Socialized or Not, We Can Learn from the VA

Art Kellerman RAND optimizedIn a post on the New York Times’ Economix blog not long ago, Princeton economics professor Uwe E. Reinhardt addresses the common characterization of the British health care system as “socialized medicine.” The label is most often used pejoratively in the United States to suggest that if anything resembling Great Britain’s National Health System (NHS) were adopted in the U.S., it would invariably deliver low-quality health care and produce poor health outcomes.

Ironically, Reinhardt notes, the U.S. already has a close cousin to the NHS within our borders. It’s the national network of VA Hospitals, clinics and skilled nursing facilities operated by our Veterans Healthcare Administration, part of the Department of Veterans Affairs. By almost every measure, the VA is recognized as delivering consistently high-quality care to its patients.

Among the evidence Reinhardt cites is an “eye-opening” (his words) 2004 RAND study from in the Annals of Internal Medicine that examined the quality of VA care, comparing the medical records of VA patients with a national sample and evaluating how effectively health care is delivered to each group (see a summary of that study).

RAND’s study, led by Dr. Steven Asch, found that the VA system delivered higher-quality care than the national sample of private hospitals on all measures except acute care (on which the two samples performed comparably). In nearly every other respect, VA patients received consistently better care across the board, including screening, diagnosis, treatment, and access to follow-up.

Asch and his team also found that VA patients were more likely to receive recommended care than patients in the national sample. VA patients received about two-thirds of the care recommended by national standards, compared with about half in the national sample. Among chronic care patients, VA patients received about 70 percent of recommended care, compared with about 60 percent in the national sample. For preventive care, the difference was greater: VA patients received 65 percent of recommended care, while patients in the national sample received recommended preventive care roughly 45 percent of the time.

Other studies have generated similar findings. In 2010, an interdisciplinary team of researchers published a systematic review of prior research that compared the quality of surgical care provided by the VA with that provided by relevant non-VA hospitals and healthcare systems. Based on the available evidence, the authors determined that VA and non-VA settings generally provided comparable surgical care and achieved similar outcomes. What differences the team did find favored VA care in 3 instances and non-VA care in 5. In 15 comparisons, care was not different.

The following year, this team published a second systematic review, this time focusing on how well VA and non-VA facilities deliver medical and non-surgical care. After examining 36 high-quality studies, the team concluded that the VA almost always came out on top when the study examined how well health systems follow recommended processes of care. When the study compared mortality rates, VA and non-VA facilities generally achieved similar outcomes.

Earlier this year, a team of RAND and Altarum Institute researchers published the results of a major, national evaluation of the quality of mental health and substance use care provided by the VA. Many of these patients not only struggle with complex mental health and substance use disorders, but serious physical problems as well. As a result, they are extremely difficult and expensive to treat.

In their report, the RAND-Altarum team noted that although the VA has not yet reached the high standards it has set for itself, between 2007 and 2009 quality improved significantly despite substantial growth in the number of veterans served. In fact, the team determined that the VA already has higher levels of performance than private providers for seven out of nine indicators, and VA patients endorse similar levels of satisfaction with VA care as patients in the private sector. A summary of the team’s findings was recently published in the journal Health Affairs.

“Government health care” is often characterized as wasteful and inefficient. But here too the VA’s experience suggests otherwise. In 2007, the nonpartisan Congressional Budget Office (CBO) released a report (PDF) that concluded that the VA is doing a much better job of controlling health care costs than the private sector. After adjusting for a changing case mix as younger veterans return from Iraq and Afghanistan, the CBO calculated that the VA’s average health care cost per enrollee grew by roughly 1.7% from 1999 to 2005, an annual growth rate of 0.3%. During the same time period, Medicare’s per capita costs grew by 29.4 %, an annual growth rate of 4.4 %. In the private insurance market, premiums for family coverage jumped by more than 70% (PDF), according to the Kaiser Family Foundation.

Every health system has its faults, and the VA is no exception. In recent years, it has been challenged by severe budgetary constraints and a surge in demand, as large numbers of injured and ill veterans return from the wars in Iraq and Afghanistan. Its Vietnam-era veterans are aging rapidly and the agency must contend with growing case complexity. When a system as big as the VA falls short, anecdotes about shortcomings get more play than reams of data.

But the VA also has formidable strengths. Early on, the VA embraced many of the attributes that characterize our nation’s top-performing private healthcare systems: It was an early adopter of an interoperable electronic health record; it has strong affiliations with the nation’s top medical schools; it regularly measures and applies quality data, and it has a salaried medical staff that is well-aligned with the agency’s mission.

RAND is committed to data- and fact-driven analysis. As the nation struggles to confront the twin challenges of rising healthcare costs and uncertain quality, we should be willing to embrace innovative practices wherever they exist, whether they are developed in private, for-profit health care systems or so-called “socialized” ones, like Britain’s NHS or America’s VA.

Art Kellermann serves as Dean of the F. Edward Hébert School of Medicine at Uniformed Services University of the Health Sciences. This post originally appeared on RAND.org  August 8, 2012. 

