Correspondence
Quality of Care in the Veterans Health Administration
N Engl J Med 2001; 344:1168-1170April 12, 2001
- Article
To the Editor:
I am writing in response to the article by Petersen et al. (Dec. 28 issue)1 on the Veterans Health Administration (VHA). For the sake of VHA patients, I hope the VHA system does measure up. But the very idea of continuing the system in today's world is like that of trying to preserve a dinosaur. Why not cover all veterans with either federal medical insurance or Medicare, without copayments or deductibles, and provide a low-cost drug benefit as well? The gains in quality — such as paperless medical records, systemic audits, better accountability, improved immunizations, cancer screening, and counseling for abuse of tobacco and alcohol — could all be incorporated into the current system, without the need to maintain an expensive, separate bureaucracy and exclusive facilities. Many veterans choose to use private physicians even when they have access to free care in the VHA system because they prefer to be part of our pluralistic society rather than isolated among fellow veterans. Research could continue unimpeded as well. It is difficult objectively to make a case for continuing the VHA system, even if the care does measure up.
1 ReferencesJerry Frankel, M.D.
1441 Redbud Blvd., Suite 261, McKinney, TX 750691
Petersen LA ,Normand S-LT ,Daley J ,McNeil BJ . Outcome of myocardial infarction in Veterans Health Administration patients as compared with Medicare patients. N Engl J Med 2000;343:1934-1941
Full Text | Web of Science | Medline
To the Editor:
In the study by Petersen et al., the population of VHA patients examined should have been compared with Medicare beneficiaries in a staff-model health maintenance organization, since the provider models are similar.
The suggestion that mortality rates directly reflect quality of care is specious at best. There are just too many variables that make up the undefined concept of “quality of care.” For example, since the VHA institutions did not receive patients by paramedical services from the general population, there was a difference in how patients presented to the emergency department, which is the source of the majority of admissions for acute myocardial infarction. Since VHA institutions are invariably teaching hospitals, the initial evaluation and treatment were probably performed by residents rather than by experienced, and usually board-certified, emergency physicians staffing the private hospitals that generated the Medicare data.
In the Medicare cohort, 12,505 of 41,754 patients (30 percent) were excluded. In the VHA cohort, unlike the Medicare cohort, sampling was performed and resulted initially in the exclusion of 8117 of the 13,310 patients (61 percent) and then in the exclusion of 2707 of the remaining 5193 patients (52 percent). Thus, of the initial sample, 81 percent were eliminated from the analysis.
The article demonstrates that similar cohorts in two different health care delivery systems in the United States have similar mortality rates — hardly a revelation and not a finding that shows a relation to “quality of care.”
Stephen C. Acosta, M.D.
Doctors House Calls, Portland, OR 97202-0938Author/Editor Response
The authors reply:
To the Editor: Dr. Acosta suggests that we compare VHA care with care delivered in Medicare staff-model health maintenance organizations. Our goal was not to compare similar systems of care but to highlight the potential consequences to patients of dissimilarities in the organization of health care services. We agree that quality of care is a multidimensional construct. Outcomes1 are only one aspect of such assessments.2 In addition to outcomes, we also reported the results of process-of-care comparisons.
Our sampling method allowed us to draw a national VHA sample, and the exclusions mentioned were for differences in age and sex between the two cohorts. We made these exclusions to reduce the confounding of our findings by differences between the two cohorts in patient characteristics.
Dr. Frankel believes that it is difficult to make a case for continuing the VHA. In response to such suggestions, others have pointed to the four main missions of the Department of Veterans Affairs.3 The first mission is to provide health care to eligible veterans. In an example of the safety-net function of the VHA, it has become the nation's largest single provider of services for homeless people and for those with the acquired immunodeficiency syndrome. Special programs for patients with spinal cord injury, post-traumatic stress disorder, blindness, and other medical conditions exist throughout the system. To meet the many needs of its patients, the VHA provides a broader array of psychiatric, substance-abuse treatment, and social services than is typically seen in private or other federal health insurance programs. The second mission is to conduct education and training programs. More than 60 percent of physicians in the United States have received all or part of their training at VHA medical centers. The third mission is to conduct research that will enhance the provision of health care to veterans. Because of the large size of the VHA, it is uniquely able to mount large-scale, cooperative trials that have significantly affected the care of patients with tuberculosis, hypertension, atherosclerotic disease, diseases of the prostate, and other conditions.4 Studies such as ours, funded in part by the VHA, assess the quality of the health care provided to veterans. The fourth mission is to serve as the primary backup service to the Department of Defense medical care system and to assist with emergency medical care in natural and other disasters. If the VHA ceased to exist, it is not clear how these functions would be replaced in the current health care market, and at what price.
