VA health care system treats vets better than private facilities
Coming fresh off of featuring Kip Sullivan’s “Single Payer Health Care Financing Presentation – Three Part Series,” also “Continuing the Conversation concerning Medicare and Medicare Advantage Part 1 and Part 2.” and Kip Sullivan and Ralph Nader Talk Tradition Medicare vs Medicare Advantage; I came across this article by Suzanne Gordon concerning Veteran healthcare and its facilities. Suzanne advocates for veterans and the VA along with Phillip Longman of Open Markets Institute and the author of the “Best Care Anywhere.”
For the record, I am a Marine veteran.
The VA is woefully underfunded and has been for a while. I suspect the underfunding is purposely done so as to cause it to perform poorly. This has caused the VA issues with providing care for vets coming out of Iraq and Afghanistan.
If you do not know, one of the advantages the VA has is its own negotiated pharmaceutical formulary with has lower prices than what you would find in Medicare or commercial healthcare. There has been talk about allowing Medicare to use it. Maybe sometime soon, the commercial healthcare carpetbaggers in Congress may allow Medicare to use it also. Purposely and with the passage of the PPACA, Congress blocked any negotiation of pharmaceuticals by Medicare.
Suzanne discusses “fee for service” healthcare the same as Kip Sullivan does. There will always be a fee for service in healthcare. Under Single Payer healthcare, those fees would be set by Single Payer for healthcare. Medicare also sets fees it pays for healthcare services minus pharmaceuticals. In comparison, Commercial Healthcare Insurance typically pays ~twice (or more) than what Medicare pays and even more than what the VA costs are.
Under a false pretense, Congress has allowed veterans to use Commercial Healthcare facilities due to the under-funding by Congress causing the issues at the VA. Suzanne discusses fee for services as an issue and also discusses up-coding by commercial healthcare used by veterans. These are legitimate beefs in today’s healthcare system.
There is another issue with commercial healthcare to which veterans are being exposed to and to which commercial healthcare is salivating over . . . value-based payment healthcare. An outcome measure asking whether a given outcome occurred (is the patient’s blood pressure under 140/80?), whereas a process measure asks whether a certain process was conducted (did the doctor prescribe hypertension medication for patients with high blood pressure?).
This leads to upcoding and the resulting fees for service Suzanne is pointing too as being an issue. Medicare Advantage codes its patients yearly for the following year. CMS pays MA plans for care based upon the coding and whether used or not. Veterans over 65 using commercial healthcare rather than the VA may be exposed to upcoding if they are absorbed into the commercial healthcare system. Typically, this would be Medicare Advantage which is notorious for upcoding.
My message above lays the groundwork for what I see occurring and Suzanne’s message today in discussing the potential closing of Veteran Administration facilities.
Memo to the Veterans Affairs Secretary: Don’t Close VA Facilities, Suzanne Gordon and Russell Lemle, Washington Monthly1
On March 14, Department of Veterans Affairs Secretary Denis McDonough is expected to release a long-awaited list of VA facilities and services that may be shuttered in the coming years. McDonough’s potential hit list is required by one of the most problematic sections of the VA MISSION Act of 2018, legislation vastly expanding the outsourcing of veteran care to private-sector providers. The law mandates the creation of the Asset and Infrastructure Review (AIR) Commission, which would consider which of the VA’s health care facilities to close, improve, repurpose, or consolidate. The secretary’s list will include not only entire medical centers but also inpatient units, emergency rooms, and outpatient clinics. Critics of the AIR process worry that commission members (who have yet to be announced) will ignore a wealth of studies demonstrating that the VA delivers better outcomes at a lower cost than the private sector. They worry, too, that the VA will close facilities and programs instead of improving infrastructure, hiring needed staff, and even expanding utilization.
If there was any doubt that the VA delivers higher-quality care at a lower cost than the private sector, that concern should definitively be put to rest by a new study in the British Medical Journal2, one of the most prestigious scientific journals in the world.
