Bureaucratic Medicine: A View of the Veterans' Hospitals

In the course of his medical training, DR. RICHARD S. DILLON worked in seven American and two English hospitals, and nowhere, as he says, did he encounter the waste and inefficiencies which he met with in the institution operating under the Veterans Administration. Dr. Dillon is today the chief resident physician at the Bryn Mawr Hospital.


THERE is much good to be said for the hospital system run by the Veterans Administration. The medical and nursing care it provides is good. Its training programs are often excellent. It provides care for patients who otherwise might not seek medical attention because they have not the financial resources, have not the proper awareness of their disease, or have not concern enough about their illness to pay a private physician for care.

Examining the strengths and weaknesses of the VA is especially important today. The VA is a large hospital system with admission policies so nonspecific in practice that in truth it represents a system of government medicine available to only 22 million of our population. Those who, because of their sex or the time of their birth, did not don a uniform are eligible for neither a VA pension nor VA hospitalization. When one considers the nature of the illnesses treated at the VA hospitals and the service histories of the patients, one realizes how unjust this is to the other 160 million people who are footing the bill.

In 1961, 6.7 percent of the tax dollar was spent in providing monetary and medical assistance to qualified veterans. In the Annual Report of the Administrator of Veterans Affairs the cost of operating the VA Department of Medicine and Surgery programs in 1961 was given as $1,003,417,568, a sum equivalent to 18.6 percent of the total VA expenditure.

Because of its size and the nature of the population it serves, the VA enjoys relative freedom from criticism and investigation. Unfortunately, there is considerable waste in the VA, and improvement will come only through pressure from an informed public.

The fact that the veteran population may grow, calling for an enlarged VA hospital system, and that we are considering various medical programs for the aged makes it worthwhile to evaluate the VA hospital system. This is a report of a hundred consecutive patients that I treated at a veterans’ hospital over two two-month periods. It is not my purpose to question the gratitude we owe the men who have made sacrifices in the defense of our country. But I should like to discuss these patients to point out why the VA hospitals are inefficient and wasteful and how the medical care of the deserving veteran might be administered more effectively.

The veterans’ hospital where I worked is one of 170 such hospitals around the United States. Patients legally eligible to fill these beds meet one of the following requirements: they have diseases or injuries incurred or aggravated by wartime service or they have non-service-connected disabilities and have stated under oath that they cannot afford private care and have filed a financial statement of their assets and liabilities. Of my one hundred patients, ten were admitted because of service-connected illnesses. Four others had service-connected illnesses but were admitted for another, unrelated disease. The others, by and large, claimed to be indigent. These figures are well in accord with the national averages. Of 38,713 patients who were being treated on the general medical and surgical wards by the VA on October 31, 1960, for example, 9.82 percent received care for service-connected disabilities.

The Veterans Administration operates three kinds of hospitals: those for tuberculosis, for neuropsychiatric disorders, and for general medical and surgical diseases. In the fiscal year of 1961, of the 537,002 admissions to these hospitals, 2 percent were admitted to the tuberculosis centers, 7.6 percent to the neuropsychiatric hospitals, and 90.4 percent to the general medical and surgical hospitals. This article is especially pertinent to the 485,211 admissions in the last group. It is not pertinent to the VA domiciles and state homes, which in 1961 had an average daily member load of over 26,000 elderly citizens.

The VA hospital system is not to be criticized for the caliber of its professional service. This has improved tremendously as a result of the VA policy of fostering ties with medical centers and promoting research. In December, 1960, eighty-nine hospitals had close associations with medical schools and academic centers. At present there are board consultants available in most of the specialties. The VA in the last few years has produced many excellent research papers, both in the basic sciences and in clinical investigation. In such things as evaluating drug therapy, the VA organization has demonstrated definite advantages over independent medicine; large numbers of patients with a single disease can be treated in a single therapeutic program, and significant statistics can be obtained. The VA nursing service is also excellent. As in most hospitals, there is some shortage of nurses, but in the VA their turnover rate is relatively low and they are relatively well paid. All in all, the patients do get good medical care, and their treatment need not be cut short because of financial need.

