What is Wrong with the Veterans Administrations Hospitals?
This past Memorial Day weekend I gave a lot of thought to those who have passed defending our freedoms and way of life as well as those who have served and survived to be cared for by our society.
About 3 years ago stories began to break about a scandal involving a Veterans Administration (VA) hospital in Phoenix. It was the latest news to surface about issues at VA hospitals on top of those in Texas, Colorado, Wyoming and South Carolina. Last Fall a story surfaced about conditions at a VA morgue in Illinois. A few months ago there was a story about how the problems continue in Phoenix after investigations, an Office of Inspector General report and additional funding to “fix” the problems.
In October of 2015, a New England Journal of Medicine article made four major observations with recommendations to reform the Veterans Health Administration (VHA). Their observations were as follows:
- Urgent need for strategic vision and dynamic decision making argues for a new VHA governance board that is representative, expert, empowered, and relatively insulated from direct political interactions.
- The VHA is experiencing a crisis in leadership because of an organizational environment that’s perceived as disempowering, frustrating, and occasionally toxic. The VHA scored in the bottom quartile on every measure of organizational health we assessed. VHA leaders are accountable for quality and patient satisfaction but have little authority or flexibility. Risk aversion and mistrust further inhibit innovation and demoralize otherwise passionate and committed professionals.
- The recent growth of the VHA Central Office (by more than 160%) has not improved performance — the VHA scores in the bottom quartile in 35 of 37 management practices as compared with peers assessed for the report — but has added new onerous administrative burdens for professionals who deliver patient care. 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.
- The VHA lacks fundamental enterprise systems and data tools that are required to achieve high-quality care and patient satisfaction. Once cutting edge, the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record (EHR) has been stagnant for a decade, and clinicians are frustrated with the lack of integration and mobility and the feature deficits as compared with commercial systems.
While all these problems exist, the fundamental problem is much simpler than any of these.
I came across a speech by former by VA Secretary Bob McDonald who spoke about the history of the VA and their affiliation with US medical schools and how it came to be that nearly 70% of all US physicians complete some part of their training at a VA hospital (present company included). Secretary McDonald mentioned:
“In 1946 when General Bradley was leading the VA, 16 million troops were being demobilized, and there were 670,000 casualties of World War II – many on waiting lists at VA hospitals. General Bradley had an access problem like we can hardly imagine. And the quality of care available for Veterans was unacceptable. Bradley assessed the VA care like this: ‘…the quality of VA medicine…was not literally ‘medieval’…but it was – and had been – mediocre.”
So, while it may be there is a lack of vision, oversight, accountability, toxic leadership, onerous bureaucratic organization and processes, decrepit physical facilities and outdated information technology systems, the problem is actually a simple one that is the vision and mission of the Veterans Health Administration itself: To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans.
You see, while the VHA may be the single largest integrated healthcare delivery system in the US, if not the world, the entire system is based on a consumption model rather than a prevention model of healthcare.
There is no vaccination for PTSD to prevent it after living through the Vietnam War or missing limbs after Iraq or Afghanistan. There is no radiology examination or laboratory test to screen for soldiers, sailors and airmen who will develop cancer later in life when they age and become eligible for other benefits when they receive their initial benefits decade earlier.
The VHA, unlike a health maintenance organization, has no mechanism to prevent illness and disease, but rather only treat illness and disease. For service to their country.
To care for him who shall have borne the battle.
The system, more than 70 years ago had access issues, complicated by many chronic illnesses in Veterans of Korea, Vietnam, Iraq and Afghanistan and others as those Vietnam veterans become 65 and older. Many of those from Iraq and Afghanistan have returned with injuries that in the past would have been fatal.
The system had “waiting lists” long before Phoenix and since. In the past, the VA offered to have care provided by civilian hospitals at Medicare rates. The civilian system became overwhelmed, unable to accommodate their populations, at a rate often below what private payers would have paid for the same diagnosis related groups or admissions.
Do the well-meaning, well-intentioned physicians, nurses, technologists, therapists and support staff, of over 300,000 VHA employees want to see signs that read “VA lies. Patients die”? Of course not.
The problems mentioned earlier are a result of the capacity issue, not the cause. The system is collapsing under its own weight with lack of capacity and access.
Sure, the system is bloated, inefficient, outdated, undermanned and led by “toxic leadership”. But I think much of this is due to the government charged with funding the VHA rather than the VHA itself. Decades of leadership from both political parties have chronically underfunded the VHA which has led to “death lists” and a general lack of accountability.
As many US physicians have trained and work or have worked in VA hospitals, the responsibility of caring for those who have stood on that fence called “freedom” is an awesome experience. The generation that fought in the Pacific and liberated the concentration camps to those that stood up to communism and terrorism, their service and their related injuries cannot be this devalued by our society.
Increase capacity and accountability with appropriate compensation for providers and administrators and less bureaucratic regulations that allow for both patients and providers to be empowered in their health.
And provide appropriate care to some of the most vulnerable patients in our society, our Veterans, who have earned better, having borne the battle.
