The firestorm over improper manipulation of the Veterans Health Administration (VHA) medical appointment scheduling system finally consumed two top officials at the agency. Robert Petzel, M.D., head of the Veterans Affairs’ (VA) medical branch, resigned in mid-May, followed two weeks later by VA Secretary Eric Shinseki.
The departures were occasioned by revelations that personnel at some VA medical centers falsely created the appearance that waiting times for primary care appointments were within the 14-day mandated limit, when in fact they were often much longer. Juggling the appointment system was one way of improving a center’s scores on the department’s performance management system and consequent eligibility for staff bonuses.
The resignations were only the crest of a wave that had been building for some time. In December 2012, the Government Accountability Office (GAO) said that the VA’s reports of medical appointment waiting times were “unreliable” and recommended improvements. Then, after reports surfaced about acute problems at the Phoenix VA Health Care System, the VA’s inspector general found numerous irregularities. About 1,700 veterans “were and continue to be at risk of being lost or forgotten in Phoenix HCS’s convoluted scheduling practices,” said a review issued May 28. Some veterans had died while waiting for appointments, leading to further outcry.
An audit conducted between May 12 and June 3 by the inspector general covered 731 VHA facilities and revealed that the scheduling problem was connected to availability of professional resources as well as to bureaucratic gamesmanship.
“Meeting a 14-day wait-time performance target for new appointments was simply not attainable given the ongoing challenge of finding sufficient provider slots to accommodate a growing demand for services,” said the second report. “Imposing this expectation on the field before ascertaining the resources required and its ensuing broad promulgation represent an organizational leadership failure.”
The overall increased demand for services was caused not only by an influx of new veterans from recent wars in Iraq and Afghanistan but also by the increased needs of Vietnam War–era vets as they age.
Katherine Watkins, M.D., notes that from 2004 to 2008, the number of veterans using the VA health system for mental health needs rose 38 percent, but staffing did not increase proportionately.
“This is a staffing issue,” agreed Katherine Watkins, M.D., a psychiatrist and senior scientist at RAND Corp. who led a 2017-2010 evaluation of quality of care for veterans with mental illness, in an interview with Psychiatric News. “I don’t think they’d be altering their records if they had the staff capacity.”
Ironically, most observers believe that the quality of care within the VHA is generally good—once a veteran gets in the door.
Watkins said that VA respondents ranked the quality and timeliness of access to mental health care as comparable to the private sector and better than the public sector “for those already in the system, but not so well for first timers.”
Indeed, there is wide variation in every facet of the VHA.
“It’s like in any big organization,” said former VA psychiatrist Thomas Horvath, M.D., now a professor at the Menninger Department of Psychiatry at Baylor College of Medicine. “The top 25 percent are very engaged and do an excellent job, and the bottom 10 percent are terrible. Ideally, you would identify the bad apples and fix or fire them, reward the top, and manage the middle.”
Horvath speaks from experience. He served as a VA psychiatric unit chief, a medical center chief of staff, and part of the Mental Health Strategic Group at VA headquarters in Washington, D.C.
Things have gotten worse since the early 2000s, he said in an interview. Many medical center directors, most of them veterans themselves, have retired, to be replaced by people who are often not veterans and who have administrative, rather than clinical, backgrounds.
Horvath would like to see the VA’s new secretary come from the ranks of recent military veterans.
“The place needs to be way less civilian and much more friendly to the military,” he said. “Even now, there’s still no guarantee that a new patient will be asked for a military history—that’s an incredible indictment.”
What the VA needs today, said Horvath, is someone like Kenneth Kizer, M.D., the VA’s undersecretary for health in the 1990s, who presided over a wholesale reformation of the system. Kizer is now director of the Institute for Population Health Improvement at the University of California Davis Health System and a professor of emergency medicine in the UC Davis School of Medicine.
“Kizer was a truly tough and extremely well-informed chief medical director,” said Horvath. “He didn’t tolerate nonsense or waiting lists. He told the truth and insisted that others tell the truth, too.”
In a recent “Perspective” in the New England Journal of Medicine, published online June 9, Kizer noted several markers of the system’s decline over the last 15 years. In his day, the VA used two dozen clinically focused quality measures.
“Now there are hundreds of measures with varying degrees of clinical salience . . . [which] not only encourages gaming [the system] but also precludes focusing on, or even knowing, what’s truly important,” wrote Kizer and Ashish Jha, M.D., M.P.H., a physician at the Boston VA Healthcare System. The system has also grown more bureaucratized, with the central office staff increasing from 800 in the late 1990s to about 11,000 today, they said.
But it’s unfair to blame Shinseki and Petzel for the scheduling mess, said Horvath. “They were just too optimistic about human nature.”
There is no shortage of proposed remedies. Horvath would like to see another director in Kizer’s mold: a no-nonsense boss to crack the whip and totally transform the system.
Kizer called for a narrowly focused performance-management system in the VHA that concentrates on clinical outcome measures, improved technology to connect patients and clinicians, and better communication with private-sector health organizations and the public.
Watkins is less sanguine. “I doubt changing the person at the top will make a big difference,” she said. ■