THE VA hospitals are to be criticized, however, for their inefficiency and waste. My patients were all hospitalized for unnecessarily prolonged periods of time. Their total stay in the VA was over 3281 days (some of them were still running up hospital days when this article was written), whereas their estimated stay in a private hospital would have been 948 days. Thus, they averaged 32.8 days per hospitalization in the VA, while they might have averaged 9.5 days in a private institution. These figures, while derived from only one VA hospital, are in good accord with the national averages. According to the 1961 Annual Report of the Administrator of Veterans Affairs, patients on the medical and surgical services of all the VA hospitals averaged 33.3 days per hospitalization, whereas, according to Blue Cross, during 1961 the average length of stay in private or community hospitals in our state was 9.9 days on the medical services and 8.1 days on the surgical services; adult males on all services averaged 10.8 days.

It is also interesting to note that the 23,083 patients whom the VA hospitalized in private hospitals in 1956 (as is the practice when no VA facilities are available in a given locality) on general medical and surgical services averaged 17.7 days per hospitalization, while the average in VA hospitals was 31.4 days. As will be seen later, there are many reasons why the VA patient may be hospitalized longer than the private patient. That a difference in age between the VA patient and the average private patient is not a significant explanation is seen from the fact that the VA charts its average 1960 patient as being 52 years old, while the Blue Cross average adult male in the latter half of 1959 was found to be 51 years of age. The age grouping of VA patients hospitalized in VA and non-VA hospitals is similar; the prolonged hospitalizations in the VA hospitals must largely be attributed to inefficiency.

The nature of the patients’ illnesses did not contribute to the prolongation of their hospitalizations. As will be seen, 29 percent of my patients had “illnesses” which did not require hospitalization. Rather, it was due to inefficient X-ray and laboratory facilities, a desire on the part of the hospital administration to keep the beds full to maintain their federal appropriations, the desire of some homeless or deserted patients to remain in the hospital (or the desire of their families to keep them there), or the interest of the physician in investigating some particular aspect of the patient’s disease Other factors include the limited outpatient service and restrictive hospital discharge policies.

Each of the above is easily illustrated. One man entered because of mental symptoms; clinically, he was felt to be hypothyroid. To prove this diagnosis, three laboratory tests were desired: a cholesterol, a BMR, and a radioactive iodine uptake study. The isotope laboratory requested the first two studies before it would make its test. The patient had been admitted on a Thursday; the next Thursday was the Thanksgiving holiday; and the laboratory performed cholesterol determinations only on Thursdays. The diagnosis on this patient was correctly made on the first day of his admission. He was in the hospital about eighteen days before it was proved. An efficient organization would have performed the necessary tests in two to three days. The laboratory believes it is economizing by performing numerous tests once or twice a week — fewer technicians are necessary. However, patient hospital days are increased.

The next case illustrates two points. The patient was admitted because of an asymptomatic peptic ulcer and a strangulated heart. His chest X ray revealed an unusual heart shadow, for which he had been studied in detail at another VA hospital. About a month elapsed before his records arrived from the other hospital and revealed that we had nothing with which to concern ourselves in regard to his heart. In the interval, however, we obtained an X ray of his stomach to evaluate his ulcer; the request was in at the X-ray department for about two weeks before the study was obtained. Both of these things are, unfortunately, the rule rather than the exception; it takes weeks to obtain records from other hospitals (especially VA hospitals), and the X-ray department is days to weeks behind in its requested service. Again, it might be questioned whether the VA is economizing with fewer X-ray technicians at the expense of increased patient hospital days. Also, it might be pointed out that if patients were not allowed the privilege of seeking care at more than one VA hospital, unnecessary duplications in laboratory and X-ray procedures and delays in awaiting records might be avoided.

