During a period of growing Republican criticism and eagerness for major changes at the Department of Veterans Affairs, officials there might find some solace in two recent independent reviews of an agency that dishonored itself.
A Harvard Business School case study, published in November and updated this month, concludes that the team assembled by VA Secretary Robert A. McDonald has “made impressive progress over the past year.” In July, a literature review in the Journal of General Internal Medicine found “the VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care.”
Neither article is a blanket endorsement of VA health care, which remains tainted by the scandal that erupted in 2014 over the covering up of long patient wait times. Neither article deals with the many cases of management retaliation against VA whistleblowers, who exposed much of the wrongdoing. Yet each shows the nation’s largest integrated health-care system performs far better than Republican rhetoric indicates. Just in the past few days, GOP Sens. Ron Johnson (Wis.) and Charles E. Grassley (Iowa), called for new agency leadership as they told President-elect Donald Trump “it is clear that not all veterans are receiving the high-quality care they deserve.”
Former House speaker Newt Gingrich used spiteful language when he asked whether federal employees “who kill veterans should stay in their jobs.”
McDonald, appointed by President Obama after the scandal led to the resignation of Eric Shinseki as VA secretary, has made significant changes. Trump, nonetheless, acted as if nothing had been done as he made shaking up the department a pillar of his presidential campaign.
“Our most basic commitment — to provide health and medical care to those who fought for us — has been violated completely,” he said at the Veterans of Foreign Wars national convention in July. “The VA scandals that have occurred are widespread and inexcusable.”
In September, he told the American Legion a “total reform of the Veterans Administration” is required. (Note to Trump: VA has been the Department of Veterans Affairs since it became a Cabinet-level agency in 1989.)
Trump didn’t get the department’s name right, but he’s correct about the scandals having been widespread and inexcusable. I’d add disgraceful. But Trump and those who continue to attack VA might not be aware of the ongoing reforms under Obama and McDonald, or perhaps the critics choose to ignore that side of the story.
The Journal of General Internal Medicine review, prepared by a team of researchers from the Rand Corp., a non-partisan think tank, identified 69 articles that examined one or more Institute of Medicine quality indicators that apply to VA health care. Among the findings:
- Safety: 22 of 34 articles found VA generally performed as well as or better than other systems
- Mortality: “VA facilities generally performed comparably or favorably relative to other settings.”
- Morbidity: VA had mixed results compared with non-VA facilities.
- Complications: “Surgical complication rates were similar among VA patients and non-veterans.”
- Effectiveness: 17 of 24 studies “showed better performance in VA facilities.”
- Outpatient care: “was generally strong in VA facilities. … VA patients also received more effective care than non-veterans based on 10 of 11 quality measures in the first study year and all 12 quality measures in the second study year assessing diabetes, cardiovascular, and cancer screening care.”
- Non-ambulatory care: VA and non-VA care were “generally of similar quality.”
- Medication management: “Elderly VA patients were less likely to receive inappropriate medication than were patients in Medicare HMOs.”
- Availability of services: “VA centers were less likely to offer extensive reproductive services but more likely to offer mental health care” than 13 Department of Health and Human Services Centers of Excellence. “VA patients and Medicare/Medicaid-insured patients were less likely to receive kidney transplants than were patients with private insurance.”
The Harvard article begins by noting that 14 of the department’s 17 top leaders were eventually replaced after the scandal. The transgressions have totally overshadowed a number of points that McDonald has tried to emphasize, with limited success. According to Harvard, VA:
- provided some training to 70 percent of U.S. doctors, “making VA a pillar of the nation’s health care system.”
- researchers have earned three Nobel Prizes in medicine.
- did the first successful liver transplant.
- developed the nicotine patch and the cardiac pacemaker.
Despite steadily growing budgets, the report said, VA funding has been “outstripped by the growing veteran population, mounting costs, and increasing complexity of care.” The report’s authors are Professors Ryan W. Buell and Robert S. Huckman and independent researcher Sam Travers.
After McDonald’s team took over, they “uncovered a department in disarray,” Harvard reported. “For example, roughly 500,000 veterans were waiting for appointments system-wide, but there weren’t systems in place to identify how many of those veterans needed to be seen urgently and how many required routine care.”
McDonald dubbed his set of reforms “MyVa.” One of its “most significant new programs was the Diffusion of Excellence Initiative, which solicited innovative health care practices from VA employees across the enterprise and helped spread these practices to other VA facilities,” the Harvard article said.
VA101 and Leaders Developing Leaders are training programs designed, Harvard said, “to help transform VA’s culture.”
Progress has been made, but that generates other issues.
As service improved, wait times for patients increased. The reason: Better service attracted more patients. “In some ways,” according to Harvard, “making service better was making service worse.”
If VA must have a service problem, that’s the one to have.