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.

Wednesday, May 10, 2006

Divided Loyalty: A Tale of Two Primary-care Doctors, VA and Private

"Should I or shouldn't I?"

That's the question millions of Medicare recipients are asking as the May 15 deadline closes in for signing up for the new Medicare prescription drug plan without a stiff lifetime late penalty.

With dozens of plans to choose from -- each with different formularies, premiums, coverage, and co-pays -- people are confused and afraid of making the wrong choice. Meanwhile, the clock ticks ...

Well, I'm not one of those lying awake at night racked with worry. I did a cost/benefit study of Medicare Part D and decided that, for me, the coverage stinks. On top of that, the out-of-pocket costs are outrageous (and sure to get worse), except for people who are very poor and who take lots of prescription drugs.

But I also have a back-up, and a good one: the VA. As a veteran, like the lucky veteran here being treated by a VA doctor, I have been going to the VA for many years. The VA offers veterans prescription drugs at a modest $7 co-pay (soon to rise, however), without a monthly premium and without the diabolical "donut hole" of Part D.

Desperate to get people to sign up for the plan, the Bush Administration has been trotting out people telling the camera how much they will save. Some will be saving money -- until they fall into the infamous donut hole in which all coverage ceases and starts again only after thousands of dollars more are paid out of pocket, in addition to the monthly premium.

Medicare Part D is a debacle and has been from inception. For most people the coverage is lousy, expensive, unreliable, and primarily serves the insurance companies and drug companies who all but wrote the bill. It is basically a complex system of subsidies to private insurance companies. And five of the biggest are in the process of helping themselves to about 80% of the gravy.

Paul Krugman of The New York Times summed up Part D's wrongheadedness: "Drug coverage could simply have been added to traditional Medicare. If the government had done that, everyone currently covered by Medicare would automatically have been enrolled in the drug benefit.

"Adding drug coverage would also have saved a lot of money, both by eliminating the cost of employing private insurance companies as middlemen and by allowing the government to negotiate lower drug prices. This would have made it possible to offer a better benefit at much less cost to taxpayers."

But before I passed on the Part D "benefit," I wanted to make sure that my VA prescription-drug benefits were a sure thing. I made an appointment with my VA primary care provider, Donna Santora(not her real name) a nurse practitioner, to discuss my VA drug benefits as a Medicare beneficiary. While I was at it, I would see about the reappearance of facial lesions.

I called on a Wednesday and got an appointment for the following Tuesday. Just like that. First, I asked about the facial lesions. "A couple of years ago, the dermatology clinic applied a new cream and the lesions went away, but now they're back," I said. "They're nothing to let go, so I think I need a dermatology appointment."

She drew closer and examined my face. "Yes, I can see. actinic keratosis. We'll get you a dermatology appointment." She wrote herself a note. "You'll get a notice."

Actinic keratoses is the most common sun-related growth. Those most at risk are fair-skinned, burn easily, and tan poorly. I'm not fair-skinned but my face burns after 15 minutes in the sun and never tans, though the rest of me does tan. The only place I get these lesions is on the face.

Though many people get these yearly and have them removed routinely, they are nothing to mess around with. If they break through the dermis, they can become invasive carcinomas which can metastasize and cause death. Definitely worth a trip to the doctor.

"Am I due for any tests?"

She went to the computer and pulled up my file. She viewed my past tests and tests due. "No, you're good. You're due for a sigmoid next year. I'll order all the physical exam blood tests. When do you see Dr. Marelli(not his real name)?"

He is my other primary care provider. It so happens that they both know each other well and cooperate in my care. In fact, for several years my VA nurse practitioner worked as a nurse with Dr. Marelli and he encouraged her to take additional training.

"I wouldn't be here without him," she says. "Also he's a great doctor, very thorough."

I go to Dr. Santora for ongoing preventive care, which is what the VA does best. I go to Dr. Marelli for what a private practice does best, which is the big stuff, such as when I needed two total knee replacements two years ago and when I was hospitalized last September with severe pelvis misalignment.

"I see Dr. Marelli on May 24th," I said. "Should I still go with the appointments so close?"

"Absolutely. We need to keep Dr. Marelli in the loop in case anything major comes up. If you get to the lab this week, you can bring the results to the appointment."

"I'll go tomorrow morning."


I had the blood drawn a couple of days ago. I walked in at 8 A.M. without an appointment and was out in twenty minutes. The results will go to my VA file and be mailed to me. I'll bring them to my appointment with Dr. Marelli on the 24th.

Next, I got down to what was really on my mind and the main reason I had asked for the unscheduled appointment. "You know this May 15 deadline for signing up for Medicare Part D is coming on Monday. I think it's a rip-off with awful coverage compared to what I get here at the VA. But before I let the deadline pass, I want to make sure I will continue to be able to get VA prescription drugs."

