Don't fix those deadly veterans hospitals. Abolish them.
What was a nice former beauty queen doing in a place like this? A room where shell-shocked, quadriplegic patients languished unfed for three days, swimming in feces and tied to their beds? Where uncertified doctors accidentally killed some vets with faulty CPR treatment and subjected others to blood-tainted needles and bacterially infected gloves? She was making a segment of 'PrimeTime.' And after Diane Sawyer and her pen-sized camera got through with America's veterans hospitals, only one logical conclusion could be drawn: Old soldiers may never die, but the VA keeps trying.
Add to those memorable TV images the revelations of Ron Kovic and the film Article 99, and you've got the average American's mental picture of the average American veterans hospital: half infirmary, half inferno. And this popular image isn't off base; it's just incomplete. The root problem with Veterans Administration hospitals doesn't lend itself to video treatment: It's how much American citizens are paying for this substandard care. Thanks to unnecessary testing, overly long stays, mind-boggling logistics, and way too many empty beds, caring for the average VA hospital patient now costs nearly twice what it would at the average community hospital. And who's paying for that waste? You are, to the tune of hundreds of millions of dollars.
If figures like that don't move you, consider James Williams' story: When the 25-year-old Nebraskan needed a kidney stone removed last year, he might have driven to Omaha's Methodist Hospital, a top-flight private institution where he could have gotten a simple lithotripsy as an outpatient for about $5,000. But Williams, a veteran of the Air Force, qualified for free treatment by the VA. So instead he was directed to fly 500 miles via commercial jet (at taxpayer expense) from Omaha to Milwaukee, the nearest vets' facility capable of performing lithotripsy. Unfortunately, Williams first had to wait three months for a slot to open in Milwaukee, so the folks at the Omaha veterans hospital decided to insert a silicon catheter into his kidney (at risk of infection) until the Milwaukee hospital was ready to admit him. After the lithotripsy, Williams had to check back into the Omaha VA to have the catheter removed. Done? Not quite. Williams has since learned he has another stone. He'll likely be forced to retrace the same medical odyssey this summer.
Hedged vets
The Sununuesque habit of airbusing vets across the country for routine procedures may seem trivial compared to the billions spent on health care annually, but replay that type of wasteful spending a dozen different ways at dozens of VA hospitals around the nation, and the bill adds up. Today, the VA spends nearly $14 billion a year to care for a mere 3 million eligible vets.
Why are we paying Connoisseur Class prices for a third-rate medical system? Thanks goes to a Congress unwilling to say no to the 5-million strong veterans' lobby, which is quick to invoke Normandy, Inchon, or Khe Sahn whenever the question of over-spending arises. Of course, as a result of Ronald Reagan's means-testing enactment, many heroes of these battles don't actually get to use the VA system-its patients include only veterans poor enough to qualify (those with an annual income of less than $18,000) or those injured while serving. And many who do use it might jump at the chance to get free care elsewhere. Nevertheless, to the veterans' lobby and the congressmen who serve it, overhauling the system seems a betrayal of a sacred contract made in the wake of World War I: In return for serving their country, veterans should have their own hospital system to meet their needs.
Certainly, all Americans should be accorded affordable, quality health care, and until we create a universal system that works, we should make especially sure our former soldiers' health needs are met. But by clinging to a bureaucratic arrangement that's about as up-to-date as leech therapy, the VA isn't just wasting money, it's hurting the very constituency it's supposed to help. If we really want to help America's needy vets, we need an entirely new approach to providing good, free health care-an approach that would replace the VA hospital system with our underused, more efficient community hospitals.
The VA will tell you that it provides an important service to veterans, but what it won't volunteer is how few veterans use its hospital system. In fiscal year 1990, nearly one third of VA hospital beds were empty. As veterans' groups are quick to point out, the number of old and sick vets is likely to increase during the next few years, as more and more World War II veterans reach their seventies. Even so, the overall veteran population has been declining rapidly since 1980.
This shrinkage and the slew of empty beds don't leave much opportunity for economies of scale-even if the VA were interested in economy. But thanks to the peculiarities of the federal budget process, the 60,000 administrators employed by the VA have little incentive to be worried about savings. In fact, too much financial worry would put those same bureaucrats out of a job.
The OMB appropriates the VA health care budget on an annual basis, not allowing financing for the future-a setup that gives the VA a powerful incentive to spend all of its appropriated funds before the fiscal year runs out. The great fear of any bureaucrat is that by saving the federal government's money this year, he'll get a correspondingly smaller outlay in the next budget cycle. So a smart administrator-one who doesn't want to lose jobs or future funds-attempts to run through all the money he's got. The result? Once a VA gets hold of a patient, the impetus is to keep him as long and as expensively as possible, even when there's no medical rationale for doing so.
