VHA Still in Trouble Because of Trump’s Hiring Freeze

As I write in this new blog in The American Prospect, Trump’s hiring freeze is hurting the VHA in spite of exemptions.

Hiring Freeze Spares Some at VA, But Shortages Still Loom

But veterans who rely on the VA for benefits, pensions, compensation, and health care are still in big trouble. Chronic staff shortages and underfunding have been at the heart of a VA crisis centered on long wait times for care. Though doctors, nurses, and certain other essential health-care professionals and support staff have been exempted from the freeze, that still leaves the VA with a multitude of vacancies that will hamper its ability to deliver high-quality care.

To be sure, the recent exemptions have led some who are worried about the VA’s future to breathe a sigh of relief. When Trump announced his blanket federal hiring freeze, it did not exempt anyone at the VA. That led lawmakers and veterans’ advocates to protest that the freeze would cripple the VHA. In response, acting VA Secretary Robert D. Snyder sent out a memorandum on January 27 exempting doctors, nurses, and other health-care professionals and clinical support staff from the freeze. READ MORE


Trump Pick Could Help VA

This was just published on the Washington Monthly Site.  It’s a great piece by a Vietnam combat veteran who was also a psychologist at the VHA for many years.  Well worth the read.

VApicTrump’s Pick for VA Secretary Could Continue Obama’s Progress by Edgardo Padin-Rivera

January 20, 2017.

Will Trump Jeopardize Prostate Cancer Research

shulkin_vha-3-960x640Will Trump Jeopardize VA Prostate Research?

by Suzanne Gordon on January 3, 2017  Beyond Chron

President-elect Donald J. Trump will soon announce his pick for Secretary of Veterans Affairs, and his nominee should honor the phenomenal research that the Veterans Health Administration provides. VHA research — the nicotine patch, the first implantable cardiac pacemaker, the Shingles vaccine, among many others — benefits not only veterans but all Americans.  Last year alone, according to VA Undersecretary for Health David Shulkin, VHA researchers published 9,480 papers in the scientific literature.

Most recently, the VHA, in partnership with the Prostate Cancer Foundation, which has helped fund the research for many major treatments,  embarked on another critical research initiative.  The Foundation has donated $50 million to the VHA, making this, Shulkin says, the largest commitment to cancer research the VHA has ever received, one that will help deliver better care to veterans  particularly those in rural and remote areas.  Foundation, CEO and President physician Jonathan Simons says the foundation is eager to work with the VHA because it is the largest health care system in America, with the most men suffering from prostate cancer of any healthcare system or institution.  Because of this the VHA, he says, provides a unique opportunity to help solve some of the most vexing riddles about prostate cancer, democratize treatment through the VHA’s superior telehealth capacity, and accelerate the pace at which new drugs and treatments are made available to the nation’s veterans.   READ MORE

New Blog Post on McCain VHA Bill — Bad News

mccainindexI just posted this on the American Prospect blog on McCain’s attempt to flimflam veterans by privatizing the VHA.


Tapped: The Prospect Group Blog

McCain Pulls a Bait-and-Switch on Vets

Almost as soon as Senator John McCain had finished working with Senator Bernie Sanders to craft the veterans’ health-care bill now known as the Choice Act in 2014, the Arizona Republican set out to renege on his promise that Choice would be temporary, and began floating plans to make it permanent.

Part of the Choice Act was the establishment of the Commission on Care, whose deliberations the Prospect has covered extensively. This week that Commission is meeting to hammer out its final report, which will include recommendations about what the VHA should look like in 20 years. Instead of waiting to see what the Commission mandated by his own bill recommends, McCain has once again jumped the gun. He is lobbying hard for a bill that would not only make the Choice program permanent, but would eliminate any restrictions on veterans’ access to private-sector health care.

McCain’s gift to veterans is a bill misleadingly labeled The Care They Deserve Act. The subject of hearings on Capitol Hill the week of June 23, the bill would make the Choice Act—a three-year experiment enacted following revelations of delays in care at VHA facilities in Phoenix and elsewhere—permanent. Choice allows veterans to seek care from private-sector health-care providers if they face more than a 30-day wait for an appointment, or trips of 40 miles or more to the nearest VHA facility.

