White Paper: Crowd-sourcing a Solution to the Dept of Vet Affairs

Sgt Aaron Kennedy, MS — Thu, 27 Aug 2015 10:49:56 -0400

All Con. Based on recent running discussions, it is beyond obvious that there is an issue with the Department of Veterans Affairs.

At the urging of COL Mikel J. Burroughs a few members of the RP Community are developing a "White Paper" with a proposal on how to "Fix" this issue.

The major advantage of the RP community is not only its size, but it's breadth of Knowledge, Experience, but also the fact that we care about this issue. We have a vested interest in seeing that it is corrected.

Below is a "Draft Outline" for a "Running Topic" where we can contribute information, and ask Research questions for this White Paper.

YOU are the Subject Matter Experts. YOU come from all walks of life now. YOU have experienced these issues, and can provide both Anecdotal, and Empirical Data needed to make changes to the system.

That said, below is what I initially suggested in a related topic, as a concept. I realize it's not a 100% fix. It's not intended to be. It's intended to be a "Philosophical Shift" which gets us towards that Fix. This will likely evolve as the discussion goes on, and WE research and determine what is or isn't feasible.

Think of this as a Planning Committee. We're developing Courses of Action. We can see the problems. We're looking for solutions. We're looking for second & third order effects to our solutions, but we're not here to just gripe about the VA (which I myself am as bad as anyone).

Thank you for your consideration in this matter.

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Overview: The key to correcting the issues with the VA is mirroring the Military Medicine system. In essence, taking a system that is non-functional or only partially functional, and making it resemble as closely as possible one that is mostly or fully functional. More specifically one that is familiar to the community which it is being applied.

Issues/Concerns/Problems with current System: The Dept of VA (et al) is a Cabinet level organization of the US Government. As such, it possessed both the strengths and the weaknesses of an Administration that size. It is "roughly" the same size personnel wise as the US Navy (being smaller than the USAF, and larger than the USMC) sitting at 300~K personnel.

Any organization of that size IS a Bureaucracy. There are a few disadvantages that have readily presented themselves in regards to the VA itself however. It is "entirely" Civilian ran, as opposed to a hierarchical structure like the Services. Second, there is a "hard" transition administratively getting information for Veterans moving from the Services to the VA, upon exodus. Third (a product of the first), is the ability to remove "low performers" from the VA, because of way the system is set up.

Philosophy of Solution: "In theory" the VHA supports nothing but "Military" (Retirees & Vets) therefore why can't we use a Hierarchical Support System like we do with "Military Medicine?" Or more aptly, why can't we use the "Military Medicine" system to support the VHA?

- Initial Suggest was using a system like the USPHS (Uniformed Service, not Armed Force) to replicate the Military Medicine System. It does not have to be the USPHS. Any "like" organization will work, and the concept of a "Military Medical Command" (MMC) has been mentioned.

In essence, replace on a 1:1 basis "Commanders, and Command Staff" at VA facilities with "Military" personnel. This changes the Oversight & Accountability of the "Directors" of these facilities. These personnel will still have oversight to the SecVA, but unlike their predecessors can be relieved for cause quickly, without the "red tape" that we deal with. This promotes a change in "Command Philosophy," which alters the "leadership environment."

The second piece is the transition of records from "DoD" or Service Level to VA. As it stands now, this is an "Active" process requiring user interaction to accomplish. This is a MAJOR drawback of the system. We need the system to be as seamless as possible going from DoD to VA to the point of Automation. There needs to be a singular system. As 100% (rare exception) of VA "customers" are former DoD "customers", this should be feasible.

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Edit (1): Removed Section(Quoted from original thread) & Placed as Response to Topic, much like CPT Private RallyPoint Member with her comments from the other thread(s):

Edit (2): Removed a couple of "tagged" people below who have responded to the thread, since there is a 20 person limit, to allow me to add more. This is "administrative" in nature (not because their input is not valuable). Please feel free to tag others or make recommendations on others who you think should be tagged.

Edit (3): Added post, below, Research Requests. Will keep them as a running tally. Feel free to link in thread, or message me if you come up with any of the date requested.

Edit (4): Added Issues/Concerns/Problems section to above.

Edit (5): Added Philosophy of solution section to above.

Edit (6): Added --------------------- breaks for ease of reading.

