The VA and What Veterans Owe Each Other
The VA is not perfect and needs to improve, but veterans have a role to play too. Don't shortchange your brothers and sisters when seeking VA medical care.
Many years ago I saw a faint black marker scrawl above a roll of toilet paper in a porta-john and the memory of that has amused me ever since. It was, like the best combat graffiti, brutally appropriate and thoroughly ironic:
Brutally appropriate because earlier in the evening my Humvee had been blown up by an improvised explosive device outside of Fallujah and I was now defecating blood. Thoroughly ironic because after being medevac’d back to base I pleaded with the captain to let me go on our next patrol, telling him I was fine. I even believed it.
My symptoms continued after redeploying home, and later stateside testing was inconclusive. I stubbornly avoided medical assistance until my wife insisted that the Department of Veterans Affairs (VA) take a look at my ongoing problem. After a colonoscopy, the doctors told me I was fine, but something I overheard from a fellow patient was not.
The doctor asked the patient – also there for a colonoscopy – if he had taken his prescription: two gallons of a nauseating elixir that causes a thoroughly violent evacuation of the bowels and intestine. Merely one gallon of the stuff kept me on the toilet the entire night. My fellow veteran patient, 40-something, rather cavalierly told his doctor and nurse that he had not bothered to finish even half of the first gallon.
Before receiving my colonoscopy at the VA hospital, I had to first schedule an hour-long pre-surgery class dedicated to explaining, with pictures, the necessity of drinking all the prescribed solution. Failure to strictly adhere to preparations would render the procedure worthless because polyps or blood cannot be seen through the unemptied intestine.
During the class, the nurse had told tales of veteran patients showing up the day of their colonoscopy eating cheeseburgers and drinking Kool-Aid (the red dye inhibits proper diagnosis). Another nurse recalled a recent week with 40 scheduled colonoscopies, each requiring a surgical room, a doctor, and a lab technician. Four patients did not follow cleansing instructions and a further 10 veterans had either cancelled on short notice or did not bother to cancel at all, robbing other veterans of an opportunity to receive needed care.
And it made me wonder: How many of those who have served are needlessly delayed medical treatment because of the apathy of other veterans?
VA has a no-show appointment rate of 13 percent, double the typical average of private medical practices in the United States. From July 2014 through June 2015 (the latest month for which data is available) that means that veterans no-showed more than 8 million appointments. Yet in the wake of last year’s veteran patient scheduling scandal, front-line staff members reported that a “lack of provider slots” was the single highest scored barrier to providing veterans timely access to care.
Perceptions of veterans have been understandably positive in the post 9/11 era, but public empathy is no excuse for veteran apathy. Recent scandals at the VA, highlighting many areas where the VA can improve, likewise provide no excuse of this apathy. The responsibility the VA has to those that have borne the battle does not supersede the responsibility that veterans owe each other.
Veteran patient apathy is partially an artifact of how military and veterans’ health care are structured and transitioned. In private health care, the patient is the customer to be treated and billed. In the military, the primary customer is the patient’s command and the cost of treatment is viewed as a function of military readiness. Understanding this, the military chain of command and the Uniformed Code of Military Justice enforce compliance with, and obedience to, medical orders.
When the soldier becomes a veteran, these distinctions change. The patient becomes the primary customer. The chain of command ceases to exist. In a heavily subsidized health care regime, this newfound freedom can exacerbate blasé attitudes about the importance of following necessary protocols. By not fully taking his prescribed cleansing solution, the veteran patient that I overheard wasted a colonoscopy appointment for himself and others. No bother, as VA doctors will likely schedule another one for him. If he should unfortunately be diagnosed with preventable colon cancer, the VA will even enthusiastically treat and care for him. But I would forgive his caregivers for wondering why they strive to better serve veterans that in many cases will not better serve themselves.
The VA has nine million veterans enrolled in its health care system. The percentage of veterans receiving disability compensation has doubled since 2001, and the average degree of those disabilities has risen by nearly 50 percent. Tellingly, three-fifths of all Iraq and Afghanistan veterans have used VA health care since 2001.
