VAN BOVEN: Fixing VA health care

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By Robert W. Van Boven

OP-ED:

As a physician who proudly serves our veterans of war, I was deeply saddened by the recent revelation of deceptive practices at the Department of Veterans Affairs in New York.

A Newsday article reported that hundreds of veterans' benefit claims were misdated by the VA to make it appear that they were processed on time. This latest affront to integrity comes at the heels of the House Veterans' Affairs Committee roundtable discussion on Nov. 19 regarding the VA's shredding of hundreds of claims at other sites. These are metastatic manifestations of a systemic illness - failures of leadership and a cultural decay at the VA.

The VA bureaucratic remedy? Plans for the VA shredding debacle include having three persons perform an inspection of a document before shredding in the future.

Yet the root problem is not the paper but the prize on productivity. As one House roundtable participant emphasized, "The VA needs to change how it measures work. ... [I]t creates incentives for shortcuts for credit." Performance based on quantity, an easily measured unit, appears to be the driving force for recognition and reward. The dishonest practice of changing dates of processing of claims illustrates how a cultural emphasis on quantity trumps quality and integrity.

Quality of care is more elusive to quantify and characterize. But therein lies what ought to be at the core of our pledge and commitment to those who, as Lincoln said, have "borne the battle," taken great risks, suffered great wounds or given their lives for us.

How to fix the mess? It begins with leadership.

Failures in integrity and leadership are evidenced when Dr. Ira Katz, VA official for mental health, sent an e-mail in February to "Shhh" others about 1,000 suicide attempts monthly by veterans at VA facilities. Closer to my home in Texas, the closing of a Dallas VA psychiatric ward in April after four suicides in four months also begs the question of leadership and quality.

Also in Texas, misguided priorities in a culture are reflected when a psychologist team leader at Central Texas Veterans Health Care System (CTVHCS) sent e-mails to other mental-health specialists in May, arguing, "Given that we are having more and more compensation seeking veterans, I'd like to suggest that you refrain from giving a diagnosis of PTSD straight out." Post-traumatic stress disorder (PTSD), a serious mental-health condition, is estimated by the Rand Corp. to affect nearly one out of five soldiers returning from the war in Iraq and Afghanistan. CTVHCS also serves as a poster child of bad behavior in another case study, when leadership suppressed and failed to act on disclosures of suspected fraud, waste, mismanagement and funding of scientifically invalid work in humans. (See the VA inspector general report "Healthcare Inspection: Alleged Research Funding Irregularities at the Central Texas Veterans Health Care System, Temple Texas" at www.va.gov/oig.)

A cultural problem? An insulated bureaucracy that overly relies on internal monitoring sets the stage for stagnancy and resistance to reform of systemic problems. Alas, when disclosures of wrongdoing are made internally within the VA, suppression and inaction can occur. Beware to the potential whistle-blower, as the internal policing of the VA may "have ears to hear, and hear not."

How can we tackle veterans' doubts of integrity and transparency of the system? A new system of regional, independent oversight to provide early, proactive opportunities for central oversight by Congress could replace the reactive options left after the media unearth problems.

These advisory bodies could also serve as better, truly independent safe havens of refuge, above and beyond those offered by the VA's own inspector-general, for those fearing reprisals for speaking out. As we enter a historic, new administration and new VA leadership, let the message of reform permeate the VA as well so that we can better serve our returning soldiers and the nation's brave veterans.

Dr. Robert W. Van Boven, a VA physician, is director of a traumatic brain-injury-imaging research program in Texas.