Once it is determined who is granted access to the system and how this system is going to be paid for, the next step is discovering how these health care services are going to be delivered. After all, the point of our nation becoming part of the noble cadre of nations that recognize access to health care for all citizens as a civil right of some kind is to actually treat sick people. Sounds like a given, but how do they go about doing it?
Primary Care – The PACT Model
The key to delivery in the VA is through the Primacy Care Provider (PCP). There is one doctor (MD), or nurse practitioner (NP) that is charged with providing the basis to all services to an individual Veteran. The team also has a small cadre of Registered Nurses (RN), Licensed Practical Nurses (LPN),
Nursing Assistants and Medical Support Assistants (MSA) that work in support of the PCP. This is in effect, a small clinic that operates similar to many health care systems and even at private clinics.
What the PACT team does, is provide the Veteran with general services, also a given since the MD is typically a general practitioner. This team should handle routine services, and also does the grunt work in terms of keeping track of medical history. They provide this based on particular medical criteria designed to stay abreast of common health factors affecting the given population. As noted in the previous essay, most of the Veteran population is older and male.
This means the PACT can focus on the types of issues older men typically face. Examples of such conditions include obesity, hypertension, diabetes or any condition that will worsen over time if a relationship with a physician is not maintained. If a condition worsens, the PCP will know about it and be in a good position to alter his or her plan of care. This proactive approach is often pointed out by advocates of single payer health care systems as a feature of these systems since most of the time healthcare in the United States is a reactive proposition. Reactive in the sense that most people will simply wait until that bump gets bigger, or that knee becomes too unbearable to walk on, or it hurts too much to urinate in the morning before finally making an appointment to see a doctor.
Symptoms may not appear until it is too late for treatment to be effective for many fatal diseases; the system is more likely to catch an underlying condition while it is most effective to treat in this proactive system. Catching these conditions early on has the added benefit that it is often more cost effective than catastrophic treatment (6).
There are studies that Longman cites in his book that suggest a correlation to this approach leading to better outcomes versus the patient waiting until the symptoms get too unbearable (6). There are some studies that go so far as to say that VA patients live a longer life, in spite of disability, alcoholism, PTSD, et cetera, being more frequent than in the general population. Even studies with outcomes in specific areas cited as performing better than the private sector (6). The overall cost of such a system also has a tendency to be lower than the fee for service model. One study from 2004 suggested all VA services provided during FY 99 if reimbursed at Medicare rates would be result in an estimated 17% higher cost to the taxpayer (1).
This is where things get a little more complicated. Consider what many third party insurers require of their customers to see a specialist. Typically, if a customer wants their insurance to pay for specialty care they will have to first go to a primary care clinic to initiate a referral. What this does for the insurer, is inform them the requested service is medically necessary. This necessity is important to insurers because specialty care providers have a tendency to provide services that are more expensive than their general counterparts. Similarly, in order to see a specialist, a Veteran must first see their PCP. This step allows the PCP to discuss all of the options available to the Veteran and if their condition truly warrants the expertise of a specialist they will initiate a consult.
The consult is essentially a documented source of communication between the PCP and the specialist. Once the PCP enters the consult, the specialist is notified via a provider alert on the Electronic Health Record (EHR) Software. They will review the PCP notes, review the Veteran’s charts if necessary, and if the specialist agrees the service is necessary the specialty clinic’s MSA will contact the Veteran to schedule an appointment. At this point, the treatment varies with the Veteran’s circumstances. It could be an evaluation, a noninvasive outpatient treatment or perhaps a surgery needs to be scheduled with an inpatient stay. All of these specific circumstances are documented on the consult. Once the service is provided, the specialist will document their findings in the EHR to be ultimately reviewed by the PCP. If the specialist does not agree the services are needed, the reason why is documented and the consult is discontinued. If the specialist needs more information, a lab for instance, this will be documented and sent back to the PCP, this way the specialist has every resource available to make an informed decision.
Drugs–the legal variety.
The reason often cited for the efficacy of VHA versus private sector hospitals is the VistA EHR system. It allows a somewhat simple integration between clinics as discussed in the previous sections. It also allows medical data to be stored easily, and later used for research purposes. During the Clinton administration, Ken Kizer, the SecVA at the time, implemented a prescription drug formulary by researching this data as well as recognizing that once Veterans go to the VA they typically stay there. For whatever reason why they stay, they identified they were there for life.
