Saturday, May 13, 2006

VA Health Care: Patient-centered, Superior, Low-cost, Tech-savvy. Showing the Way?

"How Can I help you?"

"How are you going to pay for today's visit?"

The first question is what you get at the VA. The second is what you get at most other health facilities. As one who depends on both the VA and private health care, I can tell you that for patients the VA question feels a lot better. Photo shows veterans being helped at the Worcester, Mass. VA Outpatient Center where I go.

At the VA, patient care is the priority, period. Plus, the care is preventive. That's not a misprint. Prevention is something that almost all health professionals talk about, believe in, and want to do. But too often everything seems to work against the practicing of it.

In the first place, prevention by definition presumes a healthy patient. Doctors tend not to see healthy patients; mostly they see people with chronic diseases, frequently on an emergency basis after a flare-up. Before going to a doctor, many people wait until they have raging symptoms. Then they hie into the doctor's office, or more likely the nearest emergency room, for a quick fix.

At the VA outpatient center in Worcester, Mass.,most of the patients are older and many have chronic conditions. Quite a few are veterans from World War II, Korea, and Vietnam and use wheelchairs and walkers. They are also not the easiest patients in the world.

Still, with rare exceptions, they get ongoing, attentive and personal care -- often from the same doctor for years -- and preventive care is an important part of it. At the front desk, there is no talk of money or what is covered or what is not covered. The copays for visits and prescription drugs, which are filled by the clinic's own in-house pharmacy, have risen dramatically but are still comparatively low.

The prescription drug co-pay recently went from $2 to $7 and is slated to rise yet again. This compares to prescription drug co-pays of $25 and $35 and more required by many health insurance companies.

Despite a shortage of doctors, waiting is minimal and the staff at the front desk is unfailingly courteous and helpful. Though the Worcester facility serves herds of veterans, the dedicated and stable staff -- one sees the same faces year after year -- deliver top-notch service. They often do something else that is rare in health facilities elsewhere: they smile at patients.

For many years, the VA health system, the largest health-care provider network in the country by far, was underused. But then as costs of health premiums, prescription drugs, and hospital visits soared, leaving millions of Americans without health insurance and unable to pay for care, pressure built to increase access to the VA system.

Congress passed legislation in 1996 opening the VA health care system to all veterans who had served at least two years active duty. Almost overnight, the number of veterans receiving VA care went from under three million to 25 million. Within a few years, the VA found itself swamped. Pretty soon disabled veterans had to wait six months to see a primary care doctor.

The VA was forced to tighten eligibility requirements. Today the VA now accepts as new patients only veterans with service-connected wounds or injuries. In addition, eight levels of priority have been established, ranging from 100% disabled from war wounds as the highest to unwounded peacetime soldiers (like me) at the bottom.

Veteran bottom-dwellers like me are no longer accepted by the VA. Priority for care is now given to veterans who have "borne the battle.” That means that my younger brother, Vic, a former marine who fought in Vietnam and who was wounded in the stomach by a grenade and is classified as 100% disabled, gets priority for appointments over me.

Vic, who retired from the marines after 24 years of service, holds the bronze star and other combat decorations. In the eyes of the VA, my two years at a Nike missile site in California staring at a radar screen and running drills designed to detect and foil a missile attack on the homeland aren't equal to Vic's combat, and they aren't.

I said to Vic, “So now it means that if the two of us walk into the VA with a medical emergency, they leave me in the corner to die while they make heroic efforts to save your life.”

“Sounds about right to me,” he said.

My youngest brother Reggie, who served four years in the Marine Corps recently applied for VA care after he lost his job and his health insurance. He was turned down.

I mentioned the new VA categories to Dr. Krantz, my doctor at the time. She said, “I don't care what your classification is. I didn't know what it was until you just told me. I treat every patient exactly the same, period.”

I smiled.

With Dr. Krantz then and with Dr. Santora today, every VA visit is devoted to preventive medicine. It is all about reviewing my electronic file to see what tests are due, ordering what is needed, and talking about test results. If a specialist is called for, a referral is made.

Dr. Santora has just made a referral to the VA dermatology clinic for the actinic keratosis on my face. She made the referral on a Tuesday; I got a call the next Tuesday for an appointment with the Dermatology Clinic on Thursday -- two days from now as I write this.

Since I wrote the last sentence, I got a call from a friend suggesting that I get a full-body check while I am at it. I plan to do so. The more people who are involved to looking out for my health, the better I like it.

Sometimes, with all health issues taken care of, VA doctor and patient gab.

