The Much Needed Revamping Of Military & Veteran Health Care
Cures for Walter Reed: Another Laudable Report on How to Fix Military Medicine
Before looking at the recommendations of the panel, it must be stated that the first major reform in both military and veteran health care is making the funding of both a first priority.
From the late 1970s through the 1990s there was a tremendous effort to downsize the military medical infrastructure. Naval Regional Medical Centers (MRMCs) were deliberately downsized to Naval Hospital (NH) status. When there was a staffing shortage--and there was almost always a staffing shortage--the method of resolving the shortage was to change the numbers and parameters of staffing. In February of 1980 NRMC Great Lakes (Great Lakes, Illinois) was listed at 73% staffing capacity. In March of that same year it was listed at 100%, but the number of staff onboard had not changed at all. With a stroke of a BUPERS (Naval Bureau of Personnel) and subsequent stroke of a BUMED (Naval Bureau of Medicine), NRMC GLakes went from 73% to 100%. The new commanding officer was less than pleased at the process, as were those nurses, doctors and corpsman that now had to pull double the duty hours just to keep pace.
Major Army hospitals and medical centers were closed or downsized as well. Coast Guard bases were somewhat insulated because only a few duty stations actually had their own hospitals or even a dispensary. Air Force hospitals suffered a similar fate, as did the MEDVAC system operated by the Air Force as a service for all three branches (including the Marine Corps as part of the Navy).
The VA health care system has NEVER been fully funded. Instead, it has been treated as an after-thought, receiving less and less funding (percentage wise) year after year. The VA has never been given a fully funded vision from Congress and has relied on orders from the executive branch to determine how much original funding, and supplemental funding, it has received. As a result, the VA has a system of priorities for providing vets care, which translates into many lower categories of vets (Categories 4-8) receiving care only when there were funds available to do so. That is currently the case as we speak. Veterans in Categories 6-8 are not currently being treated at the VA because the entire VA funding is going toward treating those vets with combat-related, service-related or chromic conditions.
The end result of denying the health care promise to veterans is that one-third to one-half of homeless individuals (depending upon whose study is cited) are veterans from Korea, Vietnam, Grenada, Kosovo, Gulf War I and the period between these conflicts. Even though veterans that served faithfully with a promise of lifelong health care in return for their willingness to serve faithfully in an environment where the risk of death occurs everyday (e.g. the risk of death on an aircraft carrier is higher than steelworkers, policemen, firefighters and healthcare workers combined), they are being turned away. Additionally, the funding issue requires that any veteran seeking care from the VA system must supplement the VA budget through co-pays or insurance (if they have it).
Fundamentally there is an inherent injustice in the VA system when it requires a vet to contribute to the funds for care: these folks were promised health care services as part of their commitment when they enlisted or were commissioned.
Then, too, as we have seen from the various reports--and far too many vets (or their families) can attest to, firsthand experience--the quality of health care at the VA is often sub-standard. The system relies too heavily upon hiring foreign-born, foreign-trained physicians and nurses (often ignoring the veteran corpsmen and medics that received excellent training while in service and cannot find a path to civilian credentials upon discharge) for staffing. Then, too, the VA system relies too heavily upon the rotation of interns and residents from the various medical schools associated with the VA hospitals.
When the affiliation with major medical schools was first arranged (Chicago University Medical School was one of the first), the program was hailed as a godsend because it supplemented the VA attending staff and provided a staffing boost. But in the subsequent years, these student doctors have become the entirety of the primary care system, answerable to a Chief Resident more often than a Chief of Service. Most of the Chief of Service positions are filled with doctors that had difficulty getting their US medical credentials because their training was through medical schools and hospitals in places like India, Pakistan, Jordan, Iran or other places.
A good for instance is my own treatment at the VA for kidney stones. The Chief of Service was a Muslim Indian named Dr. Khan. Dr. Khan was an impressive man that met with me twice before my uroscopic procedure. I could barely understand half of what he said because his accent was difficult to understand. Having medical training from the military (Navy Hospital Corp AND Army Medic), I was better informed and more knowledgeable than most patients. But there was a major problem concerning the accuracy of medical progress notes in my case. There are several narrative reports in my medical files that indicate that there were anywhere from three to ten stones in my right kidney, ranging in size from 2-15cm in diameter. The actual CT Scan showed five stones in my right kidney. Yet, a later narrative report indicated these stones were in my left kidney. The problem stemmed from the fact that I had four residents treating me and performing the workup before I got to the operating suite. There was no genuine supervision of these residents by attending staff. While the VA has a new and excellent electronic medical records system, the accuracy of the reports being entered is less than 100%, making the system a product of the feared GIGO (Garbage In-Garbage Out) syndrome dreaded by anyone involved in collecting data and information. The obvious lack of supervision and original involvement of an up-to-date cadre of attending physicians has been problematic and has hurt the quality of care provided by the VA.