Here's how it works. Let's say you're a 25-year-old vet with a bone spur in your big toe. VA protocol requires that a gamut of tests be administered to all patients scheduled for surgery, allowing no adjustment of its policy for each type of patient. So you go through the same chest x-ray, EKG, physical, and blood and urine exams as the 70-year-old cigarette smoker in for a bypass. After waiting about two months for the tests to be processed, you'll have to check into the hospital for your relatively simple operation not once (as would be the case in a community hospital) but two or three times-each time for more unneeded exams or 'precautionary' procedures. And each time, nurses and staff are paid to put you through this diagnostic rigmarole.
Thanks to budget-extenders like these, the average expense per admission at VA hospitals in 1990 tallied $7,164, compared to the $4,947 average at community hospitals. And while, according to a Washington Monthly analysis, Medicare pays community hospitals approximately $3,000 for a gall-bladder removal and allows five and a half days to complete it, the average VA hospital cost for the same procedure is nearly $6,000 at an eight-day stay. Prostate removal? Community hospitals are forced to operate for the less than $3,000 that Medicare will give them and keep patients for an average of just under five days. The VA takes nearly seven days at a cost of $4,600.
Of course, the VA might tell you that its figures are inflated because the vets who turn to it are generally older and sicker than the average hospital patient. And some are. But even if they aren't, the hospitals won't send them home in a hurry. A 1985 General Accounting Office (GAO) study reported that with better management VA hospitals could have cut inpatient days by 43 percent. 'The VA is the only hospital system in the country where the average length of stay is measured in seasons, not days,' says a private health care consultant.
What allows this type of waste to proliferate is simple: the absence of a disciplined regulatory system for VA care. While the Medicare bureaucracy has its problems Oust ask any of the thousands of doctors who have enough Medicare paperwork to repaper their waiting rooms), the VA could learn a lesson from Medicare rules that prevent superfluous spending on items like extra overnight stays or useless exams. While a recently established VA hospital reimbursement system will pay each hospital a fixed amount depending on the type of care given to a patient, the procedures and costs are audited by no outside entity. 'The VA won't accept any requirements for accountability,' laments a former Senate veterans affairs committee staffer.
Of course, the real irony is the low quality of much of that overpriced care. To their credit, VA hospitals have been leaders in treating spinal cord injuries, initiating innovative programs to address alcohol and drug abuse, and caring for the elderly. Moreover, the system boasts a number of excellent hospitals, most of them affiliated with top medical schools, such as the Brockton-West Roxbury VA Medical Center, which has ties to Harvard's program, and the UCLA-linked West Los Angeles VA Medical Center. But, as has been documented by several recent studies, the care at the average VA hospital tends to be well below average.
So well below, in fact, that just this past November, a congressional investigator discovered incompetence and neglect at each of the six veterans hospitals she examined-failings she determined in several cases to have been the primary cause of a patient's death. In her testimony before a House subcommittee, she spoke of finding 'nurses who] allowed patients with life-threatening illness to languish for hours, even days, without monitoring.' The worst case involved a Cheyenne, Wyoming, patient whose bladder cancer, a normally curable illness, metastasized while he waited 45 days for the hospital to settle a contract dispute with its urologist. When someone finally noticed that the patient had lost 30 pounds and the cancer had spread, they shipped him to the Denver VA hospital, where he soon died.
Semper fiasco
In many ways, the care and cost problems of the VA system only mirror those that beset American health care as a whole, from lack of fiscal and medical accountability to poorly trained staff. But the VA system, with its limited number of hospitals and its manageable clientele, could be reformed into a model of first-rate health care provision. Unfortunately, nearly every major effort to change the way the veterans do their medical business has been dead on arrival, thanks to the troika that guards veterans' interests: the VA, the veterans' lobby, and Congress.
The VA's motivation to thwart reform isn't tough to plumb. A full 90 percent of the VA's staff is involved in running its medical system, thus any talk of radical change in the health-care process directly threatens the VA's main source of power, not to mention a huge chunk of its budget. And while bureaucratic self-protection is nothing new to government, the VA's intransigence is backed by one of the most formidable phalanxes in American politics: the American Legion, the Veterans of Foreign Wars, the Disabled American Veterans, and other smaller groups that comprise the veterans' lobby.
The lobby's leaders boast of being able to deliver more than a million letters to Congress on any given issue, and they don't take lightly any serious attempts to change their health care system. Consider what happened in February, when the VA agreed to join with the Department of Health and Human Services in a pilot program allowing non-vets to use VA hospitals in rural Virginia and Alabama, where hospitals are few in number. The veterans' lobby threw a fit, arguing that such a move would shut veterans out of their own hospitals, even after a VA spokesman had told them that opening the vacancy-heavy facilities to non-vets would have 'no impact' on veterans in the two states and would perhaps enhance service there.
