Hon. ALAN CRANSTON, ASSOCIATION OF AMERICAN MEDICAL COLLEGES, Chairman, Senate Subcommittee on Health and Hospitals, DEAR SENATOR CRANSTON: The Executive Council of the Association of American Medical Colleges adopted the following resolution at its June 22 business meeting: The value of biomedical science in an educational environment is long recognized. This is particularly true in the function of the VA hospital. The Executive Council of the Association of American Medical Colleges strongly endorses and reaffirms the role of basic and clinical research in the goal of health care delivery by the VA. I am pleased to transmit to you this resolution supporting the role of the VA in promoting basic and clinical research. Sincerely, JOHN A. D. COOPER, M.D. (From the Journal of the American Medical Association, June 5, 1972) THE POTENTIAL ROLE OF THE VETERANS' ADMINISTRATION'S HEALTH CARE SYSTEM At no time in modern history has there been a greater need for expanding and coordinating the existing elements of the health care system in America. The demands on this system have been created by a number of factors which can be expected to continue to increase for the foreseeable future. Among these factors are the following: Greater public expectations and demands for improved quality of care as a result of the new knowledge and technical advances made possible by biomedical and social research in disease, health, and medical care. The desire for maximum application to all the people of that knowledge for the maintenance of health, the prevention of disease, and the treatment of illness at reasonable cost. Greater expectations for increased and more equitable availability of quality health care to all segments of the population. Extension of existing voluntary and legislated prepayment plans and the creation of new systems for purchasing health care for the entire population. Increased amount and scope of social legislation. Changing age distribution of population, with increasing numbers at both ends of the age spectrum. Ever-increasing need for continuing education of the health professions and the public for the appropriate and efficient utilization of health care knowledge and resources. It is evident that the present and future health care needs of all the people cannot be met without improving the delivery systems. In view of this, it is inevitable that some form of national health care program will be adopted within the next few years to meet this need. This will further increase the demand on the system, and exert increasing pressures on the existing resources and those that can be developed in the immediate future. Although a variety of studies for meeting these health care needs have resulted in legislative proposals in Congress, none yet appears to have achieved a critical mass of acceptance or coordinated support. At this time, no single proposal can be identified as acceptable to all of the organizations, institutions, sociopolitical forces, or individuals involved in the nation's health care system as either deliverers or consumers. (342) A Health Care System.-If all persons are to receive the maximum benefits of the increasing knowledge of health maintenance and disease, a health care system must be devised which will work in a coordinated manner. By definition, a comprehensive health care system is a viable formal or informal dynamic, cooperative, cohesive, and coordinated organization of health care agencies, facilities, and staff designed to render a full spectrum of health care, ranging from primary prevention to extended care for all segments of a geographically defined population. A creatively developed health care delivery system must meet certain professional and economic requirements: A functional integration of the health services and resources of any region and their effective utilization for the transmission and encouragement of new knowledge and techniques in order to provide high quality care, and make optimal use of all health manpower. Comprehensive health care services that are available, accessible, and economically feasible for all U.S. citizens, with participation by the recipient in the financing of the service, depending on his ability to pay. Maintenance of choice in selection of the type of service and the professional providing the service. Maintenance of the quality of health services through peer review, continuing education, and continuing professional evaluation of all health professionals. Built-in tangible and scaled incentives for both professionals and institutions for effecting economy of operation. Built-in mechanisms for protection of the necessary traditional types and for the creation of new types of health manpower and facilities, and for continuous evaluation and improvements in the system for health care delivery. Built-in mechanisms for maintaining a steady progress in the state of the art and science of health through research. Improved awareness by those who use the system of where and how services are available, and assurance that they will be available and continue as long as needed. Provision of health services by a method that enhances not only the dignity and self-respect of the individual, but which contributes to the total society of which he is a part. There is need for vigorous effort to accomplish these objectives. Historical Framework of the Current VA System.-Some systems already exist as models for meeting some of these requirements. They have potential for improving the delivery of health care. One such system is that operated by the Department of Medicine and Surgery of the Veterans Administration. The Veterans Administration's medical program is the largest health care system under centralized management in the United States today. Its antecedents can be traced to the first programs of hospital and domiciliary care established by the federal government in national homes for disabled volunteer soldiers in 1865. From that time until 1918, there were no essential changes in this elementary system, except that it was complemented by the legislatures of many of the states of the union and of the old Confederacy by the establishment of "soldier's homes" with associated hospital-type facilities. Parenthetically, it should be noted that, except for the expansion of its institutions and their activities in gross terms, there were few significant changes in the nonveteran health care systems during this same period. After World War I, responding to the needs of a large number of returning veterans with service-connected disabilities, Congress established a more organized and comprehensive federal medical care system as its first effort to provide both inpatient and outpatient care. During the subsequent decades, further laws entitled veterans to receive care in VA hospitals if they were not able to pay the cost of private care. This program required the veterans to declare themselves unable to pay for their own care. Unfortunately, but quite naturally, the