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Wednesday, June 11, 2014

What is this VA scandal about?

I’ve been hearing about the VA (Veterans Health Administration)scandal recently. A traipse through the high quality media coverage available on the internet has brought me up to date. Apparently, in 2012 a physician at the VA in Phoenix began to call attention to the fact that her hospital was providing inadequate care, specifically that her emergency department was overcrowded and dangerous. In the primary care arena, reports that veterans had to wait ridiculously long times for appointments were investigated by the General Accounting Office and a report was released in 2013 that found that documentation of wait times was inconsistent, but that it appeared that veterans had to wait an unacceptable amount of time for appointments.

Later in 2013, another doctor from the Phoenix VA reported that wait times were unacceptably long and that patients were dying because they were waiting so long to be seen. Numbers I’ve read on the internet include 6 weeks to even be called back about making a primary care appointment, 9 months to get an echocardiogram, 6 months to see a cardiologist. Administrators have reported wait times less egregiously long than they really are, with one set of figures for official reporting and another more accurate set that is secret (at least that’s what it sounds like.) Investigations into other VA medical centers, including one in Albuquerque, suggest that this is a widespread problem. There has been official outrage and promises to fix the problem.

It has been decades since I worked in a VA hospital, but this all sounds pretty familiar. Long wait times were also a problem when I worked in Group Health, a health care cooperative in Washington. The situation was similar: patients in the VA system often have care that is completely free of charge. This is true of indigent veterans, veterans with disabilities that are felt to be service connected and several other categories of eligibility. Even veterans who have to pay something for care have a pretty good deal compared to many private health insurance options.

In Group Health, costs for visits and medications were also really low which made people more inclined to wait for care or accept other inconveniences. At Group Health I remember my scheduler telling me that I was “a month out for routine appointments and 2 months out for routine physicals.” That meant that patients who wanted to see me for their stuffy nose would no longer have the same stuffy nose, and if they had pneumonia they would either die or avail themselves of some sort of emergency visit. For physicals it wasn’t necessarily a big deal except that patients had to schedule their lives around when they needed to be in town to see me. For a physical. I can see scheduling a trip to Europe or an audience with the Dalai Lama that far out, but it did seem kind of wrong to schedule a physical 2 months away. And then, naturally, they would forget, because that’s a long time to keep something on your radar.

The reason for the long wait times was that Group Health, like the VA, was a system in which there was a certain amount of money per patient to be served and the administration wanted to spend as little of that money as possible, so as to stay under budget. One way to save money was to hire fewer physicians and ask them to see more patients. As physicians we either needed to see patients more quickly or have longer wait times, which naturally got even longer as time passed. I felt inadequate because I couldn’t see patients faster and frustrated when long wait times meant that patients were sicker when I finally saw them, meaning that I really couldn’t see them in a short amount of time. When I saw sicker patients I had a tendency to order more tests and referrals, which made the patients cost the system more, which made the budget woes of the company worse, encouraging them to further curtail their staffing. False economies with support staff were also common, when phones went unanswered leading to angry patients who took more time to mollify and then received inappropriate care.

I have treated patients who get their care from the VA and they do tell me that it takes a long time to see their primary care doctor and there is so much turnover that they never really get to know him or her and that there is an even longer wait to be seen be specialty providers. The reason I see VA patients is because they actually do have other options than receiving all of their care through the VA. Many of them have Medicare and some have private insurance. Many VA patients end up in non-VA emergency rooms and are then admitted to non-VA hospitals. The VA pays for the hospitalizations, in those cases, if they don’t have the capacity to take the patient in transfer. It is expensive, but allows the VA to maintain their present capacity and staffing. The patients usually tell me they prefer to be cared for in the non-VA hospitals because they feel like they get better treatment. Still, when they can, they return to the VA because it’s free, or at least very inexpensive.

One of the articles I perused on VA statistics said that the cardiologists at the VA see far fewer patients per day than private cardiologists. I don’t know for sure that it’s true, but it sounds familiar. Private specialists usually make more money if they see more patients and so they optimize their efficiency. They often use nurses and physician’s assistants to gather much of the history and physical data they need so that they can just pop in and tell the patient the diagnosis and the plan. They have learned to perform the procedures that make up the majority of their income quickly and skillfully, because satisfied patients are loyal and lead to referrals, which makes for mutually enjoyable relationships and more money. In the VA the patients are a semi-captive audience and the physicians are on salary which doesn’t inspire efficiency. Once a waiting list becomes unmanageably long it ceases to be an effective motivator to see more patients.

Elected officials of all sorts are “mad as hell” about the care that veterans are receiving and are going to fix this problem. It would be nice if they could, but it will take huge commitment to change. The Veterans Health Administration is the second largest department in the U.S. government, with a yearly budget of over $150 billion. There is probably enough money in the VA system as it is to adequately staff it, but that will mean that they will have to cut administration costs and totally streamline what is undoubtedly a horribly complex and entrenched bureaucracy. The clinical culture will have to change. There needs to be some sort of incentive to provide really good service, which is difficult in the U.S., where this is usually provided by competition and money. Deciding to be excellent is an important step, but the VA is huge and has considerable inertia. Scandals and overhauls have been part of the way the VA rolls, including immense changes in efficiency about 15 years ago, with ripples that are likely part of what we are noticing now.

I have been a strong proponent for paying for health care by the person rather than by the visit or procedure, because that would cause us to care for patients in ways that reduce the cost and intensity of treatment. If sick people truly cost more to treat, preventing them getting sick would be economically advantageous. The VA is essentially prepaid, so why doesn’t it work this way, and how could it transform itself into a model of health promotion and sickness prevention?

I think there are several dynamics at work. First is that the consumers, the veterans, don’t have a say in how their benefits are administered. It is incredibly hard to uncover the budgets of any health system and it would be unthinkable to have the veterans who are actually cared for in the VA take a close look at how their money is being spent. Transparency and meaningful patient input would be powerful. Secondly, large bureaucracies grow and become more complex and less amenable to change with time. Tasks need to be simplified and administrative routines changed. Third, it doesn’t appear that there is imaginative leadership in the VA to reinvent a nearly ancient system in a way that preserves what is good and moves boldly in the right direction. Perhaps someone wants to take that on?

To summarize, then, the VA has been quietly suffering in its chronic inadequacy for decades. It serves an important role and has a unique way of operating which could, with the right interventions, be a model for excellent health care. The chance that any of this will happen soon, or because our leaders are suddenly mad as hell, is zero.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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