Vital Signs: Looking At The VA As A Model

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Vital Signs: Vermont Charts A New Course For Health Care

(Host)   State lawmakers struggling to create an affordable health care system may want to take a closer look at the VA.   The Veterans Administration runs the largest integrated health-care system in the country, actively serving over six million Americans, about 24,000 in Vermont   While the VA spends less per patient, this government-managed health-care program is managing to outperform the private sector on many fronts.  

VPR’s Nina Keck looks at how. 

(sound of laughter and talking)

(Keck)  Most mornings, Herny Vergi – a World War Two veteran from Rutland, has coffee at the local Legion Post.

(Vergi)   "There’s 8 of us that are over 80 years old.   Eight of us that sit here over 80  . . . (And I’m not one of em!")     "He looks older then us, but he’s not. .  . (laughs.)." 

(Keck)   The men are all veterans and most get their health care through the VA – either at the hospital in White River Junction or at the VA’s primary care clinic in Rutland.

(Verdi)    "This Dr. Lees in Rutland – he gets you in the chair and he’s got a computer right there and he goes up and down for your medicines and he checks everything and he goes on the computer and you need medicine and boom boom boom – two days later you’ve got it.  It’s fantastic.."

(Keck)    Verdi’s opinion is not unique.   David Van Amburg – managing director of the American Customer Satisfaction Index, which tracks consumer opinions, says in their most recent surveys, the VA consistently outscored the private sector in both inpatient and outpatient services.

(Amburg)   "We’re measuring the quality of the hospital experience –  food bed, nursing care and so on and value – the kinds of costs that that patient incurs at hospitals and how they would rate those costs given the quality of the service – finally they are looking at loyalty – we’re looking at the likelihood to use that hospital again."

(Keck)   Phillip Longman is a journalist who’s written extensively on the VA hospital system.   He says twenty years ago, many people shuddered at the thought of getting medical care there.    But he says that’s changed.

(Longman)   "I think part of why the VA had this tremendous transformation is it was a revolution from below.  It was back in the really bad old days when the central office of the VA was really dysfunctional.  You had ordinary people taking it upon themselves to improve their own working conditions and thereby improve the conditions of their patients."

(Keck)  Longman’s book, "Best Care Anywhere – Why VA Healthcare is Better Than Yours," tells how doctors, pharmacists and others who worked at the VA in the 1970s and 80s tinkered with early computers to better track patient information.   They created bulky, experimental systems that Longman says eventually evolved into the country’s first fully integrated electronic medical records.

(Longman)   "One of the key ways to understand why the VA is so far ahead and why it’ll stay so far ahead is this software was written for doctors by doctors in completely open source code.   So as doctors can see ways to improve the system can do so continuously evolving the product."

(Zullo)  "It’s fantastic, once you learn it and you know how to use it it’s the greatest thing since sliced bread."

(Keck)  Physical Therapist Jason Zullo heads rehabilitative services at the VA in White River Junction.   While many hospitals in Vermont are just beginning to use electronic records, the VA’s system has been up running for over 15 years – nationwide.    Zullo says that’s created a continuity of care that simply doesn’t exist in the private sector.

(Zullo)   "I came from an acute rehab hospital in Lexington Kentucky.    And when we received a patient from a variety of sources – other than paper notes that were jotted down or some verbal report that you were fortunate to get some pieces on.   You were on your own to meet and greet the patient, assess and you were kind of starting from square one each time."

(Keck)  Zullo says with VA patients, there’s a highly detailed road map to follow.

(Zullo)   "So when we have a patient who receives care in Florida during the winter and then comes back to Vermont in the summer – we can access their records – see what happened – what was going well, or not well."

(Keck)    Dr. Lanier Summerall is chief of mental health and behavioral sciences at the Vermont VA.    She says the electronic health record system was one of the main reasons she chose to work at the government facility.

(sound of typing)

(Summerall)   "As you can see, multiple levels of security with type type typing to get in.   Passwords to get into the general computer, passwords to get into the medical records."

(Keck)   She can go back in time and look at lab results, tests or drugs that were prescribed 10 or sometimes even 20 years ago.

(Summerall)  "The capacity to have a delirious or otherwise mentally status impaired veteran in the ER and be able to figure out what was going on with them when they were in California two days ago is immensely powerful and helpful and obviously changes outcomes."

(Keck)    The computer system also saves money because doctors aren’t calling for tests or other procedures that have already been done.

The VA saves even more money by following strict treatment protocols.   Costly, experimental therapies that the VA believes don’t have a proven track record are typically not covered.   It’s a form of rationing that keeps costs down, but detractors say some patients are denied new treatment options that could potentially help them.

(sound of VA hallway)

(Keck) At the VA’s rehabilitation unit in White River Junction, physical therapist Jason Zullo rolls out something else the VA believes will save money and improve care.

(Zullo)    "This is a Tandberg unit – this is the camera and as you can see it’s rather small –  it’s not very large."   (sound of rolling)

(Keck)  The portable video camera about the size of a floor lamp – is one of many the VA is using to provide telemedicine services at their satellite clinics. 

(Zullo)   "The high resolution camera allows us to view things up close and personal so to speak.   So for example, wounds, if you need to see the granular tissue that can be viewed – where most of your run of the mill cameras aren’t that good."

(Keck)  So a patient in the northeast Kingdom with a spinal injury or a diabetic from Bennington worried about foot ulcers can visit one of the outlying VA clinics while a specialist in White River Junction or elsewhere consults from afar.    Zullo says other VAs are experimenting with using the cameras in patient’s homes.   He says it’s something the state of Vermont might want to consider as it looks at ways to trim costs while providing more care.

(Zullo)   "From the private sector how I see this going is it would be wonderful to have these units at the local library, the homeless shelter, churches and fire houses.  Wherever you could find the room."

(Keck) Jason Zullo says the VA’s use of technology is a huge plus.  But even more important, he says, is their ability to care for a patient long term – often for life.   That’s different from the private sector, where people may change insurance companies and doctors frequently.   And unlike regular hospitals and doctors who make their money by treating people who are sick, the VA has an economic incentive to keep people well.   Dr. Lanier Summerall says it’s a lot easier to do that with patients you have a longstanding relationship with.

(Summerall)    "For instance a 22-year-old who might present one time to a physician that he is drinking 6 to 12 beers on the weekend with friends – is not going to attract as much attention as if they’re seeing the same person or health care system who notices that that pattern is now growing to 2 days a week or three days a week."

(Keck)    Still, if you’re going to compare the VA with what the state of Vermont might develop for a health care program you have to keep a few things in mind.    First, the VA doesn’t provide care for everyone.  They don’t treat kids and the vast majority of their patients are men.   

Most VAs don’t have high trauma emergency departments that take all comers at all hours.  VA’s typically piggyback with teaching hospitals, which means they don’t have to hire as many specialists.  And while many veterans use the VA for some of their care, they may also use primary care doctors, specialists and other hospitals outside the VA system as well.  

So a truly accurate cost comparison may be difficult.    Phil Longman acknowledges that while the VA has come a long way it’s still a hulking bureaucracy, micromanaged by Congress and continually worried about funding.   Despite all that, Longman says anyone trying to design a cost effective government managed health care program – ignores what the VA has accomplished at their peril.  

For VPR news, I’m Nina Keck.




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