Under McCain’s new plan, the nine million veterans eligible for VHA care would be free to use any private health-care facility or provider, for any form of service, with the federal government paying the tab—no questions asked. McCain has gathered seven other Republican sponsors for his bill, all of them pushing the new conservative narrative that the VHA is broken beyond repair. This, of course, ignores reports by a Choice Act-mandated Independent Assessment of the VHA, which documents that its veteran/patients actually receive better care, at lower cost, than millions of Americans who rely on private sector health care.

What’s wrong with The Care They Deserve Act? Just about everything, which is why many veterans service organizations like the Disabled American Veterans (DAV) and Vietnam Veterans of America oppose the plan, and why the VHA’s own undersecretary for health, David Shulkin, has proposed a more sensible alternative.

Economists advising the Commission on Care estimate that McCain-style privatization could triple the cost of veterans’ care to almost  $450 billion a year—money that would not be well spent. The VHA’s clinicians and other staff specialize in the complex health problems related to military service, and deal with patients who are older, sicker, and poorer, with more mental health problems that those cared for in the private sector. The average elderly patient in the private sector shows up presenting between three to five physical problems. The “co-morbidities” of a Vietnam vet, for example, can number from nine to 12. That’s why VHA primary care providers spend at least 30 minutes with their patients per visit, compared to the ten or 15 minutes allotted to patients in the private sector. Will private sector providers want to take the time to care for aging, sometimes homeless, often mentally ill, veterans? Even if they do, will they be able to detect the difference between ordinary type 2 and Agent Orange-related diabetes, or be equipped to parse the myriad symptoms of PTSD?

McCain’s bill promises veterans a choice between VHA and private sector care. In reality, it would ultimately erode choice by weakening the VHA option, putting the entire veterans’ health system at risk. The VHA’s current budget is determined by how many veterans use the system and for what services. If far more eligible veterans start using private sector health care, there will be less funding available for VHA services that are unavailable elsewhere, and for maintaining the agency’s highly specialized research and clinical expertise in military-related health problems. As funding for costly private sector care eats up more of the VHA’s annual budget, there will be hospital and clinic closings, along with VHA staff layoffs. To reduce expenditures on veteran health care, Congress may also be tempted to make eligibility for veterans’ health-care benefits even more restrictive than it is today.

If Congress wants to improve the VHA, it should embrace the reform proposals of Shulkin and those Commission on Care members who want to allow veterans access to private sector providers in networks coordinated by the VHA. With luck, this recommendation will appear in the Commission’s June report. Strengthening the VHA, and giving veterans the choice to see outside providers if necessary, would really give veterans the care they deserve.



Article by Under Secretary for Health at the VHA from Federal Practitioner

vha_mat_croppedPhysician David Shulkin is now Under Secretary for Health at the VHA.  He has just written a compelling explanation of why the Veterans Health Administration is different than private sector health care systems. And he should know.  For years, he was a chief executive officer at a number of prominent private sector health care facilities. Dr. Shulkin has just written a concise explanation of the difference between VHA  and private sector healthcare for The Federal Practitioner. While this article focuses on the way the VHA serves veterans, it also spotlights the models of integrated care  the VHA has developed — models that should be adopted in the wider healthcare system.

I asked his permission to post it here.  When someone with Under Secretary Shulkin’s experience with private sector healthcare explains why it can’t replace the VHA, we should listen.

Is VA health care really “all that different” from what veterans would find in the private sector?

As someone who spent more than 25 years managing private sector health care organizations and recently joined VA as its under secretary for health, I’ve had the unique opportunity to compare the health care systems. Over the past several months, I’ve met with veterans and their families, veterans service organizations, VA clinicians, facility staff, and veteran employees at all levels. Through these meetings and travel to dozens of facilities, I’ve come to realize that many of the essential services provided by the VA cannot be found in or even replicated in the private sector.

Over time and in partnership with successive generations of veterans, the VA has evolved into an interconnected, institutionalized system of care and services. And while many of these services aren’t unique to the VA, ours is the only health care organization that combines these services “under one roof” and integrates them in a way that is veteran-centric.

