Article by Under Secretary for Health at the VHA from Federal Practitioner
Physician David Shulkin is now Under Secretary for Health at the VHA. He has just written a compelling explanation of why the Veterans Health Administration is different than private sector health care systems. And he should know. For years, he was a chief executive officer at a number of prominent private sector health care facilities. Dr. Shulkin has just written a concise explanation of the difference between VHA and private sector healthcare for The Federal Practitioner. While this article focuses on the way the VHA serves veterans, it also spotlights the models of integrated care the VHA has developed — models that should be adopted in the wider healthcare system.
I asked his permission to post it here. When someone with Under Secretary Shulkin’s experience with private sector healthcare explains why it can’t replace the VHA, we should listen.
Is VA health care really “all that different” from what veterans would find in the private sector?
As someone who spent more than 25 years managing private sector health care organizations and recently joined VA as its under secretary for health, I’ve had the unique opportunity to compare the health care systems. Over the past several months, I’ve met with veterans and their families, veterans service organizations, VA clinicians, facility staff, and veteran employees at all levels. Through these meetings and travel to dozens of facilities, I’ve come to realize that many of the essential services provided by the VA cannot be found in or even replicated in the private sector.
Over time and in partnership with successive generations of veterans, the VA has evolved into an interconnected, institutionalized system of care and services. And while many of these services aren’t unique to the VA, ours is the only health care organization that combines these services “under one roof” and integrates them in a way that is veteran-centric.
Further, as our country continues to struggle with improving health outcomes and unsustainable increases in health care costs, the VA can play a crucial role. As a long-standing, highly integrated, and patient-focused provider of care, the VA can lead the way in advancing the nation’s health care. This is the appropriate role for government: Do what the private sector cannot or will not do, given the nature of its enterprise.
The VA has 3 core strengths that distinguish its services from those of the private sector in caring for veterans: (1) system wide clinical expertise regarding service-connected conditions and disorders; (2) a team approach to primary care that is veteran-centric; and (3) a holistic view of the veteran that includes physical, psychosocial, and economic determinants of health, as well as critical support services for family members and caregivers.
First, the VA brings together comprehensive expertise on service-connected health issues in a single health care system. Our clinicians are trained to identify, assess, and treat a wide spectrum of health issues, such as spinal cord injury and limb loss, conditions arising from environmental exposures, and traumatic brain injury. Additionally, VA specialists have expertise in the treatment of mental health issues, substance abuse, suicide prevention, and post traumatic stress disorder (PTSD). Further, the VA has a long track record that includes national programs in audiology and speech pathology, blind rehabilitation, chiropractic care, physical medicine and rehabilitation, prosthetic and sensory aids services, recreation therapy, and polytrauma care.
In contrast, knowledge of and expertise in these crucially important health care issues are not nearly as widespread in the private sector. For example, less than 50% of private practice primary care providers (PCPs) regularly perform screening tests for PTSD and depression.1 In addition, only 15% of community-based mental health providers are proficient in treating military and deployment-related issues such as PTSD, and less than 20% of PCPs have sufficient military culture competence to take a veteran’s military history.1
The VA’s second core strength is its team-based, veteran-centric model of primary care that focuses on patient-driven, proactive, and personalized care. This patient aligned care team (PACT) addresses not only disease management, but also disease prevention, wellness, and health promotion. The PACT model often includes PCPs, nurse care managers, social workers, pharmacists, nutritionists, behavioral health professionals, administrative clerks, as well as the veteran, family members, and caregivers. Through PACT, veterans can attend group clinics and educational seminars, access web-based information via a personalized patient portal, and directly communicate with their care team by phone, secure messaging, or telehealth. The PACT approach has proven effective: Several studies examined its impact on reducing avoidable hospitalizations, emergency department visits, and behavioral health issues and on improving communication among health care professionals.2-4
The VA’s third core strength—a holistic approach to patient care— also is not uniformly seen in the private sector. All too often the private sector health care system addresses only the patient’s chief complaint, focusing on the physical manifestation of an illness or the patient’s psychological condition. Ensuring a patient’s well-being requires the integration of the physical, psychological, social, and economic aspects of health and a thorough understanding of how these factors impact treatment compliance. As any health care professional knows, even the best treatment plan cannot succeed without patient compliance. In this regard, the ability to address nonmedical issues is as important as the treatment plan.
By taking a holistic view of health and inviting veterans to do the same, the VA addresses these and other compliance issues head-on. The VA is positioned to provide help, as appropriate, with transportation; caregiver support; homelessness; pharmaceutical benefits; clothing allowances; counseling in readjustment centers; and a full range of physical, psychological, dental, and social services.