Note: Expect edits as necessary. Nothing is set in stone. Happy to change things as new ideas come in. Happy to debate anything and everything. The goal is to make what doesn't work, work.

Response by SGT Ben Keen made Aug 27 at 2015 10:54 AM

SGT Ben Keen — Thu, 27 Aug 2015 10:54:47 -0400

I like the idea! I'm willing to help.

Response by PFC Joseph Levi made Aug 27 at 2015 10:57 AM

PFC Joseph Levi — Thu, 27 Aug 2015 10:57:38 -0400

I think your ideas/solutions are very viable and well thought through. When everything is finished with the planning, let me know and I will forward it to my boss, Congressman Chris Gibson, a retired Colonel.

Response by TSgt Joshua Copeland made Aug 27 at 2015 12:35 PM

TSgt Joshua Copeland — Thu, 27 Aug 2015 12:35:46 -0400

Federal EHR that seamlessly and wholly transitions from DoD to VA is the biggest lynchpin continuity of care regardless of what the doc is wearing.

Response by CW3 Kevin Storm made Aug 27 at 2015 12:38 PM

CW3 Kevin Storm — Thu, 27 Aug 2015 12:38:44 -0400

Without insulting anyone here, the day USPHS takes over the VA, I will be amazed. Lets look at the two organizations. The VA is a cabinet level position, USPHS falls under Health and Human Services, they don't even have a seat at the table, so that would be a step down for Veterans everywhere. As no one is going to remove USPHS from HHS and make them cabinet level. If you think the VA is willing going to go down without a fight, not going to happen.

Now lets look at the residency program within the VA. Most VA facilities are tied to a Major University. My facility is tied to Stanford, down the road SFVA is tied to UCSF, people who get into these top tier schools normally go on from here for another 3-4 years of higher level education in a given specialty. Our chance to recruit the best and brightest get slim. Why you ask, what can I offer a Doctor that they could not get at a clinic at Stanford? Money, they got us beat, equipment, can't compete. Cutting edge research, while we do a fair share of research, we don't have Nobel level research that some universities are doing. A ten year commitment and give up a weekend? You don't work with a lot of Doctors do you? It will sound good at first, till they get a better offer and debt reduction from another facility without the 10 year obligation. Keep in mind with the Passing of the Affordable Care Act, facilities nationwide are scrambling to get more doctors, PA's and RNP's to aid with the influx of new patients. It is a sellers market right now.

Pay and benefits, depending on where you live, pay and benefits for Federal employees do not keep pace with what the local economy is doing. That applies to healthcare as well, which is why so few stay the course in USPHS to retirement.

Now to get more Active Duty about to leave the service into the VA:
Change Federal Hiring criteria to give Uniformed Service Members the same ability to transfer from their respective service to Federal employment as a Federal employee (Career Status, if honorably discharged)
For honorably discharged Veterans, almost the same but career conditional, which means you can still apply like most federal employees but their is time frame you get to keep this status.

Now what does the VA do: Healthcare, Student Services, Home Loan Services, continued...

Response by SSG Warren Swan made Aug 27 at 2015 12:47 PM

SSG Warren Swan — Thu, 27 Aug 2015 12:47:19 -0400

I really like the ideas floated here, but I have a question. You mention about staffing the hospitals with reservists and NG. Good idea, but where would the continuity come from, and where would the quality be? I would think we need both, and short of bringing them up on long term orders, I don't see where those would (continuity and quality) come in.

Response by CPT Private RallyPoint Member made Aug 27 at 2015 1:57 PM

CPT Private RallyPoint Member — Thu, 27 Aug 2015 13:57:40 -0400

The following was also a part of the original thread as recommendations for items to be covered in a white paper. "The V.A. has 9 million enrolled veterans (6 million who seek care on a regular basis), 320,000 employees, 151 medical centers, 820 outpatient clinics, 300 storefront "Vet Centers" and over 50 regional offices. It has a budget of $60 Billion for healthcare but an overall budget of $165 Billion. Where is the other $100 Billion going? Anyone know where to find the records from the Oversight committee? We always hear the funding isn't available as an excuse for why some service members are not receiving the care they need. As you can see the numbers are disproportionate. V.A. resources need to be allocated more smartly in the future. The continued influx of new Veterans and larger numbers are yet to come as the Soldiers from conflicts Vietnam and the Cold War are replaced by those of the Gulf War and beyond. The population is far more dispersed now than it was before. The changing demographics has resulted in the V.A. not having resources where they are most needed (Urban and Coastal areas). V.A. personnel can be moved from one facility to another to help off set some of this problem. This way experience is not lost.

