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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.

Thursday, July 14, 2016

VA Benefits: Isn’t the VA Supposed to Give Me the Benefit of the Doubt?


This week, we have an excellent article from guest-blogger Shannon Brewer, an attorney with Hill and Ponton, a law firm that specializes in veterans disability law. You can check out more of their blogs on their Veterans Law Blog.

The VA benefits system was designed to be a non-adversarial, veteran-friendly system.  The idea is that the VA exists to provide benefits to veterans who have earned those benefits through their service to this country.  In an ideal world, veterans would apply for and be granted benefits without a need for representation because the employees of the VA would assist them in filing and developing their claims.  Unfortunately, that is not always the case in the real world.  In the real world, veterans are faced with a back-logged and broken system which produces delays in receiving healthcare and benefits.  The veteran-friendly design of the VA benefits system, however, does provide some advantages to veterans that applicants for other federal benefits programs do not receive.  Veterans traditionally have benefitted from relaxed requirements for filing a claim as well as from relaxed standards of evidence required to prove a case.

Anyone who has watched a crime show on television is familiar with the standard of proof (or evidentiary standard) required to convict someone of a crime.  To send someone to jail for a crime, the prosecutor must show that it is “beyond a reasonable doubt” that the accused committed the crime.  This standard is exceptionally high in order to prevent innocent people from being convicted of crimes that they did not commit.

To obtain VA benefits, a veteran need not even approach “beyond a reasonable doubt.”  Veterans need only show that it is “as likely as not” that his or her current VA disability was caused by military service.  This standard is also called a “preponderance of evidence.”  In other words, if there is even slightly more evidence for than against a veteran’s case, the VA is supposed to award benefits.

This relaxed standard of proof leads to what we call the “benefit of the doubt” rule.  This VA rule requires that after the VA considers all evidence in a veteran’s case, if it finds that the favorable and unfavorable evidence is approximately balanced (or in equipoise, to use the VA’s term), the benefit of the doubt goes to the veteran.  To use baseball terminology, the tie goes to the runner. So if there’s a 50/50 chance that the veteran’s disability began during or was caused by service, the veteran is entitled to benefits.

This benefit of the doubt rule might come into play, for instance, where the veteran submits a medical opinion from his doctor which indicates that his back disability was caused by years of limping from his service-connected knee disabilities.  The VA then gets a compensation and pension (C&P) exam where the examiner’s opinion is that the back disability was not caused by the limp.  If both examiners have based their opinions on the correct facts and valid medical literature, and the evidence is otherwise equally split between favorable and unfavorable evidence, the evidence can be said to be equally balanced, or in equipoise.  In that circumstance, the VA should grant benefits to the veteran.  If, however, the VA determines that the veteran’s medical opinion was not based on the correct facts or was not based in valid medical literature, it has the freedom to determine that the evidence is not balanced and decide against the veteran.

So, while the benefit of the doubt rule can be a powerful tool in favor of the veteran, it is not a magic wand to repair cracks in the veteran’s case.   The benefit of the doubt rule does not require the VA to accept the veteran’s account of events if other evidence contradicts

The benefit of the doubt rule, however, is widely misunderstood and is often the source of great frustration for claimants. Despite what many believe, the rule does not mean that VA must make an award anytime a claimant submits an account of an event supporting an award. The rule also does not mean that VA has to believe a claimant, a claimant’s spouse, or claimant’s doctor when other evidence is in conflict with their statements. VA is always required to weigh such evidence against other evidence, such as service records or other medical opinions, but VA can find other evidence more convincing.