As someone who has spent considerable time in the private sector, I can report that delivery of such services is the exception, not the rule, especially given the current system of health care reimbursement. The benefit of a holistic view is underscored by numerous outcome studies showing that the VA performs as well as, if not better than, the private sector. For example, screening and prevention outcomes at the VA have been consistently better than those at community care sites.5
Studies also suggest that standard care measures, such as control of blood pressure and hemoglobin A1c levels, are often better in VA patients compared with non-VA patients. Studies of risk-adjusted mortality rates generally found improved outcomes for VA care or little difference between VA and non-VA care.6-9 Moreover, a recent independent assessment of the VA reported that the VA performed as well as, and in some cases better than, the private sector on a number of key indicators.10
In my first year as the VA under secretary for health, I have come to appreciate these strengths even more and to sharpen my understanding of what makes VA care different from private sector care. Five distinctions are clear:
1. Veteran Patients Are Inherently Different
The VA manages a patient mix that is distinct from what civilian community providers typically treat. The majority of veterans who utilize VA health care are collectively sicker and poorer and have fewer support services than age-matched non-veteran patients.10,11 When compared with the general population, veterans are more likely to have as many as 3 additional comorbid physical conditions as well as a possible mental health diagnosis.
Similarly, the VA also cares for a higher percentage of minorities who, as a group, too often encounter barriers to care in community settings. Given these disproportionately higher numbers of patients facing access issues, the VA has done better than the private sector in reducing barriers to care for many health measures.12 For many veterans, the VA has become a lifeline of health care support and service.
2. Reimbursement and Incentives
The veteran patient population typically requires more time during a typical doctor visit than private sector physicians generally can provide. Ever-changing reimbursement schedules have forced many private sector PCPs to shorten patient visits in order to survive economically. Because VA physicians are salaried, they don’t face the same constraints on time spent with patients. Further, there is less of a mismatch between financial performance and clinical performance and, therefore, less likelihood of inappropriate tests and services.
3. VA Employees’ Sense of Mission
Almost 95% of VA staff believe the work they do is important.13 In annual employee surveys, the VA sees a high commitment to service from its employees. Additionally, 40% of VA staff are veterans, who can relate to veteran patients in ways nonveterans cannot. As under secretary for health, it has been a remarkable experience seeing this sense of mission translated into everyday care and observing the very personal connection between VA employees and patients.
This sense of mission, embedded throughout the organization, has a far-reaching impact that includes the relationships formed with veterans. In stark contrast to the private sector, where patients may receive care from multiple sources and switch providers and insurance companies with increasing frequency, veterans tend to forge lifelong relationships with the VA. In turn, this stable and consistent relationship strengthens doctor-patient communications and provides a solid foundation for shared decision making. These long-term relationships also may improve the continuity of care and the ability to track long-term outcomes.
4. VA’s Unique Integration of Clinical Practice With Education & Research
As someone whose residency included training at VA, I’ve long appreciated the VA’s ability to advance health care, incorporate new learning, and promote best practices. These capabilities are fortified by its 70-year partnership with academic affiliates. Through academic partnerships, the VA trains tens of thousands of health care professionals yearly and conducts cutting-edge research on all the service-connected issues described above, as well as chronic illness, disparities in care, and emerging areas such as personalized medicine.
The VA Research and Development Program is the nation’s only intramural research program entirely dedicated to the health of veterans. Further, more than 60% of VA researchers are clinicians, which means their studies are framed by daily interaction with patients, and their study findings are put into practice more quickly.
5. VA Investment in Large-Scale Capabilities
As the largest integrated health care system in the U.S., the VA can invest in capabilities that are difficult for smaller systems to undertake. For example, the VA electronic medical record platform has enabled the organization to capture veteran health data systemwide for more than 2 decades, longer than almost any other health care enterprise in the country. Additionally, the ability of the VA to house and analyze “big data” is more advanced than that of most other health care systems, in part because of its considerably larger scale. This capability supports the holistic approach to care noted above and makes it possible to consider the numerous social and economic determinants of health and to track outcomes over time. This capability also supports the VA Million Veteran Program (MVP), a research effort that is building a genomic database of 1 million users of VA health care. Through the MVP, researchers will be able to use genomic and clinical data to develop personalized therapies for veterans and address some of America’s most significant research questions.14
As we continue to transform the VA and improve veterans’ health care, it is essential to understand that VA care is different from private sector care. It also is essential to understand—particularly given an environment of intense public scrutiny—that this fundamental distinction is embedded in the VA mission “to care for those who have borne the battle for their country.”
At the same time, it also is crucial to recognize that, although VA care is distinctly different from private sector care, our ongoing transformation means closer collaboration with the private sector—that is, for veterans seeking care from community providers. In this regard, we are working to achieve a tighter integration of the care offered to veterans in both sectors by working to develop a high-performance network that includes care from both VA and the private sector.15
Finally, in the midst of such a transformation, it is imperative to underscore that one factor will remain the same: our long-standing and unwavering commitment to provide patient-centric care and value to every veteran. As the under secretary for health, it is my great privilege to see this commitment daily and to better position the VA to serve our veterans and the nation.