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Thursday, May 22, 2014

What is this VA scandal about?

I've been hearing about the VA (Veterans Health Administration) scandal recently. A traipse through the high quality media coverage available on the internet has brought me up to date. Apparently in 2012 a physician at the VA in Phoenix began to call attention to the fact that her hospital was providing inadequate care, specifically that her emergency department was overcrowded and dangerous. In the primary care arena, reports that veterans had to wait ridiculously long times for appointments were investigated by the General Accounting Office and a report was released in 2013 that found that documentation of wait times was inconsistent, but that it appeared that veterans had to wait an unacceptable amount of time for appointments. Later in 2013 another doctor from the Phoenix VA reported that wait times were unacceptably long and that patients were dying because they were waiting so long to be seen. Numbers I've read on the internet include 6 weeks to even be called back about making a primary care appointment, 9 months to get an echocardiogram, 6 months to see a cardiologist. Administrators have reported wait times less egregiously long than they really are, with one set of figures for official reporting and another more accurate set that is secret (at least that's what it sounds like.) Investigations into other VA medical centers, including one in Albuquerque, suggest that this is a widespread problem. There has been official outrage and promises to fix the problem.

It has been decades since I worked in a VA hospital, but this all sounds pretty familiar. Long wait times were also a problem when I worked in Group Health, a healthcare cooperative in Washington. The situation was similar: patients in the VA system often have care that is completely free of charge. This is true of indigent veterans, veterans with disabilities that are felt to be service connected and several other categories of eligibility. Even veterans who have to pay something for care have a pretty good deal compared to many private health insurance options. In Group Health, costs for visits and medications were also really low which made people more inclined to wait for care or accept other inconveniences. At Group Health I remember my scheduler telling me that I was "a month out for routine appointments and 2 months out for routine physicals." That meant that patients who wanted to see me for their stuffy nose would no longer have the same stuffy nose, and if they had pneumonia they would either die or avail themselves of some sort of emergency visit. For physicals it wasn't necessarily a big deal except that patients had to schedule their lives around when they needed to be in town to see me. For a physical. I can see scheduling a trip to Europe or an audience with the Dalai Lama that far out, but it did seem kind of wrong to schedule a physical 2 months away. And then, naturally, they would forget, because that's a long time to keep something on your radar.

The reason for the long wait times was that Group Health, like the VA, was a system in which there was a certain amount of money per patient to be served and the administration wanted to spend as little of that money as possible, so as to stay under budget. One way to save money was to hire fewer physicians and ask them to see more patients. As physicians we either needed to see patients more quickly or have longer wait times, which naturally got even longer as time passed. I felt inadequate because I couldn't see patients faster and frustrated when long wait times meant that patients were sicker when I finally saw them, meaning that I really couldn't see them in a short amount of time. When I saw sicker patients I had a tendency to order more tests and referrals, which made the patients cost the system more, which made the budget woes of the company worse, encouraging them to further curtail their staffing. False economies with support staff were also common, when phones went unanswered leading to angry patients who took more time to mollify and then received inappropriate care.

I have treated patients who get their care from the VA and they do tell me that it takes a long time to see their primary care doctor and there is so much turnover that they never really get to know him or her and that there is an even longer wait to be seen be specialty providers. The reason I see VA patients is because they actually do have other options than receiving all of their care through the VA. Many of them have Medicare and some have private insurance. Many VA patients end up in non-VA emergency rooms and are then admitted to non-VA hospitals. The VA pays for the hospitalizations, in those cases, if they don't have the capacity to take the patient in transfer. It is expensive, but allows the VA to maintain their present capacity and staffing. The patients usually tell me they prefer to be cared for in the non-VA hospitals because they feel like they get better treatment. Still, when they can, they return to the VA because it's free, or at least very inexpensive.

