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High Quality in Veterans’ Health Care and Clinician Autonomy: Are They at Odds? (Part 1 of 2)

By Dr. Ram Krishnamoorthi
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In July 2009, in the thick of the contentious health reform debate of that year, The Daily Show’s Jon Stewart interviewed neo-conservative commentator William Kristol. When the conversation turned to whether Americans deserved the right to health care, Kristol brought up veterans’ health care, and Stewart caught him in a gotcha moment:


Stewart had pinned Kristol on 2 points: 1) that all Americans did not deserve the right to the high quality health care that veterans received from the VA, and 2) that the care that veterans received from the government-run VA was indeed high quality health care. On point #1, I don’t think Mr. Kristol felt very guilty. On point #2, he realized his ideological error and started to back-track.  But it was too late. Kristol had inadvertently stumbled onto an irony that he and many anti-government conservatives have to grapple with and that many Americans may not know:

The Veterans Health Administration (or the VHA as it is now known), the largest integrated health care system in the country providing care for over 6 million veterans, out-performs the private sector on a variety of quality measures. And it has done so for over a decade.

Writers, such as Philip Longman who wrote the book The Best Care Anywhere and a number of articles on the Veterans’ health care system, Ezra Klein of the Washington Post (2009

and most recently this month), and health services researchers, have long advertised the successes of the VA since its dramatic transformation in the 1990s.

Published data abound. In 2003, Jha and colleagues reported an astounding study in the New England Journal of Medicine comparing the VHA’s performance on quality indicators of care with that of private sector providers for a national sample of Medicare fee-for-service beneficiaries from every state.  On 11 out of 11 indicators collected in 1997-1999, such as screening mammography, pneumococcal and flu vaccinations, and aspirin, beta-blockers, and ACE-inhibitors for heart disease, the VHA’s care was significantly better than the private fee-for-service system. A 2004 paper in the Annals of Internal Medicine reported that for diabetes care, 5 VHA centers performed better than commercial managed care in a geographically matched sample on 7 out of 7 accepted process measures of quality. Such measures included testing hemoglobin A1c and providing eye and foot care. In another study, Asch and colleagues developed composite measures of quality using the RAND corporation’s 348 measures of quality on 26 medical conditions and found that for 12 VHA centers, chronic disease and preventive care were better for VHA patients than for a national sample of patients receiving care in the private sector. However, using data from 1998-1999, they did not find this superiority on measures of acute care.

The latest data published in this month’s Annals, however, provides more positive results on one area of acute care: cancer treatment. On several quality measures for colon, lung, prostate, and certain hematologic cancers recommended by national guidelines, Veterans received equal or better care than their Medicare counterparts in the fee-for-service private sector. The VHA had better rates of early diagnosis and curative resection of colon cancer and standard chemotherapy for a type of non-hodgkins lymphoma. Interestingly, the VHA had lower scores in the use of two advanced radiation therapies for prostate cancer. An editorial explains that evidence of these technologies’ effectiveness accumulated only after the study period’s completion, pointing to the VHA’s careful review of evidence before making major capital investments with their limited global budget.

Sweeping generalizations about all of Veterans’ care should not be made, for the data is focused on accepted measures of quality. Granted, there are not many such quality measures, as compared to the vast array of medical problems faced by clinics and hospitals. What is remarkable, however, is that the VHA provides care for a population of patients with among the highest burdens of chronic disease in the country. Not just for diabetes, kidney disease, and heart failure.  Not just for the service-related injuries of brain trauma, amputation, and spinal cord injury. But also for the complex behavioral, psychological, and socioeconomic consequences of their lives after military service.

How could this be? The historical reputation of the VA has been scandal-ridden, from Teapot Dome corruption at its inception, to horrible treatment of some veterans post-Vietnam (captured on screen by Oliver Stone in Born on the 4th of July, in which amputee veteran Tom Cruise describes his Bronx VA as a “f—ing slum”). As recently as 1992, three hospital in-patients were found dead near a Salem, Virginia VA hospital. Two had been lost by the hospital for months and one had been lost for 15 years. As Longman writes in his book, some of the VA’s reputation was exaggerated by veterans’ groups, as an understandable retaliation to years of shabby funding, neglect of VA facilities, and tactics to get more funding.

Everything changed in 1995. With the help of lobbying by these veterans’ groups, the VA’s Undersecretary for Health Dr. Ken Kizer led a metamorphosis, de-centralizing a bloated bureaucracy and closing down poorly performing hospitals. These hospitals were fast becoming unnecessary as Kizer drove the emphasis more towards primary care. He created a culture of continuous quality improvement and coordination of care, using one of the country’s largest electronic medical record systems. Mental health services and social services were a prominent need for generations of veterans riddled with the ills of post-service life.

In addition to improving measures of clinical quality, the changes have paid off in the VHA’s reputation among veterans. Veterans report higher “customer satisfaction” than do patients who get their care in the private sector.

But, what about physicians? Although internal surveys are conducted by the VA about employee satisfaction, published data on physician satisfaction at the VHA is lacking. What seems to be a theme among surveys of physicians outside of the VHA is that a major part of professional satisfaction is clinical autonomy. For example, in a physician survey in the Kaiser Permanente system, a staff-model HMO which resembles the VHA more closely other hospitals, physicians’ control over their clinical care, along with strong social support among other health care providers, was the most important mediator of professional satisfaction. 

But, it seems that central to the VHA’s quality success is its system-wide adoption of a culture of quality improvement. And at the heart of this culture are the performance measures, standardized across the whole VHA with mandated benchmarks in many cases by the Central Office.  Financial bonuses are tied to meeting these benchmarks, both at the employee level of managers and clinicians and at a facility level for a particular hospital that performs well. These mandates do not incentivize clinician autonomy, and many within the VHA feel they impose guideline-based, one-size-fits-all medicine to all veterans. More importantly, collecting and reporting the data to meet these benchmarks at the physician level is often burdensome, subtracting time from the individualized attention that physicians wish to devote to patients.

I’ll explore this phenomenon further in my next post, Part 2 of the VHA’s quality of care and clinician autonomy, and discuss its relationship to health care reform in the rest of the country.

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  1. Lisa Plymate

    Would just comment that Jon Stewart is discussing "military" health care, as opposed to "veterans" health care. Those are two different systems. I think both systems deliver good quality health care, but the computer systems are different; the VA's system is far superior to that used in the DOD - unless that department has finally realized they should be using the same system as the VA. (The DOD spent well over $20 million developing their own, far inferior, system rather than employing the already-well known VISTA. This was a clear example of government waste.) Nonetheless, the overall points are well taken.

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