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Meta-Analysis Examines Quality of VA Health Care
In Congressional testimony, VA officials frequently tout studies that indicate that the VA delivers high-quality health care that meets or exceeds the care delivered at private facilities. These studies often stand in sharp contrast to the criticism leveled at the VA and news stories of health care discrepancies. However, a new meta-analysis of studies on quality at VA facilities suggests that the VA health care system generally performs better than or similar to other health care systems for providing safe and effective care to patients.
The study, published in the Journal of General Internal Medicine and conducted by RAND Corporation researcher Courtney Gidengil , MD, MPH, found 69 articles on VA quality across dimensions, including safety and effectiveness. According to Dr. Gidengil, 22 of 34 safety studies and 20 of 24 studies that focused on effectiveness showed that VA facilities provided the same, if not better, quality of care as do private facilities. These studies focused on safety measures, preventive medicine best practices. In the studies, surgical patients in the VA system and VA nursing homes patients had death rates similar to patients in other health systems.
“We found that the overall quality of care in the VA health system compares favorably to other segments of the U.S. health care system,” said Dr. Gidengil. “In some areas, the quality of care provided by the VA exceeded what we found in other settings, although there were areas where the quality of VA care fell short.”
The study updated and expanded on a similar study conducted in 2009. In addressing timeliness, equity, efficiency, and patient-centeredness, there was too little data to draw reliable conclusions. Similarly, studies on the availability of services had mixed results. During the past 5 years, the study was not able to find any trends indicating whether the VA was superior or inferior compared with other health settings.
“Comparing the VA to other health care settings can be difficult because the VA has a patient population that is different from most other settings, with patients who may be sicker,” Gidengil said. “But it's important to do more of this work in the future so we can better understand the quality of care the VA provides.”
Support for the study was provided by the VA.
In Congressional testimony, VA officials frequently tout studies that indicate that the VA delivers high-quality health care that meets or exceeds the care delivered at private facilities. These studies often stand in sharp contrast to the criticism leveled at the VA and news stories of health care discrepancies. However, a new meta-analysis of studies on quality at VA facilities suggests that the VA health care system generally performs better than or similar to other health care systems for providing safe and effective care to patients.
The study, published in the Journal of General Internal Medicine and conducted by RAND Corporation researcher Courtney Gidengil , MD, MPH, found 69 articles on VA quality across dimensions, including safety and effectiveness. According to Dr. Gidengil, 22 of 34 safety studies and 20 of 24 studies that focused on effectiveness showed that VA facilities provided the same, if not better, quality of care as do private facilities. These studies focused on safety measures, preventive medicine best practices. In the studies, surgical patients in the VA system and VA nursing homes patients had death rates similar to patients in other health systems.
“We found that the overall quality of care in the VA health system compares favorably to other segments of the U.S. health care system,” said Dr. Gidengil. “In some areas, the quality of care provided by the VA exceeded what we found in other settings, although there were areas where the quality of VA care fell short.”
The study updated and expanded on a similar study conducted in 2009. In addressing timeliness, equity, efficiency, and patient-centeredness, there was too little data to draw reliable conclusions. Similarly, studies on the availability of services had mixed results. During the past 5 years, the study was not able to find any trends indicating whether the VA was superior or inferior compared with other health settings.
“Comparing the VA to other health care settings can be difficult because the VA has a patient population that is different from most other settings, with patients who may be sicker,” Gidengil said. “But it's important to do more of this work in the future so we can better understand the quality of care the VA provides.”
Support for the study was provided by the VA.
In Congressional testimony, VA officials frequently tout studies that indicate that the VA delivers high-quality health care that meets or exceeds the care delivered at private facilities. These studies often stand in sharp contrast to the criticism leveled at the VA and news stories of health care discrepancies. However, a new meta-analysis of studies on quality at VA facilities suggests that the VA health care system generally performs better than or similar to other health care systems for providing safe and effective care to patients.
The study, published in the Journal of General Internal Medicine and conducted by RAND Corporation researcher Courtney Gidengil , MD, MPH, found 69 articles on VA quality across dimensions, including safety and effectiveness. According to Dr. Gidengil, 22 of 34 safety studies and 20 of 24 studies that focused on effectiveness showed that VA facilities provided the same, if not better, quality of care as do private facilities. These studies focused on safety measures, preventive medicine best practices. In the studies, surgical patients in the VA system and VA nursing homes patients had death rates similar to patients in other health systems.
“We found that the overall quality of care in the VA health system compares favorably to other segments of the U.S. health care system,” said Dr. Gidengil. “In some areas, the quality of care provided by the VA exceeded what we found in other settings, although there were areas where the quality of VA care fell short.”
The study updated and expanded on a similar study conducted in 2009. In addressing timeliness, equity, efficiency, and patient-centeredness, there was too little data to draw reliable conclusions. Similarly, studies on the availability of services had mixed results. During the past 5 years, the study was not able to find any trends indicating whether the VA was superior or inferior compared with other health settings.
“Comparing the VA to other health care settings can be difficult because the VA has a patient population that is different from most other settings, with patients who may be sicker,” Gidengil said. “But it's important to do more of this work in the future so we can better understand the quality of care the VA provides.”
Support for the study was provided by the VA.
Zika Vaccine Developed by Walter Reed Researchers Shows Promise
The Walter Reed Army Institute of Research (WRAIR) is teaming up with the vaccine division of Sanofi Pasteur to co-develop a Zika virus vaccine. The vaccine is one of 2 vaccines that showed promise in a test on mice; the other is being developed by Dan Barouch and colleagues of Beth Israel Deaconess Medical Center in Boston.
Data concerning the 2 vaccines effectiveness in laboratory testing were published in the June 28 issue of Nature. “These data demonstrate that protection against the Zika virus challenge can be achieved by single-shot subunit and inactivated virus vaccines in mice and that Env-specific antibody titers represent key immunologic correlates of protection,” Larocca and colleagues reported. “Our findings suggest that the development of a ZIKV vaccine for humans will likely be readily achievable.”
The WRAIR researchers developed the vaccine in close collaboration with the NIH’s National Institute of Allergy and Infectious Diseases (NIAID). The vaccine was created from a purified, inactivated Zika virus.
“[It] has been proven to be safe, effective and able to meet regulatory requirements of the U.S. Food and Drug Administration,” Army COL Stephen J. Thomas, MD, an infectious diseases physician, vaccinologist, and the WRAIR Zika program lead told DoD News.
According to the agreement between Sanofi Pasteur and WRAIR, the organizations will share data related to the development of immunologic assays designed to measure neutralizing antibody responses following natural infection and immunization with the vaccine candidate, biologic samples generated during the performance of nonhuman primate studies, and biologic samples generated during the performance of human safety and immunogenicity studies.
In addition, the company will provide production of clinical material in compliance with current GMP (good manufacturing processes) to support phase II testing. “We’re looking at this from both a short- and long-term perspective, collaborating to get into the clinic quicker to provide a vaccine in response to the current emergency,” said John Shiver, PhD, senior vice president of R&D at Sanofi Pasteur.
David Loew, head of Sanofi Pasteur, commented,“In addition to exploring our own vaccine technology...we are looking at other pathways to get a Zika vaccine into the clinic as soon as possible”." Loew added, “This exciting collaboration with the WRAIR creates the opportunity to rapidly move forward.”
According to the NIH, later this year NIAID and WRAIR expect to start 2 clinical trials of inactivated viral vaccines, including the one described in the Nature study. The trials, each involving dozens of volunteers, will test whether the vaccines are safe and elicit an immune response in people.
The Walter Reed Army Institute of Research (WRAIR) is teaming up with the vaccine division of Sanofi Pasteur to co-develop a Zika virus vaccine. The vaccine is one of 2 vaccines that showed promise in a test on mice; the other is being developed by Dan Barouch and colleagues of Beth Israel Deaconess Medical Center in Boston.
Data concerning the 2 vaccines effectiveness in laboratory testing were published in the June 28 issue of Nature. “These data demonstrate that protection against the Zika virus challenge can be achieved by single-shot subunit and inactivated virus vaccines in mice and that Env-specific antibody titers represent key immunologic correlates of protection,” Larocca and colleagues reported. “Our findings suggest that the development of a ZIKV vaccine for humans will likely be readily achievable.”
The WRAIR researchers developed the vaccine in close collaboration with the NIH’s National Institute of Allergy and Infectious Diseases (NIAID). The vaccine was created from a purified, inactivated Zika virus.
“[It] has been proven to be safe, effective and able to meet regulatory requirements of the U.S. Food and Drug Administration,” Army COL Stephen J. Thomas, MD, an infectious diseases physician, vaccinologist, and the WRAIR Zika program lead told DoD News.
According to the agreement between Sanofi Pasteur and WRAIR, the organizations will share data related to the development of immunologic assays designed to measure neutralizing antibody responses following natural infection and immunization with the vaccine candidate, biologic samples generated during the performance of nonhuman primate studies, and biologic samples generated during the performance of human safety and immunogenicity studies.
In addition, the company will provide production of clinical material in compliance with current GMP (good manufacturing processes) to support phase II testing. “We’re looking at this from both a short- and long-term perspective, collaborating to get into the clinic quicker to provide a vaccine in response to the current emergency,” said John Shiver, PhD, senior vice president of R&D at Sanofi Pasteur.
David Loew, head of Sanofi Pasteur, commented,“In addition to exploring our own vaccine technology...we are looking at other pathways to get a Zika vaccine into the clinic as soon as possible”." Loew added, “This exciting collaboration with the WRAIR creates the opportunity to rapidly move forward.”
According to the NIH, later this year NIAID and WRAIR expect to start 2 clinical trials of inactivated viral vaccines, including the one described in the Nature study. The trials, each involving dozens of volunteers, will test whether the vaccines are safe and elicit an immune response in people.
The Walter Reed Army Institute of Research (WRAIR) is teaming up with the vaccine division of Sanofi Pasteur to co-develop a Zika virus vaccine. The vaccine is one of 2 vaccines that showed promise in a test on mice; the other is being developed by Dan Barouch and colleagues of Beth Israel Deaconess Medical Center in Boston.
Data concerning the 2 vaccines effectiveness in laboratory testing were published in the June 28 issue of Nature. “These data demonstrate that protection against the Zika virus challenge can be achieved by single-shot subunit and inactivated virus vaccines in mice and that Env-specific antibody titers represent key immunologic correlates of protection,” Larocca and colleagues reported. “Our findings suggest that the development of a ZIKV vaccine for humans will likely be readily achievable.”