The study’s lead author is David C. Chan, professor of health policy at Stanford University and also an investigator at the VA. Chan’s coauthors includes four economists and researchers connected with Stanford University, the University of California at Berkeley, and Carnegie Mellon. Unlike many previous studies that contrasted the experiences of veterans cared for at VA facilities with non-veterans treated in the private sector, this study compared the outcomes of 583,248 veterans over the age of 65 who were enrolled in the VA health system and also covered under Medicare. When these veterans called an ambulance for a health emergency, they were randomly taken to either a VA or private-sector hospital.
The differences were startling. Veterans treated at VA facilities were 20 percent less likely to die the following year than veterans taken to a private-sector hospital. Every one of the 140 VA hospitals in the study outperformed their private-sector counterparts. What the authors dubbed the VA’s “mortality advantage” was even greater for veterans who were African American or Hispanic. This advantage lasted months after the patients left the ER. Not only was private-sector hospital care less effective, its price tag was 21 percent higher than care at the VA.
In the typically understated fashion of medical journals, the authors advised the “nature of this mortality advantage warrants further investigation, as does its generalizability to other types of patients and care. Nonetheless, the finding is relevant to assessments of the merit of policies that encourage private healthcare alternatives for veterans.”
In other words: Stop privatizing the VA.
It’s finally time to acknowledge what Phillip Longman of the Washington Monthly and the Open Markets Institute argued 20 years ago: The VA health care system offers the Best Care Anywhere3 and should serve as a model for all of us.
The VA delivers such high-quality care, as Chan and his colleagues explain, for several reasons. It has a fully unified electronic medical record, and care is fully coordinated and directed by effective primary care teams.
Rebecca Shunk, a primary care physician at the San Francisco VA Healthcare System, explains what this kind of care coordination looks like in an emergency.
When one of my patients shows up in the emergency room, our primary care patient aligned care team (PACT)—which includes a primary care physician or nurse practitioner plus a registered nurse, licensed practical nurse, and medical support assistant—is immediately alerted.
Whether the patient is admitted to the hospital or not, the Primary Care PACT RN will do a routine call to the veteran 48 hours after his or her ER visit to find out how they are doing and what they need. They will make sure that the veteran has a close follow-up visit with their primary care provider or a member of the team. And then, of course, we will find out if they have any other needs. For instance, do they need durable medical equipment—a walker, a cane, do they need home nursing, physical therapy? We can make all this happen quickly through our robust home care program.
Shunk adds that the primary care team can quickly organize an appointment with a specialist like a cardiologist or a pulmonologist.
Studies show that this kind of coordination leads to the VA’s better outcomes. It’s not routine in the private sector. “In fact,” Shunk laments, “it’s hard to even get a patient’s record from a private-sector provider.”
Chan and his coauthors speculate that the VA mortality advantage may also stem from the follow-up care being determined by the patient’s need, not the private-sector provider generating revenue in a fee-for-service system. As the authors explain, VA staff members are salaried and have no incentive to overtreat. Outside of the VA, one in seven health care dollars is spent on unnecessary, sometimes toxic, and often futile treatment.
In another paper4 published shortly after the BMJ article was published, Chan and two of his coauthors dug even deeper into the data about ER experiences at the VA and the private sector. Their analysis provides further insights into why private-sector care is more expensive and sometimes more dangerous. After an ER visit, private-sector providers are more apt to transfer patients to inpatient rather than outpatient care and keep them in the hospital longer:
The authors note;
“Services with high reimbursement (under fee-for-service arrangements) are more likely to be performed in non-VA hospitals.”
As the VA Office of Inspector General has reported5, thousands of private-sector providers under the MISSION Act’s Community Care Network have engaged in the notorious practice of “upcoding” when they bill the VA for services. To generate more revenue, they may bill for complex evaluation and management services they have not performed. The same seems to be true when billing during and following an emergency. As the authors write,
The odds of reporting high vs. low-complexity services are more than five times higher in private hospitals vs. the VA.
The VA, on the other hand, increases the delivery of less remunerative outpatient and rehabilitation services. The authors add that the kind of rigorous telephone follow-up Shunk describes above “are only reported at the VA.”
The authors conclude,
Widely publicized concerns about the quality and capacity of the VA system, the largest public healthcare delivery system in the US, have fueled public perceptions that the VA health system is falling short of providing good care to the many veterans who depend on it. Our findings join those from other studies in suggesting that, for the system overall, those perceptions do not match reality. This conclusion has important implications for health policy. Enabling or encouraging veterans to obtain care outside the VA system could lead to worse, not better, health outcomes, particularly for veterans with established care relationships at VA facilities.
