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.''
Turning the System Around
What the VA hierarchy did was the medical equivalent of calling in the Marines. In 1994, it hired Dr. Kizer, who had made major improvements as director of California's Department of Health Services, to become undersecretary of health, the chief executive officer of the agency's medical-care system.
Dr. Kizer, a no-nonsense former Navy medical officer with broad experience in running public and private health-care operations, already had some strong ideas about what was needed to fix the VA system, and he lost no time in putting them into action.
For a start, he reorganized the VA's disjointed collection of nearly autonomous hospitals, setting up 22 regional networks and forcing them to compete with one another-within prescribed budgetary limits-in making improvements. Traditional bureaucratic stovepipes, in which, say, all nurses reported to a single authority, were removed. Instead, the staff was reshuffled-in this case, according to the kind of care that was being provided. Nurses who worked in mental health wards, for example, reported to the chiefs of those psychiatric units.
Turning the VA system on its head, Dr. Kizer moved away from the previous practice of providing all medical care through big VA hospitals. Instead, he set up hundreds of outpatient clinics where veterans would go first to primary-care physicians-general practitioners and internists-who would handle most of their medical needs and shepherd them in dealings with specialists. Rather than having to drive hundreds of miles for basic medical care, most patients could get treatment within 50 miles of their homes. Care also is more personal this way: Patients see a single doctor, rather than being shunted to whoever is available that day.
Almost simultaneously, Dr. Kizer established high performance standards for a wide array of medical quality indicators-from blood-pressure monitoring to procedures for treating heart-attack victims-and set up a system for keeping tabs on how well they were being followed.
To help manage the effort, Dr. Kizer installed a massive information technology system that computerized everything from patient records, X-rays, and pharmacy orders to hospital compliance with the new VA performance standards. With few exceptions, paper records at the VA are now a relic of the past.
Finally, Dr. Kizer set to work revamping the existing VA culture, cajoling physicians and managers to embrace the changes and to work harder to improve medical care. Physicians who balked were pressured to come around or, in some cases, quit. Dr. Kizer closed six VA hospitals he thought were unneeded or substandard and merged several others. He also stepped up recruiting for top-quality physicians, beefing up ties with private teaching hospitals to attract part-time staffers who were noted in their fields.
To help reduce medical errors, which the U.S. Institute of Medicine says result in almost 100,000 hospital deaths a year, Dr. Kizer set up a new "patient safety'' program and hired Dr. James P. Bagian, a physician and former astronaut who had run the National Aeronautics and Space Administration's investigation into the space shuttle Challenger explosion, to head it. Together, they moved to reverse the traditional reticence of medical personnel to report mistakes or close-calls, and got them instead to point out such problems immediately so procedures could be devised to keep them from happening again.
That meant convincing physicians, nurses, and other staffers that they no longer would be blamed or punished if they admitted they made an honest mistake in some procedure-and in fact that they might well be rewarded for staving off future errors. To Dr. Bagian, such logic was elementary. "When you go to an aircraft investigation, nobody asks whose fault it is,'' he says. "They want to find out how it happened so they can prevent its happening again.'' Today, errors and close-calls are analyzed, and doctors and nurses take steps to fix any systemic problems. Dr. Bagian's National VA Center for Patient Safety in Ann Arbor, Michigan, serves as a system-wide sounding board, collecting information and providing encouragement and advice. "It's become a national resource,'' says Dr. Dennis S. O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, which oversees hospital accreditation in the United States.
The transformation, carried out at lightning speed by medical standards, was stunning: By the time Dr. Kizer's changes fully took effect in the late 1990s, the VA system had vastly improved its medical care, made treatment far more accessible, reduced errors dramatically, revamped the attitude of its physicians and nurses, and shifted to a completely electronic record-keeping system that catapulted it ahead of most private hospitals in quality and management. The kinds of hellholes that Kovic and other critics complained about were cleaned up and brought up to snuff. Waiting times-and hassles-for patients were cut significantly. Many medical authorities outside the government say the VA has become a model for private medical institutions.
Incredibly to some, the VA has saved money in the process by improving its management system, cutting out unnecessary tests and lab work, and streamlining its handling of prescription drugs. While the VA's overall medical budget doubled to $30.7 billion between fiscal year 1993 and fiscal year 2006, the number of patients it is treating has soared to 5.4 million, up from 2.8 million before, with a staff 5% smaller than in 1993. After the figures are adjusted for inflation, the savings are even more impressive: The average cost of treating each VA patient fell to a low of $3,983 in 2002, down from $5,691 in 1995. It was $4,281 in 2005, still well below the 1995 figure.
