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.

The new reform bill will make it far easier to discipline or fire VA managers for malfeasance or ineptitude (some, like the Washington Post’s editorial board, say too easy) to curb a culture of apathy that seems to have built in some parts of the department, hurting both the veterans it exists to care for and the reputation of VA employees who do their work well. The legislation demonstrates how the VA is at a crossroads, choosing between whether to continue building or leasing new facilities, or to use private health professionals more often. Congress allocates $1.5 billion for the leasing of 27 new facilities, most for outpatient care. Another $5 billion goes toward increasing medical staffing. The bill also increases graduate medical education funding to aid recruitment efforts.

Nonprofit veteran-service organizations like the American Legion, Wounded Warrior Project, and Iraq and Afghanistan Veterans of America are split. Older groups typically want the department to focus on medical centers, community clinics, and employment, while newer ones tend to be more open to incorporating the private sector, though virtually no one’s calling for complete privatization.

This reform leans toward the private sector. That can work if the VA is able to track how, what, and where its patients receive care outside its system, but the Government Accountability Office has criticized the department for its inability to do so before. Once again, the success will depend mostly on better organization and less apathy towards dysfunction.

This emergency-reform bill’s funding only lasts two years, during which VA will have to authorize and address the findings of an independent top-to-bottom review of the system. The VA’s budget has increased—sizably, from approximately $39 billion for the department’s medical administration in 2008’s fiscal year to appropriations of $59.1 billion in this current one—over the last several years, even as the rest of the government has had to make due with less. If that report comes back saying that VA needs to improve, the way forward may be more reliance on outside private care than continued reinvestment of personnel and resources into the system.

Congress is flooding the VA with resources to deliver care in a timely manner to vets. It will be up to newly confirmed VA Secretary Robert McDonald to change the hearts and minds of the department.