Currently the V.A. health care system is broken into regions creating small kingdoms. This is why we see so many veterans giving drastic different accounts of their experiences in dealing with the V.A. clinics and hospitals. The Director of the V.A. needs to be able to establish National policy that will apply to all regions. Currently our government representatives don't work together with regards to V.A. resources but instead each works for his/her district leading again to more uneven care availability. We need to bring them together to develop a better V.A. Health System Nationally.

Upper management needs to be selected based on their ability and track records as managers not on the length of time they spent deployed.

The Information Technology System in the V.A. is woefully behind. Not just in terms of processing but also in terms of software and hardware. It is time for the DOS based system to go. It is difficult to use, it fails, the regional systems are not linked together for record access, the regions are unable to communicate because they have developed their own individual software systems. Inventory software needs to be upgraded and sharable between regions. This is also a part of why there is difficulty in integrating with the public health care providers (they have upgraded their systems) .....

Another large problem with the V.A. is the way it is organized from the top down. Their integrity from the top down is in question. Not to oversimplify but replacing the Director of the V.A. does little to fix a systemic problem. Accountability must be happening at all levels."
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Response by Sgt Aaron Kennedy, MS made Aug 27 at 2015 3:24 PM

Sgt Aaron Kennedy, MS — Thu, 27 Aug 2015 15:24:15 -0400

All Con.

Per CPT Private RallyPoint Member's Post, I am submitting to the community the following requests:

Research Request 1) Department of Veterans Affairs: Organizational Chart

a) Veterans Health Administration: Organization Chart

Research Request 2) Department of Veterans Affairs: Budget (Recent calendar year), specifically broke down by "Office" a la VHA, VBA, etc.

Research Request 3) Per Sgt Spencer Sikder Top Level Post(s). Billing/Logistic process "Birth to grave." If we can get an "Infographic" or a baseline understanding of the process.

a) with VHA

b) within "Military Medicine"

c) within Medicare

Response by SCPO Penny Douphinett made Aug 27 at 2015 3:41 PM

SCPO Penny Douphinett — Thu, 27 Aug 2015 15:41:24 -0400

Interesting idea and possible solutions. I am one of the lucky ones to be in a Kingdom as someone called them where I have very few complaints yet I understand this is not the norm.

My biggest fear about any "fixes" to the VA is privatization - anything less than that and I am onboard!

Response by Sgt Spencer Sikder made Aug 27 at 2015 5:24 PM

Sgt Spencer Sikder — Thu, 27 Aug 2015 17:24:02 -0400

I like the idea of having Public Health Service involvement, I would like to hear from those on Indian Reservations who are now serviced by USPHS and how they like their care and it's availability. I do know USPHS used to or maybe still does repackage medications for redistribution in addition to medical clinics. From friend who worked for USPHS, the only basis for getting a referral at the time was for only loss of limb or loss of life.

Additionally, it's mentioned VA being FEMA training, etc. sites. VA is currently a huge part of the FEMA response now. When there is a disaster of local, state or national levels, VAs are part of the recovery process, they have traveling Pharmacies, they set up temporary medical facilities (what they call it, escapes me right now) and have preposition medical supplies/inventory at certain undisclosed locations within the continental boundaries. Many, leaders and staff in VA are FEMA trained/certified.

As for the Records and Administrative pieces, VA and DOD have struggled for many, many years to come up with an integrated system. I am aware of at least one place where the two systems speak to each other, that's Tripler Army Hospital (or whatever the official name is anymore). I suspect the co-joined facilities elsewhere in the country could be as well, but I know the Tripler model is working.

How well, not sure. The missions of the two organizations seem to struggle for a unified identity. Military's mission it appears is to get the warrior back into the battle. Whereas the VA's mission is for long term care and recovery.

Response by MAJ Ken Landgren made Aug 27 at 2015 6:18 PM

MAJ Ken Landgren — Thu, 27 Aug 2015 18:18:50 -0400

FEMA would be a disaster as they have a hard time planning, coordinating, and executing. A large problem are VA employees and managers who lie, cheat, steal. They treat the VA as a kingdom where personal rules usurps regulations and laws, and they suck at FUOPS.

