The Unique Case of the VA Model

Bruce Feinberg, DO: We talked earlier about the Amazon, Berkshire Hathaway, and JPMorgan Chase situation, and maybe that’s what they do. Maybe they figure out how you replicate things that work, like Geisinger. But in prior conversations today, we’ve talked about what things are needed to be successful, and you need scale, you need membership, and you need diversification. You need these things, and we have a system, the VA, that has all those pieces. It has been touted at one time as one of the earliest and best for its IT [information technology] systems and interoperability aspects, but now it has fallen on hard times. Given its size, and the cost structure, is the VA problem fixable? Is it a lack of funding? Is it management? Is it the failure of a government sector trying to manage something that could be better managed in the private sector? I’m curious.

Mark S. Soberman, MD, MBA, FACS: Yes.

Bruce Feinberg, DO: What are your thoughts on what happens in the VA? It’s servicing such a difficult and needy population, and I don’t see that population necessarily being better served currently in the private sector world.

Mark S. Soberman, MD, MBA, FACS: I think part of the conversation is that it’s such a hot potato politically. As soon as you start talking about the privatization of all or part of the VA, it becomes a very emotional conversation. My experience with the VA has been there are some things that they do exceptionally well, and there are some things that they do rather poorly. I wonder whether it’s possible to take an objective look and say, “How do we best serve that population? What are the things that we should keep whole in the organization?” Those are probably things like primary care, mental health, and things that are unique to the veteran population. What are the things that should be contracted out or handled with a Medicare-type card or something like that? For high-acuity things like cardiovascular surgery and neurosurgery, maybe that’s the answer. I don’t know.

Bruce Feinberg, DO: Where would our physicians-in-training be trained if it weren’t for the VA?

Mark S. Soberman, MD, MBA, FACS: Well, we can continue to train the primary care doctors and the psychiatrists.

Michael Kolodziej, MD: Come on, you guys have worked in the VA, just as I do. I think a big part of the problem the VA is experiencing now is a reflection of the fact that the patients they serve have changed. They’re not the World War II or Korean War veterans who accumulated traditional chronic medical illnesses. Now we have the Vietnam War and Gulf War veterans who have a different spectrum of medical problems. I remember distinctly how I trained in Philadelphia, and there was an outstanding spinal cord unit. It was the best in the world. The Philadelphia VA would send their spinal cord patients there for care. They have some profound strengths. Their IT platform has often been singled out as being good; it’s interoperable, and it’s comprehensive. They’re building a personalized medicine program that I think could be potentially just dynamite.

They have the ability to have enterprise-level direction in the projects that they wish to undertake, which frankly, working at Aetna, I longed for many a day. There are things that they do, and they do well. I think they haven’t adapted to the patients they need to serve. There’s a certain—I hate to say it this way—mentality about the way people do things in government institutions like that, which are not necessarily consumer friendly or patient focused. That needs to change for them to really come to the leading edge of healthcare delivery. It’s not unfixable. It is fixable, I think, really. But I think that they have a serious problem now.

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