The new VA Secretary has an opportunity not only fix the VA, but to innovate and lead in delivering healthcare in the U.S. Here are some places to start:
• Focus on keeping people healthy and productive, not just repairing the sick.
• Use social and military networks to deliver care.
• Aggressively use telemedicine to improve access and triage.
• Don't "double down" on expanding existing resources, when better options can be found.
• Evaluate existing infrastructure to see if its still appropriate to serve the VA's goals, if not, deploy new strategies, don't expand old ones.
Specific examples of how to put this to work:
1. The Physician Shortage. Primary care doctors will hate me for saying this, but allied medical staff can do much of their job well. Nurse Practitioners and Physician Assistants are well-trained and can provide front line care for patients without acute problems.
2. Mental Health Access. Since the invasion of Iraq, more military families have lost a soldier to suicide than to conflict in the last 10 years. Mental health evaluation should be conducted at each VA visit and urgent mental health consultations should be no further than one's keyboard. Many companies are helping private citizens access providers and even helping companies provide access to skilled mental health providers through secure portals. The VA should use telemedicine to bring mental health services into primary care offices and veterans homes. When a veteran needs to talk, someone should be there, not in six months, not in six weeks, but within hours.
3. Centering Care. Military men and women live and support each other in close units. They've got each other's back, so why should this stop after they return home. The VA should create care management groups that extend the same supportive philosophy into the VA. Veterans facing chronic diseases should have their care delivered and explained in groups within the same community. In other fields researchers have found that patients preferred care delivered in groups with similar conditions. They talk to each other, learn about their condition, and benefit from other patients' questions or solutions to the same condition that they might not have thought of alone. Patients, learned more, were happier together and had better outcomes. Does anyone doubt that a dozen patients looking after each other and helping one another to manage their diseases together will do better than 12 individual patients navigating a complex medical process and system alone? Why not create care platoons of patients with similar conditions living in similar areas? Such networks can keep patients healthy and decrease the burden on the VA system.
4. Reassess utilization at the hospitals. The VA operates 152 hospitals; most were built before 1970 when patients routinely spent a week in the hospital for surgeries that are now delivered as outpatients where the patient goes home the same day. Surgeries are less invasive and sick patients are encouraged to recover out of hospitals to reduce the risk of dangerous hospital acquired infections. Today, we often find too many hospital beds, not too few. The VA may not need more beds, but it needs to optimize those they have. Before blindly writing another check to build a hospital, strengthen outpatient care through a network of offices, providers and platforms, then focus on developing centers of excellence where veterans can receive specialized care.
In nominating Mr. Bob McDonald to lead the VA, the President chose someone with extensive managerial experience and an honorable military record. I hope Mr. McDonald will use this opportunity not only to fix the many problems at the VA, but to innovate and lead. The military, has a long history of social innovations. Despite recent scandals, the VA has a long history of productive, successful innovation, including development of an electronic medical system that leapfrogged existing medical records and care management systems in 1990s. Vista was replicated and adopted around the country and internationally. Its time for the VA to lead again.
The VA can again lead. And the time is right for a revolution in health care, one that uses technology and social networks not only to treat the sick, but to keep the people healthy, productive and fulfilled.
The problems facing the VA are not dissimilar to those facing the US as a whole. In response, hospitals, insurers and physicians groups have created accountable care organizations dedicated to keeping people healthy and delivering effective care. The VA is the largest accountable care organization in the U.S. Mr. McDonald is reputed to be a skilled manager, but reforming the management structure is only part of the solution for the VA. As a life member of the U.S. Army Ranger association, Mr. McDonald must appreciate that he is again in a position to "Lead the Way" not only for the VA, but on health care. Good luck Mr. McDonald.