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POLICY: In Defense of the VA System

Like fellow contributor Eric Novack, THCB alum Maggie Mahar has been following the Walter Reed story closely.  Maggie doesn’t buy the criticism that the problems at the facility are due to the fact that Walter Reed is a government run hospital. She’s  also unhappy about the fact that critics are using the occasion to target the VA system in general. Maggie is the author of the critically acclaimed “Money Driven Medicine: The Real Reason Health Care Costs so Much.”

Too many news reports about the scandal at Walter Reed use the story to malign the VA hospital system–and to suggest that when government gets involved in health care, the result is disaster.

First, Walter Reed is not part of the Veterans Administration Health Care System. It is a U.S. Army Medical Center.Secondly, while not every VA hospital is perfect, overall,  the VA is one of the very best  health care systems in the U.S.–thanks to a major overhaul by undersecretary of health Kenneth Kizer in the 1990s. Its electronic medical system has done an extraordinary job of co-ordinating care and all but eliminating medication errors.

As Business Week reported last year (July 17th, 2006) , “if you want to be sure of top-notch care, join the military. The 154 hospitals and 875 clinics run by the Veterans Affairs Dept. have been ranked best-in-class by a number of independent groups on a broad range of measures, from chronic care to heart disease treatments to the percentage of members who receive flu shots. It offers all the same services, and sometimes more, than private sector providers.”

A string of studies published in published in medical jouranls back up these claims.  For  the full story of the VA’s transformation. see Philip Longman’s “The Best Care Anywhere” in Washington Monthly, January 2007.

That said, the Bush administration has steadily cut funding for the VA hospital system, and as a result, access and waiting times have suffered. By 2005 the number of patients the Veterans Administration was treating had doubled over 10 years to roughly 7 million. Meanwhile, the VA had cut costs by half. Such efficiency is admirable– but at that  point, the budget was too tight.

And that was 2005. As the war in Iraq dragged on, the number of wounded multiplied.

Yet just as this administration failed to provide fighting soliders with the armor they needed, it has failed to give the VA the resources it needed to keep up with the carnage.

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Bob FlemingBill ErvinEric NovackSteven ZeitzewTom Leith Recent comment authors
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Bob Fleming
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Bob Fleming

On 19 November 1967 I was sitting on Hill 875 at the Command post when a US. aircraft dropped a bomb and it tree burst above us. The VFW magazine, (Mar 2006)called it The “worst friendly fire incident in Vietnam. I was NEVER EXAMINED OR TREATED for TBI. Now Im having problems and the VA doesnt seem to be able to hear me when I tell them that. Who’s ass do I have to kiss to get treatment for TBI?

Bill Ervin
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Bill Ervin

I believe that all the discussion on budgets, who was president and what they did is irrelivant. The VA system has some excellent physicians and programs. I am a service connected disabled vet. In the past 5 years I have had several experiences which I believe the quality of care was less than acceptable. I first had an “unusual” chest xray in November of 2004 by the time they did the biopsy in 2006 it had progressed to stage IIB. After having a lung removed the care I received in ICU was poor. In my opinion the care given in… Read more »

Eric Novack
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Eric Novack

Steven- thanks for the information… as you know, the issue is not one of taking care of true emergencies– though community physicians certainly notice insurance statuts, it does not change how I treat patients, at least. I also cannot argue that the VA formulary is, in and of itself, bad. I would say that today’s Medicare beneficiaries would be in for a rude awakening if tomorrow it was announced that their formulary now mirrored the VA system. As a matter of policy, of course, it does not reflect particularly well on our government bureaucracy that our nation’s veterans can find… Read more »

Eric Novack
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Eric Novack

Steven- thanks for the information… as you know, the issue is not one of taking care of true emergencies– though community physicians certainly notice insurance statuts, it does not change how I treat patients, at least. I also cannot argue that the VA formulary is, in and of itself, bad. I would say that today’s Medicare beneficiaries would be in for a rude awakening if tomorrow it was announced that their formulary now mirrored the VA system. As a matter of policy, of course, it does not reflect particularly well on our government bureaucracy that our nation’s veterans can find… Read more »

Steven Zeitzew
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I am an orthopaedic surgeon who works at the Veterans Administration in Los Angeles. I thought I would clarify an earlier point of contention about emergency care. When I inquired about this I discovered that our Chief of Staff is permitted to authorize care at an outside Emergency Room. I assume this is the case at other VA hospitals, so Eric Novack may wish to seek authorization for emergent care he provides to veterans in the future. For what it’s worth I think our formulary improves medical care. Medications are reviewed by physicians and pharmacists on the basis of scientific… Read more »

Eric Novack
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Maggie- nothing ad hominem intended. While we agree that funding increases have been insufficient, I continue to stand by my claim (and you appear to be agreeing) that the funding levels for the VA are far higher today than in the last year before this administration.
In your original post, you did not claim that funding increases have not kept up with demand and/or inflation— what you DID write was “the Bush administration has steadily cut funding for the VA hospital system”– I maintain that statement is false.

