonia vaccine, chest x-ray or eye exam, while alerts warn doctors who prescribe drugs with adverse interactions. Doctors enter prescriptions, diagnoses and procedures while seeing patients. Graphs showing blood pressure, cell counts and serum chemistry are available at a keystroke.
Nurses use hand-held scanners to match bar codes on drug bottles to those on patient wristbands, virtually eliminating medical errors. Patients can also view their medical records and refill prescriptions online. They can list their vitamins and supplements, and track their diet, exercise, weight, pulse and blood sugar. Video conferencing links small-town patients to urban doctors. Small appliances called Telebuddies let clinicians monitor patients with chronic conditions. Home measurements from weight scales, blood pressure cuffs and blood glucose monitors are sent to nurses for review. “A nurse may monitor several hundred people, then phone those with abnormal readings,” says Gail Graham, director of health data and informatics.
Computerized records allow doctors to practise scientifically driven medicine. Records are mined to compare various treatments or identify abnormal patterns. Clusters of heart attacks among Vioxx users alerted the agency to problems with the drug. “That's the kind of population-level medicine you can do with electronic medical records,” says Longman.
A 2004 American College of Physician Executives survey found one exception to widespread “frustration and disenchantment” with medical technology costs and lack of buy-in from doctors: the Veterans Administration. Offered one respondent: “If you fully involve yourself in the VA computerized record system, you would never go back to any other way of caring for patients.”
The agency also has the country's largest medical education program, helping to train more than half the nation's doctors. “VA is a hot internship now,” says Longman. Young doctors, he says, aren't crazy about chasing paper or dealing with clunky propriety information technology systems.
A 2007 Congressional Budget Office report credited the agency's decentralizing and use of performance targets and information technology as factors in its success. Unlike fee-for-service systems, which encourage overtreatment and largely ignore prevention, Veterans Administration doctors have no incentive to overtreat, and having patients for life makes preventive care cost-effective.
“The VA has to live on a budget, so that creates a lot of discipline we don't have in our system,” says O'Kane.
A forthcoming Congressional report will indicate whether other health care systems should adopt the agency's methods. Its software is already in use, or soon will be, in Egypt, Finland, Germany, India, Jordan, Mexico, Nigeria, Norway, Pakistan and Uganda. “But in the US,” says Longman, “the way profit interferes with care, we've had hardly any institutions take it up.”
In Best Care Anywhere, Longman suggests giving all veterans and their families access to the system but stops short of recommending it be opened to everyone. Instead, he proposes linking hospitals that agree to follow the administration's methods. Americans who buy insurance through the program could stick with the network, which would compete with private insurers, through job changes and relocations.
Of course, the Veterans Administration has its problems. Its low-cost prescription drugs, network of community clinics and a 1996 bill authorizing it to care for all veterans brought in more patients, resulting in backlogged enrolments and long waits for appointments. It expects to treat 5.8 million patients this year, up from 3.2 million in 1999. The government's failure to provide additional funding for the increased workload forced the agency to begin rationing care in 2003 by freezing enrolment of vets without service-related injuries who didn't meet a stringent needs test. “Denying any veteran his or her earned benefit is a broken promise of a grateful nation,” Marty Conatser, national commander of the American Legion, told a Congressional committee in 2007.
In February 2008, Iraq and Afghanistan combat veterans became eligible for 5 years of free medical care, up from 2, further straining the system. Advances in body armour and battlefield medicine means soldiers who might have died in combat are coming home with severe injuries. Increasing cases of post-traumatic stress disorder and traumatic brain injury have taxed the mental health and neurology programs. Two veterans' groups filed a class-action lawsuit last year, alleging denial and delay in providing mental health benefits for veterans suffering post-traumatic stress disorder, with some committing suicide. A federal judge rejected the case, saying he hadn't found system-wide violations, while the remedies sought were beyond the court's jurisdiction. The agency added 3700 mental health professionals in the past 2 years and recently named 2 panels to recommend steps to reduce veterans' suicides.
The American Legion wants Congress to allow elderly veterans to use their Medicare benefits at the Administration, where they'd receive better care. A 2005 Congressional Budget Office report states this could save the government $29.5 billion over 8 years. Republicans oppose the idea, saying it would hurt the private sector. The Veterans Administration's performance, says Longman, is difficult for conservatives to process. “I really don't think the American people will go for wholesale reform of health care until they're convinced [US health care] is not just expensive, but also bad care.”