Health Reform of VA

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For the Department of Veteran Affairs, 2014 was a turbulent moment. Following a claim that lengthy waiting times have been covered up for the ill veterans, an inquiry has been begun at several veteran health facilities. The uncovered details was damned, including the finding of concurrent waiting lists, cancellations for dead patients, denial of medical benefits and hundreds of deaths due to delayed treatment (Hegseth, 2016). The ensuing scandal led to the resignation of Secretary Eric Shinseki and the creation of the Veterans Access, Choice, and Accountability Act of 2014 that gave the mandate for a commission to initiate a deeper probe of the department. A new Secretary, Robert McDonald was appointed to mitigate the issues and restore normalcy to the VA healthcare system. Unfortunately, a third party report released in September 2015 illustrated that the VA Department was indeed under serving the 9.1 million veterans. Among the shortcomings identified were a negative organizational culture, poor management, disorganized communication structures, lack of accountability, outdated patient management systems, poor relations between the employees and managers and a culture of retaliation towards employees that raise complaints (Journalist’s Resource, Havard Kennedy School, n.d.). In conjunction, these issues led to inconsistent care across facilities and chronic problems in regards to access of service for the men and women who have repeatedly laid down their lives to serve the nation. Given this issue, it is essential that the right features be put in place to ensure that a dynamic change in the current VA health care system is realized.

Although the White House and Congress instituted several measures to improve VA healthcare, the provision of quality and timely care to veterans remains a significant challenge. The myriad of issues plaguing it have a systemic root, and as such, an integrated analytic theory is applicable for the explanation of the problems as well as the creation of recommendations for their resolution. The Policy Windows theory, developed from John Kingdon’s classic theory for the setting of agendas identifies key issues that garner attention in numerous policy systems. The theory posits that an issue will only receive serious attention when the problems, policies, and politics converge, therefore creating a policy window through which the possibility of change can be created (Stachowiak & ORS Impact, 2013). The national scandal surrounding the VA healthcare system, the numerous policy recommendations made by the government appointed committees and third parties as well as the national mood that insists on the resolution of the problems accurately cover the scope of the VA healthcare issues. Although there is a lot that could be done for the improvement of the department, some of the critical issues, such as patient access, quality of care and the dysfunction of the patient management system are a common issue across the national healthcare industry. The core root of the VA healthcare tribulations is the disorganized clinical operations that see some centers function like clockwork while others have to create dual lists to conceal the fact that some veterans are denied the benefits and succumb to their conditions while awaiting treatment. Therefore, enhancing the operations that take place in the delivery of care will ensure that the delay in care is alleviated and that the veterans receive the quality of care and access merited by their status.

Background

Due to the numerous clinical problems plaguing the VA health care system, there were adverse consequences that affected the access as well as the quality of primary and specialty care throughout the VA healthcare centers across the country. The system suffers from a shortage of providers, clinical managers as well as members of the support staff, and the few that are available have to cater to the nine million veterans across the nation. A report by the Commission on Care states that of all the VA health sites surveyed, 94% reported that the delays would be drastically reduced if there was an increase in the number of licensed practitioners that would improve access to care (Commission on Care, 2016). This shortage is coupled with outdated and impotent policies that are unable to properly assess and optimize the available human resources. As such, the providers that are available are ineffectively utilized, and their collective productivity is suboptimal. Due to the low number of support staff, some of the highly trained clinical personnel are forced to perform their tasks and are therefore unable to provide the level of care that is permitted by their licenses. Instead of utilizing their time providing specialty care, doctors are nurses clean the examination rooms, fill documentations with patient information, escort patients to different hospital areas during their stay, order prescriptions and schedule consultations. Most of these duties are the mandate of support staff, who have the skills to accomplish the tasks in a cost effective manner. The VA health care centers also fail to fully utilize the skill set of the advanced practice registered nurses, who in addition to functioning as professional nurses, they possess advanced degrees that enable them to provide primary, specialty and acute care to patients. The lack of adequate personnel stems from an impaired employee recruitment process which hinders the VA department from hiring, retaining and training support staff that can carry out the duties that take up time for the doctors, advanced practice registered and regular nurses. Since the scandal broke out in 2014, the VA department has been making moves to alleviate the disparity in care stemming from inadequate staff.

