The Veterans Affairs Healthcare System Under Secretary for Health, Dr. Robert Petzel, discusses why this has become a model system of care

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Mark Masselli: This is Conversations on Health Care; I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

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Mark Masselli: Margaret, I hope you had a nice 4 of July weekend. It feels like
there is a lot to celebrate these days as the health care overhaul begins. In the
last three months administration officials have issued rules allowing young adults
to stay on their parents’ policy and forbid the denial of coverage to children with
pre-existing conditions. They have also notified nearly four million small
businesses of a new tax credit to help foot the cost of insurance and they began
accepting applications for a separate program that will reimburse employers for
some of the cost of providing health benefits to early retirees and speaking of the
retirees, the government sent out checks of $250 to all Medicare beneficiaries
who pay a high price for their medications.

Margaret Flinter: Well Mark, that’s a lot of tangible progress in Health Care
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Reform in a few months. I did have a great 4 of July and as you know I was in
Washington for most of it but I think the focus was much more on the weather
which was hot, the fireworks which were spectacular and the crowds which were
big than Health Care Reform. But the holiday’s over, the fall elections are on the
horizon and of course health care will be back in the spotlight. And one thing the
administration will probably be tramper is its technology that’s making information
available to consumers. We saw the big launch last week of HealthCare.gov, the
new website where consumers can get information about both public and private
health insurance options in their states and that launch coincided with many
states successfully enrolling people in temporary high risk insurance pools. I
hear the phones are very busy.

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Mark Masselli: They really are. And that HealthCare.gov has become the 10
most popular Google search phrase according to Politico’s Mike Allen. Margaret,
did you get a chance to check out that new site I did and it is easy to navigate
and with a few clicks you can get your personalized options about where to go
and purchase affordable health care coverage for you and your family?

Margaret Flinter: I did check it out and tried some different scenarios. It feels to
me like we are at the cusp of a new era in transparency and making information
available to consumers that they can really use to make decisions.

Mark Masselli: And even if you are not shopping around for insurance I suggest
checking it out to get information about the new health care law. It’s a great
interactive timeline that tells you what new laws are kicking in and exactly when.

Margaret Flinter: And Mark, we are also very excited about today’s guest. You
know we had been planning an episode on the Veteran Affairs Healthcare
System since we began the show back last September. We have excellent VA
system here in Connecticut and of course we participate every year in the
Veteran Stand Down for Homeless Vets here in Connecticut. But I am pleased
today to announce we have Under Secretary of Health for the VA Dr. Robert
Petzel here today to speak with us about the VA system and the quality
revolution it went through in the 1990s and what the VA system today can teach
us about transforming health care. And of course we will be talking with him
about the new demands that need to be addressed for today’s returning women
and men from Iraq and Afghanistan.

Mark Masselli: No matter what the story, you can hear all of our shows on our
website Chcradio.com. You can subscribe to iTunes to get our show regularly
downloaded or if you would like to hang on to our every word and read a
transcript of one of our shows, come visit us at Chcradio.com.

Margaret Flinter: And as always, if you have feedback, email us at
Chcradio.com, we would love to hear from you. Now, before we speak with Dr.
Petzel, let's check in with our producer Loren Bonner for the headline news.

Loren Bonner: I am Loren Bonner with this week’s headline news. President
Obama has appointed Dr. Donald Berwick to head the Centers for Medicare &
Medicaid Services. In a surprise announcement late Tuesday night, the
President said he was going to bypass Congress and act on the recess
appointment because according to his spokesperson, many Republicans and
Congress have made it clear in recent weeks that they were going to stall the
nomination as long as they could solely to score political points. Although
Berwick is known as an inspiring leader and has been endorsed by many major
medical societies, he would have faced a long difficult struggle to win this senate
confirmation. Recess appointments are good until the end of the next session of
Congress or late 2011. The much anticipated website to help consumers learn
about their coverage options launched last week. Healthcare.gov is being called
a one stop shop for health care. The website is loaded with basic information
about plan availability, eligibility, benefits from the federal government and 5500
plan offerings from more than 1000 insurance companies. The Health
Department’s Chief Technology Officer Todd Park said this is revolutionary for the
American consumer.

Todd Park: It is the first website to collect both public and private health
coverage options from across the country in a single place and even more coolly
to automatically sort through that huge catalog based on short series of
questions that you answer, they come up with a menu that’s right for you.

