Sunday, June 1, 2014

VA Health Care, Good Intentions, and Unintended Consequences

In the mid-1990s, I had the experience of consulting for VISN (Veterans Integrated Service Network) 11 of the VA system which includes Michigan, Indiana and parts of Illinois.  I was asked to help them develop a strategy to bring more primary care to communities that had no VA facilities. Even then, the problem of access to care, and especially access to high quality primary care, was seen as a major issue for veterans.   I visited communities in northeast Indiana and helped the VA system develop options to either build a contract system to use independent primary care doctors as an arm of VA care, or to actually have VA employed doctors work in community based outpatient facilities with the major VA medical centers reserved for referrals from those community based practitioners.   My job was to deliver the options in a way that could facilitate decision making and be made operational.  The experience I had was consistent with the revelations now receiving media coverage and congressional scrutiny.  I saw excellent clinical care and horrendous service which significantly limited access to care. 

I am not the only one to recognize that these problems are not new.  A Wall Street Journal editorial entitled “The VA’s Bonus Culture” starts by saying “It must feel like Groundhog Day at the Veterans Affairs Office of Inspector General.  On Wednesday it issued an interim report – its 19th since 2005 – documenting excessive wait times at VA hospitals.”  The lack of public attention to all of the previous reports is a sad fact. I will not attempt to explain it except to say that there is constant competition for public attention as problems are plentiful.  That is part of our contemporary world. 

The persistent nature of the problems is the result of a flawed system of flawed incentives.  I don’t doubt that the implementation of the current VA system was done with the best intentions.  In the 1980s and 90s, there was a persistent belief amongst the architects of this system that the effective use of technology, and the use of state-of-the-art electronic medical records would result in a better quality of care. The belief ran that these approaches in turn would drive ‘care efficiency’ by instituting best-practice protocols embedded in the use of this technology. This ‘efficiency’ would allow for more care to be given to more veterans at a lower cost and in a timely manner.  Twenty years ago the VA system also instituted the use of specific metrics in assessment of its employees to properly reward those who met their metrics and punish those who did not.  The career-advancement incentive for these VA professionals became the following of proper protocols and meeting their “numbers” rather than an incentive system based on individual patient progress, veterans’ satisfaction with their care and improved quality of life for people using the system. Again, I do not question the good intentions of those who instituted this system, but looking at the current situation of the VA in turmoil and with my thirty years of experience in the world of Health Policy, I can confidently point to these efforts as inadvertently leading to the major underlying problems of VA healthcare.

We are now seeing the logical consequence of a system designed and executed poorly.  In individual VA networks and hospitals, this poor incentivization made it so that the administrator who challenged this system was likely to be replaced while the one who accepted it as is and perpetuated its broken bureaucracy was likely to be promoted.  Of course, back then the elected officials in the legislative and executive branches did not know that computers would not be the entire answer, and that the incentives they put in place would drive creativity of the wrong type – creativity in manipulating the system to gain raises, bonuses and promotions with little regard for the care of the patient.  We have now found ourselves with a system that was never designed to expose and correct resulting problems or respond to the changing needs of veterans.

Health care, even when consistent with best science and greatest public policy, is greatly affected by the context of our lives that make each of us unique: our values, our beliefs, our family, our culture, our finances, and our work.  Inflexible systemic ‘solutions’ in the provision of care, curated either by government or by private industry, can handcuff us to programs and policies that, though driven by a desire to improve the world, end up creating incentives that bear little relationship to those initial good intentions.  We need small solutions built for each person carried out by people whose only incentive is tied to how they help that human being in their care. We need to acknowledge that part of the responsibility of health care providers is to be caring and compassionate to all aspects of the lives of their individual patients.  Illness is isolating and being thrown into a big bureaucracy only adds to the isolation.  No person, let alone our veterans, should walk through illness alone.  When on the actual battlefield, it is sometimes said that you do not fight for country, or for your cause, but for your buddy next to you.  When you spend time at a VA facility, broken as its administrative system may be, you see the buddy system in full force as veterans stand outside, share stories and experiences, and remember the tremendous camaraderie of their unit, and their team. If only the system were built to incentivize its workers to more fully appreciate the importance of those stories, experiences, and camaraderie in the implementation of care.

All answers, especially large scale answers, always have unintended consequences and any answer we develop today in reaction to this crisis is likely to have flaws. We need to build a system that is flexible and able to innovate on the go as we learn more about the unique ails and lives of our soldiers. We need people, our medical professionals and administrative staff, to be trained and incentivized to be interested in what is best for individual veterans.  We need a system that assesses all VA employees on the human connections they make with veterans and their families and on their successes in helping our veterans access the care they need and deserve. We need professionals who listen and make themselves part of the military unit that provides care. 

Programs to lower cost and improve quality of care must be driven by individual patient needs, as determined by patients and health professionals working together.  The sacred trust of a caring relationship cannot thrive in a world that tries to shoehorn people into systems that fail to adjust and innovate to the changing science, changing values, changing populations, and changing realities of the people being served. Illness is a battlefield and, as healthcare providers, it is our duty to make those battling illness feel as though we have their backs.  Let’s build dynamic, flexible systems that acknowledge all the veterans’ needs including the need to have someone they trust at their side.