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Friday, April 3, 2020  Spokane, Washington  Est. May 19, 1883
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Opinion >  Syndicated columns

Andrew J. Cohen: The VA is working just fine, thank you very much

By Andrew J. Cohen Special to the Washington Post

“A government-run, single-payer, bureaucratic health-care system that doesn’t work.” That’s how Sen. Ron Johnson, R-Wis., described the Department of Veterans Affairs last month on “Meet the Press.”

Johnson’s remarks are typical of Republicans in Congress, who have made no secret of their intention to privatize the department. President Donald Trump’s firing of Veterans Affairs Secretary David J. Shulkin constitutes the latest Republican assault on the agency. Shulkin’s poor judgment regarding his well-publicized trip to Europe would not have provided sufficient cause for firing were it not for his well-known opposition to the privatization of VA services. Remember Treasury Secretary Steven Mnuchin’s use of government aircraft or EPA Administrator Scott Pruitt’s need to fly first class?

What is clear is that the dismantling of VA is desirable to Republicans because of what it represents: a successful, publicly funded, integrated health care system.

Yes, I said successful.

Sure, VA suffers from a bloated bureaucracy. Delays in getting appointments with primary-care providers have been subjected to considerable scrutiny. But doctor shortages plague U.S. health care as a whole. Just ask anyone who is seeking a new primary-care physician.

VA provides much-needed care to a complex, chronically ill and largely elderly population. The abundance of published, peer-reviewed data indicates that VA care is comparable or, in many cases, superior to that in the private sector. An independent assessment of VA by the consulting firms of Grant Thornton and McKinsey & Co. along with the Rand and Mitre corporations found that, compared with private-sector care:

VA post-operative complications were lower.

VA inpatient care was more or as effective.

VA hospitals were more likely to follow best practices for prevention of catheter-related infections.

VA mortality rates decline more rapidly for some conditions.

Veterans in nursing homes were less likely to develop pressure sores.

VA outpatients received better follow-up care, better mental health and obesity counseling, and better blood-pressure control.

Elderly VA patients were less likely to receive medications that could make them sicker.

For more than 40 years, I have practiced as a kidney specialist, largely in the world of private insurance and Medicare. Ten years ago, as part of my employment in a Brown University medical school-affiliated practice, I became section chief of nephrology at the Providence VA Medical Center. Having worked in both worlds, I can say with full confidence that the care of veterans with complex medical conditions, such as chronic kidney disease, in VA facilities is generally far superior to that of private health care. That’s because VA coordinates care among many needed providers via its systemwide electronic medical record and at a lower cost. Collaborative care, coupled with lower drug costs (unlike Medicare, VA negotiates drug prices with pharmaceutical companies), makes VA highly cost-effective.

And VA circumvents profit-driven decision-making, which permeates the U.S. health care system. Recent research in the Journal of the American Medical Association illustrates this well: A study looked at more than 11,000 veterans with kidney failure age 67 or older receiving kidney care through either VA or Medicare providers. While those treated by Medicare physicians were more likely to be started on dialysis, regardless of co-existing conditions such as dementia or metastatic cancer, two-year mortality was substantially lower in those treated in VA facilities, despite an equivalent severity of illness.

This study confirms my personal observations over many years. In the private sector, kidney specialists are more likely to expedite dialysis in sick, elderly patients despite the absence of clear benefit. This is because transferring patients to dialysis is both easier and more lucrative for kidney specialists. The JAMA study demonstrates what many fighting for “right care” – avoiding potentially toxic drugs and unnecessary tests and procedures – have long understood: Contrary to unsubstantiated claims, VA provides clinically appropriate and often superior care.

Andrew J. Cohen is former chief of nephrology at the Providence VA Medical Center, where he continues to practice, and a professor of medicine at Brown University’s Alpert Medical School.

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