One of the first steps in resolving the VA health care system is to revamp the criteria and compensation offerings for physicians, eliminating the need to hire foreign-trained physicians because American-trained doctors won't take these low-paying positions.
One of the first steps for the military hospitals is to increase the staffing of hospitals, clinics and dispensaries with a proper number of corpsmen (medics), nurses and American-trained physicians, AND elevate the military medical infrastructure back to an acceptable standard, keeping it there even when there isn't an active ongoing war.
Amen! But this is a typical response... throw a little paint on it and call it a done deal.
The military HAD such a program called an "OMBUDSMAN" program. The Army and Air Force actually have commissioned Social Workers within the system, but the staffing levels for either ombudsmen or social workers has never been adequate for the tasks at hand. But given the nature of traumatic brain injury, a caseworker with between 1-5 cases should be a good start.
But what about those vets and active service members without TBIs? Shouldn't the vet with a limb amputation, or with major burns across the body, or with severe injuries about the torso be entitled to a case worker as well? Shouldn't the vet suffering from PTSD, "shell shock" or other psychiatric disturbances have a caseworker as well? Once again we can see an inherent bias by those that do not understand the systems, the dynamics, or the problems... treat the problem that is getting the most attention and ignore the rest.
As a vet, I still hold Bush, Cheney and Rumsfeld responsible for the faltering of the military and VA health care systems. Like the issues with field armor for vehicles and personnel, these leaders of our military failed to properly prepare for war and sent our troops into harm's way without assuring that the promise of health care was in place.
Shame on them!
Before looking at the recommendations of the panel, it must be stated that the first major reform in both military and veteran health care is making the funding of both a first priority.
From the late 1970s through the 1990s there was a tremendous effort to downsize the military medical infrastructure. Naval Regional Medical Centers (MRMCs) were deliberately downsized to Naval Hospital (NH) status. When there was a staffing shortage--and there was almost always a staffing shortage--the method of resolving the shortage was to change the numbers and parameters of staffing. In February of 1980 NRMC Great Lakes (Great Lakes, Illinois) was listed at 73% staffing capacity. In March of that same year it was listed at 100%, but the number of staff onboard had not changed at all. With a stroke of a BUPERS (Naval Bureau of Personnel) and subsequent stroke of a BUMED (Naval Bureau of Medicine), NRMC GLakes went from 73% to 100%. The new commanding officer was less than pleased at the process, as were those nurses, doctors and corpsman that now had to pull double the duty hours just to keep pace.
Major Army hospitals and medical centers were closed or downsized as well. Coast Guard bases were somewhat insulated because only a few duty stations actually had their own hospitals or even a dispensary. Air Force hospitals suffered a similar fate, as did the MEDVAC system operated by the Air Force as a service for all three branches (including the Marine Corps as part of the Navy).
The VA health care system has NEVER been fully funded. Instead, it has been treated as an after-thought, receiving less and less funding (percentage wise) year after year. The VA has never been given a fully funded vision from Congress and has relied on orders from the executive branch to determine how much original funding, and supplemental funding, it has received. As a result, the VA has a system of priorities for providing vets care, which translates into many lower categories of vets (Categories 4-8) receiving care only when there were funds available to do so. That is currently the case as we speak. Veterans in Categories 6-8 are not currently being treated at the VA because the entire VA funding is going toward treating those vets with combat-related, service-related or chromic conditions.
The end result of denying the health care promise to veterans is that one-third to one-half of homeless individuals (depending upon whose study is cited) are veterans from Korea, Vietnam, Grenada, Kosovo, Gulf War I and the period between these conflicts. Even though veterans that served faithfully with a promise of lifelong health care in return for their willingness to serve faithfully in an environment where the risk of death occurs everyday (e.g. the risk of death on an aircraft carrier is higher than steelworkers, policemen, firefighters and healthcare workers combined), they are being turned away. Additionally, the funding issue requires that any veteran seeking care from the VA system must supplement the VA budget through co-pays or insurance (if they have it).
Fundamentally there is an inherent injustice in the VA system when it requires a vet to contribute to the funds for care: these folks were promised health care services as part of their commitment when they enlisted or were commissioned.
Then, too, as we have seen from the various reports--and far too many vets (or their families) can attest to, firsthand experience--the quality of health care at the VA is often sub-standard. The system relies too heavily upon hiring foreign-born, foreign-trained physicians and nurses (often ignoring the veteran corpsmen and medics that received excellent training while in service and cannot find a path to civilian credentials upon discharge) for staffing. Then, too, the VA system relies too heavily upon the rotation of interns and residents from the various medical schools associated with the VA hospitals.
When the affiliation with major medical schools was first arranged (Chicago University Medical School was one of the first), the program was hailed as a godsend because it supplemented the VA attending staff and provided a staffing boost. But in the subsequent years, these student doctors have become the entirety of the primary care system, answerable to a Chief Resident more often than a Chief of Service. Most of the Chief of Service positions are filled with doctors that had difficulty getting their US medical credentials because their training was through medical schools and hospitals in places like India, Pakistan, Jordan, Iran or other places.
