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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