30 April 1999
Kenneth Kizer, MD, MPH
Dr. Kenneth W. Kizer was confirmed by the U.S. Senate as VA's Under Secretary for Health on September 28, 1994. In this capacity, Dr. Kizer functions as the chief executive officer of the Veterans Health Administration. He oversees the nation's largest integrated healthcare system, with a medical care budget of over $17 billion, approximately 200,000 staff and 172 hospitals, 376 ambulatory care clinics, 131 nursing homes, 33 domiciliaries, 205 readjustment counseling centers and various other facilities. In addition to its medical care mission, the veterans healthcare system is the nation's largest provider of graduate medical education and one of the nation's largest research organizations. Since assuming his position, Dr. Kizer has become the chief architect of re-engineering the veterans healthcare system.
Dr. Kizer's professional experience prior to joining VA includes positions in the private sector, philanthropy, academia and state government. Among the corporate and philanthropic boards he has served on are Health Systems International, Inc., one of the nation's largest managed care companies, and The California Wellness Foundation. He has held senior academic positions at the University of California, Davis, and continues as an Adjunct Professor of Public Policy at the University of Southern California. Among his state government positions, Dr. Kizer was Director of California's Department of Health Services for over six years, during which he set a record of both achievement and longevity. He has served on the boards of a number of other foundations, companies and professional societies, and been a consultant to several foreign countries.
Dr. Kizer is an honors graduate of Stanford University and the University
of California, Los Angeles. He is board certified in five medical specialties,
and has authored over 300 articles, book chapters and other reports in
the medical literature. He is a Fellow of the American College of Emergency
Physicians, the American College of Occupational and Environmental Medicine,
Dr. Kizer began with an overview of the Veteran's Health Administration,
which oversees the nation's largest integrated healthcare system. The VHA
has an essential role in providing medical care to veterans, training health
professionals, and providing emergency management services (a.k.a. "disaster"
health care). Because 35% of the homeless are veterans, it is also the
As Dr. Kizer's tenure began in 1994, the VA, like other health care
entities, faced the need to increase quality while cutting costs. "The
VA had not kept up with the rest of the country," Dr. Kizer said, in terms
of innovative delivery systems and quality improvement initiatives. "Care
was hospital-focused, specialist-based, and episodic." The VA was widely
viewed as too rigid,
The changes in the VA were guided by principles that stressed the patient as the center of the health care universe. "We decided that the business of veteran's health care is health care, not hospital care," Dr. Kizer noted. Responding to trends in the past 50 years, the VA recognized that health care had become primarily an outpatient activity.
First, the VA implemented a new operational structure organized around
22 Veterans Integrated Service Networks (VISNs), replacing the previous
system of free-standing hospitals and clinics operating largely independently
throughout the country. In addition, the VA instituted a capitation-based
method of allocating resources to each VISN, replacing the cost-based methods
In addition, the VA decentralized decision making. "Like politics, all health care is local," Dr. Kizer explained. To increase accountability for these decisions, the VA implemented performance contracts-the only government entity to do so.
Dr. Kizer listed the impressive accomplishments of this transformation.
From 1994 to 1998, the VA closed 54% of acute care beds, decreased bed-days
by 62% and staffing by 11%. At the same time, it increased the number of
patients treated by 18%, increased ambulatory visits by 35%, and instituted
universal primary care. "By 1998, most patients could name the person
Most importantly, the VA developed a framework by which to measure quality.
This framework includes morbidity rates, mortality rates, longevity (e.g.
one-year survival rates), functionality scores, and performance indicators.
Throughout the VA, function is measured by routine administration of a
version of the SF-12 to patients. Performance indicators include a
Although the VA has received modest increases in appropriations in the past five years, the amounts have not fully covered the mandatory salary increases for the VA's 185,000 employees. Thus, these changes have been made without additional government funding.
Looking toward the future, Dr. Kizer noted that the demand for VA health care is higher than ever, with Vietnam-era veterans now reaching an age where they are requiring larger amounts of care. World War II veterans have increasing acute care and long term care needs. In the VA, the numbers of the oldest-old will increase 700%. "For the VA, the demographic imperative is now, but the rest of the country will be there in 15 to 20 years," Dr. Kizer stated.
Dr. Kizer identified two immediate issues that could prove costly for the VA: one, expensive new treatments for Hepatitis C, which disproportionately affects the VA patient population; and second, the proposed Patients Bill of Rights, legislation that would mandate payment for out-of-network emergency care.
In response to a question from the audience, Dr. Kizer said that lessons
learned from the VA experience could be transportable to other health systems.
"Fundamentally, the VA and other systems are facing the same issues. They're
more similar than they are different." Specifically, he thought that other
systems could learn from the VA's implementation of performance contracts