As much bad press as the Department of Veterans Affairs received several months ago for delays in patient care that led to at least 40 deaths, the proposed solution stands to potentially prove even more disastrous.
I recently ended a nearly six-year career with a regional section of the VA that handles the referral of veteran medical care to the private sector. When a veteran needs to receive medical treatment outside the VA system, my sub-department would facilitate the process of authorizing said treatment.
As the scandal that rocked the VA in May was due to perceived “secret wait lists” of patients not being timely scheduled to receive medical treatment within the VA, the gut-level response from politicians and the bureaucratic apparatus was: send veterans outside the VA system to get treatment.
One little detail seems to have escaped the notice of the powers-that-be: no new employees were hired in my sub-department to handle the nearly three to four times increased workload.
So now as the numbers within the VA system begin to look a lot better, the reality is the core issue of timely veteran medical care is actually getting worse.
Context
This is a difficult post to write and is a vast departure from the topics I normally address. Yet, I have an obligation to expose negligence that endangers the life and health of fellow human beings.
I am not revealing any information that is classified or hidden. It is, however, information that either several people in power are ignoring; for whatever reason don’t know how to address; or are ineffectively attempting to address.
I am not interested in naming names or venting about my work experience. In truth, there are no names that I could name, as the ultimate fault for these problems does not lie with anyone that I worked with. I am not referring to any individuals I directly worked with, of which several were good and admirable people.
The blame lies at the top of the hierarchy: the president, congress, and (primarily) top-level department leadership that are completely out of touch with the reality of what happens on the ground level because they only seek the input of those who aren’t at the ground level (with the possible exception of a few “token” average employees in an attempt to demonstrate otherwise).
This is not a partisan issue. It has to do with politicians in general, the political climate coming out of Washington that infects all government agencies across the country, and a bloated federal government that has taken on too many responsibilities in trying to control too many aspects of society.
I’m not a “small-government conservative,” merely a former bureaucrat who recognizes that the more things a bureaucracy attempts to handle, the more layers are added to the bureaucracy, the more people are involved in making decisions, and thus the more convoluted and complicated the entire system becomes, ultimately resulting in vast amounts of red tape, waste, corruption, and inefficiency.
When that kind of bureaucracy becomes entangled with providing healthcare for matters of life and death, it is inevitable that procedural complications will result in cases of death.
These are not theoretical, idealistic political musings on my part: it is the stark reality of what actually happens as witnessed by one who was there.
Numbers and Structure
If Wikipedia is to be considered a reliable source, the VA has over 280,000 employees and an annual budget of nearly $80 billion.
Where those 280,000 employees actually are and what they are doing is a mystery to me, as I worked directly for one of the largest VA geographic regions serving a veteran population of approximately 1 million with an office staff of about 100. Those 100 people were the only staff allotted to select outside facilities to treat these veterans, authorize treatment, and collect and pay claims.
Understanding the organizational structure of the VA would take an advanced degree. It is confusing and difficult to understand for those of us who worked within the system, let alone for those on the outside looking in.
The head of the entire VA is of course the Secretary of Veterans Affairs, which is a cabinet-level position. The direct medical portion of the VA is known as the Veterans Health Administration (VHA). The VHA is subdivided into 23 national geographic divisions called VISNs (Veterans Integrated Service Networks). Within each VISN there exists at least one VA hospital and several local clinics called CBOCs (Community Based Outpatient Clinics).
Several programs and organizations exist under the auspices of every one of these tiers, making accountability cloudy at best. For example, two weeks ago the program that I worked with – Non-VA Care – was a single office that was subdivided into three sections, each under the oversight of a different VA department: authorizations reports to the VHA’s Chief Business Office (CBO); claims reports directly to VISN-level leadership; and the medical review staff reports to the local VA hospital.
Veterans are encouraged to receive their primary medical care with a doctor within the VHA system, either at a VA hospital or CBOC. This primary care physician (PCP) is the veteran’s main doctor and in theory coordinates any medical care the veteran needs to receive.
Whenever the VA either does not provide the kind of medical care a veteran needs; the veteran lives too far away to be seen by a VA provider; or the veteran cannot be seen in a timely fashion by VA medical providers, Non-VA Care is contacted to coordinate the veteran’s care in the private sector.
I was an authorization clerk. My job consisted of receiving requests for outside medical treatment from VA PCPs; sending these requests to medical staff to determine if the request qualified to send to the private sector; upon approval from medical staff, creating authorization paperwork to send to private medical vendors in order to coordinate veteran care; notifying veterans of the pending treatment in the private sector; following up with veterans and private vendors in order to ensure that the care was taking place; and processing additional treatment requests from private vendors after the initial medical evaluation.
I was part of a three-person team that handled all outside medical care concerning urology, dermatology, vascular care, nephrology, imaging (MRIs, CT scans, X-rays, etc.), pain treatment, general surgery, speech therapy, and endocrinology for approximately a million veterans.
That is not an exaggeration. All those medical specialties. Handled by three people. For a million veterans.
Yet, despite all these things, the office and my specific three-person contract team was by and large handling the workload coming our way within a timely fashion.
Then, the VA got some bad press.
Systemic Failures
While the veteran population for the area approached a million, the actual number of veterans being seen by the VA facilities is far smaller. Approximately 125,000 unique visits were recorded last year, which better reflects the actual number of veterans in-system. The possibility constantly exists, however, that increasing numbers of those million veterans could potentially seek treatment through the VA.
