First, with the resignation of the US Secretary of Veterans Affairs, the president should consider appointing an outstanding leader with experience in the nonmilitary health care industry, especially given the current controversies that exist with the Veterans Health Administration system.
Second, access to care must be improved for all veterans. With the increased number of veterans enrolled in the VA health care system, more physicians, nurses, and support staff should be hired to remain commensurate with this growth rate. Although advocated by some, hiring nurse practitioners and physician assistants to replace primary care physicians may be an unwise strategy. This is not the time to test unproven and controversial solutions. Resources must be prioritized and directed to follow demand. The Veterans Equitable Resource Allocation, the financial model developed to distribute the VA health care dollars to VA facilities across the nation, is intended to for this purpose, but it is constrained by artificial regional boundaries and poor adjustment for high-cost conditions and therapies.
Third, the US government’s administrative hours concept, defined as 8:00 am to 4:30 pm, does not apply to clinical care any more than it does to military operations. There must be a realization that health care delivery should occur at all hours of the day and night, and resources should be allocated accordingly. This change alone could substantially shorten wait times and reduce patients’ failure to keep appointments by expanding clinic hours and increasing the availability of operating and interventional suites and recovery areas. Extension of work hours has already been initiated in select VA facilities, with notable success. In addition, the requirement for 2-week service and pay periods with a defined tour of duty is challenging for the recruitment and retention of physicians, and in particular, specialty physicians. Changing this practice would allow the VA to retain the services of much-needed specialty physicians, thereby reducing the costs of outsourcing these services and providing more comprehensive care within the VA health care system.
Fourth, VA hospitals should reassess and update their academic affiliation agreements with emphasis on fair terms and mutual benefit. Favorably negotiated contracting for clinical services with affiliate hospitals could expand access to clinical care to veterans and reduce waiting lists.
Fifth, partnership with the private sector may be the key to making health care delivery timelier. Logistics experts specializing in workflow and transportation, working closely with clinicians, can improve the efficiency of patient scheduling and transportation to assure that timely appointments are made and fulfilled. At the same time, providing veterans who live far from a VA facility with private care insurance could improve health care access and eliminate the need for long-distance travel.
Sixth, accountability is more important than ever before. By incentivizing individuals to meet an arbitrary goal (ie, new appointment within 14 days), the VA has unwittingly created an administrative process that became too focused on numbers and is vulnerable to manipulation and fabrication. If there are to be incentives, they should be based on overall performance with respect to patient-centered outcomes, and these incentives should depend on measurable indicators of better health, as well as efficiency. Manipulating quality assurance measures cannot be tolerated.
Seventh, the quality of care at the VA should be compared to that at non-VA hospitals to showcase the VA’s outstanding clinical outcomes in many disciplines and to identify areas for improvement. Of note, the National Surgical Quality Improvement Program (NSQIP), the criterion standard in measuring risk-adjusted surgical outcome, was originally developed in the VA system in direct response to a law that mandated the VA to report surgical outcomes in comparison to national averages. However, the current VA Surgical Quality Improvement Program (VASQIP) is now maintained independently from NSQIP. Harmonizing VASQIP and NSQIP data collection and definitions would allow for direct comparisons in patient outcomes between VA and nonfederal hospitals. Given the differences that exist in patient populations between VA and nonfederal hospitals, robust risk adjustment of NSQIP and VASQIP data based on nearly 100 risk-adjustment variables will be crucial.
Eighth, the VA’s federal workforce must be modernized by recruiting from outside the system instead of relying on what has become an internal system of promotions and relocations. At the same time, VA hospitals should retain and incentivize committed and loyal physicians and other health care workers. This will require a redesign of the VA’s human resources policies that could also facilitate vetting and hiring of new staff. Also, the VA has a long history of minimizing terminations of ineffective and poorly performing employees by repeatedly shifting them to other departments. Instead, the employment of those who do not perform to a high standard should be terminated.
Ninth, the VA’s purchasing, acquisition, and inventory processes should operate more efficiently to meet clinical needs. Competitive contracting will reduce costs, but only if a nimble contracting process is in place. The VA’s current system for obtaining bids on contracts is complex, archaic, wasteful, and slow. Contracts should be developed by personnel with the content expertise in the area in which the contract is being considered.
Tenth, the VA needs to implement changes to attract the best and brightest work force. Currently, VA hospitals are viewed as second-tier facilities, and the majority of physicians do not seek VA hospitals as their first employment option because of lower pay, limited resources, and system-wide inefficiencies. Matching its favorable benefit package and rich educational environment with an attractive work environment will allow the VA to obtain a quality workforce. To attract the best physicians, the VA must compensate physicians at a level commensurate with the private sector. Although the creation of the VA Title 38 Physician and Dental Pay Ranges tables was an attempt to address this issue nearly a decade ago, the pay tables have not kept pace with the AAMC or MGMA compensation tables.