Suzanne Gordon

Suzanne Gordon is a journalist and co-editor of a Cornell University Press series on health-care work and policy issues. One of her latest books is Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety. Her website is www.suzannegordon.com.

Recent Articles

Report: VHA Care Commission Recommends Private-Sector Options

As conservatives and congressional Republicans seek to dismantle the Veterans Health Administration, members of the commission called for giving veterans more private-sector options.

(Photo: AP/Mark Thiessen)
(Photo: AP/Mark Thiessen) The Veterans Administration Outpatient Clinic in Anchorage, Alaska A fter almost a year of meetings and hearings, the Commission on Care has finally issued its report on the future of the Veterans Health Administration. “Care delivered by the VA,” the congressionally mandated report states, “is in many ways comparable or better in clinical quality to that generally available in the private sector.” But with problems in accessing services, in variations in care, and in the managerial culture at various facilities, the commission believes that the major remedy lies not in outright privatization but in giving veterans more private-sector options, a finding that veterans groups fear may also weaken the decades-old system. One of the commission’s most complex and potentially problematic recommendations involves the creation of a “VHA Care System,” that would integrate private-sector providers into a VHA-supervised network. The network would service only those...

Union Conducts Nationwide Anti-VHA Privatization Protests

The American Federation of Government Employees (AFGE), the largest labor union representing federal and District of Columbia government workers, announced Tuesday that about 40 anti-VHA privatization rallies will be held nationwide. The move comes as the VA Commission on Care, the congressionally-mandated body tasked with making recommendations about the future of Veterans Health Administration, closes in on an early July release date for a report on the agency’s future.

The Veterans Council of the AFL-CIO and the Roosevelt Institute, a New York-based think tank, held a conference, “Keeping the Promise: What’s Next for the VA” in Washington last week. National health-care experts, VHA officials, and the directors of five veterans service organizations (VSOs), outlined what veterans stand to lose, if the VHA is privatized, which is precisely what one group of commission members (the so-called Strawmen), who represent the hospital industry and the Koch Brothers-funded Concerned Veterans for America, has proposed.

VA Undersecretary for Health David Shulkin and top VHA research, teaching, and clinical services officials described the VHA’s progress in improving access to VHA services. The VHA’s Million Veteran Program, which amasses health care and genetic information on hundreds of thousands of veterans, will be making significant contributions in efforts to individualize treatments for a variety of medical problems facing Americans. The VHA is a global leader in telehealth services, which allow providers to connect with patients who live miles away from a clinic or hospital. This type of care brings much-needed services to underserved areas, particularly in the 55 percent of rural counties that lack a single psychiatrist, psychologist, or social worker, according a recent HRSA report.

Terri Tanielian, a senior social research analyst who served as director of the RAND Center for Military Health Policy Research for more than a decade, delivered a key message. She debunked the idea that private sector mental health providers can adequately care for the nation’s veterans.  

Tanielian explained that a recent RAND study, “Ready to Serve,” found that only 13 percent of the nation’s mental health providers have an understanding of military culture or an awareness of the appropriate kinds therapies for civilian patients with specific mental health concerns. If mental health providers cannot provide suitable therapy regimes for civilians, how can they care for veterans with complex, military-related problems?

The VHA’s Marsden McGuire, the VA’s deputy chief consultant for mental health care, explained that the agency provides “wraparound services that other health care systems cannot.” In 2014, The American Journal of Public Health devoted an entire issue to VA programs like the national system of Veterans Courts that help veterans avoid or shorten jail or prison terms through housing, employment, and substance abuse programs. These measures go a long way to explain why, when surveyed, veterans overwhelmingly support the VHA, according to Joshua E. Ulibarri of Lake Research Partners Veterans.

According to Garry Augustine of the Disabled Veterans of America and other groups, veterans fear that a fragmented private-sector system will deliver inadequate care. They believe that private-sector providers have little or no understanding of their specific problems and are too often motivated by profit rather than interest in individual veterans.

