The revelation that a Veterans Administration Hospital in Phoenix falsified its reporting of waiting times for veterans seeking medical care pushed a festering problem past its breaking point forcing Washington to wake up and take action. General Eric Shinseki, Secretary of Veterans Affairs and probably one of the most honest men in the city, ended up falling on his sword for his commander over the matter. On the theory that it is bad politics to appear soft on supporting our veterans, funding committees for the Veterans Administration that had been languishing in the hyper-polarized and consequently paralyzed Congress, sprang into life. Both the House and Senate have just passed versions of their own bills to address the wait-time issue and some attendant reforms. It is virtually certain some compromise will emerge soon.
The term scandal has been used with regard to the long wait-times. Certainly to the extent that quality and utilization data were falsified in order to look good on paper, scandal is too kind a word. Another kind of scandal is demanding that the VA system perform to a specified standard but withholding the resources required to do so. We see a lot of that in Washington.
Is it better in the private sector?
When it appeared that the VA system itself did not have sufficient capability to provide services to existing veterans, and that the location of clinics and hospitals does not always match up with the locations of the veterans themselves, a groundswell of suggestions arose proposing that if the VA cannot do it alone, let the private sector help! This is not intrinsically an unreasonable suggestion. The private sector is already helping with military retirees and families. There are certainly capabilities that the VA must have that the private sector is ill-suited to deal with, but most care provided in the VA system is nuts-and-bolts medicine that can be provided by the same providers used by nonveterans. Indeed, I have argued in these pages that better coordination or contracting with non-VA facilities can avoid community duplication and help assure that Veterans get at least as good care as the rest of us. It is only a short step to a system in which the government pays non-VA providers directly, at least for specific services or in places where the VA does not have resources available in a timely manner. (Of course, wait-times in the private sector are often very long too, especially for those without commercial insurance!)
Stepping right up.
The push to allow the VA system to pay for medical services by private providers was immediately endorsed by the lobbies for hospitals, medical schools, physicians, and no doubt other potential recipients of a government check. Naturally, willingness to participate depends on how much will be paid. Whatever emerges from Congress will probably specify payments similar to Medicare or the military’s Tricare. Of course there will be conditions on who is eligible for private services based on distance from an existing VA facility (say 60 miles) or on some specified upper-limit of wait-time.
The AMA is suggesting that its members prepare a registry of physicians willing to take care of veterans. Imagine that! The fact is that the training of virtually all physicians practicing today was subsidized by the federal government, and that both teaching and other hospitals receive massive amounts of supplemental government funding. The question I would ask is why should not every physician or hospital be delighted and even expected to accept a veteran– or for that matter a Medicare or Medicaid patient– without discrimination? This is certainly not the case today. In large measure, the lower levels of reimbursement in public programs often places such patient groups outside of the mainstream of medical care or sequestered in facilities that others choose not to use. I do not mean to imply that healthcare providers should be expected to take a loss caring for veterans. That is not fair to either the veterans or the providers.
What might end up in the final bill?
A few weeks weeks ago when the drumbeat for federal action finally reached my ears, I reviewed both the House and Senate VA appropriation bills. I cannot say I was particularly pleased. I half-expected to find earmarks specifying where the new hospital replacement for the Robley Rex VA hospital in Louisville should be built. None was there– yet!
What I did find were the customary earmarks that are the fruit of political contributions. The most recent Senate version is very specific about where new clinics must be built. These earmarks were not in the basic VA Appropriation Bill and were no doubt concessions made to obtain favorable votes, or expressions of the will of the powerful. Who knows, perhaps a new facility is actually needed in these places, but wouldn’t you rather see some other process used to ensure efficiency and fairness in the use of our money?
What services should be covered and who should decide?
The Senate’s basic VA Appropriation Bill specifies new mandated medical service coverage for veterans, including chiropractic and fertility enhancement for veterans of either sex. (There was no mention of coverage for that politically dangerous word, “contraception.”) Most private insurance does not cover fertility treatment, but it would be hard to argue against such for individuals whose service-related experience had contributed to infertility. However the fact that legislators so concerned about too much government spending would write into law an endowment for chiropractic therapy troubles me. In my opinion, and in the consensus of every evidence- or science-based clinical review of which I am aware, there is no more medical benefit to chiropractic than a good massage. It makes no more sense to cover chiropractic therapy than aroma-therapy, acupressure, homeopathy, or any of the other magic-based services offered to a desperate public. The tragedy is, as with so much even in main-line medicine, that we pay for things that are not effective. The VA wait-time issue can provide political cover for much mischief. These two specific coverage mandates have not yet made it into the final “waiting-time” bill, but it isn’t over until the final gavel falls and this bill is what is called a vehicle!
The new bills are not terribly long and reasonable summaries are available. I will add some links for your use. It won’t pay to go into detail now because whatever compromise is reached in the next week or so will likely contain additions and subtractions and, I predict, a host of specific new earmarks. I would not be surprised to find one targeted for Louisville.
I like the VA system, and so do most of its patients.
None of this should be used to disparage the VA system as a whole. I was a VA physician all of my professional life, including a stand as a direct employee. I was, and remain, proud of the commitment of these institutions and their employees and professional staffs to the veterans they serve. Where humans are involved, as is true for all other healthcare systems, examples of error or worse will be easy to find. Yes it can at times be a frustrating bureaucratic system to deal with, but is it less frustrating than the private employment-based insurance system most of the rest of us are stuck with? I doubt it.
Our VA system in Louisville recently was rated higher than all its private sisters by the organization that accredits hospitals. In the public forums I have attended over the past few years, its current patients are generous with their praise for its leadership. The VA has had a working electronic medical record long before the rest of us. It was and is a leader in hosting research that shows what works and what doesn’t– critical research that other funding sources do not support. It was ahead of its time in standardizing best practices. Until we have the single payer or national health service that we all deserve, the VA Health System deserves enough support to give it parity with the rest of us. For its special programs that deal with the sequela of military service, it should have even more support than it has now– and not just grandstanding talk.
Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
June 13, 2014