JGIM Editorial Discusses Lessons Learned from VA's History of Transformation and Potential Future Scenarios
In the 1970s and 80s, the VA healthcare system was widely viewed as an inefficient safety net provider for Veterans at best. Its turnaround in the 1990s was one of the most dramatic in healthcare history, and included the restructuring of the VA healthcare system into VISNs, which embraced decentralized decision-making but still held individual VISNs accountable for success through measures of quality and efficiency. In this same issue of JGIM, an article by O'Hanlon, et al presents an updated view of the evidence on VA's quality of care and a strong scientific case to support their main conclusion: After the transformation in the 90s, VA had quality and safety measures that were as good, or better, than the private sector – and even top-rated healthcare organizations. However, does the controversy over wait times demonstrate that VA has reverted to its old ways? If so, how can the VA healthcare system find its way back?
While the demand for services increased as thousands of Veterans from the conflicts in Iraq and Afghanistan sought VA care, the waitlists for that care grew increasingly longer, which prompted a new intensified performance measure for wait times that sought to minimize the proportion of patients who had to wait longer than two weeks for an appointment. Faced with a performance measure that many felt was unreasonable and unattainable, some in the field began to cheat – and the Phoenix scandal followed. So why did Veterans encounter such long waits that led to cheating about access to care? In researching the literature for this Editorial, Dr. Hayward found that the real question should be: Why do we think that the access problem is due to the VA system, rather than a dramatic increase in demand for services during a time when VA had an inflation-adjusted decrease in its per capita funding? Between 2007 and 2014, VA increased outpatient visit availability by more than 25% per capita despite a substantial reduction in its inflation-adjusted budget per capita.
The recent Commission on Care Report offers an excellent starting point for thinking about VA's future, but policy leaders and the public will face difficult choices in trying to find the best way to provide Veterans with high-quality care at a price for which there is adequate political will. Moreover, offering better access to care will likely involve contracting with private sector providers, which will require careful thought, competent implementation, local flexibility in making decisions, and periodic refinements. A return to VA's earlier lessons of the value of decentralized decision-making, tight accountability for quality and efficiency, and respect for two-way communication between the field and central management might result in a systematic review of VA 5 to 10 years from now that reaches the same conclusions as O'Hanlon, et al, but includes success in both quality and access.
Dr. Hayward is part of HSR&D's Center for Clinical Management Research (CCMR), Ann Arbor, MI.
Hayward R. Lessons from the Rise – and Fall? – of VA Healthcare. Editorial, Journal of General Internal Medicine. January 2017;32(1):11-13.