OPINION: VA Wellness and the Prioritization Problem
Wellness is important, but so is system optimization
This story was originally posted in its entirety on the NYC Veterans Alliance blog, 28 June 2017
Last Friday was a busy day for VA Secretary Shulkin: New legislation for enhanced whistleblower protections and shortened investigative and termination procedures for VA employees was signed into effect, indicating a welcome change in administrative practices to ensure improved quality of service through ensuring the right people with the right priorities are in the right positions.
Following the signature, Secretary Shulkin spoke to the press on issues beyond the bill, hinting at his new direction for VA healthcare. It was during this impromptu presser that Shulkin uttered the words “Our system incentivizes disability, when our system should be incentivizing health and well-being.”
Secretary Shulkin clarified: this did not mean the reduction of benefits. Disability pay will remain in effect, but he believes there should be an accompanying expansion of wellness programs to encourage Veterans to self-improve their condition. This tied into the legislation, which passed by establishing evidence on stagnation of VA care due to retaining employees who were perceived as no longer working for the good of the Veterans, yet unable to be reviewed or terminated in a timely fashion. With his comment, the Secretary was observing that improved care is not only in the hands of VA and its employees; some of the onus is on the willingness and ability for the Veterans to heal, and incentivizing them to do so is the next step the VA should take.
Incentive is indeed important; VA monetary compensation and extended care is directly tied to the extent a particular disability has on daily life. This is contrary to the common misconception that VA ratings are based on the severity of an injury when it occurred, making the payment a reparation. Instead, the intent of the disability payment is to make up the difference between potential working income and actual work income due to injury. Effects on social relationships, self-care and hygiene are also taken into account during compensation evaluation, but it is still meant to be a stopgap, not an award or reparation or a “thank you for your service.” Veterans’ participation in reintegrated life should continue to the greatest extent possible. If the Veteran can better balance or recover from their injuries they will have increased ability to contribute to their communities. This, of course, would increase salaries which would decrease the need for supplemented support through VA compensation.
It’s a lofty goal, as many injuries are pervasive and in some cases (Agent Orange and Burn Pits, for example) not yet fully diagnosed. But what injured person doesn’t wish for a sense of normalcy, a day without pain or some struggle related to their injury? Ask any severely injured individual and they will likely tell you they would give back any compensation to have their limb/eye/brain function back to normal. So it should be in everyone’s best interest to incentivize recovery over disability.
Where the Secretary is perhaps jumping the gun in his statements is in the initial priority on wellness programs. The implication is that activities and support programs to improve overall health could be the modernizing kickstart to empower Veteran recovery. However, personal experience for most Veterans does not support this assumption.
A full analysis of VA healthcare reveals many barriers to wellness before the Veteran is even admitted into the primary care system, much less enrolled in any self-improvement program. Compensation exams are often conducted independent of existing records and providers, frequently leading to missed or mis-reported symptoms and conditions leading to lengthy appeals. Complex care is conducted independent of case manager inclusion, requiring the Veteran to know their own condition so well as to request follow-up appointments or additional care. The online system is continually catching up to modern technology with appointment scheduling and medication refills, made more frustrating when calling no longer connects you to human interaction but instead sends you into a maze of automated messages and routed directories.
So yes, wellness is an important component, as is the empowerment of Veterans to adjust, recover, and reintegrate. Overall improvements to combined physical and psychological health provide reductions in depression diagnoses, suicide rates, and many long-term physical care needs. This also results in cost reductions over time, which is the sustainability observation Secretary Shulkin made.
But as much as these steps need to be taken, the priority right now must be elsewhere if we intend to realize these benefits. The steps we need to take first are not those of wellness; we need to first optimize the compensation process, automating records searches and integrating systems and platforms to better capture the impact of an injury. We need to implement complex care coordinators for patients with multiple issues or over a specified rating. We need to accelerate the evaluation and appeals process, and keep ratings updated with a system that ensures doctors with knowledge of the patient are contributing to the ongoing review and treatment of conditions. We need to fix the multitude of issues with VA Choice referrals and payments. Each of these steps directly affect the care, long-term health, and general wellness of every Veteran requesting and receiving services at VA more so than enrolling them in a class or activity. The very process of VA enrollment, compensation, and care is redundant, expensive, overburdened, and overall frustrating enough to take a physical and mental toll on Veterans.
The legislation on VA hiring, retention, and whistleblowing is a first step towards refocusing the efforts of the department on care and well-being for Veterans. But to empower them to take on continued wellness, to propel themselves forward and begin to heal, we need to next facilitate their access to care.
We simply cannot implement wellness programs, or even just ask someone to be well, before we fix the system in control of their well-being.