Since its official inception in 1930, the Department of Veteran’s Affairs or Veterans Administration (VA) has struggled to keep up with servicing America’s Veterans. World War II, Vietnam, and Korea created their own challenges to the organization’s ability to provide services. However, the Global War on Terror has caused almost overwhelming surges in the number of Veterans requiring health assistance as well as those seeking educational and other benefits offered by a country grateful for their service. 2014’s scandal that culminated in the VA Secretary’s resignation serves as the most recent major outing of VA failures to consistently provide quality healthcare to its Veterans. This article asserts that the organization is not operating nor is it structured for finding and maintaining on-going success in the new millennium.
With almost four hundred thousand employees distributed across the United States and its territories, VA stands as the Nation’s second largest governmental organization. The Department has three main subdivisions, known as Administrations, each headed by an Undersecretary:
·Veterans Health Administration (VHA): responsible for providing health care in all its forms, as well as for biomedical research, Community Based Outpatient Clinics and Regional Medical Centers.
·Veterans Benefits Administration (VBA): responsible for initial Veteran registration, eligibility determination, Home Loan Guarantee, Insurance, Vocational Rehabilitation and Employment, Education (GI Bill), and Compensation & Pension.
·National Cemetery Administration (NCA): responsible for providing burial and memorial benefits, as well as for maintenance of VA cemeteries.
In the FY 2019 Budget, President Trump proposes a total of $198.6 billion for the Department of Veterans Affairs. This request, an increase of $12.1 billion over 2018, is designed to ensure the nation’s veterans receive high-quality health care and timely access to benefits and services. The 2020 AA request includes $79.1 billion in discretionary funding for Medical Care including collections and $121.3 billion in mandatory funding for Veterans benefits programs.
The Veterans Administration reports there are 18.8 million veterans currently living in the United States, and that they serve 9 million of them each year. At the time of this writing, it was not possible to determine how many Veterans were serviced at their 1,065 outpatient sites and 170 VA Medical Centers. Presumably, VA services the remaining 9.8 million Vets through contracted private sector resources. No information could be found amplifying this area, as well. If these numbers are correct, the US is spending $196 billion to service veterans at a cost between $10, 425 and $21,777 per Veteran per Year. Either way, these numbers are troubling because even with the use of VA-owned facilities and private sector resources, the Veteran population remains underserved.
Further, Veterans need a “Continuum of Care” patient care model where the system guides and tracks patients over time through a comprehensive array of health services spanning all levels and intensity. The current VA healthcare delivery system falls short in this area. Unnecessary tests are often performed because the VA does not accept military health care records for use in designing care and addressing issues encountered while Veterans were on active duty. Rather, the VHA only uses military records to determine eligibility through their disability rating system.
The VHA does not operate as a “Best Practices” system. They do not systematically benchmark medical treatment by diagnosis. Benchmarking leads to better care, better outcomes and improved efficiency (i.e., saving money). Private sector healthcare systems began benchmarking care over 20 years ago. Medicare’s payment system was modified in the 1980’s to reflect analyses of care data and they transitioned to using Diagnosis Related Groupings (DRGs). Data continues to drive the system and is used by private insurers as well to effect improvements in the healthcare delivery to patients while simultaneously improving lives and money.
The US Department of Health and Human Services runs the Agency for Healthcare Research and Quality. AHRQ runs a metrics system that measures the quality of service of 656 healthcare systems. VA is not one of them. Why? In 2016 the VA quietly stopped sharing data on the quality of care at its facilities with a national database for consumers; despite a 2014 law requiring the agency to report more comprehensive statistics to the site so veterans can make informed decisions about where to seek care. Rather than take part in public and benchmarked rating systems, VA uses its own platform, Strategic Analytics for Improvement and Learning (SAIL). The biggest issue with SAIL is that it does not show key metrics by facility over time. Rather, it shows a vague chart of “Star” ratings by facility and whether, in the VA’s opinion, it improved, stayed the same or declined. To truly report how well the Agency serves Vets, they must institute transparency and benchmarking against other healthcare systems.
SAIL is designed to include actionable metrics that are important to assess healthcare delivery and quality. However, many of these metrics are not publicly reported, and many are the same as public hospitals and care systems. How do those compare? Therefore, it is not possible to directly compare evaluation findings derived from SAIL with other systems published by public and private sectors. Instead, SAIL is developed for the VA to drive internal system-wide improvement.
Because of metrics and issues like the ones cited above, growing choruses of voices are shouting for the privatization of the agency, specifically the Veterans Health Administration. Proponents cite the fiscal gains and agency’s overall failure to effectively and efficiently utilize its resources. Opponents cite concerns over the private sector’s failure to provide adequate access to quality healthcare and its inability to deal with the mental issues caused by battlefield experiences.
Perhaps the best path ahead is an expanded public-private partnership with Government oversight.
A New Way Ahead
As stated above, VA’s three main organizations are managed from its headquarters in Washington DC. Examining each organization to determine how much of their function can be “contracted out” and managed by Headquarters as a “program” with Government oversight constitutes a new and untried approach to managing the agency.
