It’s one of the largest integrated health care systems in the United States. It takes care of over nine million patients in 170 hospitals within nearly every state. Its patients are on average, older, sicker, and more disadvantaged than the rest of the American population. If you had to guess which hospital system I’m describing, would you think HCA? Sutter? Kaiser? Nope, it’s the Veteran Health Administration, or as it’s more commonly known, the V.H.A.
Unfortunately, the public perception of the V.H.A. has soured over the past decade. Our political leaders have denigrated the establishment with John Boehner stating that V.H.A. hospitals “provide substandard care” and, “if you’re a real doctor, you’re probably not working at the V.H.A.” This is striking when considering that the V.H.A has, in many cases, historically outperformed commercially managed hospital systems. The sentiment against the V.H.A has led many politicians to consider privatizing V.H.A services, mainly arguing that doing so would lead to greater market competition and improvements in the quality of its medical services. Well, I’m here to tell you that we may be misguided in these assumptions. Unlike most hospitals in the country, the V.H.A. wasn’t built to satisfy insurance corporations, extract the highest profit margins, or provide the highest returns for investors. Rather, the sole purpose of the V.H.A. is to help veterans, full stop. This notion has systematically transformed the V.H.A. into a one-of-a-kind organization that treats the ills that most affect our veterans: substance abuse, homelessness, and chronic medical conditions. Remarkably, it provides these services through a unique single-payer model. In turn, as our country continues its slow trek towards a more universal form of health care, the V.H.A has much to teach us about the power of a centralized single-payer system to integrate EHRs, treat chronic medical conditions, and react to public health emergencies.
I was introduced to the V.H.A as a first-year resident in Baltimore. As a novice to the V.H.A. model of care, I was pleasantly surprised by the internal consistency of the system. Many patients came to our hospital from V.H.A-associated long-term care facilities or nursing homes. These facilities ran on the same electronic platform as our hospital. This meant that any documented care they received at their nursing homes, rehab facilities, outpatient clinics, or other V.H.A hospitals was easily accessed through an all-in-one electronic health record. Even information on a patient’s social situation (i.e., homelessness, food stamps, legal proceedings, monthly income, etc.) was readily available. I didn’t have to hunt down outside records, call family, or spend valuable time trying to extract information from a patient who may be altered. This is the holy grail for private EHRs, like Epic or Cerner, who are struggling to emulate the V.H.A’s level of integration. In turn, it should come as no surprise that many of our country’s most important population-based public health studies have come from data collected through the V.H.A’s EMR.
The internal consistency of the V.H.A’s health system allows providers to coordinate medical care and improve medical adherence rates. For example, let’s say a veteran who receives housing through the V.H.A comes into the hospital and is diagnosed with COPD. As a provider, I can have the hospital case manager and social worker coordinate with an outpatient housing team to quickly set up a home oxygen supply, transportation services, home nursing, meals on wheels, and assistive devices (home hospital beds, commodes, etc.). Additionally, providers can track the progress of these services through the all-in-one EMR rather than having to contact each company separately. It’s not that this is impossible to do in a non-V.H.A hospital, it’s just that it is difficult to coordinate providers who may be siloed in their own distinct private institutions.
In addition to the V.H.A’s comprehensive EHR and novel approach to chronic medical conditions, it has developed into a system that can rapidly adapt to public health emergencies. Its strong federal oversight provides a central decision-making authority that rapidly lets newly formed policies disseminate through its satellite hospitals. The COVID-19 pandemic has been a powerful example of this. In the early days of the pandemic, the V.H.A implemented a strategy to provide outpatient surveillance for anyone who tested positive for COVID. This meant that every non-hospitalized patient was sent home with a pulse oximeter, thermometer, and home telehealth follow-up. Once they returned home, they were instructed to measure their vitals daily and relay them to a nurse who would then monitor their clinical status. If they were deteriorating, the nurse would prompt the veteran to return to the hospital for admission. This simple strategy worked to reduce unnecessary hospital admissions while still facilitating close surveillance of infected patients in the outpatient setting. Now, this is where the power of the V.H.A comes in. Due to its central-decision making authority, the V.H.A was able to scale these interventions to all its other satellite hospitals rapidly. It could bargain and buy thermometers/oximeters in bulk and deliver them throughout the country with existing supply chains. This also held true for vaccine delivery as the V.H.A could identify vaccine allocation guidelines, proactively prepare mass vaccination facilities, and mobilize early to vaccinate V.H.A staff and veterans all across the country.
As with any large bureaucracy, the V.H.A has its share of problems. Long ER wait times, aging infrastructure, funding issues, etc. And yet, even with all the bureaucratic inefficiencies and negative public optics, the V.H.A has continually innovated in those areas that have come to define modern health care in the United States. As we’ve seen, this is a direct result of its integrated EHR, focus on chronic conditions, and central decision-making authority. The ability of the V.H.A. to provide these services ultimately flows from its single-payer system. The V.H.A. receives funding from the Department of Veterans Affairs, which is allocated funds by the federal government. The funding is split into mandatory and discretionary forms of spending. The mandatory spending is dictated by law, while discretionary spending changes yearly based on fluctuating needs.
In turn, this funding structure is hugely cost-saving since the V.H.A can bargain and choose the necessary health services for our veterans (which Medicare cannot do). As we can now appreciate, the V.H.A model of care looks strikingly similar to current public single-payer health care system models. The COVID-19 pandemic has shown that health care in the United States needs to be more centralized and equipped to handle a rapidly changing medical landscape. The V.H.A. has been structured to do just that while still providing exemplary care for chronic medical conditions.
In response to skeptics that say a single-payer health care system wouldn’t work in the United States, I’d say that we’ve had the V.H.A all along, and it’s doing just fine.
Naveen Reddy is a neurology resident.
Image credit: Shutterstock.com
