The Right Coast

Editor: Thomas A. Smith
University of San Diego
School of Law

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Thursday, March 8, 2007

Let's privatize care for veterans
Tom Smith

Here's what we should do:  Give veterans enough benefits so they can afford to get the care they deserve from private sources.  You could do this with medical vouchers.  It would be cheaper than supporting the inefficient and notorious VA hospital system, and it would result in better care for people who really deserve much better care than they are getting.  The line I used to hear from LWJ when she rotated through VA hospitals in her training was, it's a good thing veterans are so tough, because VA care would kill anybody else.  That ain't right. 

And just in case we have to revisit HillaryCare in the future, we should remember this little lesson in what kind of medical care we can expect from the guvment.

THIS from today's SD Union-Trib on VA hospital system snafus.

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Tom Smith


There's a lot of confusion on this but recall first that the big controversy isn't over a VA hospital but an army hospital (it's a serpate system), that much of the "care" at Walter Reed had been contracted out (didn't seem to do much good) and that the VA system under the Clinton administration had a higher satisfaciton rate then any private health system did. So, it's not so clear to me that what you call for is really justified from the facts.

Posted by: Matt | Mar 8, 2007 5:49:50 PM

Matt, use VA hospitals much? I did. Once. Well, twice, really. The first time and the last time was the same time.

Various people have been trying to shape up the VA system for more than 25 years. Iron triangles of some VA users and their families, VA hospital employees, and Congressional sub-committees have stopped it most of the time.

No one who has another real choice uses VA hospitals to my knowledge. Generally, I would expect current military health facilities to be better than VA facilities, not worse. At least the difference between the USAF hospital I spent time in was waaaaaaaay better than the VA facility I was allowed (I couldn't go to the nearest one, I had to go to the one closest to my 'official' address) to use.

The point is bureaucratic control of health care. Check out what's happening in the UK right now. Hospitals are refusing elective surgery for otherwise qualified patients *even though they have available operating rooms and surgical staff* in an effort to balance their budget prior to April 2007 to protect the political career of the current Minister of Health. Figures.

Posted by: JorgXMcKie | Mar 8, 2007 6:18:36 PM

I'm not sure how much first hand experience anyone has with the VA, but i have been going to them for the last three years to have a non service related heart problem treated. I have nothing but good things to say about the service and care i receive from them,

I was treated by them about 25 years ago for a different ailment and the turnaround and attention to customer service is amazing.

For example:

Appointments are kept with as little as a 20 minute wait time.

I did a return visit to the cardiology department for a potential problem following a catherization treatment and was actually seen by the head of cardiology within 10 minutes.

My primary care physician actually listens when he sees me and adjusts treatment accordingly but has also been known to followup with phone calls to my home.

I have a neighbor (purple heart- Nam) a born complainer if there ever was one who recently went to the VA at my urging was diagnosed with cancer and can not believe the level of care and caring he has received.

Now granted i am getting up in years (55) but i am wondering if what i read in the press or on blogs is more real than what i have seen with my own eyes, verified by my neighbors own experiences.

Posted by: BT | Mar 8, 2007 6:42:05 PM

Tom, we are in agreement. Public health care systems are a bad idea. Public health insurance, however, may not be.

Posted by: USD Law Student | Mar 8, 2007 6:47:54 PM

The plural of anacdote is not data. Here's an article on the VHA from last year ( ):

Bullet points from the article:
• In 2003, the New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be "significantly better."

• The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In 7 out of 7 measures of quality, the VA provided better care.

• The National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.

•In the latest independent survey, 81 percent of VHA hospital patients express satisfaction with the care they receive, compared to 77 percent of Medicare and Medicaid patients.

How did the VHA get so good? You'll have to read the article (but as said above, it was Clinton).

Posted by: Jacob | Mar 8, 2007 6:51:25 PM

VAs are often affiliated with tertiary care teaching hospitals. Residents and faculty from those teaching hospitals often rotate at VAs. In my last faculty position at a teaching hospital associated with a VA hospital, I would often give second opinions on cases, gratis of course, referred from the VA.

I need to look more closely at that study, Jacob, to see how they dealt with this phenomenon. Perhaps the VA is better at the benchmarks set up for the particular study, if you see what I mean. I could imagine setting up different parameters and getting different results.

Posted by: MD | Mar 8, 2007 7:06:50 PM

The VA does well on quality measures because it has made it its mission to do so. And these measures are a very inadequate surrogate for actual quality of care; as the comments above indicate, doing well on such measures is very compatible with poor care. To quote from a va doc (see who made this point accurately:

In the late 1990s, the Veterans Health Administration was publicly chastised because it provided variable-quality (terrible to good), high-cost care. VHA administrators took this to heart and determined to make the VHA into the best healthcare system in America. Did they kick out bad administrators, lazy employees, money-wasting managers? Did they recruit top hospital adminstrators and top-notch physicians? No to both. They looked at current indicators of quality from the Joint Commission for the Accreditation of Healthcare Organizations and made damn sure the VHA would do well on those indicators. Even if the indicators were dumb. Even if they were behind the times. Even if there were more important things to address to improve care. The result is that the VHA has an undeserved reputation as the best healthcare system in the nation.

Posted by: Tom | Mar 8, 2007 7:08:23 PM

I'm a physician who trained at three different VA hospitals, three different universities and two public hospitals. I now work at a private university hospital that doesn't have an affiliated VAH.