Editor’s note: An earlier version of this post incorrectly identified Kellerman as an employee of RAND corporation. THCB regrets the error.  

27 replies »

  1. No Peter. It is impossible to manage any organization where the union can control who gets fired or who gets moved from one position to another.

  2. So you’ve already determined this is the union’s fault, and the AG does not say so he’s not telling the truth?

  3. Just because the ACA is a bad plan doesn’t mean that some parts of it cannot be used in the appropriate way. Among other things the problem with the ACA’s use of subsidies is it treats some groups ( identical in demographics, need etc.) better than others, and it forces people to hold back advancement.

    Whether I agree with the ACA or not it was stupidly written.

  4. Unions can make it near impossible to fire anyone and that brings quality and production to a near standstill.

    I saw that personally in the City Hospitals in NY. All sorts of outrageous things were done that negatively impacted care, but to fire a union member was forbidden. I have seen and experienced episodes that would make your head stand on end.

    The IG’s report? Did you read what Neil Barofsky wrote about TARP? He was the IG for TARP and the one that stopped him from doing his job was the Secretary of the Treasury. BTW Barofsky was a Democrat and a liberal. An excellent prosecutor.

  5. “This doesn’t mean that the government can’t offer targeted subsidies.”


  6. Allan, unions tend to be easy run for cover scapegoats, but so far no smoking gun nothing really has said they created this. Management seems alone in gaming the system to achieve bonuses. If union enforced policies created the wait times they’ll get the blame soon enough.

    I’ll wait for the AGs report.

  7. Each individual should be the purchaser and owner of their own insurance so that in the end each individual determines what they are being insured for and how important insurance is to them. This doesn’t mean that the government can’t offer targeted subsidies.

  8. The union is now under the light so they are going to disavow a lot of things they did in the past. I remember what unions used to do at the city hospitals in NY. The unions supported actions that were inhumane and contrary to the ethics of almost all normal people. This doesn’t mean I am against unions, only their abuse.

  9. Barry, patient feedback is important but needs to be combined with other types of information to gain importance.

    Example: Certain actions by physicians might improve their performance scores while at the same time hinder the doctors ability to make an appropriate diagnosis.

  10. Incentives and performance metrics matter in all areas of economic activity including healthcare. However, any system can be gamed by those inclined to do so. I think patient satisfaction surveys can provide valuable feedback relating to issues of access, wait times for an appointment and wait times in the waiting room before being seen by the doc or NP as well as bedside manner. Issues around whether or not the treatment was appropriate, the diagnosis was accurate, and the standard of care was met are best left to independent audits. If a change can bring about improvements in the system even if it’s not perfect, we should try it. Don’t let the perfect be the enemy of the good.

  11. I don’t have a problem conceptually with trying an experimental drug under these circumstances as a last resort for someone who is otherwise likely to die soon.

    As a taxpayer, though, I would want to see full documentation of what the effect, if any, of the drug was in order to maximize the research value of the treatment effort for future patients. Also, even if the drug company provides the drug for free, I wonder how much the incremental cost for hospitalization and physician services would be across the population given access to experimental drugs.

    We’re all going to die of something and it’s legitimate to question how much society should be prepared to spend on longshot treatments when our overall healthcare costs are already excessive compared to other countries.

  12. “We don’t need the VA to treat Medicare patients that have heart disease. We don’t need the VA to treat Diabetes. We need the VA there to treat war injuries that are best left to specialists that the VA might be best at.”

    I think I agree with you Allan but try to get veterans to agree.

    Not sure this can be off loaded to VA unions.

    “VA Employees’ Union Calls for End to “Culture of Fear” for Whistleblowers”

  13. We need a VA that is honest and above board. It must respect the veteran whose only reason for being there should be that he was injured in battle protecting our nation. We should be protecting the VA, not union members.

    We don’t need the VA to treat Medicare patients that have heart disease. We don’t need the VA to treat Diabetes. We need the VA there to treat war injuries that are best left to specialists that the VA might be best at. If we owe the vet 100% healthcare grant a subsidy so he can get it outside of the VA. Let the VA work with outside personal to provide the best possible care. Provide centers of excellence for spine and brain injuries due to battle even if it means flying a vet to the center.

  14. I think those who want the VA dismantled better be prepared for veterans waiting in line with everyone else for access. My understanding of the VA is it was supposed to put vets ahead of the line. If private docs are going to handle the vets how much will they be paid to see a vet – higher than Medicaid/Medicare to ensure prompt service?

    Canada does not use a VA type system, but it also has far fewer vets.

  15. ” Satisfaction surveys are very misleading.”

    I agree Allan. My wife’s state supported hospital uses them. They’re mostly about perception not reality, and are used as cover for more funding. They cloud important trees while looking at the forest. I would prefer outside private random audits.

    From interviews I’ve seen of VA employees they fear retribution from being whistleblowers, or merely problem reporters. But whistleblowers in the private sector also suffer terribly from doing the right thing.

