New Revelations From Red Team Experts
By VHPI Senior Policy Analyst Suzanne Gordon
A recent Congressional oversight hearing dedicated two hours to the following question: Is the current network structure inside the Veterans Health Administration (VHA) adequate?
In 1994, Kenneth W. Kizer, President Bill Clinton’s Under Secretary for Health, launched a major overhaul of the VHA that came to be known as “The Kizer Revolution.” It was, in fact, the biggest turnaround of a healthcare system in American history.
One of Kizer’s major innovations was to replace a system of fragmented hospital fiefdoms that delivered care of variable quality with a coherent national structure organized around 22 Veterans Integrated Service Networks (VISNs). These regional networks allowed for greater planning, coordination, and accountability.
Over the years, particularly in the last decade, VHA has experienced some unfortunate lapses in accountability and leadership, as well as variability of care. Some would-be VHA privatizers now seem to blame these lapses on the VISN structure. One of them – Mariannette Miller-Meeks (R, IO), is chairwoman of the Health Oversight subcommittee that held the hearing. During it, she and other members derided the structure as they grilled four witnesses: Dr. Kizer; Alfred Montoya, VA Deputy Assistant Under Secretary for Health Operations; Ryan Lilly, VA director of the New England VISN; and Julie Kroviak, from the VA’s Inspector General.
Dr. Kizer powerfully defended the structure he created. In his testimony, he said:
Structures are not independent of the people who work in them, nor of the leaders and managers whose job it is to ensure that staff achieve desired outcomes, whether that be in quality of care, cost management, or other domains. It has been my experience over the past 40 years in executive leadership roles of various kinds that lapses or failures in leadership and poor execution of established policies and procedures and/or insufficient delineation of roles and responsibilities are much more likely explanations for performance or accountability problems than organizational structure.
Kizer also reminded lawmakers that much of the American healthcare system is now working to establish integrated networks in the VA’s mold. “[This] should reassure the Committee that the conceptual underpinnings of and rationale behind the VISN structure are quite sound,” he said.
Kroziak, of the Inspector General, as well as subcommittee members on both sides of the aisle chastised VHA senior administrators for failing to establish clear policies, roles and responsibilities for VISN leaders. In her comments and responses to questions, Kroziak cited numerous instances of failures in leadership at the VISN level that contributed to patient safety problems. It was an interesting contrast from her written testimony, where she emphasized the negative impacts of MISSION, including the “magnitude of the related costs and staffing to manage” increased referrals to community care through the Veterans Community Care Program (VCCP), a parallel system of private sector mandated by the legislation.
In the VA Maryland Healthcare System, for example, Kroziak noted that “nearly 100 personnel were recruited to just schedule and coordinate community care for veterans.” Kroziak also discussed the administrative and clinical burdens imposed on staff who are trying to coordinate care with often uncooperative private sector providers, insisting all of this warrants “standardized VISN-level coordination.”
Kroziak concluded her remarks by reiterating the need for a VISN structure that would “clarify roles and responsibilities for those who could track and identify trends in non-compliance in real time and intervene proactively.” While she called for this kind of clarity and structure within the VHA, she did not call for the same kind of structure or even monitoring of care provided by the VCCP.
The only person to clearly tackle the challenges of administering two separate healthcare systems was Kizer. He not only identified the central problem but also pointed to the folks who created it in the first place: Congress.
“Clearly,” Kizer explained in his written testimony, “VHA’s managerial challenges have increased in recent years for multiple reasons and especially because of enactment of the MISSION Act of 2018. In brief, this new law requires that the VHA function both as a fully integrated healthcare delivery system (as it has done since the 1990s) and as a payor for now millions of enrollees getting care in the community at a cost of over $30 billion in 2023.”
He continued: “Importantly, these two different functional roles – i.e., being an integrated delivery system and a large healthcare payer - require different guiding philosophies and principles, operating infrastructures, skill sets, and authorities, which is probably why no private healthcare system in the U.S. tries to simultaneously accomplish both of these functions. Pursuing these roles concomitantly materially complicates and confounds management’s ability to accomplish either, especially with regard to predicting funding needs and the number of patients that will be cared for each year so that staffing and other resources are available to provide needed services.”
The question Congress and the country must answer is not whether the VISN structure is appropriate for the modern VHA. It is whether it makes financial, clinical, and ethical sense to demand that the VHA run two parallel systems. The clear truth right now is that VA leaders and administrators, whatever their flaws, are being set up for failure. That’s because Congress is asking them to develop rules and policies and be held accountable when, in fact, they can’t predict their budgets or patient caseloads, and don’t know what kind of healthcare enterprise they are being asked to administer.
While the VHA clearly has leadership problems, the only way to ensure that there is little variability in the care delivered by the VHA is to demand administrative clarity and accountability from the folks who hold the real power over the VHA: Congress.
