We've been posting this week on our New America colleague Phil Longman's new edition of "Best Care Anywhere," which tracks the remarkable transformation of VA care. The VA has its flaws -- but it also has considerable strengths that the rest of the health care system would do well to pay attention to. It uses electronic medical records to closely and effectively track and coordinate patient care. It uses evidence-based medicine. It has team-based care where doctors cooperate and communicate, instead of fragment and confuse. And it has long -- often life-long -- relationships with its patients, meaning investments in wellness and prevention and coordination can pay off. And it measures quality. Longman has been studying and writing about the VA for several years and he has been thinking about how the rest of the health care system can absorb or apply its lessons. Here is one idea he puts forth on how large nonprofit urban community or teaching hospitals -- the "St. Elsewheres" -- can turn themselves into VA-inspired systems.
For years, the debate over health care has rested on the assumption that the uninsured should be brought into the health-care system the rest of us use. But what if something like the opposite is true? What if the best way to help the uninsured is to make the health-care delivery system they already use -- the St. Elsewhere model -- better, more efficient, and more affordable -- in short, more like the VA? And what if, eventually, the rest of us could join that system?
Longman says the first step is covering the uninsured, particularly low income people. We're on that path now with the passage of health reform. But we don't have to put all the newly covered people into the current strained fee for service system and Medicaid. He proposes creating the "Vista Health Care Network" (VistA is the name of the VA's electronic medical record system). Invite the "St. Elsewheres" and individual doctors to join an integrated delivery system to serve the newly insured. Like the VA, it would have a team approach, use health IT and comparative effectiveness protocols. Doctors would be salaried, and rewarded for quality not quantity. In other words, it would be what has now become known as an "accountable care organization."
Longman predicts many struggling hospitals would see it as a lifeline. "Reimbursement rates would be set much higher than in Medicaid, and when combined with the efficiency in the VA model of care, they’d be high enough to guarantee the solvency of participating providers."
The hospitals that take Vista’s offer would have to radically change the way they do business. They’d have to join the twenty-first century and integrate health IT into the practice of medicine. They’d have to embrace the VA’s safety culture. They’d also have to shed acute care beds and specialists and invest in more outpatient clinics in which, for example, diabetics could learn how to manage their disease, or people with high blood pressure could join smoking-cessation and exercise programs.
As with the VA, there would also be much more emphasis on integrated mental health-care and substance-abuse programs. Also as with the VA, doctors who work for these hospitals would be salaried and earn bonuses for effective performance (keeping their patients well). No longer would doctors have financial incentive to engage in overtreatment.
Longman predicts that patients, or customers, would welcome the change. They are used to long waits to get care in crowded ERs. The transition to a "new, integrated, rationalized system would be easy and welcome. They would be able to get preventive care, such as regular doctor checkups, as well as chronic care, such as effective management of diabetes, and not face the stigma and stress of medical bankruptcy."
Young people would find themselves drawn to the system he says, because of its low cost and national reach. They can move around, and not have to change plans. People who are in the Vista network but who end up getting jobs that provide insurance should be able to stay in Vista if they choose; Longman argues for a "modest legal fix" that means employers could pay their share of a worker’s insurance premium into Vista. Vista patients who hit Medicare age could stay in the system too if they chose.
Too radical? Not at all, he says. “The model for Vista comes, not from Canada or France, but from an all-American institution widely cheered by the nation’s veterans.” If it’s good enough for wounded warriors and the American Legion, maybe it deserves a second look.