Conjure up any image of how bad government-run medical care can be, and chances are the first picture that comes to mind will be a VA hospital. For much of the post-Vietnam War era, the popular perception of VA facilities has been one of dilapidated, often-filthy buildings, uncaring doctors and nurses, chronic shortages, and patients who sit around, neglected.
Movie director Oliver Stone struck a chord with his 1989 film, Born on the Fourth of July , in which actor Tom Cruise portrayed Ron Kovic, the former Marine who became an anti-war activist after being paralyzed in Vietnam. In a fit of rage over the squalid conditions and poor treatment he received in a rat-infested Veterans Administration hospital in New York, Cruise's character screams: "The place is a f---in" slum!'"
One of the best-kept secrets in health care, however, is that the Veterans Health Administration, as the VA's medical arm now is known, has overhauled its health-care delivery system over the past 12 years, transforming it into a responsive, high-quality medical care network that's being lauded as one that private hospitals and clinics ought to emulate.
"Today, the VA is both the largest and the best-integrated health-care system in America and maybe in the world,'' says R. James Nicholson, the current secretary of Veterans Affairs, who took office after most of the changes had been made and now faces the challenge of keeping the system intact in the face of mounting budget pressures. "That's not just the pride of the secretary, but of third-party people who evaluate these things.''
Last year, the private Washington-based National Committee for Quality Assurance, which ranks medical-care facilities according to 17 key performance measures, said VA hospitals were outperforming other public and private hospitals in every category. A 2003 study published by the New England Journal of Medicine rated VA care "significantly better'' than Medicare-financed private medical facilities on 11 separate measures of quality.
The Annals of Internal Medicine , another prestigious medical journal, published a study in late 2004, concluding the VA "performed consistently better'' than other providers in a national sample "across the entire spectrum of care, including screening, diagnosis, treatment, and follow-up.'' The American Journal of Managed Care also has praised the VA's transformation. An American Legion survey taken after inspection tours of 60 VA facilities each year rates VA care as outstanding.
"Over a decade's perspective, it's been stunning-one of the truly outstanding stories [of improvement in medical care] really, in the world,'' says a recognized expert on the quality of medical care, Dr. Donald M. Berwick, president of the private Institute for Healthcare Improvement in Cambridge, Massachusetts. Even more amazing, Dr. Berwick says, is that it was all done in the public spotlight, with Congress and the White House looking on.
To be sure, that doesn't mean that the VA is flawless. Just as in the private sector, some VA medical centers are better than others. The VA's much-praised computerized record-keeping system still has a few gaps; it doesn't automatically pick up information from veterans' visits to private physicians or outside hospitals yet, for example. Patient waiting times, much improved from those of a decade ago, are starting to get longer again. The agency can do more to cut the cost of pharmaceuticals, some experts say. And the VA still needs to modernize some of its physical plants-the average age of VA hospitals is about 40 years.
"It's still a work in progress,'' says Dr. Kenneth W. Kizer, the former top VA official who launched the agency's overhaul in the mid-1990s.
Nevertheless, the old complaints have vanished, and there's widespread agreement-among health-care professionals and patients alike-that the system has improved dramatically.
"We're not your father's VA,'' says Dr. Jonathan B. Perlin, the VA's undersecretary of health and head of the department's health-care system.
The VA's gains are a big leap by any measure. While medical experts and veterans say VA care overall was never quite as bad as the reputation it had, there was general agreement that the system was in serious trouble. The VA hospital system suffered from bureaucratic paralysis. Decisions too often were slow to come and influenced by politics, and day-to-day operations were erratic. Record-keeping was sloppy. Shortages-of both physicians and equipment-abounded. Morale was low, and too many physicians and staffers seemed uncaring and unwilling to go out of their way for patients. Moreover, the quality of medical care varied widely from hospital to hospital. Several facilities were in danger of losing their accreditation. Some critics argued that the entire system should be scrapped.
"The status quo was not viable,'' Dr. Perlin says, looking back. "It was clear that we needed to change, or we'd become obsolete.''