Best Care Anywhere

by Phillip Longman

  Wired for Science

  VistA is also useful in identifying medical procedures that don’t work, as well as particular doctors or surgeons who are not getting good results. For example, VA researchers have been able to use VistA’s database of medical records to create the first national, risk-adjusted analysis of how patients fare after undergoing different types of surgery in different veterans hospitals. The study showed good news for the system as a whole. Between 1994 and 1998, mortality rates for major surgery fell by 9 percent, while morbidity rates, or the rate of complications after surgery, fell by 30 percent. But the study also quickly showed where outcomes were best and worst, thereby pointing to which surgical teams could stand as exemplars and which needed improvement.5

  VistA’s records can also provide important insights into the environmental factors behind disease and reveal important and otherwise overlooked correlations. For example, in October 2005, Dr. Fletcher, with a few keystrokes, checked to see how many patients in DCVAMC had blood pressure readings exceeding 140/90. The answer that came back was 45 percent. When he checked again in January 2006, he found that 50 percent had readings exceeding 140/90. Perplexed, he had VistA retrieve all blood pressure readings going back to 1998 and made an important discovery: blood pressures increase every winter and drop every summer. This insight has important implications for how blood pressure readings are interpreted and for prescribing appropriate medications. It has only come to light because of VistA.

  VistA also makes it possible to track down new disease vectors with great speed and effectiveness. For example, when a veterans hospital in Kansas City noticed an outbreak of a rare form of pneumonia among its patients, its computer system quickly spotted the problem: all the patients had been treated with what turned out to be the same bad batch of nasal spray. VistA today plays a key role in the VA’s avian flu surveillance program and allows for real-time data links with the Centers for Disease Control and Prevention—features that are likely to be invaluable in the event of bioterrorist attacks as well.

  VistA has also proved invaluable during natural disasters. When Hurricanes Katrina and Rita devastated New Orleans and the Gulf Coast in 2005, just about the only people whose health-care records weren’t gone with the wind or buried in mud were veterans registered with the VA, and it made a big difference. Floodwater swamped the VA hospital in New Orleans and destroyed its hospital in Gulfport, Mississippi. In all, an estimated 100,000 veterans in the area were forced to evacuate. But thanks to VistA’s backup files, all patient records were preserved and within 100 hours became continuously available through a special Web site accessible to VA medical personnel around the country. “So if the patient walked into any VA and said, ‘I’m an evacuee from New Orleans,’” explains Terry Algood, chief of pharmacy at the Jackson Veterans Affairs Medical Center in Mississippi, “then that meant I could call into the Katrina Web site, look at the prescriptions, and then transfer those prescriptions into their database right there and take care of the patient on the spot.”6

  The VA estimates the total direct cost of installing VistA came to about $300 million in wiring and $450 million in computers. Its upkeep costs $485 million per annum, or about $90 per patient—quite a bargain!7

  But it is not just information technology spawned by the Hardhats that transformed the VA into what is now the nation’s best-performing health-care system. It also took shrewd and charismatic leadership from above to reengineer its culture and rationalize its processes. The story of the man who led that effort is one of the few truly successful examples of the Clinton era’s many attempts to reinvent government. In essence, he succeeded by allowing the institution to take advantage of three of its unique features: its large-scale and deeply integrated information systems, its long-term relationship with its patients, and its comparative freedom from market-driven forces that have impeded the quest for quality health care in the private sector.

  FIVE

  The Kizer Revolution

  Thanks to the triumph of the Hardhats, the veterans healthcare system was emerging in the mid-1990s as a world leader in the use of information technology to improve the practice of medicine. But the system was in deep political crisis—a quarter of its hospital beds were empty.1 One government audit in 1994 found that 21 out of 153 VA surgeons had gone a year or more without picking up a scalpel.2

  It looked like what would finally undo the veterans healthcare system was the rapidly declining population of veterans. By the mid-1990s, World War II veterans were passing away at a rate of 1,000 per day. Moreover, those who survived in retirement tended to migrate from the Northeast and the Midwest to the Sunbelt, leaving veterans hospitals in places like Pittsburgh or on the Colorado plains with wards of empty beds and idle staff. Meanwhile, in places like Tampa and St. Petersburg, veterans hospitals were overwhelmed with new patients, who, facing overcrowded conditions and overworked staff, found plenty to complain about.

  Adding to the threatening climate of opinion, some liberals as well as conservatives were beginning to ask questions about the veterans health-care system that they would not have dared to raise at any other time in the twentieth century. “You mention the word ‘veteran,’ and you’re supposed to pitch forward on your sword,” Senator Alan K. Simpson, Republican of Wyoming and chairman of the Veterans’ Affairs Committee, complained to the New York Times in 1994. He and other fiscal hawks increasingly saw spending on veterans health as just another wasteful form of pork barrel spending.

