Do We Really Need the VA?

VA Phoenix Signage LG

Last Wednesday, President Obama called the much-publicized problems in the Veterans Affairs health system “disgraceful” as delays in care in at least 26 facilities grabbed media attention. In testimony before Senate and House Congressional committees, VA officials disclosed systemic misrepresentations about the timeliness of treatments in VA primary care clinics: rather than getting care within 14 days of request, many veterans appear to have waited 6-12 months to see a doctor, and some are alleged to have died while waiting.

In referencing a special report due this week that assesses the scope of the problem in the Department of Veterans Affairs, the President’s commitment to fix the problem was unequivocal: “I want to see what the results of these reports are and there is going to be accountability.”

As I have watched the VA storyline play out over the course of the past few weeks, I found myself asking questions the reporters weren’t:

Why do we need to operate a separate system of 820 clinics and 151 hospitals for Veterans?

Might the system of care for the 21 million it currently serves not be better coordinated through the U.S. health care system of 5200 public and private hospitals, 820,000 physicians, 1200 federally qualified health centers, 2000 community mental health clinics, 56,000 pharmacies and 1700 retail clinics? In most communities, there’s a surplus of beds.

In most communities, those with insurance can get doctors’ appointments and receive treatment. Veterans who lack private coverage, like those who are uninsured, have fewer choices. It is not a capacity issue: it is an economic issue.

And common sense suggests we might redeploy some the VA health administration’s $60.3B budget for better coordination with the private systems that already operate in our communities while reducing duplication of services and their associated costs.

Why don’t we get serious and fix the problem of access to primary care shortage once and for all? It’s not just a veterans’ problem. Those who live in poorer neighborhoods lack access.

Those on Medicaid face long waits to see a primary care doctor for the first time. And those lacking coverage altogether use emergency rooms and public health clinics as their primary care providers. The Federal Trade Commission says expanding scope of practice responsibilities for nurse practitioners solves it. The Affordable Care Act proposes expanding the supply of primary care residencies and increased pay (though nowhere near compensation paid specialists). Academic medicine says it’s a matter of better recruitment and improved training. The key primary care medical societies say it’s a matter or money and role: paying general internists, family physicians and pediatricians more and giving them responsibility as gatekeepers to the rest of our specialty-heavy system. These are important but not enough.

And why does it take the media spotlight to prompt righteous indignation over access issues in our system? We all know access is an issue for the uninsured and underinsured. It is widely documented, but solutions are reported rarely. It goes beyond primary care, but it’s an issue nonetheless.

What’s the solution?

Paying primary care physicians more might encourage a few more smart kids in undergraduate school to consider the career, and innovation in the medical school curriculum around team-based care and accelerated competency-based training might encourage a few more to enter the profession, but that’s not enough. There are three keys to the solution in my view:

Employer activism: employers have enormous untapped influence on how primary care is used in the U.S. beyond benefits design for their 141 million employees and dependents. They sit on boards of hospitals. They contribute to political campaigns. They run trade associations and exert influence in statehouses and DC. Every employer that provides health insurance pays a hidden tax to fund primary care delivered through hospital emergency rooms for the uninsured and redundant clinics operated by the VA and other government agencies. Employers are the difference. Employers can accelerate their own primary care gatekeeper system via in-house primary care clinics. Employers can meld the skillsets of pharmacists, dentists, mental health professionals, optometrists and nutritionists into newer, more comprehensive patient-centered medical homes that can manage population health better while lowering costs. Employers are community leaders and access to effective, efficient primary care is a community problem. Employer activism, focused on fixing access to primary care, would turbo-charge the solution.

State legislative leadership: federal policy about fixing the shortage of primary care physicians is cumbersome. It deduces that primary care is delivered primarily by physicians, only dispensed via visits, and only accommodated by expanding access to medical residencies and financial inducements for PCPs who agree to practice in underserved communities. These help but take a decade to implement. Meanwhile waiting times for primary care get longer and fewer physicians-in-training are pursuing primary care as a career. States have the authority to expand scope of practice for pharmacists and nurses to diagnose and treat. States have the capacity to pass tort reforms that would enable primary care teams to manage populations more effectively without fear of plaintiff’s bar. States have the ability to incentivize hospitals to create well-run integrated primary care networks that offer a full compliment of physical and mental health services cost effectively. And states can encourage spending changes from bricks to clicks to enhance care coordination and population health. Ground zero for primary care solutions is the statehouse, not the White House.

