The Obameter

Make the Veterans Administration a national leader in health reform

"Make the VA a leader of national health care reform. … This includes efforts to improve electronic records interoperability, expand effectiveness research, promote wellness programs, and instill more accountability for performance and quality improvement initiatives."


Updates

VA: Progress on some fronts but not all

Given the heat the Veterans Administration faced after its hospital in Phoenix, Ariz., was caught cooking the books to make patient wait-times disappear, this promise might seem dead on arrival. But the picture is more mixed than that.

The goal of making the VA a leader of health care reform is expansive and vague, making it too difficult to measure on its own.

In context, however, this promise is based on specific measures candidate Barack Obama said he wanted to take. Obama included it in a lengthy white paper on veterans policy in 2007. He's fallen short on some promises in that document, such as the one to reduce the claims backlog. We rated that Promise Broken.

This promise targeted the quality and practices surrounding veterans care.

So let's go through each part.

Electronic medical records

Sharing patient records quickly and digitally no matter who patients see or where they go for care is the holy grail of reform across the health care landscape. It's proven tougher than you might expect and, according to the Government Accountability Office, Congress's program auditing arm, the VA has tried but come up short.

For Congress, a major goal for the VA was for it to work hand in hand with the Defense Department.

In a recent report, the GAO said that efforts to build a joint patient records system with the Defense Department were "unsuccessful," so the VA shifted to going solo. While the "VA has developed a number of plans to support its development of its electronic health record system," the GAO auditors expressed doubt that the work would be done in 2018 as VA officials predicted.

On the other hand, Paul Shekelle, who is both a staff physician for the VA in Los Angeles and a researcher with RAND, a prominent policy analysis group, told us medical records are easily transferrable within the VA.

"There is no question this is better now than eight years ago, and way, way better than any other health system I know of," Shekelle said. "Routinely in clinic, I have patients show up in Same Day Care saying things like 'I need my medication refilled,' or whatever, and they just are in from Florida or Minnesota or wherever and don't know the names of their medications, and I am able to look up right then and there everything that was done for that veteran in Florida or Minnesota — medications, doctor's notes, lab test results, everything."

Effectiveness research/Accountability for performance and quality

We look at these elements together because knowing what works best doesn't mean very much if staff don't put those steps into practice.

The VA's Center for Healthcare Organization & Implementation Research has the job of doing the research and bringing caregivers along. The center lists many projects, from preventing infections during surgery to using blood thinners to avoid strokes. So, for starters, the research is underway. Some projects, like the one on blood thinners, are done. That one reported that all the clinics had either done what the research recommended or were hiring people to do so.

The VA came up with software to show practitioners how well they were doing, and the report said it "has been fully operational since May 2013, and is facilitating performance measurement."

This process never ends. Technologies and drugs change, and practices have to keep up. So the bottom line for now is that the VA is doing the research and measuring performance.

Shekelle said sometimes this went too far.

"The VA's measurement and performance management has grown faster than the science can support, so that now we are being measured on and having benchmarks set for things where this is no science base for how to improve it," Shekelle said.

Wellness

The VA has wellness programs for veterans. Depending on what the veteran wants, the Office of Patient Centered Care and Cultural Transformation folds education, diet, exercise, counseling, yoga and meditation into the overall care regimen. The approach is most intensive for veterans with Post-Traumatic Stress Disorder. A review of studies by VA researchers found between one-fourth and one-half of veterans were using some form of these methods. Nearly 90 percent of VA facilities offer complimentary and alternative medicine services.

Follow-up from wait-time scandal

The disclosure of efforts inside some VA centers to hide the actual wait-times for care led to the Veterans Choice Act of 2014. That law funded audits to track whether the reforms actually helped veterans. The RAND corporation assembled the work of many separate research groups into a final report. Its findings showed progress, with more work yet to be done.

Specific to this promise on health care, analysts concluded that the "quality of care delivered by VA is generally equal to or better than care delivered in the private sector."

On the matter of veterans' ability to get the care they need, the report said some veterans continue to face delays "especially in a number of key specialities," and that the VA "has stepped up the purchase of care from the private sector," although little was known about the timeliness or quality of that care.

The scandal itself continues to rankle. Sen. John McCain, R-Ariz., said the agency has failed to truly hold managers accountable.

