2018 Panel Discussion on "Veterans Choice Program and Value-Based Care in VHA: How Can VHA Comp

The 2018 Annual Meeting of the AVAS was blessed with several enlightening panel discussions. The initial panel discussion (moderated by Jason Johanning, MD and Ronnie Rosenthal, MD) was on “Veterans Choice Program (VCP) and value-based care in Veterans Health Administration (VHA): how can VHA compete with private sector?“ Carolyn Clancy, MD (Executive-in-Charge, VHA) led the panel with her discussion on “What are the goals of VCP from the central office perspective? how can VA compete with private sector to deliver high-quality subspecialty surgical care?“ Dr. Clancy discussed the challenges faced in the VA. She noted that we should not allow these challenges to overshadow the potential greatness to be gained by the VA system. These challenges include:

  • Bureaucratic system

  • Duplications of functions and system of workarounds

  • Numerous uncoordinated initiatives

  • Inconsistent roles and responsibilities management/ leadership transitions

  • Weak governance structure with little decision-making authority

Dr. Clancy conceded that VHA headquarters should help facilities bypass these barriers. She explained that the Network should decide which services must the VA provide and which we should divert to the community. This discussion was a constant reminder that the VA must strive to be a Veteran driven system of care that focuses on the following:

  • Leverage of technology and tools

  • Provision of care without boundaries

  • Provision of seamless care coordination

  • Provision of care when needed

  • Empowerment of veterans in their own care

  • Delivery of Whole Health.

She also reminded the group that in many aspects the VA is ahead of the Healthcare game. We are way ahead of the world in terms of what we can do remotely. The VA has been outperforming the private sector in most indicators for some time now. Our challenge for our veterans is that they had previously been serving well outlined missions. In addition, they learn the cardinal principal that you always take care of your buddy. However, in the outside world, life is not so well organized. It is difficult for veterans to adjust to a world that is not well organized. Dr. Clancy outlined the Priorities of the VA as Follows:

  • Greater choice for Veterans through an integrated High Performing Network

  • Quality and Safety

  • Improving patient experience.

She concluded that in the end we must remember that the drivers for customer service are really the communication between doctors and nurses. Dr. Vince DeGennaro, MD (Chief of Staff Miami VA HCS, surgeon) followed with his discussion on “how do you balance VCP vs maintain keeping in-house surgical volume?“ Dr. DeGenanaro began his talk by reminding the audience that “Any captain can captain the seas when things are calm but it takes a REAL captain to lead the ship when things are rough.” Dr. DeGennaro noted that community care will remain an essential component of Veteran care. To do this we need to improve Veterans’ choice of community providers in meeting their needs. We need to simplify veteran eligibility with a focus on Veterans’ needs. We need to consolidate community care programs and add convenient care benefits with timely payment strategies. We must also permit medical record sharing in the network. Perhaps most importantly per Dr. DeGennaro was the need to address clinical staff shortages through expansion of GME and improve VA hiring and retention. Dr. DeGenarro discussed that measuring patient experience is not as simple as we attempt to make it sound. The experience is entirely graded by the patients’ expectations. He noted that the “secret of change is to focus all of your energy NOT on Fighting the old BUT on building the new.” He explained that our focus should be on customer service. He noted that those who do not make customer service a priority will have responsibility to bear. Transparency will be vital for us to survive. The need to remember our internal customers was emphasized – including the strengthening of the Primary care-Specialty Care alliance. Dr. DeGenarro reminded everyone of the scarcity of surgeons across the US. He explained that the shape of the future will be a group practice with APRNS with an MD assigned for consultation. There should be a specialist traveling to those smaller sites once a month at minimum. He emphasized that the MD lectures to Primary care providers monthly on case studies is vital. Complex care would then be deferred to the hub. He concluded by reminding us that “however beautiful the strategy, you should occasionally look at the results” because “we are often not measuring what we think we are measuring”. Edward J. Young, M.D. (Professor, Baylor College of Medicine and Chief, Infection Prevention & Control, Michael E. DeBakey VA Medical Center, Houston, TX) discussed “Why I choose VA care”. Dr. Young is in a unique position (as a veteran, former Chief of Staff and currently practicing infectious diseases physician) to explain why one would choose to obtain care at the VA. Dr. Young reviewed Hollywood’s depiction of VA hospitals, noting that three of five films cited depicted a positive picture whereas in the remainder, the VA was portrayed negatively, sometimes virulently negative. Dr. Young presented an unofficial survey of the attitudes of some of his clinic patients regarding their reasons for choosing VA care. Camaraderie outnumbered lack of insurance or reputation of VA by most respondents. Next, he reviewed a 2010 HSR&D report comparing the quality of care in VA and non-VA settings. Among 17 reports comparing surgical specialties, 9 reported no difference, 3 reported better outcomes by VA and 5 reported worse outcomes by VA. When more recent publications were reviewed, VA surgical outcomes were comparable to or better than the private sector in most areas studied. In fact, the outcome of heart surgeries and vascular procedures performed in the VA were statistically superior to non-VA facilities. Possible reasons for superior performance included VA’s investment in electronic health records (1970s), performance measures (NSQUIP 1980s and SAIL 1990s), and embedded teaching and research programs.


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