Veterans Health Administration
|Veterans Health Administration|
|Jurisdiction||Federal government of the United States|
|Headquarters||810 Vermont Avenue NW., Washington, D.C., United States
|Employees||279,792 (March 2011) |
|Annual budget||$47 billion USD (2011) |
|Agency executive||Robert Petzel, Under Secretary of Veterans Affairs for Health|
|Parent Agency||United States Department of Veterans Affairs|
The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics, hospitals, medical centers and long-term healthcare facilities (i.e., nursing homes).
The VHA division has more employees than all other elements of the VA combined.
|Health care in the United States|
|Government Health Programs|
|Private health coverage|
|Health care reform law|
|State level reform|
|Municipal health coverage|
The first Federal agency to provide medical care to veterans was the Naval Home in Philadelphia, PA. The home was created in 1812 and was followed by the creation of Soldiers Home in 1853 and St. Elizabeth's Hospital in 1855. Congress created the National Home for Disabled Volunteer Soldiers in 1865 in response to the high number of Civil War casualties. These homes were initially intended to be room and board for disabled veterans. However, by the late 1920s, the homes were providing a level of care comparable to hospital care.
President Hoover created the Veterans Administration (VA) in 1930 to consolidate all veteran services. General Omar N. Bradley was appointed to VA administrator and Bradley appointed Major General Paul Hawley as director of VA medicine, both in 1945. Hawley successfully established a policy that affiliated new VA hospitals with medical schools. Hawley also promoted resident and teaching fellowships at VA hospitals. Ultimately, Hawley was responsible for starting the hospital-based research program at the VA. Bradley resigned in 1947. However, upon resignation, 97 hospitals were in operation and 29 new hospitals had been built. As a result, the VA health system was able to serve a much larger population of veterans than it had served in previous years.
President Reagan Elevated the VA to cabinet status in 1988, which became known as the Department of Veterans Affairs. The Department of Veterans Affairs oversees the Veterans Health Administration.
In the mid-1980s the VHA was criticized for their high operative mortality. To that end, Congress passed Public Law 99-166 in December 1985 which mandated the VHA to report their outcomes in comparison to national averages and the information must be risk-adjusted to account for the severity of illness of the VHA surgical patient population. In 1991 the National VA Surgical Risk Study (NVASRS) began in 44 Veterans Administration Medical Centers. By 31 December 1993 there was information for 500,000 non-cardiac surgical procedures. In 1994 NVASRS was expanded to all 128 VHA hospitals that performed surgery. The name was then changed to the National Surgical Quality Improvement Program.
Beginning in the mid-1990s VHA underwent what the agency characterizes as a major transformation aimed at improving the quality and efficiency of care it provides to its patients. That transformation included eliminating underutilized inpatient beds and facilities, expanding outpatient clinics, and restructuring eligibility rules. A major focus of the transformation was the tracking of a number of performance indicators—including quality-of-care measures—and holding senior managers accountable for improvements in those measures.
VA Health Reform 
1993 Clinton Healthcare Reform 
The Clinton Healthcare Plan was a health care reform proposed by the Clinton Administration. Even though the reform was not successful, a task force was created in response to the Clinton Healthcare Reform proposal to determine if the VA was ready for managed care. The negative results of market research forced the VA system to re-evaluate its current operations. Research revealed that 3 out of 4 veterans would leave the VA network if a national healthcare system were adopted. They also found that there was a high demand for primary care throughout the VA system. Research showed that many VA facilities believed that 55 percent of patients would choose to receive primary care at the VA facility if a primary care system was fully implemented in 1993. The study also showed that the VA facilities believed that 83 percent of veterans would choose to receive primary care at the VA if fully implemented by 1998. These results made it clear to the administration that it was time for a reform.
1994 VA Primary Care Directive 
This directive required all VA facilities to have primary care teams by year 1996. As a result, percentage of patients receiving primary care at the VA increased from 38 percent to 45 percent to 95 percent, during 1993, 1996, and 1999. This mandate served as the foundation for the VA reorganization under Dr. Kenneth W. Kizer.
Dr. Kenneth W. Kizer and the VA Reform 
Dr. Kizer, a physician trained in emergency medicine and Public Health, was appointed by President Bill Clinton as Director of U.S. Veterans Health Administration in 1994. He was hired to update and modernize the VA health system in order to eliminate negative perception and to align the system with current market trends. Core issues included:
- -Advancements in technology and biomedical knowledge
- -Aging and socioeconomically disadvantaged Medicare patients
- -Coordinating care
- -Rising healthcare costs
There was much opposition to a major reform. Many legislators preferred an incremental change over a wide-scale reform. However, Kizer was known as being very innovative. In order to publicize his vision he expressed his mission and vision of the "new VHA" and outlined seven key principles to guide change. His ultimate goal was to provide coordinated, high quality care at a low cost.
