There’s been a minor flurry of articles about the Veteran’s Administration health care system recently, a flurry that is both welcome and a bit tardy. It would have been helpful indeed if these had come out during the furor over health reform. Better late than never.
Let’s tackle cost first. The CBO’s most recent report indicates the VA does a much better job controlling cost than the private sector delivery system (used by Medicare). According to the CBO,
“Adjusting for the changing mix of patients (using data on reliance and relative costs by priority group), the Congressional Budget Office (CBO) estimates that VHA’s budget authority per enrollee grew by 1.7 percent in real terms from 1999 to 2005 (0.3 percent annually) [emphasis added] .2 Though not the decline in cost per capita that is suggested by the unadjusted figures, that estimate still indicates some degree of cost control when compared with Medicare’s real rate of growth of 29.4 percent in cost per capita over that same period (4.4 percent per year).”
In contrast, the private insurance sector [pdf] saw premiums increase over 70% over the same period (I know this isn’t exactly apples-to-apples, but no matter how you slice the apple, 70% is still a lot more than 1.7%)
How about patient satisfaction? Again, the VA scores better than the private sector.
“In 2005, VA achieved a satisfaction score of 83 (out of 100) on the ACSI for inpatient care and 80 (out of 100) for outpatient care, compared with averages for private-sector providers of 73 for inpatient care and 75 for outpatient care…For VA, the scores for inpatient and outpatient care were 84 and 83, respectively, while the average scores for the private sector were 79 and 81.”
In the press, Maggie Mahar posted on Phillip Longman’s new edition of Best Care Anywhere; Why VA Healthcare is Better than Yours; quoting Longman’s foreword “Health care quality experts hail it [the VA health care system] for its exceptional safety record, its use of evidence-based medicine, its heath promotion and wellness programs, and its unparalleled adoption of electronic medical records and other information technologies. Finally, and most astoundingly, it is the only health care provider in the United States whose cost per patient has been holding steady in recent years, even as its quality performance is making it the benchmark of the entire health care sector.”
Merrill Goozner published an interview with Longman, who noted “In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the
leading edge of medical research, due to its close affiliation with the nation’s
leading medical schools, where many VA doctors have faculty positions.”
Longman’s book is a timely update to his 2007 edition, providing new insights into the effectiveness of the VA’s VistA IT infrastructure and coverage of adoption by the private sector of VistA.
Another recent article noted the system is responsible for 24 million veterans (treating about 5.5 million last year), has a budget of “$50 billion and operates more than 1,400 care sites, including 950 outpatient clinics, 153 hospitals and 134 nursing homes.”
The piece quoted Elizabeth McGlynn, associate director of Rand Health and author of a study of the VA: “You’re much better off in the VA than in a lot of the rest of the U.S. health-care system,” she said. “You’ve got a fighting chance there’s going to be some organized, thoughtful, evidence-based response to dealing effectively with the health problem that somebody brings to them.”
Which brings up this question –
Where would you like to get your health care, and which inflation rate would you prefer?
Jun
3
And the demographic doesn’t account for any of this? Your not comparing apples to oranges your comparing apples to bowling bowls. Your average military member is smarter and healthier by far then your private insurance. A large percent of VA members have dual coverage and only use the VA for specific and infrequent care. We cordinate benefits with VA every day. Well cordinate really isn’t the right word as we always pay first then on a rare occasion will they go to the VA for treatment.
Pure propoganda, and they are not by anymeans the only healthplan with flat cost, I have numerous clients with 6 years flat cost trends or negative.
from the study;
“Veterans in some priority groups rely more heavily on VA for their care, while others receive the majority of their medical services from other sources, such as Medicare, Medicaid, private health insurance, the military health system, or public hospitals. VA estimates the dollar value of all medical care received by enrolled veterans from all sources (including out-of-pocket payments) and then calculates the percentage of that care received from VA.
Disabled veterans receive the highest portion of their care from the department (see Figure 3). Veterans in priority groups 1 through 3, with service-connected disabilities, receive between 33 percent and 47 percent of their care, on average, from the department. Veterans in priority group 4 (mostly housebound veterans) receive about 49 percent of their care from VA, on average. Low-income veterans in priority group 5 turn to VA for about 43 percent of their care. For veterans in priority group 6 (which includes veterans suffering from exposure to toxic substances as well as recent combat veterans), the figure is 24 percent; and for veterans in priority groups 7 and 8, the figures are 21 percent and 22 percent, respectively. ”
70-80% of care is being delivered by Private Insurance or Medicare and this somehow has any relavancy, actually it is a model that has been very effective for the government under Medicare and Medicaid, pass the cost on to private insurance then bash them for not controling it.
