Help­ing the VA rein­vent it­self again for the next decade

Modern Healthcare - - Q & A -

Dr. Jonathan Perlin is chair­man-elect of the Amer­i­can Hos­pi­tal As­so­ci­a­tion and chief med­i­cal of­fi­cer and pres­i­dent of clin­i­cal ser­vices-qual­ity at Nashville-based HCA, which op­er­ates about 180 hos­pi­tals and 80 out­pa­tient cen­ters.

He is on tem­po­rary spe­cial as­sign­ment un­til Septem­ber as se­nior ad­viser at the Vet­er­ans Af­fairs Depart­ment, work­ing with top of­fi­cials there in­clud­ing new VA Sec­re­tary Robert McDon­ald. Be­fore join­ing HCA in 2006, Perlin was un­der­sec­re­tary for health in the VA. Prior to that, he served as med­i­cal direc­tor for qual­ity im­prove­ment at the Med­i­cal Col­lege of Vir­ginia Hos­pi­tals-Vir­ginia Com­mon­wealth Univer­sity Health Sys­tem. Mod­ern Health­care Ed­i­tor Mer­rill Goozner re­cently spoke with Perlin about the VA’s prob­lems, what re­forms are needed and how health­care re­form is af­fect­ing hos­pi­tals over­all. This is an edited tran­script.

Mod­ern Health­care: What is your role and what are your ob­ser­va­tions so far as se­nior ad­viser at the VA?

Dr. Jonathan Perlin: I’m help­ing script a future of higher qual­ity, greater trans­parency and greater trust, and help­ing en­sure that vet­er­ans get the level of care that they’ve earned through their ser­vice and sac­ri­fices.

MH: What led to the cur­rent sit­u­a­tion at the VA?

Perlin: I think it’s fair to say the VA has lost the trust of the Amer­i­can public and of the vet­er­ans them­selves. What I have ob­served in the work of act­ing Sec­re­tary Sloan Gib­son and Dr. Carolyn Clancy is a com­mit­ment to ac­count­abil­ity and trans­parency and ad­dress­ing those is­sues where trust has been lost. I’m work­ing on not only re­duc­ing the wait­ing times for vet­er­ans, but also en­sur­ing trans­parency in all as­pects of per­for­mance.

In the 1990s, the VA faced a ques­tion about the value of its health ser­vices. It had to think about how it would de­fine value and mea­sure and im­prove and be ac­count­able. The elec­tronic health-record sys­tem pro­vided the glue to cre­ate a sys­tem out of pieces of care and the fuel to quan­tify progress.

The VA trans­formed from a port­fo­lio of hos­pi­tals to a health sys­tem. That meant fewer beds and that VA care had to be ac­ces­si­ble in more places. But it also meant ac­cess to in­for­ma­tion and tele­health ser­vices to pro­vide care in the vet­er­ans’ homes. There was a rein­ven­tion. I’m still try­ing to un­der­stand what has changed since that time. But this is an op­por­tu­nity for the VA to take a hard look at it­self and again rein­vent it­self for the next decade.

MH: Do you think that having vet­er­ans go into the pri­vate health­care sys­tem will be an effective way of de­liv­er­ing care?

Perlin: The VA has to take a hard look at man­ag­ing the over­all needs of vet­er­ans. It’s hard to achieve ex­cel­lence and have ev­ery tech­nol­ogy in ev­ery ge­o­graphic lo­ca­tion across the coun­try, and vet­er­ans de­serve ex­cel­lence and ac­cess.

There is a co­hort of vet­er­ans who are uniquely vul­ner­a­ble be­cause they are older and sicker, with phys­i­cal and men­tal health di­ag­noses, and are poor to the point of food in­se­cu­rity. The VA is re­ally good at pro­vid­ing a ta­pes­try of ser­vices for those vet­er­ans. Those vet­er­ans de­serve a sys­tem that can thread to­gether all of their needs, in­clud­ing health ser­vices, dis­abil­ity ben­e­fits, pensions and so­cial needs, in­clud­ing home­less­ness, sub­stance use and men­tal ill­ness. The VA can re­ally tie it to­gether, reach­ing out to the vet­eran’s home, pro­vid­ing tele­health and mech­a­nisms to re­ally mon­i­tor those vet­er­ans. I’m not say­ing that VA does it per­fectly, but the VA threads to­gether those ser­vices for those par­tic­u­larly vul­ner­a­ble vet­er­ans.

