Private-sector health plans and providers won't be the only ones under Congress' healthcare-quality microscope this year. The Department of Veterans Affairs will be answering some tough questions about the quality of care delivered in its more than 700 healthcare facilities.
After focusing on the reorganization of the $17.7 billion VA healthcare system for about three years, the congressional panels overseeing the VA's healthcare facilities are beginning to take a closer look at how that reorganization has affected quality in local facilities.
That reorganization has involved decentralizing system management to 22 veterans integrated service networks, or VISNs, merging management of many separate facilities, closing nearly half its inpatient beds, increasing outpatient visits, trimming personnel and putting VA networks on capitated budgets.
Kenneth Kizer, M.D., VA undersecretary, argued in a recent interview that his system is ahead of the private sector in identifying and correcting quality problems.
That opinion is not widely shared in Washington. Members of Congress have begun questioning the VA's capitation formula. Physicians, along with some veterans groups, have challenged the VA's increased use of advanced-practice nurses in place of physicians (Aug. 4, 1997, p. 27; Oct. 6, 1997, p. 62).
More recently, the VA's own medical inspector's office found deficient care in VA hospitals in Castle Point, N.Y., and Montrose, N.Y. There, the office found a doubling of the percentage of cases in which care was poor or marginal between October 1996 and March 1997.
In addition, Democrats on the Senate Veterans Affairs Committee in December published a report saying the VA doesn't do a good job of coordinating its quality assurance programs and often abandons them instead of correcting flaws.
The report also criticized the VA's activities to monitor quality management programs and improve quality, and said the VA is worried more about touting its performance measures and customer feedback than about improving actual quality of care.
It recommended establishing an advisory board to develop a nationwide quality management program under Kizer's supervision.
That report's findings were echoed in a draft of an "independent budget" for the VA developed by numerous veterans and patient-advocacy groups. That document also calls for a comprehensive quality monitoring program in the VA and seeks additional legislation or money if needed to improve quality.
A Senate Democratic aide said the VA's reorganization raises questions about systemwide quality management.
"As we start to give VISNs more responsibility, who's left in the central office to monitor the quality?" the aide asked.
But Kizer contended the VA healthcare system, as a taxpayer financed provider, faces such scrutiny that it already is more accountable to the public than private-sector providers.
"I think we're ahead of the curve in terms of having our problems aired and having that critiqued," Kizer said.
The Senate Democrats' report has sparked a letter-writing battle between Kizer and Sen. Jay Rockefeller (D-W.Va.), senior Democrat on the Senate VA committee.
In a letter responding to the report, Kizer cited outcomes measures for prevention and chronic disease in which the VA outperformed the private sector, as well as improved survival rates for high-volume medical and surgical conditions. He also detailed quality programs he has tried to implement in the VA.
Last week, Rockefeller shot back, saying in a reply to Kizer that the VA often responds to quality problems by starting new programs that sound good but don't necessarily improve quality. He asked that Kizer outline specific plans to make sure that any new programs are not dismantled in the future and explain how those programs will "result in a coherent and integrated quality management system."