Should President Elect Trump push to privatize the Veterans Affairs Department?

When people think of privitation they think it will be great because for profit companies are incentivized to cut costs. While this is true, it misses half the picture. For profit companies are incentivized to maximize profit and one if the ways they do that is by cutting costs, the other is by increasing revenue. This has been part of the issue with for profit healthcare. The profit maximizing price to treat someone with a life threatening condition is everything they own, and as much debt as they can obtain. Tying the deep pockets of the government into that may make a lot of people in the private sector a lot of money, but it is the wrong direction, particularly given our federal debt situation.

Edit: changed where I incorrectly said revenue when it should have been profit.

SP5 Mark Kuzinski I think it is a combination of both. Best practices implemented from the some the great private healthcare giants, the best of the active duty military healthcare command leadership, with Government Funding and the right former Military Veteran to provide oversight directly to the President. Here is a White Paper that Sgt Aaron Kennedy, MS and a few others of us put together with a brief suggestion on how it should be overhauled. Sorry for the Length!


12 October 2015

Congressman Chris Gibson
1708 Longworth HOB
Washington, DC 20515

Attn: Stephanie Valle, Chief of Staff

Re: Proposed White Paper Reorganization of Department of Veterans Affairs


Dear Ms. Stephanie Valle:

First, let me introduce myself, my name Colonel (retired) Mikel J. Burroughs. I’ve spent the last 37 years of my life serving in the United States Army on Active Duty, in the National Guard, Deployed, and in the United States Army Reserves. Secondly, a small group of concerned veterans headed up by Sergeant Aaron Kennedy, United States Marine Corps and others who are connected on a website called RallyPoint decided to prepare some idea(s) and proposals on how or what the reorganization of the Department of Military Affairs might look like, particularly in the healthcare portion of the organization.

We have attached a ten (10) page proposed reorganization white paper for the Department of Veteran Affairs that we would like for you and your staff to review in hopes that it will spark some interest and additional questions. We realize that an undertaking of this magnitude in attempting to reorganize the Department of Veterans Affairs is a far more complicated project than just ten (10) pages. We are very interested in your thoughts along the proposed high level approach we are recommending.

Our goal is to peak enough interest that maybe the Congressman will want to dig into this deeper and champion legislation to make the recommendations to congress for reorganization of the Department of Veteran Affairs healthcare and lead the way to fix the continuous problems facing the organization today. We welcome your feedback, negative or positive, and we stand ready to answer any additional questions you may have regarding our outline of proposed changes.

Respectively,



Mikel J. Burroughs
COL (Ret)





White Paper Draft v2.3 (10/7/2015)

Overview

Perhaps the simplest way to look at the Department of Veterans Affairs (DeptVA) is based on the "Eras" of Veteran that it currently serves. In modern times, there are two major eras vying for resources, which can best be described as stressing the system at the seams. Those Eras are the Vietnam Era Veterans, and the Gulf War Era. http://www.benefits.va.gov/pension/wartimeperiod.asp

The Vietnam Era has a significant aging veteran population (estimated at between 54-80~) which places them in the range of major health concerns because of life expectancy, as well as those that are era specific. The more modern veterans, though younger are enrolling at greater rates contributing to an increased enrolled & patient population for the DeptVA.

Over the last decade, although the total number of living veterans has decreased dramatically over the last 13 years (down 17%), the number of VA Enrolled Veterans has increased (up 77%).
http://www.fas.org/sgp/crs/misc/R43579.pdf

This trend should continue for the next 5-10 years as our Vietnam era veterans reach life expectancy (death), and we see the former Draft Model shift to the All-Volunteer Force Model (AVF) at which point there should be a (significant) decrease in total veteran population. However, this does not take into account increase potential recruiting for conflicts in the future.

