Veterans' Health Insurance Benefits Are Embarrassing.

Many policy wanks like to talk about the success of Veterans' health insurance benefits giving them access to life saving therapies at a fraction of the cost of private industry.  Have you ever wondered how that's possible?  I haven't, because I know the truth.  It's called the rationing, something the rest of America is not ready to accept as their reality, yet.  To reduce the price our government pays for veterans' health insurance benefits, you simply have to make access unavailable and shift the cost to the veteran themselves on a geographical and time based axis.  Here is a disgraceful experience I recently had with a VA system.

I evaluated a 57 year old male in the  ED who presented with failed outpatient therapy of COPD  and  pneumonia.  Several years ago the VA removed the private contract once in place to allow veterans to stay in their communities and receive care in their home town.  That means the only way a veteran can now receive care in nonVA hospitals and for the hospital to get paid for it is if the patient is too unstable to transfer to the local VA inpatient hospital 75 miles away.  

When this new policy was announced, I was originally told I was not allowed to discuss finances or insurance issues with the patient as to give the impression we were making treatment decisions based on financial obligations.  I refuse to play that game.  The patient has every right in the world to know that their government will not pay for their care if they are stable enough to transfer and that the private hospital will bill them full price for the services rendered.  I simply refuse to allow my patients to be subjected to tens of thousands of dollars of medical bills because they didn't fully understand the ramifications of their choice not to be allowed transfer to the VA inpatient hospital.

Whenever I am asked to admit a patient from the ER, I make absolutely sure they understand the economic implications of their decision. For those folks who have Medicare or Medicaid benefits, they usually decide to stay and pay the associated deductibles because they hate the VA system that much.  For those younger folks who have no alternative payer source, 99% of the time, once they are fully informed of the economic consequences, they allow themselves to be transferred to their VA hospital.  

So here I am with a young man who's veterans' health insurance benefits is all he has got.  After explaining to me how the VA clinic almost killed him, he painfully agreed to be transferred to the VA hospital, 75 miles away.  After the process was initiated, I learned he was 20th on the list for admissions.  The VA was full.  So I documented in capital letters all over the chart:

VA HOSPITAL REFUSED TO ACCEPT HIS VETERAN HEALTH INSURANCE BENEFITS DUE TO LACK OF AVAILABLE BEDS.  THE VETERAN REQUIRES INPATIENT HOSPITAL ADMISSION FOR TREATMENT OF HIS ACUTE COPD AND PNEUMONIA.  EVERY DAY, THE VA WILL BE NOTIFIED TO REQUEST TRANSFER TO THEIR FACILITY.

Hopefully, when the VA attempts to refuse payment, this type of documentation helps to  support the  medical necessity of  admission to the private hospital.  I admitted the guy and started him on antibiotics and nebulizers.  Three days later, he was much better.  He hadn't felt that good in weeks.  So I decided to discharge him home.  The only problem was, he was leaving on a Saturday afternoon.  And I soon learned you never want to discharge a veteran with only veteran health insurance benefits on a Saturday.  I wanted the patient discharged on Levaquin, because of their rapid response to treatment over the prior three days and failed outpatient response to less powerful antibiotics.  I also needed him to go home with a new prescription for aerosolized duoneb (combination albuterol + ipratropium).   So I got on the phone and asked to speak with the  on call physician for his local  VA physician.  And wouldn't you know it.  I was transferred to the operator for the VA system 75 miles away.  

Happy:  Hi, this is Dr Happy.  I need to speak with physician taking calls for Dr Notavailableonweekends.

Operator:  We don't have doctors on call for Dr Notavailableonweekends.  You need to call the VA in your town for that information.

Happy:  That's not true.  There is nobody available in my town for Dr Notavailableonweekends.  That's why my operator sent me to you.  I need to speak with the doctor on call for Dr Notavailableonweekends.

Operator:  We don't have anyone on call.  You need to call your hometown VA.

Happy:  Listen.  T-a-l-k-i-n-g R-e-a-l S-l-o-w B-y N-o-w.   I am talking to you because there is nobody in my town taking calls.  

Operator:  Let me transfer you to my supervisor

Supervisor:  How can I help you?

Happy:  I need to speak to the doctor on call for Dr Notavaiableonweekends in my town.  

Supervisor:  We don't have anybody on call.

Happy:  What do you mean you don't have anybody on call.  I have a patient who's doctor is unavailable.  I need to speak with whom ever the VA established as responsible for taking questions about his care

Supervisor:  You don't have to be rude.

Happy:  I keep getting bounced around.  My patient has a doctor who is unavailable.  I need to speak with a VA physician who can assist me in discharging my patient.

Supervisor:  I can transfer you to the physician of the day in our emergency room

ER Physician:  How can I help you doc

Happy:  Thanks for taking my call.  I have a patient 75 miles away that I'm discharging from our hospital after a three day stay for pneumonia and COPD whom I couldn't get transferred because you guys had no beds.

ER Physician:  Yeah, I know, it's been full here.

Happy:  Well, they are ready to go home and I need to have some scripts filled. How do I do that?

ER Physician:  The VA pharmacy in your town is not open on Saturdays.  And the VA has no agreement with any pharmacy in your town to fill medications using veterans' health insurance benefits.  So the only way your patient can get their scripts filled and have the VA pay for them is to drive 75 miles each way and pick them up here, in my ER.

Happy:  Wow.  That's unbelievable.  The VA doesn't think patients get sick on weekends?  What happens if they go to a local ER and need a script on a Saturday.

ER Physician:  They have to drive here to pick it up.

Happy:  That's crazy.

ER Physician:  That's the VA for you.

Happy:  I know.  I trained there.

And that's how the VA system is able to control costs.  By making health care inaccessible to veterans. That's an embarrassment to our country and our veterans.  How many policy wonks that salivate over cost and quality of care studies comparing the VA with private insurance include the out of pocket expenses veterans are exposed to every day with this kind of garbage health care system.  The answer is none.  The fact of the matter is, the VA is a giant time rationing tool that uses lack of access as a major cost control mechanism.  That's fine and dandy, as long as the American public is aware and accepts that as a cost control mechanism.

Of course, my patient can't drive 150 miles round trip to pick up an antibiotic and some nebulizers, so I called around for him.  And what I found was just as appalling.  The cash price for two additional doses of Levaquin 750 mg tablets at Walgreens was $75.  Two tablets for $75?  That's outrageous.  Walmart was slightly better at $60.  Still outrageous by any means.   And the duoneb aerosol?  $150 for a month at Walgreens and $120 a month at Walmart.  Both the albuterol and ipratropium have long been generic medications.  But sell them in combination form and the cost is outrageous.  

I found it interesting that if you bought the albuterol aerosol and the ipratropium aerosol separately and simply inhaled them separately, you could get 25 doses of each on the $4 Walmart list.  That's one weeks worth of both for $8 or an entire month for $32, instead of the $150 to buy the combination form.  So I told him to bite the bullet.  Since he was improving rapidly after two weeks of outpatient failure, I wasn't about to change the Levaquin to something else.  Nor was the patient able to drive 150 miles round trip to pick up their medication.  So they spent almost $70 out of pocket to fill their necessary medications, that their veterans' health insurance benefits should have covered.  

Except the VA decided they did not want to be a full service health care system and instead have chosen to ration care based on limiting access both by time and geographic separation.  Welcome to the future of government health care.  It's here and now.  And your veterans experience it first hand every day of the week, or at least every Saturday and Sunday.