"Under needlessly generous civil service rules, many VA employees who were originally fired for wrongdoing have since been reinstated at the VA," McCain wrote for the Fox News website on May 27, 2016. "In some cases, corrupt executives were even promoted."

In sum, the Veterans Administration has taken many of the core steps that are part of health care reform. Its strongest performance is in the area of checking what sort of care works and using that to shape what providers do. Regarding wellness programs, the VA has them. For electronic health records, the picture is more mixed.  While the VA's system seems to help its own providers, it has yet to deliver better coordination with providers outside the VA. Independent assessments both praise and criticize the VA, which suggests that its role in health care reform is more complicated than a simple yes or no answer. We rate this as a Compromise.

Sources:

Obama for President, Fulfilling a Sacred Trust with our Veterans, Aug. 21, 2007

Veterans Administration, Office of Patient Centered Care and Cultural Transformation, 2014

RAND, Balancing Demand and Supply for Veterans' Health Care, 2016

Office of Sen. John McCain, McCain & Hegseth in FoxNews.com: "It's time for the real reform our veterans deserve", May 27, 2016

Veterans Administration, Center for Healthcare Organization & Implementation Research, accessed Dec. 5, 2016

Government Accountability Office, Electronic health records, July 13, 2016

Washington Monthly, The VA Isn't Broken, Yet, March 2016

Email interview, Paul Shekelle, co-director, Southern California Evidence-Based Practice Center, RAND Corporation, Dec. 2, 2016

Email interview, Carrie Farmer, senior policy researcher,  Behavioral and Policy Sciences Department, RAND Corporation, Dec. 2, 2016

Email interview, Rebecca Coffman, communications director, Concerned Veterans for America, Dec. 2, 2016

Legislation passed to address veterans’ health problems, but what will impact be?

A scandal that plagued the Veterans Affairs Department earlier this year prompted us to move this promise from Promise Kept to Stalled. We wanted to update it once again following action by Congress and President Barack Obama to address those problems.

This promise — to "make the Veterans Administration a national leader in health reform" — was based on four tenets laid out by Obama: electronic records interoperability, effectiveness research, wellness programs, and accountability for performance and quality improvement initiatives. The progress made in those areas during Obama's six years, however, was overshadowed when it was discovered that a Phoenix VA office falsified wait-time data to see a doctor.

It turned out to be a system-wide problem in which VA employees at various offices lied about how quickly they saw patients, in order to take advantage of a program that incentivized VA hospitals if they scheduled a primary care appointment within 14 days. The actual wait time at the Phoenix facility was 115 days.

The Obama administration eliminated this incentive in June. Acting Secretary of Veterans Affairs Sloan Gibson said it actually created "incentives to engage in inappropriate behavior."

In the months that followed, Congress reached a rare bipartisan agreement to fix the troubled VA. Obama passed the $16.3 billion plan in August, of which about $12 billion is new spending.

Here's what the legislation does:

  • Allocates $10 billion toward private practices that will treat veterans who cannot get an appointment with their local VA hospital within 30 days or who live 40 miles from a VA hospital. This represents a significant shift in policy. Previously, veterans were treated inside the system.

  • The bill allocates $5 billion to hire new doctors, nurses and other health professional at VA hospitals, which are generally considered to be understaffed.

  • The rest, about $1.3 billion, will go toward building 27 new VA medical centers across the country.

  • The VA would also be barred from creating performance-based goals tied to wait times, and allows the administration to dismiss poorly performing senior executives within the department.

It remains to be seen what impact this will have toward fixing the VA problems and fulfilling Obama's promise to "make the Veterans Administration a national leader in health reform."

For example, the clause that allows the VA to take action against poorly performing executives might increase accountability, an area Obama promised to improve. As Obama noted, "If you cover up a serious problem, you should be fired. ... And if you blow the whistle on an unethical practice, or bring a problem to the attention of higher-ups, you should be thanked. You should be protected for doing the right thing. You shouldn't be ignored, and you certainly shouldn't be punished."

VA supervisors threatened to retaliate against employees who filed complaints about improper scheduling. Holding them accountable for stifling whistleblowers could improve accountability and transparency within the system and discourage bad behavior.

