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New LAND WAR MAVEN Column: "Saving Heroes" - Protecting Veterans

Expert essay on proposed reforms and improvements to US military veterans care - Operation Relentless Care

Operation Relentless Care

New Land War MAVEN Column:

Lieutenant Colonel Scott E. Rutter

U.S. Army (Retired)

The Department of Veterans Affairs (VA) has a single mission: to care for Veterans injured while serving our country. This has been a difficult task for the VA because it’s leadership over the years has failed to understand the very difficult decisions that must be made to ensure this mission is accomplished. Intervening political, employment, contractual factors serve only to hinder the mission. It is not a choice between government provided care and private care, it is only the choice for the best care. The leadership of the VA needs to take a large step back and assess the battlefield. When Servicemembers are asked to risk their lives in defense of this nation, they do not consider will I be cared for if I am injured. They only think of their dedication and commitment to this nation, our freedom and their fellow Servicemembers. I know, I was there. And now, I am here. A beneficiary of the VA system.

Operation Relentless Care’s mission and intent is to secure the highest quality care for our Veterans. When we go to battle, we don’t care if you are a Democrat or Republican, our mission is clear and we must execute. There are 4 “Lines of Advance” in this mission:

1) Complete restructuring of the VA organization structure

2) Aggressive implementation of technology with specific emphasis on cloud computing and methods to enhance productivity and medical outcomes

3) Implementation of a nationwide scheduling system

4) Deep integration between the DoD and VA systems. Each one of these tasks builds upon the other and is interconnected to achieve mission success.

In August 2014, the VA issued a VA Directive 0213 entitled, “Department of Veteran Affairs Organizational Changes
Policy” in order to establish a policy on organizational changes within the VA. Ostensibly, the goal was to eliminate, abolish and or redistribute the functions of the various components of the VA, create new Administrations, offices, facilities, or activities in
the VA and fix the functions of any Administration, office, facility or activity. In March 1995, the Under Secretary for Health submitted A Plan to Restructure the Veterans Health Administration, a “Vision for Change.” Over 20 years ago, the VA was grappling with the same issues. The model proposed then “optimizes VHA’s ability to function as both an integrated and a virtual health care organization; it provides structural incentives for efficiency, quality and improved access; it builds in a form means of ensuring a high degree of stake holder involvement; and it provides for a level of accountability not typical of government agencies.”

Interestingly, in that document it defines the establishment of 22 Veterans Integrated Service Networks (VISNs). If we fast forward to today, the VA is currently divided into 21 VISNs and continues to be plagued by embedded structural issues that hinder optimal care to our Veterans. While I don’t have the space here to detail all of the lost productivity, lack of integration and degradation of care that results from the current structure, some examples warrant review. Each VISN is managed (controlled) by an organization that individually reports to the VA headquarters. Within each VISN, there can be a large number of hospitals and clinics that cover a designated geographical area. In the original manifestation of this structure, the benefit of a desegregated structure allowed the headquarters to focus on policy, budgets, planning and shifting the healthcare delivery functions of individual hospitals to intermediary VISN entities that coordinated care between facilities in those areas. At that time, it was an idea that was workable because technology was not available to truly be the integrating mechanism.

Now that we have a general idea of the structure of the VA system, let’s discuss why it doesn’t work today. Each of the VISNs is managed by a team of professionals which have direct reports from each of the hospitals and clinics within the VISN region. The VISN leadership must report metrics and results to the main headquarters in Washington DC where funding and resource allocation decisions are made. In an attempt to simplify a very complex structure, we can understand where quality and medical decisions can the thwarted by this structure. Our Veteran who exited the service in Fort Stewart, GA decides he wants to live in Portland, OR and moves to that location. He then “registers” with the Portland, OR VA and becomes a patient of the VA Portland Health Care System. By “registering” with the VA in Portland, those facilities can now count him as a patient. Every additional patient ascribes funding benefits and all care is directed within the VA Portland Health Care System. Every procedure, appointment, radiology scan, blood test, psychological interaction is tracked in this particular system location and when reported to the headquarters is counted, providing the VA Portland Health Care System with head, appointment and procedure counts that support their hospitals and clinics, including new purchases, personnel levels and every detail of their funding requests. When our Veteran decides he no longer wants to reside in Portland, OR, he must remove his registration from there and then reregister in his new home town and the process starts up again for his receiving VA facility.