The WRAIR researchers developed the vaccine in close collaboration with the NIH’s National Institute of Allergy and Infectious Diseases (NIAID). The vaccine was created from a purified, inactivated Zika virus.
“[It] has been proven to be safe, effective and able to meet regulatory requirements of the U.S. Food and Drug Administration,” Army COL Stephen J. Thomas, MD, an infectious diseases physician, vaccinologist, and the WRAIR Zika program lead told DoD News.
According to the agreement between Sanofi Pasteur and WRAIR, the organizations will share data related to the development of immunologic assays designed to measure neutralizing antibody responses following natural infection and immunization with the vaccine candidate, biologic samples generated during the performance of nonhuman primate studies, and biologic samples generated during the performance of human safety and immunogenicity studies.
In addition, the company will provide production of clinical material in compliance with current GMP (good manufacturing processes) to support phase II testing. “We’re looking at this from both a short- and long-term perspective, collaborating to get into the clinic quicker to provide a vaccine in response to the current emergency,” said John Shiver, PhD, senior vice president of R&D at Sanofi Pasteur.
David Loew, head of Sanofi Pasteur, commented,“In addition to exploring our own vaccine technology...we are looking at other pathways to get a Zika vaccine into the clinic as soon as possible”." Loew added, “This exciting collaboration with the WRAIR creates the opportunity to rapidly move forward.”
According to the NIH, later this year NIAID and WRAIR expect to start 2 clinical trials of inactivated viral vaccines, including the one described in the Nature study. The trials, each involving dozens of volunteers, will test whether the vaccines are safe and elicit an immune response in people.
Legionnaires Disease: An Ever-Growing Risk
In 1976, several thousand members of the American Legion were celebrating the bicentennial in Philadelphia, and many were staying at the Bellevue-Stratford Hotel. Within a week of the convention, more than 182 attendees, mostly men, had been hospitalized with tiredness, chest pains, congestion, and fever, and 29 had died.
Finally, a year later the deadly bacterium infecting them was identified. Although also responsible for earlier outbreaks, Legionella pneumophila had been breeding in the hotel’s cooling towers. An important overlooked clue was that even people simply walking by the hotel got sick.
Although that outbreak led to changes in how water management and climate control systems are monitored, the bacterium still takes about 5,000 lives a year. According to the CDC, between 2000 and 2014, reported cases of legionellosis, which comprises both Legionnaire disease and a milder form, Pontiac fever, jumped 286%.
The data come from 27 field investigations of outbreaks, involving 415 cases. Of those, health care-associated outbreaks accounted for 57%. Although 44% of the cases were travel related, the health care-related outbreaks resulted in more deaths.
The CDC-investigated outbreak sources all had at least 1 deficiency, and half had deficiencies in more than 2 categories. Most cases were linked to process failures, such as contaminated potable water and human error.
The infection is fatal for about 1 in 10 people. Those at highest risk are people aged ≥ 50 years, smokers, and those with chronic lung disease, weakened immune systems, or other underlying medical conditions.
The CDC says the federal government is improving health care for veterans by requiring plans for prevention of Legionnaires disease at VHA hospitals and long-term care facilities. Health care providers can test (using a urinary antigen test and a culture from a lower respiratory specimen) for Legionnaires disease in people with serious pneumonia, especially those in intensive care or who recently stayed in a health care facility or hotel, or on a cruise ship.
Widespread use of effective water management programs, the CDC advises, in addition to early diagnosis, might reduce the number and size of Legionnaires disease outbreaks.
In 1976, several thousand members of the American Legion were celebrating the bicentennial in Philadelphia, and many were staying at the Bellevue-Stratford Hotel. Within a week of the convention, more than 182 attendees, mostly men, had been hospitalized with tiredness, chest pains, congestion, and fever, and 29 had died.
Finally, a year later the deadly bacterium infecting them was identified. Although also responsible for earlier outbreaks, Legionella pneumophila had been breeding in the hotel’s cooling towers. An important overlooked clue was that even people simply walking by the hotel got sick.
Although that outbreak led to changes in how water management and climate control systems are monitored, the bacterium still takes about 5,000 lives a year. According to the CDC, between 2000 and 2014, reported cases of legionellosis, which comprises both Legionnaire disease and a milder form, Pontiac fever, jumped 286%.
The data come from 27 field investigations of outbreaks, involving 415 cases. Of those, health care-associated outbreaks accounted for 57%. Although 44% of the cases were travel related, the health care-related outbreaks resulted in more deaths.
The CDC-investigated outbreak sources all had at least 1 deficiency, and half had deficiencies in more than 2 categories. Most cases were linked to process failures, such as contaminated potable water and human error.
The infection is fatal for about 1 in 10 people. Those at highest risk are people aged ≥ 50 years, smokers, and those with chronic lung disease, weakened immune systems, or other underlying medical conditions.
The CDC says the federal government is improving health care for veterans by requiring plans for prevention of Legionnaires disease at VHA hospitals and long-term care facilities. Health care providers can test (using a urinary antigen test and a culture from a lower respiratory specimen) for Legionnaires disease in people with serious pneumonia, especially those in intensive care or who recently stayed in a health care facility or hotel, or on a cruise ship.
Widespread use of effective water management programs, the CDC advises, in addition to early diagnosis, might reduce the number and size of Legionnaires disease outbreaks.
In 1976, several thousand members of the American Legion were celebrating the bicentennial in Philadelphia, and many were staying at the Bellevue-Stratford Hotel. Within a week of the convention, more than 182 attendees, mostly men, had been hospitalized with tiredness, chest pains, congestion, and fever, and 29 had died.
Finally, a year later the deadly bacterium infecting them was identified. Although also responsible for earlier outbreaks, Legionella pneumophila had been breeding in the hotel’s cooling towers. An important overlooked clue was that even people simply walking by the hotel got sick.
Although that outbreak led to changes in how water management and climate control systems are monitored, the bacterium still takes about 5,000 lives a year. According to the CDC, between 2000 and 2014, reported cases of legionellosis, which comprises both Legionnaire disease and a milder form, Pontiac fever, jumped 286%.
The data come from 27 field investigations of outbreaks, involving 415 cases. Of those, health care-associated outbreaks accounted for 57%. Although 44% of the cases were travel related, the health care-related outbreaks resulted in more deaths.
The CDC-investigated outbreak sources all had at least 1 deficiency, and half had deficiencies in more than 2 categories. Most cases were linked to process failures, such as contaminated potable water and human error.
The infection is fatal for about 1 in 10 people. Those at highest risk are people aged ≥ 50 years, smokers, and those with chronic lung disease, weakened immune systems, or other underlying medical conditions.
The CDC says the federal government is improving health care for veterans by requiring plans for prevention of Legionnaires disease at VHA hospitals and long-term care facilities. Health care providers can test (using a urinary antigen test and a culture from a lower respiratory specimen) for Legionnaires disease in people with serious pneumonia, especially those in intensive care or who recently stayed in a health care facility or hotel, or on a cruise ship.
Widespread use of effective water management programs, the CDC advises, in addition to early diagnosis, might reduce the number and size of Legionnaires disease outbreaks.
IHS and CMS Partner for Patient Safety Improvements
The IHS and Centers for Medicare & Medicaid Services (CMS) are partnering to “strengthen the quality of care delivered in IHS-operated hospitals.” IHS hospitals will receive assistance from a CMS-supported Hospital Engagement Network (HEN) whose purpose is to help health care facilities deliver better care and spend more efficiently. The effort includes IHS hospitals in the Great Plains Area.
The HENs focus on reducing preventable patient harm, such as hospital-acquired infections and avoidable readmissions. They help identify proven solutions and then share them among hospitals. The HENs also track and monitor hospital progress in meeting quality improvement goals. The IHS will be able to access technical assistance and support, for example, from quality improvement experts.
This is not the first time the 2 organizations have joined forces. The new partnership actually dates from 2013, when some parts of IHS participated in a “first-round” HEN. “Quality improvement is a continuous effort at IHS hospitals—as it is at all health care facilities,” says Mary Smith, IHS principal deputy director. “Working with a Hospital Engagement Network brings more resources and underscores our commitment to focus on delivering efficient and high-quality care for our patients.”
The IHS and Centers for Medicare & Medicaid Services (CMS) are partnering to “strengthen the quality of care delivered in IHS-operated hospitals.” IHS hospitals will receive assistance from a CMS-supported Hospital Engagement Network (HEN) whose purpose is to help health care facilities deliver better care and spend more efficiently. The effort includes IHS hospitals in the Great Plains Area.
The HENs focus on reducing preventable patient harm, such as hospital-acquired infections and avoidable readmissions. They help identify proven solutions and then share them among hospitals. The HENs also track and monitor hospital progress in meeting quality improvement goals. The IHS will be able to access technical assistance and support, for example, from quality improvement experts.
This is not the first time the 2 organizations have joined forces. The new partnership actually dates from 2013, when some parts of IHS participated in a “first-round” HEN. “Quality improvement is a continuous effort at IHS hospitals—as it is at all health care facilities,” says Mary Smith, IHS principal deputy director. “Working with a Hospital Engagement Network brings more resources and underscores our commitment to focus on delivering efficient and high-quality care for our patients.”
The IHS and Centers for Medicare & Medicaid Services (CMS) are partnering to “strengthen the quality of care delivered in IHS-operated hospitals.” IHS hospitals will receive assistance from a CMS-supported Hospital Engagement Network (HEN) whose purpose is to help health care facilities deliver better care and spend more efficiently. The effort includes IHS hospitals in the Great Plains Area.
The HENs focus on reducing preventable patient harm, such as hospital-acquired infections and avoidable readmissions. They help identify proven solutions and then share them among hospitals. The HENs also track and monitor hospital progress in meeting quality improvement goals. The IHS will be able to access technical assistance and support, for example, from quality improvement experts.
This is not the first time the 2 organizations have joined forces. The new partnership actually dates from 2013, when some parts of IHS participated in a “first-round” HEN. “Quality improvement is a continuous effort at IHS hospitals—as it is at all health care facilities,” says Mary Smith, IHS principal deputy director. “Working with a Hospital Engagement Network brings more resources and underscores our commitment to focus on delivering efficient and high-quality care for our patients.”
