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Since April of this year, literally hundreds of articles along with knee-jerk calls for resignations, election year posturing, and most importantly, the actual investigation of things we have been complaining about for years.
The following are some fixes proposed by several organizations and a key component of the VA that must change – The VA Culture of Corruption.
Vietnam Veterans Of America --VVA Recommendations to Restore VA
The shortage of clinicians, which leads to “gaming the scheduling system,” is not unique to the Phoenix VAMC, nor is it confined to another 26 VA Medical Centers (VAMC), as recent news reports indicate. It is, in fact, the case at most all Veterans Health Administration’s (VHA) service-delivery point, including at the VAMCs, the satellite Community Based Outreach Clinics (CBOCs), and the free-standing Outpatient Clinics (OPC). The fear of not meeting performance measures has fomented an environment of “shady” reporting. Manipulating the scheduling system is a ploy that appeases VA leadership and congressional inquiries, while keeping local VAMCs eligible for monetary “rewards.” The current system of performance measures needs to be reviewed and reformed so that accurate data is generated. It is only through truth in reporting that problems areas can be identified, thus allowing for timely, corrective actions by those charged with caring for our nation’s veterans. Performance reviews ought to be based on such data that tracks the outcomes of actions taken. This may be the real road to performance reviews. Without truth, there will be no faith in the system, and the system will ultimately disintegrate. VVA recommends the following corrective actions:
SERVICE PROVISION
• That the President mobilize Reserve and National Guard units, as well as FEMA medical services, to supplement the uniformed units, to serve, for the next 30 to 90 days, as screening/triage units for all veterans currently on waiting lists at all VA Medical facilities. All veterans found to have urgent medical conditions are to be seen by a qualified VA clinician within three days of their screening. If the VA facility is unable to see the veteran within three days, the VA staff must arrange--and pay for--immediate care outside of the VA. Veterans not found in need of urgent care, who cannot be seen by the VA within 21 days, shall be assisted by VA staff to access an outside clinician under the VA “fee-for-services” program.
• That all VAMCs establish special screening units, making them operational within 90 days, so the military medical units and the FEMA units performing the initial screening can stand down. These units should screen ALL veterans who are waiting for initial care (not just those who are already service connected, compensable veterans) to test for the leading causes of morbidity/mortality among veterans in the VHA system. These screenings would include, but not be limited to, mental health (i.e., suicide); heart disease; hepatitis (particularly Hepatitis C); lung cancer; prostate cancer; bladder cancer; colorectal cancer; leukemia; skin cancer; and all other leading killers of veterans. Those who test positive for any of these conditions would be seen by a VA clinician within 3 days. If the VA staffing is insufficient to meet any such urgent need, the VA staff would assist the veteran in securing the immediate services of an outside clinician.
• That all VHA staff with clinical credentials and training, who are not currently in direct services provider positions, are to be reassigned to serve a minimum of 4 days per week in provision of direct clinical care.
• That all VHA administrative staff--including those on VISN staff with non-clinical credentials--are to be redeployed to work directly with clinical care providers to assist with the delivery of direct clinical care to alleviate the administrative load on clinicians. Administrative staff duties would include assisting those veterans, who cannot be seen by a VA clinician, in securing timely care through the use of the fee-for-service program with a private provider.
• That all veterans’ military history is programmed into the veteran’s permanent VistA electronic health record, to include: branch of service; time and location of where the veteran served; and the veteran’s MOS. This information would be keyed to electronic clinical reminders to the VA providers of care who see such veteran. For reference, see: http://www.publichealth.va.gov/exposures/providers/index.asp and
http://www.va.gov/OAA/pocketcard/.
• That by January 2015, the VA would expand, to a national scale, the “Grow Our Own” program to train clinicians and allied health-care professionals, as well as physicians and other health-care practitioners. These veterans would be required to work for VA for two years in exchange for every year of education provided by VA (or pay back the cost of their education).
• That a mandate is issued requiring that every VA clinician enroll and complete the Continuing Medical Education (CME) courses regarding medical conditions which may affect veterans as a result of exposures or incidents in their military service, to include: CME courses on parasites; cold injuries; toxic exposures; and caring for combat wounds. The VA clinician’s completion of CME courses is to be tracked and considered in the clinician’s annual evaluation.
PLANNING & REVIEW
• That the President and the Secretary of Veterans Affairs convene a “Clinical Care Crisis Resolution Commission” (CCCRC) and name members drawn from a pool of former VA Secretaries and Deputy Secretaries, former Secretaries of Under Secretaries for HHS, as well as other clinical experts from elected or appointed offices, in addition to leading experts from private or public hospital systems and private insurance systems. At least two representatives would be selected from the VSO/MSO communities to serve on the CCCRC.
• That the first meeting be held on or before June 6, 2014. The CCCRC would have a life of 90 to 120 days. The preliminary/interim findings and any recommendations would be issued within 30 days, and updates would be provided subsequently at 30-day intervals. The CCCRC would be afforded the resources to hire a limited number of staff to review and synthesize past findings (since 1998) of all panels and commissions regarding veterans’ benefits and health care, as background for the panel. We suspect that these will assist in speeding the work of the panel.
• That, after the preliminary redeployment of resources, the VHA would work closely with the CCCRC to estimate the true clinical needs of each facility, based on the demographics of the population served at that facility, as well as the changing needs of that population within the system.
• That a formula is developed that takes into account the wounds, illnesses, maladies, diseases, and adverse medical conditions or risks that result from military service. That the “Millman formula” be discarded, because it will always underestimate clinical needs of veterans at a geometrically accelerating pace over a series of years. The Millman formula is a civilian formula that does not account for the special health-care needs of military veterans.
FINANCES
• That an immediate, emergency supplemental appropriation of “two year” money be allocated, in the minimum amount of $2.5 billion, to be used solely for direct clinical care. The bulk of these funds would go toward hiring, on a permanent basis, additional clinical services providers. Funds would also be used to cover fee-basis services, until such time as the VAMCs have achieved sufficient permanent capacity to deliver such needed care in a timely fashion.