initial laws which established the VA as a provider of health care and subsequent extensions of those laws have resulted in anomalies in terms of today's practice of medicine and the system for delivery of care. The fact is that entitlements to service are not in terms of groups of veterans, but in terms of disabilities. While a veteran with a serviceconnected condition could be given care on an inpatient or outpatient basis, a veteran with a non-service-connected condition could only be treated on an inpatient basis. Simply put, this meant that the applicant for care of a nonservice-connected condition not only had to have a condition sufficiently serious to require hospital care, but also had no legal right to care before or after hospitalization. No provision was made for illnesses which can be prevented or stabilized outside the hospital in terms of preventive medicine or ambulatory care. As time passed, the hospitals of the VA became increasingly the institutions to which veteran-patients turned for their health care needs. This resulted in legislative and administrative accommodations to the aforementioned inconsistencies to ensure that the system remained workable and responsive to professional, social, and economic changes. The developments and changes within the VA system have been well documented. The important events of the 1960's are of great significance to the issues and suggestions contained in this report. In general, during that period certain legislation and its implementation made inroads toward correcting some of the anomalies referred to earlier, and toward broadening the entitlements to care within the VA system. The following are specific examples: Care before and after hospitalization was authorized and utilized as an initial method for meeting the pressing need for outpatient services. Nursing home care was established both as a service within VA facilities and contracted for in community nursing homes. A grant-in-aid program was authorized to provide assistance to states for construction of additional nursing homes for veterans' care. Authority was established to provide for sharing of scarce medical resources and facilities within the VA system and with facilites of the private sector. The Department of Medicine and Surgery was authorized to engage in programs for exchange of medical information to provide a system for continuing education of physicians and other allied health professionals. Comprehensive care was authorized for veterans totally disabled as a result of service-connected conditions. The requirement that veterans aged 65 or more certify their inability to defray the cost of hospital care for non-service-connected conditions was removed. In recent years, the VA departed from prior methods of funding hospitals on the basis of average daily patient census. This change, along with previous provisions for treatment before and after hospitalization, led to a sharp drop in the average length of patient stay, and this trend has continued. STRENGTH AND POTENTIAL OF THE CURRENT VA HEALTH CARE SYSTEM The laws under which the VA health care system operates limit its ability to provide many of those services and facilities that are recognized as essential to the new patterns of care. However, there are many strengths and potentials in the system that commend it as a model for the future. It is a system in being for 25 years, and represents a federal investment in excess of $50 billion for operating funds and capitalization. That system and a commitment to support it can be expected to continue as an integral part of the federal government's responsibility to veterans. As such, it is not only essentially a prepayment system, for an identified section of the population, but it is a functional system for the delivery of care to those who are so "insured." The locations of its facilities provide geographic accessibility through an excellent pattern for regionalization, so that a facility is within 100 miles or a twohour drive from 90% of the 28 million veterans. Its current plans for regionalization not only involve a potential for maximum use of existing facilities and professional manpower, but also provide a potential for a viable and expandable network of continuing education and collaborative research activities. As already implemented, such regionalization permits both a minimum of expensive duplication and a maximum potential for integration with health 1 Kracke, R.E. The medical care of the veteran. JAMA 143: 1321-1331, 1950. 2 Armstrong G.E.: The medical program of the Veterans' Administration. JAMA 171: 540-544, 1959. 3 Hill, S.R. Jr.: Degrees of freedom open to new and developing medical schools in the utilization of Veterans' Administration hospitals. J Med Educ 45: 564-570, 1970. 4 Lewis, B.J.: VA medical program in relation to medical schools. House Committee Print No. 170, 91st Congress, 2nd Session, Jan. 19. 1970. facilities in the public and private sectors. This potential, made possible by the sharing law (P.L. 89-785), becomes even more promising in helping to alleviate the concern for increased quality and availability of care and the optimum use of health facilities and manpower in providing care to all the people. The flexibility of the system has potential for various possibilities, including expansion of either the facilities and services, on the one hand, or the population served, on the other. By its working affiliations with some 81 schools of medicine and with other professional and technical schools located in some 400 universities, colleges, and junior colleges, together with its own intramural education activities, the VA has one of the nation's largest educational and training capabilities for the development and interaction of health manpower. The autonomy and resources of the VA system permit experiments and innovations in research and development in both health care and administration, and the immediate system-wide use of those results which have proved themselves. Its centralized administration permits cooperative purchasing and distribution techniques for supplies and equipment that result in sizable economies. Because of health information accumulated on its target population during and after service in the armed forces, it has available to it a health data base of about 28 million persons, or one eighth of the total population with, in many cases, similar information on members of their families. Its system for the delivery of health care provides the potential for the widest possible latitude in modes of patient care. Its one-class service for all patients provides a model to help meet the current demand for equity and equality to match efficiency and economy in the total health care system. RECOMMENDATIONS FOR IMPROVEMENTS OF THE VA HEALTH CARE SYSTEM It is recognized that no health care system is, or perhaps ever should be, considered complete in all its facilities. services, or administration. However, certain specific activities should