House Veterans’ Affairs Subcommittee on Health Hearing
Testimony by
Chairman Benishek, Ranking Member Brownley, and members of the Subcommittee, on behalf of the four co-authors of The Independent Budget (IB)--AMVETS, DAV (
We believe that two clear conclusions can be drawn from the CBO report. First, comparing the cost of health care administered by the VA to the cost of private-sector health care is not an "apples-to-apples" comparison. In fact, the CBO points out a number of factors that suggest that trying to compare VA health care and private-sector health care is essentially a fool's errand. I will address a number of these points in this testimony.
The second observation that can be drawn from this report is that it expresses no definitive conclusion on the question of which model of health care is more cost-effective. Ironically, when this report was released, we witnessed a number of interested groups and media reports suggest the report concludes that VA health care is not more cost-effective, and by extension not higher quality than private-sector health care. However, the CBO report makes no such finding. In fact, we believe the report reaffirms in many ways the value and uniqueness of VA health care.
While we appreciate the concept that the delivery of cost-effective, high quality health care should be equated across all sources of health care, such a notion ignores the many factors that make VA health care unique. The CBO report clearly outlines some important distinctions that further explain why a direct comparison between VA health care and private-sector care is difficult to say the least. Foremost among these distinctions is the fact that the
Representatives of private-sector health care organizations have testified to this very issue. At a hearing before the full
This point often gets at the heart of the discussion about physician patient panels. Proponents of private-sector health care continue to complain about the seemingly unsatisfactory number of patients that VA physicians treat individually. The CBO report suggests that VHA primary care practitioners see an average of 1,200 patients per panel, while private physicians see an average of 2,000 patients. However, CBO emphasizes that a more thorough examination of workloads for both entities should be completed before any conclusions can be drawn. The CBO explains that it is important to evaluate the case-mix and average morbidity of patients seen and the number of visits by those patients in each setting.
The second major distinction that the IB co-authors believe is the crux of the problems that the VA health care system has faced in recent years is the fact that the VHA is funded through an annual, prospective appropriations process. Under ideal circumstances, this would not be a challenge if the Administration requested and
Deputy
Ultimately, we believe the central question when comparing VA health care to private-sector health care should focus on the quality and value of care. While we recognize that there is much debate underway about the quality of care being delivered at VA medical facilities around the country, we believe that private-sector health care systems by and large could not stand up to the same level or intensity of scrutiny VA is under. We will not dispute the idea that timely access to high quality health care services remains a clear objective that the VA is not achieving in a satisfactory manner. Access to health care, along with the cost and quality of that care, are generally considered the three major indicators for evaluating the performance of a health care system or provider. Prevalent delays in delivering timely care result in patient dissatisfaction, higher costs, and increased risk for adverse clinical consequences.
Moreover, while an argument could be made for primary care for some veteran patients to be delivered outside of VA, it is an indisputable fact that most of VA's specialized services--spinal cord injury care, amputee care, blinded care, polytrauma care, etc.--are incomparable resources that could not be duplicated and successfully sustained in the private sector. Establishing a scenario whereby veterans could choose to leave the VA health care system under the guise of more cost-effective care being available elsewhere, would place the entire VA system of care at risk. Former VA Secretary
"Vouchers (a previously proposed component of private-sector care) are not necessary to ensure high-quality health care...While this may have value in areas with long waiting lists, it raises serious questions. The VA system is valuable because it is able to provide specialized health care for the unique medical issues that veterans face, such as prosthetic care, spinal-cord injury and mental-health care. If there is too great a clamor for vouchers to be used in outside hospitals and clinics, the VA system will fail for lack of patients and funds, and the nation would lose a unique health-care asset."
