I feel for them. I really do. In a way, it's terribly sad. Young men and women going to war, getting countless injuries, disability and mental trauma for fighting wars. And what do they get in return?
A system hell bent on creating obstructionist care at every step of the way. This was my experience at one VA in one city in one period of time. I don't know if it is the normal experience through out the country. But I have no reason to believe it isn't. Maybe others could comment for me.
My experience with with the VA was great from a pathophysiology standpoint. These old smoking, hard drinking, hard doping fat guys destroyed their bodies. They have lots of disabling illness. Rarely combat related. Most of it lifestyle related. That was my experience.
When I get a sick patient now, I can often refer to them as having "vet like qualities". They are the prototype internal medicine patient.
EMR Comparison
Successful software implementation starts with choosing the right system. This checklist contains over 50 of the most important features to look for when evaluating:
Other useful information is available at my EHR Resource Center.
Coronary Artery disease
Diabetes
Emphysema on chronic oxygen
Obese
Smokers
Peripheral vascular disease
Congestive heart failure
Hypercholesterolemia
Peripheral edema
Wheeling around in the scooter.
The vast majority of them have all 4 limbs in tact. Most can tell me what "% disabled" they are. It is a badge of honor in the VA system to be over 100% disabled. I have no idea how the determination is made. Another government mystery to me.
As a resident, I worked in an outpatient internal medicine clinic 1/2 day every other Friday afternoon for 3 long painful years. Painful, not because the patients were bad. Painful because the obstructionist bureaucracy in place to do everything it could to block access to what I thought the patient needed. The VA was just beginning the brilliant idea of turning doctors in training into secretaries and clerks.
for $40,000, the government decided I wasn't working hard enough in all my other duties and decided I must now be responsible for hand typing all my clinic notes and entering all my own orders.
Entering labs
Entering xrays
Entering consults
Entering medications
It wasn't good enough towrite legibly what I wanted and have a clerk enter my orders.
No It was now my responsibility to play doctor and secretary.
Let me tell you how things usually played out.
1/2 day clinic runs about 3 1/2 hours. That's about 200 minutes from start to finish. When a resident "retired" after their 3 years of training, the new intern in the new class of residents would acquire that panel of patients.
Now, new patients are constantly entering the system and others die off. The decision on who got what new patient was basically a crap shoot. If you had an opening in your schedule, you got a new patient as entered by the clinic clerk, until your clinic was full for that week. As I remember our clinic was considered full at about 10-12 patients.
With 200 minutes, this works out to a maximum of 20 minutes per patient. A resident in training, learning, understanding doctoring has now been assigned the duty of Head Clerk In Charge. The nurses did what they could to help and some were great, helping with orders here and there.
But the rules in place made it my job to navigate the system, call appropriate offices, enter all my orders. And I was available 1/2 day every two weeks. So anything I ordered would have to wait 2 weeks for me to follow up on. It is a glowing example of inefficient use of resources.
Since I could schedule my patients when ever I wanted to, the goal for most residents in training was to fill up your clinic with follow up visits. Patients that you know very well. That you dictated yourself. That you can understand your own train of thought, disease management plans. The goal was to try and avoid new patients at all costs. Because trying to see a new patient in a clinic was one of the most painful things any resident could undergo.
In fact, I had folks in my residency class that actually scheduled DEAD PEOPLE into their clinics so when they didn't show up it was a way to thin out their clinic day. And it's amazing that they did this over and over again. With nobody watching. Or caring.
The only way I was ever able to finish the clinic was to count on no shows. It was a physical impossibility to handle a clinic when all patients showed up. The goal was no shows. Scheduling dead people. Avoid new patients by any means possible.
That's VA hospital employed, salaried doctors mentality for you.
This was the structure of VA medicine. Government run health care. Clinic style. To get a cardiology appointment would often take months and months. Procedures and imaging? Weeks to months. It was a system full of inefficiencies. The mentality was always what can I do to avoid work today. What can I do to make this problem someone elses. Turfing your patient to other clinics for them to deal with it was the norm.
Since I only had clinic 1/2 day ever 2 weeks, what do you imagine happened when my clinic was canceled for what ever reason. I'm out of town. I'm on vacation. I'm sick. Whatever. Since my clinics are booked up months in advance, that patient would have to wait months to see me again. It was always a frustrating endevor for the patient.
