John Locher/AP Photo
The Department of Veterans Affairs medical facility in North Las Vegas, seen in April 2015
The VA Mission Act of 2018 was sold as a panacea that would address the perceived ills of the Veterans Health Administration (VHA). Boosters claimed that, by offering veterans a permanent path to private-sector treatment through the VA Community Care Network (CCN), veterans would receive timely, high-quality care, which they argued is too often unavailable at just the VHA.
Since the implementation of the law in June 2019, the press and federal watchdogs have documented significant struggles in matching this promise. The Prospect has heard from VHA doctors, nurses, psychologists, and other staff from across the country who shared concerns about the private sector’s competence in caring for veteran patients.
One of the most troubling cases highlighting these problems recently emerged in Las Vegas. Three private hospitals that have contracted with the CCN to treat veterans requested that nurses from the VA Southern Nevada Healthcare System “work” in their facilities to complete routine activities that would ordinarily be performed by the hospitals’ own employees at the hospitals’ expense. The situation suggests that private hospitals aren’t equipped to handle veteran patients, and can only do so with government employees filling the gap on the taxpayer’s dime.
In late November, Cheryl Martin, a VHA administrator in community care, sent a memo to Linda Ward-Smith, the local president of the American Federation of Government Employees (AFGE) Local 1224. It informed Ward-Smith of an impending new program to “embed” a cadre of VA nurses at three private-sector hospitals—Sunrise Hospital, MountainView Hospital, and University of Nevada-Las Vegas Medical Center (UMC). The memo said this program was necessary to “better meet the needs of our veteran patients.”
Sunrise and MountainView, the first two hospitals named in the memo, are owned by the Hospital Corporation of America (HCA), the largest for-profit hospital network in America. HCA has a decades-long history of perpetrating health care fraud and abuse, yet continues to rake in billions in profits each year.
The private hospitals specifically requested that a group of community care nurses, whose work often involves synchronizing care between the VA and the private sector, be assigned to “ensure discharge planning and be available to explain VA benefits to a Veteran.”
Discharge planning involves preparing patients to leave the hospital for home or another health care setting. Because it requires extensive knowledge of complex medical conditions as well as of the community resources available in a particular area and who will pay for them, skilled nurses or social workers typically perform this task.
Charlene Harrington, professor emerita at the UCSF School of Nursing, told the Prospect that “every hospital is legally required to do discharge planning.” It is, according to Gail Eierweiss, former director of revenue management services at the UCSF Medical Center, part of any hospital’s overhead expenses.
The request for help reveals that private-sector hospitals that salivated over acquiring the veteran population may have now discovered that caring for veteran patients is a very expensive proposition. Unlike the civilian patients these hospitals are used to dealing with, most veteran patients have multiple service-related medical and mental-health conditions, as well as social needs related to—among other things—joblessness and homelessness, social isolation, substance abuse, and high risk for suicide. Instead of allocating or hiring enough nurses and social workers to help them, private hospitals are poaching VA nurses at taxpayer expense.
“Not only are we paying you these high dollars, but now hospitals want to take and pull our scarce resources over so they can get up to snuff?” Ward-Smith, the local union president, told the Prospect. “If we’re paying private-sector hospitals all this money because they said they were able to care for veterans, the hospitals should do whatever it takes to care for our veterans, not use our resources to do it. There is something wrong with this whole picture.”
“What’s happening in Las Vegas should be a wake-up call. Congress must take immediate action to make sure that critical VHA resources are not diverted to enhance the corporate bottom line.”
Even before this memo was issued, Ward-Smith and other nurses across the country had voiced concerns that VA leadership was shifting nurses from caring for veteran patients to coordinating private-sector care. In some cases, new staff have been hired for this time-consuming purpose, rather than to take on clinical roles.
The Las Vegas VHA hospital, whose doors are open to nearly a quarter of a million veterans, has faced chronic nursing shortages for years. According to federal data, the Vegas system now has 141 vacant nursing positions. News of the proposed program raised serious concerns among the struggling nursing staff in Las Vegas. “Why are we sending nurses to private-sector hospitals when they are needed here?” Ward-Smith asked.
She said the union—and the nurses involved in the program—are also concerned about issues of legal liability, job description, and congressional notification, as well as whose orders nurses are to follow once they are essentially working in the private sector.
In addition, VA nurses do not carry personal malpractice insurance, raising myriad concerns over how a tort claim would be handled. As of this writing, a veteran harmed in a private-sector facility does not have access to the VA’s tort system but would have to sue the physician, nurse, and/or hospital individually. Would VA nurses be legally liable in such cases? In spite of asking management for clarification, Ward-Smith said she has received no response.
This work of turning the VA into a de facto temp agency for private-sector hospitals also represents a fundamental repudiation of claims that the private sector is perfectly competent to take care of veteran patients. As several RAND Corporation case studies make clear, the private sector is unprepared to treat veteran patients and unwilling to learn how.
“It’s like saying you know how to begin to do a surgical procedure but you don’t know how to complete it and so you have another surgeon come in and finish the job,” said Harrington of the proposed program. “Hospitals cannot say they are competent to do discharge planning for some patients but not for others. If they can’t provide discharge planning for all their patients, they should not be accepting them.”
It is unclear when the program will be implemented and if other private-sector hospitals will ask other VHA systems to similarly embed nurses in their facilities. The Department of Veterans Affairs declined to respond to questions, but press secretary Christina Mandreucci insinuated the one of the story’s authors was “an opinion writer with a clear agenda” and that “it’s hard to imagine that his intent is to report objectively.”
Danita Cohen, a UMC spokesperson, said the hospital was not aware of any nurse-sharing agreement. "Perhaps the VA is in talks to do this but they have yet to reach out to UMC," she said in an e-mail. The two HCA hospitals have yet to respond.
The Mission Act stipulates that VA Secretary Robert Wilkie can unilaterally cancel contracts with private-sector providers for a number of reasons, including when they are found to be incompetent. Requesting to hire VA temps is an admission from these hospitals of lack of competence almost by definition. The VA secretary may also cancel contracts if an entity has been convicted of a serious offense under state or federal law, which HCA was in 2000.
It’s likely that Wilkie, an ardent supporter of the Mission Act, won’t take any such actions. In fact, community providers have yet to provide crucial data to VA on quality and access, information that was requested in the act.
“What’s happening in Las Vegas should be a wake-up call,” Ian Hoffmann, an AFGE legislative representative who covers Nevada, told the Prospect. “Congress must take immediate action to make sure that critical VHA resources are not diverted to enhance the corporate bottom line.”
UPDATE: An earlier version of this article stated that HCA raked in "tens of billions in profits" each year. The most recent figures show HCA earning tens of billions in revenues but $3.8 billion in profit in 2018. This has now been changed to "billions in profits." We regret the error.