Tragically, documents leaked to the Washington Monthly indicate that the VA secretary has ignored long-standing evidence of the VA’s cost and quality advantage. In turn, the VA recommends closing inpatient units and even some emergency departments across the country. Since a hospital can’t have an emergency room without an inpatient unit, this would mean shuttering even more ERs than any slated for closure. With the VA secretary and his consultants, many of them holdovers from the Trump administration, seemingly determined to ignore the scientific evidence. We hope Congress and the AIR Commission will reject the recommendations. The coronavirus pandemic has led to many hospital closures and dangerous understaffing in the non-VA health care system. It is more important than ever to not just preserve existing VA capacity but possibly to even expand it.
1Memo to the Veterans Affairs Secretary: Don’t Close VA Facilities | Washington Monthly,
2Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study | The BMJ
3Best Care Anywhere: Why VA Health Care Is Better Than Yours | IndieBound.org., Phillip Longman, February 2011
4Is There a VA Advantage? Evidence from Dually Eligible Veterans | NBER
5VHA Risks Overpaying Community Care Providers for Evaluation and Management Services
Blog – Suzanne Gordon (suzannecgordon.com)
I always worried that I (as a vet) would eventually end up in the VA hospital system, which I understood even while still ‘in service’ to be terrible. Mrs Fred has long-term care insurance; I was not eligible due to heart-related issues. No worries, I told her; just send me over to the local VA when the time comes.
Secretly, I believed the only service I’d ever receive would be free pill-samples at the check-in desk. Later communication with the VA advised that was more than I was entitled to.
Last year, an old vet died in that facility. He wandered out of his room and was found, dead in a stairwell, several weeks later.
But, no worries for me. I saw no combat; I will never be eligible for VA care.
As I have said, however, I ain’t complaining. I got my (‘no combat for you!’) benefits up front.
There are many levels of eligibility and sublevels. I believe yours would be a Level 8 or at the bottom of the barrel. They do accept veterans at that level. No one gets to choose where they served. You go where they tell you. Entitled to? That is a rip . . . Do not believe the verbal sh*t.
You should get the application and fill it out. List your health issues. If you were exposed to any toxic issues such as what Marines experienced at LeJeune from drinking and bathing in their water. There are also issues with capacity. Not enough vets to keep a facility open.
No Long Term Care? Did you bother with AARP? Have you checked out USAA? and other Veterans associations. AARP has LTC. I am in that one because getting into the VA ones are difficult. Ted Kennedy died before he could get that portion of healthcare passed.
The VA is a public institution unlike private, commercial hospital and healthcare. Do you really think they do not have their issues with people dying? I always love when they come in and want to give me blood thinners. Have you checked my records?
“…There are also issues with capacity. Not enough vets to keep a facility open…”
In Richmond, VA, there are also issues with capacity, but the other way around. My dad, who lived in Madison and then Culpepper, VA used to go to the VA hospital in Martinsburg, West Virginia, where it was far less crowded and much better maintained both in sanitary and staffing. The extra time that was spent traveling was more than compensated by the reduced time in waiting rooms.
I went to the VA hospital here once with a broken metatarsal bone in the mid-70’s before I got a job with decent health benefits. It took a couple days to just get to see a doctor by which time x-ray showed it had begun to mend crooked already and the doctor said best to just let it go by that point. My dad stayed in the one here once and complained about the junkies wandering the halls as well as the slow access to treatment. After that he went to Martinsburg for care.
Everybody has a story about the VA and of course none of this shit happens at Commercial Hospitals profitable or nonProfit. Except the later can hide its issues. The VA is wide open to critique. If I had a broken bone – which is painful – I would be at an Emergency Room and not trying to schedule an appointment with a doctor.
VA Healthcare has issues and mostly because of the funding which comes out of Congress. Not to worry though Ron, Congress is attempting to privatize it just like Medicare. 18% of GDP spent to line the pockets of commercial healthcare. Cut it in half to be realistic. Soon that $32 billion for Medicare for all will look kind of small when Commercial Healthcare keeps growing.
