21 Jun Wait Lists Grow as Many More Veterans Seek Care and Funding Falls Far Short
One year after outrage about long waiting lists for health care shook the Department of Veterans Affairs, the agency is facing a new crisis: The number of veterans on waiting lists of one month or more is now 50 percent higher than it was during the height of last year’s problems, department officials say. The department is also facing a nearly $3 billion budget shortfall, which could affect care for many veterans.
The agency is considering furloughs, hiring freezes and other significant moves to reduce the gap. A proposal to address a shortage of funds for one drug — a new, more effective but more costly hepatitis C treatment — by possibly rationing new treatments among veterans and excluding certain patients who have advanced terminal diseases or suffer from a “persistent vegetative state or advanced dementia” is stirring bitter debate inside the department.
Agency officials expect to petition Congress this week to allow them to shift money into programs running short of cash. But that may place them at odds with Republican lawmakers who object to removing funds from a new program intended to allow certain veterans on waiting lists and in rural areas to choose taxpayer-paid care from private doctors outside the department’s health system.
“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.”
Since the waiting-list scandal broke last year, the department has broadly expanded access to care. Its doctors and nurses have handled 2.7 million more appointments than in any previous year, while authorizing 900,000 additional patients to see outside physicians. In all, agency officials say, they have increased capacity by more than seven million patient visits per year — double what they originally thought they needed to fix shortcomings.
But what was not foreseen, department leaders say, was just how much physician workloads and demand from veterans would continue to soar — by one-fifth, in fact, at some major veterans hospitals over just the past year.
According to internal department budget documents obtained by The New York Times, physician workloads — as measured by an internal metric known as “relative value units” — grew by 21 percent at hospitals and clinics in the region that includes Alabama, Georgia and South Carolina; by 20 percent in the Southern California and southern Nevada regions; and by 18 percent in North Carolina and Virginia. And by the same measure, physician care purchased for patients treated outside the department grew by 50 percent in the region encompassing Pennsylvania and by 36 percent in the region that includes Michigan and Indiana.
Those data include multiple appointments by individual patients and reflect the fact that patients typically now schedule more appointments than they did in the past. But even measured by the number of individuals being treated, the figures are soaring in many places: From 2012 to 2014, for example, the number of patients receiving treatment grew by 18 percent at the Las Vegas medical center; by 16 percent in Hampton, Va.; and by 13 percent in Fayetteville, N.C., and Portland, Ore.
Mr. Gibson said in the interview that officials had been stunned by the number of new patients seeking treatment even as the V.A. had increased its capacity. He said he was frustrated that the agency was running short of funds. “We have been pushing to accelerate access to care for veterans, but where we now find ourselves is that if we don’t do something different we’re going to be $2.7 billion short,” he said.
He said he planned to tell Congress this week that the agency needed to be able to shift funds around to avoid a crisis this fiscal year. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card,” which allows certain veterans to obtain taxpayer-funded care from private doctors. That money would be used to pay for hepatitis C treatments and other care from outside doctors.
In future years, Mr. Gibson said, more money will also be needed. He said he intended to tell lawmakers, “Veterans are going to respond with increased demand, so get your checkbooks out.”
The largest driver of costs has been programs designed to send patients to outside doctors, either because of delays seeing V.A. clinicians or because patients need treatments outside the system. Other major factors include the demand for new prosthetic limbs and for the new hepatitis C treatment.
The “daily obligation rate in medical services” inside the Veterans Health Administration — the part of the department that handles medical care — is $166 million, or 9.2 percent higher than last fiscal year, according to a presentation last week for senior department leaders. Costs for drugs and medications have risen by nearly 17 percent, with much of the increase because of the new hepatitis C treatment, according to the document. An agency memo from last month stated that the need for the new hepatitis C treatment “has greatly outpaced V.A.’s ability to internally provide all aspects of this care.”
The crisis may come to a head when Mr. Gibson testifies on Thursday on Capitol Hill, where Republicans have already criticized what they see as foot-dragging by the department on starting the Choice Card program. One congressional official briefed on the budget problems also said the agency had been slow to recognize how much demand and costs would soar for hepatitis C treatments. The budding crisis may reopen a partisan debate about veterans’ health care that has paralleled a larger philosophical debate about the size of government.
Last year’s waiting-list crisis led to complaints that the department was divided by an acrimonious and retaliatory culture, where whistle-blowers were punished and constructive criticism was stifled. But many experts say the principal problems were a shortage of doctors and nurses in the system, the nation’s largest integrated health care organization, and a lack of office space for patient care — while demand rose sharply from aging Vietnam War veterans and service members from Iraq and Afghanistan.
The department’s inspector general eventually concluded that “the systemic underreporting of wait times resulted from many causes, to include the lack of available staff and appointments, increased patient demand for services, and an antiquated scheduling system.”
New York Times – July 8, 2015