DM Register: Overhaul the VA?Yesterday's Des Moines Register featured an editorial promoting the elimination of the VA Hospital system.
I'll point out the motivation behind the article:
The Department of Veterans Affairs underestimated the cost of veterans' health care this year by $1 billion. Now, Congress is rightly scrambling to find the needed dollars. Soldiers who risk their lives for this country are promised health care. Congress has an obligation to keep that promise.
The Register starts off with a very salient point. The VA budget - written two years ago for a FY 2004-2005 request - was drastically underestimated. Sometimes underestimation happens in forecasting, but in this case, something else happened between now and when the VA budget was forecasted 2 years ago. From Reuters:
"The bottom line is there is a surge in demand in VA (health) services across the board," said Veterans Affairs Secretary James Nicholson.
The Veterans Administration assumed it would have to take care of 23,553 patients who are veterans from the wars in Iraq and Afghanistan but that number had been revised upward to 103,000, Nicholson told a House of Representatives panel.
Nicholson told a House Appropriations subcommittee that his agency's estimate of Iraq and Afghanistan veterans in need of health care services was now four times greater than thought.
The VA budget is vastly underfunded - because the number of veterans has increased by 103,000 in the last two years! The VA has also been facing the strain of another aging population: The Vietnam Veterans.
The Register editorial continues:
But Congress also has an obligation to use taxpayer dollars efficiently. The outdated VA system doesn't make sense in the 21st century.
The veterans health-care system runs parallel to the country's existing network of clinics and hospitals. That duplication is inherently inefficient.
Tax dollars support staffing and maintaining clinics and hospitals that serve only one segment of the population. And sending veterans to specific locations means some are forced to drive long distances for their care and medication. It limits their choices in care. It further fragments an already fragmented health-care system.
What makes more sense: The government should grant insurance coverage to veterans, similar to the way it insures millions of Americans through government programs such as Medicare or Medicaid. With an insurance card in their billfolds, veterans could receive free care at any hospital. The government would reimburse the hospital for that care.
That would allow veterans to receive state-of-the-art treatment at facilities of their choosing. It would allow them to visit doctors and pharmacies closer to home. Existing hospitals could add staff to serve the special needs of veterans the way hospitals already staff diabetic educators or social workers. Perhaps federal dollars could even pay their salaries.
The Register here is following a few older assumptions here. To refute a few of them:
- The Medicare and Medicaid programs are facing financial problems, far more severe than any predicted shortfalls in the Social Security budget. The VA costs were underestimated for easily understood reasons - the Medicare/Medicaid financial shortfalls are due to medical costs of the program spiralling out of control.
- The VA does run several satellite clinics to handle routine care, such as simple checkups, etc. The costs of medicine purchased through the VA system are also much cheaper than pharmacy-based programs due to the VA having the ability to negotiate lower prices. (This is what should have been done with the Medicare Drug Benefit.) For the most part, the VA prescription system is one of the more popular VA programs.
- The assumption that VA hospitals are of drastically lower quality. Washington Monthly summed up just how false that assumption has become:
Yet here's a curious fact that few conservatives or liberals know. Who do you think receives higher-quality health care. Medicare patients who are free to pick their own doctors and specialists? Or aging veterans stuck in those presumably filthy VA hospitals with their antiquated equipment, uncaring administrators, and incompetent staff? An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be “significantly better.”
Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care. It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.
The difference is that the VA system in the 1980s and 1990s was forced to adopt computerized systems to track patients in response to calls for the VA system to become more efficient.
In fact (from the same article), the director of the VA during much of the transformation in the 1990s was singled out in a book on business management:
By 1998, Kizer's shake-up of the VHA's operating system was already earning him management guru status in an era in which management gurus were practically demigods. His story appeared that year in a book titled 'Straight from the CEO: The World's Top Business Leaders Reveal Ideas That Every Manager Can Use' published by Price Waterhouse and Simon & Schuster. Yet the most dramatic transformation of the VHA didn't just involve such trendy, 1990s ideas as downsizing and reengineering. It also involved an obsession with systematically improving quality and safety that to this day is still largely lacking throughout the rest of the private health-care system.
The difference between the VA system and the private health-care system is that the VA has been able to focus on the quality and affordibility of patient care - not profits.
That's not something we should abandon for another 'privatized' system that degrades quality and pads private profit margins.
