4 Things Washington Could Do Right Now to Fix the VA

Spoiler alert: None of them involve floor speeches or finger-pointing.

World War II paratrooper Donald R. Burgett, 89, salutes the US flag as he poses for a portrait at his home on April 29, 2014 in Howell, Michigan. Burgett landed in Normandy and fought in the D-Day battle as part of the Able Company, 506th Parachute Infantry Regiment and the101st Airborne Division of the US Army. 
National Journal
Jordain Carney and Stacy Kaper
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Jordain Carney Stacy Kaper
May 22, 2014, 3:59 p.m.

Part Three in a series on Vet­er­ans Af­fairs. Read Part One here and Part Two here.

The worst news: A gov­ern­ment bur­eau­cracy is stand­ing between vet­er­ans and their health care, and vet­er­ans are dy­ing be­cause of it.

The bad news: Wash­ing­ton has already tried, and is now retry­ing, its typ­ic­al re­sponses to a crisis, and they’re not work­ing.

Money has been thrown at the prob­lem and the prob­lem is still there. An ad­min­is­trat­ive head has rolled — and un­der a newly passed House bill, oth­ers would likely fol­low — and the prob­lem is still there. And when politi­cians are done with their spas­tic grand­stand­ing and fin­ger-point­ing, the prob­lem will still be there.

There is no good news.

But there is hope of a sil­ver lin­ing: The vet­er­ans’ deaths can be what gal­van­izes the gov­ern­ment in­to fix­ing a sys­tem that has been far too broken for far too long. And if Pres­id­ent Obama and Con­gress are will­ing to move past politick­ing to search for policy solu­tions, ex­perts say there are steps that could be taken right now to bet­ter con­nect vet­er­ans with the care they need.

Here are four of them:

1. Con­gress could ask doc­tors — not vet­er­ans — to handle the pa­per­work.

Un­der the Vet­er­ans Af­fairs Ad­min­is­tra­tion’s cur­rent sys­tem, vet­er­ans must fill out lengthy and com­plic­ated claims forms if they want re­im­burse­ment for their care, and those forms of­ten ar­rive at the agency either in­com­plete or in­cor­rect.

Com­pare that with the private in­sur­ance car­ried by most ci­vil­ians, whose doc­tors typ­ic­ally sub­mit re­im­burse­ment to the in­surer. Were a sim­il­ar pro­cess to be ad­op­ted by the VA, the agency would be re­ceiv­ing claims by leg­al pro­fes­sion­als or mil­it­ary doc­tors who would be bet­ter trained and more ac­cus­tomed to filling them out — and thus much more likely to file them ac­cur­ately.

So what would it take to re­lieve vet­er­ans of the re­spons­ib­il­ity for filling out forms that most privately in­sured pa­tients are free of?

An act of Con­gress, and a sig­na­ture from Obama.

The VA claims pro­cess is set by stat­ute, and so to change it law­makers would have to pass new le­gis­la­tion al­low­ing for changes. And there are oth­er changes they might con­sider as well …

2. Con­gress could re­quire the VA to give more vet­er­ans the be­ne­fit of the doubt.

If Con­gress wanted to change the pro­cess to make life easi­er for vet­er­ans, they could also scratch the VA’s policy of go­ing through each and every claim filed. The IRS doesn’t in­vest­ig­ate every tax re­turn. Medi­care doesn’t in­vest­ig­ate every doc­tor bill. So why does the VA in­vest­ig­ate each and every claim that vet­er­ans file?

In­stead, the VA could mir­ror the private sec­tor by gen­er­ally ap­prov­ing the ma­jor­ity of claims that look ac­cur­ate, and only audit­ing a sample or those that raise red flags, says Linda Bilmes of Har­vard Uni­versity’s Kennedy School of Gov­ern­ment.

“You should have the kind of pro­cess that you have at cus­toms, where you don’t check every bag. Be­cause if you checked every bag of every­one step­ping off the plane, you’d have a huge back­log,” she said.

The VA ex­pressed ser­i­ous con­cerns about the pro­pos­al. Ac­cord­ing to a VA spokes­per­son, that sys­tem would “res­ult in the ma­jor­ity of vet­er­ans get­ting mon­et­ary com­pens­a­tion for dis­ab­il­it­ies that can­not be de­term­ined to be due to ser­vice.”

And while that may be true, at a time when Con­gress and Obama are de­clar­ing bet­ter care for vet­er­ans a na­tion­al emer­gency, they should be ready to re­quire the VA to err on the side of vet­er­ans.