Of note however is the percentage of enrolled veterans has steadily increased, resulting in more patients even though the total population has been decreasing over the last decade. In essence, we are approaching equilibrium, but on an upturn, not a downturn. The system will continue to be stressed for at least five more years, and in approximate fifteen, we will see a similar stressing which will last twice as long as the one we are experiencing now, because our Gulf War, Contingency, & OIF/OEF Veterans will be reaching the age our Vietnam Era vets are at now.

Assessment

Simply put, the DeptVA was never designed to be this big. It has scaled past the point of efficiency. As we saw in the post WWI era, the WWII DeptVA had to be restructured to meet the needs of the modern vet. As America has gotten bigger, and our Veteran population has grown larger, and the services we are providing them has gotten more comprehensive, we are seeing a “ripping at the seams” of the current model’s capability.

The DeptVA needs a restructuring. However, this restructuring does not need to be nearly as comprehensive as the one from WWI to WWII, as most of the ground work was already done, when it was decentralized. The DeptVA is currently decentralized into several regions throughout the country, with each Region acting semi-autonomously. Within each region there are a variety of Regional Offices (50+), Medical Centers (151), Outpatient Clinics (820), and Storefront “Vet Centers” (300~). These facilities service the existing (and future) veterans, and can best be compared to Naval Vessels, as opposed to Units.



There have what can only be called countless reports of corruption in various facilities throughout the Nation, as the organization has been pushed past capacity. We have asked it to do too much with too little, and like any machine, when stressed, parts will fail. However, corruption may be a misnomer. Each of these major incidents lacks the key element of personal gain which is truly essential for that descriptor. Yes, there is a loss of integrity, and policy violation, but it is a systemic breakdown as opposed to true corruption.

This lends it more to an Oversight and Accountability problem, which is resulting in Administrative symptoms.

This theory seems the most reasonable in that we are seeing random problems throughout locales, and some areas have strengths in what other areas have weaknesses. Were we to apply the scientific method, we would not be able to specifically isolate what is causing any one issue, other than people.

However, the common thread appears to be resource management, and the demand to do more with less. In essence stresses on the system, resulting in bad judgment by people in management, with varying effects (decisions).

Proposal

We started from the theory that the military (et al) has a mostly if not fully functional system in place to support the service members (henceforth referred to as veterans for ease) akin to that of the DeptVA.

"As such, why can't the Department of Veterans Affairs 'mirror' the system currently in place by the services?"

Without conducting a major overhaul of the DeptVA, what would be the simplest means of making the two systems virtually identical? The DeptVA is approximately the size of the Navy (320,000 Personnel vs. 326,000 Active Duty) when it comes to personnel, therefore we can use that as a baseline for personnel matters. Additionally, because of the Region & Facility structure, the parallels become more and more similar as they are explored. Therefore, we imagined the DeptVA as a Nominal Navy where each Group of Regions is a Fleet, and each Facility was a Vessel within the Fleet. Once the DeptVA is looked at through this metaphor, the concept of treating each facility (vessel) as independent commands takes shape.

Note: The United States Navy is currently divided into seven (7) distinct Fleets or Geographic (operational) Regions. By separating the DeptVA Regions into a similar seven (7) Fleets, we can directly mirror the structure of the USN, using a Fleet Admiral (O-10) as head of each region, and officers of lesser grade in billets below.

But for simplicity’s sake, we approached it from a Command Staff aspect. Replace the Director and Command Staff at DeptVA facilities with (Uniformed) Commissioned Officers on a one-for-one (1:1) basis. These officers could be drawn from the US Public Health Service (USPHS), or another branch and substitute the existing SES/GS/GM employees for officers of similar grade. In essence, rather than having Federal Civil Servants, we would have Commissioned Officers who are directly accountable to the SecVA & SecHHS (& the President) as the lead management team of each major facility.

The goal would be to change the Command Philosophy. By having someone who is directly accountable, who can be immediately replaced, and who can hold those below him accountable, we are able to correct issues as they arise rather than let them fester until they become public issues which are reactionary. Additionally, this allows a much smoother Office of the Inspector General (OIG) and Congressional Inquiry process, which provides significant increases in Oversight at all levels.