I have seen some strange looking ducks at the VA clinic/hospital. It was crowded. Did not see any junkies which I used to chase to the brig. What else would you like to enlighten us with Ron?
not sure this is relevant:
long time ago there was public debate about deciding whether veterans’ illness(-es) were “service related” in order to be eleibible for VA care.
I had worked briefly at a VA hospital in Florida. attending an intake interview I watched in horror as a man who was seeking treatment for an old back injury that was service related.
the interviewers asked him questions like “who is president?” and “what year is it?” he was not sure of his answers so they decided his back complaints were psychological.
meanwhile they accepted for treatment a young man who was trying to beat a drug charge by seeking treatment for his drug problem. i was assigned to his case. to me he was an obvious con artist and i didn’t think i could be any use to him.
nevertheless when the “service related?” issue came up I wrote some person in washington suggesting that guaranteed treatment at VA be part of the compensation for ANY military service (w/o regard for whther the condition was service related. they forwarded my letter to the appropriate agency for consideration. i got a form letter from them telling me it was up to congress.
in other words, nothing.
i don’t know if they ever changed the service related requirement.
but i think it is obvious that Congress is in the hands of the enemy. was then. obvious now.
it’s obvious my back problems are psychological.
In all things, then individual results may vary, but in general for VA hospitals the provider’s zip code is a big factor in quality of care. Cities with relatively large low income veteran populations find their VA hospitals over worked and understaffed, not the best conditions for healthcare.
do you think that might have something to do with a disfunctional government?
or maybe just a disfuntional us.
Glad you asked. I did some research into McGuire VA Hospital here in Richmond, VA and then tried to verify those findings, but it will take Run to really finish that verification. What I found here was the quality was cyclical and many of the problems go to funding such as poor parking and under-staffing of medical providers, while the bulk of issues fall on non-medical staff from managers all the way down to admission clerks. The funding issues are cyclical based on the changes in POTUS and Congress, but also media exposure. The non-medical staff problems are cyclical based on funding and also media exposure. They need better IT/IS (funding), but also just a good swift kick at times. Even Chairman Mao complained about bureaucrats in his Little Red Book. So, here prior to the 2014 VA care scandal that focused on the VA hospital in Phoenix, AZ, then McGuire had been terrible for years, except for the performance of the medical treatment staff for those lucky enough to see one. After that got O’Barry’s attention thanks to 60 Minutes, then McGuire improved greatly, although overwhelmed again over the last two years (like every hospital everywhere). Run lives in Phoenix now and I imagine their VA hospital is performing way better than eight years ago also.
sounds like what i ran into when i worked for Food Stamps in the eighties. perhaps because of Reagan, but mostly, I think, because of “people” the purpose and even the laws were frustrated by bad or lazy administrators and front line workers. who ignored both at their convenience.
there was a certain amount of fraud by the customers..some just to meet the unreasonable requirements to qualify, and some just from people playing the system, including some relatives of the administrators. but the cost of rooting out the fraud was not worth the damage it did, or would do. In any case it never rose to anywhere near the level of hysteria generated by the Right. who, I think, are now showing their true colors: they are haters, insane, and enjoyers of human suffering. the fact that half the population agrees with them should scare us. but it does accord with my perceptions from a very early age, before i ever heard of politics: about half the people you meet are haters. they enjoy causing you pain. and if you think my estimate is too high, you are not counting all the enablers who are not quite brave enough to confront you personally, but are glad to stand behind someone who is.
You know ronnie;
Tough guys like you who talked about the clerks and the jerks probably did exist in the Army and could threaten the office personnel with retaliation. You see in the Corps everyone learns how to shoot and they were expected to join in when needed. So the guy next to you might be that office clerk and you might have to depend on them. So a 6’1″ 155 pounder like myself could easily bracket you at 500+ yards using metal sights with a stock M14. I would keep your threats to yourself.
Veterans aren’t the only ones waiting for health care, May 23, 2014
who is ronnie? i haven’t seen any threats here (except maybe yours).
I think you may be overreacting to what some of us have said which neither disagrees with you nor is hostile toward your cause, but are just discussions of some aspects of the problem…some possible aspects.
