Kentucky voices

VA lesson: defend and deny bad health policy

June 22, 2014 

This Memorial Day was unlike any other for me. I spent much of a day when our nation should be honoring our fallen veterans reading about the Phoenix Veterans Affairs scheduling scandal, which was rapidly expanding nationwide.

The secretary of Veterans Affairs was forced to resign, just a few months after the Health and Human Services secretary retired, also under cloudy circumstances. A nationwide audit was ordered. It revealed serious problems but nothing that suggests the VA is in a state of collapse.

In Kentucky, the audit provided good news about our state's VA's performance.

Without doubt, the VA system is under tremendous stress caring for aging Vietnam veterans along with an unprecedented influx of wounded soldiers from the wars in Iraq and Afghanistan. Advancements in body armor technology have markedly lowered fatalities but with a cost of increased traumatic brain injuries and chronic disabilities.

When soldiers who have paid a grave price defending our nation are not receiving the help they need, the only response is outrage and demands that our leaders investigate and rapidly fix the system.

In response, more than 6 million appointments that were on the books as of May 15, 2014 were reviewed. Nationally, 4 percent had waiting times 30 days over their desired date, according to the audit. In addition, 63,869 enrolled veterans over the past 10 years were waiting for or had not received an appointment date.

In the Lexington VA, 3 percent of appointments had required a wait of more than 30 days beyond the desired date. In Louisville, it was 2 percent. In the Phoenix VA 11 percent of appointments required a wait of 30 days or more, with the deaths of as many as 40 veterans allegedly caused by these delays.

Of great concern, 13 percent of scheduling staff said they had received instructions to change the appointment date requested by veterans which reduced the reported wait times. Nationwide, 76 percent of all VA facilities had one instance of such a practice.

Allegations of illegal retaliation against 37 whistle blowers from 19 states are being investigated by the U.S. Office of Special Counsel.

Of the 17 VA facilities in Kentucky, the auditors found only two merited further scrutiny: The Fort Knox and DuPont Community Clinics, part of the Louisville VA Medical Center.

An important question: What implications does this have for health-care reform policies? As our health-care costs continue to spiral out of control, are the VA system's alleged cover-ups and cooking of the books a harbinger of things to come and would it be worsened if we morph into a single-payer system?

The answer is an emphatic "no."

Institutions that rely on a "defend and deny" culture and bolster their reputation through public-relations campaigns and a few stellar service lines exist in both the government and private sectors.

Ironically, a possible example of "defend and deny" in the private sector was illustrated by the consideration of Toby Cosgrove, CEO of the Cleveland Clinic, as the new secretary of Veterans Affairs. Based largely on reputation, U.S. News & World Report ranks the Cleveland Clinic as one of the nation's top hospitals. It also has a gold-star rating by the Joint Commission.

But soon after Cosgrove's name was floated earlier this month, Modern Healthcare reported serious safety concerns at the Cleveland Clinic.

Concerns about deficiencies in the medical staff and governance were so severe that the Cleveland Clinic had been notified that it was on track for termination of its Medicare contract. Modern Healthcare also reported an instance of the clinic refusing to show inspectors all the notes in a case under investigation. Just hours after the story broke, Cosgrove took his name out of consideration.

In contrast, health-care systems that have adopted full disclosure of medical errors have not only saved money on malpractice payments but also can more readily address deficiencies in quality.

The full-disclosure philosophy was pioneered by Dr. Steven Kraman at the Lexington Veterans Administration in the 1990s and has since been adopted by the University of Michigan and Stanford University.

It may be a major reason the national audit found that Kentucky VA facilities perform better than average, with fewer re-evaluations recommended in Kentucky, and none for the Lexington VA.

The United States needs to approach what has happened in the VA not as an indictment of any one type of system, but as a critical learning opportunity on the importance of transparency and how the culture of our health-care system desperately needs to change.

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