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June 05, 2014 3:15 PM The Architect of the VA’s Quality Transformation Under Clinton Speaks Out

By Phillip Longman

The New England Journal of Medicine is out this morning with a notable article on VA health care co-authored by Dr. Kenneth W. Kizer. As undersecretary for health during the Clinton administration, Kizer lead a quality transformation of VA health care that leaves him today one nation’s most respected voices in the movement for health care delivery system reform. He was also a key source for my book, Best Care Anywhere, which describes how the VA revolution took place.

Kizer’s analysis of what happened to the VA health care in recent years largely comports with my own. The quality of VA health care, as studies such as this one (pdf) attest, remains generally as good or better than what is found in the private sector. But the VA has lost some of its advantage over top-tier private integrated health care delivery systems, both because these providers are getting better, and because some VA hospitals have become quite uneven in their performance.

Kizer notes for example, that:

The Phoenix VA Medical Center — ground zero of the wait-time scandal — has mortality rates for common conditions that are among the highest within the VA and higher than those in many private hospitals. Its rates of catheter-related bloodstream infections are nearly three times the national average.

Kizer, and his co-author Ashish K. Jha from the Harvard School of Public Health, lay much the blame on too much control being reconsolidated in the VA’s central office in Washington. This is the opposite of the lesson taken by many members of Congress and others who are calling for still tighter central controls. But, while Kizer’s and Jha’s take may seem counter-intuitive, it rings true with my own experience.

Much of the idealism and innovation in the field that made VA such a bright star in health delivery system reform 10 years ago has been eroded by the reemergence of heavy-handed, centralized managerial control, concentrated in the hands of political appointees in Washington. This centralization is particularly true in the realm of digitalized medicine, where no longer are VA doctors and other frontline employees allowed to play the key role they once did in developing cutting edge applications of health IT. Most of the damage was done by the Bush administration, which did its best to reinvent the top-down hierarchal structure that had made the VA such a mediocre institution in the 1970s.

As with any large public institution, whenever there is a real or perceived failing in the field, it empowers those who want to centralize power and enforce rigid standards. Sadly, that response often has demoralizing effects that make the problems facing an institution worse.

Phillip Longman is a senior editor at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches health care policy. He is also a senior fellow at the New America Foundation, where Atul Gawande is a board member.

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