Trump Releases 10-Point Plan for VA Reform
Donald Trump, the presumptive Republican Party nominee focused on the VA and veterans’ health issues in a speech Monday in Virginia Beach, Virginia. In the speech, Mr. Trump called for civil service reform, access to community care for all veterans regardless of Choice program eligibility, and more VA mental health care providers.
“It is the job of the next President to make America safe again, for everyone,” Mr. Trump said in a prepared speech. “That promise of protection must include taking care of every last veteran.”
Echoing the recent recommendations of the Commission on Care, Mr. Trump argued that access to care in the community should be guaranteed for all veterans. “We must extend this right to all veterans, not just those who can’t get an appointment in 30 days, or who live more than 40 miles from a VA hospital, which is the current policy.”
Hillary Clinton, the presumptive Democratic Party nominee, did not directly respond to Mr. Trump’s proposal or those of the Commission on Care. However she has previously stated that she opposes efforts to privatize veteran care. Mrs. Clinton has touted her role in increasing aid to families of veterans and active- duty service members and expanding coverage to include National Guard and reservists as a member of the Armed Services Committee.
Charging that the VA was “corrupt,” Mr. Trump vowed to begin an investigation immediately if he is elected president. “I will instruct my staff that if a valid complaint is not addressed, that the issue be brought directly to me,” he said. “I will pick up the phone and fix it myself if I have to.” The Republican candidate called for civil service reform so that the VA can more easily fire employees.
The Republican candidate’s remarks also drew on the pre-release of information from the VA’s research into suicide rates. Noting that the rate of veteran suicide is lower among patients in the VA system compared with the rate of those who do not use VA services, Mr. Trump called for expansion of mental health services at the VA. “A shocking 20 veterans are committing suicide each day, especially our older veterans,” Mr. Trump said. “This is a national tragedy. The evidence shows that if veterans are in the system, receiving care, they are much less likely to take their own lives than veterans outside the system. That is why we must increase the number of mental health care professionals inside the VA— while ensuring that veterans can access private mental health care as well.”
In his speech, Mr. Trump vowed to enact the following VA reform proposals:
1. I will appoint a Secretary of Veterans Affairs who will make it his or her personal mission to clean up the VA.
2. I am going to use every lawful authority to remove and discipline federal employees or managers who fail our veterans or breach the public trust.
3. I am going to ask Congress to pass legislation that ensures the Secretary of Veterans Affairs has the authority to remove or discipline any employee who risks the health, safety, or well-being of any veteran.
4. I am going to appoint a commission to investigate all the wrongdoing at the VA and then present those findings to Congress as the basis for bold legislative reform.
5. I am going to make sure the honest and dedicated people in the VA have their jobs protected and are put in line for promotions.
6. I will create a private White House Hotline that is answered by a real person 24 hours a day to ensure that no valid complaint about VA wrongdoing falls through the cracks.
7. We are going to stop giving bonuses to people for wasting money and start giving bonuses to people for improving service, saving lives, and cutting waste.
8. We are going to reform our visa programs to ensure American veterans are in the front, not back, of the line.
9 We are going to increase the number of mental health care professionals and increase outreach to veterans outside of the system.
10. We are going to ensure every veteran in America has the choice to seek care at the VA or to seek private medical care.
Donald Trump, the presumptive Republican Party nominee focused on the VA and veterans’ health issues in a speech Monday in Virginia Beach, Virginia. In the speech, Mr. Trump called for civil service reform, access to community care for all veterans regardless of Choice program eligibility, and more VA mental health care providers.
“It is the job of the next President to make America safe again, for everyone,” Mr. Trump said in a prepared speech. “That promise of protection must include taking care of every last veteran.”
Echoing the recent recommendations of the Commission on Care, Mr. Trump argued that access to care in the community should be guaranteed for all veterans. “We must extend this right to all veterans, not just those who can’t get an appointment in 30 days, or who live more than 40 miles from a VA hospital, which is the current policy.”
Hillary Clinton, the presumptive Democratic Party nominee, did not directly respond to Mr. Trump’s proposal or those of the Commission on Care. However she has previously stated that she opposes efforts to privatize veteran care. Mrs. Clinton has touted her role in increasing aid to families of veterans and active- duty service members and expanding coverage to include National Guard and reservists as a member of the Armed Services Committee.
Charging that the VA was “corrupt,” Mr. Trump vowed to begin an investigation immediately if he is elected president. “I will instruct my staff that if a valid complaint is not addressed, that the issue be brought directly to me,” he said. “I will pick up the phone and fix it myself if I have to.” The Republican candidate called for civil service reform so that the VA can more easily fire employees.
The Republican candidate’s remarks also drew on the pre-release of information from the VA’s research into suicide rates. Noting that the rate of veteran suicide is lower among patients in the VA system compared with the rate of those who do not use VA services, Mr. Trump called for expansion of mental health services at the VA. “A shocking 20 veterans are committing suicide each day, especially our older veterans,” Mr. Trump said. “This is a national tragedy. The evidence shows that if veterans are in the system, receiving care, they are much less likely to take their own lives than veterans outside the system. That is why we must increase the number of mental health care professionals inside the VA— while ensuring that veterans can access private mental health care as well.”
In his speech, Mr. Trump vowed to enact the following VA reform proposals:
1. I will appoint a Secretary of Veterans Affairs who will make it his or her personal mission to clean up the VA.
2. I am going to use every lawful authority to remove and discipline federal employees or managers who fail our veterans or breach the public trust.
3. I am going to ask Congress to pass legislation that ensures the Secretary of Veterans Affairs has the authority to remove or discipline any employee who risks the health, safety, or well-being of any veteran.
4. I am going to appoint a commission to investigate all the wrongdoing at the VA and then present those findings to Congress as the basis for bold legislative reform.
5. I am going to make sure the honest and dedicated people in the VA have their jobs protected and are put in line for promotions.
6. I will create a private White House Hotline that is answered by a real person 24 hours a day to ensure that no valid complaint about VA wrongdoing falls through the cracks.
7. We are going to stop giving bonuses to people for wasting money and start giving bonuses to people for improving service, saving lives, and cutting waste.
8. We are going to reform our visa programs to ensure American veterans are in the front, not back, of the line.
9 We are going to increase the number of mental health care professionals and increase outreach to veterans outside of the system.
10. We are going to ensure every veteran in America has the choice to seek care at the VA or to seek private medical care.
Donald Trump, the presumptive Republican Party nominee focused on the VA and veterans’ health issues in a speech Monday in Virginia Beach, Virginia. In the speech, Mr. Trump called for civil service reform, access to community care for all veterans regardless of Choice program eligibility, and more VA mental health care providers.
“It is the job of the next President to make America safe again, for everyone,” Mr. Trump said in a prepared speech. “That promise of protection must include taking care of every last veteran.”
Echoing the recent recommendations of the Commission on Care, Mr. Trump argued that access to care in the community should be guaranteed for all veterans. “We must extend this right to all veterans, not just those who can’t get an appointment in 30 days, or who live more than 40 miles from a VA hospital, which is the current policy.”
Hillary Clinton, the presumptive Democratic Party nominee, did not directly respond to Mr. Trump’s proposal or those of the Commission on Care. However she has previously stated that she opposes efforts to privatize veteran care. Mrs. Clinton has touted her role in increasing aid to families of veterans and active- duty service members and expanding coverage to include National Guard and reservists as a member of the Armed Services Committee.
Charging that the VA was “corrupt,” Mr. Trump vowed to begin an investigation immediately if he is elected president. “I will instruct my staff that if a valid complaint is not addressed, that the issue be brought directly to me,” he said. “I will pick up the phone and fix it myself if I have to.” The Republican candidate called for civil service reform so that the VA can more easily fire employees.
The Republican candidate’s remarks also drew on the pre-release of information from the VA’s research into suicide rates. Noting that the rate of veteran suicide is lower among patients in the VA system compared with the rate of those who do not use VA services, Mr. Trump called for expansion of mental health services at the VA. “A shocking 20 veterans are committing suicide each day, especially our older veterans,” Mr. Trump said. “This is a national tragedy. The evidence shows that if veterans are in the system, receiving care, they are much less likely to take their own lives than veterans outside the system. That is why we must increase the number of mental health care professionals inside the VA— while ensuring that veterans can access private mental health care as well.”
In his speech, Mr. Trump vowed to enact the following VA reform proposals:
1. I will appoint a Secretary of Veterans Affairs who will make it his or her personal mission to clean up the VA.
2. I am going to use every lawful authority to remove and discipline federal employees or managers who fail our veterans or breach the public trust.
3. I am going to ask Congress to pass legislation that ensures the Secretary of Veterans Affairs has the authority to remove or discipline any employee who risks the health, safety, or well-being of any veteran.
4. I am going to appoint a commission to investigate all the wrongdoing at the VA and then present those findings to Congress as the basis for bold legislative reform.
5. I am going to make sure the honest and dedicated people in the VA have their jobs protected and are put in line for promotions.
6. I will create a private White House Hotline that is answered by a real person 24 hours a day to ensure that no valid complaint about VA wrongdoing falls through the cracks.
7. We are going to stop giving bonuses to people for wasting money and start giving bonuses to people for improving service, saving lives, and cutting waste.
8. We are going to reform our visa programs to ensure American veterans are in the front, not back, of the line.
9 We are going to increase the number of mental health care professionals and increase outreach to veterans outside of the system.
10. We are going to ensure every veteran in America has the choice to seek care at the VA or to seek private medical care.
Standard vs Intensive Emergency Stroke Treatment
Standard and intensive blood pressure treatments are equally effective in emergency treatment of acute intracerebral hemorrhage, according to a study funded by the National Institute of Neurological Disorders and Stroke. That is, reducing systolic blood pressure rapidly to 140-179 mm Hg worked as well as reducing to 110-139 mm Hg.
“For decades, doctors wondered whether intensive blood pressure management was more effective than standard treatment for controlling intracerebral hemorrhage,” said principal investigator Adnan Qureshi, MD, professor of neurology, neurosurgery and radiology at the Zeenat Qureshi Stroke Research Center, University of Minnesota in Minneapolis. “Our results may help patients and their doctors make better treatment decisions.”