Among my cases were men admitted for dandruff, asymptomatic rheumatoid arthritis, mild tonsillitis, fatigue, athlete’s foot, and acute obesity. Admissions like these at a time when the hospital census is low remind the ward physician of the need to keep the beds full. The administration, in order to maintain the hospital appropriations, to have funds for the equipment and staff they feel are desirable, and to avoid operating on a shoestring, may welcome any admission, regardless of his medical needs. At such times it is unfortunate for the really sick patients if the ward physician has performed his work too well and discharges his other patients. The doctor, barraged with a burst of new admissions and occupied with performing physical examinations on relatively well patients, will have less time for the sick. Maintaining a full house is not a silent policy of the administration at our hospital; the new residents were told on orientation this year that attempts would be made to keep the beds full and that any patient they rushed through would be replaced with another. Nor, apparently, is this a silent policy at other VA hospitals. The 1957 Annual Report of the Administrator of Veterans Affairs lists the following principal diagnoses for 1956: 1612 fungus infections, 3964 acute upper-respiratory infections (colds?), 3072 cases of hypertrophied tonsils and adenoids, 1588 cases with “disease of the teeth,” 17,524 cases with diseases of the skin, and 1564 patients with “deflected nasal septums.”

Appropriations, however, are not the only pressure to keep the beds full. Our veterans’ hospital, like many others, is associated with a medical school. It is desirable to have patients in abundance for teaching purposes. We have five junior students and one senior per ward. From the point of view of their training, it would be ideal for them to see and “work up” as many patients as possible. However, these students could be farmed out to other public and private hospitals.

The desire to extend admissions may originate sometimes at levels lower than the administration. A specialty may be given a ward for patients, provided those in charge demonstrate they continually have a patient load sufficient to fall it. If the beds cannot be utilized, the patients are distributed among the general medical and surgical wards, where the specialist may or may not be invited to see them. Thus, the ward neurology chief might have mixed emotions about pushing patients through his service. Efficiency too well marked might be rewarded by loss of his service.

Doctors are not different from other government employees. They, too, may want to extend their departments. Parkinson’s Law can be seen at work in medicine also. Thus, whereas our medical chest department operated last year with one chief, one resident, and one assistant resident, this year it has been enlarged to include an assistant chief and a fellow, and there are plans to build a cardiopulmonary laboratory. The number of chest patients has not been markedly increasing. The enlarged staff, however, will require more patients to justify its existence. The need for the cardiopulmonary laboratory might also be questioned. One might inquire if there should be 169 other such laboratories around the country. Why should one be founded in our hospital? Hopefully, some beneficial research might be accomplished. In 1960, there were 6569 individual VA research projects carried on by 5800 different investigators. There were 707 in the field of heart and vascular disease alone. Because of these projects, patient hospitalization is often prolonged. On the other hand, these research laboratories often perform services which, financed by research funds, help to lower the official costs of hospitalization for the VA patient.

RESTRICTIVE discharge regulations effectively prolonged lengths of stay at our hospital. No patient could be discharged on weekdays unless the hospital registrar was notified a day in advance. No patient could be discharged on weekends unless the registrar was notified before 2 P.M. on Friday. No patient could be discharged from a ward where the resident doctor was delinquent in the dictation of his patients’ hospital summaries. These regulations were an inconvenience both to the doctor and the patients. A patient who could not be discharged on a Friday had to wait until the following Tuesday. He might have chosen, if he lived nearby, to leave the hospital on pass (in which case the hospital got credit for a full bed), but he had to return to sign his discharge papers, or he would have been declared A.W.O.L. and officially lost his hospital privileges for the next three months. In such cases, four unnecessary hospital days were paid for by the taxpayer. Dealing with these well patients robbed the ward physician of time to care for the sick. often takes credit for nonexistent “24-

