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Monday, July 18, 2016

The Commission on Care Final Report—The Facts

On June 30th, the Commission on Care released their report to the VA with recommendations on how to best address and fix the issues within the Veterans Health Administration (VHA).

The Commission on Care is a board of specialists that was formed by the Veterans Access, Choice, and Accountability Act of 2014. Their specific purpose was to review and analyze the current VHA, identifying problems with the system that have been interfering with the ability of the VA to provide adequate healthcare to veterans.

After more than a year of work, the Commission published their final report. The report identifies the primary weaknesses within the VHA and provides 18 recommendations on how best to fix these issues.

It is necessary to note that this report comes less than a month after the Caring for our Heroes in the 21st Century Act was submitted to Congress. That act calls for a major overhaul of the VHA, switching VA healthcare over from a government run organization to an independent non-profit. I discussed the details of that bill, including pros and cons, in a blog last week.

Interestingly, the Commission on Care’s report offers many similar suggestions as the act, but without officially privatizing the VHA. Ultimately, the result would be pretty close, if fully realized.

Below, I’ve discussed the facts of each of the 18 recommendations sequentially and provided my personal thoughts on each.


Recommendation #1: The VHA Care System. This proposed system would create area-specific networks of both VA and VA-approved civilian healthcare providers. Veterans would have the ability to choose their primary care providers from anyone within the network, who would then be in charge of referrals to specialists. The basic idea is to create a network that combines the best aspects of both the civilian and VA health services in each area in order to specifically meet the unique needs of the veterans in that area. All civilian providers would have to be credentialed by the VA in order to join the network.

Thoughts: Good recommendation overall. It would definitely expand availability to care, and the focus on getting providers that meet the specific needs of vets in a given area is great. Requiring civilian providers to be credentialed is a good way to ensure quality, but it might discourage many of the best providers from doing it because of the hassle. This recommendation also doesn’t truly provide free choice to the veterans. It’s more of a modified HMO than a PPO with the primary care provider closely overseeing all aspects of the veteran’s care.

Recommendation #2: Improve VHA staffing. The Commission determined that a huge part of the current problems at VA facilities is due to insufficient staffing. This recommendation is for the VHA to focus specifically on improving the support staff at facilities to enable physicians more time to provide quality care with less time spent doing things that could by done by support staff.

Thoughts: Yes. This is definitely an essential step to improving VHA care.

Recommendation #3: Clinical appeals. The VHA currently doesn’t have a single set system in place in regard to clinical appeals, so resolving disputes regarding a patient’s care is difficult, to say the least. The Commission recommends that the VHA adopt a clinical appeals process similar to ones used by private health insurance companies.

Thoughts: This would make life easier for so many. Having a single system would ensure that the system is understood across the board, resulting in fewer vets getting the run-around from confused employees. It would also ensure that similar cases are adjudicated the same, thus creating a more fair system, similar to when the DoD switched all the branches over to using the VASRD.

Recommendation #4: The Commission recommends that the VA create a “culture to inspire and support continuous improvement” to the VHA system. To do this, the VA would use the Veterans Engineering Resource Center to more effectively share best-practice ideas throughout the VHA system. Reengineering centers would also be used to identify problem areas and offer support to fix them.

Thoughts: This recommendation is an incredibly vague solution to a very real problem, which concerns me. As I discussed in my comments on the Caring for our Heroes in the 21st Century Act I blogged on last week, a big problem with the VHA is the inability to properly manage the business-side of things. An organization needs the ability to incentivize their employees, reorganize their system if the needs of their patrons are not being met, fire underperformers, etc. While this recommendation acknowledges this problem, the solution is underwhelming. Sharing ideas doesn’t give anyone the actual power to fix things. Who knows? Maybe this would actually set a base that would encourage change in the right direction, but I’m skeptical.

Recommendation #5: Eliminate any disparity in health care among vets. The Commission notes that there is data that shows inequalities in the care minority and vulnerable veterans receive. The Commission calls for proper funds and support to be given to the Office of Health Equity in order for them to fully implement programs to eradicate such inequalities.