Another core clinical issue that impairs the effectiveness of the VA health department is the lack of safeguards that allow all the veteran beneficiaries to obtain all the medical benefits that come with their status. Although it is a common practice among several health insurers and federal care providers, the healthcare plans provided by the VA department do not have established processes that define care benefits as well as the measures to be taken during a medical dispute (Commission on Care, 2016). These processes have not been imperative for the VA as the care packages are not based on payment and the department does not necessarily have tp preserve resources from the patients. Instead, the VA healthcare system is run on eighteen policies, collectively known as the Veteran Integrated Service Network (VISN) (Commission on Care, 2016). So as to counter this issue, the department launched a program known as the MyVA initiative that is constituted of different goals, geared towards the overall improvement of service access and delivery for the veterans. Under the initiative, a patient advocacy team has been created in line with the requirements from the patient care centers. However, the veterans still lack clear directives to follow for any grievances, and there are no clear cut defenses that ensure that the veterans acquire the necessary medical care needed. The guidelines that are present are not as comprehensive or as well developed as those provided by private and federal insurers (Commission on Care, 2016). As such, the members that subscribe to either provider get far better access than the veterans, therefore creating inequity in care. Regardless of the lack of proper guidelines, there are policies in the VA department that require the healthcare centers to establish advocate programs that deal with the complaints that are brought up by patients. A bill passed in 1996 by Congress ratified an eligibility reform statute that provided access to a uniform benefits package to all the veterans that were enrolled into the healthcare program (Commission on Care, 2016). Following the passing of that bill, the VA department launched a survey that reviewed the different methods through which VA care centers handled the disputes that were brought up by patients. The disorganized methods utilized across the country as well as the bill prompted the creation of the VISN in 2000, which would allow for the formation of an external review board that would evaluate the decisions that were made by the clinical boards (Commission on Care, 2016). The VISN directives also allowed veterans to carry out internal appeals should they feel that the decision made by the clinic was somehow unjust. They established a policy that allowed patients as well as their representatives to bring forth any disputes that pertained to unsatisfactory delivery or denial of care that could not be resolved within the clinical setting and that a review of the dispute could somehow lead to different, potentially more beneficial outcomes. As per the VISN directives, the policy required the VISN Director to create and write down policies and a set of procedures to be followed whenever an internal appeal is raised. The VISN retained the authority to request an internal review during the appeal proceedings. Although the VISN was a useful guideline for a while, it was established as a temporary measure to bring normalcy into the VA medical benefits scheme and has since expired. Six years later, it is still used as a reference as the VA department is yet to draft new measures or renew the VISN.

Alternatives

There are various measures that the Veterans Affairs department can put in place to resolve the personnel issues. Amendments can be made to streamline the recruitment process which will allow the VA to hire more staff. A ruling made by Congress has also allowed the department to offer the prospective employees a salary that is up to par with the current market rates for medical support assistants (Commission on Care, 2016). This action will allow the VA healthcare centers to employ more support staff. Efforts towards the proper allocation of duties among the staff have could also be made. The department should deploy clinical managers who will oversee the needs of the patients and match them with the resources provided by the staff. Clinical managers are commonly utilized by several clinics and hospitals. Their duties include assigning caseloads to staff members, ensuring that hired staff meets the required qualifications, organizing the workflow to allow the centers function at an optimal level, setting time targets and monitoring telephone protocols. They could be applied to VA care centers to execute the listed duties and ensure that the clinics and hospitals function in tiptop shape. The VA department should strive to ensure all the all its hired advanced practice registered nurses all allowed to fully practice across all the states. As such, the nurses will have the authority to independently deal with patients, hence lessening the burden that has been placed on the doctors.

To resolve the issues that prevent some veterans from fully accessing their medical care benefits, the VH department could adopt a fraction of some of the procedures that are utilized by federal and private insurance providers. For instance, the affordable care act, commonly referred to as Obamacare, requires the provision of external reviews for all the beneficiaries that have had their internal appeals denied, regardless of the health care plan to which they are subscribed. The VA could implement a similar process in the care dispute proceedings as the veterans are currently prohibited from requesting an external review of their disputes unless it is personally reviewed and overseen by the VISN Director. The Medicare package includes an extensive review process that is applied to all clinical disputes as a requirement in the resolution of care organization and beneficiary disagreements. It allows recipients to carry out an internal appeal with the possibility of requesting for an accelerated external review, the second probe into an initial review and an independent review to be conducted by a third party. Furthermore, it grants the beneficiaries a right to appear in front of an administrative law judge, the review of a dispute by the Medicare Appeals Council and, as a last resort, a review by a federal district court (Commission on Care, 2016). Medicaid requires the locality of the care organization to consider all the appeals that are brought forth by the beneficiaries and the provision of ample time by the State to carry out fair hearings that identify if a particular care center was justified in denying or terminating care that was medically necessary to a beneficiary. The VA department could benefit from implementing such measures. Although they do offer the veterans and care centers enough time to resolve their disputes, the possibility of an expedited review is not provided, therefore creating inequity between the veterans and those that work in federal institutions. The policy in the VA healthcare department is also detached from its beneficiaries as it does not provide opportunities for meetings with veterans and getting to listen to their cases. Veterans are also denied the opportunity to hold hearings during the dispute, and they are not allowed to keep getting their health care benefits while the case is ongoing.

