NEWS

VA System a Model for Health Care, Experts Say

Renee Twombly

Once viewed as a bastion of bureaucracy that treats only poor or wounded veterans of military services, the hospitals and clinics of the Veterans Administration (VA) have gained a new-found popularity that has resulted in well-publicized waiting lines and an escalating budget crunch.

Since 1996 when Congress threw open the doors of the VA health care system to any veteran, and after it made all prescription drugs available for $7 a month, demand for medical services has increased like a perfect storm, said Anthony Principi, secretary of the VA.

Five million Americans are enrolled in VA health care—1.2 million more than in 2001—and 200 million prescriptions were filled in the last year, said Principi. To keep pace, the VA’s budget has recently grown by one-third, to $65 billion, making the department the second largest in the federal government. But there still is a significant mismatch in the VA between demand and funding, according to a Presidential Task Force report issued in May.

VA oncologists, however, say they are weathering the storm in good shape. According to the VA’s chief cancer care administrator, Thakor Patel, M.D., none of the veterans who have been diagnosed with cancer are waiting for care. Of the 150,000 veterans waiting for their first clinic appointment, some for up to 6 months, Patel believes most are seeking a consultation with a primary care specialist so that they can be eligible for the prescription drug benefit.

If any of those waiting are diagnosed with cancer, however, they will be seen by an oncologist within a week or two and added to a network of oncology clinics that takes in about 35,000 newly diagnosed veterans each year and is treating an estimated 175,000 cancer patients, Patel said.

The ability of the VA to offer what Patel calls Cadillac cancer care to veterans is the result of integrated communications systems and quality controls that have been put in place over the past decade, he said. This infrastructure includes everything from computerized medical records and a sophisticated system-wide comparison of outcomes to a simple phone call tree that is frequently used to find specialized care for individual patients. Mix in the VA’s esprit de corps and Patel said the result is a system that is not without problems, but is offering care he said is as good as, if not better than, that found in the private sector.

For example, he recently had a call from a VA oncologist in California looking for promising experimental therapy for a stage IV colon cancer patient who had no response to all traditional therapies, so Patel sent an e-mail to cancer care contacts at each of the VA’s 21 divisions, known as the Veterans Integrated Service Network (VISN). I sent out an e-mail and within a half hour I had a response from a Texas VISN offering participation in a phase I/II study of a new protocol, he said.

The cooperation between these independent VISN units also extends, when necessary, to sharing medications. Although the VA pays less for drugs than any other federal or private health program because of a special agreement with the pharmaceutical industry, it still has to pay a lot for the latest and most costly drugs. They are often available throughout the network, but when one VISN cannot pay for such top-dollar drugs as interleukin-2 (at up to $30,000 for a week’s treatment), it works with others in the network that can.

The bottom line, said Patel, is that we make sure veterans are provided with the best cancer care we can offer. If the newest techniques are not provided in house, then the VA will work with one of its affiliated medical schools or other outside resources, Patel said.

Praise for Model Systems

Kudos for the job the VA is doing was reflected last year in an Institute of Medicine report, Leadership by Example, that was third in a series that is examining the national health care system.

I am a big fan of the VA, said the IOM member who chaired the report, Gilbert Omenn, M.D., Ph.D., professor of internal medicine, human genetics, and public health at the University of Michigan, Ann Arbor. He said the VA offered a model to the rest of the country’s hospitals in at least three different areas.



View larger version (132K):
[in this window]
[in a new window]
 
Dr. Gilbert Omenn

 
The VA’s integrated health care information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation, the report said. Its impressive electronic medical record, which uses barcodes to identify patients, and tracks laboratory reports, images and physician notes, is amazing, especially since the technology used to put it together is not fancy, said Omenn.

The VA’s patient safety program and surgical quality improvement program are also first class, Omenn said. The VA [hospitals] are good training sites and good partners to academic medical centers. And the care is equivalent.

The VA offers the gold standard in surgical care, a model that is being adapted to the private sector, said Darrell Campbell Jr., M.D., also at the University of Michigan. A VA initiative, called the National Surgical Quality Improvement Program, began about 15 years ago when Congress passed legislation mandating a review of what was then believed to be below par surgical care. Since then, the VA has developed a system that measures the quality of surgery in a new way, said Campbell, and as a result, 30-day post-operative deaths decreased by 27% from 1991 to 2000.

Now, each of 131 VA hospitals employs a trained nurse reviewer to collect prospective, risk-adjusted outcomes data on surgery patients. This method levels the field, and measures real results, said Campbell, who noted that this system has also worked well in a pilot trial at three academic medical centers.

With a recent grant from the Agency for Healthcare Research and Quality (AHRQ), Campbell said the program will be expanded to 14 academic centers, and now the American College of Surgeons wants to use it and expand it to 150 hospitals in the next few years.

I am very excited about it, he said. I think this is the most valid, reliable way to measure and improve the quality of surgery.

Striving to Improve

But VA cancer care also has its challenges, and among them is the annual challenge about budget, staffing and equipment and replacement, said Omenn. The VA has an acute inability to meet the pay that nurses, physicians, and technicians can expect in the private sector, added Raye-Ann Dorn, who runs the VA’s Central Cancer Registry. Attracting qualified people is a major problem she said. You can’t run a radiology program without radiologists.

And because each of the 21 VISNs is designed to adapt to local needs in the area of the country it serves, there are differences in the delivery of care and management of programs, according to the Presidential Task Force report. To know one VA is to know one VA, said Albert Muhleman, M.D., chief of hematology/oncology at the Cincinnati VA Medical Center and a VA doctor since 1973. But he also said that some decisions have been centralized, such as the choice of new drugs, a process he heads as leader of a nationwide group of advisers. As long as the literature supports use of a drug, we advise it, he said.



View larger version (135K):
[in this window]
[in a new window]
 
Dr. Albert Muhleman

 
Other top priorities for improvement, outlined in a new 5-year national cancer strategy plan released in June by Patel’s office, include expanded patient education; cancer screening; and palliative, hospice, and end-of-life care.

Patel also said that VA oncologists need to increase their participation in NCI-sponsored clinical trials. Although the VA and the NCI entered an agreement in 1998 to expand veterans’ access to clinical trials, it has been slow going in some VISNs because of competition with research under way at academic medical centers that are often across the street from VA hospitals.

Many VA oncologists have joint appointments with academic health centers, and in some cases that is very helpful, but it can also mean that if the academic center is the lead for a particular trial, it may not want to pay the VA to participate, said Andrea Denicoff, a clinical trials nurse specialist in the NCI’s Office of Clinical Research Promotion who serves as a clinical trials liaison with the VA.

But Denicoff added that the VA has always been a great place to do cooperative research. Our goal now is to take something that was already considered productive and make it even better.

The VA’s patient population makes it a great place to both give care and to conduct research, contends Mitchell Margolis, M.D., director of clinical medicine at the Philadelphia Veterans Affairs Medical Center. The fact that the patients have a lot of complex medical problems and that they cannot afford to pay for their care lends a certain satisfaction to the process, said Margolis, who has worked at the Philadelphia hospital for 12 years, and who also holds a joint appointment at the University of Pennsylvania. I love the VA, he added. The disparity between the VA and the private sector has greatly narrowed, and although the VA bureaucracy gets a bad reputation, it is no worse than any place else.



             
Copyright © 2003 Oxford University Press (unless otherwise stated)
Oxford University Press Privacy Policy and Legal Statement