The VA often takes credit for nonexistent “24hour admissions,” which help to improve the VA statistics in regard to pertinent hospital days per hospital admission. This is really but a paper-work admission; the patient is officially admitted, a brief summary of hospitalization is dictated, and the patient is officially discharged, all on the same day. This is usually done to allow the hospital to follow a patient for prolonged periods of time in the outpatient department. Legally, the VA is allowed to practice only limited outpatient medicine. It is allowed to have discharged patients return for follow-up to its clinics for a three-month period. At the end of this time, the patient without service-connected disability is supposed to return to the care of his own physician. This method of prolonging follow-up is usually employed in those cases in which the physicians have special interest or in which the patient loudly requests financial assistance. The 24-hour admission is actually a common occurrence; the clinic secretaries automatically give the doctors the forms to fill out. Because the VA provides the patient with travel pay, these admissions are quite agreeable to the patient.

There is one element in the veterans’ hospital system which allows for all the above-mentioned inefficiencies. The people receiving medical services are not the people directly paying for them (or so they seem to feel). No patient would choose to patronize a private hospital system which wasted his money and time so effectively.

Many of the patients themselves take the inefficiencies of the VA in their stride. Some have no families and have adopted the VA. Some are unemployed and enjoy passing a few months in the hospital. Some lack faith in the judgment of their own physician and come to the VA for another opinion. A few are hypochondriacs who gain their main satisfaction in life from having their various complaints investigated. Others are abandoned by their families to the safekeeping of the VA. These things are easily illustrated from my cases. One man was in the hospital 450 days because his wife would not take him home. He had no special problems requiring unusual care or medications. He was not destitute; he owned a boardinghouse, which his wife kept, and he had a pension. Our social worker made arrangements for a younger man to room in their house to give her assistance in the mornings and evenings in exchange for rent. She refused these plans. Every time the ward physicians threatened to discharge the patient, she would call the American Legion officer to intercede for her. Her husband never did go home. His doctors finally transferred him to an old soldiers’ home.

The atmosphere at a VA hospital is unlike that at any other hospital. The corridors are relatively quiet. There are not numerous visitors. On each ward, seriously ill patients are separated down side halls, where they have private rooms; most of the patients are ambulatory and have beds on large wards. The average patient dresses in green pants and jacket during the day. He walks to meals, which are served in a large cafeteria. Few patients appear any sicker than the average man in the street. At night they play cards, attend movies, play bingo, watch television, or participate in a hospital show. Their personal needs are met by volunteer workers, who may provide them with free cigarettes and toilet articles. During the professional baseball season, groups may leave the hospital for a day to attend a game. Life is more comfortable here than in other hospitals; the hustle and quick pace are absent.

REALIZING the waste of the VA hospital organization, few Americans would complain if the money were being spent for the care of those maimed in the defense of this country. None would begrudge this group the very best care we can provide. However, only 9.8 percent of all the patients hospitalized in the VA system have service-connected illnesses.

My first patient with a service-connected illness had ulcerative colitis. This is a disease of unknown etiology manifested by bloody diarrhea and felt by some to have a psychological background. He is receiving 100 percent compensation for this disease. He has also been found to have multiple sclerosis. He works as a helper on his brother’s farm.

The next man was service-connected for idiopathic epilepsy, which was discovered in the service and for which he receives $237 per month. During his one year in the army, he shot himself in the finger. We treated him for a peptic ulcer. When employed, he does construction work.

The third man had an interesting history. He claims to have been an all-state football player in his Illinois high school, in spite of the fact that he had congenital toxoplasmosis of his retina (a parasitic infestation of the eye, contracted while in his mother’s uterus, and resulting in permanent scars on the retina). He had apparently been shipped to Italy before a physician, while examining him for a respiratory infection, discovered his retinal scars and sent him home to be discharged for partial blindness and to receive a pension of $167 per month. He is now a selfemployed painter. We treated him for an alcoholic gastritis.