VA is no better nor more cost effective then private insurance when you factor everything in. It looks great when you cherry pick some facts and try to extrapolate them but VA couldn’t even begin to offer 100% care to its few million members let alone grow to a solution for the entire country.
A good post, Joe. My brother works at the VA as a physician, and is very pleased. They have a real committment to evidence based medicine.
Nate – of course the demographics have a role. I don’t know what the VA’s demographics look like, but I’d hazard a guess that there are lots of older folks in their group, along with a big chunk of younger people, many with serious injuries from the recent conflicts.
I’d also note that your comment refers to cost and not to the quality of the system and/or patient satisfaction and/or IT. With that said, this is not an analysis of costs but rather trend, and the demonstrated ability of the VA to constrain trend much more effectively than the private sector. You appear to be conflating trend with cost.
If you have numerous clients with flat trend on a pmpy basis, congratulations. This isn’t a comparison of the VA to individual employers but of one delivery and financing system to others.
Paduda
Nate – It seems you’ve got your statistics wrong.
You say “70-80% of care is being delivered by Private Insurance or Medicare” yet your citation notes the range is actually 53% – 79%. How do you come up with 70-80%?
Second, you cite no evidence to support your assertion that the VA is a “model that has been very effective for the government under Medicare and Medicaid, pass the cost on to private insurance then bash them for not controling it.” On what do you base this assertion re the VA passing on cost? Opinion? Where’s the data?
Third, your assertion that “model that has been very effective for the government under Medicare and Medicaid, pass the cost on to private insurance then bash them for not controling it.” is contradicted by reports from CBO and RAND. In addition, you are confusing trend – percentages with cost – dollars.
Finally, I’d reiterate the data supports the VA’s reputation as a very high quality delivery system with satisfaction rates higher than those enjoyed by the private sector.
Paduda
Joe- perhaps you missed my oped from last November– describing what really happened in the Phoenix VA last year when the money ran out…
Having spent much time in the VA as a student and resident, I do not cast dispersions on the intent or quality of VA medical system personnel, of any job description.
But the key fact remains: the system in which care is delivered is critical — and, while the VA does some things well, there is no question that the rationing that happened in Phoenix would not be acceptable to Americans, if widely known.
Also- I did not realize, as a proponent of the VA, you were such a fan of medical liability reform — as individual doctors are not sued under the system– only the VA as an institution. But, I suspect that is not one feature of the VA that proponents of the system would like to be widespread.
The oped:
http://www.washingtontimes.com/news/2009/oct/04/the-doctor-will-see-you/
The acceptance of technology by the VA is a good reason why your stats reflect a big gap between the apples and the oranges.
Examples can be seen with the Electronic Medical Records initiatives mandated by the govt for its military agencies.
Its no secret as to the cost savings incurred by going with this latest trend and it reflects in your statistical summary.
In my opinion, stakeholders in the private sector, especially TPAs, have been slow to accept technology and to utilize it as well.
For example in our niche industry…Video Job Analysis, a simple yet interactive job description, that enables a doctor to go online and objectively determine modified RTW restrictions, was readily accepted by the VA. And why wouldn’t they? What doctor wants to shift thru a 10 page job description when they can view online, essential functions with short video clips! The apples get technology!
But for the oranges in the private sector, stakeholders looked at this technology as “Why should we be doing anything new with our RTW programs? They are just fine…”
The VA does not have this status quo mentality…While not perfect in all instances, the delivery of VA care is state of the art and it should be for our military.
…And if they add little to the nation’s bottomline while doing so, chalk one up for the Washington.
Eric
welcome back to MCM.
There’s no question the VA system has problems, although the data indicate the quality of care delivered by you and your colleagues is well above that provided by the average private institution. There’s also no doubt that some private health care delivery systems also deliver great care.
I’d make the distinction between such anecdotes as the Phoenix incident and the more complete picture painted by the RAND and CBO analyses. Anecdotes are often more compelling while data-driven analyses tend to be dry and dull. Nonetheless, I would argue that for policy making purposes the latter are more useful.
I’m curious as to how you managed to infer my views on medical liability reform from a post on the VA that did not address that issue. I’d suggest that inference cannot be made with any credibility.
Congratulations on the piece in the Washington Times. You are correct, I do not subscribe to that publication.
I find your use of the term ‘rationing’ interesting. I don’t think the strict definition of the term applies. If you are using a broader definition I’d suggest there is as much if not more ‘rationing’ on the part of private insurers such as Golden Rule, Wellpoint, and others. Uf that is the case you may be right as Americans don’t like their ‘rationing’ either.
Joe- did not single you out on the liability issue — but those others you quote are quotable elsewhere as not in favor of that kind of a liability system.
If your best defense is to imply the VA is no different than private insurers… and I might add likely little different than the worker’s comp carriers you represent… it is hardly an endorsement.
