PNHP backgrounder on the VA – June 2014

PNHP has physician-spokespeople who are available to the media for comment on these issues. To schedule an interview, contact PNHP communications director Mark Almberg at mark@pnhp.org.

1. Waits for care in the Veterans Health Administration are probably similar to (or shorter than) waits elsewhere, but are more carefully scrutinized in the VA.

• Notwithstanding recent reports of long waits for non-urgent care at some sites for new patients, a recent audit of VA wait times system-wide found that 96 percent of the 6,004,350 appointments currently scheduled have wait times of 30 days or less. Only 4 percent of appointments have wait times of more than 30 days.
• At the Phoenix VA, where the investigation started, 89 percent of appointments have wait times under 30 days. The average wait for established patients to see a primary care doctor was 3 days, and to see a specialist was 14 days.
• Overall, the audit found 57,436 veterans (<1 percent of appointments) can’t be seen in the next 90 days and are waiting for appointments, and another 63,869 veterans (1 percent) have enrolled in the VHA in the past 10 years but have never sought an appointment, most likely because they have other coverage. (Some veterans sign up for the VA in case eligibility standards tighten in the future.) The VA plans to contact the last two groups (VA Audit Wait Times Fact Sheet, 6/9/2014).
• According to a recent Massachusetts Medical Society survey, the average wait time for a new patient appointment for an internist in that state (which has the most doctors per capita) is 50 days and for a family physician is 39 days (MMS Patient Access to Care Study, Massachusetts Medical Society, 7/2013).
• According to a recent Merritt Hawkins survey of wait times, the cumulative average wait time to see a physician in five specialties (family medicine, OB/GYN, dermatology, cardiology and orthopedic surgery) in 15 major metropolitan markets in 2013 was 18.5 days, and in some cases much longer (2014 Physician Appointment Wait Times, Merritt Hawkins).
• Even the longest waits for care in the private sector don’t reflect the true extent of unmet need because over one-third (37 percent) of adults forgo care due to financial concerns (Schoen et al., “Access, Affordability, And Insurance Complexity Are Often Worse In The United States Compared To Ten Other Countries,” Health Affairs, 11/2013).
• In many locales, Medicaid patients face long waits because many private physicians and hospitals do not accept Medicaid. A recent study found that children with Medicaid waited 22 days longer for an appointment than the privately insured (Bisgaier et al., “Auditing Access to Specialty Care for Children with Public Insurance,” NEJM, 6/16/2011).

2. Long waits in the VA result largely from inadequate resources, especially a shortage of clinicians, not inefficiency.

• There are over 400 positions for primary care physicians that are currently unfilled in the VA, reflecting both a national shortage of primary care doctors and the VA’s relatively low pay scale (Oppel and Goodnough, “Doctor Shortage Is Cited in Delays at V.A. Hospitals,” New York Times, 5/29/14).
• The VA has faced a surge in demand by aging Vietnam-era vets with a rapidly growing burden of chronic illness and the 6.4 million veterans of the wars in Iraq and Afghanistan, many of whom have severe injuries that will require lifelong care and/or mental health problems such as PTSD. Another factor contributing to increased demand is a greater willingness to seek mental health care among younger veterans.
• The loosening of VA eligibility standards by the Obama administration in 2010 contributed to a large influx of new patients. Veterans with certain illnesses that have been linked to Agent Orange exposure (including Parkinson’s disease, prostate cancer, diabetes and ischemic heart disease) are now presumed to have a service-related condition and to be eligible for VA care. The VA simultaneously reduced demands for documentation supporting claims of post-traumatic stress disorder (Longman, “VA Care: Still the Best Care Anywhere?” Washington Monthly, 6/3/2014).
• While the VA budget kept up with overall medical inflation between 2003 and 2012, rising from $25.5 billion to $45.5 billion, the increase did not take into account the increased demand for services (Merrill Goozner, “Beyond the theatrics of the VA wait-list scandal,” Modern Healthcare, 5/24/2014).
• The inadequate supply of VA resources is particularly acute in the South (e.g. Phoenix and Miami), where the population of older vets has increased rapidly, but VA resources have not.