So, going back to the structural issues that are endemic within the VA, the condition in which one government hospital must compete against another government hospital for patients creates a multitude of perversions. On top of this, the VA has developed metrics that compare VA hospitals based on results that drive results in contravention with patient care. So, if the facility gets funding based on how many patient appointments it makes, the facility is rewarded for creating an appointment. At the same time, the facility is penalized for having Veterans remain in the Emergency Department, so they will be pushed to rush people through the Emergency Department into appointments, which can delay care. Then when appointments are not available, they will make the appointment and then cancel it because the act of making the appointment is the metric that is counted and cancelling happens as an afterthought. Again, delaying patient care, but in both cases benefiting the VA hospital in its funding requests. Let’s go one step further, the VA has decided that each hospital has its own Chief of Staff that reigns supreme over the decisions of that hospital, again ostensibly to ensure care provided locally is appropriate and within medical guidelines. The problem is that there is massive variation in the care provided facility by facility because of how the “central” guidance is implemented. In addition, each facility is responsible for credentialing its providers (doctors, nurses, etc.) individually. This means every time a doctor goes from facility to facility or in the case of telemedicine, multiple facilities, each VA hospital re-credentials and re-credentials over and over again. The universal VetPro system has been hijacked by the control of the local facilities, each using their own forms and requiring local committee meeting approval, often 3-4 people\committees approving each provider.

A total and colossal waste of time, money and directly impacts the availability of care to the Veteran as this process can take months (sometimes 6-9) in each facility as each hospital is chronically understaffed in this area. Yet, when a patient is sent into the private sector there is limited, if any review, of their medical credentials because they are not privileged at the VA facility. If the focus is on patient care, this process is completely backwards. Every provider of services to a Veteran should be vetted and every provider within a facility should be able
to provide services throughout the VA once they are approved and found fit for service. The decisions of one Chief of Staff are not supremely better than another and the months of credentialing add nothing to quality of patient care. But, it does retain the control
and purview of the VISN and VA hospital. Organizational fiefdoms of each VISN and each VA hospital creates clear and dangerous manipulations of the metrics and directly impacts the availability of providers. These are just a few examples that scratch the surface, there are a multitude of others.

The first “Line of Advance” for this operation is to replace the current organization structure of 21 VISN and remove all transferrable VISN level operations to centralized VA functions. All scheduling and registration shall be done by a national registration and scheduling process and all credentialing of personnel shall be done at a single point shareable with all VA hospitals. This sharing of credentials is permitted by the Joint Commission, the primary external medical facility review mechanism in the US. Funding for VA hospitals shall be based on usage as determined through the centralized registration and scheduling functions. Contracting functions should exist within the VA facilities and report to a centralized contracting office that maintains pricing and terms for each type of service throughout the United States.

This is a change that some would say would destroy the VA, but the VA is in destruction mode at the current time. In order to implement this, the following three additional lines of advance need to be implemented as a stepwise progressive change in the
operations and functions of the VA system.

Technology (Line of Advance 2: Aggressive implementation of technology) is the savior and the bane of the VA system. A failure to aggressively implement new technologies has allowed the VA organizational structure to persist. Without technology, transparency in the operations is not available to decision makers. Why can Amazon or Walmart track their inventory around the world in the click of a button and the VA can’t register our Veterans for services throughout the United States? If there is an expert surgeon in Wisconsin that a Veteran needs a special procedure from New Mexico, service should be available to that Veteran. One VA. Technology will open up the avenues of communication between the VA and our Veterans, expose the layers of waste in the VISN structure, ensure providers are tracked and credentialed appropriately wherever they provide service, open up telehealth opportunities, create real metrics that reflect actual operations, significantly reduce costs and personnel count and improve access and quality of care. The VA does not need privatized health care, it needs a completely new technology implementation plan. The VA has somehow created this fallacy that the patient information in the VA is more valuable than the patient information
at Columbia Presbyterian in New York, it’s not.

Appropriate controls must be put in place, but all patient information is the same and must be protected in accordance with HIPAA and the guidance defined by the Department of Health and Human Services, nothing more and nothing less. In order to secure funding at the VISN level, the VA has manipulated the need to secure patient data into a reason to run local data centers throughout the United States which arguably are less secure than other options in the marketplace. IT equipment ages quickly and new technologies are available all the time, the VA must embrace these new technologies and offer transparency, security, mobility, and greater access through this task. The government even created a program to certify private industry cloud service providers call FedRamp cloud certification, the VA needs to fully embrace this initiative. Companies are developing new products, medical solutions and software to simplify operations, the VA needs to evaluate and implement those that work with agility and decisive decision-making. This is where Veterans should be benefiting from private industry, this is where synergies exist and new technologies must be tested. The common knee jerk reaction that the private sector is not as secure as the government sector is flat out wrong, and it is time that the VA make these changes or Veteran care will continue to erode to the point of pushing the VA
out of existence as a viable provider of Veteran healthcare.

