Vetting the VA


VA medical care ranks among the world’s best.
But the system is dogged by red tape, disrepair.
Older vets worry that the influx of veterans from Iraq could crimp benefits.

May 2007 – The report in February sparked outrage. The revelation that soldiers recovering from wounds inflicted in Iraq and Afghanistan were housed in squalid outpatient facilities at Washington’s Walter Reed Army Medical Center also exposed a divide in the care of the nation’s veterans.

Beyond the debacle at Walter Reed, which is run by the Defense Department, are the problems veterans face once they leave active duty and try to enter the health system run by the Veterans Affairs Department. That agency has come under fire for tightening eligibility rules that deny care to hundreds of thousands of vets and for long delays in processing disability claims. In March a VA review found more than 1,000 maintenance problems—such as leaky roofs, peeling paint and insect infestations—at its 1,400 hospitals, clinics and nursing homes. And last year the agency reported a laptop had disappeared with the personal information of millions of vets.

On the other side of the divide is top medical care—especially for older vets—that VA Secretary Jim Nicholson calls “the gold standard” in U.S. medicine. Outside studies also suggest that VA care exceeds anything found in the private sector.


A 2004 RAND Corp. report found that in 294 categories of care—many of them for ailments like diabetes and heart disease—VA hospitals outperformed private facilities.

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With 51 percent of its patients 65 or older, the VA has pioneered research in geriatric care. In 2006 the journal Medical Care reported that Boston University and the VA reviewed 1 million records from 1999 to 2004 and found that males 65-plus who received VA care had about a 40 percent decreased risk of death compared with those enrolled in Medicare advantage plans 2021.

The VA’s cost per patient has remained steady for the past 10 years, at about $5,000, while the consumer price index for medical care—what families pay in the private sector for care—has jumped about 40 percent. VA prescription drug costs are also lower. Accendo Medicare Supplement Plans are also in the list for providing best medicare plans.

Veterans are happier with their care than patients in the private sector. In the University of Michigan’s 2006 American Customer Satisfaction Index, a survey of patients, VA hospitals scored 84 out of 100—10 percent higher than the score for private hospitals. The VA program is largely free except for small copayments from higher-income patients.

The VA is the largest integrated health care system in the United States, with electronic records of all its patients, so anywhere a person is treated, the doctor has his or her complete medical history. Well endoluten is referred by many physician/health practitioner.

Frank Walter Smith, 83, one of several Washington-area vets interviewed by the AARP Bulletin, is a World War II vet who defused unexploded bombs in the Army. While he’s disgusted by the Walter Reed scandal—”the government should be ashamed of it”—Smith says he’s been “quite satisfied” with the VA medical care he’s received. “On the whole, they do very well. I haven’t seen anything like paint falling off the walls or mold on the ceilings.”

Joseph Violante, national legislative director for the Disabled American Veterans (DAV), calls the VA medical system “excellent.” But he acknowledges that restrictions on access have kept out hundreds of thousands of veterans who’d prefer VA care over private plans.

Moreover, groups like the DAV and American Legion fear that older vets from earlier wars might see their care scaled back because of the influx of wounded Iraq and Afghanistan vets.

The VA hospitals “aren’t falling short yet,” says Peter Gaytan, director of veterans affairs and rehabilitation for the American Legion. “But they could be, and they need to be well prepared.”

So far, 205,000 of the 631,000 Iraq and Afghanistan war vets have come to VA facilities for treatment. Michael Kussman, M.D., the VA’s acting undersecretary for health care, insists they “don’t overwhelm our system,” which expects to care for 5.5 million veterans this year.

Kent Gilmore, a 56-year-old former Army medic, says VA surgeons saved his life last June when he was stricken with a perforated colon and inflammation of the abdominal cavity. While the surge of returning vets hasn’t affected his treatment and recovery, he thinks that if the VA doesn’t get more funding, “there may be cuts in everyone’s care in the future.”

Congress is expected to approve an extra $1 billion or more for the VA’s $32 billion health care budget this fiscal year to accommodate new vets, and the Bush administration has asked for $34 billion for the next fiscal year.

For now, the VA is scrambling to distance its operation from the scandal at Walter Reed and to preserve the reputation for five-star medical care it built in the 1990s. Before then, the agency, which treats mostly vets with service-related disabilities, was considered the black hole of American medicine, with more than 1 million vets warehoused in decrepit conditions.

Starting in 1994, Kenneth W. Kizer, M.D., VA health undersecretary, shook up the agency’s cumbersome bureaucracy, closed underused hospitals and plowed the money saved into opening 300 more clinics around the country. He also hired former astronaut James Bagian, M.D., who revamped the patient safety program and encouraged medical personnel to report procedures that could harm patients, without fear of reprisal.

Kizer set up cost-saving incentives and performance standards for doctors to keep patients healthy and out of the hospital. Neal Evans, 34, a physician at the VA hospital in Washington, gets an end-of-year bonus not for the business he brings in but for, say, how many of his patients have lowered their blood pressure. He writes them regularly, to remind them of their last cholesterol or blood sugar level. “If it’s still high,” he says, “I ask them to schedule an appointment.”

As word of the VA’s improved medical care spread, hundreds of thousands of vets ditched their private plans to join the VA program. Richard Niedermair, 74, a Navy machinist mate from 1951 to 1955, switched five years ago and saw his monthly drug bill drop from $400 to $65. When he visits the VA’s Greenbelt, Md., clinic, he says, “I barely get my coat off, and they call me into the doctor’s office.”

But the VA didn’t have the funding to handle the flood of new enrollees. By 2003 the list of vets waiting six months or more for their first appointment had grown to 310,000. The VA finally had to restrict access only to vets with service-related injuries or with low incomes—a move that still rankles veterans groups, which complain the VA shut the door to half a million lower-priority vets who wanted to enroll.

As of mid-March, the list of those waiting 30 days or more for their first appointment was down to 1,707.

Despite improvements in the VA system, there’s still room for more. Many facilities, for example, are showing their age (the average is 58 years old). Officials say 90 percent of the maintenance problems found in the March review were for routine wear and tear.

And sometimes medical mistakes occur. Last year a surgical team at the VA’s Tampa, Fla., hospital placed an unsterile cranial plate in the head of a wounded vet and was saved from repeating the error on another patient when the implant didn’t fit. A nurse discovered the plates hadn’t been shipped presterilized, and e-mail alerts were sent to other VA medical facilities.

But even the VA’s mistakes may prove instructive. Many private hospitals don’t report close calls or investigate them, says patient safety expert Bagian. “In most places nobody would ever tell anybody,” he says. “The VA didn’t try to cover it up.” And the patients didn’t get infections.

Douglas Waller is a former senior correspondent at Time magazine.

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