In the 110-site international study, 1,000 patients were treated within 4.5 hours of a stroke. Half were assigned to intensive treatment and half to standard treatment. Brain scans taken 24 hours after treatment showed no difference in the rates of hemorrhage growth between the 2 groups. Because the researchers found no differences, the study was stopped after enrolling 1,000 patients rather than 1,280.
Moreover, after 90 days, the rate of death or severe disability was about 38% in both groups—a number much lower than the expected 60%. Patients in the intensive treatment group had a slightly higher rate of serious adverse events in the 90 days after the stroke but at lower levels than expected. The researchers say that may be because more than half of enrolled patients had experienced mild strokes and had a better chance of good results.
Their findings suggest that intensive reduction in the systolic blood pressure level does not provide “an incremental clinical benefit,” the researchers say. Dr. Qureshi noted, “Rapidly lowering blood pressure to normal levels may further damage the brain. The levels we used are tolerable for emergencies. Normal levels can be safely obtained gradually.”
Standard and intensive blood pressure treatments are equally effective in emergency treatment of acute intracerebral hemorrhage, according to a study funded by the National Institute of Neurological Disorders and Stroke. That is, reducing systolic blood pressure rapidly to 140-179 mm Hg worked as well as reducing to 110-139 mm Hg.
“For decades, doctors wondered whether intensive blood pressure management was more effective than standard treatment for controlling intracerebral hemorrhage,” said principal investigator Adnan Qureshi, MD, professor of neurology, neurosurgery and radiology at the Zeenat Qureshi Stroke Research Center, University of Minnesota in Minneapolis. “Our results may help patients and their doctors make better treatment decisions.”
In the 110-site international study, 1,000 patients were treated within 4.5 hours of a stroke. Half were assigned to intensive treatment and half to standard treatment. Brain scans taken 24 hours after treatment showed no difference in the rates of hemorrhage growth between the 2 groups. Because the researchers found no differences, the study was stopped after enrolling 1,000 patients rather than 1,280.
Moreover, after 90 days, the rate of death or severe disability was about 38% in both groups—a number much lower than the expected 60%. Patients in the intensive treatment group had a slightly higher rate of serious adverse events in the 90 days after the stroke but at lower levels than expected. The researchers say that may be because more than half of enrolled patients had experienced mild strokes and had a better chance of good results.
Their findings suggest that intensive reduction in the systolic blood pressure level does not provide “an incremental clinical benefit,” the researchers say. Dr. Qureshi noted, “Rapidly lowering blood pressure to normal levels may further damage the brain. The levels we used are tolerable for emergencies. Normal levels can be safely obtained gradually.”
Standard and intensive blood pressure treatments are equally effective in emergency treatment of acute intracerebral hemorrhage, according to a study funded by the National Institute of Neurological Disorders and Stroke. That is, reducing systolic blood pressure rapidly to 140-179 mm Hg worked as well as reducing to 110-139 mm Hg.
“For decades, doctors wondered whether intensive blood pressure management was more effective than standard treatment for controlling intracerebral hemorrhage,” said principal investigator Adnan Qureshi, MD, professor of neurology, neurosurgery and radiology at the Zeenat Qureshi Stroke Research Center, University of Minnesota in Minneapolis. “Our results may help patients and their doctors make better treatment decisions.”
In the 110-site international study, 1,000 patients were treated within 4.5 hours of a stroke. Half were assigned to intensive treatment and half to standard treatment. Brain scans taken 24 hours after treatment showed no difference in the rates of hemorrhage growth between the 2 groups. Because the researchers found no differences, the study was stopped after enrolling 1,000 patients rather than 1,280.
Moreover, after 90 days, the rate of death or severe disability was about 38% in both groups—a number much lower than the expected 60%. Patients in the intensive treatment group had a slightly higher rate of serious adverse events in the 90 days after the stroke but at lower levels than expected. The researchers say that may be because more than half of enrolled patients had experienced mild strokes and had a better chance of good results.
Their findings suggest that intensive reduction in the systolic blood pressure level does not provide “an incremental clinical benefit,” the researchers say. Dr. Qureshi noted, “Rapidly lowering blood pressure to normal levels may further damage the brain. The levels we used are tolerable for emergencies. Normal levels can be safely obtained gradually.”
Docs to CMS: MACRA is too complex and should be delayed
The proposed federal regulations to implement the MACRA health care reforms are too complex, too onerous on small and solo practices, lack opportunities for many to participate in alternative payment models, and should be delayed for a full year, at least.
That was the message that emerged from hundreds of comments regarding the proposed rule that were submitted by physician organizations and other stakeholders.
“The intent of [the Medicare Access and CHIP Reauthorization Act of 2015] was not to merely move the current incentive program into [the Merit-based Incentive Payment System], but to improve and simplify these programs into a single more unified approach,” the American Medical Association said in its comments, noting that “numerous changes” will be needed in the way cost and quality are measured.
AMA also called for a better, faster way for physicians to develop alternative payment models. “We strongly urge CMS to vigorously pursue this objective and establish a much more progressive and welcoming environment for the development and implementation of specialty-defined APMs than proposed in the [proposed rule].”
AMA also suggested that CMS provide more flexibility for solo and small practices, align the four components of MIPS so it operates as a single program, simplifying and lowering the financial risk for advanced APMs, and providing more timely feedback to physicians.
The organization also called for CMS to “create an initial transitional performance period from July 1, 2017, to December 31, 2017, to ensure the successful and appropriate implementation of the MACRA program. In future years, for all reporting requirements, CMS should allow physicians to select periods of less than a full calendar year to provide flexibility.”
In its comments, the American Medical Group Association questioned whether the proposed rule actually would lead to improved quality of care and reward value.
In the proposed rule, “CMS will measure and score quality and resource use or spending separately,” AMGA wrote in its comments. “CMS will not measure outcomes in relation to spending. CMS will not measure for value. If value is left unaddressed in the final rule, it will be difficult at best for the agency to meet MACRA and the [HHS] secretary’s overarching goals.”
While expressing support for MACRA conceptually, officials with the American Academy of Family Physicians wrote that they “see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule.”
Specifically, AAFP criticized the proposed rule for allowing small and solo practices to form “virtual groups” in order to earn bonuses, despite it being mandated by law.
Solo and small group practices who participate in MIPS to should “be eligible for positive payment updates if their performance yields such payments, but would be exempt from any negative payment update until such a time that the virtual group option is available,” AAFP officials wrote.
They also called for medical home delivery models to be included in APMs, in an effort to improve on the limited opportunities for family practices in particular to participate in alternative payment models.
The American College of Physicians also called for safe harbors for small and solo practices until virtual group options can be established.
ACP, like other groups, questioned that medical homes are not recognized as alternative payment models and argued that Congress intended medical homes to qualify as APMs “without bearing more than nominal financial risk.”
Despite the flexible approach to the overall quality payment program, CMS has “created a degree of complexity” and must “continue to seek ways to further streamline and simplify” the move to quality payments, according to comments from the American College of Cardiology.
The ACC also expressed concerns that the reporting requirements under MIPS and some of the APMs will limit the ability for cardiologists to report the most meaningful measures, particularly if they are part of a multi-specialty group, and suggested changes in scoring methodology or to allow more than one data file to be submitted in multi-specialty situations.
It also expressed concerns that the rule as proposed could adversely effect small practices, rural practices, and practices in health professional shortage areas, and “in the absence of other solutions such as virtual groups in 2017, CMS should monitor policies and provide effective practice assistance to these practices.”
The proposed rule provides no support for small practices, according to the American Gastroenterological Association.
“Upon release of the proposed rule, we were disappointed to see that not only will APMs be essentially closed off to small practices in the first years of implementation, but the MIPS program will significantly harm practices with less than 25 eligible clinicians,” AGA noted, citing data presented by CMS that 87% of solo practitioners will receive a negative adjustment with an aggregate negative impact of $300 million and for all practices with less than 25 eligible clinicians, the aggregate negative adjustment will total $649 million.
“Any system in which smaller practices are so heavily disadvantaged is unacceptable,” AGA said. CMS has previously stated that the regulatory impact statement would likely change and reflect a smaller impact for small and solo practices once more updated information can be modeled when the rule is final.
Additionally, AGA expressed concern over the limited engagement in APMs that will be possible under the proposed rule. “Given the importance of APM participation to both the practice and reimbursement of Medicare physicians, access to advanced APMs should be provided to all physicians.”
The association also expressed concern that the definition of APM is not broad enough and suggested that it be widened in scope so that it can capture payment models that have been created using the AGA’s Roadmap to the Future of GI Practice. It recommended a number of models be classified as APMs, including the colonoscopy bundled payment, gastroesophageal reflux disease episode payment, obesity bundled payment, Project Sonar (a chronic disease management program for IBD), and the Medical Home Neighbor.
The American College of Rheumatology called for a delay in the implementation of any final MACRA regulations, noting in its comments that with requirements set to begin in 2017, the current implementation schedule “does not provide enough time for providers to implement the required changes,” though ACR does not recommend a specific start time.
ACR also questioned how the criteria for APMs was set up, noting expressly that Physician Focused Payment Models may not meet the APM requirements. The group is seeking clarification on whether these models will qualify as an APM.
“Medical home APMs should also permit specialty physicians to participate, including small group and multispeciality groups, in keeping with the need for APMs to be flexible with their criteria and the role of specialty physicians in providing chronic care.
The American Academy of Dermatology Association echoed a number of concerns voiced across the medical profession and is calling for a delay in the implementation of MACRA’s regulations.
In particular, AADA noted that the regulations are not friendly for small and solo practices in general and little is contained within the proposal to “meaningfully engage specialist physicians in APMs.”
The association also is calling for broader mechanisms to allow for the development and recognition of APMs, including recognizing specialty-focused medical homes.
The group also is calling for pilot programs to test the validity of the measures that will form the basis of quality payment incentives and penalties.
In an effort to protect small and solo practices, AADA is calling for an exemption from MIPS or APM requirements until a virtual group option is developed, tested, and is fully operational.
The American Psychiatric Association echoed a number of broad concerns raised across the physician spectrum, including calling for a to the first year of implementation to July 1, 2017, and lasting through Dec. 31, 2017, as well as enabling the formation of virtual groups at the onset of implementation in its comments.
But APA also noted that mental health presents a variety of unique issues that need to be addressed.
For example, the association notes that psychiatrists work across a number of practice settings, including academic health centers, hospitals, clinics, nursing homes, and private practices, as well as offering services via telemedicine.
