3. Restructure the VA health care system. The VA divides its health system of 151 hospitals and 820 clinics into 23 regions that don’t align with any other geographic scheme within the federal government. These regions lack the leadership, staff capacity, and authority they need to oversee health care facilities. As a result, hospitals have evolved into fiefdoms unto themselves, giving rise to the expression, “If you’ve been to one VA hospital, you’ve been to one VA hospital.” This system must be broken apart and rebuilt to give the secretary the ability to implement national policy, standardize practices, and ensure quality patient care. Ideally, the VA would cut the number of regions and align them in some way with the regions used by the Department of Health and Human Services or Department of Defense TRICARE system. Within these VA health care regions, senior executives should be selected for management expertise and ability, not just for time served as a VA clinician. And regional executives should be picked by the secretary and be accountable to him or her—potentially with a requirement for Senate confirmation—not unlike the system for selection of generals and admirals, who require Senate confirmation at the very top levels.
4. Rebuild the VA’s healthcare IT system. Twenty years ago, the VA led the nation in development of electronic health records. Today, the VA has fallen behind. The VA’s antiquated systems contributed to the chaos in Phoenix where, reportedly, front-line employees used DOS-based systems to manage appointments and clinical resources. This problem is exacerbated by the VA’s balkanized system of regions, hospitals, and clinics. Many facilities have customized their software in ways that don’t mesh with other VA facilities. The next VA secretary must completely overhaul this system, much as Shinseki did for the VA’s benefits system (at great cost). The VA should consider replacing its antiquated appointments system with one that is more transparent, allowing veterans to see wait times and relative availability across the system, and make health care decisions accordingly. Such solutions exist in the private sector. The VA should embrace them. Likewise, the VA must invest in its health records system, and ideally build one that meshes with the system now being procured by the Pentagon.
5. Integrate better with the private and nonprofit sector. The VA provides exceptional medical care, particularly for service-connected issues such as prosthetics, hearing loss, and combat stress. However, more than two-thirds of veterans seek medical care from non-VA sources rather than the VA, and that’s unlikely to change. Many more veterans get care from nonprofit providers, especially for mental health issues. The VA must find ways to integrate its care with that given by the private and nonprofit sector, to provide veterans with “continuity of care” wherever they get seen. More pointedly, the VA must better leverage external resources to fill gaps and shortfalls in its care, such as in primary care and mental health care. The demographic changes within the veterans community suggest the VA is seeing its peak demand now, from young and old veterans alike. Building permanent VA infrastructure may not make as much sense as leveraging private providers, contractors, and nonprofit organizations to serve veterans (ideally knitted together by a common health records system).
6. Build a bridge across the Potomac. One of Shinseki’s greatest failures belongs also to two other revered cabinet officers, former Defense Secretaries Robert Gates and Leon Panetta. Defense and the VA failed to create an integrated health records system (or separate systems that would talk to each other), and have failed more broadly to synchronize and align the two agencies’ care for veterans, service members, and military families. The redundancies between these two agencies cost the taxpayers billions of dollars each year, and worse, create gaps for veterans to fall into, such as when claims submitted to the VA can’t be substantiated for lack of Pentagon service records. Even Shinseki, with his long Army lineage and prior service as the top Army general, failed to partner effectively with the Pentagon. The next secretary must do better, especially in a post-war era of fiscal austerity, when both agencies are likely to have fewer dollars to serve their respective populations.
There’s a lesson from military history that applies well here: Winning armies rarely learn. It takes the strategic shock of defeat to catalyze learning and change within armies. Although the VA doesn’t fight wars like its brother agency the Defense Department, it retains a military culture because of its leadership and the large number of veterans who work there. And like the Pentagon, the VA only learns or changes well under enormous external pressure, such as the kind that comes upon losing a war, or occurs during a political scandal like this one.
Notwithstanding this week’s headlines, the data overwhelmingly show the VA has done well in supporting veterans over the last decade or two. Patient satisfaction scores are high; the claims backlog is down; the VA has worked with the nonprofit community to reduce veteran homelessness by roughly 24 percent in five years. The list goes on. Nonetheless, deep problems remain within the VA that threaten its ability to succeed in the years to come. Today’s political crisis may offer the strategic shock the VA needs to address these core issues, now under a new secretary, to serve our veterans as well as they have served us.