Whether the money spent on new doctors and clinics improves the system is something to keep an eye on as well. Veterans groups have also expressed trepidations at shifting some veterans to private practices, noting that treating battle wounds and complications from duty requires unique understanding and skills.

There is reason to believe strides have been made, and we'll reevaluate this promise once these changes go into effect. For now, this promise remains Stalled.

Sources:

Email interview with Jessica Santillo, spokeswoman for the White House, Nov. 6, 2014

Veterans Affairs Department, "The Road to Veterans Day Action Review," Nov. 6, 2014

Vox, "Congress passed a plan to fix the VA. Here's what it does," July 31, 2014

White House, "President Obama Signs Bill to Give the VA the Resources It Needs," Aug. 7, 2014

CBS News, "VA may have retaliated against whistleblowers, watchdog says," June 6, 2014

Stars and Stripes, "Obama signs landmark VA reform law," Aug. 7, 2014

Long wait times overshadow other accomplishments

We last reported on this promise in 2012, looking at the four points mentioned in Obama's campaign materials: electronic records interoperability, effectiveness research, wellness programs, and accountability for performance and quality improvement initiatives. Based on significant improvement in those areas, we rated this pledge a Promise Kept.

Even back then, however, we noted that the Veterans Health Administration had longstanding problems with patient backlogs. In a separate report, we looked at his promise to reduce the Veterans Benefits Administration claims backlog and rated it Promise Broken.

On this promise, though, the Veterans Health Administration was winning kudos from academic journals for being a model or leader in health care because of its advances in electronic health information systems and comparative effectiveness research.

A spokesperson for Veterans for Common Sense told us there were other steps forward in veterans' health care under Obama, specifically an expanded suicide prevention hotline and a budgeting process that would mean fewer delays in providing medical services.

As of early 2014, though, those advances are being overshadowed by headlines about veterans dying while waiting for care at VA facilities in Phoenix, VA workers creating phony documentation about wait times, and other questions about the availability of care. We expect it will take some time to sort out how extensive the problems are and whether they are widespread throughout VA facilities.

Needless to say, if veterans can't access care, that puts into question whether the VA can claim to be a national leader in health care reform.

We expect to look at this promise again before the end of Obama's term. In the meantime, we're changing the rating to Stalled.

Sources:

CNN, Veterans dying because of health care delays, Jan. 30, 2014

CNN, Phoenix VA officials put on leave after denial of secret wait list, May 1, 2014

Washington Post, As outrage over VA allegations grows, Obama and aides scramble to respond, May 20, 2014

Washington Post, A guide to the VA health care controversy, May 15, 2014

Arizona Republic, Deaths at Phoenix VA hospital may be tied to delayed care, April 10, 2014

Fox News, Obama assigning deputy chief of staff Nabors to oversee VA review, May 14, 2014

The Washington Post, VA mental health system sharply denounced at hearing, April 25, 2012

The New York Times, Veterans Department to Increase Mental Health Staffing, April 19, 2012

The New York Times, Veterans Wait for Benefits as Claims Pile Up, Sept. 27, 2012

Wall Street Journal, The Digital Pioneer: Veterans hospitals have already fought this battle—and offer plenty of lessons on how it can be done, Oct. 27, 2009

Journal of Health & Biomedical Law, Medicare coverage policy and decision making, preventive services, and comparative effectiveness research before and after the Affordable Care Act, Jan. 1, 2012

Journal of Corporation Law, Controlling Health Care Costs Through Public, Transparent Processes: The Conflict Between the Morally Right and the Socially Feasible, 2011

Health Affairs, The Veterans Affairs experience: comparative effectiveness research in a large health system, October 2010

Health Services Research and Development Service, Comparative Effectiveness Research — The New Imperative, May 2009

InformationWeek, Health Care: VA Telehealth Lauded As Model Healthcare Program, Jan. 24, 2012

U.S. Department of Veterans Affairs, FY 2011-2015 strategic plan(accessed on Nov. 26, 2012)

Interview with Paul Sullivan, spokesman for the Veterans for Common Sense, Nov. 8, 2012

Email interview with Mark Ballesteros, spokesman for the Veterans Health Administration, Nov. 23, 2012

VA made strides in health reform goals

The government system for providing health care to veterans received national attention in 2008 when Barack Obama first ran for president. In a campaign document outlining his plans for improving the lives of veterans, Obama said he would make the U.S. Department of Veterans Affairs a leader in national health reform.

