(Photo: AP/Molly Riley)
A little-noticed recent report by three leading research groups found that on critical measures, the Veterans Health Administration (VHA) consistently performs as well as and often better than private sector health-care providers. The VHA does this with patients who are sicker, older, and poorer than many of their counterparts seen in the private sector.
Among the key findings of the report, conducted by the consulting firms Grant Thornton and McKinsey & Company, along with two nonprofit research companies-the RAND Corp and the MITRE Corporation-were that:
• Postoperative morbidity was lower for VA patients compared with non-veterans receiving non-VA care.
• Inpatient care was more or as effective in VA as in non-VA hospitals.
• VA hospitals were more likely to follow best practices in the use of central venous catheter line infection prevention and rates of mortality declined more quickly in VA over time than in non-VA settings for specific conditions.
The report also found that veterans in nursing homes were less likely to develop pressure ulcers; that outpatients and those suffering chronic conditions got better follow-up care, and that VA health providers offered better mental health and obesity counseling and blood pressure control, particularly for African Americans. Importantly, income and educational disparities were smaller at VHA facilities in such areas as diabetes, heart disease, and cancer screenings.
The report confirmed what many fighting for what is known as "right care"-defined as avoiding toxic, unnecessary tests, medications, and procedures-have long understood: that the VHA, contrary to its status as a GOP and media whipping boy, has been a pioneer in providing clinically appropriate care to veterans.
Elderly patients in the VHA were less likely to receive the kinds of medications that can make them sicker and sometimes even kill them, the report found. VHA patients were more likely to be spared toxic chemotherapy within 14 days of death or be admitted to an ICU 30 days before death. This was attributed to the VHA's commitment to palliative and hospice care.
Health care quality expert Charlene Harrington, a professor emeritus the University of California at San Francisco, called the report "really impressive, particularly given the patient mix and chronic underfunding."
The findings of the 600-page report, released in volumes one and two, might come as a surprise to the VHA's many critics on and off Capitol Hill, including the news media. Media coverage of the VHA has focused on the negative, with little reporting on successful VHA programs. A recent USA Today cover story on performance bonuses for over 150,000 VHA employees, for example, glossed over the bigger picture and cherry picked findings of poor performance by a handful of senior executives. A follow-up editorial called for an end to all all bonuses at the VHA.
Republican members of Congress determined to privatize the VHA have similarly ignored its actual overall performance. At a November 18 hearing, House Committee on Veteran's Affairs Chairman Chairman Jeff Miller, a Republican from Florida, declared that the VHA's future success would not depend on continuing a record of significant accomplishment, but on "non VA providers." Indeed Miller warned of "difficult conversations" ahead about "the purpose of the VA health-care system and what it should and feasibly can achieve."
To be sure, the report also details a number of ways the VHA can improve-remedying chronic shortages of primary care and specialist physicians in some areas of the country; dealing with lack of space in older VHA facilities, and repairing an aging information-technology architecture.
The report also points to variation in treatment and quality in a system that has more than 150 hospitals and almost 1,000 community outpatient clinics. Here, however, it offers an important caveat: Variation in the private sector is sometimes even more pronounced. On some measures of care recommended to achieve clinical targets, the report found that "commercial HMOs, Medicare HMOs, and Medicaid HMOs all exhibited much more variability than the VA facilities" on this measure.
Despite recent public criticism of the VA for long patient wait times, the study found the VA is actually performing well on this measure. To wit: "VA's reported wait times for new patient primary and specialty care are shorter than wait times reported in focused studies in the private sector." For those who live in rural areas short on VA facilities, the report added that "expanding access to non-VA providers may help with routine or emergency room care, but not with advanced or specialized care." Nor would veterans living in these areas have better access to teaching or academic facilities.
Significantly, most of the clinical research studies summarized in the report were conducted before Congress allocated additional funds last year to hire more doctors and nurses and other staff, thereby improving access to and quality of VHA care. In other words, there was a legitimate basis for many VHA employees getting 2014 bonuses for their individual contributions to overall institutional performance so favorably rated. Unfortunately, the VHA's better-than-average standard of care has received little notice in the news media and Capitol Hill.
