The VA wait list scandal: A sign of our future?

A Veterans Affairs hospital in Fort Collins Colorado, it was recently revealed, falsified its wait times for outpatient clinic appointments. In order to appear to meet the goal of clinic appointments within 14 days, the hospital taught its clerks how to falsify the appointment records to create the illusion that the appointment goals were being met. Many of the 6,300 veterans treated at this clinic actually waited months for their appointments. Yet the clinic clerks were required to “cook the books” else they were punished by being placed on a “bad boy list.” Aside from the moral outrage of treating our veterans in such a callous manner, this episode provides a glimpse of coming attractions for health care delivery in the U.S.

The Veterans Health Administration is the largest integrated health care system in the United States with 150 medical centers, 1,400 hundred outpatient clinics, and 53,000 health care providers. Such systems are, “Poised to play a pivotal role in reform efforts,” according to health care academics. This is the “one stop shopping” model of health care delivery, with all services under one structural umbrella, all providers employed by the system, providing integration and continuity of care. It’s also the progressive holy grail of single-payer universal health care. The president is a proponent of such a system, as is his former Medicare chief Donald Berwick. The U.S. health care system is sliding toward single-payer, so it would be instructive to consider how the VA news foreshadows the future.

The first place to look would be at the British National Health Service. The aforementioned Donald Berwick told us, “I am a romantic about the NHS; I love it.” The NHS is famous for its wait lists. Their website reassures British residents, “You have the legal right to start your NHS consultant-led treatment within a maximum of 18 weeks from referral, unless you choose to wait longer or it is clinically appropriate that you wait longer.”

Consultant means specialist. So that persistent headache, stomach ache, vision loss, or cough will be addressed promptly by an appropriate specialist within four and a half months. Hope the headache isn’t from a brain tumor and the belly pain isn’t from cancer because in 18 weeks, the concern may be moot. If “clinically appropriate,” you may wait longer, such as for a hip replacement. Not life threatening, only painful and inconvenient, so a 6-month wait in Wales is deemed reasonable.

What happens when the wait lists become too long? Several years ago the NHS had over 150,000 people waiting longer than 18 weeks for their specialist care. New Zealand, with a health care system similar to the NHS, faced this problem in 2007. They promised patients treatment within six months. But when the wait list grew too long, they simply removed 35,000 people from the wait list, sending the patients back to their GP. If the GP could have solved the patient’s problem, they would have and not referred them to the specialist at the public hospital. So back to square one for the patient.

This sounds much like the VA hospital. If the wait list is too long, just remove everyone beyond the targeted wait and voila, the wait list is operating as promised. Don’t think this could happen in the U.S.? The VA hospital in Phoenix had two separate wait lists, “One of them secret, deliberately put in place to avoid the VA’s own internal rules.” That way no one finds out that veterans promised timely care get anything but, in a system, “Where wait times can last more than a year.”

Brian C. Joondeph is an ophthalmologist and can be reached on Twitter @retinaldoctor.  

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  • QQQ

    “It’s also the progressive holy grail of single-payer universal health care. The president is a proponent of such a system, as is his former Medicare chief Donald Berwick. The U.S. health care system is sliding toward single-payer, so it would be instructive to consider how the VA news foreshadows the future.”
    ————————————————————————————-
    “I don’t believe in a government that protects us from ourselves.”
    -Ronald Reagan-

  • QQQ

    This article came from BBC in March 2013 about overhauling the U.K’s NHS. Good read.

    “Q&A: The NHS Shakeup:
    http://www.bbc.com/news/health-12177084

  • mikeva

    The Veterans Administration has no or a limited productivity standard. Relative value units might not be perfect but at least you have a standardized tool to work and measure critical aspects of delivery.

    With that said, I’m sick of the fear mongering. We’ve had decades to make improvements in health care. It is true that we’ve started to make impacts on readmissions, outcomes, costing, self-pay, and outpatient expansion, but we still have monetary problems. We need infrastructure, labor, and some dreaded disruption with automation of physician efforts.

  • mikeva

    I want to understand. You’re telling me the VA does more or less 12 procedures in 3 days. Some divisions in a acm might only do 2 procedures an hour. I’ll give you 4 procedures per hour in line with no teaching and the best operations.

  • Joe

    There is another aspect of the whole VA issue that is being ignored and that’s the VA’s unwillingness to pay for care when it’s rendered by other providers. Having spoken to colleagues in other areas and states, we aren’t the only group getting blown off when it comes to payment. So even when veterans do get care (ER, for example), it’s not being compensated.

    • querywoman

      That might help some.

  • Dorothygreen

    The VA system has many good features but:

    Seems that incentives to VA Directors are a significant part of the problem. The director at the Phoenix VA, was about to receive a $9000 bonus. I suspect the VA Directors can get bonuses for a lot of things that relate to saving money (even if it is at the expense of adequate staffing, promotions to qualified staff or the worst of all at the expense of veterans waiting for care.

    Their salaries are reasonable, but certainly not those of CEOs of large hospitals who receive bonuses for keeping expenses down (this might be similar to the VA), but mostly by keeping revenue high doing needless procedures, even at the end-of-life, admitting patients unnecessarily from ER to keep beds filled. And of course there is the “secret master charge” and collectors visiting patients before they are even discharged (all reported in the news in the last couple of years).

    While private hospitals can fairly be criticized for being “greed machines”, they do not have the “laziness factor”. This speaks to D. Wang’s observations of the low number of procedures
    performed at VA. It is not easy to fire someone in the VA. And the VA has a union for non-professional employees – the AFGE. Probably started for a good reason, but just like the “greed machine” CEOs, union
    leaders can get too much power and to maintain it support employees against management efforts to have productivity accountability, efficiency and even go to the extent to rid themselves of a pesky boss who expects them to do their job and be accountable.

    Years ago I read that communist would never work because of laziness and greed (Overstreet and Overstreet) circa 1950. That made sense to me then and certainly seems the case around the world in more than just healthcare.

    Those developing the US health (care) model should take this into consideration. It seems for the US, a Swiss model would be the best. The people of Switzerland want fair and affordable health care for all. There are brakes on greed through mandates – no private insurance for basic services. All is insurance, the government’s role is to negotiate prices and rates with insurance companies doing it at the Canton (state level) with docs and hospitals. Those who can afford top docs and other perks pay through their premiums – no such things as concierge medicine or
    go to the front of the line as “fast as the speed of cash”. In such a system, service connected veterans would go to the front of the line.

    The insurance companies can make a profit, not an outrageous profit, but enough so there is competition and efficiency. The quality of Swiss health care? Some think it is the best. It is at least in the top 5, has mandatory coverage, choice, efficiency and quality, and costs half of the overall US health care.

  • querywoman

    There is absolutely no way to keep anybody, anywhere from lying. Systems should have checks and balances to monitor situations.
    The Abu Ghraib scandal in Iraq never surprised me. Conquerors and other jailers torture.
    We are supposed to accept that lies will happen and have install effective monitoring techniques.