Difficult Issues at the VA
Arthur L. Caplan, PhD: I'm Art Caplan, from the Division of Medical Ethics at the New York University (NYU) Langone Medical Center. Welcome to Close-Up. This is an interview program during which we have the opportunity to talk to leaders in healthcare, health policy, and medicine. I am happy today to have a colleague of mine, Dave Chokshi, with me, who is in the Department of Medicine and the Department of Population Health at NYU Langone Medical Center.
I want to explore two areas with you. One is a big, and very tough, topic that will be of interest to many readers; that is the US Department of Veterans Affairs (VA). We hear about all kinds of issues and problems confronting the VA. We have a new VA Director. You had an opportunity to spend some time at the White House as a White House Fellow working on VA issues with the head of the VA at that time, and you have been thinking hard about where the VA should go.
Let me go right to the hard question. Why do we need the VA at all? Should we do away with it?
Dave A. Chokshi, MD: I don't think so. As you mentioned, I had a chance to work with Secretary Shinseki, who was heading up the VA. I was there in 2012 and 2013, and one thing that I took away from that experience was getting to know both the employees at the VA and the veterans whom they serve. Beyond healthcare, the VA beyond has an incredibly important mission to serve people who have served our country. In many cases, it does the best job of any service organization that is trying to take care of those veterans' needs.
Dr Caplan: Clearly, it is a huge system, with facilities all over the United States. It might be as big as the British National Health Service, if not bigger.
Dr Chokshi: Depending on how you measure it, yes. The VA has 151 medical centers and more than 800 clinics, and that is just the healthcare delivery system of the VA. The VA also takes care of many benefits, including educational benefits, housing, and employment training, as well as cemetery administration. So, it is a very large system. In some ways, it makes sense to have that comprehensive set of benefits under one agency within the federal government.
Waiting for Care at the VA
Dr Caplan: We keep hearing about VA hospitals being overwhelmed, and waiting lists. What is your read on complaints that veterans have about access to services?
Dr Chokshi: The access question is a challenging and complicated one. What we have seen come to light over the past few months is capacity constraints within the VA, particularly when it comes to outpatient appointments in both primary and specialty care. There are gaps and delays in both of those realms. Because the number of veterans who are enrolled in the VA has increased recently, and because of a more general shift from hospital-based provision of medical care to ambulatory care, we have seen a very big surge in the number of outpatient appointments in the VA system. The numbers have increased from 58 million appointments in 2005 to an estimated 95 million appointments this year.
Dr Caplan: Is that the aging population—more eligible people? What is going on?
Dr Chokshi: It is a combination of factors, including an increase in enrollment. There were 7.7 million veterans enrolled in 2005, and 9 million veterans enrolled this year. There is a slight increase in enrollment, but more generally, it is a consequence of the idea that we can provide more of our medical care in the outpatient setting. So we are seeing a transition from hospital-based services to outpatient-based services, and that is where the VA has struggled to keep pace with demand, even though considerable resources have been invested, particularly in the Obama administration. The VA healthcare budget has approximately doubled during the Obama administration years. There is a resource question, and we may talk about the recent law that President Obama signed to try to address some of those constraints, but there are also some real management issues that have to be grappled with.
Dr Caplan: Tell me about that.
Dr Chokshi: Ken Kizer, who was the Undersecretary for Health and was in charge of the VA healthcare system during the Clinton Administration, has written the most cogent analysis of this. Much of what had been decentralized in terms of administration, operations—the organization of delivery of healthcare among those 151 medical centers and more than 800 clinics—has become centralized again, with a gradual accretion of personnel in central office management. That is a big problem. The size and scope of what the central office is responsible for makes it challenging to have meaningful oversight. That is issue number one.
The second issue -- and it's not a particularly sexy topic, or one that catches headlines -- is the performance metrics that are being used to evaluate the delivery of healthcare.
Dr Caplan: How does that get in the way?
Dr Chokshi: The wait time for appointments is a good example of how that has been a challenge. That was at the center of the crisis that the VA has been facing over the past few months.
The central office decided to choose a performance metric, which was that a veteran would be seen within 14 days for a first primary care appointment. Because of the capacity constraints, that was probably an unrealistic metric, and a sequela of that was that if people couldn't deliver on the metric, they would find ways to try to game the metric to achieve it. That doesn't excuse the unethical choices that were made in some cases in terms of falsifying those data, but we have to look at the system level implications of it as well.
Should the VA Outsource More Care?
Dr Caplan: You can't set a goal that you can't reach. Before the recent troubles that have beset the system, a lot of people were saying that the VA has better information technology than anyone else, and the quality of care has risen under Kizer and Shinseki and other secretaries, so the VA was doing a great job in high-quality care. How does that square with what we are hearing now?
