Hi and welcome to another weekly installment of the Monday Morning Quarterback.
I’m your host, Benjamin Krause, and this week we are talking about health care.
As some of you may know, VA health care has been front and center within the news media. Issues range from problems ranging from cover-ups to huge bonuses not connected to performance.
If you missed it, here is a link to The Daily Show and their bit about VA health care.
Last week, an article was published in JAMA: Surgery by Dr. Kamal Itani, a VA employee. It was called, “This is not your father’s VA.” Come to find out, it is very similar to a 2006 article in some ways, titled “It’s Not Your Father’s VA” published by the US Naval Institute.
Curiously, Washington Post published a slam article about VA health care called, “VA’s reputation for health care takes a thrashing.” That same week, Congress held some hearings on the issues of bad VA health care.
Conversation about Dr. Itani’s article spurred a heated conversation thread on Facebook, and lead to the topic being selected this week. Then, we asked the question, “Should VA Health Care be the US Model?” on Friday.
Our goal was to find out what you all actually think about VA health care aside from all the spin we read from DC.
This MMQB will help give you enough information to being your own search for truth in the matter starting with veterans health care statistics. We also examine Dr. Itani’s article more thoroughly.
This MMQB is broken down into four sections
- Section I: Veterans Health Care Stats
- Section II: Why veterans are divided
- Section III: Meet a real spin doctor
- Section IV: Apologetics for VA health care?
Veterans Health Care Stats
Over the weekend, we ran a bunch of polls throughout social media about the following question:
What is your gut feeling about VA Health Care?
A total of 185 veterans responded in two days. 111 veterans perceive VA health care in a positive light. The headline could come out either way:
- 40 Percent of Veterans Negative on VA Health Care
- 60 Percent of Veterans Positive on VA Health Care
I like this one:
- Just Over Half of Veterans Surveyed Perceive VA Health Care Positively
|What is your feeling about VA Health Care?||
|Disabled Veterans – Chapter 31 Voc Rehab||
|Disabled American Veterans||
|Gulf War Veterans||
|VA IS LYING||
|Vietnam Veterans of America||
Facebook was the best medium for the question, and here are the forums we used:
- VA IS LYING
- Disabled American Veterans
- Gulf War Veterans
- Vietnam Veterans of America
- Disabled Veterans – Chapter 31 Voc Rehab
Samples of what Veterans Said
Veteran 1: Outstanding!!! The VA in Madison, WI (co-located with the University of Wisconsin Hospital) is awesome! No problems here!!!
Veteran 2: Tuscaloosa VA is great!
Veteran 3: The one in Ft. Wayne sucks. I’ve dealt with Numerous depts & so far they’re all bad. Bad attitudes too.
Veteran 4: VA lacks concern for veterans. Healthcare in jail is better…
On the fence
Veteran 5: MSW social services care/ advocacy for disability and other related needs is the big problem. Before bad mh care and when homeless had limited or mediocre med care access till got away from homeless clinics who blocked most , but now specialty medical is ok though far and PC medical is local , local PTSD specialist- Phd is a huge improvement.
Veteran 6: In some areas they do really good. But in other areas they suck. And a lot of it is there attitude. And it takes forever if you can’t find anyone to help. I need a lift for my wheel chair it’s been requested for 60 days. I get a call from them asking why I need it. I tell him I can’t walk now so I bought a pickup so I could get the lift to pick it up by the door because I can’t walk yo back of truck to load wheel chair. He said well I will have to send it back to your dr so he can redo the paperwork requesting the lift and explain why you need it. Lol. And of course dr wants to see me again before he does but no appointments available for 100 days because I’m not a priority cause I’m not sick. Lol even though I explained why I needed it.
Why Veterans are Divided – It’s a Mixed Bag at VA
I recruited the help from my friend Jim Strickland here. I have not worked within either VHA or private health care, and Jim has. For that reason, he seemed like a great source. Here is what he had to say about VA’s claim at the core of Dr. Itani’s article, unedited.