  Meanwhile, serious voices on the other end of the political spectrum called for simply dismantling the veterans health system. Richard Cogan, a senior fellow at the Center on Budget and Policy Priorities in Washington, told the New York Times in 1994: “The real question is whether there should be a veterans health-care system at all.”3 At a time when the other health-care systems were expanding outpatient clinics, the VA still required hospital stays for routine operations like cataract surgery. A patient couldn’t even receive a pair of crutches without checking in. Its management system was so ossified and top-down that permission for such trivial expenditures as $9.82 for a computer cable had to be approved in Washington at the highest levels of the bureaucracy.4

  The major veterans service organizations, such as the American Legion, still supported the VA, but many individual veterans, especially younger ones, would use its hospitals only as a last resort. Hollywood once again captured and helped reinforce the public’s negative perception of the VA with the movie Article 99, which was about a group of doctors in a veterans hospital who had to contend with too many patients, budget cuts, and ruthless administrators.

  Press reports, meanwhile, continued to serve up chilling anecdotes and damning conclusions. “The VA’s War on Health” read a Wall Street Journal headline in 1993. “The Worst Health Care in the Nation,” the Washington Times echoed in 1994. It was a demoralizing time for those who still believed in the nobility of the VA’s motto, which is, in words borrowed from Abraham Lincoln’s second inaugural address, “to care for him who shall have borne the battle, and for his widow, and his orphan.”

  Within the Clinton White House, skepticism about the veterans health system also ran deep. Early in the first term, Hillary Clinton and other proponents of the administration’s original health-care plan had imagined that veterans hospitals might simply be folded into a much larger federally organized system of “alliances” they were planning. Even after their master plan crashed and burned in 1993, many in the administration still questioned whether veterans hospitals ought to have a future.

  Enter Ken Kizer

  In January 1994, Kenneth W. Kizer, MD, MPH, was surprised to learn, if for no other reason than that he was a registered Republican, that he was on the administration’s short list of candidates to head the Veterans Health Administration—a position that had remained unfilled since Clinton’s election in 1992. He could hardly be sure at first what the administration might have in mind. “There were a fair number of people who thought th
e system wasn’t salvageable: people in the administration, people out of the administration, the health policy wonks. You know, there were a fair number who just said no,” Kizer recalls.

  Yet his background, temperament, and intellect had given Kizer a unique vision of not only how to reform the veterans health system, but also how to turn it into a model of twenty-first-century health care—a vision that fortunately reached the administration’s ears. In announcing his new VA Under Secretary for Health, the president enthusiastically noted, “Dr. Kizer brings a wide range of clinical and administrative expertise to the VA at a time when tested leadership will be crucial to the Department’s success in the framework of national health-care reform.” It was a prediction that has become more true today than Clinton probably dared to imagine. Indeed, future historians may well record that among Clinton’s greatest legacies was the reform of the VA, which transformed it from one of the biggest arguments against socialized medicine into one of the best arguments for it.

  Kizer was idealistic enough about his vision that when he got the nod from the Clintons, he gave up a comfortable professorship at the University of Southern California, left his wife and kids behind, and threw himself into his new job. “Everyone said don’t take the job. Or take it if you want to have yourself a fling in Washington, but don’t delude yourself by thinking that you’re actually going to be able to do anything,” Kizer recalls. “There was universal consensus that if there was one agency that was the most politically hidebound and sclerotic, it’s the VA. But what I saw, and what I thought the opportunity was, was that they had all the pieces.”

  Whatever else it was, the VA’s health-care system was a system, however ill fitted its various pieces might be. It operated 159 medical centers around the country, 375 ambulatory clinics, 133 nursing homes, 39 domiciliaries offering care to the homeless and substance abusers, and 202 readjustment counseling centers. Moreover, it had a clearly defined base of patients with whom it maintained nearly lifelong relationships, thereby opening up the prospect of effective investment in prevention and disease management.

  Kizer also liked the VA’s clear mission—to keep patients healthy—and that it didn’t have to maximize shareholders’ profits or doctors’ incomes. Also, because its mission centered on patients rather than profits, a core of VA employees were highly idealistic and committed to improving quality. As Kizer saw it, the great opportunity lay in truly integrating this system and taking advantage of its potential, including investment in prevention, primary care, and highly coordinated, patient-centered, evidence-based medicine.

  Kizer was not deeply experienced in the ways of the VHA, much less Washington. The Republican outsider, he was one of very few people to ever head the VHA who hadn’t come up through its ranks. After his first day on the job ended at about 9:00 p.m., he found himself locked outside the VHA’s underground parking lot and spent an hour pounding on doors trying to get someone to help him retrieve his car. When he finally did gain entry, he found his car vandalized. Weirdly, someone had stolen the headrests.

  But Kizer was well prepared in every other respect. Orphaned at an early age, he had worked his way up through Stanford and the University of California at Los Angeles, becoming board certified in six medical specialties. His experience with military medicine included an internship at a VA hospital as well as service as a rescue diver in the navy reserves during the 1970s.