Veterans Health Administration: Fund a healthcare insurance program to be managed by a US healthcare insurance company and give each Veteran an insurance card usable at any hospital or doctors office in the United States, with no Co-Pay. Of course this would require policy directing how the 3rd party insurer would manage care to prevent it from morphing into a “denial” system preventing Veteran treatment. This is a must as some 3rd Party insurers tie bonuses to saving money at the expense of their patients. Just as it occurs in the private sector, the VA would evaluate these plans on an annual basis for effectiveness and efficiency. Accordingly, health plans would bid for the Government's business.
Government contracting of private sector health insurers is not a unique approach. For example, Federal Employees Health Benefits (FEHB) Program, the Federal government employees’ health insurance comes from a program backed by a private sector healthcare plan that provides many options. However, in the interest of clarity, it must be noted that in the example cited above, employees pay as well. To be clear, the program being suggested here should require no participation payment by Veterans.
How should the Government fund this insurance program? Shutter all VA hospitals and clinics. In plain words, the US Government is running a healthcare program that competes with world-class hospitals for physicians, nurses, technicians and equipment, often in the same neighborhood. And the contest is not going well for the VA.
In the case of Boston, the VA hospital is 20 minutes from Massachusetts General. In Washington, DC, the VA hospital is .3 miles from Medstar Washington Hospital Center, literally across the street from one another. Another example, the state of Wyoming has two major Veterans hospitals, one each on the northern and southern borders, and both on the eastern side of the state. Allowing veterans to access any hospital in the state would eliminate the need for some Vets to travel across the state for service. Additionally in the case of Wyoming, the two Veterans hospitals also have close proximity to major private sector health delivery systems.
Veterans Benefits Administration: Contract out this activity in total with oversight by a VA Program Manager. Benefits Management is not a new area of business in the United States. These companies feature state of the art business processes and telecommunications platforms. Anyone who has tried to contact the VA on a Monday or Tuesday knows the anxiety that accompanies an hour-long, or worse, hold-time. In an effort to resolve wait times, VA instituted a "call back" system - a great step. However, this system has frequent outages resulting in the aforementioned extended wait times.
Again, savings from outsourcing this function can go to fund the aforementioned veterans healthcare insurance program.
National Cemetery Administration: Of all the functions under the VA umbrella, this is perhaps the most unique. Traditions and ceremonies surrounding the internment of our Veterans are sacrosanct and not easily replicated by the private sector. That said, the memory of the issues at Arlington National Cemetery still resonate. Any modernization analysis should also include the possibility of outsourcing this function.
Veterans Mental Health: Outgoing VA Secretary David Shulkin cited his concerns for the viability of Veterans mental health treatment as one of the reasons that privatization would not work. Granted, providing good access to mental health services continues to challenge even the best healthcare systems in the US. While private sector health systems continue to struggle with this front, the VA has hardly set the bar for delivering the service. So the challenge then is to not negatively impact the delivery of this service to Veterans. Most of the larger hospitals that would provide non-mental health services, as described above, offer some form of mental health care services. With the expanded outreach that a greater number of hospitals would provide, the ability to detect and triage Veterans in need of mental health services would also expand. The new challenge then would be to ensure hospitals providing services to Veterans receive the appropriate level of training and exposure to best practices.
Mental Health is a valid concern and it may be an area that can serve as a base program for an improved mental health program within the private-sector healthcare system. To explain, the issue in the private sector is that insurers, both private and Government, stopped paying for most inpatient therapies and moved them to outpatient settings. Then, they greatly reduced rates of payment for outpatient treatment making it economically unfeasible for most healthcare delivery systems to provide that service. By funding payments to providers for the treatment of Veterans with PTSD and other mental health diagnoses, it may help to broaden the base of mental health services as a whole. The VA will probably argue that their mental health program is unique and cannot be replicated. Perhaps so, but the VA is treating a very small percentage of the affected Veterans. Questions remain: How do we broaden the net to serve those Veterans not receiving these much-needed services? And what are the consequences when a Veteran goes untreated? To the Vet? To the community?
Jobs: The closure of a large percentage of the VA’s 1,065 outpatient sites and 170 medical centers would certainly create a temporary unemployment challenge. Since most of these personnel work in the healthcare industry, presumably the most qualified of them will find work at other medical facilities. The remaining workers will have to find a way to transition their skills for use in other fields. A good transition plan should greatly minimize the impact.
The Department of Veterans Affairs is Dedicated to Service
This writing is designed to challenge the belief that the VA as it is currently structured can serve the Nation’s Veterans in the years to come. It offers a different approach to providing services to Veterans, both those who have already seen the horrors of war and those yet to do so. Today’s Veterans Administration struggles against a superior private-sector and benefits management system, its own internal management and technology systems, and finally, public perception of their abilities. As a leader, I believe that most people come to work with the best intentions. Consequently, no ill is intended toward the VA leadership or its many employees-they are serving our country under extraordinary circumstances. Rather, a close examination should be made as to how the VA operates and how it is structured. Changing the chief administrator alone will not allow the organization to meet its challenges. It is said the United States of America has the greatest healthcare in the world - first class. We routinely thank our Veterans for their service and sacrifice. Then, we give them 2nd rate…no…3rd rate healthcare. We can do better.