comparison of management, organization, and provision of healthcare services by veterans health...
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Comparison of Management, Organization, and Provision of Healthcare Services by Veterans
Health Administration and Veterans Affairs Canada
By Oleg Nekrassovski
The present paper aims to compare care coordination or system integration, management
accountability, resource allocation, and information management of the health care system
managed by the Veterans Health Administration (VHA), and that of its Canadian analog
managed by the Veterans Affairs Canada (VAC).
VHA follows a primary care model, which involves adherence to clinical guidelines and the
sharing of information among providers. To this end, VHA uses its health information software
to coordinate and document care provided to its enrollees (Congressional Budget Office Report,
2009). Moreover, some progress has been made by the VHA with regards to exchange of
patients’ health care information with Department of Defense’s military health system
(Congressional Budget Office Report, 2009).
VHA’s Computerized Patient Record System (CPRS) includes a computerized physician order
entry system, an electronic medical record, diagnostic test results, medical image viewing,
electronic pharmaceutical management system, etc. (Ahnen, 2010). VHA patient’s primary care
physician as well as his/her other providers can quickly see the services received by the patient
within VHA by accessing his/her VHA electronic health record. Thanks to CPRS (and the
encouragement of VHA’s management), VHA’s health care providers are able to follow up with
outside providers on services or medications received by the patient outside of VHA, and enter
them into the patient’s electronic medical record (Congressional Budget Office Report, 2009).
VHA also maintains an on-line personal health record, specifically for usage and modification by
patients. This allows the patients to incorporate records of care received from various (VHA and
non-VHA) providers, and then share this information with all of them; so as to make the
coordination of care, easier (Congressional Budget Office Report, 2009).
In contrast to the high level of integration displayed by the VHA’s health care system (Ahnen,
2010), VAC doesn’t even have its own health care system. Instead it relies on provincial health
care systems, private providers, and its small medical staff, for providing health care to veterans
(1996 May Report of the Auditor General of Canada). Moreover, it was found that the extent to
which VAC managed the care it was responsible for providing, was inconsistent. The extent of
VAC’s activities, in this respect, turned out to be dependent on the variable provincial
healthcare programs, location of the departmental facility, and the program element (1996
May Report of the Auditor General of Canada). Also, the expected quality of care provided by
VAC is thought to be not too well defined or monitored; the partnerships between VAC and
provincial healthcare systems and private providers are not well developed; while VAC does a
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poor job of holding various healthcare providers accountable for the appropriateness, level,
cost, and outcomes of service provided (1996 May Report of the Auditor General of Canada).
On the other hand at VHA, accountability is in place at all levels (Rettig, 2003). VHA holds its
senior managers accountable for many performance indicators, which include quality-of-care
measures (Congressional Budget Office Report, 2009). Moreover, all of VHA’s personnel are
subjects to a performance management system. And unlike in the past, VHA physicians can be
dismissed for reasons not limited to their clinical incompetence (Rettig, 2003).
Usage of VHA’s services is limited to veterans, who once enrolled, get assigned to one of 8
priority groups, based on their service-related exposures, service-connected disabilities (SCDs),
assets, income, etc. (Congressional Budget Office Report, 2009). Priority group 1 veterans are
rated to have 50% or greater SCDs; while priority group 2, have 30-40% SCDs. On the other
hand, aside from including veterans with 10-20% SCDs, priority group 3 also includes former
prisoners of war, recipients of the Purple Heart, those who were discharged from service due to
SCDs, and those who received wrong treatment or vocational rehabilitation, from VHA, which
resulted in a disability (Congressional Budget Office Report, 2009). Veterans belonging to
priority group 4 also have serious disabilities, but these disabilities are thought to be unrelated
to their military service. Priority group 5 includes only low-income veterans that are more or
less free of disabilities. While priority group 6, consists of veterans who are seeking care solely
for problems associated with environmental exposure in line of duty. These veterans are also
deemed to be more or less free of disabilities. Finally, priority groups 7 and 8 consist of
veterans with health status comparable to that of priority group 5, but with higher incomes
(Congressional Budget Office Report, 2009).
VHA puts emphasis on effective provision of outpatient care, especially on the provision of
mental health and substance abuse counseling; primarily because veterans use these VHA
services more commonly than others; in no small part because 80% of VHA enrollees have
additional health care coverage and rely on VHA for only part of their health care. Also, many
veterans may not have private coverage for such services (Congressional Budget Office Report,
2009).
VHA does not charge its enrollees any fees for care for service-related conditions. Moreover,
members of highest priority groups generally don’t get charged any inpatient or outpatient
copayments even when it comes to care unrelated to their military service. Also, veterans in
priority groups 1 and 5 are not required to pay copayments for medications. While veterans in
priority groups 2 through 6 that have reached an annual cap of $960, have their copayment
requirements waived for the rest of the year (Congressional Budget Office Report, 2009).
