The Veterans First Act: significant progress, but still a band-aid

The Senate’s new omnibus bill, The Veterans First Act, represents Congress’s latest attempt to resolve performance deficiencies within the Veterans Administration; but this bill will not significantly improve performance.  In fact, it could make things worse for our veterans. As Chair of the Blue Ribbon Panel overseeing the Veteran’s Choice Act Independent Assessment of the VA Health Administration (VHA), I believe actually putting veterans first will require much more than proposed in the Veterans First Act.  Without radical reform of VHA governance, leadership, structure, culture and data systems, the Veterans First Act may even exacerbate problems we communicated to Secretary McDonald and Congress last September.

Yes, the bill offers constructive proposals to improve veterans’ disability benefits, education, and programs to end veterans’ homelessness.  With regard to health care, the bill details much-needed reforms, including competitive compensation for top-performing managers, protection for whistleblowers, enhanced management training and improved medical management of opioids to relieve pain while lessening potential for dependence. In addition, the bill strengthens accountability by providing new authority and flexibility to hire, discipline and terminate VA employees who have performed egregiously or committed certain crimes.

{mosads}Despite these positive attributes, this Senate bill falls woefully short of what is required to meaningfully reform the VA. Compared to its peers, the VHA scores in the bottom quartile of 35 of 37 management practices, and the bottom quartile of every measure of organizational health. Without governance reform, the well-intentioned provisions of this bill will not be achieved, just as they have not been achieved previously when Congress has attempted to fix parts of a system that is fundamentally broken. VHA leadership and providers will continue to operate in a toxic atmosphere of distrust and retaliation. In this regard, it is perhaps not surprising that federal unions oppose the Veterans First Act, in part out of fear new disciplinary authorities could be used for political reprisal instead of remedying poor performance.   

In addition, the Senate bill mandates multiple new reports to Congress, with a new array of unproven metrics and standards. If anything, these new “big government,” unfunded mandates will only add to the burgeoning VHA Central Office, resulting in a downward flow of increasingly onerous administrative burdens that will further diminish the ability of front-line health professionals to care for the needs of their patients.  Our Independent Assessment found that this dynamic was at the core of many VHA problems.

Moreover, without funding to replace the antiquated, frequently manual, business systems and data tools, even the nation’s most proficient professionals operating in an optimum organizational culture could not achieve the bill’s stated objectives.   

Our Independent Assessment recommended bold, transformational solutions to remedy the root cause issues that have stifled recommendations already detailed in 137 previous VHA assessments.  Without bold reform,Veterans will continue to die on waiting lists while legislative placebos merely temporize public outrage. 

Reform must start with the transformation of the current VHA from a bloated government bureaucracy into a highly functional, lean, non-profit, federal corporation led by an expert governance board composed of the most capable health care leaders and patient advocates.  The corporation would be overseen at a high level by the President and Congress, but not micro-managed by either.  Similar to private sector best practices, the board would empower regional and local leaders (not the central VA bureaucracy) to deliver and coordinate care within local regions. Under such a structure all care would be VA care, but not all care would be provided in VA facilities or by VA providers. Outside care would be streamlined through the creation of a single, easily understood program to authorize care around the course of medical treatment — not arbitrary, legislatively imposed time limits. Coordinated care would also be incentivized, so veterans’ outcomes and satisfaction would be aligned with provider and management rewards, just as they are in the private sector.  

These reforms would enable VA health care to once again be at the leading edge of health care in this country. Without such a systemic reform, I am afraid we will see the continuing weakening and ultimate disappearance of the VA health care system and the concomitant loss of health care expertise that is essential to serve the many unique health care needs of our veterans.

The time for legislative Band-Aids is over. We must demand bold, curative solutions from our elected leadership, or else I fear that the next “Blue Ribbon Panel” will be doomed to merely reiterate recommendations already made to a bureaucracy that is structurally and functionally incapable of implementing change.

Brett P. Giroir, MD, is founding CEO of Health Science and Biosecurity Partners, LLC and Managing Director of the Kirchner Group. Most recently, Dr. Giroir chaired the independent Blue Ribbon Panel for the Veterans Choice and Accountability Act of 2014, whose comprehensive assessment and recommendations to reform the Veterans Administration Health System were delivered to Congress and Secretary Robert McDonald on September 1, 2015.

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