Further, as our country continues to struggle with improving health outcomes and unsustainable increases in health care costs, the VA can play a crucial role. As a long-standing, highly integrated, and patient-focused provider of care, the VA can lead the way in advancing the nation’s health care. This is the appropriate role for government: Do what the private sector cannot or will not do, given the nature of its enterprise.

The VA has 3 core strengths that distinguish its services from those of the private sector in caring for veterans: (1) system wide clinical expertise regarding service-connected conditions and disorders; (2) a team approach to primary care that is veteran-centric; and (3) a holistic view of the veteran that includes physical, psychosocial, and economic determinants of health, as well as critical support services for family members and caregivers.

First, the VA brings together comprehensive expertise on service-connected health issues in a single health care system. Our clinicians are trained to identify, assess, and treat a wide spectrum of health issues, such as spinal cord injury and limb loss, conditions arising from environmental exposures, and traumatic brain injury. Additionally, VA specialists have expertise in the treatment of mental health issues, substance abuse, suicide prevention, and post traumatic stress disorder (PTSD). Further, the VA has a long track record that includes national programs in audiology and speech pathology, blind rehabilitation, chiropractic care, physical medicine and rehabilitation, prosthetic and sensory aids services, recreation therapy, and polytrauma care.

In contrast, knowledge of and expertise in these crucially important health care issues are not nearly as widespread in the private sector. For example, less than 50% of private practice primary care providers (PCPs) regularly perform screening tests for PTSD and depression.1 In addition, only 15% of community-based mental health providers are proficient in treating military and deployment-related issues such as PTSD, and less than 20% of PCPs have sufficient military culture competence to take a veteran’s military history.1

The VA’s second core strength is its team-based, veteran-centric model of primary care that focuses on patient-driven, proactive, and personalized care. This patient aligned care team (PACT) addresses not only disease management, but also disease prevention, wellness, and health promotion. The PACT model often includes PCPs, nurse care managers, social workers, pharmacists, nutritionists, behavioral health professionals, administrative clerks, as well as the veteran, family members, and caregivers. Through PACT, veterans can attend group clinics and educational seminars, access web-based information via a personalized patient portal, and directly communicate with their care team by phone, secure messaging, or telehealth. The PACT approach has proven effective: Several studies examined its impact on reducing avoidable hospitalizations, emergency department visits, and behavioral health issues and on improving communication among health care professionals.2-4

The VA’s third core strength—a holistic approach to patient care— also is not uniformly seen in the private sector. All too often the private sector health care system addresses only the patient’s chief complaint, focusing on the physical manifestation of an illness or the patient’s psychological condition. Ensuring a patient’s well-being requires the integration of the physical, psychological, social, and economic aspects of health and a thorough understanding of how these factors impact treatment compliance. As any health care professional knows, even the best treatment plan cannot succeed without patient compliance. In this regard, the ability to address nonmedical issues is as important as the treatment plan.

By taking a holistic view of health and inviting veterans to do the same, the VA addresses these and other compliance issues head-on. The VA is positioned to provide help, as appropriate, with transportation; caregiver support; homelessness; pharmaceutical benefits; clothing allowances; counseling in readjustment centers; and a full range of physical, psychological, dental, and social services.

As someone who has spent considerable time in the private sector, I can report that delivery of such services is the exception, not the rule, especially given the current system of health care reimbursement. The benefit of a holistic view is underscored by numerous outcome studies showing that the VA performs as well as, if not better than, the private sector. For example, screening and prevention outcomes at the VA have been consistently better than those at community care sites.5

Studies also suggest that standard care measures, such as control of blood pressure and hemoglobin A1c levels, are often better in VA patients compared with non-VA patients. Studies of risk-adjusted mortality rates generally found improved outcomes for VA care or little difference between VA and non-VA care.6-9 Moreover, a recent independent assessment of the VA reported that the VA performed as well as, and in some cases better than, the private sector on a number of key indicators.10

In my first year as the VA under secretary for health, I have come to appreciate these strengths even more and to sharpen my understanding of what makes VA care different from private sector care. Five distinctions are clear:

1. Veteran Patients Are Inherently Different

The VA manages a patient mix that is distinct from what civilian community providers typically treat. The majority of veterans who utilize VA health care are collectively sicker and poorer and have fewer support services than age-matched non-veteran patients.10,11 When compared with the general population, veterans are more likely to have as many as 3 additional comorbid physical conditions as well as a possible mental health diagnosis.