There's no question that you can get good health care at a VAH. My experience (and that an anecdote N = 1, certainly not data) is that they're less efficient and less capable of handling stress (lots of admissions, very sick admissions, etc) compared to university and private hospitals. However, when they have quality leadership (and some does exist in the VA system) they can be quite competent.

And I'll say this: compared to the county hospital I worked at for awhile (Cook County Stroger), the VA is way superior in just about every bureaocratic and efficiency measure. That doesn't mean I want our national health care to look like the VA.

The problem with Walter Reed, as I understand it, was that it was scheduled to be closed in the next few years (due to the base realignment issue, the health care was being merged into Bethesda Naval, a newer facility). The Army being what it is, it wasn't going to spend money on maintaining a facility that was slated for demolition -- imagine the war-cries of Democrats who discovered that money was being put into a facility that was being closed. The Army couldn't win on this one.

Posted by: Steve White | Mar 8, 2007 7:15:35 PM

I'm not sure anyone really knows what they want regarding healthcare. I take that back: People seem to want fast, excellent, reliable, undeniable and cheap healthcare. Quite a hat trick.....

Posted by: MD | Mar 8, 2007 7:25:08 PM

TO: All
RE: I Wouldn't Trust the VA.... administer Salk Oral Polio Vaccine.

Years ago, when I was doing my first tour as a young soldier in the 82d Airborne Division, my Mother passed away, screaming in my Father's arms from a massive cerbro-vascular accident. It destroyed him too. He fell into the bottle. So badly that a few months later he was admitted to the local VA facility for liver cirrhosis.

I came back on emergency leave, again, to see him.

When I arrived at the VA facility he looked like he was about to die. I asked him what was wrong and he told me that he had not been fed in several days. I confirmed his report with the nurse on duty. She said it was the VA doctor's orders.

In my honest opinion, they were trying to kill him by starvation! [Oh. He died a 'natural' death.] Like some Baby Doe that was born with a medical condition that the parents didn't want to deal with.

My sister and I got him OUT of the VA hospital and nursed him back to health OURSELVES!

On the other hand, the VA facility in Denver has a very good rep. However, it is co-located with the University of Colorado's primary medical school. If they were fouling up by the numbers, the practioners at the CU facility next door would report all over the world.

So, you'll get some good reports here and there, but the bad reports will be suppressed, until things like what is reported to have happened at Walter Reed come out into the open.



Posted by: Chuck Pelto | Mar 9, 2007 1:48:58 AM


Aside from quality of care issues, which are serious, there is also the family aspect. By giving recuperating soldiers a voucher for care at a non-military hospital the soldiers get to pick and choose where they get treated which also has many additional benefits.

1. The soldier can choose a hospital near his family. I cannot possibly understate the importance of this. Right now I assume quite a few soldiers either only see a few members of their family able to take the time off from work and deal with the financial burden of traveling to the soldier's location. By moving the soldier closer to his/her family this benefits not just the soldier but also the family. Particularly if the soldier is married and has small children.

2. Soldiers without a need for close family attendance could choose a hospital in a location they prefer for their recuperation. I cannot stress how extremely cool this is. I served in the US Marines starting in 1982, but only for a fairly short time, however if anybody told me I could choose to recuperate in Hawaii, Florida, California or Alaska, at my preference, I'd be completely and utterly jazzed out of my mind.

And IMHO nothing makes recovery work better than the patient starting off being really happy.

3. I seriously doubt any such voucher program would cost more than the current active military hospitals + VAH system.

Posted by: ed | Mar 9, 2007 6:17:37 AM

I'm often amused by such debates. For example, people who say the VA can't be good now (or a few years ago before it got the Bush treatment- does anyone not think he'd screw that up too? why would it be the exception?) because they went to it many years before it was improved by Clinton. A powerful bit of reasoning, that. Or people who know, a priori like, that they'd get better health care from 'the market'. Now, one reason people opposed Hilary Clinton's plan (a plan that was much to complex so as to try and not upset insurance companies too much) was that they thought it would give them too little choice in picking doctors. But, the "market" itself worked out, with the rise of HMO's, to give people on average significantly less choice then they would have had under the Clinton plan. Similarly people think that market methods much be better at getting people what they want here, since they are generally pretty good for that, but every survey has indicated that not-for-profit health care plans have massively higher satisfaction rates than do for-profit ones. Markets are wonderful in some areas and bad in others. If you think otherwise you're probably a fanatic. The evidence seems to show pretty strongly that health care is one where they are at best a very limited piece of the puzzle. (Doctors would probably make less money. Sorry Tom.)

Posted by: Matt | Mar 9, 2007 6:25:01 AM

Fantastic idea. Look at the differing quality level cares in the administration of the active duty family member medical vs. dental plans -- the medical plan, TRICARE, is an absolute bureaucratic nightmare. The differences between the three plan levels are incomprehensible to everyone -- the providers, the patients, and, worst of all, the TRICARE staff. They cannot tell you which plan is best for you, how the plans differ, etc. The rules for TRICARE care are terrificly complicated, and one misstep, even an honest one, can lead to an unpleasant surprise bill months or years after the service was provided.

Cf. United Concordia, commonly misnomered as "TRICARE Dental"...completely privatized system. You find a civilian dentist who will take the plan (and has agreed to accept the United Concordia rates), make an appointment, and that's it. No waiting. No difficult reimbursement forms. No lengthy rules and regulations. It is a dream.

Privatize the VA now! Within 10 years, it will be cheaper and within 6 months the quality of care/timeliness will improve.

Posted by: Anon USD student | Mar 10, 2007 11:30:24 AM