He launched his reorganization plan in 1995 by decentralizing the VA system. He organized all VA operating units into 22 geographic based networks known as Veterans Integrated Service Networks (VISNs). This allowed networks to manage themselves and adapt to the demographics of their location. Patients were then assigned to a group of doctors who would provide coordinated care. One director was hired for each VISN network. Instead of hiring all directors internally, a third of the newly hired VISN directors were hired outside of the VA system. The directors were responsible for meeting performance goals and improving upon measurable key efficiency and quality indicators. Directors monitored performances and reports were generated to show each network's performance. Some of these indicators included:
- -chronic disease quality
- -prevention performance
- -patient satisfaction ratings
- -utilization management
The reform also changed the procedure for allocating funds to the various VISNs. Historically, funds were distributed between hospitals based on historical costs. However, it was found that this method affected efficiency and quality of services. Therefore, funding for each VISN was distributed based on the number of veterans seen in each network, rather than on historical values.
The New England Journal of Medicine conducted a study from 1994-2000 to evaluate the efficacy of the healthcare reform. They gathered the results of the evaluated key indicators from each of the networks and interpreted the results. There were noticeable improvements, compared with the same key indicators used for the Medicare fee for service system, as soon as two years after the reorganization. These improvements continued through year 2000. These results indicate that the changes made throughout the VA healthcare system, under the leadership of Kizer, did improve the efficiency and quality of care in VA healthcare system.
Use of Electronic Records 
VHA is especially praised for its efforts in developing a low cost open source electronic medical records system VistA  which can be accessed remotely (with secure passwords) by health care providers. With this system, patients and nurses are given bar-coded wristbands, and all medications are bar-coded as well. Nurses are given wands, which they use to scan themselves, the patient, and the medication bottle before dispensing drugs. This helps prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives.
At some VHA medical facilities, doctors use wireless laptops, putting in information and getting electronic signatures for procedures. Doctors can call up patient records, order prescriptions, view X-rays or graph a chart of risk factors and medications to decide treatments. Patients have a home page that have boxes for allergies and medications, records every visit, call and note, and issues prompts reminding doctors to make routine checks. This technology has helped the VHA achieve cost controls and care quality that the majority of private providers cannot achieve.
VA Today 
Overall Evaluation 
"Patients routinely rank the veterans system above the alternatives, according to the American Customer Satisfaction Index." In 2008, the VHA got a satisfaction rating of 85 for inpatient treatment, compared with 77 for private hospitals. In the same report the VHA outpatient care scored 3 points higher than for private hospitals.
"As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators." 
A study that compared VHA with commercial managed care systems in their treatment of diabetes patients found that in all seven measures of quality, the VHA provided better care.
A RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality; Patients from the VHA scored significantly higher for adjusted overall quality, chronic disease care, and preventive care, but not for acute care.
A 2009 Congressional Budget Office report on the VHA found that "the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines — particularly those that VHA has emphasized in its internal performance measurement system. Such research is complicated by the fact that most users of VHA's services receive at least part of their care from outside providers." 
VA Mental Health Services 
The percentage of veterans seen at the VA with a mental illness was 15 percent in 2007. Trends show that the percentage of veterans with mental illnesses will continue to increase. The VA has directed its attention to this growing trend and is making mental health care for veterans a priority. For example, the VA allocated an extra 1.4 billion dollars per year to the mental health program between 2005 and 2008. They also implemented a five-year Mental Health Strategic Plan to expand and improve the mental health program. The status of the Mental Health program in 2006 was evaluated as a part of Mental Health Strategic Plan. The results are as follows:
- Quality of care at the VA was shown to be better than the private sector. The VA had a higher level of performance then the private sector for 7 out of 9 indicators. In fact, they "exceeded private plan performance by large margins."
- Patients did not indicate improvement in their conditions. However, they had a very favorable opinions of their care.
Healthcare for Women Veterans 
With the population of Women veterans projected to rise from 1.6 million in 2000 to 1.9 million in 2020, the VA has been focusing on integrating quality women's medical services into the VA system. However, studies show that 66.9 percent of women who do not use the VA for women's services consider private practice physicians more convenient. Also, 48.5 percent of women do not use women's services at the VA due to a lack of knowledge of VA eligibility and services. This study indicates that the VA still has room for improvement with convenience and education regarding women's medical services.
Doctors who work in the VHA system are typically paid less in core compensation than their counterparts in private practice. However, VHA compensation includes benefits not generally available to doctors in private practice, such as lesser threat of malpractice lawsuits, freedom from billing and insurance company payment administration, and the availability of the government's open source electronic records system VistA.
The VHA has expanded its outreach efforts to include men and women veterans and homeless veterans.
The VHA, through its academic affiliations, has helped train thousands of physicians, dentists, and other health professionals. Several newer VA medical centers have been purposely located adjacent to medical schools.
The VHA support for research and residency/fellowship training programs has made the VA system a leader in the fields of geriatrics , spinal cord injuries , Parkinson's disease , and palliative care.