Loren Bonner: The administration will continue to add to the site as
implementation moves forward. For example, pricing information will become

available for private plans along with more information about benefits and cost
sharing. Eventually, this site will serve as a portal for the state based health
insurance exchanges that are planned for 2014. Enrollment for the temporary
pools began last week; 29 States plus the District of Columbia will be running
their own and 21 States will have the federal government do it for them. Besides
the much anticipated website, another overhaul initiative received recognition last
week. HHS announced that it has begun accepting applications for the early
retiree reinsurance program created by the new health care law. HHS Secretary
Kathleen Sebelius says many employers are eager for the help to keep their
retiree insurance plans in place.

Kathleen Sebellius: 30 employers were so enthusiastic about the plan that they
brought their applications in person hand-walked them in. So I think it indicates
that employers have really been paying attention, this is a very important
program and it helps people who are younger than Medicare eligibility age to
really make sure that their insurance coverage stays affordable.

Loren Bonner: The law sets aside $5 billion that businesses, unions and state
and local governments can use to cover the health care costs of their retirees
and the retiree’s family. However, the early retiree reinsurance program is only
expected to cover a fraction of those who wish to use it. A new report by the
Employee Benefit Research Institute found that if the subsidy reached all early
retirees and their dependants, half the money would be exhausted in the first
year of the program.

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Loren Bonner: This week on Conversations on Health Care we are looking to the
veterans health administration as a model system of care. The psychological
stress becomes more prevalent among returning veterans from Iraq and
Afghanistan, VA hospitals around the country are figuring out better ways to
understand, diagnose and treat mental health disorders for returning soldiers.
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According to a study by researchers at Stanford University, 1/3 of the 1.9 million
men and women who have served in Iraq and Afghanistan, have suffered from
Post-Traumatic Stress Disorder or PTSD. It's the most prevalent mental health
problem for today’s veteran. At San Francisco’s VA Medical Center, Dr. Karen
Seal, a leading PTSD researcher, started the operation Iraqi Freedom Integrated
Care Clinic which provides primary care, mental health and social services to
Iraq and Afghanistan veterans in one single setting. Dr. Seal is trying to
encourage veterans to see a therapist since most shy away from it. One study
she conducted for the Journal of Traumatic Stress found that among vets who did
receive a PTSD diagnosis through a VA clinic, 90% didn’t complete a course of
treatment. The Integrated Care Clinic opened in 2007 and today almost 100 vets
come in to receive treatment. A team of three doctors including Dr. Seal, combat
specialists, physical therapists, pain experts and neuropsychologists work
together to help vets feel better and to cop with their illness better. Dr. Seal

believes primary care doctors need help treating a younger clientele with different
stresses than wars past. Currently, her clinic is working on making an
instructional video to help primary care doctors learn what to do when a young
veteran exhibit signs of PTSD. The clinic is also studying computerized cognitive
processing therapy a series of brain fitness exercises. With the help of the clinic
and Dr. Seals’s research, the San Francisco VA has added several dozen mental
health clinicians in the last few years and it's also helping them become a
national hub for PTSD research.

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Mark Masselli: This is Conversations on Health Care. Today, we are speaking
with Dr. Robert Petzel, Under Secretary of Health in the Veterans Health
Administration in the Department of Veterans Affairs. Welcome doctor. You have
directed several VA medical centers in the Midwest before you were appointed
Under Secretary of Health in 2009 so you have witnessed a transformation in
quality at the Veterans Health Administration during the ‘90s that made it the
revered health system it is today. In studies published in peer-reviewed journals,
the VA beats other health care providers on virtually every measure of quality,
patient safety adherence to evidence based medicine, coordination of care, cost
effectiveness and patient satisfaction. What propelled the VA quality revolution
and have you been able to sustain those gains?

Dr. Robert Petzel: That’s an excellent question Mark. There were a number of
things I think that were responsible for this back in the middle 90s. Number one
is there was this tremendous sense of urgency. The VA did not have a very good
reputation for quality at the time so that everybody was poised to do something.
Congress was supportive, the administration was supportive. The elements I
think that led to this were several. One is that there was a decentralization of
authority if you will and decision making out of Washington into what we call the
networks, the 22 regional networks that the Veterans Health Administration had
just established. Two is that we began to develop a set of matrix, a set of ways
to measure quality and safety well ahead of the rest of the country; this was
something that was really quite new. A third is that a series of clinical practice
guidelines that is our guidance as to what should be done and how care should
be delivered in certain circumstances particularly with chronic diseases were
promulgated within the Veterans Health Administration. Fourth is that we
developed a performance management system where senior executives within
the Veterans Health Administration were held responsible for achieving certain
levels of performance in terms of quality as well as number of other things. I
think the fifth thing is that there was definitely committed leadership who believed
that this organization could establish itself as an organization of excellence. So
in my mind those were the major things that contributed. Have we been able to
sustain this, yes we have and the question on it of course is why have we been
or how have we been able to. Again I think there are a numbers of reasons and
probably most importantly is that people within the organization now do believe

indeed that we are an organization characterized by excellence. There is a
tremendous amount of pride in that and a tremendous amount of pride in
maintaining that reputation.