Often times I had patients who had no interest in having a doctor at the VA. All they wanted was their free medications. They would come to my clinic, pretend to care what I say, then ask for their refills and begone until the next year. I caught on pretty quick how to tell who these people were. Usually they came with their wives. Were well dressed and well groomed. People I know had money. Successful business people.
And just like the wealthy Medicare patients, they were there to feed at the troughs of their Entitled benefits. Why shouldn't they. It's human nature to want FREE=MORE. And if the government is giving away free money, you can rest assured poor and rich alike will be there to fill up their wallets and pill bottles.
And I was their medication pimp. I honestly didn't' care. I figured out quickly to play the game. Tell them I'm OK if all they want are medications. It saved me a lot of work with the primary care prevention hoops I would have to run through. I prescribe their meds and they leave. These patients allowed me to catch up on my clinic time. The problems usually arouse when the patient would come with a note from their outpatient PCP with a med that was not on our formulary. But I would simply substitute or tell them they would have to get it else where.
Now I know that not all VAs are run by residents. And all I can speak of is my experience in a resident run VA hospital. A system that, despite it's fabulous computer data base/ EMR, has so many ingrained inefficiencies that I remember the first day I ever had as a private practice physician was like an awakening. Never did I imagine that efficient medicine, real time medicine was a possibility. If I ordered a test, it happened 5 minutes ago. not 5 days from now.
I was able to be a doctor again.
I have patients every day who carry both VA and Medicare benefits and they swear to me that they will do everything they can to avoid the pit of VA medicine. It seems to me like not much has changed in the last 5 years. And for anyone who believes that turning our health care delivery in to a giant government run single payer system, for which the VA is, I shutter to think of what that would be like.
Like I have said previously, imagine what life was like when brick phones were just coming out.
That's how single payer government medicine operates.
In spite of the reported benefits and quality indicators showing high marks on their report cards, the delivery process of VA medicine is exactly like a brick phone. Service is spotty, rarely is there a quality connection between the players and a great satisfaction from both parties is entirely dependent on luck.
A system hell bent on creating obstructionist care at every step of the way. This was my experience at one VA in one city in one period of time. I don't know if it is the normal experience through out the country. But I have no reason to believe it isn't. Maybe others could comment for me.
My experience with with the VA was great from a pathophysiology standpoint. These old smoking, hard drinking, hard doping fat guys destroyed their bodies. They have lots of disabling illness. Rarely combat related. Most of it lifestyle related. That was my experience.
When I get a sick patient now, I can often refer to them as having "vet like qualities". They are the prototype internal medicine patient.
Successful software implementation starts with choosing the right system. This checklist contains over 50 of the most important features to look for when evaluating:
- electronic medical records
- medical billing software
- scheduling software
- technology, security and certifications
Other useful information is available at my EHR Resource Center. Coronary Artery disease
Diabetes
Emphysema on chronic oxygen
Obese
Smokers
Peripheral vascular disease
Congestive heart failure
Hypercholesterolemia
Peripheral edema
Wheeling around in the scooter.
The vast majority of them have all 4 limbs in tact. Most can tell me what "% disabled" they are. It is a badge of honor in the VA system to be over 100% disabled. I have no idea how the determination is made. Another government mystery to me.
As a resident, I worked in an outpatient internal medicine clinic 1/2 day every other Friday afternoon for 3 long painful years. Painful, not because the patients were bad. Painful because the obstructionist bureaucracy in place to do everything it could to block access to what I thought the patient needed. The VA was just beginning the brilliant idea of turning doctors in training into secretaries and clerks.
for $40,000, the government decided I wasn't working hard enough in all my other duties and decided I must now be responsible for hand typing all my clinic notes and entering all my own orders.
Entering labs
Entering xrays
Entering consults
Entering medications
It wasn't good enough towrite legibly what I wanted and have a clerk enter my orders.
No It was now my responsibility to play doctor and secretary.
Let me tell you how things usually played out.
1/2 day clinic runs about 3 1/2 hours. That's about 200 minutes from start to finish. When a resident "retired" after their 3 years of training, the new intern in the new class of residents would acquire that panel of patients.
Now, new patients are constantly entering the system and others die off. The decision on who got what new patient was basically a crap shoot. If you had an opening in your schedule, you got a new patient as entered by the clinic clerk, until your clinic was full for that week. As I remember our clinic was considered full at about 10-12 patients.