3. Studies indicate that quality of care at the VA is, on average, as good as or better than in the private sector.

• A Rand study found that: 
  • VA patients received much more of the care recommended by national standards, 66 percent as opposed to 50 percent in a representative national sample of non-veterans.
  • Among chronic care patients, VA patients received about 70 percent of recommended care, compared with about 60 percent in the national sample.
  • For preventive care, the difference was greater: VA patients received about 65 percent of recommended care, while patients in the national sample received 45 percent.
  • VA patients received consistently better care across the board, including screening, diagnosis, treatment, and follow-up (Asch et al., “Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample,” Annals of Internal Medicine, 12/21/2004).
• A recent systematic review concluded: “Studies that assessed recommended processes of care almost always demonstrated that the VA performed better than non-VA comparison groups. Studies that assessed risk-adjusted mortality generally found similar rates for patients in VA and non-VA settings” (Trivedi et al., “Systematic review: comparison of the quality of medical care in Veterans Affairs and non-Veterans Affairs settings,” Medical Care, 1/2011).
• A direct comparison of quality in the VA and Medicare Advantage (MA) plans concluded that: “Among persons aged 65 years or older, the VA health-care system significantly outperformed private-sector MA plans and delivered care that was less variable by site, geographic region, and socioeconomic status” (Trivedi et al., “Quality and equity of care in the VA and Medicare Advantage health plans,” Medical Care, 6/2011).
• Patients cared for in the VA have lower risk-adjusted mortality compared with those in private Medicare Advantage plans. (AJ Selim et al., “Risk-adjusted mortality as an indicator of outcomes: comparison of Medicare Advantage Program with the Veterans Health Administration” Medical Care, 4/2006).
• Patient satisfaction scores at the VA are consistently higher than the private sector. For patients recently discharged from a VA hospital, average overall satisfaction is 4 points higher (84 out of 100 points) than for patients discharged from non-VA hospitals. When asked if they would use a VA medical center the next time they need inpatient or outpatient care, veterans overwhelmingly indicate that they would (96 percent and 95 percent, respectively). (Final report: 2013 Customer Satisfaction Inpatient Survey, CFI Group, 3/2014).

4. VA costs are lower than private sector costs and rising more slowly.

• If the VA were paid at Medicare rates, the payments would be 20 percent higher than actual VA costs, a difference of more than $5 billion in 2003 (Nugent et al., “Value for Taxpayers’ Dollars: What VA Care Would Cost at Medicare Prices,” Medical Care Research and Review, 2004: 61, 495-508).
• According to the Congressional Budget Office, between 1999 and 2005, per enrollee costs grew by 1.7 percent in the VA compared to 29.4 percent in Medicare and 70 percent for private family coverage (CBO, “The Healthcare System for Veterans: An Interim Report,” 12/2007).
• In 2009, the VA provided $3.2 billion worth of care to Medicare HMO enrollees, but collected only $9.4 million for that care – providing a large subsidy to the private plans (Trivedi, A., et al., “Duplicate federal payments for dual enrollees in Medicare Advantage Plans and the Veterans Affairs health care system.” JAMA, 7/4/2012).
• Privatizing the VA would increase costs and reduce quality. Allowing private HMOs into Medicare has raised Medicare’s costs by over $283 billion since 1985. In addition, the VA “significantly outperforms” Medicare Advantage plans on quality measures. (Hellander et al., “Medicare Overpayments to Private Plans, 1985-2012,” International Journal of Health Services, Volume 43, Number 2, 2013 and Trivedi et al., “Quality and equity of care in the VA and Medicare Advantage health plans,” Medical Care, 6/2011).

5. The alleged fraudulent reporting of wait times by VA officials was apparently stimulated by pay-for-performance (P4P) incentives. Similar fraudulent reporting occurs in the private sector. P4P incentives are the problem, not the VA.

• 95 percent of Medicare HMOs falsely inflate their quality statistics (Cooper et al., “Underreporting high-risk prescribing among Medicare Advantage Plans: A cross-sectional analysis,” Annals of Internal Medicine, 10/2013).
• Behavioral economics research indicates that such financial incentives generally result in widespread cheating (Ariely, “The Honest Truth About Dishonesty,” 2013).

6. The VA is not a single-payer system. It coexists with many other payers, and not all veterans are eligible for care at the VA.

• Of 21.6 million veterans, only 9.1 million are enrolled in the VHA system.
• 2.3 million veterans and their family members were uninsured in 2010. Nationally, 41.2 percent of uninsured veterans report unmet medical needs and 33.7 percent report delaying care due to cost (Haley and Kenney, “Uninsured Veterans and Family Members,” Urban Institute, 5/2012).
• VA care is not an entitlement. Iraq and Afghanistan veterans are automatically eligible for VA care for five years after discharge. After that, they are subject to means testing or must show that they have a service-related condition like Vietnam-era veterans to determine if they are eligible. Eligibility determinations can take 6-9 months or longer, and are often confused by veterans and the media as waiting times for appointments, which are completely separate. The need to determine eligibility would be unnecessary in a single-payer system.