Guest author: Jim Strickland of VAWatchdog.org
The VHA is still touting the Rand study of over a decade ago to brag of their excellent care. In some ways the VHA system is clearly superior and in many others it fails miserably. Trying to define all of that is a huge effort.
As you know, I worked for 35 years in civilian health care. I began my career as a technologist trained in the Army and retired as an executive in health care consulting. I was an administrator running cardiac care centers as well as holding executive positions in the medical device manufacturing industry. I flatter myself in believing I’m a pretty good judge of how each (civilian v. VHA) system works and what works best.
Ultimately, it’s all a crap shoot. Believe it or not, a veteran may get outstanding care if he pulls the right doctor when he’s assigned to a primary care physician. The next veteran in line at the same facility may get less than adequate care with a different physician. However, the VA does the better job of keeping us from getting sick. Preventative health care is far superior at VA. We get a lot of tests for diabetes, cancer and many other conditions that we wouldn’t get in the civilian sector because civilian insurance won’t pay for “screening” in many cases.
We also have a very efficient medication delivery system. I’m always impressed at how well the VHA pharmacy system works. Consider that any time you get a prescription at VA, it is evaluated by a registered pharmacist. The pharmacist is seen as a consultant to the prescribing doctor and prevents a lot of bad drug interactions and so on. This is a very important and not well recognized benefit we have. My local VA clinic has 3 full time consulting pharmacists on staff. There is no dispensing pharmacy at my clinic so all these guys do is to visit with patients and consult to physicians.
A huge factor that comes into play is the veteran himself. Most veterans are male. Men are notably reluctant to visit doctors unless they’re about to die. This is true of men whether they are veterans or not. VA gets extra points by aggressively promoting health screenings and sending reminders to get to appointments and so on.
VA fails when it comes to an elusive quality of genuine caring. I was just discussing the usual 1000 yard stare that VHA employees seem trained to give. The usual VHA employee is so far disconnected from the veteran he or she serves that it’s like they aren’t in the same room. Most civilian facilities have mastered that because they have a profit motive and they want you to feel like a valued customer and to come back and spend your money there. Nobody at VHA “owns” the veteran whereas in civilian facilities, everyone is encouraged to take every guest or patient on as their responsibility.
Many VA facilities are tied directly to teaching hospitals. That’s great if you have an interesting or rare disease. Then you get the attention of a professor who has seen and done it all. If you have a routine hernia, your care is handled by a resident or fellow in training. Yes, they are supervised by real doctors but your care is a teaching event, more about the student than you.
In the civilian sector, I’d guesstimate that at any hospital with over 150-200 inpatient beds will provide the average person with better care than VA. They are intensely competitive these days. Profit margins at hospitals are about the same as at your local grocery. If a hospital shows a profit of 4% on overall revenues, that’s a resounding success and the CEO will be awarded accordingly. Many hospitals are constantly in the red or very close to it.
The only way a hospital can compete with the other hospital in town is by the quality of their care. If that quality dips or is perceived to dip, patients often choose the other guy. Veterans don’t usually have that luxury.
On the other hand, small and rural hospitals all across America are death traps. When you see a hospital of fewer than 100 inpatient beds, you can bet that most of the doctors working there are only here because they aren’t qualified to work for the VHA. I’ve worked in rural settings where the medical staff was riddled with physicians in drug and alcohol treatment programs and nurses are all 2 year RN’s or LPN’s rather than the standard 4 year or masters level nurses you find at bigger facilities.
I’ve told my wife and friends that if I’m injured near to a rural hospital, don’t let me be taken there. I’ll take my chances on traveling to a real hospital.
In the final analysis, I don’t know of any way to compare the overall care of a civilian v. VHA facility. We can compare defined sectors of the care and I believe that in the final analysis, each will be found to be pretty good. I’ve experimented by using my Medicare and I engaged a respectable civilian physician for about 18 months. It was a total bust. I saw the doctor once and then I was assigned to an RNP. The RNP was very nice but she way over-prescribed all the new and expensive medicines she could think of.
