Issues in Health Administration: How the VA Quietly Provides the Top Healthcare in the Country

The VA, as it stands, is not an experiment in universal free healthcare. Different levels of eligibility determine different levels of support. Combat veterans are a top priority, followed by veterans with service-related disabilities, former prisoners of war, veterans exposed to toxic substances and environmental hazards, and low-income veterans. One’s priority level determines how much care a veteran is eligible for, and how much that care will cost.

While veterans in the VA system don’t need to pay a monthly premium, they may have a copay, which can range from a few dollars to a few thousand dollars. In the final calculation, those the VA does treat get access to affordable and humane healthcare that rates above the rest in quality.

The VA gets several things right. It also has room for improvement. But the lessons to be learned from its experiment in high-quality, patient-centered care can have an impact on the way healthcare services are provided in the United States.

According to RAND’s research, the VA outperforms non-VA healthcare on 45 out of 47 outpatient quality measures. Gallup polls show veterans as being the most satisfied demographic when it comes to their healthcare. How the VA achieves this is largely thanks to its singular, integrated structure, which cuts out most of the middlemen.

Lifetime Patients, Lifetime Providers

A patient at the VA is often a patient for the rest of their life. This means the VA has a long, detailed, and largely uninterrupted health history for its patients. Notably, the VA was also one of the pioneers of electronic medical records.

It also means that the VA is incentivized towards providing preventative care services; they’ll incur the economic benefit of having a healthy patient (or the economic detriment of an unhealthy patient) later in life. Of particular note are the VA’s behavioral health programs, which, according to the bipartisan Commission on Care, are largely unrivaled in the private sector. It’s also exemplary at polytrauma rehabilitative care, which can’t be found practically anywhere else, at any price.

Natural, Patient-Centered Approach

Another instrumental factor in the VA’s top-quality care is its commitment to a patient-centered approach. On a broad level, some of this is a result of demographics: approximately a third of all VA employees are, themselves, veterans, and more apt to understand the people they serve. But it’s also the result of innovative policy.

At the VA, Patient Aligned Care Teams (PACTs)—which include occupational, physical, and recreational therapists, along with nurses, a social worker, a case manager, and a psychologist—collaborate to integrate mind and body care in a patient-centered way. This a drastically different system than the private sector, where a primary care physician can be responsible for well over 2,000 patients; VA doctors average half of that, while still achieving added benefits to safety, efficiency, and quality.

The VA gets more than its fair share of bad press. Part of the reason for that is that the VA is under more scrutiny than any privately-run system; two standing committees in Congress, an inspector general, and veterans services organizations all act as watchdogs. But the aspiration to transparency is laudable, and the department’s faults shouldn’t be ignored. The national health system would benefit from a similar level of scrutiny.

The Wait Time Debate

In 2014, the VA was rocked with a scandal. CNN reported that as many as 40 veterans died while on waitlists at a single VA hospital in Phoenix. Even worse, it was revealed that certain VA facilities were fudging the numbers for their average wait times: instead of alerting the government to their shortcomings and asking for help, they collected pay bonuses for hitting benchmarks they never hit.

Since 2014, a narrative of long wait times at the VA has persisted. The question is: long wait-times compared to what? A 2015 study found that in general, VA wait-times for new patient primary and specialty care are shorter than those in the private sector.

Where wait-times do persist, however, is in the assessment of whether veterans are eligible to receive care, and at what level. Currently, some 2.3 million veterans and their family members are completely uninsured. Expanding the system, rather than shrinking it, is the solution.

Increased Privatization

The Trump Administration’s Mission Act has been touted as giving veterans more choice when it comes to healthcare, but private options might not be that healthy of a choice. Privatized care is, indeed, sometimes needed for veterans in rural communities who would otherwise endure long wait-times or a lack of services from a VA care center. Previously, if a patient had to wait more than 30 days to see a VA doctor, they could seek subsidized private care. The Mission Act reduced that threshold to 20, and then 14 days.

In 2018, 1.7 million veterans used some form of private care. That number could increase up to 30 percent under the new rules, adding over half-a-million veterans to private care. This outflux of services can starve VA facilities and expose veterans to significantly higher costs simultaneously. Additional concerns include the interoperability of VA and non-VA EMRs. Furthermore, the increased choice of one’s care provider undermines the integration and singularity of the VA system, and may not, according to a RAND report, show measurable improvements in wait time or care quality.

The VA is quietly providing the highest-quality healthcare in the United States, and it’s making veterans think that a similar system should be shared with other segments of the population, too.

The VA’s healthcare services operate through a single-payer system, which owns its own facilities and employs its own doctors, and cuts out many of the cost-inflating middlemen. That system is being debated at a national level, too, where it could replicate many of the VA’s successes at the national level. But some more immediate steps can be taken by private-sector health systems to imitate the VA’s best features.

A 2017 research letter in JAMA Internal Medicine found that VA hospitals outperformed non-VA hospitals on several key metrics, including patient outcomes, patient readmission, and patient mortality. The letter’s authors speculate that this difference in care is a result of the VA’s investment of time and care coordination over the last 30 years. This is also a result of the VA’s fully-integrated system, wherein many patients receive all their care from the same organization.

An increase in care coordination and patient-centered services, such as the VA’s PACT model, would help private sector health systems to treat the whole patient. Further integration of services, including the wider interoperability of EMR data, would contribute to this end. Oversight mechanisms, such as those focused on the VA, could be targeted at the private sector to eliminate perverse incentives and increase transparency.

Some political voices want to privatize the VA, and make it more like the healthcare options which are available to all Americans. To do so would come at a great cost to both veterans and the general public. The VA outperforms all other American healthcare providers on practically every metric that healthcare quality experts can devise: adherence to evidence-based medicine; investment in prevention and disease management; implementation of effective EMR systems; and patient satisfaction.

Healthcare in the US would benefit greatly from becoming more like the VA system, not the other way around.