We mention using the USPHS officers to fill the role for this specifically because of the USHHS' (parent organization) mission of Health in the US. The DeptVA would still retain all Administrative Control (ADCON), however the USPHS (or office thereof) would be Operational Control (OPCON) of the sites reporting to the SecVA.

This should begin at the Regional Level (Graphic attached), and work downward to create a hierarchal structure as opposed to the current “feudal” or “fiefdom” model that exists currently. As Regional Directors/Commanders would be “Flag Officers” (SES converted to USPHS Admirals), and location Directors/Commanders would “Commanding Officers” akin to how our Navy is arranged. The size of the facility, scope of operations/responsibilities, would dictate the rank of the commander, but in general it would be a direct conversion from equivalent SES/GM/GS grade.


We are not advocating an increase/decrease of personnel numbers, nor are we saying that existing “good” employees should be removed. However, the US government (et al) has a variety of programs that can be used to develop these officers in short order including: Transferring medical officers & administrators from other services, direct commission programs, recalling reservists & retirees, and increasing the size of USPHS while reducing civil servant structure.

Furthermore, as there are existing Regions in place, a test-bed program can be set up at Regional or even Facility level which allows limited or widespread adoption.

This corrects the issue with Oversight & Accountability, but does not address the major symptoms of Administration which appears to be the most prominent issue arising currently.

For that, a better method of hand-off needs to occur between the Department of Defense (DoD et al) and the DeptVA. As it stands, both systems currently use independent and separate systems, which are funneled through the National Archives & Records Administrations Branch. This is a major flaw in the system. This is the logjam between the two Departments. To address this, there must be a multi-phase approach to records management.

The first phase is recognizing that we are currently using an inefficient and outdated transfer system to get medical documentation from one system to another, as it stands, when a Service Member leaves the Military their Medical Records (Medical & Dental) is transferred to the National Archives system, and then it must be transferred back to the Veterans Health Administration (VHA) before it can be utilized. This is an unnecessary step in the modern era of medical record keeping.

Therefore, the first step must be in weaning off the current system of using the National Archives for Veterans transferring to the DeptVA. Rather than having all medical records go through a centralized process (National Archives), it should be decentralized based on location of ETS/EAS/Retirement. Upon exodus from military, the service members’ medical & dental records go to the closest medical facility (or Regional Office) to their final duty station. This would not affect the Service Record Book transition to the National Archive System.

Although the long-term goal is having a fully electronic record tracking system, this will reduce general administrative burden at onset of process, saving both time & money. As veterans’ records become “inactive” (Death of Veteran or Predetermined amount of time), the records can be shifted to the National Archives for final storage (as opposed to initial storage). This turns them into historical documents, as opposed to medical records.

Note: As an example, someone EASing from MCB Quantico would have their Medical Files transferred to DC Medical Center until it is needed by another location, at which point normal Medical transfer procedures will occur, just like in the civilian world.

The second phase is identifying that “Military Medicine” and the VHA have different specific goals, which must be reconciled. Military Medicine is designed to retain & maintain Operational Capability, while VHA is after service care. This does not mean the goals cannot be merged. The best way to do this is by slowly expanding VHA into the Base/Location Level (as opposed to Unit Level) Military Medicine programs. In essence, evolving Base Medical Facilities into VHA sites, creating a seamless transition when the Veteran leaves service.

This requires (long-term) replacement of Medical Officers & Medical Staff on a one for one (1:1) basis with USPHS staff at the location level. As these are generally non-deployable or specialized personnel, it will not affect unit readiness. Furthermore, by shifting operational control (OPCON) to USPHS personnel, we remove an additional logjam in the bureaucratic process. We now have “VHA” Doctors involved in the process “birth to grave”

This of course will require technology upgrades which should be done on a Region by Region basis, to “match” the existing Military Medicine infrastructure. By having a common infrastructure with the originating system (DoD) the process becomes more streamlined, reducing further backlogs. This can be done during the normal infrastructure upgrades (lifecycle), with a zero sum effect on cost. Essentially, we are replacing & upgrading systems as normal, but choosing to marry them up so they are better able to communicate with existing infrastructure (which is fully compatible across Region lines).