  Adding to this background was Kizer’s academic and professional experience in public health. He practiced emergency medicine early in his career but says he was frustrated by the limitations of having to care for one patient at a time. Hoping to take a more systematic and preventive approach to health care, he joined California’s public health department in 1984 and rose through the ranks quickly. By age thirty-two he was appointed by California’s Republican governor, George Deukmejian, to become the youngest person ever to head the department.

  Developing the state’s response to the new AIDS crisis was one of the responsibilities Kizer took on in that position. He also spearheaded California’s toxic waste cleanup efforts and early antismoking initiatives. The latter included banning smoking for the first time in the public health department’s own buildings, which proved sensitive. As it happened, California’s public health department was highly unionized. Sixteen different bargaining units included everyone from its scientists to the blind vendors who sold cigarettes in the lobby. Kizer’s experience negotiating with all of these bargaining units would later prove invaluable at the VHA, whose workforce is represented by five different unions. But equally important was the cast of mind that accompanies a responsibility for the health of whole populations as opposed to one patient after another.

  This cast of mind tends to see health care as a system, not just a collection of individual doctors treating individual patients. Thus, eliminating medical errors becomes a matter not of finding a doctor or nurse to blame but of finding root causes of failure in a health-care system’s various processes and procedures, or the lack thereof. Similarly, this cast of mind naturally looks for data to answer basic questions that too often don’t get asked in the day-to-day practice of medicine, such as which drugs work better than others for most people most of the time. Because they concern themselves with how health care works at the population level, people grounded in the public health paradigm also tend to see health itself as overwhelmingly determined by environmental and behavioral factors. The ecology of health, in this view, includes obvious factors like smoking or lack of exercise, but also less obvious ones, such as how much patients become involved in their own treatment, or how integrated and coordinated the care they receive is.

  By the time Kizer arrived at the VHA, he was well prepared to appreciate the potential of the new systematic and data-driven model of care that was already being made possible by the development of VistA. He was also well prepared to see the necessity of reorienting the VHA away from a system that emphasized acute care delivered in hospitals by specialists and toward one that put overwhelming emphasis on prevention and “patient-centered” management of chronic conditions.5 The declining population of veterans would force the VHA to undergo painful downsizing, but in Kizer’s vision this change could also be the catalyst for implementing a new and profoundly more efficient and effective model of health care.

  To achieve this vision, Kizer first had to deal with politics, starting with those of the VHA itself. “The basic thesis of the transformation, when I was talking about it to people within the VA, as well as outside … was that we have to be able to demonstrate that we have an equal or better value than the private sector, or frankly we should not exist,” Kizer recalls. “That didn’t necessarily go down well, at least at first. But as a taxpayer, why should I pay for a system that provides poor quality, is inefficient, wastes money, and that the customers don’t like?”

  Demonstrating the value of the system, both to himself and to others, required formal measures or metrics of quality. By the 1990s, it had become a truism of American business that you can’t manage what you don’t measure. But within American health care at the time, systematic attempts to define, measure, and improve quality were highly unusual. The British, with their nationalized health-care system, had a long tradition of systematically studying the actual outcomes of different medical procedures and systems, and acting on them. But in this country, remarkably few researchers even had the concept of what is today known as “evidence-based medicine,” and their work was largely ignored by health-care providers.

  Nonetheless, Kizer insisted that the system measure itself against any and all benchmarks of quality for which consensus existed among health-care professionals. The early metrics often measured inputs or processes rather than outcomes, but their use was still revolutionary by the standards of U.S. health care at the time. How many diabetic patients received treatments based on “best practices”? How long did vets have to wait to get appointments? How often did medical errors occur, and what were their pat
terns? How did patient satisfaction at the VA compare with that of other health-care systems?

  Kizer combined such measures into a gimmicky but effective management tool he called the “value equation,” which he formulated as Value = technical quality + access + customer satisfaction + health-care status/cost or price. Thanks to the continuing evolution of VistA and other reporting systems, obtaining the data for this measure of cost-effectiveness would become increasingly easier, but the answers were not always pleasing or expected. For example, while it turned out that the VHA was doing a respectable job of ensuring that its few aging female patients were receiving mammograms, only about 1 percent of its elderly male patients were being screened for prostate cancer, which at the time was considered an important, preventative measure.6

  Right Sizing

  Armed with his metrics, Kizer began leading the VHA toward its transformation. One big, unpleasant, and unavoidable agenda item was how to rationalize the VHA’s excess capacity. Because of the changing demographics of the veteran population and the shift to outpatient care, the VHA had scores of hospital complexes and other facilities that had to be closed for lack of patients. It wasn’t only a matter of money; it was also a matter of safety. When surgeons pick up a scalpel only one or two times a year, they are bound to be out of practice, along with all of their operating team and nursing support.

  To help deal with this problem, Kizer began contracting with private hospitals in areas where there were too few patients to support a veterans hospital. He also supported expanding eligibility for health benefits to veterans who were neither poor nor needed treatment for service-connected disabilities. Yet these steps were still not enough to maintain a safe volume of care at many VA hospitals. In some extreme examples, such as the veterans hospital in Grand Island, Nebraska, the average daily census of patients had dropped to just two.