What needs to improve?
For many years, the healthcare system for our veterans has been under fire for have numerous problems and providing inadequate care. Considering what these brave men and women sacrifice while serving our country this is definitely unacceptable. What problems are the most prevalent? What has been done to correct these problems? What still needs to be done?
The Veterans Health Administration (VA) is the largest integrated health care system and second largest agency in the United States. It accounts for almost $200 billion in federal spending yearly, has more than 350,000 employees and provides care to 9 million veterans at 1,240 health care facilities, including 170 VA Medical Centers and 1,061 outpatient sites, Recently, the VA has struggled to keep up with the volume of patients as service members are returning from Iraq and Afghanistan at the same time that aging and increasingly ill older veterans are making more use of it. Unfortunately, as more and more veterans are needing the services of the VA, accusations of mismanagement, breaches of the requirement to schedule timely appointments, problems with its recordkeeping on wait times and falsified records have been brought to light. This pattern is consistent with a history of well-documented problems. Under a 1996 law, veterans who need care must be seen by a provider within 30 days. However, studies done by the Government Accountability Office (GAO) found evidence wait time failures in 2000 and the Office of the Inspector General at the VA (the agency’s internal watchdog) looked at this problem in 2005, 2007 and in 2012. The GAO found that five years after the law was passed, two-thirds of the specialty-care clinics had wait times longer than 30 days. Also, an audit completed in 2007 by the Inspector General revealed that VA facilities did not always follow the organization’s scheduling policies and procedures. The December 2012 GAO report recommended that the VA take action to improve the reliability of its wait time measures, ensure uniform application of its scheduling policy, regularly monitor scheduling needs/staffing resources and improve telephone access for clinical care. On top of all of these problems, in 2014, it came to public attention that at least 40 veterans died while waiting for care at the Phoenix VA. Whistle-blowers declared that there was a secret list of patients waiting for appointments in order to conceal how long it took for patients to be treated. They also claimed that the facility later destroyed the evidence. Upon further investigation, it’s thought that use of secret waiting lists wasn’t an isolated incident and was a system-wide problem. According to subsequent investigations, these delays were a result of insufficient staffing, failure to use funds as designated, a lack of oversight for tracking consults, antiquated software systems, lack of adequate training and turnover in scheduling positions. Since the VA relies on self-certification for wait times, it was assumed that the data that is being used for oversight purposes wasn’t reliable.
As a response to the 2014 discovery, Congress passed the Veterans Access, Choice, and Accountability Act (VACAA), which directed the VA to begin a temporary program allowing veterans greater choice by letting them receive care from a provider that is part of the VA’s network of community providers, but don’t work at a VA facility. The veteran must receive prior authorization from the VA before being allowed to do this. In order to receive this authorization, a veteran must wait more than 30 days for an appointment or live more than 40 miles from a VA facility. Unfortunately, bureaucratic problems have prevented many veterans from using the program. Due to these issues, many veterans who are younger than 65 have gained health insurance coverage under the Affordable Care Act. The VACAA was $16 billion endeavor. Of the money, $10 billion was used for veterans to get care outside the VA system. Another $2.5 billion was used to hire more doctors, nurses and other medical staff at VA medical centers with the idea being that more caregivers would cut wait times. However, a 2017 investigation by National Public Radio (NPR) and its local member stations found that the VA has about the same number of new hires as they would’ve been projected to hire without the additional $2.5 billion. They also found that the new hires weren’t sent to VA hospitals with the longest wait times and the hospitals that got the new hires weren’t more likely to see improved wait times. Of the 168 VA hospitals, 33 were recognized as needing more staffs. However, the VA data shows that selected hospitals didn’t receive more resources than the others. For example, the hospital in Los Angeles was prioritized and got only about 108 new hires; whereas, the hospital in Dallas got 298 new hires, even though it wasn’t prioritized and didn’t have wait times as bad as Los Angeles and other hospitals in the system. Another example is the difference in wait times between the hospitals in Albuquerque, and Cincinnati, which have about the same volume of appointments, but Albuquerque had among the worst wait times and Cincinnati has among the best. The VA’s data shows that both received the same number of doctors. Besides not allocating resources to where they were most needed, the VA was only able to hire a few thousand doctors and nurses with the $2.5 billion. This is partly due to the fact that the VA’s hiring process takes several months, so about 13% of candidates drop out during interval after they are hired before they start working. In addition, medical professionals often find better offers at private hospitals in more urban areas and in rural areas, there are usually less doctors or nurses available to work in general. Also, the NPR report found that the rate of increase in VA staff after the extra money was not noticeably different than past years without it because the money predominately replaced, instead of supplementing the VA’s normal hiring budget. The VA states that by freeing up less restricted money, they were able to use it to take care of other needs, such as increases in pharmaceuticals, wage increases, leasing cost increases and IT increases. The VA feels that they wouldn’t have been able to have maintain the type of hiring that we were doing without the extra money.