Any patient found to have tuberculosis within two years of his discharge can claim to have a service-connected illness, as he might have contracted it while in the service. Such was the case with the next man, who in addition had inhaled some silica dust in his work. We treated him for silicotuberculosis and chronic bronchitis. He receives a pension of $209 per month. He has been working as a gravel-truck driver.

The next case was service-connected for high blood pressure, for which he drew a 40 percent pension. His high blood pressure came down to normal with no therapy, but with rest in the course of awaiting his studies.

Like many men in their sixties, the next man entered the hospital in heart failure with arteriosclerotic heart disease and died. He had had his second attack of rheumatic fever during his eightmonth period in the army and received a 100 percent disability pension for rheumatic heart disease. After his discharge in 1919, he worked forty years as a clerk.

The next patient with a service-connected illness was a thirty-year-old retired draftsman. A soldier from November, 1944, to June, 1946, he is now receiving a 100 percent pension for diabetes mellitus, which was discovered while he was in the service. His disease has many complications, so that he will probably never leave his bed, whether at home or in the hospital.

The next case is of special interest because he must be one of many in this country who have for years mistakenly believed they had tuberculosis. On the basis of an abnormal chest X ray in 1919, a diagnosis of tuberculosis was made. Although his activities have never been limited by symptoms suggestive of tuberculosis, he has been receiving a pension of $45 a month, which amounts to $22,680 over the last forty-two years. His skin test for tuberculosis has always been negative, while his skin test has been positive for histoplasmosis (a common fungus disease which is almost always harmless, although it may result in lung scars suggestive of tuberculosis). He has been receiving a pension for a disease that he has never had. He is employed as an office manager in a government agency. His current hospitalization, lasting thirteen days, was occasioned by a mild sinusitis.

Another patient was receiving $120 a month for service-connected chronic bronchitis. During his three-month service in the army he had influenza and developed a cough, which he has since aggravated by heavy smoking. He is not a cooperative patient, will not give up his smoking, and follows his medical program as he sees fit. Over the years he has developed permanent wheezes in his chest that gain him admission to the hospital whenever he so desires.

A forty-year-old career navy cook, discharged because of epilepsy, for which he received a 30 percent pension, was the next case. He revealed that he was in the habit of drinking fifteen to twenty cups of coffee a day. He was found to have occasional irregularities in his heartheat, believed to be due to his excessive coffee intake and causing him to pass out. There was no evidence that he had epilepsy. His heart rhythm has been regular since he has taken heart medicine and stopped his coffee.

The last patient with a service-connected illness was a thirty-eight-year-old man receiving $55 a month for athlete’s foot. He was treated for dyshidrosis, a sweating disorder, probably of genetic origin, aggravated by anything making the hands or feet perspire, such as heat or nervousness.

Fourteen cases constituted the service-connected illnesses in my group of one hundred patients. Four entered for illnesses not related to their service claim. None of the illnesses could be traced to injuries incurred while in the service. Some were shown to have begun before the patient entered the service. Some were diseases felt to be genetically determined. It is the belief of most VA physicians that many of these claims would have been avoided if these patients had been thoroughly examined at the time when they were inducted into the service.

ONE might ask who were my other eighty-six patients, who were non-service-connected. This is hard to answer. To be admitted to the VA in emergency situations, a patient must only claim that he is a veteran. Few of the patients are investigated, and until April of 1960, patients found to be defrauding the VA could not successfully be prosecuted. At present they may be prosecuted under the False Claims Act and be made to pay a fine of $2000 and double the cost of their expense to the VA. Still, among my patients were many we knew were not indigent. There were farmers, factory workers, salesmen, an owner of a cleaning business, and taxicab drivers, all of whom were employed. Yet they signed the oath that they were in need.