The Customers Approve
The improvement has not been lost on the VA's constitutency-the patients it serves. In a survey completed in January 2006 by the National Quality Research Center at the University of Michigan, veterans who went to VA facilities for treatment gave the VA a rating of 83 out of 100 for its inpatient care and 80 for outpatient care. By comparison, a similar survey of patients receiving care from private-sector facilities showed ratings of 73 for inpatient care and 75 for outpatient care.
"The changes have worked wonders,'' says John W. Wallace, a stocky, bearded former Army squad leader who helps keep tabs on the VA for the Vietnam Veterans of America in Maine. "These days, 98% of the veterans like the VA,'' he says.
Former Marine Staff Sergeant James McKee agrees. Mr. McKee's first encounter with Veterans Administration medical care, in 1971, was unnervingly brief. Discharged after returning from Vietnam, he walked into a VA hospital in New York, looked around in horror and headed right out the door again.
"It was pretty hectic,'' Mr. McKee says, still shaking his head over what he found then. "The hospital was filthy. There were people shooting up [drugs] in the telephone booths. The place looked like it would do more harm than good. I didn't even wait to see a doctor. I just walked out.''
Today, Mr. McKee, a 59-year-old retiree living in rural Rowe, Massachusetts, is one of the VA's biggest fans. His primary-care physician-only 30 minutes away in a nearby VA outpatient clinic-is "phenomenal,'' he says, and the agency has a program for post-traumatic stress disorder "that ought to be emulated.'' Waiting time is minimal, doctors and nurses are "very conscientious,'' and the medical care is first-rate-"comparable to the outside,'' Mr. McKee asserts.
"It's been a huge improvement,'' he says.
To many both in and outside the VA, Dr. Kizer's overhaul plan itself may well serve as something of a prototype, says the accreditation commission's Dr. O'Leary.
Although the individual elements in Dr. Kizer's scheme may seem separate, the dynamics of the plan effectively bolstered each component, making it possible to speed change even faster. Setting high performance standards enabled VA officials to prod physicians and nurses into improving their performance. Decentralizing decision making gave individual hospitals more flexibility to provide staffers with what they needed. Channeling veterans through primary-care physicians based at outpatient clinics made VA care more accessible and efficient at the same time and reduced waiting-time for patients. Moving the VA culture away from fear of blame for medical errors toward routinely reporting mistakes and close-calls helped tighten medical standards, prevent mistakes, and avert the high cost of treating the consequences of medical slip-ups.
What really held the plan together, however, was the shift to complete computerization of the VA medical system, which Dr. Kizer began imposing almost immediately. Converting all of the VA's records to electronic form enabled physicians to improve their monitoring of patients' health status and treatment, keep track of appointments and lab tests, and avoid mistakes in prescribing drugs. At a higher level, it helped remind doctors about needed procedures and tests and allowed VA officials to keep better tabs on whether their staffs were meeting performance standards. That in turn helped change the culture among physicians and nurses. "Nobody wants to be at the bottom of the barrel,'' Dr. Kizer said in an interview. "Computerization was a tool that allowed us to do the other things that needed to be done,'' he said.
Computerization
Dr. Ashish Jha, a Harvard Medical School faculty member who also serves as an internist and researcher at VA medical centers in Boston, shows just how impressive VA information technology can be. On a desktop computer in his office, Dr. Jha calls up a menu that offers him a broad array of records and memos on individual patients: a list of each patient's active medical problems, with symptoms and treatment; a record of medications the patient is taking; a list of his allergies; reminders to the physician to order specific tests or to change medication by a certain date; results of lab tests and other procedures; a record of the patient's vital signs; a copy of the patient's own advance directive, providing instructions on how long to keep him on life-support equipment; and a list of appointments the patient has with physicians and other providers anywhere in the VA system. Prescriptions are entered in the computer system, where they're automatically checked against the drugs a patient is already taking. If the new medicine conflicts with an existing drug, the system immediately notifies the doctor, to avoid medical errors.
With the click of a mouse, a doctor can call up multiple graphs, showing trends in temperature, heart rate, and other vital signs over the past several months. Electrocardiograms, X-ray films and video segments of magnetic resonance images (MRI) can all be displayed on the screen with unusually high resolution. The doctor can zoom in and enlarge sections of X-rays and MRIs to probe details.
The records, updated instantly, are available to any physician in the VA system at 157 hospitals and 876 outpatient clinics. In VA facilities, patients are issued wrist bracelets containing bar codes, and nurses making rounds use scanning devices mounted on special supply carts to make sure medicines and intravenous fluids, which also are bar-coded, are the right ones for a particular patient. (A VA nurse suggested the idea after seeing how car-rental companies use similar devices to speed checkouts when customers return their vehicles, and the agency followed up on it.)
What's more, the VA has developed a pilot program, known as MyHealth-eVet, that enables patients to log onto a special Web site and call up their own medical records, test results, X-ray and MRI images, and prescriptions and print them out on their home computers if they wish. They can also enter data when they take their own temperature or blood pressure at home or write in new symptoms when they start to feel badly. The entries become part of the patient's record. Dr. Ross Fletcher, chief of staff at the Washington, D.C., VA medical center, who is overseeing the project, says he hopes the program will go nationwide this year.