Unbridled consumerism: Technologies and online services that equip individuals to diagnose and treat themselves for uncomplicated conditions are readily available. Access to personal health records that integrate the individual’s hospital, lab, physician and health history into a personalized care path are accessible. Consumers want to control their own health. They want to know what over-the-counter therapies do and how alternative treatments might work.

They want useful information about the efficacy of drugs, the accuracy of diagnostic tests, the appropriateness of surgical procedures and whether cheaper options with the same or better outcome is available and where. They embrace group visits, personalized online tools and electronic authorization for script fulfillment.

They want to know how other consumers rate the services and products they use. They want to know how their doctors are paid and how much. And they want to know the total costs and their out of pocket portions for their drugs, hospital and clinic visits, insurance premiums and more. The power of unbridled consumerism in healthcare toward a new, national vision for primary care is virtually untapped.

Fixing the primary care access issue is as important as the Kennedy era race to space, and more important to the economic recovery than arguably any other endeavor. The VA system’s flaws are an embarrassment to the Department of Veterans’ Affairs, but the bigger story is uneven access and inadequate momentum toward fixing the primary care system in the U.S. That’s the story that’s not being told.

P.S. Lost perhaps in the media buzz about the Ukraine and the VA is the 50th anniversary of Lyndon Johnson’s Great Society legislation signed into law May 22, 1964. It brought us Medicaid and Medicare along with food stamps and other programs– arguably the most far-reaching changes in the health care system then and perhaps now. Per the Pew Research Center, when Americans were asked how often they trusted the federal government to do what is right, nearly 80% said “just about always” or “most of the time”.

Sources: US Department of Veterans Affairs (VA.gov); “2014 Survey of Patient Appointment Wait Times” Merritt Hawkins (MerrittHawkins.com); “Projecting the Supply and Demand for Primary Care Practitioners Through 2020” National Center for Workforce Analysis (HRSA.gov); CMS (CMS.gov); National Council for Behavioral Health (thenaitonalcouncil.org)

Paul Keckley, PhD  (@paulkeckley) is an independent health care industry analyst, policy expert and entrepreneur. Keckley most recently served as Executive Director of the Deloitte Center for Health Solutions and currently serves on the boards of the Ohio State University Medical Center, Healthcare Financial Management Leadership Council, and Lipscomb University College of Pharmacy. He is member of the Health Executive Network and advisor to the Bipartisan Policy Center in Washington DC.  Keckley writes a weekly health reform newsletter, The Keckley Report, where an earlier version of this post appeared.

16 replies »

  1. There is only one logical reason to have a VA hospital system – to give vets better care. If anyone says they think the current system does that better, ask them one simple question. “Would you go to a veterans hospital if you had the choice?

  2. It is a question worth investigating but an answer is likely not so easy. Why was the VA created in the first place? Vetrans have specific problems and histories that the general community practitioners are not trained to identify nor diagnose/treat. It is perhaps similar to having a traveler who picked up malaria visit a US PCP – they are likely to not pick it up early (or at all) because they are so unfamiliar with the symptoms and the condition.

    Private sector most certaintly has waste – and I agree with others who say pouring more money into it isn’t “the” solution. Perhaps the investigation should consider setting up choice for the vetrans – like Charter Schools, if vetrans can choose to participate in the Vetran plans or a local private system, then both health systems might start to care a bit more about their paitents.

  3. There’s nothing fun about going to war – it sucks – period.

    Once war gets going all sorts of companies line up to sell weaponry or provide reconstruction and other services and a great many politicians across the spectrum bow to such lobbying. So it’s not just the hawks that have gotten their hands dirty here.

  4. “War – the gift that never stops giving.”

    The point hawks don’t understand. It’s fun to go to war, it’s hell living with the outcomes. Republicans hate unfunded mandates, so maybe we should impose a war tax to remind people of the consequences.

