Brian L. Grant MD

This editorial from the Seattle Times by Roger Stark raises a number of issues worth discussing. The recent controversy about the VA has been long in the making. It is about culture and corruption. But it also allows us an opportunity to look more closely at the fundamentals of the VA, ask tough questions and perhaps make some basic changes.

There is a lack of understanding about the VA and people tend to mix up and confuse issues. And the reverential manner with which it is spoken by most elected officials makes it difficult to have meaningful conversations.

My time in the VA is quite dated, going back to several rotations as a resident physician in the 70’s and 80’s. Back then I was struck by a number of observations:

• Most admissions and patients were there for conditions that had nothing to do with military service. And a number of them were receiving permanent pensions because their conditions were identified in the course of service. Chronic Schizophrenia comes to mind. We now know that this is a biologic condition, not environmental, coincidentally becoming symptomatic in late adolescence and early adulthood when individuals may be in military service. If one lasted long enough in service, an early discharge and a lifetime of benefits would result, though the disease would have developed irrespective of service. Other medical admissions were often older Veterans with the usual maladies of age and lifestyle that one encounters in any hospital, such as heart and lung diseases, often flowing from lifestyle issues like tobacco use and diet.
•  These hospitals were large institutions, often in the same vicinity as other facilities and clinics that offer excellent care options.
• The staff were of high quality and some, like the Seattle VA, were teaching institutions affiliated with an excellent medical school, and helped train medical students and residents. They cared about their patients.

Setting aside the current controversy, we should ask several questions about the VA and where it should fit in the US Healthcare system:

• What is the social contract between the VA and Veterans? Who should it serve and why? What is the distinction between those injured in the course of duty and those not? Should those who have served but have no injuries from their service be entitled to free health care via the VA system?
• Does the current VA disability system work and when should an injury translate into economic benefits vs. treatment for the condition?
•  What are the moral hazard and political implications of tying an injury to compensation? How does compensation muddy diagnoses like PTSD and traumatic brain injury?
•  Assuming care is owed or committed, is a free-standing government run system the best way to accomplish this? What are the alternatives?

Readers of this blog know that the current healthcare system is not defended in terms of its economics. It is expensive and costs inflate far in excess of other countries with quality systems or the overall US economy. And there are inherent problems in a system where doing and procedures are rewarded while prevention and thinking is not. Furthermore the system is one where the patient is generally ignorant and disengaged on costs and treatment options and believes or acts as if the details and cost of care is an entitlement owed to them by their employer or government. This trend may be changing as cost sharing via copays and deductibles is growing under many policies. Most of us spend more time shopping for a TV set than a medical procedure or hospitalization that will cost 20-50 times as much or more, because with the TV and other personal expenditures, our interests lie in getting the best value for price.

Once we decide which Veterans to serve, could this not be better accomplished without a massive VA treatment bureaucracy? We have perfectly workable if imperfect government payment schemes including Medicare that can easily be ported to the VA and allow eligible Veterans to receive care from the facilities of their choice in the community.

Centers of excellence providing care for conditions unique to combat could be formed in partnership with high quality medical schools and research institutions for conditions such as amputations and combat-related PTSD.

Current VA resources and staff could be re-deployed into the private sector, where shortages exist presently and where demand would increase with Veterans entering the same system.

Is the current system inherently flawed and rather than focusing on current corruption, are bigger questions needing to be asked and answered?