Diabetes Care in the Veterans Affairs System and in Managed Care

TO THE EDITOR:

Kerr and colleagues' article (1) comparing diabetes care in the Veterans Affairs (VA) system and in managed care reflects a deep misunderstanding of what managed care means. Furthermore, their conclusion is self-serving and misleading. The VA system is, in fact, the largest managed care organization in the United States. Analogous to a staff-model health maintenance organization, the VA benefits from having enterprise-wide electronic medical records, employed physicians with restrictive formularies, and direct control over the practice patterns of those physicians through mandated use of practice guidelines. Commercial managed care plans rely on contracted physicians who are generally in private practice, are unlikely to have electronic records, and are much less under the control of the plan. To draw comparisons between these 2 widely disparate types of managed care organizations and conclude that a federally sponsored national health care organization would be superior to managed care is disingenuous. Kerr and colleagues should have compared both models with a completely unmanaged fee-for-service setting, for which data are available. The VA system is a managed care organization in every sense. If the VA clinical outcomes are indeed better, it is probably because of the higher-intensity care management afforded by having greater control over employed physicians. The more accurate conclusion is that managed care improves diabetes quality measures more than unmanaged care and that these improvements are related to the intensity of management afforded by the specific managed-care model. Kerr and colleagues' attempt to discredit managed care actually makes the case for it.