Review Paper - Journal of Public Health Policy and Planning (2018) Volume 2, Issue 3
The makings of veterans affairs health care reform: when values of different VA stakeholders clash
Sam Rayburn Memorial Veterans Center, Bonham, Texas, United States
- Corresponding Author:
- Frank Chen
Sam Rayburn Memorial Veterans Center
Bonham, TX, USA
E-mail: [email protected]
Accepted date: July 16, 2018
Citation: Chen F. The makings of Veterans Affairs health care reform: when values of different VA stakeholders clash. J Public Health Policy Plann. 2018;2(3):1-4.
Several veteran affairs hospitals were caught falsifying patient wait times in 2014, masking long waits and potential deaths. The main issue in this case for developing health care reform is examining which is of greater importance—implementing swift moral action so that the public sense of justice is served from the external stakeholders’ perspective, or the internal stakeholders’ moral argument of making careful, informed decisions that fix the root cause of longstanding problems and improve veterans’ healthcare? Various articles were analyzed ranging from news outlets to government sources, peer-reviewed journals, and other third-party authorities that reported on veterans’ healthcare issues. The findings provide an insightful perspective on how health care reform should occur to the satisfaction of both internal and external stakeholders for the largest and most complex healthcare system in America.
Veterans Affairs, veterans, healthcare, policy, reform.
The Veterans Affairs (VA) Central Office in Washington, D.C. sets various quality metrics that are measured for all VA facilities. Among these is patient wait times, which assesses how long it takes for a veteran to see his or her provider for a clinic visit. Beginning Fiscal Year 2011, the Secretary of the VA had set a new patient wait time target of no more than 14 days, which was significantly lowered from the prior goal of 30 days [1,2]. On April 23, 2014, the Phoenix VA hospital was caught falsifying patient wait times to make it appear like they were meeting the target. Within a month later several other VA facilities were found to have done the same. Whistleblowers revealed that secret waitlists were kept hidden from audits, and that fake appointment records were reported to the Central Office instead [3-5].
Reports surfaced of veterans dying because of long waits to see a VA provider, but reported numbers varied greatly among the media, and also were unsubstantiated by authoritative investigators, including the Office of Inspector General (OIG) . Among the reasons for the discrepancies were the massive amounts of data that had to be analyzed, and also the difficulty and complexity in differentiating between the veteran who died while waiting to see his or her VA provider for an appointment, versus the veteran who died because of waiting too long to see his or her VA provider for an appointment. The completed OIG report issued on August 26, 2014 on the Phoenix VA case stated that while six deaths related to scheduling or access to care were identified out of the 3409 veterans awaiting care, the inspectors were “unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans” .
However, fueled by the media firestorm and public outrage, Congress and the President with hurried deliberation passed a new law just 3½ months following the Phoenix VA scandal, called the Veterans Access, Choice and Accountability Act  coined the Veterans Choice Act for short, or just the Choice Program, it outsourced many veterans to the private sector to receive their care. Veterans were approved for the Choice Program if they had to wait more than 30 days to see their VA provider, or if their shortest commute to the nearest VA facility was greater than 40 miles away . The President also replaced the Secretary of the VA, and several senior executive members and other management personnel at various locations were also fired [8-10]. This case garnered heavy national media attention, culminating in extremely negative media reports which tarnished the VA brand. The rollout of the Choice Program just 3½ months later was the government’s answer to the media and public, and their swift attempt to fix the VA.
Ethical and Stakeholder Analysis
The ethical dilemma faced in this case was choosing the right thing to do through the lens of the federal government, being thrusted into public spotlight with the moral failure of several VA facilities in providing care to their veterans. The federal government was at a point where it had to address the pressures from external stakeholders of the VA—the media and public— but there was great uncertainty as to how to solve the challenges of the largest and most complex healthcare system in the nation, as well as the risk of humiliation and public blame if it didn’t do something promptly enough. However, the danger fell mostly on internal stakeholders—veterans receiving care at the VA and VA employees—as due to the political fallout from several VA hospitals falsifying wait times, now internal stakeholders were faced with excess uncertainty and pandemonium, not just with the future of veterans’ healthcare and how it would change, but also with weathering immense public scrutiny even if they were innocent. Ironically, the people with most at stake were not external stakeholders calling for justice or the government pressured to implement change, but rather internal stakeholders who would feel the ramifications immediately and must bear the consequences of public negativity which had become so rampant and generalized for all of VA.
Therefore, what started out as an extremely poor, corrupt decision from several high-level individuals at various facilities (and equally arguably from a very poor corporate decision to decrease patient wait times to an unrealistic target), became a cumulated political fallout that had to be endured by many innocent patients and employees. The moral orientation  of this case centers around fairness (justice), but fairness in terms of whose perspective? Whether it was from the external stakeholders’ lens, or that of internal stakeholders, the onus rested solely on the government being put under the pressure to enact change.