These services do not function in a vacuum. The viability of the VA health care system depends upon a fully integrated system in which the organization and management of services are interdependent so that veterans get the care they need, when and where they need it, in a user-friendly way, to achieve the desired results and provide value for the resources spent. Sending veterans into the private health care marketplace would serve only to support part of this principle while it would undermine others. Similarly, contract care simply is not a viable option for veterans with complex, catastrophic, and specialized health care needs. Sending these individuals outside of the VA would actually place their health at significant risk while abrogating VA of the responsibility to ensure timely delivery of high quality health care for our nation's veterans. This is not to suggest that leveraging coordinated, purchased care is not part of the solution to the known access problems in VA. However, granting veterans access to the private-sector, particularly when nothing guarantees that private care is more cost-effective or of greater value and higher quality, should not come at the expense of the existing health care system and the veterans who rely almost solely on the VA for their health care and maintenance of their health.
As the CBO report points out, the VHA operates one of the largest integrated health care systems in
* Comprehensive medical records that are accessible to all providers in all care locations.
* Collaboration among physicians and coordination of care among locations.
* Physicians' performance can be measured using factors that contribute to the overall health and improvement of patients.
However, CBO explains that while there are a number of integrated delivery systems in the U.S. (such as
In the book Best Care Anywhere Why VA Health Care is Better Than Yours, author
Proponents of private-sector health care for veterans also overlook the fact that VA health care providers treat veterans in a holistic manner, and throughout the course of their lives. While many individuals (including most veterans) have family physicians and primary care practices with whom they maintain relationships for long periods, they generally are not involved in holistic care.
The IB co-authors believe that the quality of VA health care is generally excellent, as long as it is accessible. In fact, as mentioned previously, VA patient satisfaction surveys reflect that more than 85 percent of veterans receiving care directly from the VA rate that care excellent (a number that surpasses satisfaction rates in the private-sector). The fact is that the most common complaint from veterans who are seeking care or who have already received care in the VA is timeliness. We believe that veterans want to receive their care from the VA. This is not to suggest that purchased care does not play a role in the delivery of health care services for veterans when necessary. But why is there a concerted effort to push that care into the private-sector? Much like the concept of "choice" provided by P.L. 113-146, the "Veterans' Access to Care Through Choice, Accountability, and Transparency Act (VACAA)," we question the motivations of such an effort. We believe that the more than eight million veterans who have enrolled in VA health care and the nearly seven million veterans who are unique users have made a choice to rely on VA. We would suggest the same about the nearly 13 million veterans who are not enrolled in VA health care. They are provided for elsewhere. These statistics suggest to the IB co-authors that a concerted effort must be made to strengthen the existing VA system to meet the health care demands of the veterans who are seeking care directly from VA.
The CBO report and previous discussions and hearings make it clear to the IB co-authors that comparing VA health care and private-sector health care is at minimum complicated, if not outright impossible. Too many uncontrollable variables would confuse any outcomes or conclusions from such a study. A common refrain we hear from those clamoring for increased access to private health care services is the lack of data from the VA on its services and performance. However, CBO raises an important point that further explains the difficulty with comparing VA health care and private-sector care. The CBO report explains that comparisons would be challenging because private-sector data are also incomplete, unavailable, and difficult to make comparable with VHA data. To be clear, the IB co-authors believe that VHA should be far more forthcoming with data that allows for a thorough examination of the timeliness and quality of its services, and the capacities VA maintains to meet these requirements. However, the concern over VA's apparent lack of transparency on data cannot be set aside when the private sector cannot, and often does not attempt to, produce the same information.
Once again, we appreciate the Subcommittee's focusing on this important issue. As the delivery of non-VA health care for veterans evolves, particularly in light of the VACAA and the expansion of Non-VA Purchased Care and the Patient-Centered Community Care (PC3) program, it will be important for
This concludes my testimony. I, and the co-authors of The Independent Budget, will be happy to answer any questions you may have.
Read this original document at: http://veterans.house.gov/witness-testimony/carl-blake-16
House Veterans’ Affairs Subcommittee on Health Hearing
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