Has the VA Become a White Elephant?

As I write this Dennis Wagner is publishing a series of articles in the Arizona Republic describing his quest to find out if care at VA hospitals has improved over the last 2 years (1). To begin the article Wagner describes the fable of the King of Siam who presented albino pachyderms to his enemies knowing they would be bankrupted because the cost of food and care outweighed all usefulness. A modern expression derives from this parable: the white elephant.

The Department of Veterans Affairs (VA) has prided itself on being a leader in healthcare. It is the largest healthcare system in the US, implemented the first electronic medical record, and more than 70 percent of all US doctors have received training in the VA healthcare system (2). This year the VA is celebrating the 70th anniversary of its partnership with US medical schools. Beginning in 1946, the VA partnered with academic institutions to provide health care and to train physicians, nurses and other healthcare professionals. “We are extremely proud of the long-standing, close relationships built over the past 70 years among VA and academic institutions across the country” said VA Secretary Robert A. McDonald. “These partnerships strengthen VA’s healthcare system, and provide high quality training for the nation’s healthcare workforce. We cannot do what we do without them.” On this Veterans Day these appear to be empty words.

To understand the VA wait list scandal and why it will be difficult to fix, it is important to understand the history of the VA academic affiliations. The VA initially affiliated with medical schools in 1946 because it had trouble attracting enough quality physicians to staff its hospitals. These affiliations led to the formation of "dean's hospitals" (3). These were VA hospitals closely affiliated with medical schools and made the VA hospitals teaching hospitals. The medical school faculty was in charge of patient care and teaching and the dean's committee oversaw it all. Not surprisingly, these dean's committees were largely despised by the non-physician directors of the VA business offices. In the mid-1990's they persuaded Veterans Health Administration undersecretary, Kenneth W. Kizer, to place them in charge of the VA hospitals as hospital directors. The dean's committees were dissolved, freeing the directors from any real local oversight. This set the foundation for the VA to return to 1945 and a culture that makes it difficult to attract sufficient numbers of quality physicians.

The inability to attract physicians is largely responsible for the widely publicized VA wait time crisis. Although the VA blames their inability to recruit on pay below what the private sector pays, this is only part of the story. VA administrators have repeatedly attempted to direct patient care leading to physician job dissatisfaction and poor morale. Rather than quality healthcare, the VA developed a list of largely meaningless metrics that substituted for quality. These so called "performance-measurements" were favored by VA administration in no small part because of the bonuses they generated for the administrators. This created a cycle of increasing numbers of measurements to generate increasing bonuses. Physicians were often pressured to remind patients to wear seat belts, not keep guns in the home, etc. leaving insufficient time to deal with real and immediate healthcare problems. In retrospect, even Kizer himself called the expanding number of performance measurements "bloated and unfocused" (4).

At first VA administrators tried to deny the problem of delayed care due to insufficient staffing. Next VA Central Office tried to make all VA clinics walk-in clinics, essentially shifting the problem to the physicians. When caught in lies about short wait times, VA Secretary McDonald fired a few administrators in Phoenix and then tried to minimize the problem (5). When announcing their progress on the problem, the VA touts the number of people it has hired but usually does not specify the number of physicians or other healthcare providers. Now the VA has decided to let nurses and pharmacists pick up the slack. The VA has proposed removing physician supervision of nurse practitioners and has begun using pharmacists for primary care (6,7).

A number of medical groups have opposed the increased authority for nurses (8). Neither nurses nor pharmacists have the length of training of physicians (9).  However, objections by the AMA and other groups are likely to fall on deaf ears. Unless the VA can recruit physician which seems unlikely without reform, what other choice do they have? It is unclear if the VA and courts will hold these less experienced and lower skilled practitioners to the same high standards they have held physicians. However, given that the VA administrators are knowingly replacing physicians with less skilled practitioners, this would seem reasonable.

Wagner's series in the Arizona Republic seems to suggest that the VA's lack of transparency makes it difficult to determine if care at VA hospitals have improved over the last 2 years (9). The conclusion from the series appears to be that the VA has not. This is not surprising given that no real reform has taken place and McDonald appears not to be in control of the VA. For example, two short years ago McDonald was proposing to downsize the VA administration (10). Like so many reforms, this seems to have fallen by the wayside under opposition from VA administration. In fact, Wagner implies that VA administration may actually have grown beyond what was already a bloated bureaucracy (9).

