Blog | Thursday, July 17, 2014

Lessons from the VA--bad performance measures and insufficient primary care

The New York Times has come great reporting on the fundamental problems leading to the “VA crisis.” Doctor Shortage Is Cited in Delays at V.A. Hospitals . The article points out 2 problems.

Let’s first look at the second problem. Administrators cheated to obtain bonuses. Why did that happen? The central office set a performance standard related to how quickly new patients had appointments. What happens when we give performance standards? Unintended consequences! Administrators cannot make physicians see every patient, so they created “work arounds.” Now those administrators are guilty, but I would submit that the performance standard idea should also get blame.

A more important problem comes from the lack of sufficient primary care physicians. This article delineates the problem beautifully. As a former VA physician (part-time for 20 years and only inpatient the last 10 years) I can tell you that the patients who frequent the VA require intense primary care. They often have multiple medical problems and often psychiatric problems. Now the electronic medical record is the best I have seen, but it still takes time to type notes and review the charts.

The VA has great benefits, and often reasonable hours, but the salaries are not great from primary care. And the U.S. has a shortage of primary care physicians, especially internists (who the VA seems to favor). Primary care internists have multiple options. Less internists do primary care than 15 years ago, and partly because many do hospital medicine (higher salary, more predictable hours, and more “days off”).

The VA crisis in primary care will continue until the job improves. The crisis will not stop with the VA. We will soon see the same crisis for Medicare patients and Medicaid patients.

We have to improve the job. We have to decrease the administrative hassles dumped on primary care physicians (actually all physicians). Primary care is the lynchpin of our health care system. Excellent primary care improves outcomes at a lower cost. And our politicians and our insurers have not addressed this issue. We do need to work very hard to fix this problem. The extra moneys put into primary care will save downstream medical costs.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.