Stopgap Bill to Provide Healthcare to Veterans Passed by Congress.

Last week, Congress finally sent to the President the “Veterans Access, Choice, and Accountability Act of 2014.” While the “accountability” in this title refers to making heads roll among the administration of the Veterans Administration, there was clearly some embarrassment and a deficit of legislative accountability that forced a dragging-and-kicking pair of adversarial political parties to agree to bail out a Veterans Administration that had been negligently and predictably starved into delinquency.

Vets couldn’t get timely appointments.
The substance of the bill deals almost entirely with the problem that veterans were facing unacceptably long delays in obtaining appointments for medical services. Not unexpectedly, a few items from the larger mouldering VA appropriation bills were tacked on. Since these were presumably items that were easy to agree on, I predict that passing the rest of the necessary VA legislation will become even more difficult, if it passes at all.

What went wrong at the VA?
A recent report of an audit of VA medical centers nationwide posited several factors that set the VA up for failure. The main reason was that there were not enough provider slots to accommodate the demand for appointments!  Furthermore, the unique and perhaps bizarre VA system of making appointments included inflexible legacy computer systems and the use of non-industry-standard terminology such as “desired date.”  Combined with the “peculiarities of the 14 day goal,” perhaps the result was fortold. In any event, there was a considerable amount of fudging the data or outright cheating in many places. Our two Kentucky VA hospital systems did well enough in the audit that they were not flagged for further review.

The bill has been summarized elsewhere. That’s a good thing, because the actual text is difficult (for me) to understand. The Conference Committee melded together two bills that did not seem all that different. That makes it all the more puzzling why there was so much fuss and delay. I suspect it had to do with how the bill was funded and concerns about the ultimate size of the budget hole that was opened. Perhaps someone can help us understand the political dynamic involved.

How much will it cost?
The bill is expected to cost $16.3 billion of which $10 billion is targeted to pay for medical services outside of the VA system for patients who cannot get an appointment within a designated time (?30 days), who live 40 miles from an outpatient or inpatient VA facility, or who live in a “highly rural area.” As I read the bill, the “Veteran’s Choice” option to seek private medical care expires in two years — long enough to develop a therapeutic relationship with a new doctor and then having to face possible change in clinicians again! Another $5 billion will be used to bolster the VA’s in-house capacity to treat veterans. The remaining $1.3 billion is targeted to miscellaneous programs including funding of 27 leases for expanded clinics and research facilities, college benefits and scholarships for surviving spouses, dealing with medical consequences of sexual assault (no mention of contraception), requiring state institutions of higher education to bill veterans at in-state tuition rates, and providing housing for veterans with traumatic brain injuries. A Commission on Care to evaluate the VA and recommend a plan for the future is established. Rules are established to bypass the Merit Systems Protection Board to make it easier or even possible to fire or demote a VA employee. The bill will be paid for in part by redirecting (?starving) $6 billion from other VA programs.

Earmarks or not?
The bill was remarkably free of obvious earmarks for special interests or rewards for reluctant legislators. Perhaps because the bill passed overwhelmingly in both chambers there was little need for sweeteners. There were 27 leases, all but two for presumably new outpatient clinics. Seventeen of these went to the 27 states represented by members of the VA Committees of the House or Senate. The states of Texas and California each got four leases. Only two other states (each with two leases) received funding for more than one lease. One $22 million lease was for a research facility in Heinz, Illinois, the home of Loyola University. Another $6 million was for a research and pharmacy facility in Texas. I do not know by what criteria these leases were granted, nor who made the decisions. The fact that funding for research crept into what was supposed to be a bill to provide medical services makes me suspicious of the placement of earmarks.

One really big earmark?
A surprise to me, because it was not mentioned in any of the coverage or summaries I read, is that plans and funding are made for up to an additional 1500 medical residents in the VA system. This is a huge number! An emphasis on primary care and mental health residents is appropriately specified. Increasing the number of graduate medical education resident positions is a major part of the bill. I suspect the hospital and medical school lobbies had a role to play in this addition. The hospital/medical school industrial complex has been pushing for more resident slots for some time.  The financial benefit to their organizations is tremendous.  Opening up 1500 new slots in a bill intended to help veterans is a backdoor way to harvesting more tuition money for the schools, and more graduate medical education payment bonuses from Medicare and Medicaid for hospitals. What a lobbying coup!  The drumbeat behind this push is the often-stated claim that there are not enough doctors.  A very recent Institute of Medicine panel on reforming the financing of graduate medical education did not drink the Cool-aid and recommended phasing out the existing system of turning out hospital-based specialists over the next few years. Which approach is better for the country?  Better the debate  be conducted in the open rather than won by end-run surprises.

