Medicine can be confusing. It is therefore often assumed that problems with medical centers and health care delivery are confusing. Sometimes they are, but not in the case of the current scandals at the Department of Veterans Affairs. The VA medical centers do not have a medicine problem. They have a math problem, a reality problem and a willpower problem.
The heart of the scandal is that veterans had to wait too long for appointments, leading to suffering and possibly death. Waiting lists exist only when the demand for appointments exceeds supply.
The math is straightforward. Demand is the number of veterans multiplied by the number of appointments needed per veteran. For new appointments, the latter number is one. In other cases, the number per veteran could be set by the VA or estimated by data. The supply of appointments is the number of doctors times the number of appointments per day.
Since the VA determines the number of doctors and the length of their appointments, they have complete control over the supply side of the equation. They could hire more doctors or shorten appointments to either meet demand or target the desired waiting time. Instead, it appears that administrators just hid the waiting lists.
The fact that there were cover-ups and off-the-books waiting lists is abhorrent, and the perpetrators should be punished. The math is so easy, however, that the lies don’t excuse the leaders. More veterans were being enrolled due to the wars in Iraq and Afghanistan and new “service connected” conditions, like Agent Orange exposure. That means one of two things: more physicians or longer waits. If neither was occurring, the discrepancy should have initiated an investigation. Unfortunately, it appears too many leaders put hitting their benchmarks over facing reality.
There is a limit to how short useful appointments can be, so as more veterans enroll, the VA will have to hire more doctors. That brings us to a much dicier problem to solve: Congressional willpower. If Congress didn’t like the waiting times, they could increase the budget. Instead, some of the senators calling for the head of VA Secretary Shinseki voted against VA appropriations.
The smaller government voices are already saying that the VA is an example of the evils of single payer medicine. That’s the wrong takeaway. Once veterans get through that first appointment, they are generally happy with VA care. The VA data system assists world class research, and provides a large enough patient population to identify problems not found in smaller research trials, allowing potentially dangerous treatments to be avoided. With less focus on billing, doctors can focus on patient care.
The VA system needs to be fixed, not blown up. It can be done, but not by setting goals that simply can’t be met. As we’ve seen, that only leads to people lying to keep their jobs. Instead, limited resources need to be fixed with additional resources. It’s an equation so simple even Congress should be able to solve it, if they have the will to face reality.