“This makes it difficult for psychiatrists to capture all the work they do, because of the combination of settings that utilize multiple, and potentially differing reporting programs and methods,” APA noted.
It added that psychiatrists generally have limited time and resources that can be devoted to Medicare quality reporting, which would make participation in MIPS and APMs more challenging, particularly because many operate in small or solo practices that do not own electronic health record systems, which would complicate reporting requirements to qualify for MIPS or APMs.
In addition to concerns with reporting in general, APA said that psychiatrists “also have limited choices in outcome quality measures.”
The proposed federal regulations to implement the MACRA health care reforms are too complex, too onerous on small and solo practices, lack opportunities for many to participate in alternative payment models, and should be delayed for a full year, at least.
That was the message that emerged from hundreds of comments regarding the proposed rule that were submitted by physician organizations and other stakeholders.
“The intent of [the Medicare Access and CHIP Reauthorization Act of 2015] was not to merely move the current incentive program into [the Merit-based Incentive Payment System], but to improve and simplify these programs into a single more unified approach,” the American Medical Association said in its comments, noting that “numerous changes” will be needed in the way cost and quality are measured.
AMA also called for a better, faster way for physicians to develop alternative payment models. “We strongly urge CMS to vigorously pursue this objective and establish a much more progressive and welcoming environment for the development and implementation of specialty-defined APMs than proposed in the [proposed rule].”
AMA also suggested that CMS provide more flexibility for solo and small practices, align the four components of MIPS so it operates as a single program, simplifying and lowering the financial risk for advanced APMs, and providing more timely feedback to physicians.
The organization also called for CMS to “create an initial transitional performance period from July 1, 2017, to December 31, 2017, to ensure the successful and appropriate implementation of the MACRA program. In future years, for all reporting requirements, CMS should allow physicians to select periods of less than a full calendar year to provide flexibility.”
In its comments, the American Medical Group Association questioned whether the proposed rule actually would lead to improved quality of care and reward value.
In the proposed rule, “CMS will measure and score quality and resource use or spending separately,” AMGA wrote in its comments. “CMS will not measure outcomes in relation to spending. CMS will not measure for value. If value is left unaddressed in the final rule, it will be difficult at best for the agency to meet MACRA and the [HHS] secretary’s overarching goals.”
While expressing support for MACRA conceptually, officials with the American Academy of Family Physicians wrote that they “see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule.”
Specifically, AAFP criticized the proposed rule for allowing small and solo practices to form “virtual groups” in order to earn bonuses, despite it being mandated by law.
Solo and small group practices who participate in MIPS to should “be eligible for positive payment updates if their performance yields such payments, but would be exempt from any negative payment update until such a time that the virtual group option is available,” AAFP officials wrote.
They also called for medical home delivery models to be included in APMs, in an effort to improve on the limited opportunities for family practices in particular to participate in alternative payment models.
The American College of Physicians also called for safe harbors for small and solo practices until virtual group options can be established.
ACP, like other groups, questioned that medical homes are not recognized as alternative payment models and argued that Congress intended medical homes to qualify as APMs “without bearing more than nominal financial risk.”
Despite the flexible approach to the overall quality payment program, CMS has “created a degree of complexity” and must “continue to seek ways to further streamline and simplify” the move to quality payments, according to comments from the American College of Cardiology.
The ACC also expressed concerns that the reporting requirements under MIPS and some of the APMs will limit the ability for cardiologists to report the most meaningful measures, particularly if they are part of a multi-specialty group, and suggested changes in scoring methodology or to allow more than one data file to be submitted in multi-specialty situations.
It also expressed concerns that the rule as proposed could adversely effect small practices, rural practices, and practices in health professional shortage areas, and “in the absence of other solutions such as virtual groups in 2017, CMS should monitor policies and provide effective practice assistance to these practices.”
The proposed rule provides no support for small practices, according to the American Gastroenterological Association.
“Upon release of the proposed rule, we were disappointed to see that not only will APMs be essentially closed off to small practices in the first years of implementation, but the MIPS program will significantly harm practices with less than 25 eligible clinicians,” AGA noted, citing data presented by CMS that 87% of solo practitioners will receive a negative adjustment with an aggregate negative impact of $300 million and for all practices with less than 25 eligible clinicians, the aggregate negative adjustment will total $649 million.
“Any system in which smaller practices are so heavily disadvantaged is unacceptable,” AGA said. CMS has previously stated that the regulatory impact statement would likely change and reflect a smaller impact for small and solo practices once more updated information can be modeled when the rule is final.
Additionally, AGA expressed concern over the limited engagement in APMs that will be possible under the proposed rule. “Given the importance of APM participation to both the practice and reimbursement of Medicare physicians, access to advanced APMs should be provided to all physicians.”
The association also expressed concern that the definition of APM is not broad enough and suggested that it be widened in scope so that it can capture payment models that have been created using the AGA’s Roadmap to the Future of GI Practice. It recommended a number of models be classified as APMs, including the colonoscopy bundled payment, gastroesophageal reflux disease episode payment, obesity bundled payment, Project Sonar (a chronic disease management program for IBD), and the Medical Home Neighbor.
The American College of Rheumatology called for a delay in the implementation of any final MACRA regulations, noting in its comments that with requirements set to begin in 2017, the current implementation schedule “does not provide enough time for providers to implement the required changes,” though ACR does not recommend a specific start time.
ACR also questioned how the criteria for APMs was set up, noting expressly that Physician Focused Payment Models may not meet the APM requirements. The group is seeking clarification on whether these models will qualify as an APM.
“Medical home APMs should also permit specialty physicians to participate, including small group and multispeciality groups, in keeping with the need for APMs to be flexible with their criteria and the role of specialty physicians in providing chronic care.
The American Academy of Dermatology Association echoed a number of concerns voiced across the medical profession and is calling for a delay in the implementation of MACRA’s regulations.
In particular, AADA noted that the regulations are not friendly for small and solo practices in general and little is contained within the proposal to “meaningfully engage specialist physicians in APMs.”
The association also is calling for broader mechanisms to allow for the development and recognition of APMs, including recognizing specialty-focused medical homes.
The group also is calling for pilot programs to test the validity of the measures that will form the basis of quality payment incentives and penalties.
In an effort to protect small and solo practices, AADA is calling for an exemption from MIPS or APM requirements until a virtual group option is developed, tested, and is fully operational.
The American Psychiatric Association echoed a number of broad concerns raised across the physician spectrum, including calling for a to the first year of implementation to July 1, 2017, and lasting through Dec. 31, 2017, as well as enabling the formation of virtual groups at the onset of implementation in its comments.
But APA also noted that mental health presents a variety of unique issues that need to be addressed.
For example, the association notes that psychiatrists work across a number of practice settings, including academic health centers, hospitals, clinics, nursing homes, and private practices, as well as offering services via telemedicine.
“This makes it difficult for psychiatrists to capture all the work they do, because of the combination of settings that utilize multiple, and potentially differing reporting programs and methods,” APA noted.
It added that psychiatrists generally have limited time and resources that can be devoted to Medicare quality reporting, which would make participation in MIPS and APMs more challenging, particularly because many operate in small or solo practices that do not own electronic health record systems, which would complicate reporting requirements to qualify for MIPS or APMs.
In addition to concerns with reporting in general, APA said that psychiatrists “also have limited choices in outcome quality measures.”
The proposed federal regulations to implement the MACRA health care reforms are too complex, too onerous on small and solo practices, lack opportunities for many to participate in alternative payment models, and should be delayed for a full year, at least.
That was the message that emerged from hundreds of comments regarding the proposed rule that were submitted by physician organizations and other stakeholders.
“The intent of [the Medicare Access and CHIP Reauthorization Act of 2015] was not to merely move the current incentive program into [the Merit-based Incentive Payment System], but to improve and simplify these programs into a single more unified approach,” the American Medical Association said in its comments, noting that “numerous changes” will be needed in the way cost and quality are measured.
AMA also called for a better, faster way for physicians to develop alternative payment models. “We strongly urge CMS to vigorously pursue this objective and establish a much more progressive and welcoming environment for the development and implementation of specialty-defined APMs than proposed in the [proposed rule].”
AMA also suggested that CMS provide more flexibility for solo and small practices, align the four components of MIPS so it operates as a single program, simplifying and lowering the financial risk for advanced APMs, and providing more timely feedback to physicians.
The organization also called for CMS to “create an initial transitional performance period from July 1, 2017, to December 31, 2017, to ensure the successful and appropriate implementation of the MACRA program. In future years, for all reporting requirements, CMS should allow physicians to select periods of less than a full calendar year to provide flexibility.”
In its comments, the American Medical Group Association questioned whether the proposed rule actually would lead to improved quality of care and reward value.
In the proposed rule, “CMS will measure and score quality and resource use or spending separately,” AMGA wrote in its comments. “CMS will not measure outcomes in relation to spending. CMS will not measure for value. If value is left unaddressed in the final rule, it will be difficult at best for the agency to meet MACRA and the [HHS] secretary’s overarching goals.”
While expressing support for MACRA conceptually, officials with the American Academy of Family Physicians wrote that they “see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule.”
Specifically, AAFP criticized the proposed rule for allowing small and solo practices to form “virtual groups” in order to earn bonuses, despite it being mandated by law.
Solo and small group practices who participate in MIPS to should “be eligible for positive payment updates if their performance yields such payments, but would be exempt from any negative payment update until such a time that the virtual group option is available,” AAFP officials wrote.
They also called for medical home delivery models to be included in APMs, in an effort to improve on the limited opportunities for family practices in particular to participate in alternative payment models.
The American College of Physicians also called for safe harbors for small and solo practices until virtual group options can be established.
ACP, like other groups, questioned that medical homes are not recognized as alternative payment models and argued that Congress intended medical homes to qualify as APMs “without bearing more than nominal financial risk.”
Despite the flexible approach to the overall quality payment program, CMS has “created a degree of complexity” and must “continue to seek ways to further streamline and simplify” the move to quality payments, according to comments from the American College of Cardiology.
The ACC also expressed concerns that the reporting requirements under MIPS and some of the APMs will limit the ability for cardiologists to report the most meaningful measures, particularly if they are part of a multi-specialty group, and suggested changes in scoring methodology or to allow more than one data file to be submitted in multi-specialty situations.