Non-VA physicians wish they had the same opportunity. American medicine traditionally emphasizes treatment after the fact: control the disease with drugs or fix the breakdown with surgery. However, this emphasis is not a medical imperative but a third-party one. The third-parties, all-powerful everywhere else, have no say in the VA. Zilch.

That makes all the difference. That's why when I go to the VA, staff asks how they can help me not how I am going to pay for the visit. That difference, more than anything else, determines quality of care. To the third-party-payers, health insurance is less about health than it is about making a profit.

Health insurance companies, like all insurance companies, don't like to pay and some go to great lengths to avoid doing so. Go to the main office of any big health insurer and you find as much as 90 percent of the building devoted to marketing and taking in money.

The small part given over to paying out money will be a tiny, out-of-the-way, forlorn section where the few employees there will be strictly on the slow track.
The standing orders of this office will be to pay later rather than sooner and only after exhausting every possible delaying tactic. Here the concept of prevention smacks too much of paying money too early for a fuzzy patient benefit way off in the future; it is bad “cash management.”

That mindset leads to HMOs who won't pay for a flu shot but then end up paying many times more when someone who doesn't get a shot because of lack of coverage comes down with pneumonia. “That's insane,” said my sister Marian, an RN formerly in charge of nursing care at a large community hospital in Melrose, Mass. She is now retired and is one of my four siblings.

That preventive medicine reduces insurance payouts in the long run by keeping payouts smaller for longer does not compute in the accounting departments of the typical American health insurance company today. The focus instead is on the time value of money, whose guiding principle is that paying later always translates into better cash flow.

This is true in almost every business except health care. In this “business,” avoiding small near-term payouts for preventive care regularly leads to an increase in future catastrophic payouts in the future, replacing near-term savings with longterm losses.

Though preventive care saves money in the long run, the many physicians who wish to practice preventive care because it is best for patients, medicine and society, come up against a brick wall of opposition from immovable health insurers and entrenched practice.

Doctors treating the elderly on Medicare are routinely under-reimbursed for their time. Generally speaking, if physicians want to get paid, they practice short-term, fixit medicine or leave the profession. A common complaint of physicians is, “I can't spend time talking to my patients because I don't get paid for that time.”

But a doctor talking to a patient is at the very heart of preventive medicine. Because the VA is financed by the U.S. Government – that is, by all of us – VA physicians tend to have more leeway to practice preventive medicine than do physicians working for HMOs or in private practice. Though VA doctors must live with tight budgets and growing financial restraints, they still have wide discretion in providing patient care.

That is why a VA doctor is able to take the time to talk to the patients about what can be done now prevent something bad in the future, sometimes the far-off future. The goal is to keep the patient healthy longer while putting off fixit intervention for as long as possible.

VA doctors have the tools to do it, too. Dr. Santora has at her command an information technology system and medical resources that are far superior to that of non-VA physicians such as Dr. Marelli who walk into the examination room carrying paper files.

After long bouts with sub-par organization, systems, and patient care, the VA has successfully reinvented itself. Though it struggles to provide care for huge numbers of veterans, it is still a model of large-scale delivery of quality health care.

In VA hospitals, when a heart-attack is entered into a patient's electronic record, the computer automatically orders aspirin for most patients; if a nurse or doctor does not confirm that the patient received the aspirin, an alarm sounds. In most non-VA hospitals this automated process is absent.

The VA maintains built-in cost and quality controls not present throughout the private hospital system or even in Medicare. For example, the VA takes advantage of its power in the marketplace to negotiate lower drug prices with pharmaceutical companies, something expressly not permitted under the prescription drug benefit recently added to Medicare.

As a result, the quality of VA patient care has steadily improved and studies confirm that the VA system delivers superior care. A study recently published in Annals of Internal Medicine compared the care received by 1,300 diabetics in VA centers in Indiana, California, Texas, Michigan, Pennsylvania, and New Jersey with that received by 6,900 diabetics in eight managed care plans. The study found that diabetic patients treated by VA doctors more often received recommended tests and treatments than did managed care patients. For example, they received more blood tests, eye exams, and foot exams.

This study and several others tells us that a nationally-funded health care system can provide excellent quality care and do so at significantly lower cost.
Administrative costs of Medicare Part D are 20%. If the Part D drug benefit had simply been added to Medicare, administrative costs would be 2% -- as it is at the Medicare itself and the VA.

Why does the VA health care system work so well? Why should such a superior, proven, in-place nationwide health system be reserved to veterans only? What can be learned from its administrators, physicians, nurses, and patients?

Despite a national debate over the health care crisis, these questions are only beginning to be asked.

So long and keep moving.


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