Cooking the books, killing the vets

va-health-care-latest-vo-trOur veterans deserve so much better than bureaucratic homicide.  And they’re still waiting.  Waiting in lines and waiting for reform of the system.

Yuval Levin writes a characteristically excellent piece about the “massive conspiracy to benefit VA employees at the expense of their patients.”  It was a highly organized effort to cook the books” that required the “active collusion of a large number of people” from telephone operators to senior managers.

…the lengths to which VA employees were willing to go to report shorter wait times is a function of a longstanding emphasis (by Congress, successive administrations, and the veterans’ groups) on wait times as a primary performance measure, but this emphasis has not been tied (by any of them) to structural reforms that might actually enable the VA to function more efficiently. Centrally run, highly bureaucratic, public health-care systems that do not permit meaningful pricing and do not allow for competition among providers of care can really only respond to supply and demand pressures through waiting lines. It happens everywhere, but when it has happened at the VA the response has been to criticize waiting times rather than to reconsider how the system is organized.

The VA has improved significantly over the last three decades, but the improvements “began from an extremely low baseline” and were essentially just “modernizing the infrastructure that supports a very inefficient bureaucracy.”  The incentives in any single-payer system are to hide the costs with rationing and lie about the lines (and waiting time):

These targets reached the point of near-absurdity in 2011 when the Obama administration set a goal of 14 days between the time a patient asks for an appointment and the time that patient sees a doctor or nurse. These targets did not account well for the huge differences between different kinds of patients seen by the VA, and they were tied directly to bonuses and salary increases for hospital administrators, creating a huge incentive to distort the prioritization system used by the VA and, as happened here, to just lie about waiting times. The Phoenix hospital in question, for instance, reported that it had managed by last year to get average waiting times down to 24 days. In fact, the IG report found, the average waiting time was 115 days. There’s no way to bridge that gap with “targets.” And there’s probably no way to really bridge that gap at all in a public hospital system like the VA.

He also makes very interesting points about the differences in patient population

Defenders of the VA system note that, despite waiting times, the system generally gets high marks from its patients, and performs relatively well compared to the larger health-care system on measures of quality. This is true and important. But it also has to be understood in the context of some key differences between the VA and the larger health-care system. Some of these differences (like the increased patient load as a result of the Iraq and Afghanistan wars) create added burdens on the VA. Others (like the system’s unusually homogeneous patient population and its not seeing the degree of aging of its patient pool that the larger health-care system is seeing because of the relatively smaller number of Baby Boomer vets compared to the prior generation) work to its advantage.

But the most important difference is that the VA is not a full-service health system. It only provides a limited range of services in a limited range of specialties, and even the system’s highest priority patients get barely 50 percent of their health care from the VA system. Much of the most complex and expensive care provided to veterans is handled by the larger health-care system. What it does do, the VA often does reasonably well, to its credit. And its patients of course also like the fact that the care they receive costs them very little (or nothing), and that they receive it in an environment designed for veterans and in which they have a lot in common with fellow patients. That’s all to the good, but it doesn’t make for very meaningful comparisons with the larger health-care system.

Those pundits who have held up the VA as a model, in some cases to argue for passage of Obamacare, should start apologizing.  And change their minds.

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