Dr Chokshi: It is an important point, and I hope that it doesn't get lost in everything that has come to light in the past few months. If you take a step back, you realize that there are real access problems, but once a veteran gains access to the system, in terms of the quality and satisfaction with the care that they receive, the VA performs at least as well as private sector hospital benchmarks. There are constraints on getting into care in the first place, but once that care is accessed, the performance of the system excels.
Dr Caplan: If I am a veteran, and I am from a small town in western Texas or out in rural North Dakota, I come home thinking that I am going to get the services I need. I have post-traumatic stress disorder (PTSD). Are we overpromising services to veterans if they live in these small, rural communities?
Dr Chokshi: A lot of attention has been paid to that, particularly with the drawdown from Iraq and Afghanistan. Many soldiers are returning to their communities in rural areas. The VA has made some strategic investments in its telehealth and tele-mental health programs, but something that was encapsulated in the law that the President recently signed is the idea that in some cases there just isn't sufficient capacity, particularly in rural areas. If a veteran is encountering long wait times, and he or she lives in an area where it is challenging to access care at the VA for one reason or another, the veteran should have the ability to see a community provider.
Dr Caplan: Outsourcing to other caregivers may make more sense.
Dr Chokshi: It's not as simple as it may sound. To use the example of PTSD, the VA employs some of the best doctors in the world to take care of PTSD.
Dr Caplan: It's not as though the private sector is full of PTSD care providers.
Dr Chokshi: Exactly, and there are special dimensions to some of those problems, such as traumatic brain injury, for which the VA has developed excellent programs. So there are tradeoffs involved in accessing care in the community rather than at the VA.
Are We Headed for a Primary Care Shortage?
Dr Caplan: We have some good news. With healthcare reform, we have extended insurance coverage to millions of Americans, and they are now going to be eligible for primary care. The bad news is that we haven't trained more primary care providers. Will we have to ration primary care?
Dr Chokshi: I am a primary care doctor myself. I take care of patients at NYU, and I have seen firsthand that there are challenges in patients being able to see a doctor. Many of the patients whom I see for the first time tell me that they have been waiting for months to see a primary care physician. There are real challenges because of the coverage expansion from the Affordable Care Act. More people have health insurance and are going to use healthcare services. I am optimistic that the healthcare system can grapple with that, because there are exemplars in terms of new models of care—employing nurse practitioners or physician assistants, for example—to take care of some patients.
Dr Caplan: I noticed that Missouri has an assistant physician idea. If someone graduates from medical school but hasn't done a residency, he or she can do primary care.
Dr Chokshi: It is a controversial idea, because the training there is not as much as what a nurse practitioner or a physician assistant undergoes, and it may be a problematic approach. However, it is an example of the more general phenomenon of trying to adapt the primary care system.
Dr Caplan: I am getting my flu shot at the pharmacy. I am not finding a primary care provider for that.
Dr Chokshi: Exactly. One thing I love about practicing primary care is you take care of everything from soup to nuts. I have healthy 18-year-olds and 80-year-olds with multiple chronic conditions in my panel. You have to take care of the entire spectrum of the population. As we get more sophisticated, there will be ways to allocate the human resources that go into taking care of all of those people in a more rigorous and sensible way.
Dr Caplan: Let me end our conversation today with a not-so-easy question. People have been trying since time immemorial to get more physicians to choose primary care, but for a variety of reasons—debt, financial incentives, the glory of the specialties—it's a tough road. Very few of those efforts have worked. Are we banging our heads against the primary care door? Should we finally say that it is not going to open, and just give up on the idea that we can get physicians to choose primary care?
Dr Chokshi: We are actually in a pretty special moment in attracting younger physicians into primary care. My choice to go into primary care was driven by the fact that it is the linchpin of a high-performing healthcare system. For people who care about reforming our healthcare system as well as taking care of the whole patient, rather than one isolated organ system, primary care is a natural place to be.
Dr Caplan: Do you think it might even be more intellectually engaging or fun in some ways?
Dr Chokshi: In many ways, it is. There is no doubt that it is challenging and the pay differential exists, but we have some policy instruments to try to address those factors to attract more people, using economic incentives, loan repayment, etc. I am optimistic that we will finally see a shift from specialty care to primary care.
Dr Caplan: I like that note of optimism about where medicine might be headed, but I should add editorially that I hope you are right. Thank you for spending some time with me.
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Cite this: Do We Still Need the VA? Or Is It Getting a Bad Rap? - Medscape - Oct 16, 2014.