• That an emergency supplemental appropriation of “two-year” money in the amount of $500 million be allocated for the use of the immediate reconfiguring of unused space at VAMCs for delivering care, or for the construction of temporary buildings at facilities where additional care could be provided, were the space available.
• That cooperation to assist in meeting this crisis is sought from the leadership of Congress on both sides of the aisle, as well as Congressional authorizers and appropriators on both sides of the aisle.
ADMINISTRATIVE & PERSONNEL ACCOUNTABILITY
• That Congress be requested to assign the relevant division of the General Accountability Office (GAO), under Ms. Deborah Draper, to work with the CCRC and the VA Medical Review teams to conduct a study on how best to significantly reduce the number of “middle-management” layers of VA bureaucracy, so that more resources are available for the provision of direct clinical care.
• That the current “policy” chain of command and the “operations” chain of command be consolidated in both VHA and in the Veterans Benefits Administrations’ Compensation & Pension Service. The need is for more direct-service providers, rather than administrators who “pass the buck” between those sections/divisions responsible for a veterans’ clinical care or treatment program.
• That the United States Attorney General direct the U.S. Attorney for the District of Arizona to avail the VA Inspector General additional investigatory personnel required for the current, ongoing investigation at the Phoenix VA. That all criminal conduct occurring at a VHA facility be prosecuted to the fullest extent of the law. That all managers and supervisors involved in “gaming the system” at the Phoenix VAMC, and at any of the other 150 VA Medical Centers, endure the full administrative punishment due, including their immediate termination in instances where abuses are proven but do not meet a level necessary for criminal prosecution.
• That the job descriptions of all managers and supervisors in the VA system be amended, and the “elements and standards” for evaluation be amended, so that the first item appearing in all job descriptions--and the standards on which managers and supervisors will be evaluated each year--is the “honesty clause,” outlining the consequences of lying or otherwise misrepresenting the truth, and for allowing false representation in any statements, reports, and systems. Those who fail to comply with the honesty clause will be subject to immediate suspension without pay, and procedures will be initiated for separation for cause.
• That any manager or supervisor who initiates or performs an act of retaliation against a VA employee who shares the truth with anyone outside of the VAMC, CBOC, OPC, or VA, shall be subject to immediate suspension, followed by proceedings for separation from employment, to include possible loss of retirement benefits.
• That all VAMCs meet on a monthly basis with local representatives of the major Veterans Service Organizations (VSOs) to discuss policies, staffing levels, funding streams, and other challenges or problems interfering with the delivery of care, in an effort to foster better communication and cooperation. These monthly meetings would involve no more than 10 or 12 veteran/military service representatives (VSO/MSO).
• That each VAMC would convene—on a quarterly basis initially, and later, at minimum, once per year--a mass briefing/town hall open to all veterans. VSOs/MSOs would provide input and have final review of the agenda for these constituent group meetings.
• That each VAMC have an OMBUDSMAN, who is also a veteran. The Ombudsman would have reporting responsibilities to the Director and to the Chief of Staff of the hospital, as well as to the Inspector General and would also have access to the Secretary of Veterans Affairs.
• That the existing whistle-blower protections be strengthened within the Office of the Inspector General, allowing for appropriate staffing and resources to more effectively investigate whistle-blower complaints.
SUPPORT
• That the cooperation of labor organizations is sought and secured during this immediate crisis, to include, but not be limited to, the Veterans’ Councils of AFGE, SEIU, UAW, and any other labor organization representing VA employees.
This would also include securing the cooperation of the Veterans Committee of the AFL-CIO, whose leadership would facilitate the expeditious reorganization needed within the VA system.
• That cooperation is sought from the medical schools and universities, as well as the major clinical specialty societies and disease advocacy groups, in assisting in the recruitment and retention of clinicians to work at VA, so that the staffing needs are, and continue to be, ample to meet capacity.
• That cooperation and assistance is sought from non-governmental organizations, such as the local chambers of congress; small business groups; associations like the Masons, the Elks, Kiwanis, the Rotary Clubs; and faith-based service groups. Many of these organizations are already helping veterans in their communities, and they would be willing to do much more if their assistance was formally requested
Source: www.vva.org May 31, 2014
COMMENT: A pretty good plan. Watch what actually comes out of this current scandal. Remember that we Vietnam Veterans went through a period of post-Vietnam experiences with the VA that ranged from good to deplorable. It depended mostly on the facility. Mental health care was so short and inexperienced, and veterans were having severe readjustment problems that an outside system, the Readjustment Counseling Service was developed. It worked because it employed veterans that had been there and done that. It employed marital counselors to work with veteran families. It still works well enough today but is limited to combat veterans. If there is something missing from the VVA plan it is the expansion of this program to take over much if not most of outpatient mental health counseling and get it away from the medical model.
FIXING SCHEDULING:
The VA is going to spend big bucks on a new scheduling system. There really is nothing wrong with the current one if things were kept honest and ethical. A big part of the VA’s problem is physically done by GS-6’s. Some bend over backwards and go around corners to get a veteran an appointment-one-on-one. They need more opportunity to do things they know work, advance in the scheduling field such as GS-7, 8 and 9 and not under the thumb of someone in charge who had a completely different background that is now in charge. They should have the authority to schedule a veteran to see any available provider, regardless of what the provider tells them. .
Some mental health providers do not have and never have had a productive schedule. Those playing FreeCell or falling asleep during sessions are in this category.
In other cases, special instructions from a primary care provider should have the highest priority. Mental health schedulers need more knowledge as to patient needs and priorities and a lot of training in people skills. They are the great unrewarded of the VA. Simply teaching those at the front desk how to deal with an elderly, hard-of-hearing veteran can eliminate most of the need for actions against the veteran.
The use of a priority system, much like that of enrollment categories would identify a rather significant number of non-service connected veterans not needing the VA skills who might be more appropriate for healthcare under Medicaid or a part of the Affordable Healthcare Act. Those who need VA care the most are often held back by some of those who could get adequate care at other than VA facilities.