3. The VA could start re­ward­ing its em­ploy­ees for qual­ity, not quant­ity.

For some re­forms, the VA need not wait for Con­gress.

For ex­ample, the agency could im­me­di­ately start de­vel­op­ing new ways to eval­u­ate its em­ploy­ees who pro­cess claims. The cur­rent sys­tem awards work cred­its to em­ploy­ees when they take a step on a claim — be it a deni­al or an ac­cept­ance. But that pushes an em­ploy­ee to fo­cus on speed, and leaves few pen­al­ties for mis­takes.

Take this hy­po­thet­ic­al: An Ir­aq war vet­er­an ap­plied for a dis­ab­il­ity claim for post-trau­mat­ic stress in Janu­ary and was er­ro­neously denied in March. Then she tried again and was denied two more times in June and in Novem­ber. Say, then, the vet­er­an were to make a fourth at­tempt in Decem­ber, and say the VA were to real­ize it had been wrong all along and award the com­pens­a­tion, the agency would claim cred­it for pro­cessing each at­tempt — without dock­ing points for the fact that they had just wrong­fully denied a vet­er­ans’ claim three times, and kept her wait­ing for nine months.

“What has to change is the way the VA counts its work. As long as VA em­ploy­ees have an in­cent­ive to go fast and not pro­cess claims cor­rectly they will do so. That is so ob­vi­ous,” said Ron­ald Ab­rams, the joint ex­ec­ut­ive dir­ect­or with the Na­tion­al Vet­er­ans Leg­al Ser­vices Pro­gram, who has worked on VA claims for 40 years, in­clud­ing 14 at the agency.

Chan­ging the in­cent­ive struc­ture needs no act of Con­gress, or an ex­ec­ut­ive or­der from Obama — though either would make it more likely to hap­pen. In­stead, the VA has the power to start mak­ing those changes the mo­ment it de­cides to.

It’s not, however, a fix without con­sequences. The trade-off between speed and ac­cur­acy leaves the VA in a bind, as both are go­ing to be needed to re­solve the back­log. But resolv­ing the back­log is mean­ing­less un­less it means get­ting care to the vet­er­ans trapped in it. And as the wait time for claims has dropped, the num­ber of ap­pealed claims has ris­en. (For more on the ap­peals con­tro­versy, see Part One on Obama’s ef­forts to elim­in­ate the back­log.)

4. Con­gress can pres­sure the Pentagon and the VA to share elec­tron­ic files.

The VA stands to be­ne­fit greatly from the De­fense De­part­ment’s in­form­a­tion — and now there is a re­l­at­ively easy way to share it: elec­tron­ic health re­cords. But for whatever reas­on, that isn’t hap­pen­ing, and the VA’s per­form­ance is suf­fer­ing for it.

Claims routinely stall as the VA waits to get ser­vice re­cords from the Pentagon, as VA staffers use those re­cords to help de­term­ine if an in­jury is re­lated to a vet­er­an’s time in the mil­it­ary.

Be­ing able to share health re­cords elec­tron­ic­ally has been a long-stand­ing goal for the de­part­ments, dat­ing all the way back to 1998. And un­der Obama, they planned to build a joint plat­form for re­cords shar­ing. But the pro­ject was dropped in 2013 after costs bal­looned in­to the bil­lions. The Pentagon is now put­ting out a con­tract for a De­fense De­part­ment-wide health re­cord sys­tem, and the VA is among the bid­ders. The agency plans to build upon its cur­rent re­cord sys­tem and see if the Pentagon will pick it.

But though in­teg­ra­tion still re­mains the end goal, the de­tails on how to get there are un­clear at best. The de­part­ments have yet to “dis­close what the in­ter­op­er­able elec­tron­ic health re­cord will con­sist of, as well as how, when, and at what cost it will be achieved,” ac­cord­ing to a Gov­ern­ment Ac­count­ab­il­ity Of­fice re­port re­leased in Feb­ru­ary.

Con­gress has thus far been little help, set­ting ar­bit­rary dead­lines that don’t get met. But the power of the pul­pit pales in front of the power of the purse, and Con­gress has both. If law­makers want to force both the Pentagon and the VA to bet­ter co­ordin­ate, that gives them plenty of pres­sure points: either by writ­ing spe­cif­ic re­quire­ments in­to the budget or freez­ing bo­nuses and oth­er fisc­al good­ies un­til the of­fi­cials get the job done.

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