Physicians, Heal Yourselves: Why VA Reform Has to Come From Inside

The bill Congress passed last week is a good start, but it's not enough to turn the troubled bureaucracy around on its own.
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Deeply rooted cultural problems, seemingly endemic within the Department of Veterans Affairs, have put veterans health care at the forefront of our national news cycle this summer. Last week, Congress passed a bill to address a culture of dysfunction that built for years under a layer of red tape. Will this rare compromise defeat the bureaucratic demons that led to some in the VA neglecting their mission?   

Probably not on its own. That will take a cultural shift at VA. But it’s likely a step in the right direction, at least in the short-term, if VA uses the tools it gives them properly.

In a best-case scenario, the $10 billion this bill provides for veterans who need care but can’t receive it from a nearby or timely VA facility will serve as a bridge to quality health providers outside the VA’s boundaries, until the government can better serve them. In a worst-case scenario much of that money will go untouched, or misused, by a VA uninterested in referring patients outside due to an almost paranoid fear that it will lead to a privatization of the entire department.

An example of this worst-case scenario occurred when the VA hospital at Columbia, South Carolina, was granted extra resources in 2011 to deal with a long line of veterans seeking routine cancer screenings. Instead of using the money to refer vets to private physicians and reimburse them, staff sat on about 80 percent of the money while a backlog of thousands of veterans built up, with some waiting more than a year. Several dozen of those waiting for consults developed cancer that could have been caught and removed, according to an internal investigation.

Reforming an organization the size of the VA is inherently difficult. It’s the second largest department in the federal government in terms of personnel (about 270,000 people work full-time for the VA, though not all in health care) and its health wing operates across 23 semi-autonomous regional healthcare networks that operate across state lines.

A little known episode in 2006 illustrates the challenges. Eight years ago, Congress initiated a pilot program called Project HERO in the four regional health-care service networks that kept patients waiting the longest. (Sound familiar?) HERO used a private contractor to coordinate care outside the VA health system, with a pre-screened network of private care providers for patients.

The pilot had mostly positive results: HERO set a goal of scheduling patients to see health-care providers within 30 days and hit that goal 88.2 percent of the time, as self-reported by the contractor. Not perfect, but the Congressional Research Service’s 2010 report said HERO could be “categorized as an enhancement regular fee basis care program,” the technical term for outside referrals to private contractors. Yet during the program “almost all [four regional networks] stated that there has been organizational resistance to change.” The pilot ended in spring last year, and the VA claims to have applied its lessons nationally, though that was met with skepticism during a House subcommittee hearing in 2012.

A common quip is that “if you’ve seen one VA [facility], you’ve seen one VA.” The independence the department grants health-care administrators allows regional hospitals and community-care centers to ostensibly allocate resources as they see best fit, and most of the time that’s what happens. But it can also give cover to a go-along-get-along culture of bureaucratic intransigence with little fear of repercussion until that comes to light as patients start dying as a result.

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Colin Wilhelm is a writer based in New York. He is a former legislative assistant to a member of the House Veterans Affairs Committee.

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