In gaining admission to the VA, patients do not have to present their discharge papers to verify their service records; many only recite their approximate dates of service. Usually there is no question as to the fact that all the patients are veterans, whether of but a few weeks or several years, but mistakes can and do occur. Just recently, for example, our hospital registrar expelled a patient who had been hospitalized twenty days for low back pain. It usually takes about three weeks for the VA to check a patient’s service record, and this patient was discovered to have been an enemy alien. born in Turkey, who had requested discharge from our army when he entered World War I. Such a case is unusual. The most common error in the experience of our registrar is that of the peacetime soldier who claims wartime service in order to become eligible for VA privileges. Fortunately, these cases are not too common either.

Many of the patients did not have illnesses which justified hospitalization. Of my hundred patients, 29 percent could be so categorized. Some had been on the waiting list and entered with asymptomatic peptic ulcers; such patients might be in the hospital two weeks or more waiting for X rays of their stomachs. Others had complaints that with the help of more careful screening might have been ignored. One man had a strained leg muscle that he incurred while walking around the golf course in improper shoes. Another entered with a complaint of phlegm in his throat which he had been expectorating for thirty years; he was cured by refusing him cigarettes and giving him a salt-water gargle three times a day; still, he was in the hospital five days before routine studies were obtained and he could be discharged.

These patients are best treated by a family doctor who knows them personally and is familiar with their idiosyncrasies. An older patient may even lose ground when he is put to bed in the hospital for studies; he might do better with a vitamin shot from his doctor and a little understanding from his family. The VA is at a disadvantage in treating such patients; it is not allowed to practice outpatient medicine. Each patient must be admitted or be referred back to his own doctor. Some patients have no doctor and claim they are financially unable to obtain one. Others are dissatisfied with their doctor and come to the VA because they feel their illness deserves more study than their doctor has allowed it.

Another 28 percent of my patients entered because of complaints requiring further study to rule out serious disease. Thus, one man entered because of chronic vague stomach complaints. To be sure his symptoms were not due to a cancer of the stomach, an X ray of his stomach and routine blood and stool studies were ordered. These studies could have been performed in the outpatient department of any hospital, but the patient was hospitalized nine days while they were performed. In a more efficient hospital, the same studies might have been done in two days.

Mild to moderate illnesses that could be said to benefit by both rest and treatment brought 25 percent of my patients into the hospital. Thus, a man with a symptomatic peptic ulcer and another with chronic bronchitis both benefited from their time in the hospital. The first was separated from the stresses of daily life that contributed to the development of his ulcer, and the second received intensive intravenous and intramuscular medications that, over a two-week period, suppressed his disease and symptoms. Both of these patients were hospitalized for prolonged periods of time, thirty-three days for the first, although he was symptom-free after the first week of his therapy, and twenty days for the second, although he received most benefit from his therapy during the first fourteen days of his hospitalization. These particular cases were, again, delayed by their studies. Others were delayed because they had nowhere else to go.

The last group of my patients, comprising 18 percent of the total, had severe or terminal illness. One man was hospitalized thirty-six days for delirium tremens, which has a mortality of about 15 percent, and went home much improved. Another was hospitalized thirty-six days for a heart attack. Another was hospitalized until his death because of cancer of the bladder and prostate. The prolonged hospitalization of the terminal cancer patient is something about which physicians in both private and public hospitals often feel guilty. At present, there is no way these patients can be cured. There are palliative forms of treatment (X ray and anticancer drugs), but it may always be asked whether these prolong the patient’s life or merely make him more comfortable. In many instances, when the family understands that the hospital has nothing to offer the patient, they prefer to take him home. Yet, when hospitalization is required for these chronically ill patients, government medicine may be at its best. Such illnesses bankrupt the patients and undermine medical insurance programs.

