VA authors argue agency wait times beat private sector: JAMA

By | January 21, 2019

Dive Brief:

  • Wait times for new patients at Department of Veterans Affairs facilities and private hospitals were similar in 2014, a new Journal of the American Medical Association study authored by researchers affiliated with the VA found. But while wait times in the private sector appeared to be static between 2014 and 2017, wait times at VA facilities “significantly improved” and in some cases surpassed the private sector in terms of access. 
  • VA facilities also increased the number of unique patients seen and improved patient satisfaction measures of access. The authors looked at four specialties in 15 major metropolitan areas: primary care, dermatology, cardiology and orthopaedics. Orthopaedics was the only specialty where wait times remained longer in the VA than in the private sector. 
  • The study was prompted by reports in 2014 that veterans were waiting too long to receive care, a scandal that marred the VA’s reputation and “created a public perception regarding the VA health care system’s inability to see patients in a timely manner,” the VA’s researchers note. 

Dive Insight:

The Trump administration has very publicly hemorrhaged Obama-era VA leadership and made clear its intent to boost private sector options — a move endorsed by wealthy right wing funders like the Koch brothers, but opposed by most veterans’ groups.

A 2014 Congressional Budget Office report comparing private sector and VA healthcare costs, one of just a handful to do so prior to this JAMA article, found about 70% of veterans enrolled in the VA’s system already receive most of their care in the private sector. 

Many of them do so through the VA’s Veterans Choice Program, which allows veterans to see private providers if they live a specific distance from a VA facility or have to wait a certain number of days to be seen. Advocates of privatization have often cited expanding this program as a means of progressing toward wholesale privatization of the VA.

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Others, such as the National Rural Health Association, believe in a spectrum of care options for veterans and support expanding the Choice program without privatizing the entire Veterans Health Administration.

Proponents of wholesale privatization argue veterans would receive better care in the private sector than they would at VA facilities, and many cite the 2014 scandal as just cause for their argument. Outside research — unaffiliated with the VA — has poked holes in the argument that private sector care is better than public VA care.

Former VA Secretary David Shulkin warned in a post-ousting op-ed that the private sector is “ill-prepared to handle the number and complexity of patients” that would require their services if the VA were downsized, “particularly when it involves the mental health needs of people scarred by the horrors of war.” A RAND survey of New York State providers, for example, found that only 2.3% met criteria for efficiently serving veterans, with mental health professionals being the least prepared. 

The VA researchers note in their study that while “an evaluation of mental health wait times is important,” the study did not include them because of a lack of private sector data. However, the results “suggest that VA initiatives, rather than changes to the overall health services market,” led to the study’s positive results. 

The researchers’ methods were questioned in an accompanying comment authored by Peter Kaboli of Iowa City Veterans Affairs Healthcare System and JAMA Network Open deputy editor Stephan Fihn, of the University of Washington. 

The study only looked at new appointments and used questionable methods to record a metric that’s historically difficult to measure, they contend. But they did not disagree with the bottom line.

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“Irrespective of the faults of both the metrics and problems with their comparison,” they write, “these findings should help to disabuse the unfortunate yet widely held belief that access in the VA is substantially inferior to that in the private sector.” 

Improvement, however, can only persist with the proper funding. 

“As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to health care services can be maintained while access in the private sector continues to deteriorate. To understand how access to care in the VA and the community evolves, more reliable and valid metrics of access to care will be essential,” they concluded.

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