The third phase is acknowledging that we have a program that works very well for a subset of our Veterans, specifically our Retirees. This is the TriCare (Various Levels). This “(supplemental) insurance” plan can be expanded to cover all Veterans. It presents administrative challenges, but none are insurmountable.

First is the issuance of Identification. As “most” veterans’ exodus after a single term (4 years), and still have obligated service, they fall under the Individual Ready Reserve rules. They can be issued an IRR ID Card (Geneva Convention Card, Reservist). Expanding this program to the remaining Veterans, in lieu of using a VHA benefits card (with appropriate “tag”) would again reduce overall administration, as well as provide a de facto Medical Benefits Card. Furthermore, as the current IRR ID Card is a “Common Access Card” (CAC), it can be used for security credentials when accessing the government system. This adds additional layers of security to one of our largest Privacy Targets (21 Million Potential Targets as current).

Veterans “could” be annotated on a Tricare Copper/Aluminum/Tin (Descriptor/Color pending) program schedule by default, which in turn would allow them to schedule care through the VHA system, and receive Referrals for outside care just like those participating in TriCare (Various Level). This would in effect replace the VA Choice program. Billing for outside care would be handled at the TriCare level, further reducing burden on the VHA system, and mirroring what exists in Military Medicine.

Finally, is working with the ever increasing staffing shortfalls. The most common presented concern is the perception of “doing more with less.” As the population of Veterans that the DeptVA services increases, this concern will continue even through the lull period in the coming years, and will increase exponentially when we encounter the next overlap of eras battling for recognition within the system.

This is the most complex problem, and is the result of the centralized hiring system used by the Federal Civil Service, or the Office of Personnel Management (OPM). This organization is very good at identifying generalized needs and filling them, however it has difficulty filling specialized needs like medical care.
http://www.va.gov/oig/pubs/VAOIG-15-03063-511.pdf

To help alleviate this, we suggest the use of Reserve Medical Officers (USPHS) and augmenting the VHA with Medical Professionals who have remaining Military Service Obligation (MSO). Reservists have been a longstanding means of reinforcing military units in time of need and crisis. By using this methodology on the proposed (mirrored) Military Medicine system, they can expand and contract to support Regions and Facilities as needed.

Additionally, as they are Military Medical Officers (vice Civilian Doctors), there are tuition reimbursement concepts, monetary incentives, retirement benefits, inter-service transfer options, and obligated service ideas that can be applied which are not normally available. Conceptually, these officers would drill one month per year to maintain status.

By adding this additional layer of personnel, who is outside the OPM system, the SecVA has the ability to identify hotspots as they are arising, and correct them before they become major issues.

Conclusion

Despite prophesies of doom, the Department of Veterans Affairs is not truly broken. It does have major concerns which are directly related to scale. These are readily apparent, now, because of the influx of multiple eras of veterans competing for limited resources as well as technological limitations, and the need to revisit the existing structure of the bureaucracy.

Over the next decade, the situation will continue to boil over, and then we will experience a lull, which will give law-makers and administrators approximately one decade to revamp and refine the existing system to meet the needs of the next generation of veterans. It is paramount that we begin planning immediately to take advantage of this lull, lest we repeat this current situation again, but with a much larger influx of veterans, and a much longer stressing period than the one we are experiencing now.

The best way we can do that is mirroring a functional system, a la the Military Medical system, and by providing oversight and accountability similar to that system. By leveraging the positives of this system, and using a phased approach over the next few years, we can gradually build a comprehensive system that meets the reality of existing infrastructure as well as veteran needs.

Civilian sector is clueless when it comes to military affairs.