It also expressed concerns that the rule as proposed could adversely effect small practices, rural practices, and practices in health professional shortage areas, and “in the absence of other solutions such as virtual groups in 2017, CMS should monitor policies and provide effective practice assistance to these practices.”
The proposed rule provides no support for small practices, according to the American Gastroenterological Association.
“Upon release of the proposed rule, we were disappointed to see that not only will APMs be essentially closed off to small practices in the first years of implementation, but the MIPS program will significantly harm practices with less than 25 eligible clinicians,” AGA noted, citing data presented by CMS that 87% of solo practitioners will receive a negative adjustment with an aggregate negative impact of $300 million and for all practices with less than 25 eligible clinicians, the aggregate negative adjustment will total $649 million.
“Any system in which smaller practices are so heavily disadvantaged is unacceptable,” AGA said. CMS has previously stated that the regulatory impact statement would likely change and reflect a smaller impact for small and solo practices once more updated information can be modeled when the rule is final.
Additionally, AGA expressed concern over the limited engagement in APMs that will be possible under the proposed rule. “Given the importance of APM participation to both the practice and reimbursement of Medicare physicians, access to advanced APMs should be provided to all physicians.”
The association also expressed concern that the definition of APM is not broad enough and suggested that it be widened in scope so that it can capture payment models that have been created using the AGA’s Roadmap to the Future of GI Practice. It recommended a number of models be classified as APMs, including the colonoscopy bundled payment, gastroesophageal reflux disease episode payment, obesity bundled payment, Project Sonar (a chronic disease management program for IBD), and the Medical Home Neighbor.
The American College of Rheumatology called for a delay in the implementation of any final MACRA regulations, noting in its comments that with requirements set to begin in 2017, the current implementation schedule “does not provide enough time for providers to implement the required changes,” though ACR does not recommend a specific start time.
ACR also questioned how the criteria for APMs was set up, noting expressly that Physician Focused Payment Models may not meet the APM requirements. The group is seeking clarification on whether these models will qualify as an APM.
“Medical home APMs should also permit specialty physicians to participate, including small group and multispeciality groups, in keeping with the need for APMs to be flexible with their criteria and the role of specialty physicians in providing chronic care.
The American Academy of Dermatology Association echoed a number of concerns voiced across the medical profession and is calling for a delay in the implementation of MACRA’s regulations.
In particular, AADA noted that the regulations are not friendly for small and solo practices in general and little is contained within the proposal to “meaningfully engage specialist physicians in APMs.”
The association also is calling for broader mechanisms to allow for the development and recognition of APMs, including recognizing specialty-focused medical homes.
The group also is calling for pilot programs to test the validity of the measures that will form the basis of quality payment incentives and penalties.
In an effort to protect small and solo practices, AADA is calling for an exemption from MIPS or APM requirements until a virtual group option is developed, tested, and is fully operational.
The American Psychiatric Association echoed a number of broad concerns raised across the physician spectrum, including calling for a to the first year of implementation to July 1, 2017, and lasting through Dec. 31, 2017, as well as enabling the formation of virtual groups at the onset of implementation in its comments.
But APA also noted that mental health presents a variety of unique issues that need to be addressed.
For example, the association notes that psychiatrists work across a number of practice settings, including academic health centers, hospitals, clinics, nursing homes, and private practices, as well as offering services via telemedicine.
“This makes it difficult for psychiatrists to capture all the work they do, because of the combination of settings that utilize multiple, and potentially differing reporting programs and methods,” APA noted.
It added that psychiatrists generally have limited time and resources that can be devoted to Medicare quality reporting, which would make participation in MIPS and APMs more challenging, particularly because many operate in small or solo practices that do not own electronic health record systems, which would complicate reporting requirements to qualify for MIPS or APMs.
In addition to concerns with reporting in general, APA said that psychiatrists “also have limited choices in outcome quality measures.”
Follow-up Findings From ACCORD
Intensive control of blood sugar levels can cut the risk of diabetic retinopathy in half, according to a follow-up study of the landmark ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial.
The finding from the ACCORD Follow-on eye study (ACCORDION) “sends a powerful message to people with type 2 diabetes mellitus (T2DM) who worry about losing vision,” said Emily Chew, MD, deputy director of the National Eye Institute Division of Epidemiology and Clinical Applications and lead author of the study report.
The ACCORDION trial is an assessment of diabetic retinopathy progression in 1,310 people who participated in ACCORD. That study tested 3 treatment strategies to reduce the risk of cardiovascular disease in people with longstanding T2DM: maintaining near-normal blood sugar levels (intensive control), improving blood lipid levels, and lowering blood pressure.
Because of an increase in death among participants in the intensive glycemic control group, ACCORD was aborted at 3.5 years. (The increased mortality, which was due to a range of causes, was seen in both intensive and standard groups.) From the data they had, the researchers found tight control reduced glycemia to an average HbA1C of 6.4% compared with 7.7% among those in the standard control group. It did not cut the risk of cardiovascular disease, but it had cut retinopathy progression by about one- third when the study was abruptly ended.
The follow-up study reassessed diabetic retinopathy 4 years after the intensive control portion of ACCORD had ended, 8 years after enrollment. Average HbA1C was nearly the same. Diabetic retinopathy, however, had advanced in only 5.8% of participants in the intensive group, compared with 12.7% of the standard treatment group.
The continuing beneficial effects—an approximately 50% reduction in risk of further retinopathy progression—are attributed to “metabolic memory,” a phenomenon also known as the “legacy effect.” Similar effects have been seen in 2 other large, long studies: the 10-year-long Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Project.
Intensive control of blood sugar levels can cut the risk of diabetic retinopathy in half, according to a follow-up study of the landmark ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial.
The finding from the ACCORD Follow-on eye study (ACCORDION) “sends a powerful message to people with type 2 diabetes mellitus (T2DM) who worry about losing vision,” said Emily Chew, MD, deputy director of the National Eye Institute Division of Epidemiology and Clinical Applications and lead author of the study report.
The ACCORDION trial is an assessment of diabetic retinopathy progression in 1,310 people who participated in ACCORD. That study tested 3 treatment strategies to reduce the risk of cardiovascular disease in people with longstanding T2DM: maintaining near-normal blood sugar levels (intensive control), improving blood lipid levels, and lowering blood pressure.
Because of an increase in death among participants in the intensive glycemic control group, ACCORD was aborted at 3.5 years. (The increased mortality, which was due to a range of causes, was seen in both intensive and standard groups.) From the data they had, the researchers found tight control reduced glycemia to an average HbA1C of 6.4% compared with 7.7% among those in the standard control group. It did not cut the risk of cardiovascular disease, but it had cut retinopathy progression by about one- third when the study was abruptly ended.
The follow-up study reassessed diabetic retinopathy 4 years after the intensive control portion of ACCORD had ended, 8 years after enrollment. Average HbA1C was nearly the same. Diabetic retinopathy, however, had advanced in only 5.8% of participants in the intensive group, compared with 12.7% of the standard treatment group.
The continuing beneficial effects—an approximately 50% reduction in risk of further retinopathy progression—are attributed to “metabolic memory,” a phenomenon also known as the “legacy effect.” Similar effects have been seen in 2 other large, long studies: the 10-year-long Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Project.
Intensive control of blood sugar levels can cut the risk of diabetic retinopathy in half, according to a follow-up study of the landmark ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial.
The finding from the ACCORD Follow-on eye study (ACCORDION) “sends a powerful message to people with type 2 diabetes mellitus (T2DM) who worry about losing vision,” said Emily Chew, MD, deputy director of the National Eye Institute Division of Epidemiology and Clinical Applications and lead author of the study report.
The ACCORDION trial is an assessment of diabetic retinopathy progression in 1,310 people who participated in ACCORD. That study tested 3 treatment strategies to reduce the risk of cardiovascular disease in people with longstanding T2DM: maintaining near-normal blood sugar levels (intensive control), improving blood lipid levels, and lowering blood pressure.
Because of an increase in death among participants in the intensive glycemic control group, ACCORD was aborted at 3.5 years. (The increased mortality, which was due to a range of causes, was seen in both intensive and standard groups.) From the data they had, the researchers found tight control reduced glycemia to an average HbA1C of 6.4% compared with 7.7% among those in the standard control group. It did not cut the risk of cardiovascular disease, but it had cut retinopathy progression by about one- third when the study was abruptly ended.
The follow-up study reassessed diabetic retinopathy 4 years after the intensive control portion of ACCORD had ended, 8 years after enrollment. Average HbA1C was nearly the same. Diabetic retinopathy, however, had advanced in only 5.8% of participants in the intensive group, compared with 12.7% of the standard treatment group.
The continuing beneficial effects—an approximately 50% reduction in risk of further retinopathy progression—are attributed to “metabolic memory,” a phenomenon also known as the “legacy effect.” Similar effects have been seen in 2 other large, long studies: the 10-year-long Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Project.
IHS Campaign Focuses on Very Long, Healthy Life
A full journey for a good healthy life takes 102 winters, according to Navajo origin stories. The IHS has launched a new bilingual suicide prevention campaign based on that idea: Iiná Ayóó’ííní’ní, or Love Your Life 102.
The suicide rate among American Indians and Alaska Native (AI/AN) young adults is 1.5 times greater than that of the national average. Among AI/AN children, adolescents, and young adults, suicide is the second leading cause of death.
The new campaign aims to connect young people with behavioral health care on the Navajo Nation. It uses modern media to share traditional Navajo teachings of honoring life and aspiring to the full 102 winters. Navajo young people tell their stories through online videos, billboards, and posters that share resources for support and help.
One of those posters features Lyn Thomas, a veteran who served in Afghanistan and Iraq and has posttraumatic stress disorder. “All that you’ve been through makes left and right turns that lead you to love your family, yourself, and your life,” he is quoted on the poster. His story, highlighted on the IHS.gov YouTube channel (https://youtu.be/IFFrV7g_JEc), tells of his journey from trauma to healing.
A full journey for a good healthy life takes 102 winters, according to Navajo origin stories. The IHS has launched a new bilingual suicide prevention campaign based on that idea: Iiná Ayóó’ííní’ní, or Love Your Life 102.
The suicide rate among American Indians and Alaska Native (AI/AN) young adults is 1.5 times greater than that of the national average. Among AI/AN children, adolescents, and young adults, suicide is the second leading cause of death.