The office wasn’t as efficient in scheduling as the VHA is! I showed up for scheduled appointments to learn my RNP had taken the day off and they forgot to call me. My prescriptions weren’t called in to the pharmacy for days after they were ordered. Consults for EKGs, x-rays and lab testing was a matter of driving from one place to another and then learning that orders weren’t forwarded and I had to wait…and wait. Overall it was an expensive and frustrating experience so I’m back at VA for all my care.
Meet a Real Spin Doctor selling VA Health Care
Back in my sales days, I heard the rebuttal, “If your product is so good, then why do you need to flower it up for me.”
Likewise, most veterans think VA health care is good. I have only had a couple issues with it. So, I cannot help but wonder why VA needs to spin its own wares to us. We are, after all, a captive consumer with limited other health care options.
For that reason, I wanted to take some time to pick apart Dr. Itani’s article to see if it passes the logical fallacy test. It does not.
As previously mentioned, the article was titled, “This Is Not Your Father’s VA.”
Subtitled “VA is a ‘model’ for transforming U.S. medicine,” VA employee Dr. Itani attempted to spin VA into a positive light recently.
The assumed goal: to sell the VA health care model to other surgeons and professionals reading JAMA: Surgery. It is a journal published by the American Medical Association.
We can tell a lot about the article be reading how Dr. Itani ends it.
He summarizes his “proof” by writing, “Clinical access, clinical outcomes, productivity, and cost in the VA are now equal or superior to the private sector.” This is based on the one Six Sigma success he cites.
Dr. Itani concludes his writing saying, “This is not your grandfather’s VA or even your father’s, private health care in the United States would do well to emulate the VA’s culture of change… It is time for the world to recognize the VA as an exemplar of value in health care delivery, equally deserving of recognition as this country’s best health care systems.”
My question: “Is this claim true and how can we know based on his 1 page article?”
Here are some ways he makes the argument to answer the question:
- Part I: Use his credentials as a doctor to write an apologetics article supporting VA
- Part II: Use a title and argument borrowed from numerous other previous “pro-VA” spin doctors (I use that term loosely here)
- Part III: Use one example to support an entire system change – Fallacy of Composition
- Part IV: Use a Weak Analogy – A and B are similar; A has a certain characteristic; therefore, B must have that same characteristic
Part I: Possible Misuse of Credentials
Use of Credentials: Dr. Itani is a doctor and chief surgeon in Boston’s VA Medical Center.
Dr. Itani was tasked to write the article in response to original research by the Association of VA Surgeons. Their research was titled, “Redesigning a Joint Replacement Program Using Lean Six Sigma in a Veterans Affairs Hospital.”
The researchers were based in Indianapolis VAMC for the most part. They were affiliated with a program called VA-TAMMCS model. This stuff is amazing, developing research that is truly cutting edge. It includes modeling on veteran behavior based on how we show up for appointments.
However, citing one example on improved efficiencies and cost savings using Six Sigma, Dr. Itani continues on to conclude that VA’s model is “a model for the transformation of American medicine in the 21st Century.”
I was left wondering, “Does one example of saving $1 million allow such a lofty conclusion?” Some might say “yes.” Others might say, “I need more information.”
I would personally prefer an argument like this coming from a policy analyst or economist after examining all cost cutting programs VA has tried.
Part II: Past PR Title
The title “This is not your father’s VA,” has circulated for years. In fact, some of Dr. Itani’s article is intellectually lifted from an article published by the US Naval Institute, in 2006 – at least the part about Oliver Stone’s movie.
In law school, we were required to cite all sources, including sources we paraphrased. Perhaps VA does not have the same high standard for doctors when they write.
Here, this same title has surfaced via VA and its apologists for some years. The first one is curiously similar to Dr. Itani’s article:
- It’s Not Your Father’s VA, US Naval Institute, 2006
- Nicholson: ‘It’s not your father’s VA’, LeMars Daily Sentinal, 2005
- Not your father’s Veterans Affairs, Vets Edge, 2011
Some veterans doubted that the article could be tied in with being part of a public relations campaign, ie propaganda. For me, it sounded very similar to some of Walter Lippmann’s propaganda about the “new” Tammany Party back in 1927.