With 200 minutes, this works out to a maximum of 20 minutes per patient. A resident in training, learning, understanding doctoring has now been assigned the duty of Head Clerk In Charge. The nurses did what they could to help and some were great, helping with orders here and there.
But the rules in place made it my job to navigate the system, call appropriate offices, enter all my orders. And I was available 1/2 day every two weeks. So anything I ordered would have to wait 2 weeks for me to follow up on. It is a glowing example of inefficient use of resources.
Since I could schedule my patients when ever I wanted to, the goal for most residents in training was to fill up your clinic with follow up visits. Patients that you know very well. That you dictated yourself. That you can understand your own train of thought, disease management plans. The goal was to try and avoid new patients at all costs. Because trying to see a new patient in a clinic was one of the most painful things any resident could undergo.
In fact, I had folks in my residency class that actually scheduled DEAD PEOPLE into their clinics so when they didn't show up it was a way to thin out their clinic day. And it's amazing that they did this over and over again. With nobody watching. Or caring.
The only way I was ever able to finish the clinic was to count on no shows. It was a physical impossibility to handle a clinic when all patients showed up. The goal was no shows. Scheduling dead people. Avoid new patients by any means possible.
That's VA hospital employed, salaried doctors mentality for you.
This was the structure of VA medicine. Government run health care. Clinic style. To get a cardiology appointment would often take months and months. Procedures and imaging? Weeks to months. It was a system full of inefficiencies. The mentality was always what can I do to avoid work today. What can I do to make this problem someone elses. Turfing your patient to other clinics for them to deal with it was the norm.
Since I only had clinic 1/2 day ever 2 weeks, what do you imagine happened when my clinic was canceled for what ever reason. I'm out of town. I'm on vacation. I'm sick. Whatever. Since my clinics are booked up months in advance, that patient would have to wait months to see me again. It was always a frustrating endevor for the patient.
Often times I had patients who had no interest in having a doctor at the VA. All they wanted was their free medications. They would come to my clinic, pretend to care what I say, then ask for their refills and begone until the next year. I caught on pretty quick how to tell who these people were. Usually they came with their wives. Were well dressed and well groomed. People I know had money. Successful business people.
And just like the wealthy Medicare patients, they were there to feed at the troughs of their Entitled benefits. Why shouldn't they. It's human nature to want FREE=MORE. And if the government is giving away free money, you can rest assured poor and rich alike will be there to fill up their wallets and pill bottles.
And I was their medication pimp. I honestly didn't' care. I figured out quickly to play the game. Tell them I'm OK if all they want are medications. It saved me a lot of work with the primary care prevention hoops I would have to run through. I prescribe their meds and they leave. These patients allowed me to catch up on my clinic time. The problems usually arouse when the patient would come with a note from their outpatient PCP with a med that was not on our formulary. But I would simply substitute or tell them they would have to get it else where.
Now I know that not all VAs are run by residents. And all I can speak of is my experience in a resident run VA hospital. A system that, despite it's fabulous computer data base/ EMR, has so many ingrained inefficiencies that I remember the first day I ever had as a private practice physician was like an awakening. Never did I imagine that efficient medicine, real time medicine was a possibility. If I ordered a test, it happened 5 minutes ago. not 5 days from now.
I was able to be a doctor again.
I have patients every day who carry both VA and Medicare benefits and they swear to me that they will do everything they can to avoid the pit of VA medicine. It seems to me like not much has changed in the last 5 years. And for anyone who believes that turning our health care delivery in to a giant government run single payer system, for which the VA is, I shutter to think of what that would be like.
Like I have said previously, imagine what life was like when brick phones were just coming out.
That's how single payer government medicine operates.
In spite of the reported benefits and quality indicators showing high marks on their report cards, the delivery process of VA medicine is exactly like a brick phone. Service is spotty, rarely is there a quality connection between the players and a great satisfaction from both parties is entirely dependent on luck.
I used to work for a private ambulance service that handled transportation for the local VA. It would invariably take an extra half-hour beyond what our company considered "reasonable" (read: how long it took at other hospitals) to pick up a patient at the VA. The VA is the only place I've ever seen actually LOSE a patient. Didn't know where he was, didn't have any idea how to find him, didn't seem to care. It was kind of horrifying.