The VHA has initiatives in place to provide a "seamless transition" to newly-discharged veterans transitioning from Department of Defense health care to VA care for conditions incurred in Iraq or Afghanistan.
The Veterans Health Administration Office of Research and Development's research into developing better-functioning prosthetic limbs, and treatment of PTSD are also heralded. The VHA has devoted many years of research into the health effects of the herbicide Agent Orange used by military forces in Vietnam.
In October 2012, the VHA announced a new goal "to care for and heal our wounded Veterans. In addition to repairing their damaged bodies and minds, VA has embarked on a unique campaign to repair their crumbling intimate relationships." 
Eligibility for benefits 
By Federal law, eligibility for benefits is determined by a system of eight Priority Groups. Retirees from military service, veterans with service-connected injuries or conditions rated by VA, and Purple Heart recipients are within the higher priority groups.
Veterans without rated service-connected conditions may become eligible based on financial need, adjusted for local cost of living. Veterans who do not have service-connected disabilities totaling 50% or more may be subject to copayments for any care they received for nonservice-connected conditions.
Eligibility for VA dental care and nursing home care are much more restricted. VA nursing homes are primarily for veterans needing care for a service-connected condition, or who have service-connected disability ratings of 70% or higher. Reservists and National Guardsmen who were called to active duty by a Federal Executive Order qualify for VA health care benefits.
In 2010, there were 1 million veterans receiving disability pensions. 25% of these were Vietnam veterans with the disability of adult-onset diabetes. More Vietnam veterans are being compensated for diabetes than any other disease.
See also 
- CHAMPVA Supplemental Insurance
- List of Veterans Affairs medical facilities
- Veterans Health Information Systems and Technology Architecture (VistA)
- Journal of Rehabilitation Research and Development
- Retirement community
- Rehabilitation Research and Development Service
- United States Secretary of Veterans Affairs
- VA History in Brief.(n.d.). Department of Veteran's Affairs
- Khuri, SF; Daley, J; Henderson, WG (2002). "The Comparative Assessment and Improvement of Quality Surgical Care in the Department of Veterans Affairs". Archives of Surgery 137 (1): 20–27. doi:10.1001/archsurg.137.1.20. PMID 11772210.
- Quality Initiatives Undertaken by the Veterans Health Administration Congressional Budget Office Report, August 2009
- Inglehart, J. K., (October 1996). Reform of the Veterans Affairs Health Care System. The New England Journal of Medicine. 335(18).
- Yano et al. (December 2007). The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health Administration's Quality Transformation. American Journal of Public Health. 97(12).
- Ashton, C., Headley, E., Parrino, T., Starfield, B. (September 1995). Primary Care in VA. Boston: Management decision and Research Center. Washington, DC: U.S. Department of Veterans Affairs. Office of Research and Development. Health Services Research and Development Service
- Yano et al. (December 2007). The Evolution of Changes in Primary Care Delivery Underlying the Veterans Health Administration's Quality Transformation. American Journal of Public Health. 97(12)
- Kizer et al. (Jun 2000). Reinventing VA Healthcare: Systematizing Quality Improvement and Quality Innovation. Medical Care. 38(6 Suppl 1)
- Kizer, K.W et al. (May 2003). Effects of the Transformation of the Veterans Affairs Health Care System on the Quality of Care. New England Journal Of Medicine. 348(22).
- Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample Annals of Internal Medicine, December 21, 2004
- "Code Red" by Philip Longman, Washington Monthly, Sept. 7, 2009
- Vets Loving Socialized Medicine Show Government Offers Savings Bloomberg, October 2, 2009
- "Effect of the Transformation of the Veterans Affairs Health Care System on the Quality of Care" New England Journal of Medicine, May 29, 2003
- Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study Annals of Internal Medicine, August 17, 2004
- Watkins, K.E., Pincus, H.A. et al., (2011). Veterans Health Administration Mental Health Program Evaluation: Capstone Report, Santa Monica, Calif.: RAND Corporation, TR-956-VHA
- Adamson et al. (2011). Veterans Health Administration Mental Health Program Evaluation. RAND Health.
- (2007). Women Veterans: Past, Present, and Future. Department of Veterans Affairs.
- Washington et al. (2006). What Influences Why Women Veterans Choose VA Healthcare. Journal of General Internal Medicine. 21.
- Relationship Retreats: Warriors to Soul Mates FatherhoodChannel.com, October 20, 2012
- PAIRS Essentials VA Program Support Guide, January 2013
- VA Health Care Eligibility & Enrollment
- Baker, Mike (31 August 2010). "Diabetes tops Vietnam vets' claims". Burlington, Vermont: Burlington Free Press. pp. 1A.
- Veterans Health Benefits and Services
- "The Best Care Anywhere" by Phillip Longman, Washington Monthly, January/February 2005
- Nonprofit Research Collection on Veteran Health Published on IssueLab