Before detailing the crisis that any honest Non-VA Care employee would tell you ought to result in the dissolution of the VA as a medical entity, I want to share some of the standard systemic problems that by themselves call for drastic reform.
Perhaps the best place to start is noting the fact that I and several of my incredibly competent and qualified coworkers were unable to be hired for our own jobs.
Yes, it’s basically as ridiculous as it sounds without further explanation.
The VA relies on several contract employees in addition to full-time federal employees. Easily two-thirds of my office consisted of contract employees.
Contracts are workers who don’t technically work for the U.S. government. They work for a temp agency contracted by the VA so the VA can more easily cut ties with employees and save money by not paying contracts federal benefits.
It is virtually impossible for the VA to terminate its own federal employees due to the influence of its union. It is also nearly a guarantee that the people chosen for federal hires will not be the person most qualified for the job.
I and several of contract employees frequently applied for permanent federal positions for the jobs we were successfully performing, only to not qualify for consideration.
The reason is the VA operates on a “points system” in determining which people qualify to be interviewed for open positions. I don’t know the exact amount allotted for specific statuses, but I do know veterans receive heavy point preference. Depending on the type of service a veteran has, the points range anywhere from five to ten. I was led to believe but can not verify that minority status received the next point preference, followed by gender status and finally education.
As a non-veteran white male with a bachelor’s degree, I could never receive enough points to qualify for interviews. Some good employees were indeed hired instead, yet the vast majority of hires were not nearly as adept as contracts at performing their jobs.
A routine practice among several contracts was cheating the system by claiming disability (either physical or mental) where none actually existed.
As frustrating as that was on a personal level, the more disturbing practice was witnessing the blatant waste of billions upon billions of dollars the VA paid up front to a private managed health care company, Health Net.
While Health Net at least half-heartedly attempts to do what it was paid to, it is inefficient, cumbersome, and avoided at all costs by VA employees.
Health Net was hired to facilitate the referral of veterans to outside doctors. The idea was Non-VA Care would provide Health Net with an authorization for a veteran to receive a particular service, then Health Net would select the vendor, schedule the veteran, and handle billing at a slightly cheaper rate than the VA’s rate.
As is often the case within government, the meeting of idealism with reality didn’t go well.
The web site Health Net established for uploading and downloading information was full of glitches; the process for providing information to Health Net proved to be far more complicated and time consuming than the normal VA process; Health Net routinely referred veterans to doctor offices over two hours away from their homes; Health Net employees routinely made errors in entries using their own programs and web site; and Health Net proved incapable of handling any case that had any type of medical urgency associated with it.
So, yeah.
Lastly, a new mandate came straight from Washington regarding the selection of outside vendors for veteran care.
In order to expedite the process for veterans to receive medical treatment as quickly as possible, previous policy had been for the department to select vendors with which it had established relationships (and thus already had necessary billing information, contacts, etc.). The new mandate, however, requires someone in the department to contact a veteran by phone to ask which vendor the veteran would like to see.
Sounds like a decent idea, right? Except it required the 15 authorization clerks to contact – on any given day – over 400 veterans by phone on top of all other duties (which include actually making an authorization for veterans to be able to receive treatment).
When a veteran requests a doctor that the department has no information on, the process is further slowed. No authorization or referral can be made until the vendor is contacted; copies of W9s are received; proper paperwork for billing processed; and vendor information entered into various databases for authorizations to even be generated.
In other words: further and further delay in actually getting medical care authorized and scheduled.
The Scandal of Idealism
The entire implosion of the VA system is symptomatic of the scandal of idealism within the federal government: politicians only make decisions that will appease the people who vote for them. The government is being operated on pie-in-the-sky ideas that have no actual basis in reality.
Anything can sound like a good idea, but the question is: can the idea actually be accomplished given the resources at hand?
Either no one is asking that question, or the politicians who do ask it are being lied to by top-level bureaucrats who are out of touch with the day-to-day operations of the bureaucracies they lead.
And why wouldn’t they lie? It’s not like anyone who works as a federal employee can actually be fired. So instead they tell the politicians what they want to hear so that the politicians are satisfied and leave them alone.
The truth is, the VA system needs to become strictly insurance along the lines of Medicare and Medicaid.
It desperately needs to get out of the business of providing or authorizing any kind of actual medical care.
The veteran population is too large and the bureaucratic nightmare that ensues is quite evidently too colossal to coordinate an effort that is this enormous and dependent on timely, life-and-death action.
God help us if the private medical sector is ever governed in any way, shape or form by a type of system that operates even remotely like the VA. The problem lies in the size of the United States.
The socialistic governments frequently lauded for their healthcare represent nations that are fractions of the size of the U.S. Canada’s population: 35 million. Sweden: 9 million. Germany: 80 million. France: 66 million. The United States: 316 million (U.S. veterans: 23 million).
Population matters because the larger the population; the larger the bureaucracy needed to organize anything on a grand scale; the more opportunity that is thus presented for confusion, abuse, incompetence, and red-tape to infect the system.
We need to wake up to the realities of our actual nation, not theories that sound nice either without or within an entirely different context.
And as such, we need to be aware of the drastic medical crises that have happened and are bound to happen if the VA continues as it is.
David S. Wisener 