President-elect Trump has been critical of the VA and McDonald. It seems likely he will be gone this January but the VA administrators will remain. Hopefully, McDonald's replacement will do better in reforming the VA. If not, it might be time to view the VA as what it has become, a white elephant whose cost outweighs all usefulness. Consideration should be given to replacing the VA with care in the private sector. Although care will be more expensive, it is better than no or poor care which is what the VA patients are receiving now.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening?. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 10/27/16).
2. Department of Veterans Affairs. VA celebrates 70 years of partnering with medical schools. Available at: http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2747 (accessed 10/27/16).
3. Department of Veterans Affairs. Still going strong - the history of VA academic affiliations. Available at: http://www.va.gov/OAA/videos/transcript_affiliation_history.asp (accessed 10/27/16).
4. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jul 24;371(4):295-7. [CrossRef] [PubMed]
5. Rein L. VA chief compares waits for veteran care to Disneyland: They don’t measure and we shouldn’t either. Washington Post. May 23, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/23/va-chief-compares-waits-for-veteran-care-to-disneyland-they-dont-measure-and-we-shouldnt-either/ (accessed 10/27/16).
6. Department of Veterans Affairs. VA Proposes to grant full practice authority to advanced practice registered nurses. May 29, 2016. Available at: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793 (accessed 10/27/16).
7. Galewitz P. VA shifts to clinical pharmacists to help ease patients’ long waits. Kaiser Health News. October 25, 2016. Available at: http://khn.org/news/va-treats-patients-impatience-with-clinical-pharmacists/ (accessed 10/27/16).
8. Rein L. To cut wait times, VA wants nurses to act like doctors. Doctors say veterans will be harmed. Washington Post. May 27, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/ (accessed 10/27/16).
9. Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. [CrossRef]
10. Krause J. MyVA re-org likely set to downsize VA workforce, a lot. DisabledVeterans.org. Jan 28, 2015. Available at: http://www.disabledveterans.org/2015/01/29/myva-reorganization-likely-set-downsize-va-workforce-lot/ (accessed 10/27/16).

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as Robbins RA. Has the VA Become a White Elephant? Southwest J Pulm Crit Care. 2016;13(5):235-7. doi: https://doi.org/10.13175/swjpcc108-16 PDF 

Honoring Our Nation's Veterans

Today is Armistice Day, renamed Veterans Day in 1954, to honor our Nation's Veterans. In Washington the rhetoric from both the political right and left supports our Veterans. My cynical side reminds me that this might have something to do with Veterans voting in a higher percentage than the population as a whole, but let me give the politicians this one. Serving our Country in the military is something that deserves to be honored. I was proud to serve our Veterans over 30 years at four Department of Veterans Affairs (VA) hospitals.

However, the VA has had a very bad year. First, in Washington there were the resignations of the Secretary of Veterans Affairs, Eric Shinseki; the undersecretary for the Veterans Health Administration, Robert Petzel; and the undersecretary for the Veterans Benefits Administration, Allison Hickey. Locally, in the light of the VA wait scandal there were the firing of the Phoenix VA Medical Centers director, Sharon Helman, and her deputies along with the retirement of her boss, Susan Bowers. Furthermore, there seem to be a never-ending string of scandals ranging from the mundane of greed-driven fraud to the more exotic of accusing a VA whistleblower of engaging in sexual threesomes. Despite a healthy increase in funding, there was the threat by VA administrators of closing VA hospitals to meet a VA budget shortfall. This resulted in Congress knuckling under to allow the use of emergency funds. Veterans groups are using billboards to accuse the VA of lying (Figure 1).

Figure 1. Billboard across from the VA October 12, 2015.

I could go on and on. However, the real question is not so much of what dirty deeds are being done, but how the VA administrators get away with it.

There has been both a lack of oversight and lack of accountability. Robert McDonald, who replaced Shinseki, has promised to punish the evil doers but has replaced action with the mantra "all is well" and has done nothing. In several instances wrong-doing has apparently been rewarded, such as Bowers replacement having lied to Congress (1). If the VA cannot police itself-and it apparently cannot-there are a multitude of regulatory agencies that have shirked their oversight responsibilities. I thought it was time to mention a few.

