D-Day for the VHA?

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Secretary of Veterans Affairs Robert Wilkie testifies during a congressional hearing on Capitol Hill. 

On Thursday June 6, the Trump administration’s Department of Veterans Affairs (VA) leadership launched its new Veterans Community Care Program (VCCP). Established under the VA MISSION Act of 2018, the VCCP will outsource the care of millions of America’s most vulnerable veterans to an army of private hospitals, physicians, and other providers. 

But rolling out this new initiative on anniversary of D-Day, the allied invasion of Normandy during World War II, could not be more ironic. 

Seventy-five years ago, American troops were well prepared for the invasion of Normandy. Today the troops on the home front, the thousands of Veterans Health Administration (VHA) physicians, nurses, social workers, psychologists, clerks, and administrative staff who have been assigned to help veterans cope with what the Trump Administration has called a “revolution” in veterans’ health care, are deeply concerned about the future stability of this new program.  

Over the course of the last two months, dozens of physicians, local VA medical center leaders, and union activists (not to mention veterans who are expected to benefit from the new options and representatives of veterans service organizations) have told the Prospect, that the VCCP is deliberately designed to set them, and the VHA, up for failure.

Consider these examples of how the program is being undermined: Under the VCCP, veterans who have to drive 30 to 60 minutes or have to wait more than 20 or 28 days for an appointment will be eligible to see private-sector doctors and hospitals. Veterans and their care providers are supposed to discuss whether moving from the VHA to private-sector care doing so is in the patient’s “best medical interest.”   

In a recent press release, Veterans Affairs Secretary Robert Wilkie assured veterans that “well-trained staff will be available to help them quickly understand their choices.” Nothing could be further from the truth. Wilkie and other Trump appointed VA leaders were supposed to provide VHA caregivers with decision-support tools that would help them navigate potentially difficult conversations with veterans about the new program. Those tools are not ready. Support and administration staff were supposed to be well trained in the specifics of the new program. They have received only scant training at best. At one East Coast VA medical center, some staff were trained and then told that the training was all wrong and that it would have to be redone.  

Primary care providers and specialists throughout the system lack accurate quality measurement tools to help them determine when it is, or is not, in the best medical interest of the patient to seek private-sector careThat’s because these tools don’t really exist in the public or private health-care sectors. Even if they did, VHA medical staff are convinced that Wilkie’s drive and wait-times standards will trump (pun very much intended) their ethical concerns for their patient’s well-being. They will, they fear, not be able to stop a veteran about to seek care from a private-sector psychologist who is not trained in evidence-based care for PTSD or from a surgeon who recommends unnecessary prostate surgery for a Vietnam veteran suffering from Agent Orange-related cancer.  

VHA providers are also worried that these new standards will introduce unnecessary friction into the patient-caregiver relationship. What happens when a veteran has heard about a great new but untested treatment offered by the private sector but not by the VHA? Will busy VHA caregivers have the time and energy to resist pressure from their patients? If they do, will angry veterans ding the VA for poor customer relations, thus lowering facilities’ quality scores and threatening their continued existence?

Secretary Wilkie assures us that the VCCP will lead to “less red tape, more satisfaction, and predictability for patients, more efficiency for our clinicians, and better value for taxpayers.”  VHA physicians and nurses have also told the Prospect that they fear that the opposite will occur. Clinical care, they predict, will erode because that they will now be spending so much time chasing down documentation from private-sector providers unwilling to provide it; scanning documents into VHA charts or authorizing private sector referrals that they will have little time to give direct care to patients. 

Many VHA caregivers also warn that costs for private-sector care will explode as non-VA primary care physicians or surgeons send veterans into a maze of unnecessary consultations within their own networks of cardiologists, pulmonologists, orthopedists, and others when care could be provided by just as well and for less money at the VHA. Veterans may also be offered telehealth appointments in the private sector when the VHA is a global leader in providing this service. The agency’s providers will not be able to effectively coordinate the care of delivered by private-sector providers notorious for their refusal to collaborate and coordinate with one another, much less with those who work in an entirely different system. 

Most importantly, under Wilkie’s new drive-time rules, expensive outsourced care could deplete the VHA budget and deprive VHA programs of the volume of patients that allow clinicians to maintain their skills and hone their expertise. As one VA Medical Center director, who asked to remain anonymous because that person was feared retaliation from top agency officials told the Prospect, under Wilkie’s access standards veterans can refuse to go to a VHA surgical program if it is more than 60 minutes drive from their home. Political appointees bent on privatization and setting the system up for failure will find an excuse to close programs that do not serve enough patients.  

Many veterans are also concerned about the great new choices they are being offered. Mark Foreman, a veteran whose hip was blown off in Vietnam told the Prospect that he has watched the VHA transform itself from a hellhole to a “magnificent system of care.” Foreman believes all the talk about providing more choices for veterans is a smokescreen. He says, “It’s about taking money from the public sector and giving it to private profiteers, not about improving the health care of veterans.” 

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