In 2016, a 15-member Commission on Care was established by Congress to outline a strategy for transforming the VA after a CNN investigation and watchdog reports revealed agency staffers manipulated data to hide systemic healthcare delays. The Commission was made up of healthcare professionals and veterans’ organization leaders. In the 300-page report the Commission finds that the billions pumped into the VA since the wait-list scandal erupted two earlier had failed to relieve many of the problems in delivering healthcare to veterans and had actually made things worse. This is despite the fact that the VA completed a record setting 5.3 million appointments in March 2016, which was 730,000 more than in March 2014. In addition, the VA distributed twice as many authorizations for government-paid, private care than in a comparable period two years ago. According to the VA’s data, nearly 97% of appointments are now completed within 30 days of the veteran’s preferred date. However, the Commission’s report highlights a variety of deficits that continue to contribute to healthcare problems within the agency, including flawed governance, insufficient staffing, inadequate facilities, antiquated IT systems and inefficient use of employees. Also, it criticized changes that have been implemented since the scandal became known, such as the Choice Program. They found that the program has only intensified wait times and frustrated veterans because of confusing eligibility requirements and contradictory processes for working with private healthcare providers. The time/distance requirement of the Choice Program would be changed under the Commission’s proposal. Instead, veterans could choose from any primary care provider that participates in the system. Veterans could also choose from specialty-care providers in the system but would need a referral from their primary doctor. In addition to these recommendations, the report cited the need for better leadership because of lack of direction within the agency. The report received mixed reactions from members of Congress, veterans’ service organizations and some of the commissioners themselves. Many felt that the central problem with the Commission’s recommendations is that it focused primarily on fixing the existing VA provider operations, rather than transforming the whole veterans’ healthcare system. Some of the skeptics cautioned against using the recommendations due to fear that increased access to private care through the VA comes with additional expenses to veterans.
By 2017, a year after the Commission’s report and three years since the wait time scandal, there had been little progress made toward providing timely services. Veterans continued to struggle with limited access, poor service and bureaucratic operational systems and processes. Due to this lack of progress, in early 2017, Trump signed a reauthorization of the Veterans Access, Choice and Accountability Act, which was set to expire in August of that year and still had nearly $1 billion unspent in the account. It’s important to note that during Obama’s presidency, the VA saw its budget increase more than $20 billion during his first two years in office and the funding for the VA rose by about 85% overall. In 2017, the VA budget was $182.3 billion, including $78.7 billion in discretionary spending. As well as all of these increases, Trump proposed a 6% boost in the VA budget for 2018. So, the problem is not that the VA doesn’t have the money, but they don’t know how to spend it wisely and don’t know how to manage things.
In June 2018, Trump also signed into law the Mission Act, which increased funding for the VA and set aside even more money for private care. Its goal is to modernize and streamline services for veterans seeking care by helping veterans receive care for those who did not live close to VA clinics or hospitals or to get services that were unavailable from the VA by altering the requirements set forth in the Choice program. Under the new guidelines, veterans who need to wait more than 20 days (reduced to 14 days by 2020) or can prove they must drive for at least 30 minutes to a V.A. facility will be allowed to seek primary care and mental health services outside the VA system. Measuring commuting time rather than distance will greatly open the private sector to veterans in rural and high-traffic urban areas. Veterans will also be allowed access to walk-in clinics, but will be required to pay co-pays for treatment after their third visit. If they want to see a specialist outside the system, veterans must prove that they would need to drive at least 60 minutes to see one at a VA facility. The number of veterans under the Choice program is approximately 8%, but it would rise to between 20-30% under the Mission Act.
Many Republicans have favored more use of the private sector; whereas, Democrats prefer to add doctors and medical centers to the government-run system. Many Congressional Republicans and the Trump administration have been greatly influenced in their beliefs by the group Concerned Veterans for America, which is an advocacy group that has ties to the billionaire industrialist brothers Charles G. and David H. Koch. As a way to save cost, the VA will employ new, rigid standards to making coverage and access decisions regarding veterans’ ability to get new medicines. In order to follow these standards, the VA will rely on reports done by the Institute for Clinical and Economic Review (ICER), an organization that examines data on the value of medical tests, treatments and delivery system innovations. Overall, this sounds like a great plan as long as the methods used need to be sound, clinical comparative and cost effectiveness research. This would make them useful tools to support coverage decision-making by customers. However, ICER gives precedence to the viewpoints of insurance companies in their evaluations and their methods are deeply flawed because they fail to recognize that different drugs affect different people differently and don’t distinguish between individuals who have variable treatment preferences and goals. ICER states that their reports assume that patients will have 100% adherence to all treatments and that this wouldn’t occur in actual practice. This false assumption undoubtedly provides biased analytics and is an invalid strategy. Since faulty tactics is what led the VA to its current problems, imposing inflexible one-size-fits-all standards on veterans will only lead to a further dysfunctional program. While the VA certainly should be work to promote affordability, use of these type of standards moves the program in the wrong direction.
