Michael E. DeBakey VA Medical Center - Houston, Texas

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Best practices

March 11, 2007

http://www.boston.com/news/education/higher/articles/2007/03/11/best_practices/

Unlike the Army's Walter Reed hospital, the VA hospital system is ranked, by many measures, as the best in the country

BOSTON GLOBE
By Drake Bennett  |  March 11, 2007

THE REPORTS OF squalor and neglect uncovered at Walter Reed Army Medical Center have been vivid -- wounded soldiers, often crippled, heavily medicated, or brain-damaged, left to fend for themselves throughout the sprawling, overcrowded facility, in rooms with mouse droppings, cockroaches, and moldy, crumbling walls.

But what has given an extra edge to the outrage has been the suspicion that Walter Reed is not the exception but the rule, the most galling symbol of a badly broken system. The Walter Reed scandal is "the tip of the iceberg of what is going on all around the country," said Henry Waxman, the California Democrat who heads the House Oversight and Government Reform Committee, at a hearing Monday. Veterans and active-duty military personnel have detailed similar problems and frustrations in other hospitals.

As the indignation has mounted, not only the military hospital system -- Walter Reed is an Army hospital -- but the Veterans Health Administration has come under attack. The VA healthcare system -- an entirely separate and far larger network of hospitals and clinics run by a civilian agency, the US Department of Veterans Affairs -- has for years been a target of conservatives. A government-operated, single-payer system with 5 million patients, it is the closest thing this country has to socialized medicine.

Some commentators have taken advantage of the recent scandal to resurrect their free-market critiques of the VA. George Mason law professor David Bernstein, writing last Monday on the widely read blog the Volokh Conspiracy, suggested that the recent scandal was a measure of vindication for small-government conservatives, "who have been criticizing the VA for years."

After all, mold, mouse droppings, and neglect fit well with the image many have of the VA system. The portrayal in movies like "Coming Home" and "Born on the Fourth of July" of VA hospitals as shabby places where veterans were ignored by incompetent staff was for decades fairly accurate. In 1992, two corpses found on the grounds of a Virginia VA hospital turned out to be patients who had gone missing months before.

Today, however, that image is dramatically outdated. By many measures, VA hospitals and clinics are in fact the best in the country, and they achieve these results while spending 25 percent less per patient than Medicare. Recent studies from the Rand Corporation, the New England Journal of Medicine, and the National Committee for Quality Assurance, a healthcare watchdog organization, ranked the VA system, by a variety of criteria, as better not only than the sort of care offered by Medicare but even the best civilian healthcare plans.

Phillip Longman, a fellow at the New America Foundation and author of the forthcoming book "Best Care Anywhere: Why VA Health Care Is Better Than Yours," says that among the veterans who rely on the system, "The overall picture is one of overwhelming satisfaction with the care."

Indeed, the great complaint among veterans today is not about the care they receive in VA hospitals, but about the difficulty of getting into the system in the first place.

The man widely credited for the turnaround is Kenneth Kizer, a doctor trained in emergency medicine who ran the VA's healthcare system from 1994 to 1999.

"You have to tailor what you're doing to the needs of the patient," says Kizer, now the CEO of the healthcare information technology firm Medsphere. "The adage I've always used is that the patient is the center of the universe."

But the changes Kizer instituted at the VA had as much to do with standardization as tailoring. To cut down on the sort of doctor errors that kill tens, if not hundreds, of thousands of patients in the US every year, the VA system spelled out clear, evidence-based treatment guidelines for its physicians. Doctors and hospital directors were evaluated and publicly rated, for example, on how often their diabetic patients had their vision and kidney function checked, or how often heart attack victims were given cholesterol-lowering drugs and beta-blockers.

Research has incontrovertibly shown that such simple measures can save lives and improve the health of patients, yet they're often neglected by doctors. According to Donald Berwick, a professor of pediatrics and healthcare policy at Harvard Medical School and a pioneer in the field of "evidence-based" medicine, in the American healthcare system as a whole, patients get these sorts of treatments only 70 to 80 percent of the time. In the VA system, that number is 98 to 99 percent.

To aid its medical staff, and to help keep an eye on them, the VA developed an electronic medical-records system called VistA. In contrast to the civilian system, in which at most a quarter of hospitals have computerized records (few of which can effectively share information with other hospitals), all VA patient records are now computerized, and a doctor at any VA hospital or clinic can immediately pull up the complete records of any patient nationwide. Safeguards built into the software have all but eliminated drug prescription errors: In civilian hospitals and pharmacies, the error rate is as high as 8 percent, in the VA system it's 0.003 percent.

Phillip Longman argues that it's not in spite of the fact that the VA is a large, monolithic federal agency that it's had such success, but because of it. Sweeping changes mandated at the top of the organization can be instituted throughout the system, and the fact that the VA gets its funding in a lump sum rather than in small payments from insurers (the way civilian hospitals do) makes it far easier to invest in large infrastructure improvements. Unlike Medicare, the VA can use its size to bargain over prices with pharmaceutical companies, and has done so aggressively.

Furthermore, the fact that VA patients, unlike those in civilian health plans, tend to stay with the system for life means there's also an incentive to focus on long-term preventive care, a proven method of keeping medical costs down.

As in any large heathcare system, complaints do remain, and the quality of care varies from facility to facility. But the concerns of veterans groups today tend to center not on the care itself but on access to it. According to Peter Gaytan, who as the American Legion's director for veterans affairs and rehabilitation has visited every VA hospital in the country, "There's no question the care has improved substantially in the past 20 years, and we're hearing that directly from patients, from veterans. The issue for us today is accessibility."

Like the military hospital system, the VA faces a surge of new patients returning from Iraq and Afghanistan with physical and psychological wounds. And the system, to an extent, has been the victim of its own success. While wait times for care were cut in the 1990s, they've begun to grow again, as veterans who could afford to be treated at civilian facilities, hearing of the system's improvement, flocked to the VA.

In an effort to address the problem, the VA tightened its eligibility requirements -- Congress has limited eligibility in the past, but a 1996 law had ensured all veterans of VA care. Since 2003, however, only those who make less than $27,790 a year (the cut-off is higher if they have dependents) or who have "service-related" conditions or recent combat experience can get in.

The change has not been popular. "Only in America," says Kizer, "would you close the doors on a system that's providing higher quality care and customer satisfaction at unprecedented levels and at half to two-thirds the cost and put those patients in another system." The way he sees it, the more veterans we can get into the VA system -- or the more the rest of the American healthcare system can learn from it -- the better.

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