I am as in favor of the need for structural health care reform as you… but, if you are going to tout the VA, you really need to be forthcoming about all the issues —
like the prostate seed implant scandal — which, if it had happened in HCA or Banner or Vanguard — would have been front page news for weeks on end… instead of a footnote.
you can make the case that denying care for 4 months to orthopedic patients is an ‘anecdote’ or that the radioactive seed problem is a non sequitur… but for the families involved, broad studies of the ‘public good’ ring quite hollow.
Eric
Eric
i’m confused. You did infer my position re med liability reform. Referring to someone in the second person does single out that person.
You’ve also put words in my mouth with your statement that “my beat defense is to imply that the VA is no different than private carriers”; I did no such thing. In fact I noted the va delivers better outcomes at lower costs.
And I thought a physician of all people would find data more compelling than anecdote. Lay people may not, but as a physician and public person is it not your job to help them understand the difference?
Do you find the RAND and CBO reports to be less compelling than the two anecdotes you cite?
From vague memory 5-6,000 have died and 50,000 injured. In a population of 5.5 million treated that is 1%, well below your 20% of a group that usually constitutes 80% of your claims. There are millions of young healthy men insured elsewhere.
“You appear to be conflating trend with cost.” Trend is cost? Trend compares cost from one year to the next. Anything that effects cost also effects trend. They constrain trend by constraining cost year after year, easy to do when your mostly young males with primary insurance some place else.
“This isn’t a comparison of the VA to individual employers but of one delivery and financing system to others.” They claimed “the only health care provider in the United States whose cost per patient has been holding steady in recent years, “ This isn’t true our self funded financing and partially self funded financing system is accomplishing the same thing. The VA isn’t the only one having success holding cost down.
The 53% on the low end is for a small percent of the total group, the average for the entire block would be closer to the 79%, I should have said 70-78%, I was off by 2%, sorry.
“On what do you base this assertion re the VA passing on cost? Opinion? Where’s the data?” VA, Medicare, and Medicaid pass on the cost, VA is the less egregious of the three. Medicaid does it at the state level by passing lawsx forcing employers to cover dependents to age 28-30. Medicare did it with all the Medicare Secondary regulations and VA did the same, from the gao website;
“For more than a decade, the Department of Veterans Affairs (VA) has been authorized to recover from private health insurers some of its expenses in providing health care to veterans with no service-connected disabilities. VA’s recovery authority was expanded in 1990 to include care provided to veterans with service-connected disabilities, as long as that care was for treatment of conditions unrelated to the veterans’ service-connected disabilities. In fiscal year 1996, VA sought to recover $1.6 billion but obtained only 31 percent of the billed amount–or $495 million–a five-percent decline from fiscal year 1995 recoveries. In its fiscal year 1998 budget submission, however, VA projects that it will be able to recover $826 million from private health insurers by fiscal year 2002. This is important because VA sought and was recently authorized to keep the money it recovers and to use it to supplement future appropriations.”
This is a clear example of how the VA system is a bowling ball compared to private insurance. You can’t do any meaningful comparison of their trend as they are nothing like private insurance.
“is contradicted by reports from CBO and RAND. “…? And do I get to know what these reports are and what they say? What part do you disagree with, that politicians bash private insurance for not controlling cost or are you denying there is a federal law that says private insurance is primary unless you have under 20 employees? I can cut and paste some quotes for you or copy the federal law for you if you really doubt me.
“I’d reiterate the data supports the VA’s reputation as a very high quality delivery system with satisfaction rates higher than those enjoyed by the private sector.” B y data you mean surveys of disparity groups of people. Ask an American how their McDonalds meal was and 50% probably wouldn’t care for it. Ask a starving person from the third world how their bowl of rice is and most would rate it very highly, are you saying rice is better then mcdonalds? It’s propaganda data not scientific data.
Joe- no ad hominems please…
Let me continue the discussion about the VA and liability…
1. Do you believe that the medical liability system at the VA might be a component of its success in the studies you cite?
2. If it possibly could, would you then be agreeing that the VA system— liability included– is better?
3. And if that is so, would it be wrong for the average reader to infer that you are at least tacitly supportive?
If not, it seems a bit like cherry picking to claim the VA is best but disassociate yourself from the medical liability system components that help drive care…
RE: some of the VA studies, the key problem, as you know, with data, particularly medical data, is that the quality and accuracy of data in determines the value of data that comes out.
note this McClatchy (hardly a right wing media source) report:http://www.unbossed.com/index.php?itemid=1564 and
http://www.gulfwarvets.com/va_appointment_success_overstated.htm
And, let me give you another ‘anecdote’ that would devastate any private sector HC entity:
http://www.scmagazineus.com/personal-info-of-265-million-veterans-lost/article/33439/
I am devotely pro-veteran– and we should be ensuring that the myriad of health care resources to our returning veterans is second to none, not second to everything-else.