Response by MSgt Darren VanDerwilt made Aug 27 at 2015 7:28 PM

MSgt Darren VanDerwilt — Thu, 27 Aug 2015 19:28:13 -0400

If I were in charge: I would turn the seperate branches medical services into one branch of its own. This would include the Department of Veterans Affairs medical services under a Military Medical Command. This command would have its own unique structure that would encompass all active duty, guard, reserve, retired, and former military personnel under its care. It would be a seperate branch, the Air Force, Army, Navy, etc., would no longer have medical services under their commands.

Individuals separating or retiring from service would see a seemless transition in regards to medical care for themselves and their families. Most problems stem from the transfer of records to the VA, this would no longer be an issue. The threat of fraudulent claims would also be significantly reduced.

All medical facilities and services would then become streamlined, efficient, and standardized.

Response by CSM Jennifer Dehorty made Aug 27 at 2015 9:21 PM

CSM Jennifer Dehorty — Thu, 27 Aug 2015 21:21:52 -0400

I am not a SME, or at least not the best qualified, but I have a battle buddy who is but is not on RP. This is one of his favorite topics. How do I get him involved or in touch with the point members?

Response by SSG Carlos Madden made Aug 28 at 2015 1:13 PM

SSG Carlos Madden — Fri, 28 Aug 2015 13:13:18 -0400

Another RP member shared this as well. https://www.rallypoint.com/answers/ben-carson-we-don-t-need-a-department-of-veterans-affairs-do-you-agree

Ben Carson: ‘We Don’t Need A Department Of Veterans Affairs’. Do you agree? | RallyPoint

Ben Carson stated that, “We don’t need a Department of Veterans Affairs. Veterans Affairs should be folded in under the Department of Defense” in order to reduce the size of the government. Carson, appearing on the “Dave Ramsey Show” Wednesday, stated there needs to be a support system for soldiers that should assist “a year before their time of discharge to be working on their integration back into society. There shouldn’t be a period of...

Response by Sgt Aaron Kennedy, MS made Aug 29 at 2015 9:58 AM

Sgt Aaron Kennedy, MS — Sat, 29 Aug 2015 09:58:15 -0400

(Quoted from original thread): My initial thoughts have always been to augment the VA using the USPHS (Uniformed, but NOT Armed Service). This in turn would allow us to have "military" (uniformed) doctors who are actually accountable, with an actual obligation to the system. Offer reserve commissions in USPHS in exchange for obligated service (reserve) to pay back student loans. College is expensive, and the ability to remove debt over a 10 year period may be just "enticing" enough to draw folks in. Advanced training to get additional years... retirement perks with 20 good years... all for 1 month a year working at a VA center.

"Second, staff the VA Medical staff using enlisted reservists (Corpsman, Medics, etc), and actually use the VA as advanced Training Facilities. Turn the VA Medical Facilities into FEMA training/management/operation sites, and offer State/Local level coursework as well. These two pieces should (help) alleviate "staffing" and HR issues.

"The above works on the idea that "Military Medicine" is functional, which I believe is 85% true. We're pretty good at that. Our issue is getting folks in, and actually doing what they're supposed to. The VA on the other hand suffers from Resource plus Bureaucracy. if we can fix resource, then we can focus on Bureaucracy. I've got a solution for Bureaucracy, but it only works if the above is viable? Does what I say above make sense, or is it out of whack

I've been working on the outline for coming on 6-12 months now (timeline is foggy at this point), but I "think" my overall "blueprint" is viable. It's likely overly simplistic in many ways. It would definitely require Congress, but... I think I can take all the advantages of Military Medicine (a system that "works") and apply it to "Social Health Care" (the VA system, a System which doesn't quite work). It's just a case of having the right folks look at it and poke holes in it, and then damn up those holes to get a 85% solution.

"If I can get the "powers that be" to buy in on the above concept (Phase 1), the next big piece (Phase 2) would be using USPHS as the actual Hospital Administrators. This changes them from "Civilian" to "Military/Uniformed" (loosely phrased) organizations, which significantly changes the Oversight. No longer do we have Civil Servants "directly" in charge of Care. We have the Surgeon General (a Rear Admiral in the USPHS) and officers within that chain of Command. Any Negligence becomes UCMJ issues not Union issues. Additionally "Primary" Staff is Uniformed, Secondary (Necessary/Longevity) staff is Civil Servant, and Tertiary is Contractor, mirroring our existing Military Medicine system.