Maggie Mahar
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Maggie Mahar

Eric– I do not twist numbers and I did not mistate the facts. I provided numbers on growth in insurance premmiums to show how the cost of care has skyrocketed in the private sector–while the growth in VA funding falls far below that level. If you would prefer numbers on total health care spending- and think they they would proove your point–why not look them up yourself? (Rather than making ad hominem attacks). Perhaps you didn’t look them up because you knew that they would not proove your point: In 2006, total spending on healthcare in the U.S. exceeded $2… Read more »

Jack Lohman
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Eric, I’ve known for 25 years doctors who teach at the VA, and I may have mistakenly believed that they were not teaching well-seasoned physicians. 🙂
The VA and Medical Colleges are where physicians are taught, and it makes sense to me that they therefore have a higher ratio of newbies compared to the average hospital. Silly me.

Eric Novack
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Maggie– the use of health insurance premium increases is not the usual way that health spending increases is measured. So, while the cost of health insurance has increased, you are twisting your stats to backtrack from your mis-statement.
Jack- show me a shred of evidence that tha VA physicians are primarily ‘newbies’. Many VA Med Centers are part of teaching programs, where docs are newer, but the faculty run the range of experience.
Barry- while it sounds great to just exclude drugs for being similar, real people can and do react differently to medications.

Tom Leith
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Tom Leith

When I was a kid just getting started in the World of Big Business, a man who was sort of a mentor gave me a book called “The Official Rules”. Awhile later, a sequel came along called “The Official Explanations”. I don’t remember which book its from, but there was The Rule of 1,000 which says something like “once an organization has 1,000 members, it can generate so much work internally that it no longer needs contact with the outside world.” This sounds like an explanation for for a lot of things, so its probably from the sequel. Anyway, we… Read more »

Ken Larson
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We need to be careful to differentitate between the Active Service Hospitals and the Veteran’s Administration. There are major differences. I am currently a resident in a Veteran’s Home after having undergone treatment through the VA for PTSD and Depression, long overdue some 40 years after the Tet Offensive that cap stoned my military 2nd tour in Vietnam with a lifetime of illness. My blog has attracted the stories of many veterans such as myself and other sufferers from PTSD who were victimized by elements of society other than the VA system of medical and mental treatment. I, for one,… Read more »

Barry Carol
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Barry Carol

Maggie, I agree that there is plenty of room for improvement in comparing the efficacy and cost-effectiveness of similar drugs vs each other as opposed to against a placebo. Less effective drugs could be placed in the highest co-pay tier which would drive down utilization, other things equal. Moreover, I note that United HealthGroup will no longer pay for Nexium because Prilosec and the generic equivalent is just about is good and much cheaper. There is no reason why other drugs that stack up as poorly in terms of value for money vs alternatives could not also be excluded from… Read more »

Maggie Mahar
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Maggie Mahar

Barry– The fact that the VA formulary is smaller may well just mean that it is more selective. The VA uses its electornic data-base–showing how patients repond to different medications–to picks the drugs that it includes in its formulary. One striking fact: the VA, the Mayo Clnic and Kaiser all stopped using Vioxx about two years before Merck was forced to take it off the makret. They all felt that it was over-priced, and no better than less expensive, older drugs. Also, the medical literature showed the possiblity of real risks. Private sector insurers continued to include Vioxx in their… Read more »

Jack Lohman
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Following is a post I made on another thread because it fits this discussion: “Of course the current VA model is not perfect, because it must compete with a private market in which physicians can make well over $500K if they are creative. Thus the VA gets the newbies and they aren’t always the best. But that doesn’t destroy the model. If all we had was a VA system with all of todays physicians folded into it and paid a progressive P4P salary, it would be a hell of a lot better than the current free-market system that is on… Read more »

Barry Carol
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Barry Carol

Maggie,
Thanks for the excellent summary and for doing the research.
I am impressed that your brother-in-law would opt for VA care, at least some of the time, given the private sector resources available in Manhattan. The VA drug formulary, however, is highly restrictive (1,300 drugs or so, I believe). That is about one-third of the number on most formularies available to Medicare Part D patients. It is questionable how satisfied Medicare patients would be if the tradeoff for government price negotiation with drug companies to get lower prices for seniors would be a formulary as restrictive as the VA’s.