I am not, as you know, a private health insurance-bot — as their behavior is often, but not always, bad.
Let me close with another anecdote: VA patients are considered uninsured outside the VA — if a soldier falls off a ladder and breaks his arm and I see him in the ED (the nearest hospital)… he is ‘cash pay’ unless he qualifies for Medicaid. The VA is very reticent, and quite slow, to ever pay for those services outside the system. I know of veterans who are stuck paying the full tab.
That is unfair and abusive to our veterans.
No ad hominems on this end. I asked a question and you avoided it. You inferred something without a shred of evidence to support that assertion. Now you attempt to use a chain of ‘if this than that’ that not only requires leaps of logic but flies in the face of actual research by credible organizations.
Re med liability, you are on shaky ground indeed to infer that the VA success is in any material way was due to limited professional liability. If you read the RAND and CBO reports, there is much discussion of technology, evidence-based medicine, best practice, dedicated staff and a diligent focus on quality improvement. Find a reference to medical liability. I couldn’t.
You are very selective in your cherry picking of issues to address and logic to follow. That is unfortunate as it reduces, if not eliminates, your ability to engage in productive debate. It is clear you want to focus the issue on medical liability, yet the data does not support that effort. Instead you rely on a chain of if-then statements, a poor substitute for rigorous analysis.
To continue to infer that anecdotal reports of problems are a better measure of performance than actual data, while criticizing the data itself, is truly befuddling. That wouldn’t pass muster in an high school debate class. I’ll match RAND and CBO against anecdote anytime. Read those studies, then get back to me.
Scary stories works on TV and shock radio but it does not help the nation find a solution.
No ad hominems on this end. I asked a question and you avoided it. You inferred something without a shred of evidence to support that assertion. Now you attempt to use a chain of ‘if this than that’ that not only requires leaps of logic but flies in the face of actual research by credible organizations.
Re med liability, you are on shaky ground indeed to infer that the VA success is in any material way was due to limited professional liability. If you read the RAND and CBO reports, there is much discussion of technology, evidence-based medicine, best practice, dedicated staff and a diligent focus on quality improvement. Find a reference to medical liability. I couldn’t.
You are very selective in your cherry picking of issues to address and logic to follow. That is unfortunate as it reduces, if not eliminates, your ability to engage in productive debate. It is clear you want to focus the issue on medical liability, yet the data does not support that effort. Instead you rely on a chain of if-then statements, a poor substitute for rigorous analysis.
To continue to infer that anecdotal reports of problems are a better measure of performance than actual data, while criticizing the data itself, is truly befuddling. That wouldn’t pass muster in an high school debate class. I’ll match RAND and CBO against anecdote anytime. Read those studies, then get back to me.
Scary stories works on TV and shock radio but it does not help the nation find a solution.
In my opinion, stakeholders in the private sector, especially TPAs, have been slow to accept technology and to utilize it as well.
The difference is when the VA invest the system is required to adapt, just look at HIPAA and EDI, we spent hundreds of millions, as an industry not me personally, to accept electronic claims and doctors decided to still send paper. 15 years later we are getting close but the initial investment was a complete waste. I can’t afford to invest my money, TPA Admin is a commodity, on every latest fad not knowing if it is going to be adapted. Unlike the providers we don’t get handouts to pay for any of this
The VA has done many great things with its care system. But in many ways we are comparing apples and oranges. Clearly a significant number of eligible “enrollees” can seek care elsewhere (often though the additional coverage they through work) and use the VA system in selected areas. So they at times can function as a supplemental insurance.
They do offer some unique services that will “pull” folks in (i.e. PTSD care)
I’m not convinced liability issues are a big part of this cost equation but if they are that speaks to the case for physician employment, not necessarily tort reform
When folks bring up the VA to me as an example as to how a governmentally-run health system can work I acknowledge its successes AND also suggest that most Americans would not want that “style” of healthcare.
As a 30-year veteran of the health care business, nothing surprises me.
In 2014, we’ll have a real mess. I guess enjoy the next four years before all hell breaks loose.
My uncle was career Air Force before going to work for a defense contractor.
When he retired, he used to go to the VA for all of his health issues.
As time passed, the VA cut back. It got to the point that if the health issue didn’t have some nexus to his military service, he had to go to a non-VA doctor or facility that accepted Medicare.
So of course the VA can control its costs. It simply reduced the amount of services that it would provide.
At the same time, my uncle found the doctors were getting younger and younger and didn’t understand the issues that older veterans had. He figured that the VA simply didn’t have the ability to compete with non-VA hospitals and private practice groups in terms of salary.