Despite this unprecedented utilization, the VA regularly bests all American health care systems in terms of average patient satisfaction. Americans neither know nor believe this. Still, whether it is the annual VA Survey of Enrollees or the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the VA regularly wins out over the competition. It does this despite treating an increasing number of veterans with combat injuries requiring specialized care. Novelty and necessity have demanded innovation: VA researchers and doctors in recent years have revolutionized prosthetics and created the nicotine patch for smoking cessation. VA personnel before them developed the first pacemaker and conducted the first liver transplant. There is good in the VA and its employees despite the refusal of many to acknowledge it.
These triumphs, however, should not overshadow areas where the VA can improve.
Sixty percent of the VA’s medical facilities are more than 50 years old, and over 1,000 were built before World War II – many to treat veterans that have long since moved elsewhere. Additional medical facilities for growing populations such as female veterans are needed in an era where capital construction costs have exploded.
The VA has more than 320,000 employees, more than a third of them veterans with honorable service, but like most other federal agencies, lacks the true freedom to quickly hire personnel and match existing talent with evolving requirements in a fluid environment. From my experience at the Washington VA Medical Center, countless VA employees are excellent, many are great, some are good, and a few are not. All should strive to test the limits that the very best of their abilities allow, and many do.
There are 10,000 senior and mid-level managers at the VA, many of whom were hired based on their superior performance in previous non-management roles. This is particularly common in military-related health professions where leaders are often promoted on the basis of clinical excellence as opposed to management potential and experience. Many VA managers can overcome this leadership challenge through training that identifies, teaches, and replicates the best practices of VA’s highest performing managers.
The VA is building more facilities and increasing its workforce to meet this unprecedented utilization. VA needs to better train its managers, and should. VA needs to be enabled to better use its talent, and can. VA leadership knows these challenges and is implementing the largest transformation in the organization’s history to address these challenges with the goal of improving the lives of the veterans it serves.
But all the resources in the world will make little difference if we refuse to acknowledge that veterans have a role to play, too. Is that obstinate 40-something I overheard one of VA’s highly satisfied patients? Maybe. Does this matter? Probably not. A highly satisfied patient can be actively disengaged in his health care decisions and responsibilities, and this meaningful distinction matters far beyond his personal satisfaction. Structural reforms alone can only accomplish so much.
Often in the service did I witness acts of self-inflicted personal neglect, many of them my own. Seldom though did I or my fellow Marines fail to seriously reflect upon how our individual actions may harm others. No better friend, no worse enemy.
I asked the captain to go back out on that next patrol because I did not want to shortchange my brothers. They needed me and I them.
That responsibility does not end when you take off the uniform.
Dave Goldich served two tours in Iraq as a Marine rifleman. He is a client development senior consultant at Gallup.
Justin 
Dave Goldich 
MH 
Rick 
Sgt. Harry 
M 
Ryan Evans 
Janet v. Graham 
ER nurse 
Tony Pellegrini 
Rick 
David,
I agree with nearly all the points you’ve presented here, but felt it worthwhile to point out that veterans going through the claim process do not get to pick their appointments. I would think this naturally lends to the higher rate of missed appointments overall. Additionally, as a former HM(FMF), I would dare to guess the VA’s patient satisfaction rate is likely a symptom of a Marine/Soldier’s experience with active duty medical providers (i.e. – throw Motrin at the problem).
That said, I also think much of the criticism the VA receives is warranted. In my own experience, dealing with VA representatives can be exceptionally difficult–largely due to the frustrations presented when attempting to start a civilian career and balance the VA claim process simultaneously. Reccomending veterans do a better job of looking out for each other is great advice. But let’s not forget that looking out for each other also includes taking notice of the real-life issues that the transition to the civilian world presents, and pushing for the VA to better accommodate veterans struggling to balance the load.
Thanks,
Justin
Hi Justin,
Thanks for your excellent points, and you are correct that appointments for veterans awaiting a disability compensation determination/rating are less flexible. Many of these though are split amongst active duty TRICARE facilities (I had several at the Camp Lejeune Naval Hospital while on active duty before I separated), VA facilities/doctors, and private practice doctors authorized to evaluate claims (I had several of these as well). These types of appointments very well could be affecting the no show rate, but given an annual VA load of nearly 60 million appointments, I think the effect is probably negligible. Worth investigating though.
