Suzanne Gordon is the Senior Policy Fellow at the Veterans' Health Care Policy Institute, as well as a journalist and co-editor of a Cornell University Press series on health-care work and policy issues. Her latest book is The Battle for Veterans' Healthcare: Dispatches from the Frontlines of Policy Making and Patient Care. She has won a Special Recognition Award from Disabled American Veterans for her writing on veterans' health issues, much of which has appeared in The American Prospect. Her website is www.suzannegordon.com.
By Suzanne Gordon | Mar 21, 2017
Lawmakers on Capitol Hill mulling legislation to extend a program that lets veterans seek health care in the private sector have revived their longstanding complaints about long wait times for care at the Veterans Health Administration facilities. Veterans Affairs Secretary David Shulkin and Dr. Baligh Yehia, the agency’s assistant under secretary, appeared before the House Committee on Veterans Affairs to testify on HR 369, a bill that would allow the Veterans Access, Choice, and Accountability Act to continue past its sunset date of August 2017.
In 2014, after revelations of wait-time problems at some Veterans Health Administration (VHA) facilities, Congress created the three-year Choice program allowing eligible veterans to seek care in the private sector if they live 40 miles from a VHA facility or have to wait for more than 30 days for an appointment. The bill would let the VHA spend what remains of the initial $10 billion (about $1 billion) allocated to Choice on care in the private sector.
At the hearing earlier this month, House Committee on Veterans Affairs Chairman David “Phil” Roe, a Republican from Tennessee, complained of VHA wait times as long as 81 days. His comments and those made by other committee members suggest that congressional Republicans are determined to ignore any evidence that outsourcing care to private sector providers won’t do much to improve access to or coordination of care for veterans. They seemed unaware, for example, that wait times for private-sector health care are also a significant problem.
A 2014 study of wait times in American hospitals by health-care consulting firm Merritt Hawkins found long wait times and large disparities depending on location. In their just released 2017 study of wait times, the firm found that wait times in 15 metropolitan areas had increased by 30 percent since 2014. The average wait time for a new physician appointment was 24 days. In Boston, the average wait time to see a family physician was 109 days while in Albany patients had to wait 122 days. Some practices were entirely closed to new patients. In Boston patients who had to wait to see a cardiologist for 133 days in 2014 were now waiting as much as 365. In Houston the longest wait for a heart doctor jumped from 26 to 43 days. In Denver the longest wait to see a dermatologist went from 180 to 365 days while the shortest delays increased from one to seven.
A 2013 Commonwealth Fund report found that, of those adults surveyed, 26 percent reported six or more days for a primary care appointment when they were actually “sick or needing care.” As the report stated “Among the 11 nations studied in this report; Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in 2010, 2007, 2006, and 2004.”
The American Prospect recently reported on an independent assessment of VHA performance and access which concluded that, “Enrollees living more than 40 miles from VA facilities are much less likely to have geographic access to specialized services in non-VA hospitals … they are much less likely to have access to academic and teaching hospitals, the sites in which more complex care is offered.”
VHA wait times mirror those in the private sector for the same reason, a nationwide shortage of primary care providers and mental health professionals. Another contributing factor is that a government agency like the VHA is unable to offer market-rate salaries to healthcare professionals. In high-cost urban areas, health care professionals who want to work at the VHA are being offered thousands, sometimes tens of thousands, more in the private sector. Not surprisingly, they follow the money. During the committee’s three-hour hearing, the issue of how low pay affected the quality of care never came up.
Committee members also considered another Choice Program problem, the coordination of care between VHA and private sector providers. Committee members offered a number of short-sighted observations, including defining care coordination exclusively in terms of giving private sector providers access to the VHA’s electronic medical records.
Coordinating care for VHA patients who are, on average, sicker, older, poorer, and have more chronic mental health conditions than their counterparts in the private sector, requires far more than access to data. The VHA has pioneered a model of care coordination: Clinicians who work in the VHA system and often in the same work on multidisciplinary teams that have been trained to engage in face-to-face communication (sometimes via Telehealth) about the complex needs of their patients.
As many studies have consistently documented, this is one of the main reasons that the VHA often delivers care that is superior to that treatment delivered by private sector providers. It is also why, as Dr. Shulkin testified, of the 1.2 million veterans who have had appointments through the Choice program in the private sector, only 5,000 of them chose to receive care only from private sector providers.
Shulkin has promised to unveil a new version of the program, what he likes to call Choice 2.0, sometime this fall. The future of the VHA will depend on how this program is configured and if members of Congress are willing to consider whether private sector providers can actually deliver high quality care. The Choice program has not worked well because it was designed hastily and implemented far too rapidly. If the recent House hearing is any indication, Congress may be poised to repeat history with Choice 2.0.
This story has been updated to include newly released data on wait times.
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By Suzanne Gordon | Dec 20, 2016
The Veterans Health Administration has weighed in on a controversy that has embroiled medicine and nursing for the last 50 years: whether advanced practice registered nurses (APRNs) can operate without direct physician supervision. On December 14, the VHA amended its medical regulations to “permit full practice authority” to many of the system’s nurse practitioners, a move that immediately drew the ire of the medical community.
Since APRNs appeared on the health-care stage in 1965 with the enactment of Medicare and Medicaid, physicians have responded with deep ambivalence. Some have embraced them as full members of the health-care team, while others—particularly leaders of organizations like the American Medical Association—have argued that nurses should not function on their own and should always—no matter how much experience they have—work under the direction of doctors. APRNs have consistently argued that they should be allowed to make diagnoses and prescribe treatments without physician supervision.
The Institute of Medicine has recommended APRNs be granted what is known as “full practice authority,” and countless studies have documented that APRNs provide safe and effective care at lower costs than physicians. The fight has been waged in various states, 22 of which have granted full scope of practice to APRNs. But as a federal employer, the VHA’s own internal regulations can supersede state law on nursing practice when there is conflict between state law and federal law. The VHA’s new ruling, which will establish additional “professional qualifications an individual must possess to be appointed as an APRN within the VA,” might actually lead to requirements stricter than those of some states.
This is by no means an arcane, internecine fight. Advanced-practice nursing appeared in the 1960s because of the need to expand health-care access in a country that did not, and still does not, produce enough generalist physicians but overproduces medical specialists. Over the years, nurse practitioners and other APRNs have become increasingly critical in both pediatric and adult primary care, as well as in specialist clinics and acute-care settings where they work on medical teams.
Of the 93,500 registered nurses, licensed practical nurses, and nursing assistants employed by the VHA, more than 5,700 are advanced practical nurses (APRNs), hired to work on primary-care teams or in settings with provider shortages. In its deliberations on the future of the VHA, for example, the VA Commission on Care recommended that APRNs be allowed to practice to the full extent of their education, training, and certification, which means without direct physician supervision.
When the VHA’s regulation came out, medical leaders expressed their usual reservations about APRN practice. During the 60-day comment period for the proposed ruling, just the hint of liberating APRN practice unleashed an unprecedented torrent of comments from the American public (including many veterans and their families) and professional organizations. AMA President Andrew Gurman immediately denounced it, saying, “We are disappointed by the VA’s decision today to allow most advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law.”
Medical leaders must stop defending an outdated model in which physicians, some of whom may have no training in either leadership or teamwork, dominate the health-care team. It is time to follow the lead of the VHA and establish a model of care that helps not just veterans, but all Americans.