  16. Satisfaction surveys are very misleading. If you go to a physician with what you believe could be a life threatening problem and he tells you that you are 100% fine and to go and enjoy yourself you love that guy. He gets great ratings. But, when in truth you needed a cardiac cath and a stent and subsequently die from mismanagement there is no form for you to fill out to complain that the doctor was a jerk.

  17. I wonder if the VA uses Press Ganey patient satisfaction surveys and scores and, if it does, what do they show? They could be a mechanism for patients to express dissatisfaction with excessive wait times and whether or not lengthy wait times are widespread.

  18. I see this both ways. I just talked to a fellow today in for a DOT physical who has been very happy with his care at the VA, as well as many others I have talked to in the past. From what I have seen and heard, it appears that mostly the care is good. However, I also agree that we need to look at what’s happened recently in terms of access, because after all if good care is available but unaccessable to a large population, that’s a problem.

    If we are going to learn any lessons at all, we see that having insurance, or a “health plan” of some sort does not gaurantee access to health care. This is true of the VA, the ACA or any other system you want to put together.

  19. I’ve looked at the VA from at least two view points. The first was early in my career when I worked at the VA. It was horrid. The latter was as a private professional that saw both good and bad care. The delays I saw were life threatening. I also saw a bureaucracy that was trying to keep its numbers up by forcing those with dual insurance to use the VA for basic problems. They used free medications as the lure.

    Why the VA in my area had to build an expensive new hospital when most of the veterans were seniors is beyond my understanding. By the time this gargantuan structure was completed most of the VA’s alive when the hospital was funded had already died.

    The VA always seemed to have time to treat the run of the mill illnesses of Medicare patients, but when a veteran needed specialized care for war injuries where the private sector was not adequately trained the VA seemed to have back logs and the like.

    Too many are looking at this problem with an ideological view and trying to protect the President of the day instead of the veterans. The VA has had problems for decades. One of Obama’s main pledges was to solve the VA’s problems. Funding for the VA had radically increased under the prior administration. If Obama was true to his word then he would have been following what was happening at the VA. The problems were not hidden as Congressman had been asked for help and the waiting lines were excessive. No one at the helm was interested in the VA. It was just good material to use for electioneering.

  20. Peter1:

    I think WWP is a great thing. What I was trying to say is that if the politicians that start wars properly funded the VA then there wouldn’t be as great a need for it.

    If one is going to war then one has to be prepared to pay for the fully burdened cost of it. And it’s not just an issue of funding rather one should be extremely reluctant to go to war ever unless absolutely necessary due to the very high human cost.

    I had a neighbor that passed a few years ago at 91 years of age. He was on a battleship in the South Pacific. He had several types of insurance and received treatment without problem, but at 91 he was still having nightmares about being shelled by Japanese battleships. So while any physical problems he had were treated it’s pretty clear that his PTSD was not and hey maybe it’s not treatable ever.

  21. Art- question: does the clear systemic falsification of VA records bring into question the validity of ALL studies looking at the VA until they can be redone with data that can be independently verified?

    Wouldn’t that be what we would expect for ANY private sector company looking at, let’s say, pharma study results? Systemic data fraud tells me all of that data meaningless and not useful until repeated with newly obtained, independent data.

    your thoughts here?

  22. Thanks Art, I think it is important to distinguish the current problems of new access vs. the quality of care that those already in the system receive. They are two separate problems, even though politicians of a certain persuasion are trying to tie this into their meme that the government cannot possibly do anything well. But the long-term success of the VA (and the NIH, the CDC, and others) show that the government can do some things quite well. It is unfortunate that every national problem now has to be viewed through the poisonous political culture that has emerged, especially on the right.

  23. My aged vet father-in-law struggled with health diagnosis and treatment using the private system through Medicare and supplemental coverage. He finally got proper diagnosis and coordinated care through the VA. His experience was fantastic as I believe most vet’s experiences are.

    Perverse incentives and lax oversight coupled with shear volumes of patients caused this recent VA scandal. War hawks love their feel good hammer military solutions, but fail to recognize the long term outcomes. Anti- guvment types might think the private sector would not produce these problems but they also would lobby against the necessary budgets to allow any system to cope with these numbers. Be careful what you wish for.

    If hawks don’t want such programs as The Wounded Warrior Project to exist they should lobby for open checkbook treatment and support for vets or tone down their perverse pro war rhetoric.

  24. Art
    I always appreciate your posts.

    However, as a researcher, your position seems out of sync. Should you not be more dispassionate in your conclusions?

    Perhaps a more fitting denouement might be: The circumstances have changed, the past does not equal the present–especially in light of data reporting transgressions–and until researchers and the government can analyze the past 5 years of material, we must reserve our conclusions.

    Perhaps you imply above, but I sense you take a glass as half full approach to VA performance (“underfunding as root cause”), when in fact, you should see no glass and no water, ie, just an empty spreadsheet for ~2009-14.


  25. Art:

    RAND and other think tanks are as partisan as they come. If the VA is doing such a bang-up job then why does Wounded Warriors Project exist?

    Rather than hear it from RAND you should talk to some vets that aren’t getting treated properly.