All the rule really means is that when all the evidence on a particular issue is equally balanced between positive and negative, VA must give the benefit of the doubt to the veteran on that particular issue. The rule only applies when there is a close call on some issue: when the evidence tilts one way or the other, the rule does not apply. Further, giving the benefit of the doubt on one issue does not mean the entire claim must be resolved in favor of a claimant. This is because the rule is applied to individual issues, not an entire claim. So, for example, resolving whether a certain event occurred during service using the benefit of the doubt rule does not have any effect on the issue of whether there is a nexus between the incident and a current condition. If the evidence is strongly against a nexus, the claim will still be (correctly) denied.
Pursuant to 38 C.F.R. § 3.102, any reasonable doubt must be resolved in favor of the appellant “when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter.”  “The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary.  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.”  38 U.S.C. § 5107(b).

“When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant.”  38 C.F.R. § 4.3.  Section 3.102 defines the term “reasonable doubt” as used in § 4.3 as doubt “which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.”  38 C.F.R. § 3.102; see Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001) (stating that section 3.102 “restates” the provisions of 38 U.S.C. section 5107(b) (benefit of the doubt) in terms of “reasonable doubt”).  Thus where the Board concludes that the evidence is not in equipoise, specific consideration of section 4.3 is not warranted.  See Schoolman v. West, 12 Vet. App. 307, 311 (1999) (explaining that where the preponderance of the evidence is against an appellant’s claims, “the benefit of the doubt doctrine does not apply”).  Mayhue v. Shinseki, 24 Vet. App. 273, 282 (2011).

Perhaps the analogy most helpful to an understanding of the “benefit of the doubt” rule is that the standard is similar to the rule deeply embedded in sandlot baseball folklore that “the tie goes to the runner.”  If the ball clearly beats the runner, he is out and the rule has no application; if the runner clearly beats the ball, he is safe and, again, the rule has no application; if, however, the play is close, then the runner is called safe by operation of the rule that “the tie goes to the runner.”  Similarly, if a fair preponderance of the evidence is against a veteran’s claim, it will be denied and the “benefit of the doubt” rule has no application; if the veteran establishes a claim by a fair preponderance of the evidence, the claim will be granted and, again, the rule has no application; if, however, the play is close, i.e., “there is an approximate balance of positive and negative evidence,” the veteran prevails by operation of 38 U.S.C. section 5107(b).  Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990).

The Court has held that the failure of the BVA to apply the benefit of the doubt rule or to set forth clearly its reasons for not applying it constitutes error.  See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Sussex v. Derwinski, 1 Vet. App. 526, 529 (1991).  In addition, the Court notes that 38 U.S.C. 1154(b) provides specifically that the Secretary “shall resolve every reasonable doubt in favor of the veteran.”  38 C.F.R. § 3.302.  Furthermore, when the BVA can cite no evidence or facts by which to impeach or contradict a claim, there is no justifiable basis upon which to deny application of the doctrine under 38 C.F.R. § 3.102.  Sheets v. Derwinski, 2 Vet. App. 512, 516-17 (1992).

Because the benefit of the doubt rule only applies in these specific situations, the rule is not applicable to many claimants. In cases where there is significant evidence in support of a claim, however, VA must provide a satisfactory explanation as to why the evidence was not balanced enough to apply the rule if the decision was adverse to the claimant.

Friday, July 8, 2016

Caring for our Heroes in the 21st Century Act —The Facts

I’m sure many of you have heard about the drastic changes recently proposed through the Caring for our Heroes in the 21st Century Act regarding VA Healthcare, but most of you are probably a bit confused about it, maybe without realizing it. I’ve read numerous articles from many different sources, and the contradictions are immense. One source stated that all VA medical facilities would be closed, another that they would continue to operate fully, and another that the VA would take on a payor-only role.

Frustrated, I finally went directly to the legal text. How are we to know whether or not to support something if we don’t know the facts?

So what does the bill actually propose and what does it all mean? Let me break it down.

In June, a proposed bill was announced called the “Caring for our Heroes in the 21st Century Act”.  (This is different than the Commission on Care report that was just released and which we’ll discuss next week.) This bill is a “discussion draft,” meaning that it isn’t the official legislation that will ultimately be passed, but just a way to put these ideas out there and get people discussing it. Because of this, it’s fair to assume that quite a bit will change before anything’s made official, if it ever is.