Thoughts: Why is this still an issue? Fix it. Now.

Recommendation #6: After establishing the VHA Care System, the Commission recommends giving the governing board of the system the power and freedom to fully control all decisions regarding facilities and assets. This would allow them to close facilities that are not beneficial to the veterans and then reassign those assets to areas in which the veterans’ needs are not being met.

Thoughts: Currently, everything has to go through Congress, meaning that rarely do things get effectively done in a timely manner. The VA has lots of underutilized resources right now, and taking the power away from Congress and giving it to the board would allow these resources to be properly allocated. It means that they’d have the power to make sure that our tax money is best used to benefit the vets.

Recommendation #7: Modernize the VA’s computer systems to a single, all-inclusive program that will streamline information sharing with all levels of the VHA and the veterans. This single system would oversee every aspect of a patient’s care, from billing and scheduling, to test results and data sharing.

Thoughts: Yes. Old computer systems that do not properly coordinate all aspects of a patient’s care just make everybody’s life harder. As a doctor, I can testify that a bad computer system directly impacts my ability to provide the best possible care that I can. This will also save a ton of time and money on administrative issues, and the veterans will ultimately be happier.

Recommendation #8: Completely reorganize the supply chain management to enable money-saving practices by eradicating bureaucratic involvement in purchasing requirements and procedures. The Commission believes that by properly reorganizing the supply chain management, the VA could save hundreds of millions of dollars.

Thoughts:  I have to quote something directly from the Commission’s report:

“VHA cannot [currently] modernize its supply chain management . . . because it is encumbered with confusing organizational structures, no expert leadership, antiquated IT systems that inhibit automation, bureaucratic purchasing requirements and procedures, and an ineffective approach to talent management.”

Dang. It is seriously refreshing to see that the Commission really looked honestly at the VA’s system. It is incredibly flawed, and not just in supply chain management. A serious reorganization of the organization’s structure is necessary in order to fix the many deep-rooted issues that negatively impact our vets. This recommendation would also lead the VHA away from the government-driven unit to a more independently functioning organization. And if this change could save us hundreds of millions, then let’s do it.

Recommendation #9: Establish a board of directors that would take over the governance of the VHA. The Commission states that the current politically appointed leadership is extremely weak for numerous reasons, including their short terms and their need to please too many stakeholders.

Thoughts: Only good can come of this. The VHA needs leadership that has the power to make concrete changes that are for the good of the veterans. Political puppets simply cannot meet the needs of those the VHA is supposed to be serving.

Recommendation #10: Create a strategy to fix the working culture of the VHA to better align staff and leadership with a single mission. The Commission noted that the VA has the lowest organizational health in government. The idea is that by having all leaders uphold and promote a specific cultural concept, employee morale will increase significantly, thus improving job performance.

Thoughts: Again, this point hits on something vital, but is underwhelming in its suggested fix. The employees at the VA need to provide better service, no question. To provide better service, they need to have a better environment at work, no question. But is just being indoctrinated with a principle by leadership really going to work? It’s a great idea to have common ideals and goals throughout the system, but without providing employees with real, concrete incentives, a true, lasting change isn’t going to happen. Employees need to be clearly rewarded for doing better work.

Recommendation #11: Create a model for the leadership pipeline that will enable the VHA to properly prepare and promote strong leaders throughout the organization. This model would reflect many of the successful models used in the private sector, and it would allow employees to have clear indicators of the qualities necessary for each leadership level and how to develop them. The model would also guide those in leadership positions to help them fully fulfil their leadership potential. Finally, the Commission recommends that Congress provide more opportunities to recruit strong and experienced leaders from the private sector.

Thoughts: An organization is only as solid as its leaders. Good employees can only make up so much for an incompetent leader. If the new proposed VHA is going to succeed, it must make changes that will allow the best candidates to fill leadership positions. To fully realize this, however, the VHA must not be limited on who they can and cannot hire, fire, and promote. Control of personnel is necessary to ensure the best leadership.