‘If you are going to have your patients for five years, ten years, fifteen years, or life,’ explains Kizer, ‘there are both good economic and health reasons why you would want to use the more expensive drugs. You have a population of patients who are at high risk for sclerotic heart disease, and you’ve got them for life. You make a different decision about what’s on your drug formulary than you might if you knew you only had them for a year or two.’ (6)
What the researchers were able to do with this was create a formulary that determined what drugs worked long term. When the FDA approves a drug, there typically is no long term research into the drug’s efficacy, only if it does what it claims and if it is safe for use. What this means is the VA will only prescribe drugs that have well-known, established effects, but also have been around long enough to be on the generic market. If a new prescription drug treatment hits the market, it is almost certain the VA will not add it to their formulary, even if the drug is truly is a medical breakthrough, as discovered with the new Hepatitis C drug (7). While it was later approved, it required a cost/benefit analysis on the cost of treatment at the VA for hepatitis C before they were able to add it to the formulary. The result is a system that according to the Heritage Foundation costs significantly less than Medicare Part D but presents its patients with no choice whatsoever in their prescriptions (3).
The VA formulary is created through access restrictions on drugs. For drugs to be covered on the formulary, their makers must list all of their drugs on the Federal Supply Schedule (FSS) for federal purchasers at the price given to the most favored nonfederal customer under comparable terms and conditions. Additionally, drug makers must offer the VA a price lower than a statutory federal price ceiling (FPC), which mandates a discount of at least 24 percent off the non-federal average manufacturer price (NFAMP), with a rebate if price increases exceed inflation (3).
Otherwise, the VA negotiates pricing based on volume, as they are the largest health care provider in the country. The drug companies that sell to the VA recognize that it is a closed system and there is little chance of market distortions from below market priced VA drugs. It is also small enough as a portion of the entire health care market, that they are able to break even by selling non-generic prescription drugs elsewhere (3).
Everything in the previous sections of this essay is utterly meaningless if Veterans cannot get an appointment.
The thing is, most major hospital systems and private practices do not worry too much about whether or not they are able to schedule patients in a timely manner. The reason being, they have many fixed costs that are baked into their operating budgets. Paying for the cost of operations requires treating patients. If they can’t get patients into beds, they go under–kind of like when airlines have no passengers. The private sector is also large enough at the moment that if a patient cannot be seen at one place, they can find another. In the grand scheme of things it is about as difficult to schedule an HVAC technician as it is to schedule an appointment with a private doctor—it just depends on where you live, and the local supply and demand for services.
Because of this, it is often difficult to find an apples to apples comparison for scheduling times. In 2014, Merritt-Hawkins published a survey on Medicare/Medicaid acceptance rates and average wait times for a number of US Metropolitan areas (2). Unfortunately, their survey uses 2013 data and is limited to a few clinic types. The VA does have a public website that currently presents average wait times at all their facilities, for a similar number of clinic types (4). For purposes of brevity, only Primary (or Family) Care and Cardiology average wait times will be displayed here by number of days. The references section has links to both resources in case further research is desired.
Ruminations on Primary Care, Specialty Care, Drugs and Scheduling
While the scheduling numbers in the area listed appear comparable or better than their private sector counterparts there is something that should be mentioned here: these data were made available as a result of a well-known scandal involving the manipulation of the wait times first identified in Phoenix, but later found to be endemic of the system as a whole. Here are a few other examples:
VISN 6 (VA, NC): https://www.va.gov/oig/pubs/VAOIG-16-02618-424.pdf
Colorado Springs: https://www.va.gov/oig/pubs/VAOIG-15-02472-46.pdf
The VAOIG website is full of these. Unfortunately, bottlenecks within the system can occur. With a large number of people congregating into urban areas, it is very likely to happen in a hypothetical single payer system. Keep in mind the VA only provides care for a small minority of Americans (around 9 million) and scaling the system for the entire population is unlikely to make it work any faster, this is the practical experience in other countries as well. There is also the question of coordinating care with a specialist. So to recap the consult management practice goes like this:
AH! ➔ Appointment with PCP ➔ PCP Agrees and writes up a consult ➔Specialist receives consult and reviews ➔ Specialist accepts and schedules appointment ➔ Treatment ➔ Specialist documents treatment ➔ Specialist informs PCP of treatment ➔ Re-evaluation by PCP if needed.
