Replacement Robley Rex Veterans Hospital– On Track Or Not?

It ain’t over ’til it’s over. (R.I.P. Yogi Berra, 1925-2015)

Earlier this month on September 10. the Robley Rex Veterans Hospital held a “Town Hall” to provide a forum for VA beneficiaries.  I went to see what was being said about the replacement hospital being constructed at the intersection of Route 42/Brownsboro Rd and the Waterson Expressway.  A tag-team of residents in the area have joined forces with University and business advocates who are still lobbying to have the hospital built downtown. These groups have been trying to scuttle the process including using the same strategies employed successfully by River Fields and others to delay and modify the construction of the new East-End bridge across the Ohio River.  For example, the big push now is for a second even more extensive environmental impact study or to try to find a possible burial site somewhere on the property!

The current partnership combines tenacious forces of anywhere-else-but-here with no-where-else-but-here and which have had some limited success.  It doesn’t hurt their efforts that the local Courier-Journal newspaper and city government aligned themselves with the downtown-only forces over 12 years ago when the replacement hospital initiative began.  Lots of free editorial ink has been assured.  As for the Veterans themselves, they have been largely unanimous in expressing their wishes to stay-where-we-are-now, or to go anywhere-except-downtown!  The local and Washington VA authorities are being pushed and pulled in every which way. One can easily feel sorry for them!  I have chronicled the process extensively elsewhere in these pages.

A footnote to the meeting.
Despite the effectively orchestrated opposition over the matter, little was said about a replacement hospital at the Town Hall meeting save that the planning and construction process was on track to break ground in 2017 and to open its doors for business in 2023.  That’s 8 years from now!  Time enough at current rates for another veteran-generating war or two, and certainly time enough for all remaining WWII veterans and a good number of Korean War veterans to pass on the the Elysian Fields. This fact has not been lost on some veterans themselves who aren’t buying it and take the local opposition to the Brownsboro Road site personally. “What was it about our service that you don’t care for?”

Is traffic a credible reason to abort?
Lots can and has been written about the various arguments used by advocates for one outcome or the other.  An early major and indeed credible objection advanced by local residents was an unacceptable increase in traffic in the area.  I visited the intersection several times at rush hours over the past year and inspected traffic at various times of the day on Google Map. I believe the traffic claims to be overblown. Improvements to the intersection in recent years and the opening of the intersection at Westport Road have done much to take the heat off.  Rush-hour traffic is no treat anywhere in Louisville, within or along the Waterson, but traffic at Brownsboro Road is far from the worst.

How much is too much?
A relatively new objection is a claim that the Government paid some $3 million too much for the land and that presumably shady appraisal work was involved. This is a reason not to build there? What percent of the total bill is this?  By all means if there have been shady doings, claw back some taxpayer money, investigate charges as seems to be happening, but move ahead with the project. A companion claim of dubious relevance is that the Veterans Administration is regularly over-budget on construction of its hospitals. This latter criticism may well be true given the nature of government bureaucracy and federal regulations.  I would wager to say however, that local efforts to torpedo the current VA plans have already added many more than $3 million dollars to the final bill, just as the bridge projects were made more expensive.

When I did time-value-of-money calculation based on the acquisition and sale values of the property, the profit margin was handsome but hardly obscene.  People regularly speculate on land hoping to make just such gains or better.

Access.
Unacceptable waiting times nationally for outpatient appointments with scandalous cover-up attempts at some hospitals was a major embarrassment for the Veterans Administration.  A respected Secretary was replaced over the matter.  The resulting shakeup is still underway.  I take it as a given that the VA system is underfunded for what it is asked to do using the rules it must follow. The current do-nothing, spend-nothing congress is reluctant to fully fund even veterans!  Currently at the Robley Rex, the waiting time for an appointment with a primary-care provider was said to be 2.9 days, for a mental health provider 2.7 days, and for a specialist 4.2 days.  I believe those are shorter times than the rest of us non-veterans have to deal with!

Where should the VA get its doctors?
Apparently the waiting time for specialists is going up.  The principle reason given for this is a loss of orthopedic surgeons.  The VA is looking to hire a new one. Having enough dermatologists and neurologists is also an issue.  So much for counting solely on the University of Louisville serving as the principle source of physician staffing for the VA.  Increasingly the Louisville VA Hospital is hiring its own physicians or contracting for outside services elsewhere.  It can do that anywhere in the county!  I think that Veterans Hospitals nationally are learning that they are not dependent on academic health centers for their staffing.  Medical schools are learning that as much as they like having captive VA patient populations for teaching and research, they cannot take their Veterans Hospitals for granted anymore.

Go-anywhere system little-used.
In response to the waiting time scandal, Congress approved a “Choice Program” to pay willing private physicians to care for Veterans who live more than 40 road miles or so from a VA clinic.  I am unaware if finding willing providers is a problem in Kentucky, but it was reassuring the hear that some 97% of eligible veterans elect to come to Robley Rex and its affiliated Louisville clinics anyway. I guess I am not surprised.  In my experience, Vets like the VA.  However, I do think that as our national healthcare system evolves, it is not unreasonable to further integrate medical care for veterans into whatever non-federal, or singe-payer system remains – at least for general and common medical services.

Claims discussed more than appointments or medical care.
An eyeopener for me was that many if not most most of the folks who attended the session did not have issues with the hospital or its clinics, but with the separate VA disability system and the waiting times involved in getting their claims and checks processed!  The planned colocation of health and claims components, now in different places, will allow one-stop shopping for vets at the new site and simplify the VA’s administrative structure. As an aside, it appears to me that the VA disability system is just as broken and subject to abuse as the Medicare and Medicaid disability systems.  We need to do better to keep people able to work. Disability programs are not meant to be, and indeed cannot carry the burden of serving as ad hoc unemployment programs.

Parking – Never as many or close enough as desired.
Parking remains one of the main day-to-day inconveniences at the present site.  A meager 45 new spaces were squeezed in atop the VA hill, and some 400 off-site spaces serviced by shuttles at a Mellwood and River Road locations were added.

My major takeaways.
Lots of other stuff was covered at the meeting that was new or of interest to me.  Most of all I was impressed with the concern, openness, patience, and sincerity of senior VA management when dealing with their Veteran charges and their families. It would be difficult to fake what I observed.

Much has been said about the low ceilings and other outdated features in this older building.  I learned that the present VA was built at a time when air-conditioning was not required.  One can only imagine what it was like in the summer.  Air conditioning was retrofitted, but for a variety of reasons both medical and non-medical, the need for a new hospital is easily justified. Lets get on with it. No individual or entity is going to be completely happy with the final result, but that is not a reason to change our path.  I have been closely observing the process of planning for this hospital for over 15 years. The VA Administration and our local VA officials have operated in an open and honest manner if not a ponderous one.  Yes, the federal rules they must follow in their byzantine administrative structure are often frustrating. Those organized to thwart the VA’s plans should be so open and accountable!

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
September 29, 2015