Just so we are clear, the Veterans Affairs problem still exists, but thanks to Shinseki’s resignation, they’re now one person short.

So imagine this email we received from a doctor with inside information. What follows is not for the faint of heart, and we have attempted to protect the individual’s identity at his or her request.

Czar,

During my training, as the WWI, WWII and Korean War Veterans were dying off, the demand for services were declining at a rate proportional to the number of veterans that served in those wars. VAs were closing wards due to lack of demand for services. During George W. Bush’s tenure, there was a large influx of young vets as a big infusion of cash was pumped in to accommodate them. Furthermore, to some degree, the VA was accepting private insurance from Vets plugged into the system. Only in recent years has means testing for pre OEF/OIF [Operation Enduring Freedom/Operation Iraqi Freedom—Czar] veterans offset the glut of veterans pre and post OEF/OIF that want access to the system. So, with regard to who gets medical benefits, it’s messy. The poor and service-connected are in. The not-so-poor that were in are still in. The not-so-poor that aren’t OEF/OIF can’t get in and if they forgot to renew (like a Costco membership) they might be out.

One of the problems with the VA is that it is a national network. There are big and little hospitals and good and bad hospitals.

For example, the ████████ [redacted] VA is a good hospital. The big problem is that we can’t accommodate demand. Folks get what they need, but they have to be on our radar. A phone call from a colleague can get a patient in quicker with a specialist.

A lot of the wait stems from supply/demand mismatch. We do not have enough doctors, nurses, and space to see everyone as fast as they need to be seen. Furthermore, the catchment areas are pretty large in rural areas. I have patients from all over the geographic region. That doesn’t even get into the folk from further places who come for things that only we do in our hospital.

The wait list issue stems from personnel (clerical/administrative) whose evaluations and performance pay (bonus) hinge on short wait times. If you create a perverse incentive , folks will jump through those hoops to meet those goals. This was compounded with the fact that there is a pop-off valve. If there’s a wait over 30 days or if it is a service not provided in the VA system, you can request a ‘fee basis’ consult which allows you to farm something to an outside institution. Again, some administrators are incentivized to keep under budget so they don’t like approving Fee Basis consult requests. Some folks also don’t request fee basis consult requests for non-urgent matters.

We lost one diagnostic device, and while waiting for a replacement, our wait list blew up to over 500. So, we started paying overtime for weekend help, we “Fee Basis”-requested the tests to be done outside, and we waived our wait list around, screaming like harpies until the administrators got us a 3rd (and coming next month 4th) machine to meet demand. We’re still doing weekend work to get the Vets in. But, we are also putting forward a very high quality product.

The VA is a big place. There are two major components, the hospital system and ‘everything else’ (benefits, pensions, etc…).

Rolling everything under DOD is a good idea to reduce administrative overhead.

The VA Hospitals take care of service-connected conditions, those without means, and other patients that meet protean criteria and/or are grandfathered in from prior protean criteria.

The good hospitals do a great job, the not-so-good hospitals are not so good. The same can be said for other places.

A number of the hospitals are affiliated with academic medical centers, and the best and brightest from those institutions will work both sides of the street. They provide a vital and robust training ground for our residents. Academic funding for research comes out of the VA as well.

Deans hospitals with academic affiliations include West Roxbury with Harvard, Palo Alto with Stanford, Jesse Brown with Northwestern and U of I Chicago.

So, what to do with the hospitals?

One option is to put every veteran who served X number of years or saw action, Tricare or Federal BC/BS for life with all monthly individual contributions and copays and based on a means test and % service connection. I have no idea how much that would cost in comparison to what exists. It also under-covers mental health needs, and probably adequately address the indigent.

It would also put our non-VA hospitals on pretty high demand. Also given the high risk pool, Federal BC/BS premiums would go up. Tricare, I’m not sure.

You will have empty hospital buildings to find some use for. Sell the property?

The Czar of Muscovy

Божію Поспѣшествующею Милостію Мы, Дима Грозный Императоръ и Самодержецъ Всероссiйскiй, цѣсарь Московскiй. The Czar was born in the steppes of Russia in 1267, and was cheated out of total control of all Russia upon the death of Boris Mikhailovich, who replaced Alexander Yaroslav Nevsky in 1263. However, in 1283, our Czar was passed over due to a clerical error and the rule of all Russia went to his second cousin Daniil (Даниил Александрович), whom Czar still resents. As a half-hearted apology, the Czar was awarded control over Muscovy, inconveniently located 5,000 miles away just outside Chicago. He now spends his time seething about this and writing about other stuff that bothers him.