4 ReferencesLaura A. Petersen, M.D., M.P.H.
Houston Veterans Affairs Medical Center, Houston, TX 77030Jennifer Daley, M.D.
Barbara J. McNeil, Ph.D., M.D.
Harvard Medical School, Boston, MA 021151
Donabedian A. Explorations in quality assessment and monitoring. Vol. 1. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press, 1980.
2
Brook RH ,McGlynn EA ,Cleary PD . Measuring quality of care. N Engl J Med 1996;335:966-970
Full Text | Web of Science | Medline3
Kizer KW ,Fonseca ML ,Long LM . The veterans healthcare system: preparing for the twenty-first century. Hosp Health Serv Adm 1997;42:283-298
Medline4
Fisher ES ,Welch HG . The future of the Department of Veterans Affairs health care system. JAMA 1995;273:651-655
CrossRef | Web of Science | Medline
Author/Editor Response
The editorialist replies:
To the Editor: As did the National Academy of Sciences nearly 25 years ago,1 Dr. Frankel advocates the channeling of veterans into the private sector, primarily under the Medicare program. He contends, without substantiation, that veterans would prefer this option.
First and foremost, the health care system of the Department of Veterans Affairs continues to exist because veterans want it. Although successive presidential administrations have attempted to trim or eliminate the VHA, it has actually grown, on account of the vigorously expressed wishes of veterans. Although only 3.4 million of the 9.4 million people who are legally eligible to obtain their care from the VHA elect to do so, those who do are more ill and disabled than persons of the same age in the general U.S. population.2-4 A substantial proportion of VHA enrollees possess other health insurance (including Medicare) yet still choose VHA care.5 Many of these veterans have complicated problems, such as psychiatric disorders or spinal cord injury, for which the VHA is specially organized. Moreover, there is no reason to assume that administrative costs would diminish. As noted in my editorial, available data suggest that the VHA is not less efficient than fee-for-service systems. Many patients and providers view the Health Care Financing Administration, which administers Medicare, as unduly complex, adversarial, inefficient, and fiscally unsound. Furthermore, satisfaction among VHA enrollees compares favorably with that of patients in other systems. Thus, any decision to eliminate the option of VHA care would likely be highly unpopular among those who matter most: the chronically ill veterans who actually use the system.
Dr. Frankel also posits that if veterans were redirected into the private sector, advances in quality could readily be extended. It is worth noting that practically all the developments in the VHA are in the public domain (including the electronic medical record), and other health systems could already have adopted them. (Many have.)
It must also be recognized that the VHA serves other functions of national importance that would not be easily restored in our current environment. Medical schools are critically dependent on the VHA for training at a time when other resources are disappearing. A large percentage of all U.S. physicians received training within the VHA. If curtailed, the Department of Veterans Affairs research program would probably not be replaced, even though its clinical focus is an essential complement to the basic work done in other federal research programs.
From a broader perspective, at a time when everyone seems disenchanted with our health care system, would it truly be sensible to dismantle an effective and popular system?
5 ReferencesStephan D. Fihn, M.D., M.P.H.
Veterans Affairs Puget Sound Health Care System, Seattle, WA 981081
National Academy of Sciences, National Research Council. Study of the health care for American veterans. Washington, D.C.: Government Printing Office, June 7, 1977.
2
Kizer KW . The “new VA“: a national laboratory for health care quality management. Am J Med Qual 1999;14:3-20
CrossRef | Web of Science | Medline3
Kazis LE ,Miller DR ,Clark J , et al. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med 1998;158:626-632
CrossRef | Web of Science | Medline4
Au DH, McDonell MB, Martin D, Fihn SD. Regional variations in health status. Med Care (in press).
5
Assistant Secretary for Planning and Analysis. The changing veteran population: 1990-2020. Washington, D.C.: Office of the Deputy Assistant Secretary for Program and Data Analyses, March 2000.
- Citing Articles (1)
Citing Articles
1
Samy I. McFarlane, Jonathan Castro, Jasjeet Kaur, John J. Shin, Douglas Kelling, Amal Farag, Nicole Simon, Fadi El-Atat, Alan Sacerdote, Emad Basta, John Flack, George Bakris, James R. Sowers. (2005) Control of Blood Pressure and Other Cardiovascular Risk Factors at Different Practice Settings: Outcomes of Care Provided to Diabetic Women Compared to Men. The Journal of Clinical Hypertension 7:2, 73-80
CrossRef