I have heard the Motrin line many times before, too! When looking at satisfaction rates for patient with multiple types of health insurance, veterans, on average, STILL rate VA higher than private or public alternatives. If VA has the highest self-reported patient satisfaction scores amongst any health care provider, then I argue that “satisfaction” is not a good metric for improving outcomes and service. Patient or customer engagement is much more actionable, hence the difference I tried to show in the article. And I could not agree with you more that the military to veteran transition process is collaborative requiring effort and improvement from the VA, too.
Right. The VA is all about how irresponsible the patients are.
Funny how easy it is to make soldiers feel that way–because we’re all used to be humiliated for refusing to assume every responsibility another soldier of higher rank bestows on us.
…so of course, the VA does everything to argue their abdications in that direction.
If Gacy, Hasan, or the Aurora Killer were to die while begging the prison hospital for help, everyone involved would be fired, sued, and criminally prosecuted. HUNDREDS OF THOUSANDS of disabled veterans die the same way, and instead, the VA is given immunity, their own police force, and it ACTUALLY takes an act of congress just to fire someone.
…and its all because of how irresponsible the dead patients are?
Everyone who had a hand in publishing this article should be ASHAMED!–but that’s the current state of our VA, isn’t it?
NOBODY IS EVERY ASHAMED OF ANYTHING.
Did you read the right article? He doesn’t even come close to saying “…its all because of how irresponsible the dead patients are”. He simply states that patients (in this case veterans) have a role to play in their own care. That’s not even controversial.
This article is there for one reason only–to shift the focus from the fact that unlike every other hospital in the US, the VA has nothing to fear in offing their patients. Instead of being held accountable, they are given immunity to local authorities, jurisdiction over investigating their own crimes, and their own police force. It ACTUALLY takes an act of congress just to get someone fired, and nobody EVER gets prosecuted.
What would Western Medicine be like if ALL hospitals did the same? Clearly the best solution to negligent homicide is to give people their own cops, right?
…and clearly, the responsible approach for a journalist is to shift the focus back to the patients.
Hi MH,
Thanks for your comments. I start from the position that VA should improve the level of care it provides veterans, and is capable of improving the level of care it provides veterans. There are many things VA can do on its end and I mentioned a few of these in the article. But a larger point I wanted to make is that something as simple as showing up to an appointment matters a great deal to many more people besides the scheduled veteran. AND that a highly satisfied patient can be disengaged from his or her health care decisions, and this disengagement can have a ripple effect on the whole system in terms of level of care.
One of the points that I had in a draft version touched on the Civil Service Reform Act of 1978, which is the law that largely established the “immunity” that you mention for VA employees, only it applies to almost all Federal employees under the auspices of the Office of Personnel Management. That law, created in response to perceived failures of Watergate and Vietnam, has probably outlived its usefulness in many areas and should be updated, but it’s not a VA-specific issue. And, having worked with many hospital systems and corporations with similar employee sizes, I can assure you that having private security or police is quite common.
VA certainly needs to improve in many areas, and in many cases can measure more actionable data to improve outcomes and the patient/customer experience. But veterans themselves routinely give VA the highest satisfaction marks of any health system in the country despite the problems that you passionately decry. To me that means that measuring veteran “satisfaction” is the wrong metric to use if we want to improve results.
I have been 100% service-connected for nearly 3 decades and have been to countless VA Hospitals all over the country. I have never been asked to rate my care, and usually can’t get ANYONE to even listen to my complaints.
Perhaps you are referring to their stupid “compliment cards,” they have in the hallways–barefaced and blatant proof they are ONLY open to comments IN THEIR FAVOR.
The VA only gets “the highest satisfaction marks of any health system in the country” when they are the ones counting and evaluating them.
[This comment was edited by the moderators to remove several insults and personal attacks. Please don’t be a jerk in the comments section]
I don’t think most people realize this fact.