The new campaign aims to connect young people with behavioral health care on the Navajo Nation. It uses modern media to share traditional Navajo teachings of honoring life and aspiring to the full 102 winters. Navajo young people tell their stories through online videos, billboards, and posters that share resources for support and help.
One of those posters features Lyn Thomas, a veteran who served in Afghanistan and Iraq and has posttraumatic stress disorder. “All that you’ve been through makes left and right turns that lead you to love your family, yourself, and your life,” he is quoted on the poster. His story, highlighted on the IHS.gov YouTube channel (https://youtu.be/IFFrV7g_JEc), tells of his journey from trauma to healing.
A full journey for a good healthy life takes 102 winters, according to Navajo origin stories. The IHS has launched a new bilingual suicide prevention campaign based on that idea: Iiná Ayóó’ííní’ní, or Love Your Life 102.
The suicide rate among American Indians and Alaska Native (AI/AN) young adults is 1.5 times greater than that of the national average. Among AI/AN children, adolescents, and young adults, suicide is the second leading cause of death.
The new campaign aims to connect young people with behavioral health care on the Navajo Nation. It uses modern media to share traditional Navajo teachings of honoring life and aspiring to the full 102 winters. Navajo young people tell their stories through online videos, billboards, and posters that share resources for support and help.
One of those posters features Lyn Thomas, a veteran who served in Afghanistan and Iraq and has posttraumatic stress disorder. “All that you’ve been through makes left and right turns that lead you to love your family, yourself, and your life,” he is quoted on the poster. His story, highlighted on the IHS.gov YouTube channel (https://youtu.be/IFFrV7g_JEc), tells of his journey from trauma to healing.
Commission on Care: Expand Community Care, Close Facilities
The Commission on Care has issued its final report, which called for the expansion of community care for all veterans through the creation of integrated community-based health care networks similar to TRICARE, expansion of eligibility for veterans, and the creation of a facility and capital asset realignment process based on the DoD Base Realignment and Closure Commission among its 18 recommendations.
Mandated by the Veterans Access, Choice and Accountability Act in the wake of the wait time, the 15-member Commission on Care was charged with providing recommendations for reforming veterans’ health care to President Obama. The commission’s recommendations carry considerable weight. The Choice Act mandated that the VA and other federal agencies “implement each recommendation that the President considers feasible, advisable, and able to implement without further legislation.”
The commission’s first recommendation was to scrap the Choice Program and establish the VHA Care System, a system of “integrated veteran-centric, community-based delivery networks that will optimize the balance of access, quality, and cost-effectiveness.” Local VHA leadership would develop the VHA Care System and base it on “local needs and veterans’ preferences.” The VHA would be mandated to furnish credentials to community providers, with the highest priority access given to service-connected veterans. The time and distance criteria used by the Choice Program would be eliminated, and veterans would be able to choose any primary care provider from within the system.
The Commission offered 4 possible models for implementing the VHA Care System. In the recommended option (an integrated network of VHA, DoD, other federally funded providers, and community providers, which requires a referral to access specialty care), the commission predicts as many as 60% of veterans would shift to community care for primary care needs, though far fewer would seek referrals in the community. The commission also predicted about a 15% increase in enrollment and an additional $5 billion in cost by FY 2019.
Another recommendation called for a “robust strategy for meeting and managing VHA’s facility and capital-asset needs.” According to the commission, the VA must reevaluate the future of individual facilities “in light of a transformative new delivery model.” A new commission, based on the military closure commissions, would help determine which facilities would remain open and which would close. “If VA could sell, repurpose, or otherwise divest itself of unused or underutilized buildings in a timely, cost-effective manner, it would free funds for the purposes for which they are appropriated,” the commission argued.
The commission also focused on personnel issues in a number of its recommendations, calling for the transformation of VHA culture and staff engagement, performance metrics for all employees, a new personnel system, and increased cultural and military competency, “to embrace diversity, promote cultural sensitivity, and improve veteran health outcomes.”
All but 2 commissioners signed the report. The commission charged that “many profound deficiencies in VHA operations require urgent reform, and that America’s veterans deserve a better organized, high-performing health care system.” While the changes may seem sweeping to many, the 2 dissenting commissioners urged even more significant changes. In a dissent letter acquired by the Washington Free Beacon, these commissioners argue that “the disappointing reality is that the commission’s final report is deeply compromised, disjointed, and incomplete. The report repeatedly invokes the need for a ‘bold transformation’ at the VHA. Yet, with a few exceptions, there is a decided lack of boldness in the Commission’s recommendations.”
Reaction has been slow as officials at the White House, VA, and veterans group digest the 308-page report. Some groups, however, already are raising concerns. The American Legion issued a statement: “Increased privatization of veteran health care services is not in the best interest of veterans or the American taxpayer. While we are still reviewing the complete report, we note that the commission had a very limited interaction with veterans who actually use VA health care, and even less time spent in VA facilities.”
The President also issued a brief noncommittal statement. “The commission's report includes a number of specific proposals that I look forward to reviewing closely over the coming weeks. We will continue to work with veterans, Congress, and our partners in the veteran advocacy community to further our ongoing transformation of the veterans’ health care system. Our veterans deserve nothing less for their sacrifices and their service.”
The VA offered a brief reaction to the report, finding commonalities in its current reform efforts. “While we will examine the report closely over the coming weeks and respond in a more detailed fashion, I am pleased to see that many of their recommendations are in line with our MyVA efforts to transform the VA into a veteran-centric organization,” Secretary of Veterans Affairs Robert A. McDonald said in the statement. “There are some things that can be done right now to help us continue our progress. Congress must act on our proposals to consolidate our Community Care programs, modernize and reform the claims appeals process, and pass the bi-partisan Veterans First Act.”
[Click through to the 18 recommendations offered by the commission.]
The full set of recommendations covers a broad range of issue for the VA:
Recommendation #1: Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community health care networks, to be known as the VHA Care System, from which veterans will access high-quality health care services.
Recommendation #2: Enhance clinical operations through more effective use of providers and other health professionals, and improved data collection and management.
Recommendation #3: Develop a process for appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other federally supported programs.
Recommendation #4: Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center.
Recommendation #5: Eliminate health care disparities among veterans treated in the VHA Care System by committing adequate personnel and monetary resources to address the causes of the problem and ensuring the VHA Health Equity Action Plan is fully implemented.
Recommendation #6: Develop and implement a robust strategy for meeting and managing VHA’s facility and capital-asset needs.
Recommendation #7: Modernize VA’s IT systems and infrastructure to improve veterans’ health and well-being and provide the foundation needed to transform VHA’s clinical and business processes.
Recommendation #8: Transform the management of the supply chain in VHA.
Recommendation #9: Establish a board of directors to provide overall VHA Care System governance, set long-term strategy, and direct and oversee the transformation process.
Recommendation #10: Require leaders at all levels of the organization to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement.
Recommendation #11: Rebuild a system for leadership succession based on a benchmarked health care competency model that is consistently applied to recruitment, development, and advancement within the leadership pipeline.
Recommendation #12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices.
Recommendation #13: Streamline and focus organizational performance measurement in VHA using core metrics that are identical to those used in the private sector, and establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership ability, and measures the achievement of important organizational strategies.
Recommendation #14: Foster cultural and military competence among all VHA Care System leadership, providers, and staff to embrace diversity, promote cultural sensitivity, and improve veteran health outcomes.
Recommendation #15: Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, applies best practices from the private sector to human capital management, and supports pay and benefits that are competitive with the private sector.
Recommendation #16: Require top executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an effective human capital management system.
Recommendation #17: Provide a streamlined path to eligibility for health care for those with an other-than-honorable discharge who have substantial honorable service.
Recommendation #18: Establish an expert body to develop recommendations for VA care eligibility and benefit design.
The Commission on Care has issued its final report, which called for the expansion of community care for all veterans through the creation of integrated community-based health care networks similar to TRICARE, expansion of eligibility for veterans, and the creation of a facility and capital asset realignment process based on the DoD Base Realignment and Closure Commission among its 18 recommendations.
Mandated by the Veterans Access, Choice and Accountability Act in the wake of the wait time, the 15-member Commission on Care was charged with providing recommendations for reforming veterans’ health care to President Obama. The commission’s recommendations carry considerable weight. The Choice Act mandated that the VA and other federal agencies “implement each recommendation that the President considers feasible, advisable, and able to implement without further legislation.”
The commission’s first recommendation was to scrap the Choice Program and establish the VHA Care System, a system of “integrated veteran-centric, community-based delivery networks that will optimize the balance of access, quality, and cost-effectiveness.” Local VHA leadership would develop the VHA Care System and base it on “local needs and veterans’ preferences.” The VHA would be mandated to furnish credentials to community providers, with the highest priority access given to service-connected veterans. The time and distance criteria used by the Choice Program would be eliminated, and veterans would be able to choose any primary care provider from within the system.
The Commission offered 4 possible models for implementing the VHA Care System. In the recommended option (an integrated network of VHA, DoD, other federally funded providers, and community providers, which requires a referral to access specialty care), the commission predicts as many as 60% of veterans would shift to community care for primary care needs, though far fewer would seek referrals in the community. The commission also predicted about a 15% increase in enrollment and an additional $5 billion in cost by FY 2019.
Another recommendation called for a “robust strategy for meeting and managing VHA’s facility and capital-asset needs.” According to the commission, the VA must reevaluate the future of individual facilities “in light of a transformative new delivery model.” A new commission, based on the military closure commissions, would help determine which facilities would remain open and which would close. “If VA could sell, repurpose, or otherwise divest itself of unused or underutilized buildings in a timely, cost-effective manner, it would free funds for the purposes for which they are appropriated,” the commission argued.
The commission also focused on personnel issues in a number of its recommendations, calling for the transformation of VHA culture and staff engagement, performance metrics for all employees, a new personnel system, and increased cultural and military competency, “to embrace diversity, promote cultural sensitivity, and improve veteran health outcomes.”
All but 2 commissioners signed the report. The commission charged that “many profound deficiencies in VHA operations require urgent reform, and that America’s veterans deserve a better organized, high-performing health care system.” While the changes may seem sweeping to many, the 2 dissenting commissioners urged even more significant changes. In a dissent letter acquired by the Washington Free Beacon, these commissioners argue that “the disappointing reality is that the commission’s final report is deeply compromised, disjointed, and incomplete. The report repeatedly invokes the need for a ‘bold transformation’ at the VHA. Yet, with a few exceptions, there is a decided lack of boldness in the Commission’s recommendations.”