First, there are both the Veterans Integrated Service Networks, the regional VA offices, and VA Central Office itself in Washington. Both these organizations have been caught in the scandals and have done nothing. Second, there is Congress. The House Veterans Affairs Committee has seemed to make a sincere effort to identify some of the problems but Secretary McDonald and his cadre of 11,000 in Central Office has repeatedly stone-walled any investigation and Congress has done nothing. Third, there is the White House. The Obama Administration has seemed more interested in declaring the problem fixed than actually fixing the problem and has done nothing.

Those are the obvious but there are some less obvious regulatory failures. First, there are the multiple hospital inspectors. Within the VA is the Office of Inspector General (IG) who is charged with investigating wrong-doing within the VA. Locally they had been called to Phoenix multiple times including for the wait time scandal but have done nothing. The poor performance resulted in the resignation of the acting VA IG, Richard Griffin, under pressure. Second, there is the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). The Phoenix VA Medical Center managed to go from a "top performer" in 2011 to noncompliant "with U.S. standards for safety, patient care and management" in 2014. Only the naive would believe that a hospital can transition that much in 3 years. There is also the Arizona Board of Medical Examiners and Nursing. Both doctors and nurses were involved in the cover-up of the wait scandal but these boards have done nothing. The VA is the largest system for training future physicians and nurses, and it seems that the future doctors and nurses might not be learning the highest professional and ethical standards. Nonetheless, the Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing have done nothing.

However, my personal disgust is highest for the Department of Justice (DOJ). It is known that seventy percent of the hospitals were fudging their wait data. The administrators, not the doctors or nurses, received bonuses for short wait times. None of the administrators have gone to jail or even been charged with fraud. None have even had to repay their bonuses. The DOJ has done nothing. If 70% of the doctors were caught faking data to received bonuses, I have every confidence that the legal eagles at DOJ would gleefully put each and every one on trial.

So what can be done? There appears to be no oversight. This was clearly illustrated in the report from the recent Human Resources (HR) team from Central Office sent to Phoenix to help with what can be kindly described as a dysfunctional department. They were essentially shown the door by the acting director, Glen Grippen, saying that he "calls the shots" (2).

The solution is that Mr. Grippen and others of his ilk should no longer call the shots. They have shown a consistent arrogance and disregard for our Nation's Veterans and those that serve them. He and others need oversight, not by a far-off committee in Washington as President Obama has proposed which will likely fare no better than Congress. Oversight could be best provided by local physicians and nurses who have interest in Veteran care but are not employed by the VA. This used to occur in many VA hospitals and was called the Dean's Committee. The dean of the local medical school along with the chairman of the departments of medicine, surgery, pathology, radiology, and others formed a committee that oversaw care at the VA. The committee had interests in the patient care of Veterans but also in the physicians who were faculty at the local medical school and the medical students, residents and fellows who were under their supervision. This committee was a victim of Ken Kizer's "prescription for change" in the 1990s. Now, this old system might be an antidote for Kizer's prescription which has seemed to turn poison.

The VA is pushing to hire more personnel to deal with wait times and lack of patient care. However, it is unclear how many of the new hires are doctors and nurses contributing to patient care and how many are administrators and bureaucrats.  My experiences and conversations with my colleagues convinces me that not all hospitals are as badly managed as those in the Southwest. Those considering a career at the VA need to carefully investigate each hospital to see if it is the type of place that the leadership will provide the resources to care for the Veterans, which is after all, the definition of leadership.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Wagner D. Department of Veterans Affairs names new regional health director. Arizona Republic. October 15, 2015. Available at: http://www.azcentral.com/story/news/arizona/politics/2015/10/15/department-veterans-affairs-names-new-regional-health-director/73900478/
2. Wagner D. VA team blasts Phoenix personnel office. Arizona Republic. November 2, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/11/02/va-team-blasts-phoenix-personnel-office/74763366/

Cite as: Robbins RA. Honoring our Nation's Veterans. Southwest J Pulm Crit Care. 2015;11(5):228-30. doi: http://dx.doi.org/10.13175/swjpcc141-15 PDF