MISSING HEALTHCARE PROVIDERS:
What is missing now from the VA, are adequate numbers of healthcare case managers for those who have complicated problems. Some have physical-surgical needs, pain control, and mental health services – concurrently and long term.
Only a dedicated case manager can effectively insure that the most seriously disabled patient’s needs are met. In some cases, coordination is required between four or more clinics. Some appointments simply cannot wait. They also need input into what outside care is immediately available when local VA services cannot provide them. Currently, managers who do not know the patient can say yes or no to consults and referrals. Perhaps someone in search of a bonus who feels saving budget money is more important than the patient’s inter-related problems. The VVA Plan would establish special screening and triage clinics for this category of veteran patients. Triage, the basis for all emergency medicine and health care seems absent from the system. Every veteran is just another routine case.
HIRING MENTAL HEALTH WORKERS.
Another missing link is the lack of master’s level counselors and therapists such as marriage and family counselors, and those who offer alternative and adjunctive treatments. Many slots dedicated to pushing pills could simply retire out and the positions used for more of the master’ level providers.
This is especially needed for conditions such as post-traumatic stress that often involve family members. The VHA simply ignores the biopsychosocial interactions and concentrates on what is easy and relatively cheap. It is not cure oriented, simply treatment of symptoms in most cases. Half and three-quarter time employees could bring to the VA more up to date practices “things that work” from those in private practice, doing research, and teaching. Those good people cannot give up their productive services for full time VA employment. They would also be less prone to threats and bullying than those needing the VA as their only means of income.
There is a wealth of experience and good alternative therapies out there that work as a continuance of treatment when the couple of evidence-based therapies are completed. Many outside agencies simply provide better PTS treatment than the VA provides. They build on growth of the individual.
THE VA HAS ENOUGH MONEY BUT USES IT POORLY.
Converting administrative and support positions would free up money to hire more providers. At last report, a nearby VA had 59% support to 41% providers. The figure gleaned from private sector more resembles the reverse and is as low as 30% support.
So often, the VA fills vacancies with employees from other fields. Often filling a vacancy is a reward for those that are members of the in-crowd. There is a good VA education system Available online for employees wishing to move into a more technical field, but it is not a requirement. That is easy to fix. A simple order from the top can fix many things wrong with human resources practices. One that should be fixed is to enforce the Department of Labor and VA laws on the books that provide for priority in hiring.
Top priority is to seriously disabled veterans, then disabled veterans, then veterans, then all others. It is easy to see that the reverse order is the norm in the VA.
As stated in the VVA report, community support is sorely needed by our veterans, particularly those most recently returning. It is sad to see how long it takes a veteran, new to the system to get properly evaluated, assessed and into systematic treatment. Again case management is a key to the complicated – polytrauma cases. There are simply not enough primary care providers, and even fewer of those who do the critical specialized screening tests such as neuropsychological assessment, speech pathology, and others whose work is needed to get the veteran onto the right track of treatment.
A case manager-scheduler team can make this happen and follow up appointments tracked. Locally, there is only one person who does neuropsychological testing. Months are required before those in need get the assessments required to get the proper treatment plan. They should be sent out ASAP, - not just handed bottles of pills and talk for 20 minutes periodically. This kind of therapy could be done by a computer.
The plan to use the military to augment the VA to reduce its backlog could be the fastest and most cost effective. There are fixes in current legislation but they may take a year to implement. With the military a shrinking organization, perhaps a percentage of positions could be transferred to the VA through reserve healthcare units. For those wishing to leave active duty healthcare, the transition would be quite easy. It would be easier if DoD would shift to the VA medical records system that works better. Immediately after WWII, the shift of medical personnel from the Army and Navy into the VA was an absolute need to correspond with the moves of millions of active service members to veteran status. It brings to mind one of possible fixes is to have just one military-veteran healthcare system. Personnel moves could be easily accomplished as the missions changed.
What I believe the VVA plan points out is the VA does not understand priorities. The veteran, discharged for unsuitability or undesirable gets the same priority in most clinics as does the seriously injured veteran. This is because it makes scheduling much easier. It doesn’t take a rocket scientist to invent something new to make it work better. Take the decisions out of the hands of administrators and give it to the primary care providers. They know the patient best and should determine the priority. Primary care is also where bonuses should start. Secondly, the specialists, third, the lower grade support people, and lastly, the managers.
FIXING VA HEADQUARTERS.
In tracking a VA directive issued by the VA Central Office, it was clear as to what was required to be reported back to the VACO. A couple of others were also looked at. It was clear that although they required local information technology work to accomplish the tasks, there were no implementing instructions on how to do this. The infamous 14-day appointment rule for veteran appointment waits was issued. One cannot find any follow-up action by the issuer as to whether or not it was even doable. It looked good on paper but resulted in the majority of reporting personnel to simply lie and cheat to provide the illusion they were complying. I believe the VA IG pointed this out as well. This particularly idiotic requirement has been halted. One can look at many VA directives and policy letters issued by the VACO online. In most cases, they are either glossed over by the OIG or perhaps reported but no corrective action is taken. VAMC directors and executive managers virtually can enforce or not enforce as it pleases them in policies.
A policy letter from the VA Secretary encouraging Nurses to add to their skills by pursuing a Nurse Practitioner Certification was distributed. No follow up was really done to see if it was encouraged at the local level. Locally, it was not. It was discouraged. 2.5 linear feet of EEO documentation clearly shows this. Although the Acting IG was quite open in stating his office’s findings of bad practices in healthcare, The VA Healthcare Administrator apparently took no action and hid some damning reports from the VA Secretary. I believe that is why the General asked him to resign. It will be interesting to see all of those who called for the Secretary’s resignation really knew or cared what was happening for the past nine years in the healthcare system. It really took an outside agency, the GAO to tell us that the VHA was a scandalous mess. If the VA OIG asked for prosecution, the former VHA Under Secretary may be in hot water along with those that did the crimes.