Regardless, if published as is, this act would essentially do three things:

1. Replace the Veterans Health Administration with an independent non-profit corporation called the Veterans Accountable Care Organization.
a.     The board of directors for this corporation would include the Secretary of the VA and other government appointed persons, 49% of which must be veterans themselves.
b.     Personnel and assets from the VA would be transferred to this corporation, terminating the Veterans Health Administration and all its functions within one year (timeline could be extended). While VA employees may be transferred, the corporation has the right to hire and fire at will.
c.      The new non-profit would continue to run all previously VA-administered healthcare centers and services, with an emphasis on the centers of excellence for service-connected injuries.
d.     The only health-related services that wouldn’t transfer to this corporation but would continue to be run by the VA are nursing home and domiciliary care.
      2. Establish two veterans health insurance programs: the “VetsCare Federal Program” and the “VetsCare Choice Program”.
a.     The VetsCare Federal insurance would cover all services offered by the new non-profit corporation (above), but any medical services for a non-service connected condition are to be covered by medicare or other insurances first before this would cover it. Pretty much all veterans currently eligible for VA Healthcare will be eligible for this.
b.     The VetsCare Choice insurance would cover any medical services received in the civilian sector, but any medical services for a non-service connected condition are to be covered by medicare or other insurances first before this would cover it. All vets are eligible for this unless they are enrolled in VetsCare Federal or if they are eligible for Medicare (or “VetsCare Senior”).
c.      When enrolling, the veteran would have to choose between the Federal and Choice programs. They can’t get both. So, basically, they would have to decide to either be treated fully by the Veterans Accountable Care Organization or by civilian providers.  (Disclaimer: The text regarding this principle is contradictory. At one point, the bill says that the Choice program is in addition, but then thoroughly discusses that it is in lieu of and that veterans must choose. Because of this, we think that veterans will have to choose and cannot do both, but this inconsistency will be ironed out in the future and may end up going the other direction.)
       3. Set up the VetsCare Advisory Commission. This commission would be in charge of :
a.     Analyzing the formation, implementation, and policies of the non-profit corporation and insurance programs and reporting to Congress on their progress for the purpose of ensuring that veterans have proper access to quality health care.
b.     Closing or realigning health care facilities. During the process of transferring things from the VA to the non-profit Veterans Accountable Care Organization, the Commission can decide which of the VA medical facilities (hospitals, clinics, etc.), if any, should be closed or realigned.  “Realignment” basically means that the facility will be under new administrative organization but will continue to offer services. Congress must approve all closures and realignments, and the Commission must guarantee that the veterans in those areas have sufficient access to their necessary healthcare.

That’s the entire proposed bill. So will all VA health facilities close? No. Some might if the Commission decides that they should, but the majority will remain functioning, just under the administration of a new, independent, non-profit organization.

By separating the actual medical services from the VA organization and instating a VA-run health-insurance program, the VA will definitely be moving closer to a payor-only position, but not entirely since nursing homes and other VA programs will still be run by the VA.

With the new health insurance options, it would be easier for veterans to receive health care in the civilian sector, but proponents of this bill are a bit deceptive about this. Most claim that this will allow veterans to be seen by any doctor anywhere and receive whatever treatment they choose. False. The reality is that the pay rates for this insurance will only be slightly higher than Medicare, and so quite a few doctors will not accept it, just as many don’t accept Medicare. Yes, veterans will have higher priority than those on Medicare, but only just. It would have to compensate quite a bit more in order for it to be a desirable option for the best specialists out there. So just to be clear, this won’t be a magic pass to any doctor anywhere.

I’d also like to point out the fact that many proponents of this bill are ignoring the steps the VA has been making (although progress is slower than this bill would allow) towards getting veterans greater access to care. The current Veterans Choice program allows veterans who are unable to obtain the necessary care within the VA system due to location, appointment availability, etc., to turn to the civilian sector for treatment. True, this program still has not met the needs of all of our veterans, and the proposed bill would greatly broaden the availability of these benefits, but efforts in this direction are not non-existent. 

