Health Care at Dept. of Veterans Affairs … What Went Wrong?

mACmILLANBy: Dr. Frank MacMillan – June, 2014

A decorated General resigns, a President is besieged, and a certain Arizona Senator is fit to be tied. Newspapers say the VA is in scandal, people die waiting for care. What happened?

The Department of Veterans Affairs is an agency of the federal government that does a lot of things. Chief among them is that it runs a health care system that takes care of our veterans who have “service connected” injury and disability after their service has ended. The Armed forces have a separate parallel health care system for active duty personnel, and there is a third system called Tricare, that cares for military dependents (the families of service personnel).

It is first necessary to understand that the VA system touches not only service connected veterans, but in fact, every physician who has gone to medical school in the United States, and/or has done an internship or residency. Your family physician, obstetrician, and surgeon all have first hand experience at the VA, because the VA is in every major city, and is affiliated with every major medical school. If you want to talk with someone who knows a bit about the VA, you only need to call the local doctor you have known many years because chances are excellent that he or she had rotated through a VA facility probably more than once in their career.

I personally rotated through the West Roxbury VA, the Jamaica Plain VA, and the Manchester NH VA. The three Boston area medical schools including Boston University, Harvard and Tufts all depend on the VA facilities to help train their students and residents. I can tell you that some of the finest and most skilled physicians that I have ever met, and have had the privilege of training under, had their primary affiliation at a VA facility.

So, how does a system with so many assets fail so miserably at getting the veterans with the most need timely access to their doctors and nurses? There are two reasons: administrative bloat and poor accountability. Many physicians who train at VA facilities do not stay because it is necessary to learn a new language to function. There are a seemingly infinite number of regulations and processes to getting anything done, there is a culture of the “system”, and medicine does not work like that anywhere else. My own observation is that veterans themselves are very appreciative of the care they receive, and almost never complain when something isn’t right. It must come from the experience of serving, they are used to the queue, and don’t usually try to manipulate the process, because everything in the military has to go through a process to produce a result.

Given the enormity of the scandal, there has been a call for heads to roll, and this is happening already. The problem of access will not be solved by decapitating the agency however. While the VA probably comes close to meeting a reasonable person’s definition of socialized medicine, so does the Army, so does Medicare, and so does Tricare. Nobody is talking about dismantling those programs. Where we are, at present, is a crisis where there is an unaccountable bureaucracy that is entirely deaf to the voices of its constituency, and that constituency of veterans has no recourse to go elsewhere and force the VA to respond to its needs. There is also a lack of oversight that can only be described as criminal, where incentives to improve access to veterans are manipulated in such a way that bonuses are paid for bogus endpoints. This should be prosecuted to the fullest extent of the law, and jail time for such offenses may be appropriate.

We don’t need to destroy the VA to save it. The Tricare program, which runs just like Medicare, allows military dependents to go to any private doctor or facility that accepts its payment (exactly the same as Medicare). Veterans should be able to have a similar portable benefit that allows them to access the civilian medical system. Having been at three VA facilities in my career, I expect that many vets will continue to use the VA system. There is a good side of that culture (outstanding doctors, veteran camaraderie) that has been forgotten in the scandal, but veterans do not deserve to be held hostage to a system when it doesn’t respond to their needs. Let’s not kill it to save it, but rather give our veterans a portable benefit that solves the access problem, and provides our VA system with the proper incentives to reform itself.

Frank MacMillan, Jr, MD, FACG

Dr MacMillan specializes in Gastroenterology and Liver diseases, is a Fellow of the American College of Gastroenterology and it’s Massachusetts Governor. He is Vice President of the Massachusetts Gastroenterology Association. Dr MacMillan is a native of North Andover and practices Gastroenterology in Haverhill at Merrimack Valley Hospital, where he currently serves as the Chief of Medicine. He has also been a member of the North Andover Board of Health since 2007.