Actions Announced by the Acting VA Secretary
- Establishing New Patient Satisfaction Measurement Program- Gibson has directed VHA to immediately begin developing a new patient satisfaction measurement program to provide real-time, robust, location-by-location information on patient satisfaction, to include satisfaction data of those Veterans attempting to access VA healthcare for the first time. This program will be developed with input from Veterans Service Organizations, outside healthcare organizations, and other entities. This will ensure VA collects an additional set of data – directly from the Veteran’s perspective – to understand how VA is doing throughout the system.
- Holding Senior Leaders Accountable- Where audited sites identify concerns within the parent facility or its affiliated clinics, VA will trigger administrative procedures to ascertain the appropriate follow-on personnel actions for specific individuals.
- Ordering an Immediate VHA Central Office and VISN Office Hiring Freeze- Gibson has ordered an immediate hiring freeze at the Veterans Health Administration (VHA) central office in Washington D.C. and the 21 VHA Veterans Integrated Service Network (VISN) regional offices, except for critical positions to be approved by the Secretary on a case-by-case basis. This action will begin to remove bureaucratic obstacles and establish responsive, forward leaning leadership.
- Removing 14-Day Scheduling Goal- VA is eliminating the 14-day scheduling goal from employee performance plans. This action will eliminate incentives to engage in inappropriate scheduling practices or behaviors.
- Increasing Transparency by Posting Data Twice-Monthly- At the direction of the Acting Secretary, VHA will post regular updates to the access data released today at the middle and end of each month at the website VA.gov. Twice-monthly data updates will enhance transparency and provide the most immediate information to Veterans and the public on Veterans access to quality healthcare.
- Initiating an Independent, External Audit of Scheduling Practices- Gibson has also directed that an independent, external audit of system-wide VHA scheduling practices be performed.
- Utilizing High Performing Facilities to Help Those That Need Improvement- VA will formalize a process in which high performing facilities provide direct assistance and share best practices with facilities that require improvement on particular medical center quality and efficiency, also known as SAIL, performance measures.
Suspending Performance Awards- VA has suspended all VHA senior executive performance awards for FY2014.
Comment: There will probably be more to come. All they have to figure out is how to get around civil service (protective service) in some cases to rid itself of wrongdoers.
I am still puzzled why the U.S. Government is even paying bonuses to executive level employees who are in service to America through the civil service program – public servants if you will. If it is to attract those pillars of the healthcare industry, it hasn’t seemed to work thus far. A bonus can’t compete with private sector CEO salaries in excess of $250,000. Some of those pillar like executives from Healthcare South are still in prison for medical fraud.
Performance awards based on statistics, numbers, and spreadsheets are prone to fraud. Solid performance ratings have to come from the consumers, not administrative officers who have courses in things like creative bookkeeping. The VA has plenty of money. What they do not have is a good priority system on how to spend it. At the top of the priority list, should be Primary Care Doctors, Nurse Practitioners, and Physician Assistants. People who are the first to see, assess and refer veterans to specialty or follow-up services. What are the lower priorities are the uneeded contracts for facilities maintenance that could be done by veterans without work and have problems with self-esteem and motivation. Perhaps the bottom priority should be the window dressings from bubble machines to landscaping that could have waited until all the medical facilities were constructed and operational.
Next time you visit the VAMC, look at the smoke shacks the VA built at a place of peace and healing. Look at the landscaping. The money could have built that needed new primary care clinic in Pahrump. How about Laughlin and Mesquite? A point is that the VA has spent hundreds of millions of our tax dollars on artwork and frills and we still need more medical treatment facilities. I always have a question – is this because of contract kickbacks or just because its easy? Lou
THE FOLLOWING IS A LETTER FROM MAJOR MILITARY AND VETERAN SERVICE ORGANIZATIONS TO THOSE ON VETERAS’ AFFAIRS COMMITTEES
June 17, 2014
Chairman Bernie Sanders Chairman Jeff Miller
Senate Committee on Veterans’ Affairs House Committee on Veterans’ Affairs 412 Dirksen Senate Office Building 335 Cannon House Office Building Washington, DC 20510 Washington DC 20515
Ranking Member Richard Burr Ranking Member Mike Michaud Senate Committee on Veterans’ Affairs House Committee on Veterans’ Affairs 825A Hart Senate Office Building 333 Cannon House Office Building
Washington, DC 20510 Washington DC 20515
Chairman Sanders, Chairman Miller, Ranking Member Burr, Ranking Member Michaud:
As leaders of the veterans community and on behalf of our memberships, we write to offer some common views regarding legislation recently passed in the Senate and the House in response to the Department of Veterans Affairs (VA) health care access crisis. We applaud the bipartisan manner in which you have worked to move legislation designed to expand access for veterans currently waiting for VA health care. Although we have had only a few days to review the legislative language contained in H.R. 4810, passed by the House on June 10, and S. 2450, passed as an amendment incorporated into H.R. 3230 on June 11, after discussion among ourselves, we have arrived at some common views, which we ask you to take into consideration during any negotiations or formal conferences conducted to achieve compromise legislation.
Although the organizations we represent have different origins, bylaws and missions, and while we do not agree on every policy position, there are certain fundamental principles and critical policy positions that we all share. One principle central to the current crisis is that no veteran who is eligible for health care services from VA should be forced to wait too long or travel too far to get medical treatment and services they have earned through their service. Unfortunately, there is no longer any doubt that far too many veterans who sought care at VA facilities waited too long to receive it or continue to wait for it; such delays must end immediately. Over the past several weeks, there has been a flurry of activity by Congress to examine the extent and causes of the current crisis and to develop short- and long-term solutions.
While we appreciate the speed with which you have moved, the opportunity for veterans organizations and other key stakeholders to provide substantive input to the process has been limited. Given the critical nature of the challenges before us, we offer the following joint comments on key elements of pending legislation to address VA’s access crisis.
1. FOCUS FIRST ON TREATMENT FOR ALL VETERANS WAITING FOR CARE
The first priority for both Congress and for VA must be to ensure that all veterans currently waiting for treatment, and those who would be forced to wait for care in the near future, are provided access to timely, convenient health care as quickly as medically indicated.