Margaret Flinter: The VA system as you said relies on evidence based guidelines
and protocols both for preventive health services and for chronic disease
management and I am sure for acute care as well. But, central to the preventive
and chronic disease services is the reliance on a primary care provider for each
patient and a robust electronic health record and of course these are two of the
key elements of high performance care that the federal health reform bill
emphasizes. All through the spring one of the questions asked was will investing
in these measures now reduce health care costs down the road? Can you share
any outcome data from the VA that might inform the country now as we begin to
make similar large investments in these areas? Have you been able to show
reduced expenditures as a result of these transformations?

Dr. Robert Petzel: Yes, we have. There are a couple of examples of that. There
was a recent article published as a result of a study done by a group from
Harvard of our computerized medical record looking at both the cost of
implementing it and cost of operating it as well as the potential savings that we
achieved. And their conclusion was that over the last 10 years we have saved
about $2.2 billion as a result of the computerized medical record. The capacity to
follow data overtime, the capacity to make decisions that are based on evidence
has led to probably fewer hospitalizations, fewer clinic visits and other things that
have saved money. We are a very good example of what can be achieved with
an electronic medical record. We are now developing what I would call a new
model of care for our primary care providers trying to integrate all of the elements
that we have available, tele-home health, telemedicine, case management,
primary care visits, group visits, the services that are available in the community
and provide a patient centered continuously improving team care delivered
health experience for our patients in primary care. And I think that when this is
developed it's going to be an excellent example of how a system ought to be
organized and how it ought to be delivering care.

Mark Masselli: Dr. Petzel in 1999 the VA formed the National Center For Patient
Safety to enhance safety standards. We have had Dr. Peter Pronovost on our
show who pioneered the checklist to reduce infections and errors. Have you
implemented this type of checklist and seen similar result in decreased mortality
and complications?

Dr. Robert Petzel: Yes. We have had Peter actually talk to us on a number of
occasions and we have in our Intensive Care Units particularly where central
lines are generally put in we have implemented the Central Line Bundle it's called
which is a description of the process and the procedures that one ought to use
and we have shown a dramatic diminution of central line infections over the last
several years as a result of that. In addition to that there are number of other

thing, the ventilator bundle is a guideline for how to wean patients off of
ventilators and we have dramatically decreased the hospital acquired pulmonary
infections in our Intensive Care Units as a result of that.

Margaret Flinter: I have been very impressed with the provider and team level
reports that I have seen from the VA that look at everything from patient
satisfaction to access to both the process measures what we did and also the
outcome measures how well the patient did. And you have referenced it as really
holding managers and the senior execs accountable but my question is have you
seen it also as fundamental to driving change in the individual provider behavior
and not just the provider but everybody else on the team the nurses, medical
assistants, receptionist, behaviorists?

Dr. Robert Petzel: We do an excellent job of providing very comprehensive data
at the network level, at the national level and at the facility level. We have work
to do yet to make sure that we make that data available to the individual team,
individual provider because I think it's fundamentally important. If you are going
to ask people to continuously improve the way they do their work which is what
we are doing then you have to provide them with data about the four domains of
health care value, cost, quality, access and satisfaction and we are not as far
along in my mind as we need to be. Now the matrix that we have and that we
use for performance management could be viewed as having sort of two
fundamental functions one of them is to provide for accountability that is you
want to see how well the organization perhaps individual people are doing in their
work but in my mind the more important thing these are able to help us with is to
drive the organization forward.

Mark Masselli: Today we are speaking with Dr. Robert Petzel, Under Secretary
of Health in the Veterans Health Administration at the Department of the Veterans
Affairs. It's true that advances in medical technology have saved more lives of
those injured in combat but it’s also true that many of those men and women live
in serious trauma that debilitates them psychologically. What more needs to be
done to expand mental health counseling and services for vets?