be considered in changing or extending the current VA health care program, to build into that system improved service to its patients and to effect a maximum cost benefit consistent with past investment and expected future commitment. The goal of these changes is the provision of comprehensive care. Over and above acute and other hospital-related care, special emphasis must be placed on preventive medicine, the maintenance of health, ambulatory care, and home services. To accomplish these goals the VA should consider such specific programs as the following: Extension of responsibility and arrangements for the provision of acute, ambulatory, and preventive care to veterans' dependents, perhaps limited initially to dependents of veterans who died in service, who have total disabilities, or who are presently hospitalized so that the needed care of the family of the veteran can be enhanced. Dependents' care could be effected through expansion of services within the system or through contract arrangements with other established and developing resources whenever such arrangements would provide easier access to and continuity of care. The determination as to which of these two methods should be used in an area would be a matter for local and regional planning. Expansion of services for eligible veterans to a full spectrum of comprehensive care, including such services as periodic physical appraisal and multiphasic screening appropriate to age and risk groupings. The development of further resources for ambulatory care and home services, including personal care and supporting services, thereby conforming with new concepts of health delivery. This development would provide for planning of continuity of services, whereby the antiquated practice of in-hospital care for all but those cases that actually require hospitalization could be changed, thus avoiding the attendant evils of forced institutionalization and overutilization of expensive hospital facilities. Provision for a progressive hospital care system based on the most economic and efficient use of facilities and personnel. Encouragement of new, imaginative, and innovative efforts by those already in the system through a new program whereby leaves would be granted for study and for participation in activities and programs of professional societies. Encouragement of the recruiting of new young health leaders from the graduating classes of professional schools of health and health care administration by providing opportunities. salaries, and advancement competitive with other segments of the health field. RECOMMENDATIONS FOR VA CONTRIBUTIONS TO THE EXPANSION AND IMPROVEMENT OF HEALTH CARE TO ALL THE PEOPLE The VA health care system can be expected to remain an identifiable service for the foreseeable future consistent with its legislated mandate and mission. However, there is a need to consider this system as it might relate to the probable development of some form of universal comprehensive health care. If and when a universal system develops, in addition to sustaining the entitlement of veterans with service-connected disabilities, it may become necessary to define entirely new criteria of eligibility for care of other veterans in VA hospitals. It also becomes a possibility that certain types of services might be provided to larger numbers of veterans by use of broader categories, including dependents of veterans and individuals eligible for care in other federal facilities. There are any number of alternatives in this regard, and any one or combination of them could significantly change the composition of patients in VA, university, public, private, and community hospitals. In any event, the VA health care system has potential for meeting expanding national health needs by participation with other components of the nation's total health delivery system. To assure mutual benefits to both systems, and to the patients cared for by them, the VA should consider the immediate expansion of some ongoing activities, the implementation of new activities and concepts, and, in some cases, both. These actions are therefore suggested for the VA health care system: Develop and extend the ongoing and suggested new approaches already listed which can be of benefit to the nation's health care delivery systems and to the people of the geographic areas in which VA health facilities are now operating. Extend the mutual sharing of services that may be in short supply with other teaching and community hospitals and health facilities in the area. Extend and implement arrangements whereby payments can be made and received by the VA for services provided to veterans with non-service-connected disabilities and to their families who qualify for Medicare or Medicaid, to those who have private insurance, and from other institutions and individuals who utilize VA health facilities and manpower on an extended sharing basis. Encourage and extend these relationships and services to include mutually beneficial working arrangements with those who actually deliver health care, including the extension of visiting and courtesy privileges to physicians who care for veterans on a private basis when such patients are hospitalized in VA hospitals. Develop programs by which laboratory, X-ray, and other services and facilities can be fully shared and utilized to their maximum capability, without duplication, among VA hospitals, university and community hospitals, and other health care organizations in the community. Continue and expand the relationship with university health science centers, including medical, dental, and other health professional and technical schools in educational and training activities necessary for maximum contribution to the health manpower resources of the country. Serve as the geographical base and clinical resource for the development of new medical, dental, and other health professional and technical schools. Actively engage in and accept the commitment to cooperative health planning and regionalization of all health services. Make more information available to all veterans concerning their entitlements and available health services. CONCLUSION The Special Medical Advisory Group has developed this report after careful consideration not only of the VA health care system, but also of the voluntary systems of health care, and also of all of the related elements including the critical problems of financing both. It recognizes that the recommendations made are not necessarily consonant with present legislative authorization of the VA. However, these recommendations reflect the concern for the total public interest and are designed to anticipate the health care demands which will be made in the years immediately ahead and in which the VA must involve itself if it is to continue to be an important part of the health care program of the United States. Therefore, it is the belief of this group that its responsibility is to bring these issues to the attention of the administrator. |