The Veterans Health Administration, a division of Veterans Affairs, is the largest health care system in the United States, with 152 hospitals, 800 community-based outpatient clinics and 126 nursing-home-care units. It serves more than 8.3 million veterans each year. Even before Obama became president, it had undergone a decade-long transformation from an inefficient bureaucracy to a model for technological and science-based innovations in U.S. health care.

As a candidate in 2008, Obama said the department would need to make progress on four fronts to meet his definition of "national leader in health reform”:

  • Improve electronic records interoperability;
  • Expand effectiveness research;
  • Promote wellness programs;
  • Instill more accountability for performance and quality improvement initiatives.

We'll take each component, piece by piece.

Electronic records interoperability: We recently wrote about Obama's goal of a connected electronic network between Veterans Affairs and the military. This would allow former service members to request health care benefits with greater ease because their medical files -- showing qualifying disabilities incurred on duty, for instance -- would be immediately accessible to physicians and nurses outside the military.

Instead, what we have today is a comprehensive electronic health network at the Veterans Health Administration and a growing number of electronic pilot projects at the Veterans Benefits Administration. The biggest outstanding problem is a disjointed records system in the military, reputed to be clunky and subject to frequent crashing, which is separate from the one in Veterans Affairs.

However, plans are in place to install electronic records systems across the benefits administration by the end of 2013; also, military department heads have agreed to launch a unified veterans-military electronic health records system by 2017. Full interoperability might be far off -- the current schedule would exceed Obama's second term in office -- but we do see some progress.

Effectiveness research: Comparative effectiveness research usually refers to studying the relative impact of different medical approaches in treating the same condition. Two of the biggest domestic policy laws signed by Obama in his first two years -- the American Recovery and Reinvestment Act and the Affordable Care Act -- both encouraged comparative effectiveness research. The economic stimulus created a new council to coordinate and guide comparative effectiveness research across federal departments (including Veterans Affairs). We dug into the annual budgets for Veterans Affairs over the last four years and found more evidence of expansion: Health research services -- which focuses on effectiveness strategies --- received $76 million in President George W. Bush's final budget, whereas it received $88 million, $94 million and an estimated $98 million in Obama's first three budgets.

Wellness programs: The Veterans Health Administration maintains a website dedicated to promoting healthful living, including educational pages on nine topics such as diet, alcohol consumption, tobacco use and exercise. It also has a weight-management program called MOVE!, a pilot program for behavioral counseling by phone -- helping veterans to quit smoking, for example -- and another pilot program for diabetes prevention. We also found the 2011-2015 strategic plan for Veterans Affairs includes a department-wide, web-based wellness initiative for department employees.

Accountability for performance and quality improvement initiatives: By boosting comparative effectiveness research, the health administration should be favoring medical options based on science-based results -- which is a kind of quality improvement. In terms of improved accountability, we didn't find much. One exception was the early push by the White House for more transparency across the federal government, including a default position of openness on Freedom of Information Act requests. Paul Sullivan, a spokesman for the advocacy group Veterans for Common Sense, said Veterans Affairs had a mixed record of complying with public records requests under Obama, but its performance was a vast improvement from the previous eight years.

Did Veterans Affairs become a leader in national health reform? The question invites a degree of subjectivity that goes beyond facts. Critics could point to the benefit claims, often health care-related, that go unanswered within 125 days of filing, which have nearly doubled under Obama. Long wait times and a growing demand for disability services, including mental health care, have drawn frequent news coverage in the past few years.

On the other hand, we also found recent examples of the Veterans Health Administration being lauded in academic journals as a model or leader in health care, in part because of gains in electronic health information systems and comparative effectiveness research. Sullivan, of Veterans for Common Sense, noted other positive changes in veterans' health care under Obama, such as an expanded suicide prevention hotline and a modified budgeting process that allows for more predictable funding and fewer delays in providing medical services.

For our purposes, it's more important to note that the Veterans Health Administration made strides in all four sub-areas mentioned in Obama's campaign promise. We rate this a Promise Kept.