But there’s no es­cap­ing the vol­ume-out­comes re­la­tion­ship. The more you do, the bet­ter you get. So the VA has to have a hub-and­spoke ap­proach—the crit­i­cal mass for the spe­cial­ized ser­vices at the hubs, but also out­reach at the spokes. One of the ques­tions that the sec­re­tary, Congress and oth­ers will have to wres­tle with is how does that ta­pes­try get fleshed out so that vet­er­ans can get care that meets their needs in terms of de­mand, tech­nol­ogy and ge­o­graphic ac­cess while main­tain­ing a ta­pes­try of ser­vices that serves those vul­ner­a­ble vet­er­ans who de­serve an in­te­grated sys­tem.

The VA has to go from a 20th cen­tury sys­tem to a 21st cen­tury sys­tem in terms of ty­ing that care to­gether. The cur­rent cri­sis gal­va­nizes at­ten­tion on mak­ing changes that I be­lieve will of­fer vet­er­ans a higher-qual­ity VA. The VA can be a lab­o­ra­tory of in­no­va­tion for the rest of the coun­try in terms of co­or­di­nat­ing care. But it has to earn trust back.

MH: Is it a good strat­egy to bring in an out­sider, Robert McDon­ald, the for­mer head of Proc­ter & Gam­ble, as the new VA sec­re­tary?

“The cur­rent cri­sis gal­va­nizes at­ten­tion on mak­ing changes that I be­lieve will of­fer vet­er­ans a higher-qual­ity VA.

Perlin: Bob McDon­ald and Sloan Gib­son are ex­tra­or­di­nary busi­ness lead­ers. It’s par­tic­u­larly help­ful that Sec­re­tary McDon­ald has run a large con­sumer or­ga­ni­za­tion. The com­bi­na­tion of Dr. Clancy, Gib­son and McDon­ald is re­ally a very healthy change for the or­ga­ni­za­tion. In a busi­ness like Proc­ter & Gam­ble, you have to lis­ten to your cus­tomers. And I think McDon­ald’s busi­ness back­ground and that fo­cus on cus­tomers is a ter­rific set of qual­i­fi­ca­tions for the VA.

MH: In your new role as chair­man-elect of the Amer­i­can Hos­pi­tal As­so­ci­a­tion, what do you see as the main is­sues fac­ing the hos­pi­tal sec­tor on the ad­vo­cacy front?

Perlin: Peo­ple look to AHA not only for ad­vo­cacy but for help in trans­form­ing to higher per­form­ing in­sti­tu­tions. The work that the AHA is do­ing in im­prov­ing qual­ity and value is ex­tra­or­di­nary. It’s chang­ing care. That is not un­re­lated to the ad­vo­cacy agenda. The AHA’s agenda is to help de­velop a glide path from the way we’ve always op­er­ated to trans­parency, mea­sure­ment, ac­count­abil­ity and higher per­for­mance in the Triple Aim.

MH: The AHA has op­posed many of the bud­get cuts com­ing out of Wash­ing­ton. Do you think that the bud­get cut­ting has gone about as far as it can go or can it con­tinue?

Perlin: One-third of Amer­ica’s hos­pi­tals have neg­a­tive op­er­at­ing mar­gins, one-third will barely break even, and a third are sol­vent. I think the ques­tion is, how do we el­e­vate per­for­mance in an en­vi­ron­ment where we all have to un­der­stand that re­sources are not in­fi­nite?

I’m proud the AHA and the hos­pi­tal com­mu­nity got squarely be­hind in­creased ac­cess to care and the com­mit­ment to value and ef­fi­ciency as em­braced by the Af­ford­able Care Act. The hos­pi­tal com­mu­nity has par­tic­i­pated in bend­ing the cost curve. Is there more to go? Ab­so­lutely. This is one of the rea­sons I’m so pas­sion­ate about qual­ity as an es­sen­tial in­gre­di­ent in im­prov­ing value. And that’s why the AHA’s ad­vo­cacy and com­mu­nity agen­das are in­te­gral be­cause I think we can help the coun­try de­fine a glide path to­ward higher value.

MH: If you look out to the end of your ten­ure as AHA board chair­man, do you see a smaller hos­pi­tal sec­tor than we have to­day?

Perlin: It’s pretty clear that a lot of care is shift­ing from the in­pa­tient to the out­pa­tient en­vi­ron­ment and from the out­pa­tient en­vi­ron­ment to the re­tail en­vi­ron­ment. But when I look to the future, I see health­care as de­liv­ered dif­fer­ently.

We need to of­fer the best pos­si­ble care when it’s nec­es­sary for pa­tients to be in the hos­pi­tal, but in fact we have to be able to de­velop a sys­tem that em­pha­sizes health. And that’s a new skill for Amer­ica’s hos­pi­tals and health sys­tems.

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