Lessons from the VA – bad performance measures and insufficient primary care

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Category : Medical Rants

The NY Times has come great reporting on the fundamental problems leading to the “VA crisis”. Doctor Shortage Is Cited in Delays at V.A. Hospitals . The article points out two problems.
Let’s first look at the the second problem. Administrators cheated to obtain bonuses. What did that happen? Central office set a performance standard related to how quickly new patients had appointments. What happens when we give performance standards? Unintended consequences! Administrators cannot make physicians see every patient, so they created “work arounds”. Now those administrators are guilty, but I would submit that the performance standard idea should also get blame.

A more important problem comes from the lack of sufficient primary care physicians. This article delineates the problem beautifully. As a former VA physician (part time for 20 years and only inpatient the last 10 years) I can tell you that the patients who frequent the VA require intense primary care. They often have multiple medical problems and often psychiatric problems. Now the electronic medical record is the best I have seen, but it still takes time to type notes, and review the charts.

The VA has great benefits, and often reasonable hours, but the salaries are not great from primary care. And the US has a shortage of primary care physicians, especially internists (who the VA seems to favor). Primary care internists have multiple options. Less internists do primary care than 15 years ago, and partly because many do hospital medicine (higher salary, more predictable hours, and more “days off”).

The VA crisis in primary care will continue until the job improves. The crisis will not stop with the VA. We will soon see the same crisis for Medicare patients and Medicaid patients.

We have to improve the job. We have to decrease the administrative hassles dumped on primary care physicians (actually all physicians). Primary care is the lynchpin of our health care system. Excellent primary care improves outcomes at a lower cost. And our politicians and our insurers have not addressed this issue. We do need to work very hard to fix this problem. The extra moneys put into primary care will save downstream medical costs.

Comments (5)

I am torn when reading these reports. My father is a VA patient and receives excellent care. His most current issue is too much care as his current doctor wants him on a 90 day office visit schedule, not the 180 day he has been happy with for a number of years.

Additionally this doctor is pushing increased testing as well as medications that in many ways are detrimental to his health. There is an insistence on a colonoscopy, against my father’s wishes, as well as driving his SBP under 100 leaving his DSP around 40. My father has already been transported with no pulse.

One major issue is the VA culture where my father has found some doctors feeling they are above their patients. This has created conflicts where questions go unanswered, or like above; pressure is applied to fit the doctor’s notion of proper care.

We do need to recognize the strains placed on the VA system. My father’s VA facility is only about three years old and one doctor told me they could double the size and still would not have the room and staff needed.

People complain about wait times for test, some of these complaints are accurate, while others are simply the frustration of not wanting to make another trip for a minor problem. The claim that a private ER would do a test on the spot ignores the cost of the capacity and the need to fill that capacity in that ER.

The doctors and house staff I have come in contact with have been for the most part caring hard working people. Administrators, like medical administrators everywhere, are a different breed. What has taken place in many VA facilities is criminal and should be treated as such, but we have to remember not to include those hard working folks on the front lines.

Standing next to my father a nice person asked who I was and what was our relationship, my father answered: He is my son. I was immediately backed against the wall and asked one question: What is your cell number? I am sure that number is still in my father’s file.

Steve Lucas

Kevin Pho, MD: Why The VA Scandal Should Be A Red Flag To Single Payor Advocates
http://www.kevinmd.com/blog/2014/05/va-scandal-red-flag-single-payer-advocates.html

I do not believe that it is just “bad” performance measures. Humans,being what they are,tend to respond to incentives and with performance measure\ target folks will often find a way to game the system.That is true in government but also private bureaucracies . Goodhart’s Law is not as certain as the force of gravity but it much better than just a run of the mill rule of thumb.Goodhart said ( my paraphrasing) “When a performance measure becomes a target, it looses its value as a measure”. I think if we keep thinking we just need better measures,things may not get better.The measures may be wonderful along some parameter but when they become a target….

Gaming the system is part of everyone’s life….it is human nature . It includes politicians, administrators and doctors…..people who don’t game the system are an exception. Every carrot stick policy leads to s more “gaming the system”

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