VA Under the Microscope

The debate over the adequacy of care at the Veterans Administration is underway over at the Health Care Blog. Maggie Mahar, author of "Money-Driven Medicine," weighed in yesterday with a defense of the VA system's superior care, and how it is being undermined by systematic underfunding by the Bush administration. The blog's sponsor, industry consultant Matthew Holt, highlighted an interesting article in the trade journal of the managed care industry that suggested executives in the nation's beleaguered HMOs could learn a thing or two from the VA. The article also contains a number of charts showing how the VA routinely surpasses other health delivery organizations in meeting best medical practice standards.

That said, Mahar's rejoinder to several commenters winds up making the same point I tried to make yesterday: the VA has been overwhelmed by Iraq war casualties, which are running at five times the rate of previous wars due to the military's ability to save the lives of the wounded. That means the physically and emotionally scarred veterans of this ill-conceived war will be with us in numbers comparable to previous wars. Meanwhile, the Bush administration and Congress have consistently funded the VA at levels well below the rate of medical inflation. The result? This exemplar for single-payer health care delivery is being overwhelmed by its challenges.

A final note: I was shocked while listening to C-span yesterday morning by the number of complaints from veterans and/or their spouses that poured in from around the country. A number of callers complained about lost paperwork. This suggests that the VA's much-ballyhooed information technology revolution still has a long way to go -- at least in the front end that touches people directly. It's great if the charts are computerized, which eliminates duplicative tests and faulty prescribing. But the lesson here is that people (patients) are just as likely to remember the way they are treated as the treatment that they receive.

Footnote: Former Food and Drug Administration deputy commissioner Scott Gottlieb has an opinion piece in today's Wall Street Journal attacking the FDA's new requirement that companies more carefully manage the distribution of risky new drugs (so-called risk management plans), a requirement that would be greatly expanded under several reform bills now before Congress. Back at the American Enterprise Institute, Gottlieb winds up defending all forms of off-label marketing and accusing those who would restrict it as mandating "cook book medicine." It's a perfect contrast with the debate over the VA. By restricting payments for pricey drugs that are no more effective than generics and adhering to evidence-based standards, the VA has been able to deliver a very high level of care at low cost for millions of vets and their families. The phrase "evidence-based medicine" never appeared once in Gottlieb's article. In his world, paying the highest prices in the world for second world outcomes is a desireable outcome. It's restrictions on physicians' choices that are the real problem.