One of the articles I perused on VA statistics said that the cardiologists at the VA see far fewer patients per day than private cardiologists. I don't know for sure that it's true, but it sounds familiar. Private specialists usually make more money if they see more patients and so they optimize their efficiency. They often use nurses and physician's assistants to gather much of the history and physical data they need so that they can just pop in and tell the patient the diagnosis and the plan. They have learned to perform the procedures that make up the majority of their income quickly and skillfully, because satisfied patients are loyal and lead to referrals which makes for mutually enjoyable relationships and more money. In the VA the patients are a semi-captive audience and the physicians are on salary which doesn't inspire efficiency. Once a waiting list becomes unmanageably long it ceases to be an effective motivator to see more patients.

Elected officials of all sorts are "mad as hell" about the care that veterans are receiving and are going to fix this problem. It would be nice if they could, but it will take huge commitment to change. The Veterans Health Administration is the second largest department in the US government with a yearly budget of over $150 billion. There is probably enough money in the VA system as it is to adequately staff it, but that will mean that they will have to cut administration costs and totally streamline what is undoubtedly a horribly complex and entrenched bureaucracy. The clinical culture will have to change. There needs to be some sort of incentive to provide really good service, which is difficult in the US where this is usually provided by competition and money. Deciding to be excellent is an important step, but the VA is huge and has considerable inertia. Scandals and overhauls have been part of the way the VA rolls, including immense changes in efficiency about 15 years ago, with ripples that are likely part of what we are noticing now.

I have been a strong proponent for paying for healthcare by the person rather than by the visit or procedure, because that would cause us to care for patients in ways that reduce the cost and intensity of treatment. If sick people truly cost more to treat, preventing them getting sick would be economically advantageous. The VA is essentially prepaid, so why doesn't it work this way, and how could it transform itself into a model of health promotion and sickness prevention? I think there are several dynamics at work. First is that the consumers, the veterans, don't have a say in how their benefits are administered. It is incredibly hard to uncover the budgets of any health system and it would be unthinkable to have the veterans who are actually cared for in the VA take a close look at how their money is being spent. Transparency and meaningful patient input would be powerful. Secondly, large bureaucracies grow and become more complex and less amenable to change with time. Tasks need to be simplified and administrative routines changed. Third, it doesn't appear that there is imaginative leadership in the VA to reinvent a nearly ancient system in a way that preserves what is good and moves boldly in the right direction. Perhaps someone wants to take that on?

To summarize, then, the VA has been quietly suffering in its chronic inadequacy for decades. It serves an important role and has a unique way of operating which could, with the right interventions, be a model for excellent healthcare. The chance that any of this will happen soon, or because our leaders are suddenly mad as hell, is zero.

5 comments:

Sara said...

Do you see similarities between the VA and how the ACA will change private sector healthcare?

Janice Boughton said...

Mostly, no. The ACA did not create a prepaid healthcare system with employed physicians. It mostly subsidized and regulated private health insurance, and included lots of innovative projects to reduce spending, especially at the level of hospitals. There is a trend toward physicians being employed by hospitals but this started before the ACA. The VA's problems stem from lack of accountability, transparency and creative leadership. These are issues with private sector healthcare too. The ACA does have some provisions to improve transparency and accountability, but we still lack any coherent, leadership.

Chris Porter MD said...

Enjoyed your perspective - especially the concept of 'choosing to be excellent'. I see the chance of cultural change as a little higher than zero. Call me an optimist.

My take http://onsurg.com/va-secrets/

Chris Porter

Janice Boughton said...

I expect VA culture will eventually change in a positive direction, maybe because of scrutiny, but not quickly. I read your article and I like that you mentioned the VA's computerized medical record system, which is great (in comparison to many others). They also license it to other health systems, which is why I got to use it. They also achieve good outcomes that are quality measures.

Janice Boughton said...

Also I read this article:
http://online.wsj.com/articles/anthony-j-principi-how-to-fix-the-veterans-affairs-mess-1401405181
in the Wall Street Journal. A former head of the VA says that we should fix the problem by limiting care for veterans to specific service connected ills (goodbye real primary care), reducing vouchers for care outside the VA system and merging the VA with the healthcare system for active duty military (Tricare.)That sounds pretty short sighted and self serving. If that's all leadership can think of excellence will come glacially slowly.