Recommendation #12: Reorganize the management processes in order to empower local leadership and eliminate waste and redundancy. The Commission points out that the responsibilities of current leadership roles are vaguely defined, creating confusion, waste, and a lack of power to properly lead and make changes. To fix it, they propose redesigning the leadership structure to create clearly defined roles and responsibilities. In addition, they propose giving the lowest leadership levels the means of decision-making so that they have the power to actually get things done.

Thoughts: Essential. In order to properly fill the needs of the veterans in a particular location, the local leadership must have the power to make the changes necessary to do so. Effective leadership only comes when leaders have a clear understanding of their roles and the power to properly fill them.

Recommendation #13: Create a model identical to those used in the private sector to measure personnel performance. Leaders will be given the power to ensure that their employees perform within the expectations, with the focus on long-term morale and overall wellbeing, not just short-term results. The VHA will “recognize meaningful distinctions in performance with meaningful awards.”

Thoughts: Now we’re getting somewhere. To create a positive work environment with high performing employees and satisfied patients, leaders must be able to provide strong incentives. While previous recommendations say that local leaders will be given far more power, nothing concrete has been said about their ability to control funds. This makes me question what type of “meaningful” rewards they can actually give. But we’re headed in the right direction, for sure. A trip to Cancun? People are going to care. A big bonus? People are going to care. A smiley-face sticker?  . . .

Recommendation #14: Ensure that all leadership, staff, and employees (including civilian providers in the network) are thoroughly trained to understand the military and cultural-specific needs of the veterans they serve.

Thoughts: It goes almost without saying that veterans are a unique patient group with very unique needs. People who have never experienced military culture, particularly deployment, simply cannot fully comprehend what our veterans have experienced. With needs that are more than just physical, civilian healthcare simply is not enough to give complete care to each veteran. This training is an excellent suggestion that will greatly improve the care our vets receive.

Recommendation #15: Completely rewrite the laws governing the personnel system to create an employment system similar to the private sector in recruitment, benefits, compensation, regulations, promotions, disciplinary processes, leave, training, and more. The Commission notes that the current personnel and staffing problems are caused by an out-dated HR system, difficult hiring processes, lower pay scales, and more.

Thoughts: To attract the best employees, the VHA must employ a system that will ensure that the employees are properly treated, compensated, and promoted. Right now, it doesn’t compete with the private sector at all and thus is severely understaffed. Make it competitive, and the number and quality of employees will greatly increase.

Recommendation #16: Create a system to ensure that these HR changes are put into effect and remain beneficial. This recommendation would create a Chief Talent Leader position at the executive level of the VHA who would be in charge of transforming and managing the HR enterprise, with the proper funding to ensure consistency throughout the system.

Thoughts: I second something the Commission says: “Effective planning for and management of human capital are core enabling requirements for any business: If the system that supports the employees fails, then the organization fails.”

Recommendation #17: Extend healthcare eligibility to those with other than honourable (OTH) discharges with extenuating circumstances. Basically, service members with OTH discharges are not considered vets, and so not currently eligible for VA healthcare. However, many of them received OTH discharges because of service-connected conditions, like PTSD or TBI. The Commission feels that these individuals deserve VA healthcare for their service-connected conditions.

Thoughts: Congress has started to address this issue, albeit very slowly. All I can really do is state my personal thoughts on the matter. If the OTH discharge was caused because of circumstances relating to a service-connected injury, then military service is responsible, and isn’t it a part of the VA’s mission to provide for service members who have been negatively impacted by their service?

Recommendation #18: Create a group of experts whose purpose is to re-evaluate and reformat the VA’s eligibility design for benefits. This group would be given the funding necessary to fulfil their purpose.

Thoughts: Not sure how long term this group would be, but if Recommendation #17 is going to be realized, someone has to make it happen.


That’s it. As I mentioned before, the recommendations are very similar to those in the Caring for our Heroes in the 21st Century Act, but much more thoroughly detailed and developed. The VHA would basically become an independent entity without officially being a separate corporation. This separate-but-not-separate organization could end up causing some unforeseen issues, but overall the recommendations in this report would definitely lead the VHA to a much more effective system and ultimately to providing better care for our veterans.

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