Education or cheap labor?
Accreditation requirements for sponsoring medical residency positions assumes the partnership of hospitals and medical schools. The fact that the VA is positioning itself to increase the number of residency positions, and therefore the faculty that are required to supervise them, implies that the VA will continue to rely on the inexpensive labor of residents and to increasingly provide care to veterans as teaching patients. As of now, there are not enough graduates from American medical schools to fill the existing resident slots. Many if not most of the unfilled current resident slots are filled with graduates of non-American medical schools.  Many of these students are superb, and some have already completed residencies in their home countries. Nonetheless, these schools would not be accreditable in the US.  This may make less of a difference in the VA where even faculty and staff physicians do not need a state medical license to practice. Perhaps the underlying question is: “Does accreditation of medical schools really matter,” or is it just a mechanism for the industry to resist outside pressures to reform for the times?

As a lifelong medical educator, I have little problem with having students, interns, and residents participate in medical care, provided that no discrimination is present and supervision is adequate. If a hospital receives federal money as a teaching hospital, why should not all its patients be considered eligible to be cared for by house-staff? Undesirably however, if the drive to recruit inexpensive medical labor is too intense, it is inevitable that trainees with weaker training credentials will be taking care of VA patients. Traditionally, in my experience, residents like the VA setting in part because the supervision there is less stringent. To complicate matters, the VA has often struggled with getting its faculty to show up on-site. This is not necessarily a good dynamic for patient care.

How is Kentucky doing?
Our state is not specifically mentioned in the bill. The most recent data for our two VA hospital systems is current as of July 15. These reports are complicated, and it’s hard for me to understand what indicators are the most important or revealing. You can take your own crack at the Kentucky and nationwide report. Compared to the numbers of June 1 discussed in an earlier article, the Louisville VA has made only modest progress. The number of total appointments scheduled more than 30 days away has fallen from 6.9% to 6.3%. The actual number of patients involved fell from 3386 to 2944. To me it seems like the most notable improvements have been in knocking the electronic waiting list down to size and elimination of some of the longest waits. Waiting times for new primary care patients have decreased from 25 to 21 days, and for specialty clinics from 50 to 42 days. Waiting times for mental health patients actually increased a little from 19 to 22 days. In Lexington, there has been even less of a change with the same 7% of total appointments scheduled longer than 30 days. Not understanding how the VA appointment system works, I don’t know what to make of these numbers.

What lies ahead?
I doubt that anybody knows for sure. If the entitlement for being given a “Veteran’s Choice Card” were solely dependent on an inability to obtain a prompt appointment, perhaps some estimates might be made. However, the extension of that entitlement to people living 40 miles away from the nearest inpatient or outpatient center opens the door very wide indeed. It is not clear to me from the bill that existing patients living 40 miles away or those with non-service-related health problems would be excluded from this privilege. Will VA patients living far from a VA hospital have similar access for inpatient hospitalization?  If I lived that far away and was offered the privilege of private medical care in a doctor’s office or private hospital in my own town, I might very well exercise that right. I might make the drive to the mother ship for some services and not for others. Depending on how a “highly rural area” is defined, there may be quite a few eligible Kentuckians, indeed eligible Americans. Pandora’s box has been opened.

The new Care Commission that will evaluate and plan how we care for our veteran neighbors will have an awesome challenge. Some in the community will suggest that providing universal single-payer or government-funded healthcare for all would go a long way to addressing the issue of whether we must have a separate hospital system to address veterans medical needs, or for that matter those of the indigent or uninsured. Some of their needs are special, most are not.

Some of you out there understand what is going on and the challenges facing the VA much better than I. Please help the rest of us out.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
Former VA Physician
August 9, 2014