Dr. Robert Petzel: Well the Veterans Health Administration has really I think
stepped up to the plate in terms of the needs of returning veterans. There is a
relative percentage of people that come out of combat who have problems with
PTSD, anxiety, depression, sometimes substance abuse and we have instituted
first of all a series of screening programs where every returning combat veteran
that sees us is screened for substance abuse, depression, PTSD and mild to
moderate traumatic brain injury. Those people who screen positive on any one of
those entities are then moved into a more in-depth evaluation and eventually
treatment if needed. In addition to that, those people that have one of those
problems are assigned a case manager who follows their progress, is available
to them and sees that they are getting things that they need. I think, in my mind,
what primarily needs to be done first of all is to understand the genesis of these

issues or problems arising out of the combat experience and research needs to
be done or whether or not we can predict with any accuracy the kinds of people
that will have problems associated with combat as opposed to those that don’t
seem to have. That’s one. Two is that we need to do everything that we can to
get these patients to us. Our biggest problem I think is the fact that not every
veteran has contacted us, not every veteran seeks our help and these are young
individuals who feel themselves to be invulnerable, immortal and can’t
understand the nature of the problems that they might potentially have and we
have worked with local providers, local veteran service officers and families to
help them understand the kinds of things that they could identify and maybe help
bring these veterans to us if indeed they need help.

Margaret Flinter: And Dr. Petzel at a time when so many communities and
practices are worried about being able to recruit and retain primary care
providers I understand at least here in the northeast that’s just not a problem for
the VA and in fact the VA is seen as a choice career opportunity for young
physicians. I am sure the opportunities for research and teaching play a role
here but I wonder do you think that you have figured out how to make primary
care practice a satisfying practice environment.

Dr. Robert Petzel: I think that what you just mentioned is indeed one of the
factors. I think the other things apply is research education, a stable practice
environment, a practice environment where you can improve your career. We
are a very good place for people to have a career in terms of moving forward or
doing different things. And the third thing is that I think we have made by giving
them the right kinds of support and being able to pay competitive salaries we
have made primary care into a more attractive practice opportunity. And it's true
that in general except for some isolated places that we don’t have a lot of
difficulty recruiting primary care providers.

Mark Masselli: Dr. Petzel, when you look around the country and the world, what
do you see in terms of innovations and who should our listeners at Conversations
be keeping an eye on?

Dr. Robert Petzel: The things that I think people ought to looking for and I think
ought to characterize the way we practice medicine is number one it should be
patient centered. And patient centeredness means a number of things, it means
that the whole system of care is setup around the needs of the patient not
necessary the providers. So the hours the clinic is available, the kinds of
services that it offers, the atmosphere both physical and the cultural atmosphere
are all aimed around the needs of the patient. And also, patient centeredness
means to me that the patients are in control of their health care that is they share
in the decision making, they make the decisions, we provide them with the advice
and the information but we have empowered them to the point where they have
the knowledge to be able to participate in the decision making process. The
couple of other things that I think are important but may be not so important from

the patient’s perspective that is I think that a health system ought to be looking at
value that is are they providing both quality and cost effective care. And I believe
that the health system ought to be looking at the population implications of what
they are doing but not just at individual patient data but also they should be
following the data about the health of the population that they are treating.

Margaret Flinter: Well we have a lot of common ground there and today we have
been speaking with Dr. Robert Petzel Under Secretary for Health and the
Veterans Health Administration at the Department of Veteran Affairs. Dr. Petzel,
thank you so much for joining us today on Conversations.

Dr. Robert Petzel: Well, it was my pleasure, thank you very much.

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Mark Masselli: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday life. This week’s bright
idea focuses on very green approach to healing, gardening. Horticultural therapy
programs are sprouting up in a number of health care facilities around the
country from hospitals to elderly care programs, crisis centers to mental health
institutions. For instance at Legacy Emanuel Medical Center in Portland, Oregon
Burn Center patients get wheeled out regularly to their private garden. The
garden is designed to stimulate the patient’s senses and provide a smoothing
environment. This system of five non-profit hospitals in the Portland area
originally started a gardening club program for dementia patients in 1991. When
they began seeing decreased anxiety and heightened concentration among
these patients, they started using gardening as an integral part of the health care
delivery. Today, there are nine different therapeutic gardens at the hospital. As
alternative approaches like horticultural therapy become more accepted the
research is also catching up. Several studies have shown how nature
contributes to good health. In one study that appeared in 2008, 18 residents
from an assisted living facility showed a significant increase in self rated health
and happiness after participating in four horticulture classes. Horticulture therapy
is also an inexpensive approach although some facilities build elaborate gardens,
all that really is needed some potting, soil and seeds. On top of that practitioners
say that in health care facilities they can feel stressful and sterile; gardens and
plants offer important relief. It's a simple approach that can go a long way to help
patients relieve stress, improve cognitive function and even redevelop fine motor
skills well at the same time greening the environment. Now that’s a bright idea.

Margaret Flinter: This is Conversations on Health Care, I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Loren Bonner: Conversations on Health Care, broadcast from the campus of
Wesleyan University at WESU, streaming live at www.wesufm.org and brought to
you by the Community Health Center.