For what it’s worth, I think “the” problem is just ordinary human behavior, including, I am sorry to say, ordinary corruption at the congressional and presidential level. That’s a tough problem to solve. won’t be helped by getting unnecessarily defensive with each other.
That was not what this post was about. It presented a study verifying what was already known. The care is better at the VA than what can be obtained at Commercial healthcare.
All of our present healthcare supply side problems stem from when Republicans and Reagan Democrats put the wrecking ball to the commercial nonprofit BC/BS system in 1986 and nonprofit hospitals in 1987; i.e., rescinded their New Deal Era 501(c) tax exemptions. Of course the demand side problems stem from an aging boomer population, which lobbyists and investors saw coming back in 1986 & 1987.
Sharks do not hate their food, but they must still kill it before they eat it.
“in general for VA hospitals the provider’s zip code is a big factor in quality of care.”
This was also answered in the BMJ study as well as others. “Previous studies have not sought to balance comparator groups in this way. In addition, with 583,248 patients followed into treatment at 2762 hospitals in 46 US states, our study is among the largest comparisons of VA and non-VA care conducted to date.”
Do you believe of the 2762 hospitals, the study chose only the good VA sites?
Granted a Congress with its focus set upon Medicare Advantage programs versus Medicare and commercial healthcare as compared to VA healthcare is an issue is problematic especially when Congress favors commercial interests. It is a problem leading up to many of the issues we may find in some settings the same as may be found in commercial hospitals.
How large a group of hospitals do you need before your view may consider that VA healthcare is just as good as commercial healthcare if not better?
Your views are typical and create illusions rather than a realistic view.
First ; “How to get VA Benefits”
You get a hold of the form and you fill it out. If you are above a certain income in your region, you will pay a deductible for your 90 day supply of drugs. The deductible is $15. There is no talking to anyone to get VA benefits. You apply for the benefits.
Second: “I listed a number of links”
The links back up what I said about the care you would get from the VA. Since no one wants to read the links and this one in particular, I will put some of the detail out here.
Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study“
“Of 1 470 157 ambulance rides, 231 611 (15.8%) went to Veterans Affairs hospitals and 1 238 546 (84.2%) went to non-Veterans Affairs hospitals. The adjusted mortality rate at 30 days was 20.1% lower among patients taken to Veterans Affairs hospitals than among patients taken to non-Veterans Affairs hospitals (9.32 deaths per 100 patients (95% confidence interval 9.15 to 9.50) v 11.67 (11.58 to 11.76)). The mortality advantage associated with Veterans Affairs hospitals was particularly large for patients who were black (−25.8%), were Hispanic (−22.7%), and had received care at the same hospital in the previous year.”
It seems regular hospitals do not favor minorities.
My second go-about with ITP had me in the hospital for 3-1/2 weeks. Nothing was working. They were going to try Rituxan and then N-Plate if Rituxan did not work. If Medicare rejected either, I was going to the VA to get approval. It does help to have a backup. Anecdotal evidence or personal experience is just that.
If you do not use the VA, it will disappear. You will have commercial healthcare where the costs to treat diabetes between 1996 – 2013 rose 50%.
Some JAMA Network evidence:
“The influence of these 5 factors varied by health condition and type of care. For example, the increase in annual diabetes spending between 1996 and 2013 was $64.4 (UI, $57.9-$70.6) billion; $44.4 (UI, $38.7-$49.6) billion of this increase was pharmaceutical spending.”
~ a 68% increase in costs driven by five factors of which pricing was the big driver. Factors Associated With Increases in US Health Care Spending, 1996-2013 | JAMA | JAMA Network
“Change in population size, population aging, disease prevalence or incidence, service utilization, or service price and intensity.” were the drivers of which Pricing Increases played a major role. You can find a version of the above here at Angry Bear. Healthcare Costs and Its Drivers Today – Angry Bear (angrybearblog.com)
Coberly, you wrote on Social Security and I have multiple articles on healthcare at Angry Bear.
I don’t know what your last comment directed at me was about.
my whole comment was just anecdotal about my very few experienes with VA. think of it as color. all it amounted to is that i think that something is wrong in Denmark.
my very specific knowledge of Social Security has nothing to do with VA or even Medicare.
but it looks to me like the “privatization” of everything is winning the war. not good for us.