Should Suicide of the VA Health Care System Be Condoned?

If the Veterans Administration (VA) health care system could be kept from becoming the world's worst health maintenance organization (HMO), could it serve as an expanded Public Health Service? A number of ominous signs suggest that the VA health care system may not exist much longer. Its aging patient population, 50 percent of whom are World War II and Korean War veterans, will never be replaced, because nuclear weapons have made large standing armies obsolete. And the 90 percent of Vietnam-era veterans who don't use the VA now because they have private health insurance will not need the VA in the future, because they will soon qualify for Medicare. It is not clear what the magic number of patients is, below which the VA's vast infrastructure of 173 medical centers and more than 300 satellite clinics and nursing homes becomes too expensive. But it is likely that hospitals will be closed for budgetary reasons long before the patient population reaches 50 percent of its current level of 2.6 million. In this sense, the VA is merely experiencing the downsizing that has become commonplace in the Department of Defense and its associated industries. The question is whether the VA should be thought of as just another satellite of the Defense Department, or whether it could serve a role in a post-Cold War economy. A more imminent sign of the VA's demise comes from Undersecretary of Health Kenneth Kizer's recent order to increase the patient panel--the number of patients seen by each physician--from 175 (2.6 million patients divided among a total of 15,000 physicians) to 450 for subspecialists or 900 for primary-care physicians during the course of the next 24 months. In effect, the VA has declared its intention to downsize to somewhere between 20 percent and 45 percent of its current physician workforce. Kizer previously paved the way for massive physician layoffs by getting Congress to rescind VA tenure in 1996. Until then, full-time physicians were guaranteed some job in their local medical center after completing a two-year probation period. Now, tenured physicians can be offered a comparable job anywhere in the VA system, such as South Dakota, so that downsizing will be legal. A more recent plan is to replace the few eventually remaining physicians in primary care with advanced practice nurses, who are obviously much cheaper. And whatever health care provider is left will be hamstrung by rigid adherence to so-called clinical practice guidelines. In addition, gate-keeping has already become much stricter, with patients having to go through their primary care providers before they can see any subspecialist; no interspecialist referrals are allowed. For those physicians who aren't getting the message that they're no longer needed by the VA, Undersecretary Kizer is helping to convince them to leave by brutally converting the VA into as unimaginative and harsh an HMO as any in the private sector. In this, he has the full cooperation of Congress and, evidently, of the president. For most of its 50-year history until recently, the VA health care system has encouraged individual physician initiative and autonomy. By providing time for physicians to conduct basic and applied research as well as to teach, VA physicians helped to define the cutting edge of medicine. Of all the physician-scientists in 1990, the VA funded 30 percent; the National Institutes of Health, with its massive budget of $15 billion (as compared with the VA's research budget of only $250 million), funded the other 70 percent of physician-investigators. Until 1992, one out of three VA grants was funded; since 1993, the funding rate has remained at one out of nine or lower. The result has been the virtual extinction of the VA Research Service at all but a few centers. In this regard, it is interesting that President Clinton has submitted an inadequate research budget for every year of his administration, which, if it had not been increased 25 percent each year by Congress, would have prevented any new VA grants from being funded at all. One wonders whether a candidate widely hailed by the biomedical research community, and who has proposed annual increases in the NIH budget, doesn't have an ulterior agenda for the VA Research Service. The surest way to kill the VA is to eliminate its Research Service. Now that the VA is ending its sixth year of drastically depressed research funding, the cardinal feature that distinguished the VA from any other large health care system is rapidly disappearing. Instead, the momentum to convert the VA into the world's worst HMO is only accelerating. The Formulary, the list of drugs approved by the VA pharmacy for physician prescribing, became closed for the first time in my medical center's history in January 1997; a rigid formulary is a hallmark of managed care. I recently found myself being forced to hand over the care of a terminally ill patient with chronic lung disease to a committee of pharmacists and physicians, none of whom had ever seen my patient. In May 1997, after supplying my emphysema patient with a nonformulary drug (ramipril) for more than a year, the pharmacy and therapeutics committee simply refused to renew the prescription--despite my being convinced that ramipril has kept this gentleman alive for the past two years. Since July 1997, I have been delivering ramipril, obtained gratis from the drug manufacturer, directly to my patient's house. Another directive, which promises to destroy any of the VA's former character that may yet survive, is "economic credentialing." Since the beginning of private-sector managed care, physicians