Comparing Patient Outcomes: Veterans Health Administration vs. the U.S. Healthcare System

I have previously stated my bias about the healthcare that is provided by the VA to its millions of Veterans. It is not a perfect system by any means. I have yet to find a health system that is always perfect and never fails the patients it tries to serve. Certainly, my father is an example of the things that go wrong for patients (see previous blog). Yet, the VA is a system that values its patients, doesn’t seek to make a dime off of them, and tries to wrap services around this population that many Americans might envy. 

But there is more. There is ample evidence that the VA provides excellent care that is easily comparable and not uncommonly outperforms the private sector. And it does it for less cost. This is not meant as a boast or to diminish the many fine things that the private sector does. The private sector also performs things that can seem almost miraculous. Yet, on a population health basis, the VA is doing quite well and I would like to introduce this system to many of you that may not be as familiar with it. We will discuss the pros and the cons.

The debate surrounding the efficacy and value of the Veterans Affairs (VA) healthcare system compared to private sector healthcare is ongoing. This report aims to synthesize available literature to compare these two systems across critical dimensions: healthcare outcomes, cost-effectiveness, and the provision of specialized services. The findings suggest that the VA often performs as well as, and in some instances better than, the private sector, particularly in areas tailored to the unique needs of veterans.

Healthcare Outcomes and Quality

So let’s look at some data –

• Patient Experience: Recent Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data show that VA hospitals outperform private sector hospitals in patient experience. Seventy-two percent of VA medical centers received 4 or 5 HCAHPS Summary Stars for patient survey ratings, compared to only 41% of similar hospitals in the private sector [1]. Over the past five years, the percentage of VA hospitals achieving these top ratings has significantly increased from 26% to 72% [1]. VA facilities also outperformed community hospitals on all 10 core patient satisfaction metrics, including overall hospital rating and communication with doctors [1]. In Fiscal Year 2023, nearly 90% of inpatient veterans reported trusting the VA for their healthcare and being satisfied with the care received [1].
• Safety and Effectiveness: A systematic review comparing VA and non-VA quality of care found that studies on safety and effectiveness generally showed the VA performs better than or similar to other healthcare systems [2]. For example, VA patients had better outcomes in measures like mortality rates, cancer care processes, and preventive care practices [2]. However, some studies indicated areas where the VA performed worse, such as higher rates of cataract surgery complications or post-CABG surgery mortality in specific instances [2]. More recent data suggests the VA is delivering superior outcomes compared to the private sector in various areas [3].
• Specific Concerns with Private Sector Care for Veterans: A “Red Team” report commissioned by the VA highlighted concerns with veterans seeking care in the private sector through the Veterans Community Care Program (VCCP). It found that veterans treated in private emergency rooms were twice as likely to die within the first 28 days compared to those treated in the VA system [4]. The report also noted that private-sector providers are more likely to perform unnecessary, invasive procedures and charge higher prices, especially in fields like oncology and orthopedics [4]. As often happens, rather than laud the VA for its care, some blamed the VA for allowing substandard providers to care for Veterans even though it is a private “insurance company” that determines what private sector physicians and hospitals are allowed to give care to VA. Why are those private entities not held responsible for finding the best private sector providers?

Cost-Effectiveness

Direct cost-effectiveness comparisons between the VA and the private sector are complex and not extensively covered in all reviews [2]. However, emerging data points to cost advantages within the VA system.

• VCCP Costs: The cost of reimbursing private-sector providers under the VCCP has risen dramatically, from $14.8 billion in FY 2018 to $28.5 billion in FY 2023 [4].
• Emergency Room Services: Private-sector emergency room services, which constitute 30% of VCCP spending, are reported to be 21% more expensive than comparable VA care [4] (this might be of interest to the rest of us who are paying for weirdly expensive healthcare).
• Budgetary Strain: Some VA medical centers are facing significant VCCP spending deficits, consuming large portions of their clinical care budgets, which could threaten the VA’s direct care system if unaddressed [4].

The VA utilizes cost-effectiveness analysis as a tool to aid decisions about medical care offerings, following recommendations from the U.S. Public Health Service task force, which include analyzing costs from both healthcare sector and societal perspectives and discounting costs and benefits [5, 6].

Specialized Services Provided by the VA

The VA healthcare system also offers specialized services and an environment of care that are often not replicated or are less accessible in the private sector, particularly for veteran-specific health issues.

• Expertise in Veteran-Specific Conditions: The VA possesses specialized expertise in areas crucial to veteran health, such as post-traumatic stress disorder (PTSD), military sexual trauma, conditions related to toxic exposures, prosthetics and orthotics, rehabilitation, and behavioral health [4, 3]. Private-sector providers often lack the specialized training and experience to effectively treat these conditions [4].
• Integrated Care Models: The VA provides care within an environment that emphasizes military competency, peer support, and a bio-psychosocial support model. This includes integrated behavioral health and interdisciplinary care teams, which are not as readily available in private healthcare settings [3].
• Accessibility of Certain Services: A systematic review found that the VA often provides services like on-site mental health care, clinical pharmacy services, and palliative/end-of-life care more readily than the private sector. VA patients were more likely to receive these specialized services [2].

Conclusion and Recommendations 

Considerable evidence suggests that the VA healthcare system provides high-quality care and positive patient experiences, often comparable or superior to the private sector, especially for conditions unique to veterans. The VA also appears to be a more cost-effective option for certain services, particularly emergency care, when compared to VCCP reimbursements.