Now proponents of the bill are definitely not the only ones to be making false or misleading claims. Some critics are claiming that by sending veterans to the civilian sector for healthcare, they will no longer have access to the specialized care that some veterans need, like ones with amputations, PTSD, or other conditions that are common to the veteran community. Yes, as discussed above, not all civilian physicians, especially the top specialists, will accept the proposed insurance program. But, as also noted above, the centers of excellence where the top research and treatments are being done for these kinds of conditions will still function under the non-profit, and veterans will have full access to this treatment, just as they do now.

A possible issue that I foresee could come with the Commission’s decision to close some facilities. Although the regulation is in there that they cannot close a facility without ensuring that veterans in that area have access to healthcare, it’s really difficult to be able to fully ensure that. If a major VA Health Center were to close, the local civilian sector would be flooded with a really large new population of patients. There would need to be a significant growth of the private sector in order to properly absorb this new demand, and that could take awhile. Such a transition would have to be very carefully planned and orchestrated to ensure that veteran care is not interrupted. It’s possible, but definitely a part of this bill that I’m concerned won’t play out as nicely as it sounds.

Additionally, having two exclusive insurance options could cause some problems since being able to receive care in only the private sector or only through the Veterans Accountable Care Organization is rather limiting, not allowing veterans the ability to truly choose the best care for all of their conditions. If a veteran has only one condition, no problem, but most have many.

For example, if I had a condition like TBI that would best be treated at a center of excellence, I would definitely want to go there for my treatment, so I choose the VetsCare Federal. But, wait. I also have another condition that isn’t as well cared for within the Veterans Accountable Care Organization. There is a really good civilian doc in my area that would give me the ideal care, though, so I choose the VetsCare Choice? Suddenly, I have to choose which condition should receive the best treatment since I can’t do both. Why do they have to be separate?

Another issue:  There is quite a bit of back-and-forth regarding the pros and cons of privatizing the veterans medical system. As a physician who has worked in both government health care (active duty military and the VA) and in private (current), I would like to share a few personal thoughts on this.

I loved being a physician in the military. I wanted to provide quality medical care for both the service members who were dedicating their lives to our country and their families. My passion is patient care, but it didn’t take long before the only way for me to get my next promotion (and thus the next pay raise) was for me to leave patient care and move into management, which I did.

As a medical facility commander, my main focus was to provide top patient care and customer service at each facility I managed, but I was very limited in the ways in which I could encourage my patient-care staff. Verbal praise is nice and all, but pales in comparison to a bonus given for productivity and patient satisfaction. I also was limited in my abilities to get rid of my worst performers, and it was often a nightmare trying to find a way to work around them. The VA’s current system has the same limitations. An independent non-profit organization like the one proposed would allow employees to be managed like they are in the private sector, thus greatly increasing the efficiency of the VA medical system.

After retiring and returning to patient care in the private sector, I encountered an entirely new system of medical practice. As a physician, I get recognition and bonuses for both productivity and patient satisfaction. This makes me a much happier doctor who is more than willing to stay late to take care of a patient who comes in just before closing because I know that that will go towards another bonus. I get very definite rewards for giving my patients better care and creating a more pleasant environment for them, and so does everyone in my office, from the desk staff to the techs. The hospital administration also has the power to fire low performers, thus creating a high quality staff whose main goal is to give each patient the best care we possibly can—something I believe our veterans deserve more than anyone.

Ultimately, I feel that our focus should always be on taking care of our veterans the best we possibly can, and I support any changes that would create a better system in which to do this.  


So, these are the details on the proposed Caring for our Heroes in the 21st Century Act. The Commission on Care report mentioned earlier also provides suggestions on how best to reform the VA Healthcare system in order to better serve our veterans, and we’ll blog about this next week.