Exploring Human Potential

The 2015 VA Assessment Report – Whose Interests Would It Serve?

Posted on | October 1, 2015 | 2 Comments


Mike Magee

To say the VA is a huge enterprise is a bit of an understatement. Over 9 million patients in a system with nearly 300,000 employees (including 20,000 doctors) and an annual budget just under $60 billion.

If the system is big, it is also controversial, and has been for a long, long time. There have been no less than 137 formal assessments of the system in the past. Falsification of waiting lists was what triggered the latest crisis. But issues of highly variable quality of care, delayed access, a phenomenal mental health disease burden, an historic and troubled step-sister relationship with academic medical centers, and decaying brick and mortar have been visible for decades.

In signing the Veterans Access, Choice and Accountability Act of 2014, President Obama provided a safety valve in allowing a non-VA treatment option for the unmet medical needs of veterans, but also funded an comprehensive assessment of VA performance in a dozen areas of delivery and management.

On September 18, 2015, the results became public, and sounded dire. To begin with, the capital needs of the system are pegged at $51 billion over the next decade. By the way, cost of construction inside the system is double that of the private sector. Timely access to a health professional requires more of everything, says the report – more staff, more exam rooms, more decision control close to the patient. The only thing that we require less of, apparently, is competing internal management silos.

There are a lot of “funny numbers” when it comes to the VA. For example, there are nearly 22 million living veterans in the U.S. But only 4 in 10 are actually enrolled in the VA health care system. Of those 9 million enrollees, only about 6 million are actual patients, and of these, on average, each receives less than 50% of his/her care from the VA. So effectively, and functionally, the system is actually servicing the full time equivalent of 3 million patients at a cost of $60 billion dollars. (And that doesn’t include the additional infusion of “research dollars” and special grants that find their way into the system). That is $20,000 + per year for each “full time equivalent” patient cared for in a system which, in the just released assessment “scored in the bottom quartile on every measure of organizational health”.

With all that, one would think that the solution to this problem could be delivered in just 5 words: “Time to close the doors”. But no, the solutions, as expressed by leaders of the assessment committee in this week’s New England Journal of Medicine, are far less definitive.

It reads, “The solution, we believe, is multidimensional but starts with immediate changes in practice that will ultimately change culture. It requires pushing decision rights, authority, and responsibilities down to the lowest appropriate administrative level and increasing the appeal of senior leadership positions by pursuing regulatory or legislative changes that create new classifications for VHA leaders. It’s important for VHA leadership to foster a ubiquitous patient-centric culture that encourages sharing of best practices (and failures), values feedback, and catalyzes innovation. To enhance continuity, we believe Congress should consider longer terms for key VHA leaders and medical center directors.”

A bit later, “We call for a shift in VHA focus from central bureaucracy to supporting clinicians in the field and clearly articulating what decision authority resides at each level of the organization. Most important, a systematic approach is needed for identifying and disseminating best practices.”

And finally, “Although VHA transformation will be a Herculean challenge, the country’s current shared sense of urgency and uniform commitment to veterans requires settling for nothing less than high-quality care at sustainable cost and within a culture comparable to that of the best health care organizations.”

A 2014 assessment of clinical preparedness in the AAMC journal, Academic Medicine, said this, “Since 2001, about 2.5 million U.S. troops have been deployed to Iraq or Afghanistan. More than 6,600 men and women have given their lives, and over 48,000 have been injured. However, these numbers do not reflect the long-term physical, psychological, social, and economic effects of deployment on service members and their families. With over one million service members separating from the military over the next several years, it seems prudent to ask whether our country’s health care professionals and systems of care are prepared to evaluate and treat the obvious and more subtle injuries ascribed to military deployment and combat.”

It also said this, “In fact, by itself, it cannot even ensure the health of the 40% of veterans enrolled in VA health care. Some three-quarters of those enrolled in VA health care also have alternate sources of health coverage, such as Medicare, Medicaid, or private insurance, and many of these veterans receive at least some portion of their health care outside the VA system. Ensuring veterans’ well-being is a duty for the entire health professions community.”

Since the passage of the Affordable Care Act, veterans have access to new insurance options that allow them to more easily opt-out of the broken VA system. And they are doing just that, in increasing numbers. So why does the most recent evaluation so clearly unlink reality (It is questionable whether the system is worth saving), with solution (Close it down, and merge these patients into our existing health delivery system)?

Part of the answer is likely geography and jobs. As with the “military-industrial complex” and military bases, these entities are spread throughout our nation, and closing them would have an immediate impact on jobs and local economies. These geographies have political representatives, and the institutions and their suppliers, who profit through weak controls, have their own networks and lobbyists who battle on, in their behalf.

But it is useful to also remember that these entities are an integral part of a larger “medical-industrial complex” which is not as readily visible, and includes the leaders of our academic health care institutions and corporate health care firms. These leaders were, in the post- WWII period, chosen to provide significant thought leadership and human resource supplies for the entire system. Today, 80% of U.S. medical schools have an active affiliation with a VA hospital. The academic medical centers and medical schools rotate over 100,000 residents and medical students through the VA, and receive a not insignificant portion of their training at these sites. Researchers from the academic centers also gain access to research subjects at the VA, and are funded by corporate and governmental grants for their studies.

The question worth asking then is who and what are the latest set of recommendations ultimately designed to serve – the veterans or the “military-industrial complex” whose interests continue to be served, even by an irreconcilably flawed system?
For Health Commentary, I’m Mike Magee.



2 Responses to “The 2015 VA Assessment Report – Whose Interests Would It Serve?”

  1. Denise Link
    October 1st, 2015 @ 1:08 pm

    I agree that simply hiring more clinicians and staff and allowing vets to access care in the community (which oh by the way is experiencing its own access to care challenges) is not enough. If the culture of centralized control and emphasis on EBP are not part of the solution, it will not change much. In addition, while I think that funding to hire more physicians and staff is admirable, an immediate and notable increase in the pool of available providers and appointments can be realized without any new hires by granting full practice authority to the NPs and Clinical Nurse Specialists who are already in the system. The IOM and other health policy panels have recommended the removal of barriers to practice for all advanced practice nurses. I am very disappointed that the bill that included that solution along with the others did not make it to the President’s desk.

  2. Mike Magee
    October 1st, 2015 @ 1:36 pm

    Thanks for your insights, Denise. Whether in the VA system, or in a more integrated approach to veterans important health care needs, the optimal use of all health professionals knowledge and skills are clearly essential.

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