Those with influence might consider the following:

• Recognize VA Strengths: Acknowledge the VA’s specialized expertise and integrated care models that are tailored to veterans’ needs.
• Address VCCP Costs: Investigate the rising costs of the VCCP and the financial strain it places on the VA’s direct care system. Implement measures to improve utilization management and revise access standards where appropriate [4].
• Support VA’s Direct Care System: Ensure the VA’s direct care system remains robust and accessible, as it is preferred by millions of veterans [4]. An “attraction campaign” to highlight the VA’s high-quality, cost-effective care could be beneficial [4].
• Foster Public-Private Partnerships Wisely: While access to private sector care can be part of the solution, it should complement a strong VA system. Evolving access standards to be more clinically appropriate and enhancing transparency in outcomes can help achieve a better public-private partnership [3].

Investing in and strengthening the VA healthcare system is crucial to honoring the commitment to the nation’s veterans, ensuring they receive high-quality, specialized, and cost-effective care.

Works cited

1. news.va.gov – VA hospitals outperform private sector in patient experience
2. (https://www.herc.research.va.gov/include/page.asp?id=cost-effectiveness-analysis)
3. prospect.org – Privatization Warning
4. (https://pmc.ncbi.nlm.nih.gov/articles/PMC5215146/)
5. herc.research.va.gov – Measuring Costs for Cost-Effectiveness Analysis
6. (https://riponsociety.org/article/the-va-assists-veterans-in-a-way-the-private-system-cannot/)

Additional Information That Might Be Worth a Peak….

Recent Studies Comparing Health Outcomes in the VA vs. Private Sector
Study Title	Population	Measure	Outcome	VA vs. Private Sector
Mortality among US veterans after emergency visits to VeteransAffairs and other hospitals: retrospective cohort study (2022)	583 248 veterans (aged ≥65 years)enrolled in both the Veterans Health Administrationand Medicare programs, study period 2001-2018.	Deaths in the 30-day period after the ambulance ride.	Adjusted mortality rate at 30 days was 20.1% loweramong patients taken to Veterans Affairs hospitalsthan among patients taken to non-Veterans Affairshospitals (9.32 deaths per 100 patients (95%confidence interval 9.15 to 9.50) v 11.67 (11.58 to11.76)). The mortality difference was particularly large forpatients who were black (−25.8%), were Hispanic(−22.7%).	VA better
Source of Post-Transplant Care and Mortality amongKidney Transplant Recipients Dually Enrolled in VAand Medicare (2021)	6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare.	5-year mortality	5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).	VA better
Comparing Postoperative ReadmissionRates Between Veterans Receiving Total KneeArthroplasty in the Veterans HealthAdministration Versus Community Care (2022)	Three-year cohort study using VA and CC administrative data from the VA’s Corporate Data Warehouse (October 1, 2016–September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare.	Odds of experiencing an all-cause or TKA-related readmission among 45,284 veterans between 2017 and 2019.	The odds of experiencing an all-cause readmission in VA were 35% of those in community care.	VA better
Study Title	Population	Measure	Outcome	VA vs. Private Sector
Differences in complications, cardiovascular risk factor, and diabetesmanagement among participants enrolled at veterans affairs (VA) and non-VA medical centers in the glycemia reduction approaches in diabetes: Acomparative effectiveness study (GRADE) (2021)	Veterans with type 2 diabetes  enrolled in the GRADE study at VA (1,216)vs non-VA sites (3,831), focusing on cardiovascular risk factors and rates of diabetes care target achievements.	Use of evidence-based therapy for this high-risk population	In those without CVD, more VAparticipants were treated with lipid (70.8% vs 59.5%, p < 0.001) and blood pressure (74.9% vs 65.4%,p < 0.001) lowering medications, and had LDL-C < 70 mg/dl (32.9% vs 24.2%, p < 0.05). Among thosewith CVD, more VA participants had BP < 140/90 (80.2% vs 70.1%, p < 0.05) after adjusting for demographics.	VA better
Comparing Veterans Affairs and Private Sector Perioperative OutcomesAfter Noncardiac Surgery (2021)	3,910,752 operations 2015-2018	30-day postoperative mortality	Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001)	VA better
Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers(2019)	New patients receiving care at VA medical centers and compare wait times in the VA medical centers with wait times in the private sector	Cross-sectional study of new appointment wait times for primary care, dermatology, cardiology, or orthopedics at VA medical centers in 15 major metropolitan areas in 2014 and 2017.	Overall wait times for new appointments in the VA were shorter than in the PS (mean [SD], 17.7 [5.9] vs 29.8 [16.6] days; P < .001). True in primary care (mean [SD], 20.0 [10.4] vs 40.7 [35.0] days; P = .005), dermatology (mean [SD], 15.6 [12.2] vs 32.6 [16.5] days; P < .001), and cardiology (mean [SD], 15.3 [12.6] vs 22.8 [10.1] days; P = .04). Wait times for orthopedics remained longer in the VA than the PS (mean [SD], 20.9 [13.3] vs 12.4 [5.5] days; P = .01), although wait time improved significantly between 2014 and 2017 in the VA for orthopedics while wait times in the PS did not change (change in mean wait times, increased 1.5 days vs decreased 5.4 days; P = .02).	VA mostly better
Study Title	Population	Measure	Outcome	VA vs. Private Sector
Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings (2018)	Quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.	Patient Safety Indicators, 30-day risk-standardized mortality and readmission measures, and ORYX, HEDIS, HCAHPS, SHEP and inpatient comparison	VA the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures.	VA better or same on most measures