While swift action was taken and immediate justice seemed to have been served in the public eye, it became quickly evident that the considerations and decision to rollout the Choice Program were made in haste, and its aftermath may in fact continue to damage veterans’ healthcare . Did the federal government take the right action with the right means and right intentions? Did the government implement a whole groundbreaking program with the best sustainable healthcare for veterans in mind? From personal experience as pharmacy director at my VA facility, I have seen an insurmountable amount of confusion among private doctor offices and veterans that now ties up more administrative resources than ever before— causing further delays in care—as well as disgruntled veterans who have gone to an outside provider only to come back. My staff and I have heard words common among many veterans who have journeyed outside and back to the VA: “Private sector ain’t any better.”
So what could have caused the disconnect? For one, veteran no-show rates and non-responses to appointment attempts made by the VA were ignored by the media, and therefore not reported during the media firestorm. This is important because at some point veterans have to take ownership of their own health— which includes showing up to appointments—and this holds true for the private sector patients as well, but the caveat is the VA does not charge veterans for missed appointments. Nevertheless, the general assumption was that private sector healthcare was better, so the government decided to give veterans who qualified for the program a choice. However, despite numerous evidencebased evaluations showing VA healthcare is just as good if not better than the private sector [13-20] private sector wait times, quality metrics, financial accountability and evidence-based data were not significantly considered in the government’s decision process. It would later be supported again in peerreviewed research articles published in the renowned JAMA and Psychiatric Services journals that VA healthcare outperforms that of the private sector [21-23].
Additionally, input from the vast majority of Veterans Services Organizations who represent the voice of veterans was not significantly considered either . Most veterans expressed the need for increased government support and funding to improve VA infrastructure and staffing operations, because of the notion that privatizing veterans’ healthcare would actually deteriorate veterans’ healthcare [24-25]. This was supported by the fact that VA outpatient visits increased by 46% in the seven years leading up to 2014, however, significant staffing shortages could not accommodate the increased caseload demands [26,27]. For years requests were made to increase federal staffing at the VA, but this only happened en masse with the rollout of the Choice Program, though it was still not enough. For instance, as of the third quarter of Fiscal Year 2018, my department’s Choice workload has increased between 19 to 21 times since October 2015—with no decrease in any other workload—yet I have not been granted any additional FTEEs to handle the increased demand despite multiple requests.
Furthermore, it was also unrealistic to apply the 14-day wait time target nationwide, because of the shift of veterans retiring in the sunbelt states and the South, and the uneven distribution of resource capacity. Therefore, what might have been easy for a VA in California or Massachusetts to meet as far as the 14- day wait time target, might have been unachievable for a VA in Arizona or Texas . The unrealistic target set by the Secretary of the VA for all VA facilities to meet promoted a culture of cheating in order to attain target numbers. The VA wait times scandal then happened, political fallout ensued, and the federal government reacted to the problem with the right reason, but with the wrong means and intentions, thus missing the mark on the principles of its actions.
Feasible options for a better ethical solution include the federal government evaluating peer-reviewed scientific journal articles on VA healthcare compared to the private sector, soliciting Veterans Service Organizations and employees’ feelings, increasing funding to help rehabilitate VA staffing and infrastructure, making firing of low-performing employees much easier than present and replacing them with the best talents possible, and outsourcing veterans’ healthcare. The best course of action would be a combination of all of these to appeal to both internal and external stakeholders.
By taking the best course of action, the government would demonstrate conscientious leadership and exemplify being an impactful and adaptive leader. A conscientious leader always considers all stakeholder angles, is always mindful and observant of issues, and with adaptive leadership approaches them with a problem-solving frame of mind .
So What Next?
Getting input from veterans and VA employees and comparing this subjective data with objective, peer-reviewed scientific data on VA healthcare versus the private sector should be the first step the federal government takes. Afterwards, the degree of which the remaining Options Analysis items takes precedence would depend on the results of the research analysis, but the bottom line is that VA infrastructure and staffing organization must be rehabilitated before the option is handed out to let veterans choose to stay with the VA or go private. This way, veterans no longer have to be stuck with long waits for a VA provider as they can choose to go see a private provider, and the VA healthcare system is not neglected as its infrastructure and staffing power would be rehabilitated so that there is fair competition. This to me would be the most ethical approach because it provides a true, sustainable solution to the country’s largest healthcare system, and also encourages nationwide competition to improve and provide the best care for our veterans. This solution would encompass the intersection of shared values, stakeholder theory, corporate integrity, and social conscience, where the wellbeing of veterans and the improvement of veteran healthcare’s challenges are considered, and the moral value of fairness and justice is served for both internal and external stakeholders. The solution not only gives veterans a choice to be seen at the VA or be seen at a private facility, but with equal footing on infrastructure and staffing power, it also further incentivizes the VA to exude corporate integrity, transparency, and conscientious practices to all stakeholders if it is to beat its private sector competition with the best veterans’ healthcare in mind.
The federal government should explore all options to true, sustainable solutions that address all VA healthcare challenges and provide the best healthcare for veterans.
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