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Best Care Anywhere: Why VA Health Care is Better Than Yours

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Philip Longman makes the case that current U.S. healthcare is a fragmented, market driven system that lags behind much of the industrialized world in both quality and access of healthcare. According to Longman, the problem with our healthcare system is that it isn't really a system and that it doesn't reward the one thing that it should - health improvement. In fact, he offers proof that in the U.S. doctors and hospitals are rewarded for providing treatment, but not necessarily providing health to their patients. To illustrate this, he offers examples from two of the nation's premier hospitals - Beth Israel and Duke Medical Center. Both initiated programs that were so successful at improving health that they became unprofitable and were ultimately terminated.

This book is filled with understandable, but often shocking statistics. For example, every year in the United States 98,000 people die due to medical errors while in the hospital, another 90,000 die due to infections that they get while in the hospital, and 126,000 needlessly die because their doctor failed to use evidence-based protocols for just four of the most common conditions.

The solution? Longman speaks effusively about the VA healthcare system. And rightfully so. It is the only fully functioning, evidence-based healthcare system in the country. The book explores the history of the VA and speaks honestly about some of the warts that mar the VA's reputation. But the truth of the matter is that the VA has turned all of that around and is currently at the front of the healthcare revolution.

Longman's book contains sections on safety, quality improvement, the concept of lifetime healthcare, and the Kizer Revolution at the VA, which dramatically improved quality and altered forever the course of veterans' healthcare.

The section on VistA, the software program that is revolutionizing healthcare, is worth the price of the book. This open source software program is really a bundle of 20,000 programs written in open source code. Surprisingly, it is being adopted extensively around the world - but not right here at home.

Longman proposes a reform of the U.S. healthcare system that incorporates the best of VistA and many other VA best practices and innovations. If you are interested in the healthcare debate and what is possible in future U.S. healthcare, I highly recommend this book.

For those interested in learning more about the healthcare debate and want to explore other opinions, I would also recommend the following three books: A Second Opinion: Rescuing America's Health Care; Who Killed Health Care?: America's $2 Trillion Medical Problem - and the Consumer-Driven Cure; and Redefining Health Care: Creating Value-Based Competition on Results.

"Best Care Anywhere's" Longman was charged by "Fortune" magazine with finding the best examples of U.S. health care management. When Longman asked experts for suggestions on where to look, he couldn't believe what he kept hearing - look at the government-run Veterans Administration system, the largest integrated health care system in the U.S. (1,556 locations). This contradicted all he thought he knew about economics and government, yet was consistently backed up by prestigious and unbiased studies. In 2003 the New England Journal of Medicine published a study comparing V.A. facilities with fee-for-service Medicare on 11 measures of quality - the V.A. proved better on all. In 2004 the Annals of Internal Medicine compared the V.A. with commercial systems in care of diabetes - the V.A. provided better care in all 7 measures. Similarly, A RAND study found the V.A. outperformed other sectors in all 294 measures. The National Commission for Quality Assurance also found the V.A. outperformed the highest-rated non-V.A. hospitals. And for 6 consecutive years the V.A. received the highest consumer satisfaction ratings of any health care system.

What about costs - surely a government-run operation would be much more expensive. Actually, the V.A.'s average expenditure/patient in 2004 was $5,562, vs. a national average $6,280 - including those who never saw a doctor during the year. Further, the V.A.'s patient population was older (half over age 65), more diabetic (one in five has diabetes, compared with one in fourteen in the general population), and greater incidences of most all chronic diseases.

How does the V.A. do it? Five keys: 1)Most of its doctors have faculty appointments with academic hospitals. 2)It's patients are enrolled for life - providing preventive care financial incentives that are lacking in the private sector where patients change plans regularly. 3)V.A. doctors are salaried, with no financial incentive to provide unneeded (and possibly harmful) care. 4)It's having enthusiastically developed internally and adopted modern information technology that helps identify best practices, prevent medication errors, assist diagnoses, and ensure appropriate care and follow-up. 5)The "Kizer Revolution" (it's Clinton-era director) cemented a fail-safing quality emphasis and a data-driven management focus.

Finally, Longmore also points out another perverse incentive for higher costs and lower quality that exists outside the V.A., using an experiment at Duke University. In 1995 its medical center offered an integrated program for congestive heart failure that included following up with patients and sharing data among doctors to identify best practices. The result was a 37% drop in revenues from fewer admits and complications. Similar results were found in Utah involving pneumonia.

Addendum from Wall St. Journal, 10/27/09: The VA's computer system also helps monitor patient care at home, especially for people with complex, chronic illnesses. The VA gives those patients special gadgets free of charge to measure weight, heart rates, blood pressure and other conditions, and the daily results are automatically transmitted into the VA's medical-record system. If the numbers exceed target levels, a nurse is notified. The VA says its in-home monitoring program has about 40,000 patients enrolled and has reduced hospital admissions by 25% and length of hospital stay by 20%. Also the system's automated reminders have boosted performance - eg. the percent of patients receiving a flu vaccine rose to 83% last year from 27% in 1995, colon-cancer screenings increased to 84% from 34% during the same period.

Bottom Line: As the debate rages over improving health care quality and reducing costs, we are fortunate to have Longmore's insightful and fact-filled "Best Care Anywhere" inform thinking. On the other hand, I'm wondering "Why hasn't our Indian Health Services taken the same enlightened path," and "Why did "Fortune" magazine kill Longmore's original article, even though it contradicted their assumptions about the free-market?"

This was a truly interesting book that is a 'must read' for those who are looking for alternative national solutions to our healthcare situation. Another related book of interest is "Medical Informatics 20/20" available on Amazon

Medical Informatics 20/20: Quality And Electronic Health Records Through Collaboration, Open Solutions, And Innovation

Best Care Anywhere is well-researched and well-written. It clearly shows us why our health care "system" is costly and sometimes dangerous, and it gives some great ideas about how it can be fixed.

I really enjoyed reading this excellent summary of the changes that have taken place at the VA hospitals and how their successes might be duplicated in the private sector. Overall an illuminating portrait of a system that went from barely adequate to outstanding and how integration of medical informatics and dedication to preventive medicine made it happen.

This book should be mandatory reading for every member of the U. S. Congress! All heads of the major media network news departments should also read it.

As a VA health care professional, I read this book with great interest and have recommended to all my colleagues and many non-VA folks. Interest and concern is high right now regarding the nation's health care crisis, and this author brings experience and knowledge to the subject, in a very comprehensible style that will enlighten all who read it.

This is a very unique perspective on looking at the broken VA health care system. What the chronically underfunded, understaffed stepchild of government accomplishes in spite of the difficult to impossible lack of concern on the part of Congress and various Presidents and administrations is truly awesome in many ways. While it is undeniable that care is uneven, and one hospital may be a disaster while another is a shining beacon of hope for veterans, for the most part what the dedicated, overworked doctors, nurses and techs manage to do is nothing short of phenomenal. Those of us vets who depend on VA health care should remember this, and reading this book will demonstrate the grass is decidedly not always greener---

I did read the original article and have been an NP at the VA for 6 years. I am pleased with the quality of care I am able to provide at the VA and am impressed with my VA generally. The book points out the significant strengths which include the supportive feel of the VA for many veterans, the benefits of caring for individuals for life and the nearly seamless electronic record. If you are considering a position at the VA or a veteran looking for quality care, this book will talk you into the right choice.

This is the best single description I have read of HealthCare that works, is comprehensive, does not discriminate against persons, medical need or history, and is test proven and cost effective.