Failing to Serve Those Who Served
The mission of the Veterans Affairs health care system is to meet the medical needs of armed forces personnel. To fulfill this mission, the VA operates the largest medical organization in the United States, with 9 million enrollees receiving treatment at 150 medical centers and 800 outpatient clinics. The VA also provides annual disability payments to 4 million veterans.
Demand for VA medical services has skyrocketed as Vietnam vets age and as service personnel from Iraq and Afghanistan (many with traumatic brain injuries and post-traumatic stress disorder) return from their deployments to the Middle East. At the same time, the agency has trouble recruiting and retaining medical personnel. The number of outpatient visits grew by 26% in a recent five-year period while the number of doctors and nurses went up by only 18%. As a result, veterans have trouble getting appointments for care and are placed on wait lists.
To shorten the waiting time for treatment, former VA director Eric Shinseki mandated that new patients be seen within two weeks of contacting a medical center or clinic. Middle- and senior-level managers were given bonuses and promotions for meeting this objective. Unfortunately, Shinseki’s mandate didn’t solve the access problem but drove it underground. Managers “gamed the system” by falsifying patient access records. They created secret waiting lists that contained the actual number of veterans seeking treatment. At the same time they created another set of shorter lists to present to VA administrators. According to these “official” lists, facilities were meeting the guidelines, which meant that managers received their bonuses. In other cases officials kept wait times down by failing to record new patients, marking the first available appointment as the one requested by the veteran, or by canceling previously scheduled appointments.
The sham wait lists came to light after a doctor at the Phoenix VA medical center complained. An audit by the Veterans Administration inspector general discovered that the deceptive practices extended well beyond the Phoenix facility, revealing what Secretary Shinseki called “a systemic, totally unacceptable lack of integrity.”1 Two thirds of Veterans’ facilities manipulated data in at least one instance in order to conceal the true extent of the access problem. An estimated 100,000 veterans (1,700 in Phoenix) were kept off official waiting lists and, in some cases, were not scheduled for the appointments they requested. The average wait time for Phoenix veterans was 115 days, and 18 to 40 patients died while waiting for care, though it is not clear if the deaths were caused by the delay in treatment. (Some on the list were terminally ill and requested end-of-life care.)
The VA inspector general put much of the blame on VA leadership for creating an “overarching environment and culture that allowed this state of practice to take root.”2 The audit called for a complete overhaul of the VA’s performance management system. A White House report said that the VA medical system had a “corrosive culture” that “encourages discontent and backlash against employees.”3
Americans were outraged at the reports of the falsified records and lengthy wait times. Military personnel risk their lives for their country, and citizens honor their loyalty and devotion by pledging to meet their needs during and after active service. Lengthy wait times break what former president Barack Obama called the “sacred trust” between the country and those who serve in uniform.
VA director Shinseki was forced to resign under pressure from congressional representatives. The new director eliminated the 14-day scheduling goal, froze all executive bonuses, vowed to change the reward system to discourage hiding the truth, and promised to fire those engaged in deceptive practices. The agency contacted those who were on the secret lists to initiate treatment. With bipartisan support, Congress passed legislation that allows veterans to seek treatment at private clinics (called Veterans Choice) when they can’t promptly schedule VA appointments or live more than 40 miles away from a veterans facility. Congress also approved $10 billion for hiring more staff and building more hospitals.
Problems continued despite the changes. Managers at some facilities still falsified wait times. The director of the Shreveport, Louisiana, VA hospital was fired after a report that patients went without sheets, pajamas, and toiletries while the facility spent millions on televisions, solar panels, and furniture. The VA inspector general warned that patients at the VA Medical Center in Washington, DC, were in danger because the hospital ran out of surgical supplies and tools. The Veterans Choice program actually increased wait times. Not only is Veterans Choice complicated and confusing, but it requires that patients apply for (and wait for) the waiver to see private doctors. Private physicians and hospitals complain that it takes up to a year for them to be reimbursed for veteran treatment.
David Shulkin, the newest director of the Veterans Administration, vows to continue efforts to better serve patients He wants to simplify and expand Veterans Choice, speed up provider reimbursements, track service quality, reduce overhead, and modernize facilities. He points out that the agency has retrained schedulers and updated software and plans to roll out a program that allows vets to book their own appointments. Evening and weekend hours have been added to the schedule along with 14,000 new medical providers.
Discussion Probes
1. Have you or has someone you know been treated by the VA health system? What type of experience did you or this other person have?
2. What leadership challenges did VA managers fail to meet?
3. What steps can the VA take to encourage managers to act as servant leaders?
4. How does the size of the VA medical system complicate efforts to improve the organization’s culture and service to patients?
5. What, if any, additional steps should the VA take to address the patient access problem and to improve treatment quality?