"The VA Med facilities essentially become extensions of "base" hospitals, which means that we can directly tie the Record and Administrative pieces together. (I have more on this, but that's Phase 3)."

Response by SMSgt Bruce Morgan made Sep 1 at 2015 2:13 PM

SMSgt Bruce Morgan — Tue, 01 Sep 2015 14:13:04 -0400

I personally do not think a military ran VA would work at all. The military is rank oriented and before long there would undoubtedly be preferential treatment. The current VA cares not about what rank you were in the military; all veterans are treated the same. I will say much pressure needs to be put in Sec. McDonald and other VA Exec Management to get the system working. In my opinion 80-90% of the VA workforce, including Exec Management should be veterans.

Response by LTC Christopher Sands made Sep 1 at 2015 9:06 PM

LTC Christopher Sands — Tue, 01 Sep 2015 21:06:05 -0400

We need a better way to communicate to each other.

Response by CPO Michelle Jones made Sep 2 at 2015 1:46 PM

CPO Michelle Jones — Wed, 02 Sep 2015 13:46:11 -0400

I like a lot of what I'm reading for solutions to the VA problems. Two points I'd like to add: As a retired USCG veteran I'm not prior DoD so myself and my shipmates medical records would be exceptions to the 100% prior DoD previously mentioned. When coming up with automated records transfer solutions it'd be great if USCG records could be a part of that discussion as well. The second thing is, there are a lot of veterans that live too far away from either VA or military hospitals/clinics. I would be great if those folks could select a VA approved provider, just like we selected a Tri-Care approved provider when not close to military treatment facility while on active duty.

Response by LTC Ian Murdoch made Sep 3 at 2015 12:33 PM

LTC Ian Murdoch — Thu, 03 Sep 2015 12:33:51 -0400

First, Sgt Kennedy, thanks for taking the initiative to kick off this discussion. Second, for full disclosure, I am an employee of the Veterans Benefits Administration, one of the three administrations under the Department of Veterans Affairs. These views are only my own, and don't represent anything official.
I think that rather than trying to come up the “the fix” for the Veterans Health Administration (VHA), it would be helpful to think in terms of discreet, quantifiable problem sets that can be addressed with potential solutions that meet the SMART criteria of being specific, measurable, achievable, results-focused, and timebound (i.e. has milestones).
As others have mentioned, VHA is huge, with hospitals and clinics all over the country, hundreds of thousands of employees, and serving millions of Veterans ranging from centenarians to Veterans in their 20s. And many of the problems are localized, so a problem in one facility may be an area of excellence in another. A solution that proves effective in one location can then be propagated to others, where appropriate.
In addition to this forum, I would encourage service members and Veterans to be engaged with the military professional organizations and Veterans’ groups and other public and non-profit groups that are partnering with the VA through the My VA initiative to better serve Veterans. And of course, we all should stay informed on the issues and regularly engage our elected representatives.
I can’t speak for VHA, but their strategy for improving care is outlined in the “Blueprint for Excellence,” which can be accessed at http://www.va.gov/HEALTH/docs/VHA_Blueprint_for_Excellence.pdf
That may be helpful as background for this discussion.

Response by SMSgt Sheila Berg made Sep 3 at 2015 9:00 PM

SMSgt Sheila Berg — Thu, 03 Sep 2015 21:00:16 -0400

The Government should provide the money from our tax dollars. Stop giving money and equipment to countries that run away and give to the enemy. Americans should not have to pay twice to take care of our Soldiers.

Response by LCpl Stephen Rose made Sep 22 at 2015 10:19 PM

LCpl Stephen Rose — Tue, 22 Sep 2015 22:19:32 -0400

I've got the best way to fix the health care aspect of the VA, it's incredibly simple. Make the people that run the hospitals use them instead of giving them better private health care. When they get put on their own invisible waiting lists, suddenly everything will be 100x more efficient. Maybe holding C&P worker's paychecks until they fill a quota would get the benefits side working more smoothly too. Every time I go to the VA, it's like seeing minimum wage Wal-Mart employees that shuffle around at 1/2MPH doing nothing but getting ready to go home immediately after their lunch break. I call it the bureaucratic shuffle. Remember those PFC/LCpl busy work days where you make one task last as long as possible? It's like that for these people except every single day.