Kenneth W. Kizer

The "New VA": A National Laboratory for Health Care Quality Management

In 1995, the Veterans Health Administration (VHA) initiated the most radical redesign of the veterans health care system since the system was formally created in 1946. One of the goals of this reengineering effort has been to ensure the consistent and predictable provision of high-quality care everywhere in the system. To accomplish this goal, the VIA has organized more than 100 different quality improvement activities according to a structure-, process-, and outcomes-focused quality management account-ability framework (QMAF) that targets 10 interrelated dimensions of quality management (QM). Each of these dimensions utilizes a defined strategy and employs a menu of quality assessment and assurance tactics. Organizing these many different quality improvement activities into an accountability framework should facilitate the development of policies and procedures that will systematize the VHAs QM. The VHAs new operational structure and its approach to quality improvement provide a unique national laboratory for health care QM.

Extreme Makeover: Transformation of the Veterans Health Care System

The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nations largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.

Serial Murder by Healthcare Professionals

ABSTRACT: The prosecution of Charles Cullen, a nurse who killed at least 40 patients over a 16‐year period, highlights the need to better understand the phenomenon of serial murder by healthcare professionals. The authors conducted a LexisNexis® search which yielded 90 criminal prosecutions of healthcare providers that met inclusion criteria for serial murder of patients. In addition we reviewed epidemiologic studies, toxicology evidence, and court transcripts, to provide data on healthcare professionals who have been prosecuted between 1970 and 2006. Fifty‐four of the 90 have been convicted; 45 for serial murder, four for attempted murder, and five pled guilty to lesser charges. Twenty‐four more have been indicted and are either awaiting trial or the outcome has not been published. The other 12 prosecutions had a variety of legal outcomes. Injection was the main method used by healthcare killers followed by suffocation, poisoning, and tampering with equipment. Prosecutions were reported from 20 countries with 40% taking place in the United States. Nursing personnel comprised 86% of the healthcare providers prosecuted; physicians 12%, and 2% were allied health professionals. The number of patient deaths that resulted in a murder conviction is 317 and the number of suspicious patient deaths attributed to the 54 convicted caregivers is 2113. These numbers are disturbing and demand that systemic changes in tracking adverse patient incidents associated with presence of a specific healthcare provider be implemented. Hiring practices must shift away from preventing wrongful discharge or denial of employment lawsuits to protecting patients from employees who kill.