  5. Bob:

    I think your points are solid, but I think more needs to be considered here. For starters, many soldiers have done multiple tours at which point problems such as PTSD and other were quite obvious.

    The answer was to jack up these young soldiers on all sorts of anti-depressants and other drugs. Some soldiers were on excess of 10 different prescriptions and still placed into forward areas.

    So on one hand you have the issue of sufficient monies existing to treat vets and active duty, but on the other hand assuming monies exist will soldiers get the right treatment?

    If one outsourced it to the private sector does the expertise exist to treat soldiers and vets? Being in the private sector and having psychological problems from work or personal matters isn’t really the same as seeing your bud get blown into pieces or seeing an IED rip apart a bunch of people.

    I don’t know whether the private sector has the expertise to handle this or not, but it’s something that should be discussed. Outside of any mental issues the physical injuries are horrific, which means the fix is very expensive. Would the private sector cover war injuries that require 20 surgeries?

    As per your comment on high deductibles leading to vets postponing care – agreed, but I’d add many of them do not even understand what their problems are. So again will someone solely private sector understand this and be able to treat it? No idea.

  6. Interesting article in a recent edition of the WSJ.

    The Government still paying a dependent of a Civil War veteran!

    War – the gift that never stops giving.

  7. Before one considers continued funding to the VA or contemplates a new system the question that must be asked is are we willing to look at and address the fully burdened cost of war.

    Politicians start wars not the young men and women tasked to fight them.

    We spent $2.5 trillion on Iraq/Afghanistan during which the money never stopped flowing (well at least to the primes).

    So the proverbial $64,000 question, regardless of what HC system is used to treat vets, is will adequate monies be appropriated to provide proper and requisite care for our veterans?

  8. I am assuming that you are saying get rid of VHA (Veterans Health Administration) under the VA. The other half if the VA is VBA (Veterans Benefits Administration) which has its own set of problems.

  9. Bob,

    You could give veterans Medi-Gap insurance and place them into the private sector. It would probably be cheaper than running the VA hospital system

  10. I can well understand the attractiveness of sending veterans into the private sector.

    Biut based on everything that has gone on with the ACA, the veterans will NOT get free care from the private sector.

    You pay not to wait, or you wait not to pay.

    I fear that faced with deductibles and coinsurance, many veterans will postpone care, and be worse off than they are today.

    I welcome anyone who would correct me.

  11. “Do we really need the VA?”


    However, listen to the howls of outrage if you try to get rid of it.

    Bottom line – it will never happen.

  12. yes, please think it through and don’t overlook that the VA is abusing the system. You WON”T find that kind of abuse in a private market or that facility would be shut down immediately.

    So we need a private market for the purpose of accountability, efficiency and quality. Otherwise, you are stuck with big government and all of the waste fraud and abuse that comes with big government.

    let’s get back to what made our country great and get rid of government control. Let the free people create the solutions,

  13. Each and every system in healthcare delivery is broken and will stay broken until the patient holds the cash he/she wishes to spend for healthcare.

    There are no value choices made by anyone unless this is true.

    “Some people will not make the right choice,” says the leftie. It is their choice to make. That is what evolution is for.

    Since everyone dies no matter how good the care, people should live and die as they choose.

    Stop stealing the right to choose from the people.

  14. I noticed that you mentioned that some states are expanding the scope of practice for nurses. Perhaps this is the best option for helping to reduce the shortage of Primary Care Physicians in our country. If it is true that people were waiting 6-12 months to see a PCP, then that is very sad. Why not not allow nurses that have had additional training or Nurse Practitioners be a part of the primary care team to help the already burdened Physicians that are providing primary care. This would allow people to make more timely visit while still getting safe competent care. I think that both Physicians and Nurse Practitioners play an important role and by working together as a team they can help to increase access to care.

  15. Here’s the thing of it, there are problems at the VA: but let’s stop and think it through, releasing all of that federal money into the private system is incredibly tempting but isn’t going to help.

    What it is going to do is create opportunities for waste, fraud and abuse that you wouldn’t believe — because all of that government money that supposed to go to taking care of poor suffering veterans?

    That money is just going to be sitting there waiting to be had

    We’re better off fixing what we do have