by John Geyman, M.D.

The V.A. scandal over access to care for our veterans is, of course, a betrayal of our government’s debt to our veterans and a national disgrace that needs fixing on an urgent basis. Typical of such scandals, there is piling on from all quarters about what should be done, although we still don’t know the full extent of the problems.

Some things we do already know, thanks to an expedited Interim Report by Richard J. Griffin, the Acting Inspector General for Veterans Affairs. That report tells us that:

  average waiting times for first primary care appointments at the Phoenix V.A. have been 115 days, nearly five times as long as what last year’s annual report acknowledged;

  1,700 patients were not placed on the official waiting list at Phoenix; 

  scheduling data were being falsified and secret lists maintained, presumably to manipulate the data for more favorable performance reviews;

  these problems are probably systemic throughout the V.A. system, to the extent that the Inspector General will expand his investigation to 41 other V.A. facilities around the country and even involve the Department of Justice to investigate possible criminal conduct;   and  the 35-page preliminary report found that scheduling problems have been found at both local and national levels by eighteen previous Inspector General reports since 2005.  (1,2)  

At this early point, there is much that we don’t know as we await the IG’s full report, due in August. As the investigation expands to include clinical reviews of the consequences of these scheduling problems, we can also expect to learn examples of gross mismanagement and unethical behavior by some in charge. 

Naturally, we are now seeing a firestorm of protest, casting blame in all directions. Some are calling for immediate action to include referral of veterans to the private sector, which raises still other questions, such as reimbursement levels and availability of primary care physicians. Many called for the resignation of General Eric Shinseki, Secretary of Veterans Affairs, which he did after so many years of meritorious service.  

As this crisis unfolds and we get more information on what has occurred, we need to sort out disinformation and demagoguery from the facts. We will hear “lessons” being advanced from various perspectives. We should also ask ourselves what lessons we cannot learn from this failure. There is a political risk that once resignations have occurred, we will go on as usual without considering more fundamental problems. 

Without knowing yet what the full IG’s report will find, we need to wonder if the V.A. has been underfunded by austerity budgets pushed especially by  Republicans. The V.A. has been facing large increases in demand as a result of several factors, including aging of the baby boom-era Vietnam veterans, the influx of wounded warriors from more than twelve years of combat in Iraq and Afghanistan, and recent changes in the law for veterans to qualify for benefits if they were exposed to Agent Orange or to hazardous substances in Iraq and surrounding areas. (3) The number of eligible veterans has more than doubled from 400,000 to 918,000 since 2009. (4)  

These questions need to be asked and answered: 

  Is the V.A.’s budget and primary care capacity adequate to meet its increased demands?

  How many veterans died or had preventable worse outcomes as a result of delayed appointments? 

  How was it possible that the V.A., which played a leadership role in developing electronic medical records in years past, tolerated systems that didn’t talk to each other?

  What’s been happening in the V.A. culture that encourages gaming of performance reports as a means to seek bonuses and gloss over problems? 

  Why wasn’t corrective action taken by the V.A. over the last nine years as these problems progressed?

As this situation evolves over coming months and even into the 2016 election cycle, we can expect to hear dispersions cast on the V.A. as an example of “the government can’t do anything right” and claims that the private delivery “system” is more efficient and less bureaucratic. These disproven claims are predictable from the right as the problems of the Affordable Care Act are further debated and alternatives considered. Meanwhile, we need to remember that the V.A. system has many successes to be proud of over the years. A good example is a 2006 report, based on studies by RAND and the Agency for Healthcare Research and Quality (AHRQ) comparing the quality of care in V.A. hospitals vs. non-V.A. hospitals (Table 1 (5) Superior quality of care in V.A. facilities has also been documented for the care of diabetes (6) and heart attacks (7). 

We can draw two parallels already between the V.A. system and our civilian counterpart. Both are challenged by increasing demands for primary care at a time when we have a national shortage of primary care physicians. And both are encouraged by various financial incentives to misrepresent performance and actual services delivered in an effort to increase funding. We know in the civilian sector that all efforts so far to “improve quality” through various financial incentives have not worked, are gamed in many ways, and even unfairly penalize doctors and hospitals that care for large numbers of lower-income, sicker people. (8) The highly respected Cochrane Collaboration, an international research body, has “found no evidence that financial incentives can improve patient outcomes.” (9)

The V.A.’s failures are a failure of its delivery system, not its financing system (except to the extent that it is probably underfunded to meet expanded needs}. Contrast that with our civilian health care system, based as it is not on service but ability to pay, which continues to be a failed system on both the financing and delivery sides. Its failures have been documented in my latest book Health Care Wars: How Market Ideology and Corporate Power Are Killing Americans, and many of the posts from my fellow Health Care Disconnects panel members over the last year. 

The health care debate will get more intense as the mid-term and general election cycles gain momentum. We will need to separate facts and evidence from ideology, disinformation and unproven claims. The current V.A. problems can and will be fixed. We need to remember the strengths of the V.A. system—especially its universal access for veterans, its not-for-profit and service ethic, and its cost containment successes, such as its bulk purchasing of prescription drugs with discounts down to about 58 percent of what civilians pay. On the civilian side, we can learn from the V.A.’s strengths as we debate how to achieve universal access to all necessary care for all Americans in a reformed system that is affordable, efficient, fair, of good quality, and sustainable in the long run. The only alternative that will do all that is a single-payer financing system of universal access, much like the V.A. accomplishes for almost 9 million veterans.  


Suggested Reading: 

1. Oppel, RA Jr, Shear, MD. Severe report finds V.A. hid waiting lists at hospitals. New York Times, May 28, 2014. 

2. Herb, J. V.A. IG finds ‘systemic’ problems. Politico Pro, May 28, 2014. 

3. Rovner, J. FAQ: V.A. and military care are different, but often confused. Kaiser Health News, May 29, 2014.

4. Blades, M. Inspector General’s interim report confirms long delays for patients at Phoenix V.A. hospital.

5. Arnst, C. The best medical care in the U.S. Business Week, July 17, 2006.

6. Kerr, EA, Gerzoff, RB, Krein, SL et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med 141(4): 272-281, 2004.

7. Peterson, LA, Normand, SL, Leape, LL et al. Comparison of use of medications after acute myocardial infarction in the Veterans Health Administration and Medicare. Circulation 104(24): 2898-2904, 2001. 

8. Pear, R. Health law’s pay policy is skewed, panel finds. New York Times, April 28, 2014.

9. Flodgren, G, Eccles, MP, Shepperd, S et al. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviors and patient outcomes. Cochrane Collaboration, July 6, 2011.

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One-liner:  The V.A. scandal raises questions about the impacts of perverse financial incentives on performance and quality of care that have parallels in our civilian health care system as well.

Abstract:   Systemic problems now under investigation in more than 40 V.A. facilities, involving falsified data boosting performance reviews, have counterparts in civilian facilities that are still not widely recognized. There are too many ways in both V.A. and civilian systems to game all current ways intended to “improve quality”, that instead misrepresent actual care performance. Despite that, there is much to learn from the V.A.’s strengths over the years.