The VA Healthcare System: A Broken System with Superior Quality

The Veterans’ Affairs Healthcare System has weathered a lot of criticism over the past several years, starting back in the early 1990s prior to a series of reforms and more recently after the disclosure of a secret wait list at some hospitals that delayed patients’ treatment. However, one positive development has been the release of VA hospital’s quality scores. Until late 2016, when they were published in a USA Today article, the ratings had been kept private, reportedly out of fears that bad scores would unfairly tarnish an individual hospital. The ratings show that, in spite of documented administrative problems and a generally poorer and sicker patient base, VA hospitals tend to outperform non-VA facilities in several key areas of clinical care.
The quality scores at VA hospitals include many of the standard ratings for commercial and public facilities, such as Agency for Health Care Quality (AHCQ) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), making it easier to compare their performance.

Median 30-Day Readmission and Mortality Rates*

Measure VA Hospitals Readmission All Others Readmission VA Hospitals Mortality All Others Mortality
Heart Attack 15.6 16.8 9.1 14.0
Heart Failure  19.1 21.9 7.7 12.1
COPD 16.2 19.9 5.9 8.0
Pneumonia 14.7 17.0 8.6 16.3

*Collection period for VA hospitals is from Oct 2013 to Sep 2015, period for all others is from Jul 2012 to Sep 2015. Data from CMS and Definitive Healthcare

Median Serious Complication Measures (rate per 1000 discharges)*

Measure VA Hospitals All Others
Collapsed Lung  0.67 0.40
Serious Blood Clot After Surgery  0.69 4.75
Post-Op Abdominal Wound Split  1.35 2.23
Accidental Cut or Puncture 0.43 1.38

*Collection period for VA hospitals is from Oct 2013 to Sep 2015, period for all others is from Jul 2012 to Sep 2015. Data from CMS and Definitive Healthcare

As seen in the above tables, the median VA hospital displayed superior performance to its median non-VA counterpart, with better readmission and mortality rates for all the major conditions measured by CMS. In terms of complication measures, VA hospitals again did substantially better, with the exception of collapsed lung rates.

Several factors may play a role in the quality difference. One possible explanation is that the VA has had a strong focus on outpatient care and preventive medicine since its major reforms in the 1990s. Studies have found, for instance, that elderly VA patients had higher rates of vaccinations for influenza and pneumonia than the general population. In addition, a recent RAND review of existing literature concluded that the VA’s outpatient centers rated higher for diabetes care and screening for cancer and heart disease, both of which can translate to better inpatient outcomes.

Another likely factor is that the VA’s status as a government entity subjects it to more oversight and scrutiny than the typical privately owned healthcare system. While not always as freely available as it is now, the VA’s performance data has been accessed by independent researchers in the past and VA administrators have issued periodic reports on clinical quality to Congress and the public. With the growing volume of VA patients stemming from military conflicts over the past several years, public pressure is a significant motivator for quality improvement.

Despite relatively high clinical quality, patient satisfaction scores present a mixed picture. Median VA hospital scores are comparable or worse compared to the median of all other facilities. As seen in the table below, the median VA score fell short in overall rating, provider communication, noise level, pain control, and whether a patient would recommend the hospital to others. Some scores, such as noise level, can likely be attributed to the older average age of VA facilities, which was 45 years, compared to 12 years at non-VA facilities, according to a 2009 report. Others may be a result of lower staffing levels that have plagued VA hospitals in recent years.

Median HCAHPS Scores*

Measure VA Hospitals All Others
 Strongly Understood Discharge Instructions  54 52
 Gave 9 or 10 Rating  67 72
 Caregivers Always Explained Medicines Administered  66 64
 Always Quiet at Night 56 62
 Doctors Always Communicated Well  77 81
 Nurses Always Communicated Well  74 80
 Pain Always Well Controlled  64 71
Bathroom Always Clean  74 73
Always Helped as Soon as Possible  65 67
Given Information About Home Recovery  87 87
Would Recommend Hospital  68  72

*Collection period for VA hospitals is from April 2015 to Mar 2016, period for all others is from Jun 2016 to Dec 2016. Data from CMS and Definitive Healthcare

While many have called for an overhaul of the VA Healthcare System, it’s important to note that the general consensus is that the main obstacles are administrative in nature, rather than clinical. A 2016 Congressional report from the Commission on Care stated that the system’s viability is threatened by “problems with staffing, facilities, capital needs, information systems, health care disparities, and procurement.” Despite poor performance by individual hospitals, it adds “care delivered by VA is in many ways comparable or better in clinical quality to that generally available in the private sector.” It’s an important distinction that is usually overlooked in the discussion over the VA. An equally worthy question to “How to fix the VA” is “How can hospitals replicate the VA’s clinical performance?”

Definitive Healthcare has the most up-to-date, comprehensive and integrated data on over 7,700 hospitals, 1.4 million physicians, and numerous other healthcare providers. Our databases include detailed profiles on all types of hospitals, featuring a wide variety of financial, clinical, and quality metrics.

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