Recommendations

The shortage of health providers that results in excessive delays and in some cases, denial of care could be resolved if the VA health department could increase the efficiency and effectiveness of the staff that is present in the different care centers across the country. The doctors, advanced and regular nurses should be allowed to make full use of the skills that grant them their licenses. As such, they could independently handle some cases instead of creating long wait times that see some veterans die as they await medical care. The VA should also continue to hire clinical managers as a requirement for every center, not as a way to mitigate the chaos that plagues some of its most controversial organizations such as the Phoenix VA healthcare center. These officers will ensure that the staff at the hospital utilizes their abilities as productively as possible. By organizing the workflow of the clinic, a lot of tasks will be accomplished within a shorter time span. The easiest way to ease the issues that stem from the shortage of staff is the addition of more members of staff. The VA department could, therefore, carry out recruitment processes that will see the department gain more employees that will cater to the needs of over nine million veterans that are currently beneficiaries of the VA healthcare program. Hiring more medical support assistants will relieve the doctors and nurses of the burden of providing care as well as logistical support for the veterans, and as such, they will be free to provide medical and specialty care, while the support staff deals with patient documentation, scheduling, and cleaning of hospital rooms.

In regards to the provision of better access to the medical care benefits that are provided to the veterans by the VA department, I would recommend that the VA develop policies that are more or less similar to the federally provided Medicare and Medicare packages. Much like the VA healthcare package, both insurances are not based on the protection of resources provided by the beneficiaries, but are based on providing affordable but quality care to those that subscribe to them. As such, the VA should revise the current clinical appeal system and establish one that provides them with the same protections that the government offers to the patients under the federal funded programs. The veterans should be at least allowed to appeal the decisions that are made by the care organizations and they should not be barred from receiving medical benefits during the proceedings as some of them may take a while. It also seems quite dismissive of the department to refuse to hold meetings with the veterans to listen to some of their claims as they abandon them to the whims of the care organizations that have been proven to delay and deny care. The veterans should also be allowed to seek an external, objective review of the clinical dispute so as to validate or overturn the decision made by the clinical review, especially if the ruling bars a particular veteran from accessing medically necessary care.

In conclusion, regardless of the span of the problems facing the VA healthcare department, there are possible solutions that can be applied to combat the issues. The process will, however, be complicated, and it will require focus and commitment to initiate and implement. Although the department has been criticized for not working fast enough, they have made some changes that are geared to restore sanity to the department. As such, any recommendations that will be made to the department, such as the ones above, should align with the efforts that are being made, or at least support them. It is also important to realize that the changes are a long-term process and as such, they will not be achieved within a short time span. The VA department should be held accountable, but they should also be granted the time they require to establish new policies and standards. The VA health department should offer the veterans quality care whenever they need it. They deserve no less for risking their lives for the good of the nation.

References

Commission on Care. (2016, June 30). Final Report of the Commission on Care. Retrieved from http://i2.cdn.turner.com/cnn/2016/images/07/05/commission-on-care_final-report_063016_1815-3-1.pdf

Hegeth, P. (2016, April 7). The VA: Still Unreformed | National Review. Retrieved from http://www.nationalreview.com/article/433760/va-still-unreformed

Journalist’s Resource, Harvard Kennedy School. (n.d.). The U.S. Veterans Affairs Department and challenges to providing care for service members: Research roundup – Journalist’s Resource. Retrieved from https://journalistsresource.org/studies/government/health-care/veterans-affairs-department-health-care-hospitals

Stachowiak, S., & ORS Impact. (n.d.). PATHWAYS FOR CHANGE: 10 Theories to Inform Advocacy and Policy Change Efforts. Retrieved from http://orsimpact.com/wp-content/uploads/2013/11/Center_Pathways_FINAL.pdf

VA Office of Inspector General. (2014, August 26). Veterans Health Administration. Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Retrieved from https://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf

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