Doctors say VA care is a model of efficiency

Minneapolis VA
The Minneapolis VA Medical Center.
MPR Photo/Lorna Benson

One argument against a public insurance option in the current debate over health care is that government typically isn't as efficient or proficient as the private sector. But some say that the Department of Veteran Affairs medical care is actually an excellent example of how the government is leading on health care quality and cost.

A third of the nation's 24 million veterans get their health care from the VA. Most qualify because they have an injury or illness that is in some way connected to their military service.

The Minneapolis VA has 80,000 patients who receive care at the hospital and its affiliated clinics. This year, the government is giving the medical center about $500 million to care for those vets. That's a lot of money, but that's also a lot of patients - including some with very traumatic injuries.

High-tech care

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In the Spinal Cord Injury and Disorder Center patient Matt Turpen is trying to customize a computer by reading pre-programmed sentences that are highlighted on his monitor.

"This is where patients who are paralyzed can learn how to operate computers," Dr. Gary Goldish said.

Turpen just arrived at the center. He was hurt in a traffic accident while serving in Germany. He's in a wheelchair and has limited use of his hands, so he needs to learn how to operate the computer by voice.

Matt Turpen
Matt Turpen learns how to customize his computer using his voice at the Minneapolis V.A. Medical Center on Aug. 14, 2009. Turpen was hurt in a traffic accident while serving in Germany and now has limited use of his hands.
MPR Photo/Lorna Benson

"And then you will be able to talk to your computer and see the words appear on the screen," Goldish said.

Some patients in the center have even more debilitating injuries that make it impossible to use their limbs or voice, but Goldish said the VA can still teach them how to use a computer.

"The computer over to the right can actually track their pupil eye movements, and the pupil movement is the mouse," he said. "They can actually search the Internet and type, do email all with their eyes."

A little farther down the hall, patient Scott Kneen flips a switch on his high-tech wheelchair.

Hydraulics in his wheelchair lifts and straightens his body so that Kneen is almost standing. He's been using this position to help heal severe sores on his backside. Goldish said this type of wheelchair has been popular among a number of veterans.

Scott Kneen
Scott Kneen demonstrate the hydraulics on his wheelchair at the Minneapolis VA on Aug. 14, 2009.
MPR Photo/Lorna Benson

"By standing you're no longer putting pressure on your buttocks," Goldish said. "And buttock sores are a real problem for paraplegics and quadriplegics."

Kneen could go to just about any hospital for his care. Besides his VA medical benefits, he also has Medicare and Medicaid insurance.

"You know they're trained to handle stuff like this," Kneen said. "And they're better at wound care and treating it. So no question I would choose the VA."

Operating on a tight budget

The Spinal Cord Injury and Disorder Center just opened in its new space a few months ago.

Legless tables
Legless tables hang from the ceiling at the Veterans Affairs Medical Center in Minneapolis allow patients in wheelchairs to sit at the table without having to worry about running into table legs.
MPR Photo/Lorna Benson

The 65,000 square-foot wing has a therapy pool with a floor that rises up to accommodate wheelchairs, a dining room with legless tables that lower from the ceiling and an outdoor multi-surface track where patients can practice maneuvering their wheelchairs on many different types of terrain. What perhaps is most remarkable about this facility is its cost.

"I was amazed that they could produce that building for $21 million," said Dr. John Drucker, Chief of Staff at the Minneapolis VA.

Drucker said the money to build the center came from a Congressional grant and some local fundraising. The budget was fixed and it was tight, but he said patients and staff still got everything they needed for top-notch care.

"We can stretch our resources in ways that get the job done clinically," he said.

In fact, the VA is used to stretching a buck. It has to deliver all the care that its patients need without exceeding its annual budget set by Congress.

It's a challenge, but Drucker said the VA has figured out a way to do things economically. Like doctors at the Mayo Clinic, most VA doctors receive a salary, so they have no incentive to order unnecessary tests and procedures to make more money. That saves the VA huge sums of money that can be reinvested in necessary care.

Also, the VA has an electronic medical record system that's the envy of many. Drucker said doctors can get detailed information about patients even if they were treated at a VA clinic across the country.

"Staff do not have to transport records," he said. "They don't have to look for them; they're just available on the computer screen in front of the provider who can use that information immediately to make a medical decision about a patient."

The electronic records have allowed them to improve patient quality and eliminate a lot of wasteful spending.

Compared to the average Medicare patient in the private market, the VA spent substantially less on its patients in 2004. That year, Medicare paid an average of $6,800 dollars per patient, while the VA was able to deliver care for approximately $5,000 per patient. That's 35 percent less than Medicare, which is the baseline widely used in measuring the cost of health care.

Measuring for quality care

The VA measures everything it does. Its doctors examine the case records of every person who dies in the medical center to see whether there were quality issues that contributed to death. They also review cases when a patient returns to the hospital with a medical problem within a week of being discharged.

They even measure access to the VA. Doctors must see 95 percent of their patients within 30 days of that patient's initial request for an appointment. Mental health patients must be seen within 14 days; and if it's a crisis, they need to be seen immediately.

Dr. Greg Filice, an infectious disease expert at the VA, said doctors receive regular reports on their success in meeting these goals.

"Sometimes we chafe at it," Filice said. "Another quality measure, another way I've got to account for what I do. And you know people are human. They get tired of this. But most of us understand that that's how we are what we are. That it's important in the long run and we all support it."

In fact, VA doctors have a lot of say in how they do their jobs. Dr. Kristin Nichol oversees research at the medical center. She said good ideas get heard at the VA because everyone is on the same team.

"We can change things here; we're all employees of the VA," Nichol said. "And if we want to re-organize or tweak things or try something differently, we can do that here."

Other hospitals don't usually hire doctors directly. Instead the doctors will often work for their own group practice and get permission from various hospitals to treat patients there as well.

Nichol said VA doctors are personally invested in the success of their medical center and she gets emotional when she describes the duty they feel to give veterans the best care possible.

"We feel a great sense of mission to our veterans, and that's a wonderful thing," she said. "I think people in other health care systems may not have that opportunity to really understand who they are responsible for. We know; we see them every day."

A noble mission

Some of the other VA doctors call their work a noble mission.

Dr. Greg Filice said it's actually how all of America's citizens should be treated by the health care system.

He admits that the VA is not perfect, but said its care is very, very good. With all of the debate swirling in Congress about the merits of a public health insurance option, he wants Americans to know that there are some things that the government does well.

"I think that the VA experience shows that it's possible for government to be a good player; an accountable player in that mix," Felice said.

Felice said the VA is a model that lawmakers should consider emulating as they try to overhaul the nation's health care system.