Many of the VA employees justify the inefficiency of the VA hospitals, the prolonged hospitalizations, and the unnecessary admissions by pointing out that it costs but a few dollars a day to hospitalize a patient in the VA. This is not true. Our VA hospital finance office calculates that it costs the taxpayer $28.02 per day to hospitalize one patient. This figure is arrived at without including the costs of hospital building and equipment depreciation, as private hospitals must. Further, the costs of laboratory and X-ray procedures are spread out over the average 33.3-day VA hospital admission, rather than the average 10.8-day admission in a private hospital. In our area, the average 1961 hospital charges per day were $37.13 for adult males. Thus, with the use of the low VA average cost, one may calculate that the taxpayers pay $933.07 for the average VA hospitalization, for which the patient would have been charged $401 in a private institution. The expense of private hospitalization is about 43 percent of that of VA hospitalization.

In explaining the prolonged hospitalizations in the VA system, VA employees are quick to state that the VA hospital patient population cannot be compared with that in private and community hospitals. They claim there is more chronic disease within the VA and that no other system is so burdened with older patients. While there seem to be no available statistics either to disprove or to substantiate this assertion, it can certainly be questioned.

First, there are all the sources of inefficiency mentioned in this article, effectively prolonging hospitalization. Second, service-connected diseases are similar in most part to those seen in civilian hospitals. There is no medical reason why an exacerbation of rheumatoid arthritis, an example of a chronic disease, should require longer care in a VA than in a non-VA hospital. Third, the VA patient populations hospitalized in VA and non-VA institutions are not too different. Each has a fair percentage of chronic patients. In 1956 the VA had a slightly higher percentage of patients with neoplasms, for example, while the non-VA hospitals had a higher percentage of patients with respiratory disease and senility. It is hard to see how a difference in patient populations, which seem to vary so slightly, could explain why the veteran averages 17.7 days when hospitalized in a non-VA hospital and 31.4 days in a VA hospital.

Finally, in examining those hospitals in which only chronic diseases are treated, it is seen that the VA averages a considerably increased period of hospitalization. Thus, VA tuberculosis patients hospitalized in 1956 in VA sanitoriums averaged 179.3 days in the hospital, while those hospitalized in non-VA institutions averaged 165.6 days. Even more marked was the difference in the average hospitalizations of patients with psychotic illnesses, who averaged 526 days in VA institutions and 135.9 days in non-VA institutions.

It may be pointed out that these are statistics and do not have exact bearing on individual patients and individual hospitals. Certainly some VA hospitals operate more effectively than others. Some, being closer to population concentrations, may admit patients who are more critically ill than those that I have described. Still, the VA national statistics are there to be compared with those of our private hospitals. As taxpayers, we should examine them closely.

How might the veterans’ hospital service be improved? Many things should be done:

1. The outpatient clinic should continue to be designed for short follow-up of all hospitalizations and unlimited care of service-connected illness.

2. False economizing in the hiring of insufficient numbers of X-ray and laboratory technicians should cease. Although laboratory payrolls might be increased, the number of patient hospital days would be greatly decreased.

3. Patients should be allowed to be discharged whenever they are medically fit.

4. Present VA hospitals affiliated with community or university hospitals should be leased or sold to the affiliated institutions. The VA staff should be incorporated into these institutions. A more elastic system would result. When the need for VA beds falls off, the beds could be utilized by nonVA patients. If a need for more VA beds should arise, the government should subsidize the expansion of these private and community institutions.

5. The VA should pay for the hospitalization of the deserving veteran in local and community hospitals which have demonstrated their efficiency. Veterans should be allowed to seek medical care only at the nearest hospital with VA beds. Hospitalization at a second or third facility should occur only by official transfer.

6. The rightfulness of compensating asymptomatic illness present on X-ray or laboratory tests alone should be reconsidered. Not only is the practice expensive, but it may actually create illness where it does not exist.

7. Service inductees might be more thoroughly examined to weed out those with pre-existing illness.

8. To gain admission to a VA hospital, patients might be required to obtain referring letters from their own physicians. Such a law would save the taxpayer money in screening patients.