ReplyDeleteI've been on the fence for a while about federally provided universal health care. Thanks for reminding me about the VA---I think my mind is made up now.
Happy,
ReplyDeleteI also trained at a university hospital affiliated with a VA. You are spot on although I was never smart enough to actually intentionally schedule dead people in my clinic.
Amen brotha
ReplyDeleteMy only question is, Why not make the current VA/EMR system (not the old system that is avavilable) freely available to all in private practice. The system stinks but the EMR was great. Instead millions and millions are spent by private practices for systems that are not nearly as good as the VA EMR. I just don't get it.
No, the EMR there is better than paper but doesn't hold a candle to my lower priced office EMR.
ReplyDeleteYour description of VA life matches my med school experience closely.
The only thing I'd add now as a private practice family doc is the utter lack of communication with private docs by the VA that causes lots of extra labs and some significant risk to our mutual patients.
As a off and on patient of the VA hospital system since 1970,I agree with everything you said. I am one of those "over 100%" service-connected disabled vetersns. In fact,rated at 140% if you add it all together. You get this from being rated at (for example) 70% for a back injury,10% for hearing loss,and 60% for PTSD. They add this all together and then somehow come up with a total rating of 70% when the time comes to pay for your disability. Don't ask me how they do this. Nobody seems to know. They mostly do it to avoid having to pay you at the 70% level if you only have one injury "worth" a finding of 70% disabled. It saves the VA money. Which tells you a lot about the system all by itself.
ReplyDeleteI have been to the point where I go to private doctors for about 10 years now and pay out of my own pocket what Medi-Care doesn't pay. I started doing this after two bad and missed diagnoises at the VA hospital resulted in my almost dying and requiring emergency surgery at the local hospital. Of course,the VA refused to pay for the emergency surgery even though I am rated at 100% service-connected disabled because the surgery wasn't done at the VA hospital. Never mind that it was emergency surgery to keep me from dying and that the VA hospital was 70 miles away in another state.
BTW,there is a difference between a vet who is service-connected and a vet who is non-service-connected. My disabilities came from Viet Nam,not being fat,drunk,or any of the other things. For example,you could be giving a disability rating of 70% or whatever because you are diabetic and unable to work because of genetics or lifestyle,not because of your military service. Service-connected vets are supposed to be given priority treatment over non-service-connected vets,but that doesn't happen. The closest VA hospital to me takes patients in the order they come in.
Because I go to private docs and pay without VA involvment,this means I have to pay for my own meds,too. This currently costs me around 200 a month because the VA refuses to fill prescriptions that are not written by a VA doctor. If I want to see a VA doc to get a prescription,it generally takes between 2 and 3 months to complete the process and they won't write refills without seeing you,which would require yet another 2 or 3 months. Since it is a 3 hour round trip drive for me to get there and back home,and then at least another 4 hours to see a doc and get it refilled,it's just not worth it to me. I end up paying for my meds out of my own pocket.
The VA does have a "fee basis" system that allows service-connected vets to go see local doctors and then bill the VA,but I live 5 miles too close to the VA Hospital to qualify for a fee basis card,and despite my mobility problems and other health problems that make it hard for me to go there and walk around and stand in lines,they have refused to make a exception for me 3 times now. They can if they want,but they won't.
ANYBODY that wants socialized medicine needs to spend 2 years getting all of their medical treatment and medications from a VA Hospital. That would cure them forever of that delusion.
Your Blog supports my firmly held belief that blogs are a complete waste of time. You are basing your experience at the VA on your residency experience a few years ago? You think the private sector, as a whole, is better than the VA system? Think again. Ask the 47 million Americans with NO health care coverage. If you have unlimited FFS health care, you likely have very good care, although most likely in excess: too many tests, too many procedures, and less cost-effective medicine. (See Elliot Fisher's work from Dartmouth if you believe the more is better.) Your current perspective may be a new iPhone, but plenty of Americans have a tin can and a roll of string. We spend more per capita on health care than any nation, yet don't have the best health care by most any measure. Until Americans and the health care industry accepts that you can't have everything right now, we will lag behind. In the mean time, the VA will continue to provide high-quality, highly efficient healthcare to our nations veterans. At the current rate of war, we will need it for many years to come.
ReplyDelete