Building on the need for technology-based solutions and a complete revamping of the VA organizational structure is the fundamental need to completely replace the appointment scheduling system in the VA (“Line of Advance” 3: Implementation of a nationwide scheduling system) . When a Veteran leaves the service, they should be registered with the VA, not with the Portland VA Healthcare System. They should be able to take advantage of the services of every single VA hospital in the United States. If there are centers of excellence for the provision of certain medical services, they should be sent there for treatment. If a Veteran calls in and clearly need psychological care, they should not be made wait more than 24 hours and should be given a list of open appointments locally and nationally, and that scheduler should be able to call the vetted private providers in the area while the Veteran is on the phone and find an appointment for them.

There should be no technology limitations to this process and there should be no organizational barriers to service to this Veteran. Nationwide scheduling will remove the built-in perversion of the current system that rewards the appointment making process and manipulating this to meet some other metric. Eliminating forever these unbelievable secret waiting lists. This change can only occur with the implementation of cloud based national scheduling system that is accessible to a national scheduling office and online scheduling for younger Veterans that want to manage their own care. This would include options for telehealth appointments, local appointments, options for appointments with private providers facilitated by the scheduling office and appointments available throughout the US. This is doable with] the technology we have today and will revolutionize the way care is provided to our Veterans. We cannot dump our Veterans in privatized care, it is uncoordinated and has its own set of issues and concerns. Coordinated Veteran care starts with coordinated scheduling so that our Veterans have the greatest access to care where they need it and can get it best.

The last “Line of Advance” is to finally remove the imaginary boundary created between the DoD and VA systems so that Veteran care does not suffer right at the time when care should be provided in the most concentrated and directed way. Injured Veterans are abused by a system that does not seamlessly move them from their service obligations to Veteran health care. There is no conceivable explanation why the medical records from the Department of Defense are not automatically transferred over to the VA and initial determinations of disability are made before the soldier leaves the service. The cost of waiting not only impacts the Veteran and can result in massive transition issues, it also costs the government significantly more due to complications that occur due to lapses in care. Why are we even discussing this? With the technology that we have today, there is not a single viable explanation for this situation. The waiting list should not exist, it’s an abuse of the Veterans. The only people
that should have to submit claims for care in the VA are those that develop issues subsequent to their service termination that were not evaluated at the time of their termination date. Yet again, technology, already in existence, can solve this problem.

The Department of Veteran Affairs is a national treasure. We need this institution and we need it to provide the care to our Veterans that volunteered to protect our freedoms and upon which the entire world relies upon to protect us from total anarchy. We can enjoy our vacations, shop online, buy cars, send our kids to school, farm, enjoy hobbies and go about a life with opportunity because of our military. For that we owe more than a debt of gratitude, we owe them care if they are injured or maimed, in whatever form they need. For decades the VA has tried in small, incremental ways to make minor changes, but the hold is fierce on the government bureaucracy. It has not been enough. This is only a short, generalized operation order needed to be executed to ensure that the VA is not destroyed by the forces that threaten its very existence. Calls for privatized healthcare are misdirected, it’s not privatized care that we need, it’s private technology and innovation implemented at the key points of pain in the VA. The VA needs to be dramatically and permanently reorganized which will damage many ingrained interests related to employment, contracts and funding. But, we have no options left. With these four Lines of Advance, the VA will emerge as a powerhouse of medical care, executing in ways that exceed private care that is plagued by profit motives and insurance company interests. The VA can and must make these changes, the American people are relying on our military to protect us into the next century and beyond.

Silver Star Recipient Lt. Col. Scott Rutter commanded the 2nd Battalion, 7th Infantry, 3ID (M) destroying Republican Guard Forces as Baghdad International Airport during the combat phase of Operation Iraqi Freedom I (2003). Scott is an Entrepreneur and Founder and President of the Valor Network, a Service Disabled Veteran Owned Small Business that is one of the largest Telemedicine/Teleradiology providers to medical facilities in the Department of Defense, Department of Veterans Affairs and the Department of Homeland Security.

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