I’m a Corrections Officer, and I can tell you that you are right–this is an absolute fact.
Prisoners aren’t always given the best medical care–but if they were to die because their requests were ignored, everyone involved would lose their job, and take a chance on being charged with murder.
Its just stunning to think about, really. The Aurora Killer’s medical rights actually ARE protected better than our disabled veterans.
Interesting right between an article leaving soldiers to blame for how badly the VA is treating us, and the place where we are supposed to comment on the article, are several pictures of soldiers’ graves.
Its almost like suggesting we’re not supposed to make any criticisms of what we just read–after all, we’re looking at soldiers funerals while we write. What kind of irresponsible person would criticize someone in the middle of a funeral?
Its not a funeral–although the kind of people who would play a mindgame stunt on veterans are exactly why there are so many.
How about showing the civilian funerals of 238,000 disabled veterans who died begging the VA for help, but never even got an answer?
We’re sure not going to see that in an article about “responsibility” are we?
M: Thanks for commenting. The related articles at the bottom are automatically generated. The article on Arlington’s Section 60 was not placed there as a subliminal message to keep you from criticizing this article.
Wonderful article on the veteran’s responsibilities TO the system. I validate the article from my own experiences using the VA healthcare system.
Thank you for your comment Janet!
I appreciate the article. ALL people need to take an active role in their healthcare. We can’t blame a system when we refuse to comply. That is for veterans and public healthcare. The VA has done a lot of great things for my family. They have gotten appointments faster then in private sector for primary care and speciality. There are bad situations, they are bad people and there are bad patients. If you want good healthcare by an advocate for yourself and do what you are told to do.
David,
Thank you for writing this article and providing some input about the VA and all VET’s responsibilities. I have recently retired after 26 years of faithful service to the Country. I am proud to be a retired member of the Armed Forces. This summer, I have submitted my medical records to the VA with the help of an AMVETS Rep. and through this process the AMVETS Rep., and the VA personnel I came in contact with, through scheduling, planning my appointments, seeing the VA employees, and the Doctors at the VA center were very helpful, considerate, and treated me very fair. Don’t get me wrong, it isn’t easy to get all of the records in place, and to make contact with someone (a VSO) to help you through the process. I had to do a lot of personal searching in order to find what I was looking for. I have submitted all of my medical records, and was seen by Doctors at the VA for many injuries I had while serving on Active Duty. I am awaiting a decision from the VA as to my level of disability that I will receive. If there are vets out there that feel they have been unfairly treated, then they need to stand up for themselves! Contact a (VSO) Veteran Service Officer at the many places throughout the country, and start the process of getting your claims reviewed. Once the claim is filed, then and only then can you have an opinion on how the VA personnel are doing there jobs. As was said on other comments, many of the people that work at VA’s are vets just like you! They have been there too! perhaps a walk through a VA Center would benefit them to remember what others are dealing with on a daily basis. Yes, Vets are entitled to compensation. But you have to ask for it. The VA doesn’t have the manpower to contact every veteran that was injured while on active duty. Step up and help yourself fellow soldiers, sailors, and airmen. God Bless America, and to all that have served this great country.
Thanks for chiming with your story, Tony! I’m thrilled to have you as a War on the Rocks reader.
I recently retired and returned to states after living overseas for 14 years. One of the most difficult aspects of American life to adjust to is the ‘individualism’ of our citizens. I read this article and felt it related very closely to my opinions about the lack of selflessness in our citizens. I like to say we’re more concerned with our rights, than what is right. What do I deserve, vs. what is good for our community. And striking a balance may not be an easy thing to achieve, but it’ll never be achieved if it isn’t a consideration. This goes along with the author’s position – are we doing what’s right for us and for the VA. Many people are stuck on how poor the VA may be, but have they done all they could to aid the VA in functioning properly? I suspect many could reply to my post by saying how they’ve done everything by the book and I’d say that this doesn’t apply to them then. Are you contributing to the problem, or working to be a part of the solution. Do you walk by the garbage and complain about filth, or do you pick it up and help with the clean up.