Wednesday, July 23, 2014

What is Wrong with the VA?

Everyone knows a veteran, and we shudder to think about our veterans being neglected by the nation that called them to service.  Scandals at the Department of Veterans Affairs, better known as the "VA," have a long history.  Today there are well over 270,000 VA employees and a budget of at least $132 billion.  The scandals are serious and are exacerbated by the vastness of the VA's mission:
·                     If favorable reviews and promotions are based upon short waiting lists, then managers are going to "fudge" the waiting lists.  VA created incentives for its managers to cheat.  In some cases they apparently shredded records, assigned patients to imaginary doctors, and hid lists.  As dishonest as some of the facility managers were, the higher-ups who set efficiency goals disconnected from reality were just as culpable.
·                     The VA has too few doctors.  The pay is less than the private sector; the work can be overwhelming; and the environment in some facilities can be stifling.  Turnover is high, and there are now about 400 vacancies.  (NYT 5-29-2014)
·                     The VA has too many claims.  As of April 20, 2013, the VA had 886,345 pending claims, and 613,469 of these had been pending more than 125 days.  The VA still keeps paper files because of endless delays in implementing the complex and expensive Integrated Electronic Health Record program (IEHR).  The paper jam coincides with the biggest spike in VA claims since World War II.
·                     The VA is staffed by federal civil service employees who, as a practical matter, cannot be fired.  In recent years, there have been well-publicized HIV and hepatitis scares in several VA hospitals because of unsterilized equipment and failure to keep safety protocols, but no one was fired.  In the private sector there would have been firings, demotions, and big lawsuits.
·                     The VA's information technology (IT) is underfunded, understaffed, and bloated with mid-level management.  There are about 8,000 IT staffers for 320,000 VA employees and contract workers, and there are nine layers of management between the VA's chief information officer and the IT staff at a VA facility. Since the VA's IT staff became centralized under their own sub-department, there are complaints that the IT managers are disconnected from the mission of the VA.  (FCW 5-1-2013) 
·                     The VA is the largest provider of mental healthcare in the world, and mental illnesses are difficult to diagnose and to treat.  Mental illness remains a vast frontier of medicine.  We know many triggers of mental illness, e.g., trauma, abuse, and radical change of circumstances.  We know the symptoms of many illnesses and can treat them with medications of varying degrees of effectiveness, but we can rarely claim we "cured" a mental illness.  VA staffers often work with permanently disabled people who have disfiguring physical injuries as well as mental illnesses.  Even if a facility has excellent staff and leadership, the daily challenge is daunting.  Sometimes a man can survive amputation or paralysis easier than the severe depression that often comes with it.  Our veterans often leave part of their souls with their lost comrades in distant places.
·                     The VA, despite heroic work by many dedicated and skilled doctors and staff, has in places a culture adversarial to the veteran.  Veterans most dependent on VA facilities are those who have the gravest and most painful injuries.  Such veterans are usually grateful for the VA but often irritated that seemingly no one has actually read anyone's file and that numerous tests are prerequisite for almost any kind of treatment.  The number and desperate circumstances of the veterans brings out the worst of some of the staff, which, at times, seem bent on making sure you do not get treatment. 
·                     The VA's immunities as a government entity make it difficult to hold accountable through the courts.  Under the federal Tort Claims Act, someone injured by negligence at a VA hospital cannot recover punitive damages.  Punitive damages are not very common in litigation, but when a jury awards them, they are screaming: "Don't do this again!"  If Ford Motor Company fails to correct a defect in the brakes of one of its car models, it can be punished severely by a jury.  However, if a government entity such as the VA ignores the standards governing civilian doctors and hospitals and injures several people severely as a result, the patients might recover their actual damages (e.g., medical expenses, rehabilitation expenses, loss of use of limb, etc.), but the jury cannot award punitive damages to discourage similar negligent behavior in the future.  Thus, risk management for the VA is not the "do or die" priority that it is in the private sector. 
            There are strong public policy arguments against punitive damages to public entities.  Nonetheless, just as you can often look at a house and figure out if the residents own it or rent it, you can often figure out from the energy of the staff whether an entity faces both market competition and tort liability.
·                     There is no efficient way to supervise a healthcare army of a quarter million.  The managers' managers need managers, who require auditors.  Though thousands of employees serve diligently and even heroically, our veterans depend on a huge bureaucracy that has a long history of mismanagement.
·                     $132 billion is so large a budget it is an abstraction, not unlike the distance between galaxies.  Even if a quarter of the quarter-million employees were accountants, they would still need supernatural powers to keep less than a small fraction of $132 billion from being wasted in and out of the VA's many facilities.


·                     Once a veteran is in the VA system, the care by law is to the grave.  This commitment is what we must demand of ourselves in gratitude for those who sacrifice for the nation.  However, the political reality is that there is always a more urgent priority for our Congress than adequate funding and supervision for veterans' healthcare.  Crony capitalists and political machines will always have more pull in Washington.

I would like to write a follow-up post on possible solutions, but I would like to hear from readers first.  Here are some links to sources of the story above: