Conversation About Veterans Administration’s Woes Has Not Yet Hit the Right Note

Current proposals to correct the VA’s course include firing Secretary Eric Shinseki (who resigned on May 30), ordering a criminal investigation by the FBI, and providing more funding to the VA. Meanwhile, the VA has seen an influx of 1.5 million veterans in the past three years, and 200,000 of them suffer from post-traumatic stress disorder (PTSD) or traumatic brain injury, according to Senator Bernie Sanders, Chairman of the U.S. Senate Veterans Affairs Committee.

But scapegoating the agency head, placing blame following a criminal investigation or more money won’t resolve the crux of the problems at the VA. In my opinion, the problem plaguing the VA is a function of both an increase in case volume AND a dramatic shift in case mix. Not only are there more patients, but also many have more serious physical and psychological difficulties than those seen in generations past. All of this could have been anticipated.

When I practiced emergency medicine in the 1980s and early 1990s, I know that my colleagues and I sometimes referred to certain patients in the ER as “the vet in bed x.” This was insensitive code for a person who often had chronic illnesses of one or other type. Although we had not lived through Vietnam as adults, we witnessed its aftermath, and we wondered out loud what the impact of future long wars might be for our generation and our healthcare delivery system.

This predictable influx of veterans returning from active battle increases the volume of patients. The new weapons of war and advances in medical care have increased survivability…so there are more survivors with more serious injuries. The length of the conflicts and the multiple deployments have dramatically increased the psychological toll on soldiers and families…and the VA, in the background, is experiencing the challenges of the aging baby boomer population…as is the rest of the healthcare system. But while the current situation might be predictable, the necessary rethinking of service delivery has yet to take place.

Today’s VA is handling a very different proportion of ailments compared to the VA of 20 years ago. Where “volume” problems can be ameliorated by providing more facilities, more providers and even – some may think – voucher-type programs (such as those often proposed in education), these “interventions” fall short in addressing case mix issues. I believe we need fresh, new approaches on top of the obvious management responses of accountability and resource increases.

What will help? We have an opportunity now to create an “Apollo Program” of sorts; the type of program designed to address a big national challenge. Solving the problems of the VA can generate insights relevant for the rest of the healthcare system. While the size of the VA and the magnitude of problem may be daunting, it also offers a fantastic multi-site environment for thoughtful re-imagination, piloting, review, tweaking.

I hope those making decisions do not seek simple solutions to complicated problems. I suggest that a high-level team be convened, led by thought leaders outside and inside the VA. More specifically, I think the deans of some pre-eminent schools of public health (like my alma mater, the Johns Hopkins Bloomberg School of Public Health which believes in “protecting health, saving lives millions at a time”, and Harvard) would be thoughtful leaders. They could engage with experts from the likes of Kaiser Permanente (for their expertise in large group care and emphasis on wellness), from South Africa-based Discovery Health and with health leaders from places like The Netherlands or Israel and others who could bring a health services research rigor to bear. Additionally, technology experts and technology could play a role, thinking through solutions that can arise from telemedicine, social networking and other avenues.

Meeting with no “a priori” assumptions of the VA situation, this group would provide long-term solutions that rise far above finger-pointing and necessary accountability. The work of this group could have significant collateral effects, showing us how to handle any massive increase in certain types of medical cases, including Alzheimer’s disease, and other diseases related to the large influx of aging Baby Boomers.

While I may be dubbed an optimist, the bottom-line for me is that today’s VA mess can be a great opportunity: we should seize the moment and bring the best fresh thinking on and thinkers from around the globe, with the appropriate rigor, to bear. We owe it to the Veterans and to the country.

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