The Chasm Between Public Perception and Clinical Reality at the VA

Ryan Black
MAY 17, 2018

George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah. Photo is in the public domain. 

There’s no 2 ways about it, Andrew Cohen, MD, says: public perception of the Department of Veterans’ Affairs can be demoralizing.

“People have been told ‘The system doesn’t work’ and ‘You’re not doing a good job’ and it is very demoralizing to the workforce, and I’m not just talking about physicians—I’m talking about everybody at VA,” he said recently in an interview with Healthcare Analytics News™. He called the attention “unfair.”

Last week, The Washington Post published an op-ed by Cohen. The Providence VA Medical Center nephrologist argued that a lot of the scrutiny the VA health system receives is actually due to its successes rather than its failures. He believes the agency does provide very good healthcare—with a few caveats—but an effective, publicly-funded health system is politically poisonous to those who want to privatize the agency.

>>READ: VA Plans to Use AI to Track Deteriorating Health in Veterans

Just 9 days before former VA Secretary David Shulkin, MD, was fired, he appeared at a population health meeting in Philadelphia and railed off statistics that he said showed the system was delivering above-average care. “When you look at pop health measures, VA almost always outperforms the private sector,” Shulkin said.

Indeed, there are a lot of studies that back up both Cohen’s and Shulkin’s positions. RAND researcher Rebecca Anhang Price led a care quality study that was published last month in Journal of General Internal Medicine. "Consistent with previous studies, our analysis found that the VA health care system generally provides care that is higher in quality than what is offered elsewhere in communities across the nation," Price said.

“The problem is, who reads those studies?” Cohen asked. “The public only hears what the politicians are saying about VA, they don’t hear a real representation of what the VA does.”

And what the VA does, according to the doctor, is often “the right thing.” No additional profit comes into the health system if patients get more tests and procedures. Cohen thinks that disincentivizes waste, and allows VA physicians to do a better job of explaining a patient’s care options—and their clinical implications—than many in private healthcare. “Patients make decisions based on a free and frank discussion in which all the options are full vetted,” he said.

But neither Cohen nor the research community will try to hide the system’s flaws. There are staffing issues, and problems with wait times to see primary care doctors. There’s also rampant variability in care quality—"‘If you’ve seen 1 VA, you’ve seen 1 VA,’” Cohen quotes a colleague. Price’s study observed wider variation in outcomes among VA hospitals than other health systems, and just this week JAMA Cardiology published a report showing similar trends.

But those issues might be expected given the sheer size of the system: It’s the largest integrated health network in the country. There’s also differences in staffing across different VA centers—some are more reliant on loaned physicians from private or academic medical centers than others, Cohen explained. And the system’s well-documented staffing shortages are more pronounced in some regions.

Bureaucracy is another problem. He places a share of the blame for the 2014 VA scandal in Arizona—which led to dozens of unnecessary deaths—on unrealistic bureaucratic mandates. "I’m not denying the fact that there are terrible things that have happened at individual VAs, and that there aren’t people who have done things that they should be ashamed of," he said. "The system was gamed by administrators trying to hit impossible targets. It’s a combination of the way bureaucracy works and the lack of a sufficient workforce." 

Cohen also wishes the VA’s health network could be more lithe. He worked in other health systems for the majority of his career before joining VA a decade ago, and he still envies the ability to make capital decisions without the constraints of a thick bureaucracy. He said that his hospital in Rhode Island needed a new dialysis facility even before he arrived and it only just got 1, and it might not have the capacity to meet current demand.

Still, he thinks if the rest of American healthcare received the scrutiny that the VA system does, the public would see issues just as serious, if not more. That’s why he thinks the politics, and the criticism that guides them, are misguided: If anything, he’d rather the rest of American healthcare more closely resemble the VA than the VA resemble the rest of American healthcare—though with a series of smaller regional systems instead of an overstretched national body.

“I’m very unwilling to even refer to the United States as having a healthcare ‘system,’” Cohen said. “What I’ve learned over the years is that we don’t have a health system, we have chaos.” From the interoperability headaches that plague private care to the fee-for-service dependence that can elicit waste and conflicts of interest, he said his career outside the VA showed him the benefits within it. He just wishes more people could see them.

“I think it’s up to those of us who work in the system and have knowledge of healthcare in general to speak more openly about this,” he said. “Physicians have been largely silent and allowed healthcare decisions to be dictated by others. And I think that’s a mistake.”

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