VA Centers Need to be Competitive in Order to Improve Quality

A recent commentary by Kyle Sheetz, MD, and David Shulkin, MD, in the New England Journal of Medicine, argued that increased competition through patient choice could improve quality at VA medical centers. 

Dr Sheetz, of the department of surgery at the University of Michigan, and Dr Shulkin, former secretary of the VA, said that despite studies showing that the VA provides superior care compared to the private sector, many areas for improvement still exist within the VA health system.

They said that with the increased tilt toward privatization, VA medical centers will need to have adequate funding in order to modernize and tackle the challenges of competing for patients. Drs Sheetz and Shulkin explained that currently, innovation is not spurred by competition in the VA health system because they operate under a fixed-cost model and therefore do not directly link increases in clinical productivity to incentives. 

“The medical centers have not traditionally competed for market share or the ability to develop specific clinical programs,” they wrote. “Though they have a history of innovation and continuous quality improvement, these efforts traditionally focus on internal benchmarks and comparisons, which have become increasingly disconnected from performance standards in the private sector, where clinicians and hospitals are exposed to numerous risks when service quality is diminished.”

The first way that Drs Sheetz and Shulkin said that the VA can introduce competition is by ensuring that all measurements (quality, clinical, and other) are monitored with precision and accuracy. Through accurate measurement, VA medical centers will be able to detect deficiencies and course-correct when the problems are actionable. 

The second way they said that the VA can utilize competition is to optimize regionally oriented networks of community-based providers and medical centers. They said that these networks could be specifically geared toward the needs of a particular region.

“Such customization will allow veterans and their doctors to compare outcomes between private-sector providers and the VA,” Drs Sheetz and Shulkin wrote. “Moving beyond the current framework centered on access standards, the VA could allow patients to use the network when its own quality on specific metrics falls below private-sector performance or the regional standard of care.”

They noted that this system would also be used in the inverse scenario—shifting patients toward VA services when the private sector falls below quality benchmarks for a specific service.

Their third idea to spur innovation through competition is to deploy real-time interventions at low-performing VA medical centers. 

They also said that decentralizing VA-decision making would benefit veterans because it would allow for more localized “utilization of the care network with longitudinal strategic planning.”

In closing, Dr Sheetz and Shulkin explained that competition will only work to improve care quality at VA centers if significant investment is made in modernizing facilities, technologies, and management practices.

“Although competition alone is not sufficient to improve quality, it can help to modernize performance standards, lead to new management practices within VA medical centers, and move the VA away from the possibility of privatization,” they concluded. “Competition also ensures that private-sector providers that wish to care for veterans adhere to the highest quality standards—and formalizing those standards through legislation would allow the VA to better fulfill its responsibility to veterans and taxpayers.”

—David Costill