For all of the bad things we hear about the U.S. Department of Veteran Affairs (VA) system, it seems like it would be easy for good science to get lost in the noise.
A new study just published (but based upon data from 2007-2008) suggests that at least in one area, the VA may be doing better than private health insurance plans.
The VA is responsible for all of the health and mental health care for military veterans. And since it’s run by the federal government, it’s an example of what a U.S. government-run healthcare program looks like in real life. Veterans receive free healthcare for life in return for their service to this country.
The new study (Watkins et al., 2016) examined two populations — one consisting of 836,519 veterans in the VA system, and another consisting of 545,484 people in the regular private plan health insurance system in the U.S. The administrative data examined came from the VA’s own internal system — the VA National Patient Care Database — while the general population data came from Thomson-Reuters MarketScan Commercial Claims and Encounter Database. Both databases included pharmacy and laboratory claims, even if the beneficiary was covered through a capitated behavioral carve out (in the case of the private claims data).
In short, they examined a lot of patient utilization data — including lab tests and prescriptions filled — for the time period between 2007 and 2008 (note that this was before many of the VA reforms were even put into place).
This study looked at seven specific factors the researchers believed would lend insight into whether or not the VA system was performing adequately (e.g., as well as the medication treatment people receive outside of the VA). These factors included: the proportion of patients who received all recommended blood-level monitoring tests during the study; the number of patients who received lab screening tests; the number of patients who filled a 12-week prescription for antipsychotics (for those with schizophrenia) and those who filled a 12-week prescription for antidepressants (for those with depression); and the number of patients who filled 12 consecutive months of prescriptions for antipsychotics, mood stabilizers, or antidepressants.
Now you’ll notice — like I did — that none of these factors are outcome variables. Instead, they amount more to “how well do patients adhere to their medication treatment plan?” And prescriptions filled don’t necessarily mean prescriptions taken.
The researchers found that not only were those covered under the VA healthcare system receiving the same level of care as private insurance persons — they were actually utilizing it and sticking to their treatment plans much better. Significantly better, in fact:
VA performance was superior to the MarketScan national average by more than 30 percent in every case. In some cases, the margin of superiority was very large. For example, the rate at which the medication lab tests indicator was met in the VA (77 percent) was 13 times the rate at which it was met in the private plans (6 percent).
Across the seven indicators chosen by the researchers, VA patients adhered better — refilled their prescriptions, got the lab tests ordered, and maintained their prescriptions — than those who had private insurance. This doesn’t mean they necessarily got better quicker, or received better quality care, because the study didn’t test for those things.
Here’s how the researchers concluded their study:
We found that the quality of care provided by the VA to veterans with mental and substance use disorders consistently exceeded the quality of care provided by the private sector for the performance indicators examined…
There’s a likely reason for these findings — VA care is very systemized and usually found all under one roof. A patient doesn’t have to drive to 3 different places to do 3 different things related to their healthcare — even for mental health care. In the bigger VA facilities, it’s all right in the same place. And it’s free — no paperwork to fill out, no co-payments to make. Why wouldn’t a person partake of that?
But the limitations to the study are significant. First, the researchers don’t know how significant private plan co-pays and other benefit levels were. For instance, in the private plan database, a patient might have to pay hundreds of dollars for certain kinds of medication every month — a significant disincentive to getting a prescription filled. Even ordinary co-pays may be problematic for some people.
Worse is the amount of time and effort involved in the private sector to actually fulfill the requirements of a treatment plan. If a lab test is needed, it usually needs to be scheduled completely separately from the doctor’s office, at a completely separate and unaffiliated facility. Same with filling a prescription, which requires yet another drive (for most people).
What the study clearly demonstrates to me is how an integrated, holistic healthcare system like the VA can serve patients extremely efficiently and well. Sadly, most of the healthcare Americans receive — especially mental health care — is not of this nature, and will continue to be fragmented, hard to access, and difficult to pay for.
Watkins, K.E. et al. (2016). The quality of medication treatment for mental disorders in the Department of Veterans Affairs and in private-sector plans. Psychiatric Services, 67, 391-396.