After the Senate voted 91 to 3 to block the program, VA secretary Edward Derwinski terminated the plan, fearing the vet lobby. 'I decided, hell, I have a chance of getting rolled over or getting off the road,' he told The Washington Post, adding that the Senate felt the same pressure in this, an election year. 'Privately, everyone was saying, A great idea, but I can't vote for it.' '
Why not? Because when lobby leaders invoke the American flag, it's hard to say no. Just listen to what one vet lobbyist, Mario Raimondi of the New York State Veterans of Foreign Wars, had to say about the common-sense plan: 'This proposal is a tragic error and a shameful display of unconcern for the American veterans and their continued need for medical assistance.'
But it's not just the lobby that Congress has to worry about, says a Senate staffer who handles veterans affairs. 'The average citizen sees the hospital system and the cemeteries as the only two tangible reminders of our commitment to take care of those who have been in the military.'
VACANCIES
Of course, after so much media documentation, even diehard congressional loyalists admit that some VAs aren't taking proper care of those military men. While some call for butterfly stitches and cash infusions, what the VA really needs is major surgery-a health care voucher system that essentially eliminates the VA hospital system, turning the most viable of its hospital facilities over to community hospitals. That would help solve two American health care crises at once: the excess of hospital beds nationwide (American community hospitals are only two thirds full) and the extremely expensive upkeep of our special facilities for vets.
Without the need to staff and maintain its own facilities, the VA could shift hundreds of millions of dollars to direct medical expenses. This approach would preserve the best of the current system-free health care for veterans in need-and eliminate the worst: the bureaucracy that has stymied the VA's ability to provide adequate care at reasonable costs.
While some of the VA hospitals would be closed under such a plan (do Boston and Chicago really need four VA units when their community hospitals are one-quarter to one-third empty?), others would be converted to community hospitals, which could serve non-veterans as well as vets, just like the pilot program in the South that was deep-sixed this winter. If the voucher system alone is too expensive for our nation to bear, the government could provide a buy-in option for nonentitled vets and thus ensure care to a much greater number of veterans.
Mind you, it's not just economists who think a plan like this might work. 'There's no real medical or financial reason why the VA ought to have its own system of hospitals,' says Dr. Steve Koukol, former surgery resident at West Virginia's Morgantown Veterans Hospital. 'It would be better for veterans and more economically effective if we threw the system out and used vouchers.' But when the subject of vouchers comes up, VA loyalists tend to note their hospitals' skill in dealing with vet-specifics. In addition to experience tending to maladies commonly afflicting veterans (battle wounds, depression, alcoholism and drug addiction, and illnesses common to older men), VA hospitals are continually lauded by medical administrators for maintaining a vet-friendly environment. But can't community hospitals employ staff skilled at veterans' care? Besides, any urban trauma center today is, sadly enough, experienced at treating gunshot wounds.
Community leaders in Baltimore argued along these lines when a localized version of the voucher plan nearly took shape back in 1982. As the city planned to tear down and replace one of the three area veterans hospitals, the Maryland Hospital Association suggested that instead of erecting a new facility, veterans should be provided with vouchers to use at community hospitals-after all, the city already had more than 2,600 empty beds. For the government and taxpayers, the plan would have meant tens of millions of dollars saved by not constructing a new unit. For the veterans themselves, it would've meant more efficient care. But to the nation's veterans' organizations, it meant heresy. Fearing a backlash at the polls, not one member of Congress was willing to propose the necessary legislation to make the plan fly, even though the empty beds in Baltimore were costing an estimated $122,000 each annually to maintain. The new $118 million Baltimore VA Medical Center will open this spring.
The ultimate irony of this is that the average poor vet in Baltimore, or Omaha or Little Rock or Tacoma, probably doesn't have the same kind of allegiance to the VA hospital as he does to the notion of good health care. 'I wouldn't have any objection to going to a regular hospital,' says James Williams, the Omaha resident shipped 500 miles for his kidney stone treatment. 'If I have that choice, I'll take it.' But these vets-the ones with firsthand experience in the dilapidated VA system-aren't the ones being heard when it comes time to talk of VA reform. 'The quality of care in the VA hospitals is, on the whole, better than that in community hospitals,' boasts Dr. Earl Brown, a former Veterans Affairs health-care administrator and staunch defender of the status quo. But does he go to a VA hospital? No,' he concedes. 'The care there is not exactly the most . . . expedient.'
That's precisely the point, Dr. Brown. And perhaps if every veterans lobbyist and loyalist congressman had to take a dose of that inexpedient care, they'd come to the same conclusion James Williams has. Sure, jury-rigging the VAs for another half-century may make our leaders gleam red-white-and-blue. But when it comes to health care, the truly patriotic move-for the guys who serve and the taxpayers who pay-is to close those VAs down.
