Physicians Leading | Leading Physicians

The VA: A Model for the Whole Health Care System

Interview · August 21, 2017

Poonam Alaigh and Tom Lee

Tom Lee interviews Poonam Alaigh, MD, Acting Under Secretary for Health for the U.S. Department of Veterans Affairs.


Tom Lee: This is Tom Lee from NEJM Catalyst, and we’re fortunate to be talking today with the acting Under Secretary for Health for the Veterans Administration, Dr. Poonam Alaigh. She has had a really interesting, varied career. She’s an internist and a vascular medicine specialist who’s started ACOs, worked on the para side, and had some experience with pharma, but what’s really relevant is that she has been working, first as a [Senior] Advisor to David Shulkin when he was the Under Secretary for Health during the previous administration, and when Dr. Shulkin was named the Cabinet officer, the Secretary for Veterans Affairs, he and his colleagues asked Dr. Alaigh to be the Acting Under Secretary for Health.

Full disclosure, I’m on the Special Medical Advisory Group for the VA, so I have worked a lot with Dr. Alaigh and I’m very interested in these issues and, frankly, rooting for her success with them. But with that introduction, let’s talk about a topic that I know many listeners and readers are interested in, which is access to care within the VA system.

So, Poonam, the VA came under a lot of scrutiny a year or so ago on access, and I know that you and your colleagues have been working very hard to decrease waiting time and also to create a system in which veterans can go outside the VA for care in certain situations. Before we talk about the approach to letting patients go outside the VA, can you do a quick update on waiting time overall? How are things going? What kind of things are you doing? What are you most excited about?

Poonam Alaigh: Absolutely, Tom. First of all, I want to thank you for inviting me. I’ve always been a great fan of yours. I respect all the work that you’ve been doing over the course of your career, so it’s always great to be having this critical discussion with someone who knows the space so well and has been dedicating his professional career to improving quality, and also patient experience, consumerism, and transparency. So thank you again for having me here.

[Let’s] talk about the act of crisis. The act of crisis really came to light in April of 2014 as a result of the Phoenix crisis, and since then the organization actually has done a lot in terms of recovering after a crisis, like any organization would be. The first phase of any crisis management is stabilization, and then resuming services, and really, then, is recovery and innovation, so that we continue to build a model that we’re all proud of, not just in the service of our veterans, but in many ways an example or a beacon, where the entire country actually learns from how the VA has approached not just crisis, but also has continued to improve the quality and access to care.

Just talking about access for a few moments, when we first had this crisis, there were many veterans waiting for care and, you know, like with anything in health care, it was truly distributed to the systems of care, to have the right systems in place, to make sure we were identifying the patients who needed care the most urgently. It’s like a clinical triage system. When patients come into the emergency room, we do a clinical triage and identify which patients need action right away.

So, our first approach, and as part of dealing with improving access, was in late 2015 when Secretary Shulkin, at that time, was the Under Secretary, and we started looking at our databases and identifying our veterans who were in the need of care most emergently and urgently. And we had two stand-downs in November 2015 and then February 2016, and really looked at all of our consults and all of our appointments to make sure that they were getting the right care and were connected to the providers they needed to be seen with in order to take care of their clinical condition.

We then embarked upon a journey that includes a three-pronged approach. The first approach, which, again, in any kind of transformation, is sort of standing down looking and seeing what the situation is, but then establishing really solid guiding principles of what needs to happen. And so, we came up with a set of nine principles that became our declaration that every medical center adopted, and there was going to [be] consistency across the system when approaching patients in need of access.

The second piece, the second prong, was looking at what the best practices were and the simpler solutions, the high-feasibility, high-impact solutions. Again, in health care, you know, we waste a lot of time, many times in doing pilots and looking at different ways to reinvent the wheel, testing models, but we had no time to do that. So what we did, and because of the unique health care system that we have, we were able to identify some of the promising and rising practices across the system. It became a very grassroots organic approach to identifying ways that we could streamline throughputs and be able to deliver timely care, and that became our implementation stage where we developed a set of best practices in an implementation guidebook that we started to disseminate.

Now many times, again, you think that by sending information, things happen, but there’s a lot that needs to be done around truly operationalizing what we anticipate doing. And so, we then had boots on the ground, where we had systems engineers who went into the field. We stratified the needs in the various hospitals and clinics and stratified them based on their highest need and the lowest performance, and we sent boots on the ground to help with reengineering the systems approaching delivery in our facility. So that was sort of our overarching approach to improving access.

