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A 'Civilian VA' Health System for All

New America Media, Q & A, Sandip Roy Posted: Oct 03, 2009

Editors Note: The most centralized, socialized health care system in the world is not in Canada, France or Britain. Its right here in the United States. The Veterans Affairs health system is government run, the doctors are government employees and every patient is in a single government run insurance plan. A 2005 analysis by the National Committee for Quality Assurance found that the Veterans health system was better than Johns Hopkins, the Mayo Clinic, Massachusetts General and every other non-VA hospital in the country on a host of performance measures.

Phillip Longman, senior research fellow in the economic growth program of the New America Foundation, is the author of the book, Best Care Anywhere, about the VA system. He spoke to New America Medias Sandip Roy on the radio show Your Call about the lessons the VA might hold for the larger health care debate.

What was the V.A. like before the reforms undertaken in 1995?

Many listeners have probably seen movies like Born on the Fourth of July, in which Tom Cruise depicts a disabled vet in a Bronx VA hospital, and I think the picture you see in that movie is pretty accurate.

But in the late '70s, working conditions got so bad at the VA that various VA doctors and other health care professionals started looking around for ways that they could improve things for themselves on their own. This was the era in which, for the first time, you could go down to Radio Shack and buy a kit to build a personal computer.

A lot of these geeky-minded doctors started doing that. They started incorporating early personal computers into their practice of medicine by developing, for example, what we would today call an electronic medical record. They were doing this to save themselves the effort of having to run around the hospital all the time, trying to find a patient to charge for test results and such. It grew into a kind of Underground Railroad as they called it.

The central office of the VA became very annoyed that VA doctors were hacking on VA time, and at one point banned the use of personal computers on VA property, and persecuted these folks by firing some of them and siccing other government agencies on them. It was really quite an ordeal that at times involved arson and violence.

But they persevered and created what is today known as the Vista Software program, which is basically the state-of-the-art health IT system in the world today. It was developed by what we would today call an Open Source Process.

Did geeky doctors really propel the reform in a government institution?

That was the sort of revolution from below. Then, in the 1990s, there was a revolution from above in the form of a man named Ken Kizer. He came to Washington in the Clinton years and took the VA health system by the throat. He realized the integration of health IT had profound potential to not only improve the working conditions of doctors themselves, but to improve the practice of medicine. Essentially, to make a long story short, it involved a whole new model of 21st Century medicine that is barely replicated at all anywhere else in the U.S. health care system.

How does the VA perform now?

The first thing to notice about the VA is that almost uniquely in American health care, it has essentially a lifetime relationship with its patients. It starts when they leave the military and extends up to long- term nursing home care, in some cases. This means that as an institution, it has an incentive to actually keep people well, and so it does.

If the VA is treating a vet who has diabetes and it fails to teach how to manage that disease, then its on the hook down the line for all the long term consequences of diabetes, such as amputation, renal failure, blindness, etc. So it has an incentive to do the right thing. For those who get into the system, it does do the right thing better than basically anywhere else on overall metrics.

About 100,000 people die each year because of hospital error. Do we know the numbers for the VA?

The VA actually led the movement in the late 1990s to get the medical profession to concentrate on disclosure of medical errors and systematic thinking about how to avoid them. So under Ken Kizer, for example, they adopted a policy that they would disclose all their medical errors under a no fault system like airline pilots have, where instead of going after the individual who committed the error, they systematically go after the environment that causes the individual to make that error. At first the VA got a black eye and created a lot of headlines about the very high levels of medical errors at the VA. Soon it emerged that the VA was doing much better on medical error than anywhere else.

Youll see in a VA hospital a ritual that I guess you can see at some (other) places, but its virtually still just in the VA. A nurse is giving a med to a patient. She has a barcode on a bracelet explaining who she is. So the med has a barcode, the patient has a barcode, she scans herself, she scans the medicines, she scans the patient. If its the wrong patient, the wrong med, the wrong dose, the wrong time, shes prevented by the computer system from making that medical error. That turns out to be huge.

Why wouldnt all hospitals want to do that?

Part of the problem is that the way we compensate providers outside of the VA gives them very little incentive for quality. You could maybe avoid some malpractice suits by investing in health IT. But the overall effect of shrewd use of health IT is to improve quality and keep people well, which reduces revenue to people operating in the private health care system.

The VA system exists because of the philosophy that veterans are owed care for their service. But the idea that all Americans deserve care is still a hard sell.