Sherman G. Gillums, executive director of the Paralyzed Veterans of America and Marine Corp veteran who was paralyzed when a vehicle rolled on top of him, told The American Prospect that many of the VHA’s current problems stem from congressional underfunding and inaction. “It is Congress’s job to fund the VA and provide oversight of its functions,” he said. “The Independent Budget [a group of VSOs that submit recommended funding levels for and policy recommendations about the VA to Congress every year] have lamented the shortfalls in VA construction, information technology, staffing budgets year after year.” 

Capitol Hill also came in for criticism from Kenneth W. Kizer, a former Clinton administration VA undersecretary, who warned that relentless attacks on the VHA over the past decade have exacerbated the agency’s insularity. “You don’t create organizational excellence by focusing on how many people you’ve fired, which [is] driven by Congress, and is too much of a focus of current VA leadership,” he said.

Representative Tom MacArthur, a New Jersey Republican, has sponsored a bill that could eventually privatize VHA mental health; Senator John McCain, the Arizona Republican, supports a bill that would make the Choice Act permanent and eliminate its restrictions; and new legislation from Representative Cathy McMorris Rogers, a Washington state Republican, who chairs the House Republican Conference would also speed up privatization of VHA services. Twenty-six VSOs sent a letter Tuesday to McMorris Rodgers protesting her proposal.

The AFGE and veterans groups are counting on the organized protests to force Congress and the commission to reassess its positions. If efforts to privatize the VHA persist, protests will likely continue throughout the summer. 

McCain Pulls a Bait-and-Switch on Vets

Almost as soon as Senator John McCain had finished working with Senator Bernie Sanders to craft the veterans’ health-care bill now known as the Choice Act in 2014, the Arizona Republican set out to renege on his promise that Choice would be temporary, and began floating plans to make it permanent. 

Part of the Choice Act was the establishment of the Commission on Care, whose deliberations the Prospect has covered extensively. This week that Commission is meeting to hammer out its final report, which will include recommendations about what the VHA should look like in 20 years. Instead of waiting to see what the Commission mandated by his own bill recommends, McCain has once again jumped the gun. He is lobbying hard for a bill that would not only make the Choice program permanent, but would eliminate any restrictions on veterans’ access to private-sector health care.

McCain’s gift to veterans is a bill misleadingly labeled The Care They Deserve Act. The subject of hearings on Capitol Hill the week of June 23, the bill would make the Choice Act—a three-year experiment enacted following revelations of delays in care at VHA facilities in Phoenix and elsewhere—permanent. Choice allows veterans to seek care from private-sector health-care providers if they face more than a 30-day wait for an appointment, or trips of 40 miles or more to the nearest VHA facility.

Under McCain’s new plan, the nine million veterans eligible for VHA care would be free to use any private health-care facility or provider, for any form of service, with the federal government paying the tab—no questions asked. McCain has gathered seven other Republican sponsors for his bill, all of them pushing the new conservative narrative that the VHA is broken beyond repair. This, of course, ignores reports by a Choice Act-mandated Independent Assessment of the VHA, which documents that its veteran/patients actually receive better care, at lower cost, than millions of Americans who rely on private sector health care.  

What’s wrong with The Care They Deserve Act? Just about everything, which is why many veterans service organizations like the Disabled American Veterans (DAV) and Vietnam Veterans of America oppose the plan, and why the VHA’s own undersecretary for health, David Shulkin, has proposed a more sensible alternative. 

Economists advising the Commission on Care estimate that McCain-style privatization could triple the cost of veterans’ care to almost  $450 billion a year—money that would not be well spent. The VHA’s clinicians and other staff specialize in the complex health problems related to military service, and deal with patients who are older, sicker, and poorer, with more mental health problems that those cared for in the private sector. The average elderly patient in the private sector shows up presenting between three to five physical problems. The “co-morbidities” of a Vietnam vet, for example, can number from nine to 12. That’s why VHA primary care providers spend at least 30 minutes with their patients per visit, compared to the ten or 15 minutes allotted to patients in the private sector. Will private sector providers want to take the time to care for aging, sometimes homeless, often mentally ill, veterans? Even if they do, will they be able to detect the difference between ordinary type 2 and Agent Orange-related diabetes, or be equipped to parse the myriad symptoms of PTSD?