Similarly, the VA also cares for a higher percentage of minorities who, as a group, too often encounter barriers to care in community settings. Given these disproportionately higher numbers of patients facing access issues, the VA has done better than the private sector in reducing barriers to care for many health measures.12 For many veterans, the VA has become a lifeline of health care support and service.

2. Reimbursement and Incentives

The veteran patient population typically requires more time during a typical doctor visit than private sector physicians generally can provide. Ever-changing reimbursement schedules have forced many private sector PCPs to shorten patient visits in order to survive economically. Because VA physicians are salaried, they don’t face the same constraints on time spent with patients. Further, there is less of a mismatch between financial performance and clinical performance and, therefore, less likelihood of inappropriate tests and services.

3. VA Employees’ Sense of Mission

Almost 95% of VA staff believe the work they do is important.13 In annual employee surveys, the VA sees a high commitment to service from its employees. Additionally, 40% of VA staff are veterans, who can relate to veteran patients in ways nonveterans cannot. As under secretary for health, it has been a remarkable experience seeing this sense of mission translated into everyday care and observing the very personal connection between VA employees and patients.

This sense of mission, embedded throughout the organization, has a far-reaching impact that includes the relationships formed with veterans. In stark contrast to the private sector, where patients may receive care from multiple sources and switch providers and insurance companies with increasing frequency, veterans tend to forge lifelong relationships with the VA. In turn, this stable and consistent relationship strengthens doctor-patient communications and provides a solid foundation for shared decision making. These long-term relationships also may improve the continuity of care and the ability to track long-term outcomes.

4. VA’s Unique Integration of Clinical Practice With Education & Research

As someone whose residency included training at VA, I’ve long appreciated the VA’s ability to advance health care, incorporate new learning, and promote best practices. These capabilities are fortified by its 70-year partnership with academic affiliates. Through academic partnerships, the VA trains tens of thousands of health care professionals yearly and conducts cutting-edge research on all the service-connected issues described above, as well as chronic illness, disparities in care, and emerging areas such as personalized medicine.

The VA Research and Development Program is the nation’s only intramural research program entirely dedicated to the health of veterans. Further, more than 60% of VA researchers are clinicians, which means their studies are framed by daily interaction with patients, and their study findings are put into practice more quickly.

5. VA Investment in Large-Scale Capabilities

As the largest integrated health care system in the U.S., the VA can invest in capabilities that are difficult for smaller systems to undertake. For example, the VA electronic medical record platform has enabled the organization to capture veteran health data systemwide for more than 2 decades, longer than almost any other health care enterprise in the country. Additionally, the ability of the VA to house and analyze “big data” is more advanced than that of most other health care systems, in part because of its considerably larger scale. This capability supports the holistic approach to care noted above and makes it possible to consider the numerous social and economic determinants of health and to track outcomes over time. This capability also supports the VA Million Veteran Program (MVP), a research effort that is building a genomic database of 1 million users of VA health care. Through the MVP, researchers will be able to use genomic and clinical data to develop personalized therapies for veterans and address some of America’s most significant research questions.14

As we continue to transform the VA and improve veterans’ health care, it is essential to understand that VA care is different from private sector care. It also is essential to understand—particularly given an environment of intense public scrutiny—that this fundamental distinction is embedded in the VA mission “to care for those who have borne the battle for their country.”

At the same time, it also is crucial to recognize that, although VA care is distinctly different from private sector care, our ongoing transformation means closer collaboration with the private sector—that is, for veterans seeking care from community providers. In this regard, we are working to achieve a tighter integration of the care offered to veterans in both sectors by working to develop a high-performance network that includes care from both VA and the private sector.15

Finally, in the midst of such a transformation, it is imperative to underscore that one factor will remain the same: our long-standing and unwavering commitment to provide patient-centric care and value to every veteran. As the under secretary for health, it is my great privilege to see this commitment daily and to better position the VA to serve our veterans and the nation.