And Tom, you know, we see over 80 million appointments a year. A third of those are in the community, and two-thirds of those are actually in the VA system. The VA system is a very large system with about 168 hospitals, thousands of clinics, nursing homes, vet centers, they’ve got counseling centers, and so it is a pretty comprehensive integrated health care delivery network.

Lee: I’ve seen a lot of innovations like your new website for giving information about where there’s access, how to get online access. What are some numbers about [for example] for the urgent appointment waiting list, which I know was in the tens of thousands when this crisis first was recognized?

Alaigh: Again, as someone I know, you are a huge advocate of transparency. As part of improving access, we committed to making sure our patients were seen the same day for urgent needs in both primary care as well as mental health. And this was something that we hadn’t done in the past. By the end of 2016 we had all of our 168 medical centers that had same-day services, both in primary care and mental health, and that meant either a face-to-face or engaging in telehealth or video care or responding by secure email or our nurse clinic. It could be various modalities.

By the end of this year, we’re going to have over a thousand additional outpatient clinics that will also be providing same-day services in both mental health and primary care. But today we have over 80 million appointments a year. Twenty-two percent of our appointments are for same-day services, and when we first looked at the time it took in 2014 to be seen for an urgent specialist appointment, it was 36 days.

Today, we’re approaching two days, so it’s been a dramatic improvement in the time that it takes to be able to see our patients for urgent clinical needs. As part of that, we’ve also looked at additional timeliness of appointments, and about 97% of our veterans are seen within 30 days of recommending an appointment.

We’ve also, as part of the transparency spirit, had the first of its kind — and I know, Tom, you were impressed by that — our access website, accesstocare.va.gov, is a very unique website where we’re able to actually go into the system, where veterans are able to go into the system, and depending on where they live and the zip code and the kind of clinic they need to go to, whether it’s for primary care, mental health, or a specialty clinic, they’re able to customize the search and within a certain radius identify the facilities that are available to be able to serve them for their clinical needs.

There’s a second section to the website that talks about veterans’ satisfaction, and it actually scores what the satisfaction level is. There’s a third piece, which is around quality, and it compares the quality of the care that’s been provided in the medical center to the surrounding private hospitals. So now, as a veteran, you’ve got all the tools available for him or her to identify what his or her priority is. For instance, a veteran may say, “I just want a better experience. I don’t mind waiting an extra a week to be seen, and so I’ll wait to go to facility A because the quality is better.” Another veteran may say, “Well, for me, quality isn’t that great right now. I don’t care about that. I just want to be seen early because that’s most convenient, and that’s the facility I want.”

So, the comprehensiveness of the different factors of care is available on one website, one platform, which allows the veteran to be able to pick and choose where he or she wants to be seen based on his or her priorities. In addition, we have in each of these medical centers different modalities by which they can be seen. For instance, it’ll give a list of all the facilities that have same-day services, but also the types of same-day services. So, I may not want to call the medical center because I know that this certain facility has a walk-in center, so I would just go in as a veteran and be seen in my walk-in clinic versus having to call my provider or my patient-centered medical home team, which we call the PACT team [Patient-Aligned Care Team] in the VA.

So, it provides all those various modalities of choice and balances wait time, quality, convenience, and satisfaction as part of the comprehensive picture. Also, I know no other medical center that actually publishes this comprehensiveness in such a public manner, but also the whole idea of measuring wait times is a new area that the VA’s leading in because the private sector does not measure wait times the way we measure wait times.

Lee: I would really encourage our listeners and readers to check out accesstocare.va.gov. It’s an amazing site with, as Poonam described, very detailed information on the access and the types of access, same-day access and virtual access, but also transparency on the satisfaction data, transparency on quality data. Frankly, I haven’t seen anything like it. I think it’s a model for where the whole health care system should go.

But let’s turn now to the topic that I know is like the subject of day-to-day congressional discussions right now, which is the VA Choice Program. Before we talk about what’s happening with that and the principles that you and Dr. Shulkin are advocating, let me just ask, I know that there are some people who’ve argued for privatizing the VA, and I know that total health care spending for the VA is about $60 billion right now. Do you have a sense of what it would cost if every veteran left the VA for all of their care, essentially everything was done on the outside?