Each of these steps requires human input; miss a step and the entire process stops. Stop early enough and treatment may never be given at all. One of the findings from an investigation determined there was little oversight at the time of the investigation of the process at all, which likely lead to unnecessary deaths (6). The prevailing issue with government systems such as these is lack of accountability.
In terms of prescription drug pricing, the VA formulary only works because it is a closed system. Scaling it up will create a massive market distortion that according to the Heritage Foundation, will only drive up costs (3). Consider the formulary is based on restricting the drugs it will pay for, and what doctors can prescribe. This will result in shifting costs to new medications for those willing to pay for it. There is also the matter of the formulary’s insistence on using generics. Generic drugs are made by a limited number of manufactures and if the only thing the hypothetical single payer will pay for are generics and the physician is required by law to only prescribe generics, it will only result in a temporary shortage due to the spike in demand. When coupled with the price controls it is probably going to take these companies longer to increase their manufacturing capacity due to limited funding. Of course if their lobbyists are half as good as they are rumored to be, they might avoid that. Not to mention the obvious result of, “billions of dollars in averted research and development expenditures by drug makers, forgone investment in an untold number of new drugs, and the considerable loss of valuable research and science jobs (3).”
Finally, there is little evidence that profit motive automatically results in poor outcomes. An informed pedant might throw out Roemer’s law. Which postulates that in the for profit model with an insured patient population, every hospital bed will be full. If the hospital finds that they are not balancing their books with primary care, they will simply shift their resources to providing a higher paying specialty—like cardiology. It is in this way they can maintain their patient population and continue to keep their revenue streams in place. If a patient needs a cardiac catheterization, they are probably going to be comforted by the fact the hospital they are at performs the procedure thousands of times a year. Given the procedure involves a surgeon threading a device through a vein in the groin and then insert a device into or near the heart, the patient might think of this as a feature rather than a bug. Finally, even if there are benefits to the “proactive” approach the VA system currently uses that can materialize in a hypothetical single payer, the argument this can only be achieved with a state-run system without the profit motive is made out of ignorance of the industry or dishonesty.
Why? Because there happens to be a similar for-profit system, that apparently made $504 million in Q1 2016 (8). While they are only available in a few areas, it just so happens they specialize in the same type of fully integrated, proactive approach to care that is touted as the feature of state run systems.
- Nugent, Gary et al. Value for Taxpayers’ Dollars: What VA Care Would Cost at Medicare Prices. Medical care Research and Review, Vol. 61 No. 4 (December 2004) pages 495-508. http://journals.sagepub.com/doi/pdf/10.1177/1077558704269795
- Merritt-Hawkins. 2014 Physicians Appointment Wait Times and Medicaid and Medicare Acceptance Rates. (2014) pages 1-32. https://www.merritthawkins.com/uploadedFiles/MerrittHawkings/Surveys/mha2014waitsurvPDF.pdf
- Angelo, Greg. The VA Drug Pricing Model: What Senators Should Know. The Heritage Foundation, No. 1420 (April 11, 2007) 1-4. http://s3.amazonaws.com/thf_media/2007/pdf/wm1420.pdf
- Department of Veterans Affairs. How Quickly Can My VA Facility See Me? http://www.accesstocare.va.gov/Healthcare/Timeliness
- Longman, Phillip. Best Care Anywhere. Polipoint Press, February 2007.
- U.S. Government Accountability Office (GAO). Report 14-808 VA Health Care Management and Oversight of Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty Care. http://www.gao.gov/assets/670/666248.pdf
- Reid, Chip. VA can’t afford drug for veterans suffering from hepatitis C. http://www.cbsnews.com/news/va-cant-afford-drug-for-veterans-suffering-from-hepatitis-c/ (06/22/2017)
- Rauber, Chris. Kaiser Permanente: First quarter profits down, but revenue and enrollment up. http://www.bizjournals.com/sanfrancisco/blog/2016/05/kaiser-permanente-healthcare-50-percent-drop.html (06/22/2017)