The Veteran’s Health Administration: Politico Scores Obama’s “Promises Kept” Record

The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics, hospitals, medical centers and long-term healthcare facilities (i.e., nursing homes). The VHA division has more employees than all other elements of the VA combined. Veteran patients routinely rank their system above the alternatives, according to the American Customer Satisfaction Index. In fact, a RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality; Patients from the VHA scored significantly higher for adjusted overall quality, chronic disease care, and preventive care. To be clear, despite the fact the VHA is a government-run enterprise, it kicks butt according to its patients –just about everywhere except in acute care and the waits required to get it.

Then candidate Obama put the Veteran’s Health Administration (VHA) into the national spotlight during his 2008 election run. In short, Obama said he would make the U.S. Department of Veterans Affairs a leader in national health reform. Did Obama keep his promises? Here is yet another one of those instances where Obama might have chosen to blame Bush, but he didn’t and won’t. Because ironically, the facts demonstrate that Obama has been a responsible steward to a virtually identical set of quality improvement initiatives started under the previous administration. Thankfully, both presidents saw it the same way. They simply wouldn’t tolerate a second-class system of care for our veterans. And apparently, they each have had the pleasure of working with some pretty good genes.

Back in 2008, Obama re-stated three fronts where his administration would keep the pedal to the metal and continue to force major improvements so that the VA could meet his definition of “national leader in health reform”:

  • Improve electronic records interoperability;
  • Expand comparative effectiveness research;
  • Instill more accountability for performance and quality improvement initiatives.

President Obama has not only kept the hammer down, but the scope and trajectories of these initiatives have been refined under his administration to accommodate the latest technologies and current thinking.

Electronic Records Interoperability: Presidents Bush and Obama each discussed the need for an electronic network between Veterans Affairs and the military. This would allow former service members to request health care benefits with greater ease because their medical files — showing qualifying disabilities incurred on duty– would be immediately accessible to physicians and nurses outside the military. Instead, under President Obama what we have today is a comprehensive electronic health network at the Veterans Health Administration and a growing number of electronic pilot projects at the Veterans Benefits Administration. Plans are in place to install electronic records systems across the benefits administration by the end of 2013; also, military department heads have agreed to launch a unified veterans-military electronic health records system by 2017. Full interoperability remains problematic due to the military’s archaic record keeping system, but Obama is keeping the pressure on and arguably, doing what is necessary (i.e. funding the correct projects) to reach the goal line.

Comparative Effectiveness Research (CER): Two of the biggest domestic policy laws signed by Obama in his first two years — the American Recovery and Reinvestment Act and the Affordable Care Act — both encouraged comparative effectiveness research. The economic stimulus created a new council to coordinate and guide comparative effectiveness research across federal departments (including Veterans Affairs). Politico confirmed that the VA’s  annual budgets for comparative effectiveness research  have continued to grow under Obama. Its Health Research Services Arm received $76 million in President George W. Bush’s final budget, whereas it received $88 million, $94 million and an estimated $98 million in Obama’s first three budgets.

Accountability for performance and quality improvement initiatives: This is a tough one to call. Politico couldn’t pin point an improvement outside of the positive differences a focus on CER is starting to have, but one exception was noted: the early push by the White House for more transparency across the federal government, including a default position of openness on Freedom of Information Act requests has been recognized as a step in the right direction. Yes, for those of you who regard our current administration as remarkably opaque, Paul Sullivan, a spokesman for the advocacy group Veterans for Common Sense, said the VA’s record under Obama is a huge improvement over the Bush era.  To be clear, grading both the levels and qualities of transparency over the last 12 years still requires reading between the lines –not a phrase you would logically associate with “transparency.” But by most all accounts, Obama gets a better grade than his predecessor.

So has the VHA become a leader in national health reform under Obama? I think it depends on your semantics. In the most literal sense, “a leader in national health reform” is quite possible, but if I have a need for acute medical care, I’m not interested in the organization’s reform status. Critics would quickly and correctly point to the rate of unanswered claims (benefits claims not acted on within 125 days of filing) that have nearly doubled under Obama. Long wait times and a growing demand for disability services, including mental health care, have also drawn frequent news coverage in the past few years, but then again, so has the rate of reported health problems that are naturally occurring in an aging vet population, compounded by two recent and ongoing wars. Contrast that criticism with academic journals citing all the positive strides made over the last few years in HIT and CER and you get an answer that likely mirrors your partisan ID. Of course, there have been other improvements, most notably a streamlined budgeting process –that’s right, a budgeting process—that has all but eliminated delays to medical services based on budgeting politics, but with long waits for care based on other systemic reasons, no one has had the nerve to take credit for that, nor should they.

I have a half baked suggestion: Our non-profit juggernauts should be enlisted, if not compelled to collaborate with the VHA more closely and meaningfully to support its efforts to improve its acute care capabilities –and wait times. Make it a part of the “fair exchange” formula that defines their preferential tax status. This might help ensure that improvements in the administration of acute care aren’t just incremental to its specific eco-system, but reflective of the best available practices in the broader market. It should also eliminate the unanswered claims problem, which appears to be less a processing issue and more of a demand management problem. With 30 million newly insured entering the system (or leaving the system, based on your perspective), and the wars in the Middle East winding down, the timing seems appropriate.

Source: Politico

—Tom Finn

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