On the relationship between service and entitlement, I think that's a very interesting point. To somehow relate service to one's country, to access to high quality health care, is not communism. It's got more of an all-American feel. It's why conservatives can go on and on about socialized medicine and never have any objection to the VA, because of that connection to service.

There's a lot of controversy, though, about how hard it is to get in. This is where the deserving part comes. Now to get into the VA you either have to have what they call a service connected disability or you are indigent. That gets really murky.

For example, now we have a lot of Vietnam vets in their 60s who are starting to come down with the early onset of Parkinson's Disease. There's a growing body of evidence that suggests that exposure to Agent Orange in Vietnam can cause you, 35 years later, to have Parkinson's much earlier than you otherwise would. Does that make you deserving of care in the VA? Is your Parkinson's caused by what happened in Vietnam? Or is it caused by the fact that your grandfather had it?

My thought is that anyone who has served in the military should have access to the VA. It would also be practical to allow their family members to buy into the VA, so that, for example, the 80-year-old World War II vet and his wife can make just one trip to the hospital and one doctor can treat their various morbidities. That makes a lot of clinical sense. It also makes a lot of taxpayer sense, because the VA is delivering this highest quality care anywhere for about two-thirds of the cost of the Medicare Advantage program.

The VA negotiates prices as a unit. Why cant Medicare?

Politics. Big Pharma has just been able to persuade Congress to prevent Medicare from doing that. So far. the VA has been able to avoid that kind of mandate. It often invests in very high cost drugs if they work. With Statin, for example, they want to make sure that your cholesterol is really controlled because they're on the hook for the consequences down the line if it's not being controlled. It's not just that they get drugs for cheap, but they also have an incentive to get the best drugs.

How is the VA coping with veterans from the Iraq and Afghanistan wars?

In most VA hospitals today, the percentage of patients who are wounded warriors coming back from Afghanistan or Iraq is about 5 percent. This means that the population being treated by the VA is largely elderly. The World War II generation is now dying off at a rate of 1,000 people a day. If we don't expand eligibility of the VA, we're going to find ourselves having these huge facilities with not enough vets to treat because the population of veterans is falling dramatically. So that's another opportunity we have to grow the VA and to have it basically become a big part of the delivery device for delivering quality care to a big segment of today's population.

How do you sell that to those who oppose government-run health care?

It used to be that most of us would be dying of infectious diseases like pneumonia. Now, most of us are dying of long-term chronic illnesses like diabetes and cancer. Therefore, a system that is more oriented towards long-term continuous care of a single patient can overcome many built-in liabilities that it might have. If you think about it, the VA should not be here. First of all, it's unionized. Second of all, it's a gigantic government bureaucracy. Third, it's micro-managed by Congress all the time. Fourth, it has to work on a yearly budget, so it has no way to do long-term planning. There's a thousand reasons why this thing shouldn't work. But it does.

Now, in practice, what would a civilian VA be? It would be basically a gigantic integrated staff model HMO that has facilities in every state. You could access your medical records in any of its facilities wherever you moved and happen to travel. That's what it would look like.

How much of the VA's experience could fit in the current health reform legislation in the Senate now?

In terms of what's going to happen this fall, none of that's going to happen. But what may well happen this fall is passage of some kind of public option insurance plan. Then we will have the exquisite task of figuring out how to actually pay for that. How do we change the practice of medicine so that a third of what we're spending isn't going for over treatment so that we don't have these hideous medical errors? Insurance reform is important. But as soon as you accomplish it, you're now into this other conversation. Conversely, if you don't accomplish it, then the only way to go forward is to work on a delivery system. To get the cost of health care down so much that insurance itself is no longer such a problem. Either way, this is the conversation we're going to have going forward for the next five to 10 years.

How do you translate the VA structure into the private system?

It has to be big. That lifetime relationship comes from the bigness of the VA. We have to have a system of public health delivery such that wherever you move in the country, you can stay within that system. If we have lots of fragmented providers, we'll never re-create that incentive structure. That's not to say that this new civilian VA monopolizes the provision of health care. You can let everybody keep on doing what they want to do outside of it. But I think you've been hearing about how popular this is among vets. If we had a civilian VA, the people who use it would like it as much as todays vets that use the VA.

Phillip Longman is the author of Best Care Anywhere about the VA system, and research director for the Next Social Contract Initiative at the New America Foundation. Transcribed by Andrew Berry.

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