VA’s Healthcare System: Problems Undo Years of Progress

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McClatchy Washington Bureau

June 3, 2014

A healthcare system "uniquely positioned to lead the country in making ... positive changes in the way healthcare is delivered."

It's not likely that the Department of Veterans Affairs (VA) will be getting many takers on that anytime soon.

But just four months ago, that was the assessment the head of the VA's healthcare system offered in an article for a publication that serves healthcare professionals working in government health services.

At the time, it was a plausible claim: The VA had spent years overcoming shortcomings in its healthcare system to emerge in the 2000s as a well-regarded health system. It had problems—many of them flagged over the years by government auditors and inspectors general—and it was prone to exaggeration in touting its successes.

But reviewers inside and outside the VA had thoroughly examined what was the largest integrated healthcare system in the nation and deemed it more than adequate.

"It's good," Katherine Watkins, a researcher for the RAND Corp., a Santa Monica, CA-based think tank, said of the VA's mental health system, which she analyzed for a 2011 report. "For mental healthcare, the VA is doing as well or better than the private sector. And in some areas, it is doing 10 times better."

The VA's strengths have been in aggressively creating a unified, integrated system. It generally does well in making sure veterans get needed medications and with other types of ongoing, routine care. Its electronic records on patients allow it to closely track patient care.

In the RAND study by Watkins, for example, veterans who were hospitalized for a psychiatric condition received follow-up care within a week of discharge nearly half the time and nearly 80% received follow-ups within a month. Such performance was generally higher than among other health systems.

"Where comparable data are available, the VA performs as well as or better than private plans, Medicare or Medicaid," the study authors wrote in the journal Health Affairs.

That a health system derided by critics in both parties, slammed by its internal auditor, criticized by the Government Accountability Office and subject to vitriolic attacks by the very veterans it is intended to serve could get such positive reviews from a serious researcher reflects the conundrum that is the VA health system over the past generation.

In the past two decades, the VA's health system had remade itself, boosting outpatient and preventive care into a growing network that included hospitals, outpatient clinics and other facilities. It de-emphasized inpatient care and sought to boost mental healthcare.

Today, the system has 151 medical centers, 820 community clinics, 300 Vet Centers that offer counseling, and a range of other rehabilitation, residential and other care centers. While the number of veterans in the nation has gradually declined in the five years through 2012, the number of veterans enrolled in the healthcare system and the number of patients both increased by 12% or more.

In a nation of about 22 million veterans, not all are part of the VA health system; in 2012, 8.8 million were enrolled and 6.3 million were patients, according to VA planning documents.

For those veterans who do get into the system—because of their disability levels, prison-of-war status, income or other factors—there is widespread satisfaction. The American Customer Satisfaction Index, a national survey run by an independent organization that allows comparisons over time and among different sectors of the economy, regularly asks veterans about their experience

On a 100-point scale, VA's most recent score for inpatients was 84—four points higher than the score for inpatients in private-sector hospitals. For VA outpatients, the score was 82, just one point below the private-sector score. Those numbers are from 2013.

The survey asks a range of questions about "how accessible and easy" it was to use the VA, how courteous the staff and doctors were, how long the waits were for prescriptions, and whether the patient, overall, found the quality of care high and the experience generally satisfying.

Despite the increase in patient loads and the recent wait-time scandal, the VA—in the eyes of veteran patients—hasn't changed much at all over time, according to a March 2014 survey report. Over the past 10 years, the annual reports show that overall satisfaction among inpatients and outpatients hasn't budged.

Beyond that, the "customer service" component of the survey "remains the greatest strength for VA with a score of 91," the survey report says. The percentage of veterans in the survey who had made a complaint about their outpatient care was down to 8% in 2013, and among inpatients down to 14%; both figures are down over recent years—from the mid-teens for the outpatient survey and from above 20% for the inpatients.

Veterans and healthcare experts say the disconnect between the saturation scandal coverage and the positive customer reviews is partially explained by the fact that veterans who do get into the system generally don't have to pay for it. Many veterans don't exclusively get their care from the VA; they also tap Medicare or private sources for treatment, and if their VA care for a specific condition or routine treatment is free they're likely to retain positive feelings about it, experts said.

As Sen. Bernie Sanders, an independent from Vermont who chairs the Senate Veterans' Affairs Committee, said on CBS over the weekend: "The truth is that when people get into the VA, the quality of care is good. The problem that we have to address is access to the system and waiting lines."

He added that the VA "in many parts of this country is providing excellent healthcare—in some cases, cutting-edge healthcare"—but that in some places the system simply did not have the doctors and the staff to make sure the veterans got timely care.

That led to the gaming of the system by staff—all in an effort to make their internal numbers look good.

But what's also clear is that the gaming had been going on for years.


In 2005, a report from the agency's inspector general found VA schedulers routinely put the wrong requested appointment dates into the system, making wait times appear to evaporate. In many cases, the scheduler checked for the next available time slot and declared it the patient's "desired date."

On Oct. 2, 2003, the inspector general said, a veteran was referred to an ophthalmology clinic. On May 3, 2004, a scheduler created an appointment, saying the "desired date" was June 21. The appointment was scheduled for June 23, the inspector general said.

Actual waiting time: 264 days. Reported waiting time: two days.

Some schedulers even kept "informal waiting lists" to consult when they were ready to make formal appointments. Investigators found that 41% of appointments contained errors in the desired dates, and that only 65% of a key type of appointment they analyzed were within 30 days of the desired dates.

Those examples were from a McClatchy Washington Bureau story in 2007; the issue was discussed in Congress and in repeated inspector general reports. But it didn't gain traction as an issue until it was put in the context of poor care or deaths resulting from those faked waiting times—an allegation that is still being investigated.

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