We understand that VA has undertaken a number of initiatives to immediately schedule appointments for veterans waiting for care, both within and outside of the VA system, and therefore any legislation that is enacted by Congress must not interfere with that ongoing process. In addition, as Congress negotiates a compromise bill that contains provisions to strengthen and restructure VA to avoid future access problems, it must ensure that any debates or disagreements over such future-oriented policies do not impede, slow down or in any way interfere with the enactment of legislation whose primary goal should be providing immediate access for all veterans currently waiting for care.
2. VA REMAINS RESPONSIBLE FOR COORDINATING ALL APSECTS OF CARE Whenever VA is unable to directly provide enrolled veterans with access to care that is medically necessary within reasonable waiting time or travel distance standards, VA must be involved in the timely coordination of and fully responsible for prompt payment for all authorized non-VA care. The Senate bill contains provisions that reflect part of this principle and should be retained, but should also be amended to allow VA to use all available means at its disposal, including the Non- VA Care Coordination Program, to coordinate such care to ensure veterans are treated within reasonable access standards. The House bill contains a provision authorizing follow-up care, an important element of care coordination; however, the length of time for completion of such care should remain a clinical determination. Both the Senate and House bills specify access standards for timeliness; however, the Senate provision set at 30 days is the better option at this time. The Senate bill also contains a provision regarding prompt payment to providers that should be retained; however, it is more important that the final version of the legislation contain clear requirements to guarantee that VA remains wholly responsible for making payments to non-VA providers.
Veterans must not be billed directly by providers for care coordinated by VA and any copayments that may be required of veterans must be collected only by VA. Finally, neither existing nor new administrative requirements concerning coordination of care should impede or further delay access to care for veterans currently waiting.
3. FULLY AND HONESTLY FUND THE COST OF PROVIDING EXPANDED CARE As Congress considers legislation mandating the expansion of VA’s purchased care authority, VA must accurately estimate the additional costs that will be incurred and request sufficient supplemental funding. In turn, Congress must then fully fund such costs with new appropriations,
separate from funding required to operate VA’s hospitals, clinics and other health care facilities and programs. Unless additional funding is provided specifically for the expansion of purchased care, needed care will remain delayed and VA facilities will be forced to continue making tradeoffs between providing additional access now through purchased care, versus expanding internal capacity for the future through additional hiring of clinicians, purchase of equipment or expansion of infrastructure.
For the current fiscal year, VA should use all unobligated balances first, then request sufficient supplemental appropriations to fulfill its planned access initiatives, which Congress must immediately appropriate. Furthermore, the FY 2015 VA appropriations bill currently pending before Congress, which includes the FY 2016 advance appropriations request, must be increased prior to final passage to reflect VA’s new estimates for purchased care for both years. It must also be increased to reflect the additional costs for expanded access in the final enacted legislation as estimated by the Congressional Budget Office, currently estimated at $35 billion for Title 3 of the Senate bill. Most importantly, in passing legislation to expand veterans’ access to health care, Congress and VA must not rely on budgetary gimmicks, such as unrealistic estimates of operational improvements, efficiencies, collections, carryovers and contingencies. These undocumented “savings” have rarely materialized and have contributed significantly to funding shortfalls that have plagued VA for more than a decade.
4. PROTECT AND PRESERVE THE VA HEALTH CARE SYSTEM
Any legislative, regulatory or administrative changes designed to respond to the VA health access crisis, whether temporary or permanent, must protect, preserve and strengthen the VA health care system so that it remains capable of providing a full continuum of high-quality, timely health care to all enrolled veterans. Both the Senate and House bills include sunset provisions as part of their expanded access provisions designed to fill in gaps resulting from VA’s current lack of capacity to treat veterans within the VA health care system, and a sunset provision should remain part of the final bill. However, unless the legislation simultaneously sets VA on a path to intelligently strengthen health care delivery, expand access and capacity, reallocate resources and ensure that overall VA funding matches its mission, the current problems confronting VA and veterans will inevitably recur.
Both the Senate and House bills contain provisions creating new commissions, studies and reporting requirements designed to examine the root causes of VA’s capacity and access problems, and some version of these should remain part of the final compromise. In addition, it is essential that such commissions look holistically at the interrelated issues of access, capacity, infrastructure and funding in order to ensure that VA in the future has sufficient resources to match its mission.
Recent legislation approved in the House, H.R. 813, and a Senate companion bill marked up in Committee, S. 932, could provide a proven framework (advance appropriations) to improve VA’s ability to better plan and manage its funding, especially in relation to infrastructure and IT projects, two areas contributing to VA’s access problems. In addition, H.R. 813 contains important provisions to increase VA’s budgetary transparency and accountability, which is critical to the success of expanding VA’s access to care. H.R. 813 would create a new strategic planning framework comprised of a Quadrennial Veterans Review, a Future Years Veterans Program, and a Planning, Programming, Budgeting and Execution (PPBE) process, similar to what is used by the Department of Defense. H.R. 813 also contains relevant provisions regarding studies about how to reorganize VA and management accountability. For all of these reasons, we strongly encourage Congress to include both H.R. 813 and S. 932 within the scope of any negotiations or conference committee on improving access to care for all veterans.
In addition, while developing final legislation designed to expand access to care outside VA, Congress must never lose sight of the continuing need to increase VA’s internal capacity to provide specialized care to veterans who rely heavily or entirely on the VA system, such as catastrophically disabled veterans. Veterans with spinal cord injury or dysfunction, amputation, blindness, PTSD and polytrauma, cannot receive the holistic specialized care they need in the private sector and will always require a robust, fully funded VA system to provide cutting edge services they deserve.
These men and women have also earned the right to rely on a VA system capable of providing all of their primary health care needs as well, which is how the current system was designed and must continue to operate.
Finally, both the Senate and the House bills contain provisions designed to increase accountability for senior employees in the VA, and in negotiating a final compromise we would encourage you to retain provisions that provide at least some minimum due process protections.
