By Tom Philpott

Commission on Care leaders defended their tough diagnosis and 18-point treatment plan for what ails the VA health care system, including their controversial push to let veterans begin to choose their own primary care doctors from new, integrated networks of VA and private-sector physicians.

Answering critics who say they went too far or not far enough in proposing to transform the Veterans Health Administration over the next 20 years, Commission Chair Nancy Schlichting, chief executive officer of the Henry Ford Health System in Detroit, and Vice Chair Dr. Delos “Toby” Cosgrove, CEO of worldwide Cleveland Clinic hospitals, warned the House Veterans Affairs Committee on Wednesday that VHA is rife with weaknesses.

The many “glaring problems,” Schlichting said, include under staffing, aging facilities, obsolete information technology, flawed operating processes, supply chain weaknesses and health outcomes that vary across VHA, all of which “threaten the long-term viability of the system.” Yet the VHA’s ability to transform is most hampered by “lack of leadership continuity and strategic focus,” and “a culture of fear and risk aversion,” she said.

By having only two of 15 commissioners from the congressionally chartered panel testify allowed committee members to focus on what a majority of industry health experts recommend, rather than complaints of veterans service groups defending the status quo or the unpopular notion of dismantling the VHA system as backed by the billionaire Koch brothers.

But Rep. Jeff Miller, R-Fla., the committee chairman who will retire in January, added his own list of VHA weaknesses that have been the focus of House committee hearings and press releases: “persistent access failures, noncompliance with federal prompt pay laws, lack of accountability, a bloated and self-preserving bureaucracy, and billions of taxpayer dollars lost to financial mismanagement of construction projects, IT programs, bonuses for poor performing employees.” The list, Miller said, is “legion and growing.”

But Miller on one issue joined with the Obama administration and most veteran service organizations. He opposes the commission’s call to establish a new layer of VHA oversight — a board of directors comprised of health industry experts who would have authority to direct VHA transformation, set long-term health care strategy and ensure both are carried out by a VA undersecretary of health who would be appointed for five-year fixed terms.

“Outsourcing the crucial role of a cabinet secretary to an independent board … neither elected nor accountable to the American people would be irresponsible and inappropriate, not to mention unconstitutional,” Miller said.

Miller and Rep. Mark Takano, of California, the committee’s ranking Democrat, agreed with many commission recommendations and noted that VA Secretary Robert McDonald said many already were being implemented as part of his ambitious MyVA reforms announced last year.

But Takano, on behalf veterans groups, criticized the commission’s call to integrate VA medical staff with networks of screened private care physicians, to allow enrolled veterans to choose their own primary care doctors, and to allow their providers in turn to manage all care including referrals to specialists on VA staffs or approved outside networks.

The worry, Takano said, is that too many veterans will choose private sector care, driving up VA costs and jeopardizing “the viability of unique VA health services” to treat spinal cord injuries, poly-trauma cases, amputee care, blindness or traumatic brain injuries. Why didn’t the commission recommend that its expanded “choice” model be tested initially to determine the effect on VA budgets and programs? he asked.

Commissioners did discuss a phased approach to include testing, Schlichting said, and that is reasonable considering the complexity of implementing these reforms.

“It’s important to balance this question of choice — making sure access is really available within every market across the country — with the issue of how we’re trying to also control those networks to better serve veterans,” the commission chair said. “Finding that balance is really important.”

Schlichting recalled heated commission debates over how and why to expand patient choice using the private sector. In the end a consensus of commissioners believe they have hit a “sweet spot” for expanding choice by preserving VA system strengths while also allowing access to outside providers carefully screened to provide quality and veteran-centric care.

The commission would allow VA-enrolled veterans to pick a private care provider even when a doctor was available inside the VA. What data did the commission rely on to decide that would be OK? Takano wanted to know.

“If you begin to the think of the VHA care system in the way we did,” Schlichting said, then “it’s not a question of VA versus provider-in-the-community. It’s one system that should be operating in a much more integrated way. And every provider within that VHA care system then would be able to provide access for veterans. It’s a different mindset than today.”

She bristled at a charge from Rep. Doug Lamborn, R-Colo., that the commission missed a chance to truly transform veterans’ health care by rejecting the vision of two dissenting commissioners who wanted VA care more fully privatized and the VHA bureaucracy largely dismantled.

Neither of those commissioners, Schlichting said, “has ever implemented a major change in a health system as Dr. Cosgrove and I have. I think we recognize the transformative aspects of what we’re proposing.”

If Congress embraces recommendations from a majority of commissioners, she said, it would begin a “process that will take many, many years to complete, recognizing the complexities of both facilities and staffing issues and leadership [and] IT interoperability … And to say that what we’re proposing is not transformative I think is just untrue.”

Cosgrove, a former Air Force surgeon, emphasized that a first step toward transforming VA health care must be replacing a woefully outdated electronic health records system with an off-the-shelf commercial system that allow providers and patients to schedule their own appointments.

He and Schlichting also stressed that VHA can’t be transformed without an undersecretary for health who sticks around, and the backing of some sort of oversight team of experts to demand adherence to sustained progress. Congressional oversight, they argued, just isn’t enough.

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