McCain’s bill promises veterans a choice between VHA and private sector care. In reality, it would ultimately erode choice by weakening the VHA option, putting the entire veterans’ health system at risk. The VHA’s current budget is determined by how many veterans use the system and for what services. If far more eligible veterans start using private sector health care, there will be less funding available for VHA services that are unavailable elsewhere, and for maintaining the agency’s highly specialized research and clinical expertise in military-related health problems. As funding for costly private sector care eats up more of the VHA’s annual budget, there will be hospital and clinic closings, along with VHA staff layoffs. To reduce expenditures on veteran health care, Congress may also be tempted to make eligibility for veterans’ health-care benefits even more restrictive than it is today.

If Congress wants to improve the VHA, it should embrace the reform proposals of Shulkin and those Commission on Care members who want to allow veterans access to private sector providers in networks coordinated by the VHA. With luck, this recommendation will appear in the Commission’s June report. Strengthening the VHA, and giving veterans the choice to see outside providers if necessary, would really give veterans the care they deserve.

The Hidden Irony of GOP Outrage over the VA Secretary’s Disney Comparison

Poor VA Secretary Bob McDonald. Neither he nor the Veterans Health Administration he oversees can ever catch a break.

On May 23, a reporter questioned McDonald about the VHA’s tracking of patient appointment times around the country. McDonald’s predecessor was forced to quit over allegations of appointment delays and a cover-up at a Phoenix VHA hospital, and McDonald has often been on the defensive about the issue as the agency tries to hire the additional caregivers needed for the influx of Iraq and Afghanistan veterans.

In his response to the reporter, McDonald suggested that in the meantime, the VHA’s performance should be judged by a broader set of metrics. “What really counts is how does the veteran feel about their encounter with the VA?” McDonald said. “When you go to Disney, do they measure the number of hours you wait in line? What is important is your satisfaction with the experience.”

Unfortunately for the secretary, his invocation of the Magic Kingdom triggered a pack-journalism social-media response. The Koch-funded Concerned Veterans for America (CVA), a leading advocate of VHA privatization, immediately denounced McDonald on its website. According to CVA, McDonald showed disrespect for all VHA patients: “The sacrifice that accompanies earning that care is not the same as the sacrifice of taking a road trip to Florida,” the CVA declared. “Shame on Bob McDonald for trivializing veteran wait times this way.”  

American Legion National Commander Dale Barnett was similarly offended. House Speaker Paul Ryan called the remark “disgusting” and “beyond the pale,” a sentiment shared by House Veterans Affairs Committee Chair Jeff Miller, a frequent critic of McDonald and ally of CVA in seeking to dismantle and privatize the VHA. There was even talk of calling for McDonald’s resignation.

After two days of negative news coverage, McDonald, a veteran himself, issued a clarification and apology to any veteran who felt his comments trivialized the VHA’s “noble mission.”

But lost in the Republican baying for more blood was a great political irony: Throughout private-sector health care, Disney’s corporate model for gauging customer satisfaction is now widely used to determine patient satisfaction and to regulate the patient “experience.”

Quality patient care requires an application of skills, experience, and teamwork quite different from the prerequisites for good “customer service” in the hospitality or entertainment industries. Yet treating sick people as “customers” has become part of mainstream management thinking.

The Disneyfication trend took off ten years ago after consultant Fred Lee published the bestselling If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently. Patient surveys using methods and metrics from resort hotels and amusement parks are now the norm in U.S. health care. A hospital’s results on the Hospital Consumer Assessment of Healthcare Providers and Systems standardized survey even determine, in part, its reimbursement rate for federally subsidized patients.

Disneyfication has spawned a huge crowd of high-priced consultants, like Lee, or Quint Studer of the Studer Group, who teach hospitals how to improve their patient-qua-customer experience to score well on questionnaires. As Studer puts it in his HCAHPS Handbook, hospital administrators need to “manage the patient’s expectations” to succeed, by convincing patients they are receiving good personal care—even if the hospital has poor nurse-patient ratios or lousy patient safety records.