"Oh," she said, putting both hands to her face in real horror." I just went through that with my mother. It was so complicated choosing the best plan for her. And that donut hole! No coverage at all. I finally picked a plan without interrupted coverage but at a higher premium, fifty-six bucks a months. But don't you worry. Nothing changes for you. "

"What if I have to go to the hospital and need drugs there?"

"Dr. Marelli and I will talk. You'll get VA drugs. As a veteran, you have a right to VA drug benefits and between the two of us, we'll see that you get the drugs that you need. Don't worry about a thing."

I smiled.

I have twinges of guilt about seeing two primary-care doctors at the same time. In some ways, it feels like having an affair, even though both know about the other and do not not seem the least bit jealous. On the contrary, both are perfectly willing to share in my care and cooperate fully on an ongoing basis.

In a health-care system in dizzying flux, with patients routinely seeing new doctors all the time, the continuity of care offered by the VA is priceless. I have only recently begun seeing Dr. Santora (yes, I know she's not a doctor but a nurse practitioner but she does everything a doctor would do for me and more -- such as preventive care -- and I think she deserves the title.) But before I got her, I had the same VA doctor for seven years, Dr. Susan Krantz while also seeing Dr. Marelli.

Dr. Krantz is wonderful, caring, and dedicated. She looks you in the eye. She listens. While keeping a professional distance, always addressing me as "Mr.," she sees not just a patient but a person. She read my online novel, State Kid. She even called me at home to double-check on this medical detail or that. When she decided to leave the VA, and medicine, she called me at home to give me the news.

I was devastated. For months after she left in December 2004, I missed her terribly. I badly wanted to talk to her to tell her how I was doing and to hear about her new life. But of course I never tried to get in touch with her because I knew that both patient and doctor had to move on.

Nevertheless, I will never forget her. When the planes struck the twin towers on 9/11, I was in Dr. Krantz's office and we received the news together. We will be forever joined by that horrific event. Nor can I ever forget how this unspeakable event did not stop her from giving her full attention to my care. Remarkable.

What are the chances of my getting another Dr. Krantz at the VA? One would think not good. And yet, I have seen Dr. Santora about three times now and, honest to God, it looks like she is cut from the same dedicated and caring mold as Dr. Krantz. I think I have hit the primary-care provider jackpot twice in a row!

All the same, at a time when unequal access to health care is a major problem in this country, when millions of people have no health insurance at all – and often no health care except the emergency room – I feel selfish. Just because I was lucky enough to be eligible for the VA health care system and lucky enough to have private health insurance, I shouldn't be acting like a health care pig.

Yet ...

Dr. Daniel Marelli is also warm and attentive. He is a tall, young-looking man in his early forties with a friendly, easygoing manner, and laser eye contact. I have been going to him for nine years. He gives me annual exam at which time I brief him on my preventive care and tests from the VA. On anything serious, Dr. Marelli sees me on short notice, actually no notice.

He follows up each exam with a personal letter explaining the results, always ending the letter with something upbeat like, “I think this is a fine report and I hope you will feel good about it.”

Dr. Marelli comes into the examining room with paper files containing everything he has on me. The appointment usually lasts about twenty minutes. The wait in the examination room before the appointment is usually longer.

Unlike Dr. Santora at the VA, who has years and years of every little detail about me in her computer and can pull it all up instantly, Dr. Marelli must depend on his paper files, what I tell him, and what he can learn through his eye balls. The VA is light years ahead of private medicine in information technology, thanks to a top-to-bottom systems revamping over the past several years.

But Dr. Marelli is patient-centered, serious, and as Dr. Santora said, thorough. In the examination room, he listens more than he talks. During the annual examination, I lie on the examination table. He takes the blood pressure. He looks in the mouth. He listens to the heart, feels the neck and and presses on the lower abdomen.

“Feel any pain,” he asks. He checks the penis and testicles. “Any problems there?” he asks. He has me roll over on his side and does a rectal exam and tests the feces for blood. “No blood,” he says.

At the most recent physical, after Dr. Marelli had completed the exam, I asked which test is the most important. Without hesitation, he replied, “blood pressure and the rectal exam. Together they tell me more about the overall health of the body than anything else. If I could do only two things, I would do those two. By the way, your blood pressure is great, one-twenty over seventy.”

At every visit, I update him on my VA care and stress my wish to maintain my eligibility for VA medical care because of “all the uncertainly surrounding the health care system. You don't know what change you are going to be hit with next.”

“Absolutely,” Dr. Masserelli said. “It makes all the sense in the world for you to continue going to the VA. Fine with me. Go to the VA for certain things. Come here for certain things. Whatever works for you is what we do. I have no problem whatsoever. Who knows what's going to happen next in health care.”

He sighed deeply, shaking his head. “It's just awful,” he said. “People should not be able to get rich on health care. It's too important to too many people.”

He started to say more, but stopped himself, leaving me with the distinct feeling that this was just the peak of a mountain of displeasure.

So long and keep moving.