be connected in a predictable and consistent manner, according to specified expectations. To date, this is something that the United States overall has not had.

However, he said, there have been a number of efforts to institute formal regionalization in the United States that date back many decades. For example, the VA decided to regionalize vision impairment and rehabilitation of the blind in 1948 and spinal cord injury in the 1950s. Other examples include the trauma care system regulations that he wrote for the state of California more than 25 years ago, and the development of Emergency Medical Services (EMS) systems that occurred throughout the 1970s.

Kizer noted that a major milestone for regionalization for non-emergency conditions was a paper by Hal Luft, Alain Entoven, and others that appeared in the New England Journal of Medicine in 1979 regarding the relationship between volume and outcomes in cardiac surgery. This, he said, has been a highly controversial subject ever since and is the basis for an ongoing debate about regionalization of cardiac surgery and surgery for a number of other infrequent conditions.

Kizer focused the rest of his talk on the efforts that have been made by the VA to regionalize a number of its services. He noted that the veterans health care system was established circa World War I and is the largest health care system in the country—albeit an anomaly in that it is a national, centrally administered, government-run, and government-funded care delivery system based on a moral or philosophical view that those who have served in the nation’s armed forces should not be denied health care regardless of financial status.

He emphasized that the VA is not part of the military health care system—a common misunderstanding—but to be a VA patient you must have served in and been honorably discharged from the armed forces. He characterized the VA as very much of an academic system: 85 percent of VA hospitals are teaching hospitals and 70 percent of the physicians are university faculty members. The VA also has a $2 billion research program.

Kizer said that that many of the reforms that occurred in the VA in the latter part of the 1990s were predicated on the concept of regionalization. During that time, the VA’s approximately 1,300 facilities of various types were organized into 22 networks, or regional veterans integrated service networks (VISNs), based on criteria about how to best use its resources to serve geographically defined populations of veterans. However, as mentioned above, regionalization of specific service lines within the VA dates back as far as the 1940s.

Kizer noted that most regionalized conditions in the VA employ a hub-and-spoke wheel model. For example, there are currently 24 very specialized spinal cord injury centers and 134 primary care spinal cord centers within