VA North Texas Health Care System
VA Health Care Still the Best
Phillip Longman, author of "Best Care Anywhere: Why VA Health Care Would Be Better for Everyone" testified before the U.S. Senate Committee on Veterans Affairs recently. He began by explaining he was neither a Veteran nor a VA employee, but inspiration for his book (now in its third edition) came from losing his wife to breast cancer in 1999. This is his testimony.
Robin was treated at a highly renowned cancer center here in Washington DC. I never blamed her doctors for her death. But suffice it to say that what I saw of this one prestigious corner of the American health-care system caused me to become extremely alarmed the problem of medical errors and poorly coordinated care.
Shortly after Robin's death, the Institute of Medicine issued a landmark report in which it estimated that up to 98,000 Americans are killed every year in hospitals as a result of medical errors (Corrigan J, et al., eds. To Err Is Human: Building a Safer Health System. National Academies Press, 2000). That's like three jumbo jets crashing every other day and killing all on board.
Then came another report published in Journal of the American Medical Association that looked not just at hospitals, but at the American health care systems as a whole (Starfield, B. Is US health really the best in the world? JAMA 284:483–485, 2000). It is estimated that through a combination of under-treatment, over-treatment and mistreatment, the U.S. health care system is killing 225,000 Americans per year. To put that in perspective, it means that contact with the U.S. health system is the third largest cause of death in the United States, following all heart disease and all cancers. These reports, combined with my personal experience, put me on a quest to find out who had the best workable solutions to America’s dysfunctional and dangerous health care delivery system. The answer that emerged was not one I expected.
As study after study now confirms, the VA system as a whole outperforms the rest of the health care system on just about every metric that health care quality experts can devise.
These include adherence to the protocols of evidence-based medicine, investment in prevention and effective disease management, use of integrated electronic medical records and importantly, patient satisfaction.
Just how the VA transformed itself is an inspiring story involving front-line employees bringing about a revolution from below as well as courageous leadership at the top, particularly during the period when Dr. Kenneth Kizer headed the Veterans Health Administration.
As I also explain in my book, important structural factors were at work as well. For example, the VA has a nearly lifelong relationship with most of its patients and does not profit from their illnesses. This gives it incentives to keep its patients well— incentives that are sorely lacking in most of the rest of the health care system. If the VA doesn't teach its patient how to effectively manage their diabetes, for example, it becomes liable down the line for the cost of their amputations, renal failures and all the other long-term complications of the disease.
Now, of course, bad medicine does happen at the VA, and when it does those who may be responsible need to be thoroughly investigated. But when such breakdowns occur, we should always put them in context by asking: "Compared to what?"
As we've seen, U.S. health care system outside of the VA is exceptionally dangerous. It would have been great, for example, if the private hospital that treated my wife had been under the scrutiny of an Inspector General (IG), whose full-time job it was to look out for failures in patient care. But of course, private hospitals don't have IGs.
Similarly, if a committee of Congress such as this one was specifically focused on the quality of care provided by that hospital, oversight would have likely helped the institution become more accountable. Or again, more mistakes would undoubtedly have come to light at that hospital and many others if effective watchdog groups akin to the American Legion looked out for the interest of non-VA patients.
But of course that kind of scrutiny does not occur. And this asymmetry creates a perverse result. For the average news consumer it can lead to the impression that the VA is limping along from one scandal to the next, even as its patients and health-care quality experts applaud its superior quality, safety and cost-effectiveness.
Finally, I'll close by pointing out another way in which context is often missing in discussion of VA health care. Overwhelmingly, the failures of the VA in recent years haven't been about the quality of health care for those who get covered. Instead, they've mostly been about the excessive waiting times, and excessive red tape that our vets must go through to establish eligibility. Here, the Veterans Benefits Administration must accept blame for not doing a better job of streamlining administrative procedures.
But in all fairness, it is Congress, and by extension the American people as a whole, who have established the laws that require most Veterans to prove that they have service-related disabilities before becoming eligible for VA care.
This is the perverse root cause of the waiting time and other problems of access. Who can say if a Vietnam Veteran is losing his hearing due to exposure to too much artillery fire or exposure to too many Who concerts?
We need to open up the VA and grow it, extending no-questions-asked eligibility not only to all Veterans but to their family members as well. This not only makes clinical sense, it makes economic sense. So long as the VA remains one of, if not the most, cost effective, scientifically driven, integrated health care delivery systems in the country, the more patients it treats, the better for everyone.