5. MAKE CHANGES IN AN OPEN AND TRANSPARENT PROCESS
As Congress and the Administration develop, debate, negotiate, enact and implement new policies and procedures, they must do so in an open and transparent manner that allows meaningful input from VSOs, veterans and other key stakeholders. The failure to share and communicate information inside and outside of VA contributed to the current waiting list crisis and both the Senate and House bills include important provisions regarding public and congressional reporting requirements that should remain part of the final legislation. Valid reporting data on access, quality, health outcomes and other metrics can provide invaluable information to help guide improvements to the health care system. In a similar spirit of openness and transparency, we would strongly urge Congress to ensure that a conference committee or other negotiations related to this legislation be open and transparent to the public and particularly to veteran stakeholders.
Furthermore, we would hope that as you continue moving towards a final compromise, that you will reach out to us for our input regarding this legislation that will have long lasting effects on the VA health care system for millions of veterans. Similarly, as you move legislation that will require VA to develop implementing regulations, we ask that you also require VA to consult with and solicit comment from veteran stakeholders prior to regulations being promulgated, even for interim final rules.
Messrs. Chairmen and Ranking Members, although this has been a very difficult few months for veterans and the VA, there remain reasons to be optimistic. We are encouraged that Congress has begun to show signs of returning to a bicameral, bipartisan approach to veterans issues, and we hope that you will continue working in this manner to address other pressing veterans matters that remain unfinished this year. We also hope that you and VA officials will continue to reach out to veteran stakeholders to hear our views, learn from our experiences and benefit from our expertise as you develop new policies, regulations and laws designed to improve the delivery of health care to the men and women who served. Thank you for your consideration of our comments.
Respectfully,
Peter Gaytan Garry J. Augustine
Executive Director Executive Director
Washington DC Office Washington Headquarters
The American Legion DAV (Disabled American Veterans)
Homer S. Townsend, Jr. Robert E. Wallace
Executive Director Executive Director
Paralyzed Veterans of America Veterans of Foreign Wars of the United States
Rick Weidman VADM Norbert R. Ryan, Jr., USN (Ret.)
Executive Director for Policy and President
And Government Affairs Military Officers Association Vietnam Veterans of America of America
Randy Reid Herb Rosenbleeth
Executive Director National Executive Director
U.S. Coast Guard Chief Petty Jewish War Veterans of Officers Association of the USA America
James T. Currie, Ph.D, Colonel, USA (Ret.) CW4 (Ret) Jack Du Teil Executive Director, Commissioned Officers Executive Director Association of the U.S. Public Health Service U.S. Army Warrant
Officers Association
Robert L. Frank Ken Hopper
Chief Executive Officer` National President
Air Force Sergeants Association Marine Corps Reserve Association
Gen. Gordon R. Sullivan President
Association of the U.S. Army
Andrew B. Davis Heather L. Ansley, Esq., MSW
Major General, USMC (ret) Vice President
National Executive Director VetsFirst, a program of United Reserve Officers Association Spinal Association
Alex Nicholson VADM John Totushek, USN (Ret)
Legislative Director Executive Director
Iraq and Afghanistan Veterans of Association of the U.S. Navy (AUSN) America (IAVA)
Robert Certain Michael Blum
Ch, Col, USAF (Ret) Executive Director
Executive Director Marine Corps
Military Chaplain Association of League
the United States
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The Ensuring Veterans Access to Care Act of 2014
- Removal of incompetent Senior VA Officials
- Shortening wait times for Veterans
- Addressing VA’s long-term needs
Senators Sanders (I-VT) and McCain (R-AZ) have worked together on legislation that would address three major areas of weakness in the current VA system that should help prevent recurrence of the recent problems with Veterans’ care:
Removal of incompetent senior VA officials
The legislation would provide the VA Secretary authority to immediately remove senior executives based on poor performance while maintaining due process for those employees. Further, it would grant authority for the Acting Secretary to remove senior executives, notwithstanding the 120-day moratorium in current law.
Shortening wait time for veterans
The legislation would standardize VA’s process for sending Veterans into the community for health care by requiring VA to take into account wait times for care at VA, the health of the Veteran, the distance the Veteran would be required to travel for care, as well as the Veteran’s preference when VA is unable to provide care within its stated goal (currently 14 days). The bill would also give VA the ability to rapidly hire new doctors, nurses and other health care providers in areas where there are identified shortages.
Addressing VA’s long-term needs
The legislation would authorize 27 major medical facility leases in 18 states and Puerto Rico and allow VA to decompress over-utilized VA facilities. The bill would require the President to create a Commission to look at VA health care access issues and recommend action to bolster capacity. Further the bill would require the establishment of a Commission on Capital Planning for VA facilities, to improve VA’s capital asset processes, from facility planning and individual project management to managing the multi-billion dollar backlog of facility construction and maintenance projects in order to ensure Veterans can receive treatment in safe facilities.
Comment: It might solve a few serious problems. It looks like a watered down version of the Omnibus Veterans Legislation of last year that was shot down by Congress. It is about 4-5 years late in coming. You already know the reasons why it was discussed during a non-election year. Lou
Top officials describe 'corrosive culture' in VA system Jun. 30, 2014 -
A damning analysis of the VA’s health care system was offered to President Obama Friday, with findings of a “corrosive culture,” low morale, poor management and widespread distrust between workers and supervisors — all driving systemic delays in health care for veterans.In a report delivered to Obama on Friday by the acting VA secretary, Sloan Gibson, and Deputy White House Chief of Staff Rob Nabors, the president was told about a history of retaliation toward employees in the VA health care system who raise valid complaints. Obama also heard about a lack of accountability “across all grade levels.”
“We know that unacceptable, systemic problems and cultural issues ... prevent veterans from receiving timely care,” Gibson said in a statement late Friday. “We can and must solve these problems as we work to earn back the trust of veterans.”
The scandal over health care involves widespread manipulation of appointment records and delays in medical and mental health appointments for tens of thousands of veterans, some of whom waited months or never received treatment. The Justice Department has joined with investigators at the VA Inspector General’s Office to see whether criminal charges should be filed against medical officials.
Gibson said earlier this month that at least “some supervisors” are under criminal investigation.
In a released summary of the report provided to Obama on Friday, Gibson and Nabors portrayed a VA health care system badly in need of restructuring.