Dr. Fletcher says having all records and prescriptions in electronic form eliminates the delays, handwriting problems, and vulnerability to loss that often come with paper records. Records of some 62,000 VA patients in New Orleans were saved intact after hurricane Katrina last year, even though the city was heavily damaged, because the files were preserved on the VA's electronic system.
Except for billing and insurance operations, the medical community in the United States has been slow to take advantage of computerization. Relatively few hospitals and clinics have fully computerized their medical records, and even those often lag behind the VA. Harvard's Dr. Jha, who also practices at Brigham and Women's Hospital in Boston, which is known for its sophisticated computer record-keeping system, says the VA's version is substantially more comprehensive and sophisticated that that of Brigham and Women's. "It's ahead of the rest of the country,'' he says.
"It has dramatically propelled the VA system into the forefront of modern care-giving,'' says Dr. Rick Erdtmann, director of the board on military and veterans' health of the U.S. Institute of Medicine, an arm of the private National Academy of Sciences set up to provide advice and information on health care.
But computerization, like the other elements in the Kizer plan, is only part of the story. The JCAHO's Dr. O'Leary says much of the success of the VA's transformation stems from Dr. Kizer's own effectiveness as a manager. "If there's one single determinant, it's that leadership sets the culture of an organization,'' Dr. O'Leary says. "Ken had to generate enthusiasm, and I would give him more credit for that than for what he mandated.''
Dr. Kizer left the VA in 1999 after becoming frustrated with Washington politics and Congress-he just took a job as CEO of Medsphere Systems Corporation, a commercial provider of information technology for the medical industry-but analysts say his successors have managed to maintain everything he put into place. Dr. Perlin, who worked under Dr. Kizer before himself becoming undersecretary in February 2005, says he's committed to keeping the VA ahead of the game.
The VA still has more to do, Dr. Berwick and other health-care monitors say. While the agency has been able to sustain its recruiting efforts and maintain high morale, that may prove more difficult as the years go by. And the VA has only recently persuaded the Defense Department to work on an interoperable record-keeping system that will allow the two departments to transfer the records of discharged military personnel to VA care seamlessly.
Although the VA insists it isn't yet starved for funds, veterans say its budget hasn't kept pace with the growing number of potential customers. The department still needs more money to expand its coverage to include almost two million veterans who are technically eligible for care but aren't getting it because the VA doesn't have the budget to treat them. In 2004, the agency stopped taking new patients who don't have service-connected disabilities and whose income exceeds a specified limit in their part of the country. With budgets tight as a result of tax reductions and increased spending elsewhere, the prospects for a big funding increase aren't bright.
Whether the VA can serve as a model for private-sector hospitals and outpatient facilities is still under debate. Some analysts say the fact that the VA is so large-with more than 1,300 medical-care facilities (hospitals, outpatient clinics, nursing homes, and rehabilitation treatment centers) under a single management-gives it the management power and economies of scale for such a transformation that most hospital chains and even giant health maintenance organizations can't muster. "The private groups just don't have that kind of leverage,'' the JCAHO's Dr. O'Leary says.
Challenges
The system also is facing some major challenges in the next several years in the form of swelling caseloads, both from returning veterans of the conflicts in Iraq and Afghanistan and from the graying of its current patient complement. Some 40% of the VA's patients are now over 65, compared to 13% of the general U.S. population. "That raises all kinds of different issues,'' Secretary Nicholson says, "not the least of which is how to provide more long-term care.''
At the same time, there is much that smaller groups can copy, from the patient-safety program to increased computerization. All of the software the VA developed is in the public domain.
"People often have the mistaken impression that the government is all screwed up and the private sector has it right,'' Dr. Kizer says. "The reality is that no one has it perfect. Many problems you see in the military or VA are the same health-care problems you see everywhere.''
Dr. Berwick especially worries that the economics of the health-care system may work to the VA's disadvantage in the future. "In most arenas, if you get better you can attract more revenue and reinvest in things, but because of the way the VA is structured, when it does get better Congress cuts its budget. If you led the VA, would you say, do I want to be so good that Congress cuts more money?''
In the meantime, the VA is enjoying a raft of plaudits from its peers in medicine and growing applause from the patients it serves. "There's been a sea-change in the VA,'' says George J. Guertin, a veteran who heads the American Legion's service bureau in the Boston area.
Mr. Pine, a former naval officer and a veteran reporter, covered military affairs for the Los Angeles Times and also reported for the Baltimore Sun, the Washington Post, and the Wall Street Journal. He is a free-lance writer living in Chevy Chase, Maryland.