Critics of the Mission Act fear that it’ll cause the destruction of the largest healthcare system in the country as billions of dollars are redirected to private care. Private healthcare has higher costs than government-provided care, which means the department will have to cut corners elsewhere in order to cover the cost of veterans seeking care outside the system. This has many concerned that the VA might not be able to pay private providers and maintain its own services. The 2016 Commission report analyzed the cost of sending more veterans into the community for treatment and warned that unrestrained access could cost well over $100 billion each year. Many critics feel that privatization is a political issue aimed at rewarding select people and companies with profits while possibly damaging care provided to veterans. We know that the private sector is already under pressure to provide acceptable access to care in many communities, therefore, it’s not equipped to handle the number and complexity of patients that would come from shifting the care of patients from VA facilities to them. This is particularly true when it involves the mental health needs of people scarred by the horrors of war. The VA has programs that address service-connected injuries and illnesses of veterans, including advanced rehabilitation, prosthetics and mental-health services. The system’s organizational model is also essential in providing care to men and women who often have multiple injuries and illnesses requiring daily management of services. Additionally, the VA partners with major academic health systems across the country to have contact with the best doctors, to teach new doctors about caring for veterans and to conduct research specifically focused on veterans’ needs. All of these have resulted in significant innovations in medicine and healthcare delivery. The agency’s understanding of service-related health problems, its groundbreaking research and its special ability to work with military veterans cannot be easily replicated in the private sector.
The Commission found that the quality of care at the VA to be very high. Even in 2014 when the scheduling scandal was going on, the American Customer Satisfaction Index (ACSI), the nation’s only cross-industry gage of customer satisfaction, ranked VA customer satisfaction among the best in the nation. Many veteran advocates agree that once veterans get access to care within the VA system, it’s superior. The Commission report says that the VA delivers high-quality healthcare but is unpredictable from one site to the next and problems with access endure. Veterans say that the care that they get is very good and the experience they have to get the care isn’t so good. It often includes numerous attempts to get referrals from primary physicians, long phone waits and navigating coverage between the VA, Medicare, Medicaid or TriCare (the military’s own health insurance). Some additional issues are requirements to still fax paperwork, having to travel for routine visits, being sent to the emergency room for ailments that could be treated at urgent care and annual visits with the doctors that last maybe 15 minutes with no examination. All of these combined together is causing delays in care and frustration for veterans because the system isn’t working at the level it’s supposed to be.
There is no question that the VA is suffering from a systemic, cultural problem. Some VA workers say low morale and management problems have not changed despite all of the legislation. They feel that there aren’t enough resources on hand to provide same-day access for patients and keep the decaying VA infrastructures operating. The ability to meet staffing levels similar to the private sector is impossible due to the incomprehensible makeup of the VA’s funding model. This is incredibly confusing because every year VA submits a budget to Congress and Congress always gives the VA every dollar they request and, most of the time, above and beyond that. Even in a time of budget-cutting, the agency doesn’t have to worry about financial support from Congress. So, Congress needs to do a better job of holding people accountable for not taking the action that needs to be done and insist the VA become more efficient, not dependent on more tax dollars to bail them out or spread the problem to the private healthcare system. The VA needs a total refocusing on its core mission of serving veterans. They need to do be more effective at projecting what their needs will be across its system and have leaders who will be honest in identifying and fixing their own weaknesses.
There are several things that we could be doing to improve the process for veterans. Rather than sending care to the private sector, we should be focusing on credentialing and training private-sector providers to be able to deal with the specific needs of veterans. The agency needs to replace its aging information technology infrastructure with a system that is designed for the delivery of complex healthcare and create a modernized, online scheduling system. The agency’s human resource department should be reformed so that it can increase compensation in order to attract and retain high-quality doctors, especially for rural areas. Congress needs to pass legislation that objectively evaluates and plans for the future needs of VA facilities to address the substantial expected growth in outpatient demand, to expand ambulatory capacity in the system and to close/replace some VA hospitals. Also, an oversight board of directors composed of healthcare experts needs to be put in place to govern this transformation process.
Our veterans deserve the best healthcare system available that produces high quality patient care with timely access. We need to hold up our end of the bargain. How can we expect our fellow Americans to risk their lives and fight for our freedom if we can’t keep our promise to care for them when they return home?