have been encouraged to minimize tests and consultations by giving sizable cash bonuses to those physicians who use the fewest. This will soon be the case at the VA. Health care providers with the lowest rates of ordering tests and consults will be rewarded by substantial (for example, 25 percent of base salary) annual bonuses. Thus, any time patients open their mouths to complain about a symptom, the physician will have the sinking feeling that his or her annual bonus is about to be placed in jeopardy. The physician's professional integrity is pitted directly against his or her family's financial well-being. In these contests, the Hippocratic oath usually loses. The secret of managed care, of course, is that the cheapest way to take care of patients is simply not to, while preserving the illusion of care. Gate-keeping may keep costs down, but ultimately at an unacceptable price, especially among sick, elderly, impoverished patients, as in the VA. Fortunately, the revolution in medical genetics promises a similar revolution in medicine just in the nick of time. Within a few years, susceptibility genes for many common diseases will be known, so that patients can be genotyped, treated more effectively, and hopefully even prevented from developing disease. This may not actually be cheaper than the current method of leaving people to their own devices and then denying them care (gate-keeping), because people will need to take medications (based on their genotype) for their entire lifetimes. Nevertheless, preventive molecular medicine is clearly the most humane method of minimizing the use of expensive medical resources such as hospitals, while maximizing patients' productivity and quality of life. Once available, preventive molecular medicine will be in so much demand that medicine will change overnight. In the context of these strong currents in American medicine, what is to be made of the devastation being wrought on the VA? It is clear that the VA will change, since there will never again be enough veterans to justify its existence. The VA's official plan is to compete for Medicare money as a lean-and-mean HMO that can underspend even the most experienced private-sector HMOs. But is there any point in having taxpayers support yet another lean-and-mean HMO? Why not just give all veterans who currently qualify for VA care the equivalent of a Medicaid voucher? Why not let veterans get their care in private-sector hospitals, as Medicaid patients do, now that most indigent-care hospitals have closed? Why not shut the VA down for good? President Clinton and Congress seem currently to be heading the country quite quickly in this direction. Without any further debate, the VA will cease to be worth saving within the next six months, it seems to me. Why bother trying to save the VA at all? Why not transform the VA, for example, into an expanded Public Health Service to care for veterans as well as the nation's current 45 million uninsured citizens? Without such a radically conservative solution to the nation's health care crisis, the only other solution would be to just give every American citizen a Medicare or Medicaid voucher to be cared for by private hospitals. There are many who already say that if the country is 50 percent over-bedded, excess beds should be removed from the public sector first. It is arguable that boarding up the VA and letting everybody enjoy access to private-sector health care is the best solution. In the private sector, the patient's sickness becomes everyone's livelihood, and the patient is guaranteed the most thorough of care. No one wants the goose that lays the golden eggs to die. A salaried system such as the VA, on the other hand, produces the opposite problem. Even useful expenses may not be incurred, and patients tend to be ignored, because a physician on a salary is paid whether patients are seen or not. Whether one chooses to see patients and do the right thing by them then becomes a matter of character, and a conscious attempt to fulfill the Hippocratic oath, rather than an automatic result of financial incentives as in the fee-for-service mode. As an aside, adding "economic credentialing" to this system will be lethal to patients! There is the additional problem of a designated health care system in which all patients to some extent are captive. This is already just as true for private-sector HMOs as for the VA. So why perpetuate the VA, which is rapidly losing any sense of mercy it might once have had? David W. Moskowitz, formerly a staff physician at the St. Louis VA Medical Center, is a general internist with the St. Louis County Department of Health and founder and CEO of DzGenes LLC. He can be reached online at dwmoskowitz@hotmail.com. But can the country afford simply to walk away from a trillion-dollar investment? Although the VA has taken several giant steps backward over the past six years, and is now taking even larger steps backward toward its own extinction--to the applause, no doubt, of those members of the administration and Congress who want fanatically to downsize government--it may still not be too late if enough people notice. I need not belabor the point that, once lost, our country's opportunity for a public-sector solution to the health care crisis will never be regained. The next few months promise to be interesting not just for the VA, but for the future of our country. It is difficult to believe that a country in which health care remains a privilege rather than a right has either a strong social fabric, or much of a future.

Should Suicide of the VA Health Care System Be Condoned?

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