“In its most extreme manifestations, it has impeded appropriate management, supervision and oversight,” the report says. “There is a culture that tends to minimize problems or refuse to acknowledge problems at all.”
With 21 regional directors who oversee 150 hospitals and 830 outpatient clinics treating 6 million veterans a year, the sprawling system is rife with the practice of ignoring, minimizing or dragging its feet on directives coming out of VA headquarters, the report says.
The Veterans Health Administration is marked by “a belief many issues raised by the public, the VA leadership or oversight entities are exaggerated, unimportant or ‘will pass,’” the report says.
Meanwhile, the culture within the health agency “encourages discontent and backlash against employees.” The report notes that nearly one in four whistle-blower cases under review by the U.S. Office of Special Counsel, tasked with protecting federal employees who step forward, originate from the VA. It said 50 of these cases are currently pending with the Office of Special Counsel, all dealing with patient health or safety.
A broad inspector-general probe looking into the scandal is to conclude later this summer. But a quicker VA audit released earlier this month found that some level of record manipulation occurred at three out of four agency medical facilities.
According to VA data released last week, the agency has contacted 70,000 veterans whose appointments have been delayed and is working to get them quicker care.
The VA audit found that within the past 10 years, at least 64,000 veterans who came to the VA for health care were never treated. Some 13 percent of VA schedulers across the country were instructed by supervisors to falsify appointment records, and 8% said they kept unofficial lists of patients whose names were kept out of approved electronic records.
The scandal forced the resignations of VA Secretary Eric Shinseki, an undersecretary in charge of health care and the VA general counsel.
Acting Inspector General Richard Griffin said that while his investigators have identified 18 veterans who died awaiting care at a VA hospital in Phoenix, further efforts are underway to determine whether the health care delays caused those deaths.
The Office of Special Counsel wrote a letter to Obama on Monday complaining that VA medical officials glossed over problems raised by employees and failed to determine what harm might have been caused to veterans.
The agency neglected to acknowledge “the severity of systemic problems and (thus was prevented) from taking the necessary steps to provide quality care to veterans,” Carolyn Lerner, head of the Office of Special Counsel, wrote to the president.
How to Fix the VA
But with 9 million patients, 320,000 employees, 971 hospitals and clinics—it’s not going to be easy.
Photo by Capt. Xeriqua Garfinkel,159th Combat Aviation Brigade Public Affairs/U.S Army
President Barack Obama had no choice but to accept Veteran Affairs Secretary Eric Shinseki’s resignation. The VA inspector general’s interim report issued this week contained too many damning findings of “systemic” problems that grew under Shinseki’s watch. Key among these was the finding that the actual VA primary care wait times in Phoenix averaged 115 days—more than four times the VA’s previously reported average of 24 days. That discrepancy revealed a gap between reality and official reporting, and suggested questions about the VA’s integrity ran all the way up to the secretary’s office.More broadly, the growing VA scandal cast doubt on the ability of the government to deliver health care, a major Obama administration priority. If the White House could not deliver on this promise to veterans, a key constituency for whom the president and vice president have frequently described health care as part of a “sacred trust,” then how could the administration be trusted to provide care for all Americans? Coming after the legal and practical challenges to the Affordable Care Act, the White House could not afford another health care failure. And so Shinseki had to go.
Unfortunately, his departure will do little to fix the broader problems in the massive VA health care system—and may even set the quasi-leaderless agency back as it waits for a new secretary to be appointed and confirmed.
Winning armies rarely learn. It takes the strategic shock of defeat to catalyze learning and change.
The VA is the second-largest cabinet agency, and the nation’s largest health care and benefits provider, with an overall fiscal 2015 budget of $165 billion (greater than the State Department, USAID, and entire intelligence community combined), including $60 billion for health care. The VA employs more than 320,000 personnel to run 151 major medical centers, 820 outpatient clinics, 300 storefront “Vet Centers,” more than 50 regional benefits offices, and scores of other facilities. This massive system provides health care to roughly 9 million enrolled veterans, including 6 million who seek care on a regular basis.It’s hard to overstate the challenges of leading this massive agency: The ideal candidate would probably fuse the best traits of a general like Shinseki, a politician like Bill Clinton, and a businessman like Lee Iacocca or Mitt Romney. The systemic integrity problems in the VA’s health care system, coupled with the broader resource allocation problems they were masking, will remain for the next secretary, whoever he or she is.
Here are six ways to begin to fix the VA.
1. Give the VA the resources it needs. Even with its massive $60 billion health care budget, the VA arguably lacks the funding it needs to treat all veterans . This resource shortfall is the root cause of the scheduling shenanigans in Phoenix: If the VA had what it needed, it wouldn’t have needed to play fast and loose with veterans’ appointments. A group of veterans organizations prepares its own shadow VA budget each year; this year’s budget called for approximately $7.8 billion more in VA health funding. This money would go to hiring doctors and nurses (assuming they’re available—a national doctor shortage affects the VA too), as well as building or leasing new facilities.
2. Allocate VA resources more smartly. The veteran population is undergoing tremendous demographic and geographic change. As World War II, Korea, Vietnam, and Cold War conscripts die, the veteran population is changing to reflect the all-volunteer force we have today: smaller, more dispersed, more diverse, and increasingly concentrated in urban or coastal areas. Unfortunately, this is not where VA hospitals and clinics are located.
The VA is seeing demand from both older veterans and younger veterans. The median age of the veteran population is 64, meaning that the majority of veterans are hitting retirement age and presenting themselves to the VA with service-connected conditions compounded by age. At the same time, veterans from the Iraq and Afghanistan cohort are seeking VA care and benefits in record numbers.
The next secretary needs congressional support to shrink or close underutilized VA facilities, build or lease new clinics (favoring outpatient clinics instead of large hospitals, following the overall direction of American health care), and move VA personnel between facilities to reflect where veterans live now, and where they need care.