Reaction has been slow as officials at the White House, VA, and veterans group digest the 308-page report. Some groups, however, already are raising concerns. The American Legion issued a statement: “Increased privatization of veteran health care services is not in the best interest of veterans or the American taxpayer. While we are still reviewing the complete report, we note that the commission had a very limited interaction with veterans who actually use VA health care, and even less time spent in VA facilities.”
The President also issued a brief noncommittal statement. “The commission's report includes a number of specific proposals that I look forward to reviewing closely over the coming weeks. We will continue to work with veterans, Congress, and our partners in the veteran advocacy community to further our ongoing transformation of the veterans’ health care system. Our veterans deserve nothing less for their sacrifices and their service.”
The VA offered a brief reaction to the report, finding commonalities in its current reform efforts. “While we will examine the report closely over the coming weeks and respond in a more detailed fashion, I am pleased to see that many of their recommendations are in line with our MyVA efforts to transform the VA into a veteran-centric organization,” Secretary of Veterans Affairs Robert A. McDonald said in the statement. “There are some things that can be done right now to help us continue our progress. Congress must act on our proposals to consolidate our Community Care programs, modernize and reform the claims appeals process, and pass the bi-partisan Veterans First Act.”
[Click through to the 18 recommendations offered by the commission.]
The full set of recommendations covers a broad range of issue for the VA:
Recommendation #1: Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community health care networks, to be known as the VHA Care System, from which veterans will access high-quality health care services.
Recommendation #2: Enhance clinical operations through more effective use of providers and other health professionals, and improved data collection and management.
Recommendation #3: Develop a process for appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other federally supported programs.
Recommendation #4: Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center.
Recommendation #5: Eliminate health care disparities among veterans treated in the VHA Care System by committing adequate personnel and monetary resources to address the causes of the problem and ensuring the VHA Health Equity Action Plan is fully implemented.
Recommendation #6: Develop and implement a robust strategy for meeting and managing VHA’s facility and capital-asset needs.
Recommendation #7: Modernize VA’s IT systems and infrastructure to improve veterans’ health and well-being and provide the foundation needed to transform VHA’s clinical and business processes.
Recommendation #8: Transform the management of the supply chain in VHA.
Recommendation #9: Establish a board of directors to provide overall VHA Care System governance, set long-term strategy, and direct and oversee the transformation process.
Recommendation #10: Require leaders at all levels of the organization to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement.
Recommendation #11: Rebuild a system for leadership succession based on a benchmarked health care competency model that is consistently applied to recruitment, development, and advancement within the leadership pipeline.
Recommendation #12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices.
Recommendation #13: Streamline and focus organizational performance measurement in VHA using core metrics that are identical to those used in the private sector, and establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership ability, and measures the achievement of important organizational strategies.
Recommendation #14: Foster cultural and military competence among all VHA Care System leadership, providers, and staff to embrace diversity, promote cultural sensitivity, and improve veteran health outcomes.
Recommendation #15: Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, applies best practices from the private sector to human capital management, and supports pay and benefits that are competitive with the private sector.
Recommendation #16: Require top executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an effective human capital management system.
Recommendation #17: Provide a streamlined path to eligibility for health care for those with an other-than-honorable discharge who have substantial honorable service.
Recommendation #18: Establish an expert body to develop recommendations for VA care eligibility and benefit design.
The Commission on Care has issued its final report, which called for the expansion of community care for all veterans through the creation of integrated community-based health care networks similar to TRICARE, expansion of eligibility for veterans, and the creation of a facility and capital asset realignment process based on the DoD Base Realignment and Closure Commission among its 18 recommendations.
Mandated by the Veterans Access, Choice and Accountability Act in the wake of the wait time, the 15-member Commission on Care was charged with providing recommendations for reforming veterans’ health care to President Obama. The commission’s recommendations carry considerable weight. The Choice Act mandated that the VA and other federal agencies “implement each recommendation that the President considers feasible, advisable, and able to implement without further legislation.”
The commission’s first recommendation was to scrap the Choice Program and establish the VHA Care System, a system of “integrated veteran-centric, community-based delivery networks that will optimize the balance of access, quality, and cost-effectiveness.” Local VHA leadership would develop the VHA Care System and base it on “local needs and veterans’ preferences.” The VHA would be mandated to furnish credentials to community providers, with the highest priority access given to service-connected veterans. The time and distance criteria used by the Choice Program would be eliminated, and veterans would be able to choose any primary care provider from within the system.
The Commission offered 4 possible models for implementing the VHA Care System. In the recommended option (an integrated network of VHA, DoD, other federally funded providers, and community providers, which requires a referral to access specialty care), the commission predicts as many as 60% of veterans would shift to community care for primary care needs, though far fewer would seek referrals in the community. The commission also predicted about a 15% increase in enrollment and an additional $5 billion in cost by FY 2019.
Another recommendation called for a “robust strategy for meeting and managing VHA’s facility and capital-asset needs.” According to the commission, the VA must reevaluate the future of individual facilities “in light of a transformative new delivery model.” A new commission, based on the military closure commissions, would help determine which facilities would remain open and which would close. “If VA could sell, repurpose, or otherwise divest itself of unused or underutilized buildings in a timely, cost-effective manner, it would free funds for the purposes for which they are appropriated,” the commission argued.
The commission also focused on personnel issues in a number of its recommendations, calling for the transformation of VHA culture and staff engagement, performance metrics for all employees, a new personnel system, and increased cultural and military competency, “to embrace diversity, promote cultural sensitivity, and improve veteran health outcomes.”
All but 2 commissioners signed the report. The commission charged that “many profound deficiencies in VHA operations require urgent reform, and that America’s veterans deserve a better organized, high-performing health care system.” While the changes may seem sweeping to many, the 2 dissenting commissioners urged even more significant changes. In a dissent letter acquired by the Washington Free Beacon, these commissioners argue that “the disappointing reality is that the commission’s final report is deeply compromised, disjointed, and incomplete. The report repeatedly invokes the need for a ‘bold transformation’ at the VHA. Yet, with a few exceptions, there is a decided lack of boldness in the Commission’s recommendations.”
Reaction has been slow as officials at the White House, VA, and veterans group digest the 308-page report. Some groups, however, already are raising concerns. The American Legion issued a statement: “Increased privatization of veteran health care services is not in the best interest of veterans or the American taxpayer. While we are still reviewing the complete report, we note that the commission had a very limited interaction with veterans who actually use VA health care, and even less time spent in VA facilities.”
The President also issued a brief noncommittal statement. “The commission's report includes a number of specific proposals that I look forward to reviewing closely over the coming weeks. We will continue to work with veterans, Congress, and our partners in the veteran advocacy community to further our ongoing transformation of the veterans’ health care system. Our veterans deserve nothing less for their sacrifices and their service.”
The VA offered a brief reaction to the report, finding commonalities in its current reform efforts. “While we will examine the report closely over the coming weeks and respond in a more detailed fashion, I am pleased to see that many of their recommendations are in line with our MyVA efforts to transform the VA into a veteran-centric organization,” Secretary of Veterans Affairs Robert A. McDonald said in the statement. “There are some things that can be done right now to help us continue our progress. Congress must act on our proposals to consolidate our Community Care programs, modernize and reform the claims appeals process, and pass the bi-partisan Veterans First Act.”
[Click through to the 18 recommendations offered by the commission.]
The full set of recommendations covers a broad range of issue for the VA:
Recommendation #1: Across the United States, with local input and knowledge, VHA should establish high-performing, integrated community health care networks, to be known as the VHA Care System, from which veterans will access high-quality health care services.
Recommendation #2: Enhance clinical operations through more effective use of providers and other health professionals, and improved data collection and management.
Recommendation #3: Develop a process for appealing clinical decisions that provides veterans protections at least comparable to those afforded patients under other federally supported programs.
Recommendation #4: Adopt a continuous improvement methodology to support VHA transformation, and consolidate best practices and continuous improvement efforts under the Veterans Engineering Resource Center.
Recommendation #5: Eliminate health care disparities among veterans treated in the VHA Care System by committing adequate personnel and monetary resources to address the causes of the problem and ensuring the VHA Health Equity Action Plan is fully implemented.
Recommendation #6: Develop and implement a robust strategy for meeting and managing VHA’s facility and capital-asset needs.
Recommendation #7: Modernize VA’s IT systems and infrastructure to improve veterans’ health and well-being and provide the foundation needed to transform VHA’s clinical and business processes.
Recommendation #8: Transform the management of the supply chain in VHA.
Recommendation #9: Establish a board of directors to provide overall VHA Care System governance, set long-term strategy, and direct and oversee the transformation process.
Recommendation #10: Require leaders at all levels of the organization to champion a focused, clear, benchmarked strategy to transform VHA culture and sustain staff engagement.
Recommendation #11: Rebuild a system for leadership succession based on a benchmarked health care competency model that is consistently applied to recruitment, development, and advancement within the leadership pipeline.
Recommendation #12: Transform organizational structures and management processes to ensure adherence to national VHA standards, while also promoting decision making at the lowest level of the organization, eliminating waste and redundancy, promoting innovation, and fostering the spread of best practices.
Recommendation #13: Streamline and focus organizational performance measurement in VHA using core metrics that are identical to those used in the private sector, and establish a personnel performance management system for health care leaders in VHA that is distinct from performance measurement, is based on the leadership competency model, assesses leadership ability, and measures the achievement of important organizational strategies.
Recommendation #14: Foster cultural and military competence among all VHA Care System leadership, providers, and staff to embrace diversity, promote cultural sensitivity, and improve veteran health outcomes.
Recommendation #15: Create a simple-to-administer alternative personnel system, in law and regulation, which governs all VHA employees, applies best practices from the private sector to human capital management, and supports pay and benefits that are competitive with the private sector.
Recommendation #16: Require top executives to lead the transformation of HR, commit funds, and assign expert resources to achieve an effective human capital management system.
Recommendation #17: Provide a streamlined path to eligibility for health care for those with an other-than-honorable discharge who have substantial honorable service.
Recommendation #18: Establish an expert body to develop recommendations for VA care eligibility and benefit design.