Veterans and the Affordable Care Act

VIEWPOINT Veterans and the Affordable Care Act Kenneth W. Kizer, MD, MPH A RMED CONFLICT HAS BEEN A FREQUENT OCCUR - rence throughout US history. During the last cen- tury, the United States has fought 8 wars that to- gether span more than 35 years, not counting numerous conflicts that are not officially considered wars. In view of the many health consequences of war, the po- tential effect of the Affordable Care Act (ACA) on health care for veterans warrants careful consideration. In 2011, there were 22.2 million veterans of service in the US Armed Forces. Veterans are a highly diverse population but can be grouped into 3 categories from a health insur- ance perspective. Approximately 37% are enrolled in the De- partment of Veterans Affairs (VA) health care system in ac- cordance with a congressionally mandated eligibility system based on having a service-connected disability, low in- come and net worth, or other prescribed circumstances. More than 80% of VA enrollees older than 65 years are also cov- ered by Medicare and about 25% of enrollees are beneficia- ries of 2 or more non-VA federal health plans (eg, Medi- care, Medicaid, TRICARE, or Indian Health Service). Another 56% of veterans have private health insurance or are cov- ered by a non-VA federal health plan, while 7% have no health insurance. These latter veterans are poor or near poor but have incomes or net worth that exceed the mean test thresh- olds for VA health care eligibility. 1 The ACA will not affect health care for the majority of veterans differently than it will affect nonveterans, and the ACA will not change eligibility for VA health care, covered benefits, co-payment for services, or how the VA health care system is administered or operated. Nonetheless, the ACA may affect health care for many veterans through its effects on access, fragmentation and quality of care, utiliza- tion of services, the health care work force, and federal expenditures. The ACA will expand health insurance coverage for low-income persons through Medicaid and state health insurance exchanges, which should make health insurance available to uninsured veterans. The new insurance cover- age options will also be available to many VA health care enrollees, expanding their health care choices and poten- tially increasing convenience and timeliness of care but also fragmenting care. Fragmentation of care is of concern ©2012 American Medical Association. All rights reserved. because it diminishes continuity and coordination of care, resulting in more emergency department use, hospitaliza- tions, diagnostic interventions, and adverse events. The VA serves an especially large number of persons with chronic medical conditions or behavioral health diagnoses— populations especially vulnerable to untoward conse- quences resulting from fragmented care. Veterans with dual or multiple health plan eligibility are known to have more fragmented care, although associated untoward effects have not been well studied. Some data sug- gest that veterans receiving care from both VA and non-VA sources are more likely to be rehospitalized and to die within a year compared with VA-only users, although the reasons for the disproportionate mortality have not been studied. 2 VA/Medicare dual-eligible veterans with myocardial infarc- tions who use both plans undergo more invasive cardiac pro- cedures without gaining a survival advantage over VA-only users, but adverse events associated with greater use of in- vasive procedures by non-VA clinicians have again not been analyzed. 3 More health care choices may adversely affect the qual- ity of care for some veterans in ways other than fragment- ing care. Physicians in private practice may not be pre- pared to treat conditions prevalent among veterans. For example, the Reaching Rural Veterans Initiative in Penn- sylvania found that private practice primary care clinicians lacked knowledge of posttraumatic stress and other mental health disorders prevalent among veterans and were unfa- miliar with VA treatment resources for such conditions. 4 Ad- ditionally, numerous studies have shown that VA enroll- ees are significantly more likely than persons receiving care from non-VA clinicians to receive evidence-based treat- ment and recommended services for prevention and early diagnosis of cancer, cardiovascular disease, diabetes, and in- fectious diseases. 5-7 VA enrollees with non-VA health insurance are known to use less VA care than those having only VA coverage, so expanding health care insurance for veterans may decrease use of VA facilities. Volume-sensitive services (eg, inten- sive care or complex surgery) at some smaller VA hospitals Author Affiliations: University of California Davis School of Medicine, Betty Irene Moore School of Nursing, Institute for Population Health Improvement, Univer- sity of California Davis Health System, Sacramento. Corresponding Author: Kenneth W. Kizer, MD, MPH, Institute for Population Health Improvement, University of California Davis Health System, 4800 Second St, Ste 2600, Sacramento, CA 95817 (kenneth.kizer@ucdmc.ucdavis.edu). JAMA, February 22/29, 2012—Vol 307, No. 8 789 Downloaded from jama.ama-assn.org by Kenneth Kizer on February 21, 2012

Duplicate Federal Payments for Dual Enrollees in Medicare Advantage Plans and the Veterans Affairs Health Care System

CONTEXT Some veterans are eligible to enroll simultaneously in a Medicare Advantage (MA) plan and the Veterans Affairs health care system (VA). This scenario produces the potential for redundant federal spending because MA plans would receive payments to insure veterans who receive care from the VA, another taxpayer-funded health plan. OBJECTIVE To quantify the prevalence of dual enrollment in VA and MA, the concurrent use of health services in each setting, and the estimated costs of VA care provided to MA enrollees. DESIGN Retrospective analysis of 1,245,657 veterans simultaneously enrolled in the VA and an MA plan between 2004-2009. MAIN OUTCOME MEASURES Use of health services and inflation-adjusted estimated VA health care costs. RESULTS Among individuals who were eligible to enroll in the VA and in an MA plan, the number of persons dually enrolled increased from 485,651 in 2004 to 924,792 in 2009. In 2009, 8.3% of the MA population was enrolled in the VA and 5.0% of MA beneficiaries were VA users. The estimated VA health care costs for MA enrollees totaled

The double edged sword of performance measurement.

13.0 billion over 6 years, increasing from

What is a world-class medical facility?

1.3 billion in 2004 to

Understanding the Costs of Patient-Centered Medical Homes

3.2 billion in 2009. Among dual enrollees, 10% exclusively used the VA for outpatient and acute inpatient services, 35% exclusively used the MA plan, 50% used both the VA and MA, and 4% received no services during the calendar year. The VA financed 44% of all outpatient visits (n = 21,353,841), 15% of all acute medical and surgical admissions (n = 177,663), and 18% of all acute medical and surgical inpatient days (n = 1,106,284) for this dually enrolled population. In 2009, the VA billed private insurers

Advancing Pain Care—Core Competencies for Pain Management

52.3 million to reimburse care provided to MA enrollees and collected

Health Care Serial Murder: A Patient Safety Orphan

9.4 million (18% of the billed amount; 0.3% of the total cost of care). CONCLUSIONS The federal government spends a substantial and increasing amount of potentially duplicative funds in 2 separate managed care programs for the care of same individuals.