Here is what we know about VA publications. VA employees cannot publish without receiving some kind of approval from VA legal, generally. This holds true for all governmental agencies and is done specifically to control message. Given the size of the VA, they cannot have all doctors merely spouting off whenever they are invited to do so.
So, VA editors and legal must have at least minimally been involved in the publication.
In this case, the article was a follow up to the publication also published in the same online portion of JAMA’s journal for that day, September 11.
Coincidentally, other VA research was published in on the same day. The “Invited Commentary” was certainly not as “pro-VA” as the article in question here. It was titled, “On- or Off-Pump Coronary Artery Bypass Grafting. How are you Trending?”
Take a second to compare the two to see what you think.
Part III: Fallacy of Composition
Dr. Itani cites one example of how using Lean Six Sigma saved VA $1 million. This is good. However, Dr. Itani goes on to later claim VA health care is superior to private care.
“Clinical access, clinical outcomes, productivity, and cost in the VA are now equal or superior to the private sector.”
Basically, he is claiming VA ingenuity works across the board. Here, it used Lean Six. Elsewhere, usage of VA ingenuity will work, too, if you follow his reasoning.
This is a Fallacy of Composition because it concludes that since one usage of a system worked, then that same system, VA ingenuity, must work across the board.
The facts do not support such a claim as stated. In other areas of VA, cost cutting measures and similar ingenuity resulted in veterans being exposed to Hep C and HIV in Buffalo. I suspect VA is experimenting with different techniques throughout the US. If we had a full list of the experiments and theories, we would know whether or not the techniques all work.
Here, and publicly, VA seems to have acknowledged this one instance. But, we know efforts to improve efficiencies have also harmed veterans (more on this at bottom).
Part IV: Weak Analogy Fallacy
Dr. Itani claims, without citing more, that VA is at least equal to private health care. He goes on to then claim VA ingenuity should be modeled by private health care, or at least serve as a model for it.
In this way, Dr. Itani draws another logical fallacy called Weak Analogy. The problem here is that private health care is radically different than VA health care – like comparing apples to oranges.
The customers are different. The doctors are different. The business models are radically different. VA is focused on cost cutting to operate within budget. Private care is focused on increasing revenue with some cost cutting.
Veterans are 90 percent male. Private care serves approximately a 50-50 gender split. Further, VA has an enormous research budget that has allowed for the implementation of massive research programs that many hospital systems could not afford.
Apologetics for VA Health Care?
The sad reality is that on 9/11, VA continues to pump out public relations (propaganda) articles like the one Dr. Itani published here. They have a huge budget for public relations that is mixed within other budgets which makes it hard to track.
He could have taking the opportunity to expand on specifically what VA is actually doing via Six Sigma and other programs. Instead, he engaged in a general apologetics argument at the time when VA is getting a lot of heat for mismanagement of cost-savings programs.
My assumption here is that VA is attempting to convince United States practitioners that the VA model is one of the best in the country. I think they are also trying to improve their public image.
Here is a quick list of issues over the past year that might contradict Dr. Itani:
- Suspended and Unlicensed VA doctors receive pay bonuses
- VA officials in Pittsburgh covered up a Legionnaires’ disease outbreak for more than a year.
- VA in Buffalo exposed hundreds of veterans to hepatitis by reusing disposable insulin injection pens
- Employee whistleblowers also report poor sterilization procedures and understaffing
- Over 5 veterans killed by formerly retired doctor
A recent article titled, “VA’s reputation for health care takes a thrashing,” should appropriately cause anyone to at least second guess the VA model.
Jon Stewart also got into the mix with his piece, “Ignoring Private Ryan.” There, Stewart highlighted that the directors of VA hospitals where scandals occurred still received huge bonuses.
In response to the bonuses, VA merely said it misunderstood how incentive pay is supposed to work.
Learn more about these issues:
Suspended and Unlicensed VA Physicians Receive Pay Bonuses (by Eric Katz, Government Executive)
GAO: VA Gave Doctors Bonus Pay without a Clear Link to Performance (by Steve Vogel, Washington Post)
VA Office Gave Bonuses While Disability Claims Piled Up (by Noel Brinkerhoff, AllGov)