HHDS.03 - The VA Healthcare Delivery System

This is Chapter 3 of 50 in a summary of the textbook Handbook of Healthcare Delivery Systems. Go to the series index here.

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Chapter 3 Summary
The VA Healthcare Delivery System

Chapter Authors
Elizabeth M. Yano - Veterans Affairs Greater Los Angeles Health Services Research & Development Center of Excellence and University of California

NOTE: Like the other chapters, the book was published in 2011 and doesn't include changes in the organization over the last decade.

1.  VA introduction & evolution

1a.  Overview

The VA is the largest (and perhaps oldest) direct healthcare system in the United States. It operates in every state with over 143 hospitals, 995 outpatient clinics, 135 community-living centers, and 49 domiciliary rehabilitation programs. It employs 12,500 physicians and dentists, 58,000 nurses, and a total of 230,000 employees. They serve over 60 million outpatient visits, and half a billion inpatient stays a year.

The organization has undergone significant evolutions over the years and its care has been subject of controversy.

1b.  Historical evolution of the VA healthcare delivery system

Wow. The VA is old. In 1636 the first benefits system for veterans disabled in the war was created in Plymouth Colony. In 1776 Congress included pensions benefits for disabled soldiers. The federal government was established the first medical facility for veterans in 1811.

Major expansion occurred in 1917 and the years following World War I including care for outpatient and hospital treatments, pensions, and care for disabled soldiers.

The Veterans Administration grew significant with hospital capital projects during the Great Depression, and from the post World War II demands.


2.  VA Quality Transformation 

2a.  VA quality in question

The VA was very hospital centric. Despite the number of US hospitals declining 12% between 1975 and 1995 with the movement to ambulatory care, the VA did not close hospital beds.  In 1993s the Clinton Administration reviewed the VA and found a ratio of 70% specalists to 30% generalists physicians.

There was almost no primary care, requiring walk-in clinic care to be the norm.

The quality of the VA has been concern of public debate for decades. By the 1990s it became clear that,

"Three out of four veterans indicated that they would 'vote with their feet' and leave the VA if given the opportunity. This threat to survival served as a call to action"

2b. VA's Quality Transformation

For this reason, the VA of the 1990s undertook massive efforts to restructure and prioritize quality. 

To streamline a new VA around primary care, the 172 independent VAs were integrated into 22 Veterans' Integrated Service Networks (VISNs).  

Hundreds of primary care and new community-based outpatient clinics (CBOCs) opened. CBOCs function as 'satellite clinics' from the parent VA Medical Center. By 1996 over 80% of VA facilities said they treated the majority of their veterans in their primary care practices, up from only half in 1993.  

The VA was an early adopter of electronic medical records in the 1990s, with significant decision support capabilities and primary care notifications. Performance metrics were tied to provision of high performance measures - such as cancer screening and seasons influenza vaccination. Clinician order entry has been implemented for decades, and patients can access their chart via MyHealtheVet.

National performance measures were set, patient rating of care, clinical quality measures programs with random chart evaluations, and high level administration data tracking. By 2000, the VA had improved in 12 of 13 quality measures, and was outperforming national averages for recommended care.

The VA proceeded the Institute of Medicine report To Err is Human with their own creation of a patient safety registry and awards program.

Despite efforts to improve the system, there remains significant controversy. Depending on what study from the early 2000s you read, it may either suggest VA care costs 20% lower than care elsewhere in the USA or may cost 33% more.


3.  VA Membership & Funding

3a. VA Membership

At time of this book's publication, in 2007 there were 23.8 million veterans. (A veteran is one who has been discharged from military service.)  Most, 7.9 million, are from the Vietnam Era, and 5.0 million from the Gulf war.  Women comprise 7.5%.

Eligibility and coverage within the VA healthcare systems is stratified based on several factors, with more broad coverage for those who are have service-connected disabilities, former prisoners of war, severely disabled, and low income. The VA also provides themost support to homeless patients, as veterans are disproportionately represented among them.

3b. VA Funding

In 2009 the US Department of Veterans Affairs budget was $96.9 billion. Almost half goes towards disability payments and income support, and the remaining $43.5 billion is divided between medical care, facilities, and some research.

In 1997 Veterans Equitable Resource Allocation (VERA) system was introduced to provided capitated funding that would follow the veteran's highest priority care based on where they went. This allowed for rapid expansion of services in new developing cities.

The finances were restructured in the 1990s into a capitation model, and each VISN would control budgets and be clinically and financially accountable for on average 5-7 VA hospitals, 25-30 outpatient clinics, 4-7 nursing homes, and 1-2 domiciliaries.  To reduce the duplication of services facility integration has merged often two hospitals under a single leadership group. 

Services not available within the VA, such as mammograms, or specific procedures will be contracted as needed.

The U.S. Treasury collects from veterans insurance plans at a rate of $100 million a month.  


4.  VA Services & Population

4a.  VA Services

1) medical care - the VA even has facilities in Puerto Rico, guam, Philippines and Virgin Islands

2) education and training - most VA hospitals have an academic affiliation, and 1/3 of residents and 1/2 of medical students train in part in the VA

3) Research - both general and in particular relevant VA conditions such as post-traumatic stress disorder, traumatic brain injury, prosthetics polytrauma. Past VA innovations included Pacemakers, MRI, CT scanners, and nicotine nicotine patch.

4) Contingency support and emergency management - connected to the Department of Defence, the VA staff and facilities may be airlifted into provide direct care in conflict zones, or during emergencies in America VA may provide emergency local care.

Outside of care provided, VA benefits include medications, medical supplies, rehab, and geriatric and extended care.  Unlike other providers, certain services are not capped - especially in the area of mental health

4b.  Special Populations 

On average, veterans are older, lower income, in poor or fair health. The patient population has special needs from radiation, weapon exposure, spinal cord injury, blindness, PTSD, and homelessness.  

Despite having a functional status equivalent to an additional two chronic conditions, the VA's risk-adjusted mortality is lower than their counterparts under Medicare Advantage.  Mental health and substance abuse problems comprise a significant burden for vetrans, and uncapped services are provided in these areas. 

The VA provides the largest spinal cord injury care network, and this is a strong area of research.  

Women in the military has increased to almost 20% of new recruits. This is up from  the historic 2% cap placed in the past and the VA has worked to adapt its services.

Recent wars in Iraq and Afghanistan have led to new exposures, such as blast injuries from IEDs, leading to mild to severe traumatic brain injury - which has become the "signature" injury from survivors of these wars. One quarter of veterans from these operations have mental health diagnoses.

Some Commentary

Unfortunately this chapter is almost a decade out of date now. I am certain the organization continues to undergo transformation and criticism. I'd need to research further to understand the truth behind the VA's actual quality and efficiency. Being such a large organization its bound to draw criticism and almost certainly to have bureaucratic sluggishness. 

On the to-do-list is to research the IT systems that the VA has used over the years, and what data sets they have available.

HHDS.04 - Outpatient Clinics: Primary and Specialty Care

HHDS.02 - Engineering and the Healthcare Delivery System