Reconsidering the Veterans Health Administration: a model and a moment for publicly funded health care delivery.

摘要

Since the Veterans Health Administration (VHA) was systemically (and systematically) "reengineered" to follow a more decentralized, managed care template more than 15 years ago (1-3), it has demonstrated accumulating achievements in health and health care delivery, over time outshining not only its own performance but that of others (4-6). In chronic disease management and preventive care, the VHA has surpassed Medicare (7), commercial managed care (8), and various community health systems in adherence to broadly accepted process measures (9). Furthermore, beneficiaries of the VHA seem to have health outcomes-including mortality-that are the same as or better than those of Medicare (10-12) and private-sector patients (13). These findings are noteworthy given the population served by the VHA, which is recognized to be highly and relatively burdened by socioeconomic disadvantage, comorbid illness, and poor self-reported health (1). It is remarkable that the VHA has been able to attain this superior-quality care at a lower cost than that purchased through Medicare, with expenditures that have increased at a much slower rate (adjusted annual per capita growth rate, 0.3% vs. 4.4%) (14, 15).