Sources:

Interview with Paul Sullivan, spokesman for the Veterans for Common Sense, Nov. 8, 2012

Email interview with Mark Ballesteros, spokesman for the Veterans Health Administration, Nov. 23, 2012

The Washington Post, VA mental health system sharply denounced at hearing, April 25, 2012

The New York Times, Veterans Department to Increase Mental Health Staffing, April 19, 2012

The New York Times, Veterans Wait for Benefits as Claims Pile Up, Sept. 27, 2012

Wall Street Journal, The Digital Pioneer: Veterans hospitals have already fought this battle—and offer plenty of lessons on how it can be done, Oct. 27, 2009

Journal of Health & Biomedical Law, Medicare coverage policy and decision making, preventive services, and comparative effectiveness research before and after the Affordable Care Act, Jan. 1, 2012

Journal of Corporation Law, Controlling Health Care Costs Through Public, Transparent Processes: The Conflict Between the Morally Right and the Socially Feasible, 2011

Health Affairs, The Veterans Affairs experience: comparative effectiveness research in a large health system, October 2010

U.S. Health and Human Services: Recovery, Text of the Recovery Act Related to Comparative Effectiveness Funding(accessed on Nov. 21, 2012)

Health Services Research and Development Service, Comparative Effectiveness Research — The New Imperative, May 2009

InformationWeek, Health Care: VA Telehealth Lauded As Model Healthcare Program, Jan. 24, 2012

U.S. Department of Veterans Affairs, History(accessed on Nov. 26, 2012)

U.S. Department of Veterans Affairs, National Center for Health Promotion and Disease Prevention(accessed on Nov. 26, 2012)

U.S. Department of Veterans Affairs, FY 2011-2015 strategic plan(accessed on Nov. 26, 2012)

Government Printing Office, U.S. Department of Veterans Affairs, Fiscal Year 2011(accessed on Nov. 26, 2012)

Government Printing Office, U.S. Department of Veterans Affairs, Fiscal Year 2012(accessed on Nov. 26, 2012)

Government Printing Office, U.S. Department of Veterans Affairs, Fiscal Year 2013(accessed on Nov. 26, 2012)

The Washington Post, Revamped Veterans' Health Care Now a Model, Aug. 22, 2005

VA takes lead in some areas of health care

Whether the Veterans Administration actually becomes a national leader in health reform remains to be seen, and veterans who recall waiting months to see a VA doctor will probably chortle at the prospect. But by building on the efforts of his predecessor, George W. Bush, President Barack Obama appears to be pushing the VA medical system that way.

In recent years, the agency has harnessed technology in a way that few major health systems can, continuing to post patient medical records electronically so they can be shared easily within the system.

On April 9, 2009, Obama ordered the VA and the Defense Department to create a lifetime electronic medical record for all members of the armed forces, which can follow them from base hospitals and clinics to VA facilities. Known as the Virtual Lifetime Electronic Record, or VLER in the acronym-enamored government, the system is supposed to provide a "seamless transition” from active duty to veteran status, the White House said, and make for better cooperation between vets' public and private medical providers.

On research, the VA's budget is set to expand by 13.7 percent in 2010, to $580 million. But add funding provided in last year's stimulus package and its research budget is closer to $1 billion, according to the American Association for the Advancement of Science, which tracks government research funding.

Regarding accountability, the VA has expanded a fellowship program that puts physicians into the agency to develop and implement new ways of improving health care at the the agency. It's called the National Quality Scholars Fellowship Program.

Again, making the VA a leader in national health care reform may prove an expensive and uncertain prospect. But Obama has gotten the effort going enough to rate this promise as In the Works.
 

Sources:

 Jan. 5, 2010, phone interview, Patrick Clemins, director of the research and development budget and policy program at the American Association for the Advancement of Science, Washington, D.C.

Research and Development at the VA, 2008 to 2010, from the American Association for the Advancement of Science.

Veterans Administration Performance and Accountability report, Nov. 19, 2009

White House news release, Virtual Lifetime Electronic Record

The Washington Post, Aug. 21, 2005, Revamped Veterans Health Care Now a Model

Health Care IT News, Nov. 25, 2009, Pilot Program to Link Electronic Medical Records

VA National Quality Scholars Fellowship Program, fact sheet.