How 'privatization' may solve the VHA physician shortages
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 “Privatization” has become the new buzzword surrounding discussion of Veterans Health Administration (VHA) Reform, from Congress, Veterans Service Organizations, Veterans Affairs (VA) officials, and even the Clinton and Trump presidential campaigns.

What this controversial “privatization” refers to is the bipartisan Commission on Care (COC) report which recommends a more permanent and less restrictive version of the VA Choice Program.  Established as a response to the Phoenix VHA scandal of embarrassingly long wait times and overcapacity, the Choice Program currently allows veterans to seek care away from their regional VA facility if veterans cannot get care within 30 days, if they live 40 miles away from the VA facility or if they face certain travel burdens. The COC Report recommends eliminating the 30-day and 40-mile criteria to access this care away from the VA facility. It recommends expanding the VHA to be the “VHA Care System” compromised of the flagship regional VA facilities that currently deliver care to veterans in addition to a new network of community-based providers with more reach into remote areas. To remediate former issues with the Choice Program, the VHA Care System puts an emphasis on IT and integration of community programs into the VHA system with electronic medical records, physician credentialing and competency.

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Lost in the political sophistry, however, is the essential role adding community-based providers into the VHA Care System would have on remedying physician shortages and recruitment issues for the VHA. While the COC report suggests addressing financial disincentives for physicians to join the VHA, the greater reason for poor physician interest is more complex and entrenched in the culture of the VHA – one that the community-based VHA Care System would cleverly circumvent.

Colloquially known as the “VA [vah] Spa” in physician circles, the VHA carries its nickname in reference to how veterans often sit for days (in the “spa”) in hospitals well beyond medical necessity because of logistical or bureaucratic limitations to letting them go home: delays in social work, demotivated ancillary staff crucial to discharge planning, pharmacy or transportation hold ups, delays for inpatient studies, etc.

While the RAND study found that care at the VHA is comparable to that of the private sector, it also found significant variability at VA facilities across the country. At its worse, this is a system reputed to be rampant with apathy and ‘pension potatoes” – staff biding time waiting for their pensions to kick in. It is inevitable that the demotivation of staff trickles over to infect even the sprightliest of physicians. No wonder the VA is seen as a place where physicians go on their way to retirement, when youthful hope to save the world has already been quashed.

Forty percent of the VHA workforce is eligible for retirement in the next few years, and as of January, the VHA had a 16% vacancy rate across all employment positions. Millennials only make up 25% of the workforce and disproportionately quit. From a clinical standpoint, what the VA needs more than anything is the bright-eyed, bushy-tailed young physicians to provide care and also bring their Millennial idealism to lead this VHA transformation.

Veterans are wonderful patients, ones that most doctors have taken care of at some point in their career from medical school or residency. These men and women are some of the most gracious, least entitled and medically interesting patients to take care of. Nonetheless the occupational hazard of repeatedly banging your head against a wall as a physician at the VHA is more than enough to outweigh a special fondness for veterans. Culture change is inherently slow, and it becomes the classic chicken-or-egg paradox: Young physicians are unlikely to be recruited until the culture of the VHA workflow changes, but until young physicians are recruited to change the culture of the VHA, the culture is unlikely to change.

This is where the much debated “privatization” has the potential to add more physicians into the VHA system, groom them to be leaders, and do so without extinguishing their Millennial optimism in the darkness of VHA indifference. The community-based network allows physicians the privilege of treating veterans, and to do so unencumbered by the headaches of working for a government bureaucracy. Along the way, it fills a pipeline for VHA leaders as physicians can tackle improvements in the reform and move their way to leadership. For all the problems of the VHA, being able to take care of veterans is an honor as a physician – one that unfortunately requires a degree of masochism to do within the current state of the VHA. “Privatization” or no, the veterans themselves will be the best recruitment tool for physicians – they just need an opportunity to remind the physicians of it.

Amy is an emergency physician, published writer and national speaker on issues pertaining to healthcare, with work featured in Forbes, Chicago Tribune, NPR, KevinMD, and TEDx. No financial disclosures.


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