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The provision of medical services to Canadian veterans is somewhat different. Veterans Affairs
Canada provides health care benefits to three groups of clients: group “A”, group “B”, and
rehabilitation clients. Group “A” clients are those that hold a VAC disability entitlement for
certain medical conditions. They can only receive approved health care benefits from VAC that
are directly related to those conditions for which they hold a VAC disability entitlement
(Veterans Affairs Canada, 2008). Group “A” clients include veterans, retired CF members,
released members of the Reserve Force and Class B Reserve on assignment for less than 180
days, retired RCMP members, civilians that are serving in RCMP, and a few serving CF members
with special pension entitlements. All other serving members of CF and RCMP are not part of
group “A” (Veterans Affairs Canada, 2008).
Group “B” are those whose eligibility for approved health care benefits from VAC is based on a
demonstrated health need and the fact that the required benefits are not covered by provincial
or private health coverage (Veterans Affairs Canada, 2008). Group “B” clients include veterans
and civilians who are receiving War Veterans Allowance benefits, or would receive them, but
aren’t because they are receiving Old Age Security benefits; various recipients of the services of
the Veterans Independence Program (VIP), including regular veterans, civilians, former
prisoners of war, Special Duty Service Veterans, and Canada Service Veterans (Veterans Affairs
Canada, 2008).
Rehabilitation clients are those who have rehabilitation needs. They are entitled to certain
benefits related to their rehabilitation needs (Veterans Affairs Canada, 2008). Rehabilitation
clients include medically-released veterans that applied within 120 days of release; veterans
with a service related Rehabilitation Need; CF veterans’ spouses or partners who have a total
and permanent incapacity and therefore can’t benefit from vocational rehabilitation; surviving
spouses or partners of CF veterans who died from injury or disease brought on by military
service (Veterans Affairs Canada, 2008).
VAC also runs a national homecare program, called the Veterans Independence Program (VIP).
VIP aims to help its clients to remain healthy and independent in their own homes. The services
provided are always based on individual health and functionality needs (Veterans Affairs
Canada, 2008). People eligible for VIP include disabled people who are receiving disability
benefits; seriously (78% +) or medium (48-77%) disabled wartime pensioners; low income War
Veterans; veterans that are receiving Prisoner of War Compensation or Detention Benefits, and
are totally disabled; Overseas Service Veterans who are in Canada and on a waitlist for a priority
access bed; low income Canada Service Veterans over 65 years of age; primary caregivers or
survivors of some veterans or civilians may also qualify (Veterans Affairs Canada, 2008).
Thus, while VHA controls an independent, self-sufficient, publicly funded health care system
(Fooks & Decter, 2005) accessible only to veterans, VAC provides financial coverage for health
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care services accessible to all Canadians, some medical treatment by the health professionals it
employs (Veterans Affairs Canada, 2012), and some personal assistance services (VIP). On the
other hand, while VHA provides care only to military veterans, VAC provides help to a far more
diverse assortment of people, which aside from veterans, ranges from serving CF members to
civilians current serving in RCMP and retired RCMP officers, to spouses or partners of CF
veterans.
Thus, the two veterans’ healthcare organizations are remarkably different. While the care
provided by VHA’s independent, self-sufficient health care system is highly coordinated and
integrated, VAC doesn’t even have its own health care system and instead does an inconsistent
job of using various independent medical services, publicly available in Canada, to care for
Canadian veterans. While VHA maintains sophisticated information management systems
aimed at simplifying and enhancing information management and sharing of information
among various providers seen by the same patient, and between patients and their providers;
no such systems are possessed by VAC. Moreover, while VAC does a fairly poor job of holding
various healthcare providers, that it uses to help veterans, accountable; at VHA all levels of the
organization are held accountable. However, while VHA provides care only to military veterans,
VAC also provides care to a variety of other military and non-military personnel. In spite of all
this, making detailed comparisons between VHA and VAC is actually very difficult as the amount
of information available on the managerial, organizational, and service aspects of VHA is very
large; while that available on the same aspects of the “healthcare branch” of VAC is extremely
small. Hence, further research on these aspects of VAC would clearly prove to be very useful.
References
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Fooks, C. and Decter, M. (2005). The Transformation Experience of the Veterans Health
Administration and Its Relevance to Canada. HealthcarePapers, 5(4): 60-64.
Healthcare-related, unpaid, research opportunities are available. Various academic specialties are required. If interested, email me at
1996 May Report of the Auditor General of Canada. Chapter 12—Veterans Affairs Canada—
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