Wednesday, June 25, 2014

The Real Problem Behind the Scandal at the VA

Now in Jerusalem by the Sheep Gate there is a pool, called in Hebrew Beth-zatha, which has five porticoes. In these lay many invalids—blind, lame, and paralyzed. One man was there who had been ill for thirty-eight years. When Jesus saw him lying there and knew that he had been there a long time, he said to him, “Do you want to be made well?”The sick man answered him, “Sir, I have no one to put me into the pool when the water is stirred up; and while I am making my way, someone else steps down ahead of me.” 
John 5:2-8

Like most everyone else, I have been watching the unfolding story of delays at Veteran’s Administration hospitals with both anger and frustration.

No one has waited as long as the man beside the pool in Jerusalem. Although that depends on how we count the time. Some veterans have died while waiting to be seen by a physician. If we count the wait times in those instances as eternity, then that would be a lot longer than the thirty-eight years that the man by the pool.

The outrage has focused on the employees who falsified the wait times in order to meet agency expectations and qualify for bonuses. And those folks certainly deserve our opprobrium. But I not could help wondering why no one was asking the obvious question: Why is this happening?

The schedulers were not falsifying wait times because it was easier than making appointments. They weren’t keeping secret lists because it was easier to keep two lists than one. And the long wait times were not caused by the falsified data.

Are doctors leaving at noon to play golf? Are they just spending too long with each patient? Are they routinely coming in late and leaving early? Are they using sick days when they are not sick? Or are there just not enough doctors to see the patients who need care?

The answer was not that hard to find, although I never heard it in any of the major news stories. They just don’t have enough physicians. Curiously, even the news stories that point to the shortage of physicians spend a lot of time going over the scandal of falsified wait times. The story of the doctor shortage is not nearly as titillating as the scandal.

The Department of Veterans Affairs is currently trying to fill about 400 vacancies among its primary care physicians, which last year came to a little over 5,000. But even a full roster would probably not be enough. The department is straining to accommodate the increasing needs of an aging group of Viet Nam era veterans as well as a large influx of veterans from the wars in Iraq and Afghanistan.

Physicians now have caseloads of about 2,000 patients per year, although department guidelines target the optimum number at 1,200. And they are being pressured to limit follow up visits to no more than two per year for each patient. As one analyst put it, they are overworked and underpaid. Primary care physicians at the VA typically earn between $98,000 and $195,000, while the median income among those in private practice is $221,000.

According to an article by Bruce Japsen in Forbes Magazine, the shortage in the VA is linked to the funding of Medicare. The Medicare health insurance program for the elderly is a major funding source for graduate medical education, known as GME. In 1997, the Balanced Budget Act put a limit on the number of residency positions available to medical school graduates as a means of limiting health care expenses. The shortage in funding has led to a shortage of physicians in the country, which is a significant factor in the shortage at the VA.

None of this excuses the VA administrators and staffers who falsified the data and hid the problem. And they should be held accountable. But punishing them will not solve the problem. We need more physicians, and one way or another we will have to pay for them.

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