3. Restructure the VA health care system. The VA divides its health system of 151 hospitals and 820 clinics into 23 regions that don’t align with any other geographic scheme within the federal government. These regions lack the leadership, staff capacity, and authority they need to oversee health care facilities. As a result, hospitals have evolved into fiefdoms unto themselves, giving rise to the expression, “If you’ve been to one VA hospital, you’ve been to one VA hospital.” This system must be broken apart and rebuilt to give the secretary the ability to implement national policy, standardize practices, and ensure quality patient care. Ideally, the VA would cut the number of regions and align them in some way with the regions used by the Department of Health and Human Services or Department of Defense TRICARE system. Within these VA health care regions, senior executives should be selected for management expertise and ability, not just for time served as a VA clinician. And regional executives should be picked by the secretary and be accountable to him or her—potentially with a requirement for Senate confirmation—not unlike the system for selection of generals and admirals, who require Senate confirmation at the very top levels.
4. Rebuild the VA’s healthcare IT system. Twenty years ago, the VA led the nation in development of electronic health records. Today, the VA has fallen behind. The VA’s antiquated systems contributed to the chaos in Phoenix where, reportedly, front-line employees used DOS-based systems to manage appointments and clinical resources. This problem is exacerbated by the VA’s balkanized system of regions, hospitals, and clinics. Many facilities have customized their software in ways that don’t mesh with other VA facilities. The next VA secretary must completely overhaul this system, much as Shinseki did for the VA’s benefits system (at great cost). The VA should consider replacing its antiquated appointments system with one that is more transparent, allowing veterans to see wait times and relative availability across the system, and make health care decisions accordingly. Such solutions exist in the private sector. The VA should embrace them. Likewise, the VA must invest in its health records system, and ideally build one that meshes with the system now being procured by the Pentagon.
5. Integrate better with the private and nonprofit sector. The VA provides exceptional medical care, particularly for service-connected issues such as prosthetics, hearing loss, and combat stress. However, more than two-thirds of veterans seek medical care from non-VA sources rather than the VA, and that’s unlikely to change. Many more veterans get care from nonprofit providers, especially for mental health issues. The VA must find ways to integrate its care with that given by the private and nonprofit sector, to provide veterans with “continuity of care” wherever they get seen. More pointedly, the VA must better leverage external resources to fill gaps and shortfalls in its care, such as in primary care and mental health care. The demographic changes within the veterans community suggest the VA is seeing its peak demand now, from young and old veterans alike. Building permanent VA infrastructure may not make as much sense as leveraging private providers, contractors, and nonprofit organizations to serve veterans (ideally knitted together by a common health records system).
6. Build a bridge across the Potomac. One of Shinseki’s greatest failures belongs also to two other revered cabinet officers, former Defense Secretaries Robert Gates and Leon Panetta. Defense and the VA failed to create an integrated health records system (or separate systems that would talk to each other), and have failed more broadly to synchronize and align the two agencies’ care for veterans, service members, and military families. The redundancies between these two agencies cost the taxpayers billions of dollars each year, and worse, create gaps for veterans to fall into, such as when claims submitted to the VA can’t be substantiated for lack of Pentagon service records. Even Shinseki, with his long Army lineage and prior service as the top Army general, failed to partner effectively with the Pentagon. The next secretary must do better, especially in a post-war era of fiscal austerity, when both agencies are likely to have fewer dollars to serve their respective populations.
Top Comment
I am a combat veteran awarded two Purple Hearts. I also worked at a VA Hospital. I read the above article and it is just about right in what is needed for the improvement of the VAThere’s a lesson from military history that applies well here: Winning armies rarely learn. It takes the strategic shock of defeat to catalyze learning and change within armies. Although the VA doesn’t fight wars like its brother agency the Defense Department, it retains a military culture because of its leadership and the large number of veterans who work there. And like the Pentagon, the VA only learns or changes well under enormous external pressure, such as the kind that comes upon losing a war, or occurs during a political scandal like this one.
Notwithstanding this week’s headlines, the data overwhelmingly show the VA has done well in supporting veterans over the last decade or two. Patient satisfaction scores are high; the claims backlog is down; the VA has worked with the nonprofit community to reduce veteran homelessness by roughly 24 percent in five years. The list goes on. Nonetheless, deep problems remain within the VA that threaten its ability to succeed in the years to come. Today’s political crisis may offer the strategic shock the VA needs to address these core issues, now under a new secretary, to serve our veterans as well as they have served us.
Phillip Carter is an Iraq veteran who now directs the veterans research program at the Center for a New American Security.
Comment: This article is typical of several others read on VA fixes. These six areas would solve most of the problems – if carried out. What is missing is the call for investigations into those recently retired and currently on the job as to wrongdoing.
As with the major GAO scandal of 1988, it took 46 prison sentences of senior executives to get the message across that honesty was indeed, the best government policy. Lou
There were several other proposed VA fix proposals but several smacked of political statements and were not used here.
I would like to add to the above comment that the VA has done well in several different areas. The major healthcare problems have been identified and changes will be made by a VA Healthcare Administration although they are still kicking and screaming. A major push to get things moving is to move those executives and decision makers that are a part of the problem, out of their jobs immediately. They are readily identifiable by patient consult paper trails.
A good thorough check of executive credentials might be in order as the problem has surfaced in more than one area already. Those employees filling positions requiring educational and professional qualifications they do not have need to be reverted to a level they are qualified for, not the one they may have occupied through other than professional services. Finally, professional employees must be held to a productive schedule providing direct patient care. Not serving on some committee or project that makes life easy for them.
Monitor those new job applicant veterans to insure the VA Human Resources people are following the Department of Labor and VA guidelines and priorities for hiring veterans. The days of “It’s not what you know but who you know” must end.
More and more surveys and studies clearly reveal that VA mental health treatment is in need of therapy. Veterans completing programs most often report no improvements. Even with this, the VA has steadfastly refused to use those alternative therapies available elsewhere. There are some very good therapists who have the skills for some of these but they are few and often discouraged from using them. As long as I have lived in this area, there has never been a patient survey done to see what patients really need, and the VA has never really conducted one to assess what skills their employees have. I think this is intentional as it would identify those more skilled than their supervisors. Lou
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