A good for instance is my own treatment at the VA for kidney stones. The Chief of Service was a Muslim Indian named Dr. Khan. Dr. Khan was an impressive man that met with me twice before my uroscopic procedure. I could barely understand half of what he said because his accent was difficult to understand. Having medical training from the military (Navy Hospital Corp AND Army Medic), I was better informed and more knowledgeable than most patients. But there was a major problem concerning the accuracy of medical progress notes in my case. There are several narrative reports in my medical files that indicate that there were anywhere from three to ten stones in my right kidney, ranging in size from 2-15cm in diameter. The actual CT Scan showed five stones in my right kidney. Yet, a later narrative report indicated these stones were in my left kidney. The problem stemmed from the fact that I had four residents treating me and performing the workup before I got to the operating suite. There was no genuine supervision of these residents by attending staff. While the VA has a new and excellent electronic medical records system, the accuracy of the reports being entered is less than 100%, making the system a product of the feared GIGO (Garbage In-Garbage Out) syndrome dreaded by anyone involved in collecting data and information. The obvious lack of supervision and original involvement of an up-to-date cadre of attending physicians has been problematic and has hurt the quality of care provided by the VA.
One of the first steps in resolving the VA health care system is to revamp the criteria and compensation offerings for physicians, eliminating the need to hire foreign-trained physicians because American-trained doctors won't take these low-paying positions.
One of the first steps for the military hospitals is to increase the staffing of hospitals, clinics and dispensaries with a proper number of corpsmen (medics), nurses and American-trained physicians, AND elevate the military medical infrastructure back to an acceptable standard, keeping it there even when there isn't an active ongoing war.
IT HAS BEEN five months since an investigation by The Post exposed squalid conditions at Walter Reed Army Medical Center, and federal policymakers now have no shortage of good advice on how to fix the bloat, inefficiency and indifference of the military health-care system. The latest came yesterday from the President's Commission on Care for America's Returning Wounded Warriors, a panel headed by former senator Robert J. Dole and former health and human services secretary Donna E. Shalala, which examined the entire system of health care and benefits that should serve seriously injured soldiers. That follows at least five other major studies released since March.
Still, not nearly enough has been done to fix the system. Some of Walter Reed's facilities have been repaired, but fresh paint at the base's outpatient buildings will not repair the confusing bureaucratic mess that wounded soldiers must face when they get home. President Bush must push through major reforms soon.
Amen! But this is a typical response... throw a little paint on it and call it a done deal.
Headlining the presidential commission's report is a recommendation to assign each seriously injured service member a single "recovery coordinator" who will guide him or her through the process of receiving care and obtaining benefits. Other recommendations include a reform of the disability benefits system: Instead of the current overlapping procedures for assigning benefits, the Defense Department would be responsible only for deciding whether to discharge a service member, while the Department of Veterans Affairs would make all decisions regarding disability payments and services. These determinations would be based on a single, comprehensive physical examination and a regularly updated schedule for assessing the severity of service-related disabilities. The commission also echoed an earlier Institute of Medicine report by calling for compensation for lost quality of life, not just lost income.
The military HAD such a program called an "OMBUDSMAN" program. The Army and Air Force actually have commissioned Social Workers within the system, but the staffing levels for either ombudsmen or social workers has never been adequate for the tasks at hand. But given the nature of traumatic brain injury, a caseworker with between 1-5 cases should be a good start.
But what about those vets and active service members without TBIs? Shouldn't the vet with a limb amputation, or with major burns across the body, or with severe injuries about the torso be entitled to a case worker as well? Shouldn't the vet suffering from PTSD, "shell shock" or other psychiatric disturbances have a caseworker as well? Once again we can see an inherent bias by those that do not understand the systems, the dynamics, or the problems... treat the problem that is getting the most attention and ignore the rest.
Some critical questions remain unanswered: How can the VA reliably quantify loss of "quality of life," for example? Even so, Mr. Bush should be seeking to urgently enact significant reforms such as those in the commission's report, so that no more veterans have to face the broken system in place now. After jogging with two wounded soldiers yesterday afternoon, the president called on Congress to act on the report and said that he had instructed Defense Secretary Robert M. Gates and Veterans Affairs Secretary R. James Nicholson "to look at every one of these recommendations, to take them seriously and to implement them." We hope that happens, and quickly.
As a vet, I still hold Bush, Cheney and Rumsfeld responsible for the faltering of the military and VA health care systems. Like the issues with field armor for vehicles and personnel, these leaders of our military failed to properly prepare for war and sent our troops into harm's way without assuring that the promise of health care was in place.
Shame on them!
posted by Jim Downey at 2:40 AM
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