Alaigh: Based on our cost estimates and based on our modeling — we use a platform called Enrollee Projection Modeling Algorithm — based on our forecast, it would cost the American health care system $200 billion. If all of the veterans received their care for all of their conditions outside the VA.

Lee: So, what’s the middle ground then? I mean, for financial as well as other reasons, how are you thinking about what are the broad principles for when patients can or even should get their care outside the VA?

Alaigh: This is actually a discussion that we’re having very actively as part of what the new Choice Program should be and what our learnings are, based on their experiences in our current program. As you know, after the 2014 access crisis, Congress did a really good job in coming up with a quick fix and being able to set up $10 billion in funding to help expand Choice so that our veterans could actually be seen in the community because of constraints and capacity from inside the VA.

Again, the VA needs infrastructure, it needs people, employees, physicians, and to be able to deal with the access crisis it was going to be difficult to stand up in a way that the veteran need was identified. So, the principle and the fact that this program started to operationalize in such a short time frame was really commendable, but we did learn a lot from the program, and we’re actually working really hard in identifying what our learnings were and how we make the program better.

So, in the current program that we have, we have a geographical or an administrative rule where if a veteran has to wait for 30 days or more for an appointment or lives 40 miles or more from a provider office, then the veteran would automatically be choiced out. In the new program, we’ve learned and we’re proposing that, that would not be the right way to be able to send patients out.

Our core principles here in the new program are how do we transform an administrative program into really a clinically driven program using the principles of high-performing network? In other words, how do we make sure that our veterans get the best possible care, whether inside of the VA or outside of the VA, and how do we identify those synergies?

As you know, Tom, one of my experiences was starting one of the first Medicare ACOs, and that was precisely the principle by which we’ve developed high-performing networks in VAs across the country. It was the same principle that we’re looking at as we’re developing the new Choice Program as part of proposing it where it isn’t clinically driven, clinically based program, but using the best of care both inside and outside of the network to form a high-performing, clinically integrated, network-driven solution where the veteran is the driver of the decision-making. So, there isn’t that gatekeeper mentality, and the veteran is working and is an active participant in the decision-making of where the care needs to be delivered. This is going to be again a change in culture.

The VA has traditionally been a paternalistic culture, so we’re evolving from being a paternalistic culture, to a veteran-centered culture, to, now, a veteran-driven culture and as part of that, what we’re really excited about, both the Secretary and I, that we’re embarking upon another innovation, which is really developing that metric system based on which we would choice out or have our veterans go into the community based on the model called ACE. So, ACE is Access, Convenience, and Experience, and so we’re developing the whole framework for what that ACE structure would be, which would be the pillar based on which we develop the clinically integrated decision-making capability and then becomes the foundation for the high-performing network.

Lee: So, what you are working toward is a more nuanced approach, but the form is really organized around needs and in certain situations, limited access within the VA system will be the driver and others measure the quality, measures of patient experience, will be the driver. It may be more complex but it sounds like it’s potentially a thoughtful way of integrating with the rest of the health care system that will enable the VA to continue to do some of the things it does best.

Alaigh: Yes. And then we’re also proposing a piece of convenience, so that as a veteran if you live in a rural area and all you want is a flu shot, then do you really have to go to a provider to get a flu shot in the VA system, or could you get it in a MinuteClinic or one of those walk-in clinics? So, that’s the other piece that we’re looking at as we’re evolving the model.

Telehealth is going to be a big piece at the same time. We do about 2 million telehealth visits. We have 700,000 unique veterans who are serviced by telehealth in a year, and that’s a model that’s rapidly being propelled forward as part of our initiative in improving access based on convenience, as well as based on quality. You know, Tom, 70% of all physician visits could be averted if there was a successful telehealth encounter.

Lee: I know that your jobs are very difficult, but they’re very important, and I take it you’re making some very good moves and I’m anticipating some real progress. I hope we’ll get a chance to talk more about the results from some of these initiatives in the years ahead. So, thanks so much for giving us your time today and for doing this work, and we look forward to hearing more from you.

Alaigh: Thanks, Tom, and I really appreciate, not just our collegial relationship, but also our partnership as we’re trying to build a new health care delivery model into the future together.

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