In some hospitals, nursing staff trained and managed under this model have been forced to use scripts when interacting with patients and families. They are coached to smile and repeat words and phrases (such as “excellent care”) that administrators want to see echoed in patient surveys.

Some hospitals now designate an employee to be “chief patient experience officer” (CXO), a position enjoying executive status. As CEO of the Cleveland Clinic, Delos “Toby” Cosgrove, now vice-chairman of the VA Commission on Care, has overseen annual patient-experience conferences for the past seven years. Despite having both a CXO and a patient experience office, the Cleveland Clinic has been investigated for patient-safety lapses that almost resulted in the hospital’s suspension from the Medicare program. Some suspect Cosgrove withdrew his name for consideration as VA secretary because confirmation hearings would have led to negative publicity for the clinic.

Inappropriately treating—and, in fact, trivializing—sick patients as customers is a central feature of health-care corporatization, and represents everything the VHA has never been and should not become. If it’s not good for veterans, it shouldn’t be good for any of us. But that would mean Republican critics would apply the same standard to the VHA as they do to private-sector health care. Dream on.

Veterans’ Groups: Don’t Scrap the VA’s Health Care System

As they meet again in Washington, D.C., this week, the congressionally mandated Commission on Care, tasked with determining a 20-year strategic plan for the Veterans Health Administration, would do well to heed the voices of veterans and veterans service organizations that it has too often sidelined from its deliberations.

In its April meeting, the commission heard from leaders of the largest veterans service organizations (VSOs)—Veterans of Foreign Wars, the American Legion, Disabled American Veterans, Iraq and Afghanistan Veterans of American, Vietnam Veterans of America, Vietnam Veterans of America, Paralyzed Veterans of America, Got Your Six, and Military Officers Association of America. All of them adamantly rejected the dismantling of the VHA, which had been recommended by seven of the commission members in their so-called Strawman Document. 

What the VSO representatives argued for was a program like the one VA Undersecretary for Health David Shulkin has proposed. Within limits, veterans would be able see private-sector providers who have been vetted by the VHA. The VHA would still coordinate the care they receive, thus attempting to integrate private-sector providers into a larger VHA network.

What these VSOs do not want is the kind expansion of the current Choice program envisioned in new legislation proposed by Senator John McCain and sponsored by seven other Republicans. The Permanent Choice Card Act would eliminate current restrictions that limit the program to veterans who cannot get a VHA appointment within 30 days, or who live more than 40 miles from a VHA facility. Under this bill, any eligible veteran can go anywhere, to any private-sector provider, for any condition. This would lead to higher costs and, the VSOs fear, to even more limitations on access to services. Veterans with complex physical and mental conditions would receive no care coordination from the VHA which, given the reality of private-sector health care, would mean no care coordination at all.   

As Rick Weidman, executive director for government and policy affairs at Vietnam Veterans of America, explained at the hearing, care coordination is critical because veterans have far more complex problems than the average private-sector patient. Which is why Weidman also urged commissioners to move beyond anonymous data when estimating future VHA use. Yes, the number of veterans the VHA serves will diminish as World War II, Korean, and Vietnam War veterans die.  The veterans who still use the VHA, however, will be sicker than the average private-sector patient. Most older adults, for example, have three or more problems, while the average Vietnam veteran, Weidman reminded the commission, has nine to twelve, which are both military- and age-related. Iraq and Afghanistan veterans have even more complex conditions.

While some commissioners seemed to be listening, VSO leaders remain concerned about those who persisted in “misunderstanding” their positions, by insisting that VSOs favored removing the current 40-mile or 30-day restrictions on the use of Choice. On April 29, seven of the VSO leaders wrote a follow-up letter to the commission, making it completely clear what they and their members want: “the development of local integrated community networks in which VA serves as the coordinator and primary provider of health care to veterans; non-VA community care would be integrated into this network to fill gaps and expand access.”

In a letter to sent to the commission, a veteran of the Iraq war put it even more eloquently: “Your solution of sending us to private healthcare providers is the wrong direction. … There is no private health care provider office that can offer me this type of care. So just fix our VA because it belongs to us not to the private sector.”

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