In the frenzy of reorganization activity sweeping healthcare, some of the best-kept secrets have been changes in the Department of Veterans Affairs healthcare system. Now the VA is poised for an even more profound transformation.
The veterans healthcare system originally was established to treat military-combat-related injuries and to help rehabilitate veterans with service-connected disabilities. Over the years, the system has greatly expanded. Today, the Veterans Health Administration, which runs the VA medical-care system and related activities, serves more than 40% of veterans with the highest priority for care. It has some 200,000 employees and a fiscal 1995 medical-care budget of more than $16 billion.
With its 172 medical centers, 375 ambulatory clinics, 133 nursing homes, 39 continuing-care facilities, 202 readjustment counseling centers and other resources, the VA is the largest integrated healthcare system in the United States.
Historically, the VA has been insulated from dramatic changes occurring in private healthcare. But, recognizing the need for change a couple of years ago, it began to take steps to respond to the new healthcare order. Since then, some VA medical centers have made notable progress, but systemwide changes sputtered until recently.
Charged with change.
Last fall, after having spent a decade in the forefront of healthcare change in California, I was asked by President Clinton and Secretary of Veterans Affairs Jesse Brown to assume the helm of the VHA. I was charged with restructuring, reorganizing and reconfiguring the system.
Since then, I have been gratified by the responsiveness of the system to change. I've also found that the VA is well ahead of the private sector in a number of areas. Unfortunately, the culture of the VA has been one of isolationism and introspection, so many of its achievements in such areas as quality improvement, performance monitoring, customer service and telemedicine are not well known outside the system.
Substantive patient environment improvements are still needed at a number of the older medical centers. However, people who have formed impressions of the VA through movies or sensationalistic news stories would be surprised to see today's modern facilities and their environments of compassionate care.
While having the basic ingredients and assets of an integrated healthcare system, the VA has never been managed and structured to operate as such. Instead, it has functioned as a highly centralized, rigid and hierarchical collage of independent medical centers.
The new VA. The new organization I have proposed-a decentralized federation of Veterans Integrated Service Networks-should provide the VA with the incentives and framework to function as a truly integrated system. It emphasizes pooling resources, rigorous cost management, population-based planning, customer service, process improvement and outcomes, and heightened attention to health promotion and disease prevention.
In the new VA, individual initiative, innovation and customer service are valued and rewarded, and a premium is placed on the integration of ambulatory care with acute and extended inpatient services to provide a coordinated continuum of care.
For our patients, these changes mean easier access (especially through community-based clinics), shorter waiting times, more personalized care, greater efficiency, and improved performance and quality.
We are planning to divide the country into 22 VISNs operating by Oct. 1. Over time this number is likely to change.
During the next several years, we also will transform what has been a hospital-based system into one that is rooted in ambulatory and primary care. By the end of this year, we plan to have approximately 25% of VA patients assigned to primary-care teams.
Several new clinics have been established, and plans are being developed for dozens more, all to be developed within existing resources resulting from shifting from inpatient to outpatient care.
The VA also has a long tradition of sharing agreements, partnerships and other alliances. For example, the VA has nearly 700 sharing arrangements with Department of Defense medical facilities, and more than 100 VA medical centers are affiliated with medical schools. A smaller number of such arrangements exist with local and state government health agencies, the Indian Health Service, and private providers.
In the future, when it makes more sense for fiscal or other reasons to use these arrangements instead of providing care with VA assets, then the VA will use this paradigm.
This reorganization also should strengthen the VA's ability to accomplish its other statutory missions of education and training, research, and contingency support during war or national emergency.
While the VA is the largest direct provider of healthcare services in the United States, it also is the nation's largest trainer of healthcare professionals and one of the nation's largest research enterprises. The VA has more than $1 billion devoted to clinical, basic science, epidemiologic and behavioral investigations.
The challenge and difficulties of changing the VA's immense bureaucracy and disparate missions is not to be underestimated. It will take time to get where we need to be. However, once operational, it should be apparent to our patients, Congress and the public that the new VA is not only a better way of providing care but also is superior to various alternatives that call for doing away with the system.
The veterans healthcare system is an investment and a national resource that the United States cannot afford to lose.