The Veterans Administration needs more doctors

The Veterans Administration problems worsen, as do the problems of the vets seeking care through the VA. Things were already bad a year ago, with revelations that veterans were waiting an excessive amount of time to get seen (read: months), sometimes being deliberately dropped from waiting lists to artificially “decrease” wait times. VA centers were also not making timely referrals to doctors outside of the VA system, their budget was inadequate, there were too few doctors at the VA, and so on.

The VA has made an effort to improve the situation.  In the past year many more patients have been seen (or referred to outside doctors, including specialists). However, seeing and/or referring these patients has come at a cost of about $3 billion.  The VA is now short of money for this program, and is looking at hiring freezes, layoffs, restrictions on some medications and other money-saving options.  It wants to ask Congress to allow it to transfer funds from other budget areas to this program, but doesn’t expect a favorable hearing. Of course, failure to act will negatively feed back into the system, making the problem worse.

When this story broke last year, I went to the VA’s primary website, along with VA medical center websites in Arizona, California, Minnesota, Alaska, Georgia, Michigan and some other states. I specifically looked for job postings for physicians.

Doctor via Shutterstock

Doctor via Shutterstock

EVERY website was advertising for physicians. Most needed internists and family practice physicians, but a number needed specialists: surgeons, ophthalmologists, OB/Gyns, pediatricians, pulmonary doctors, psychiatrists, cardiologists, etc. It’s not just remote VA hospitals and clinics that need specialists; many located in or near large cities need them, too. In some areas, the VA had completely given up the search for permanent physicians, and was instead advertising for locum tenens doctors. These doctors will sign a short-term contract to go to a site — for example, a clinic somewhere in Arizona — and work for a mutually agreed amount of time, usually between a month and a year. When  they leave, the post is open again — maybe for months or years — until another locum takes it.

Not all of these positions are at VA hospitals. Some are at free-standing VA clinics in small towns. One such small VA clinic — either in Arizona or New Mexico, as I recall — wanted a generalist physician. He would work 8-5 Monday through Friday, seeing patients, charting, reading reports, performing minor surgeries, etc. The clinic is about a 2 hour drive from the next-largest town, which has a small hospital. The physician will have to live in the town where the clinic is located, and the clinic staff is a single medical assistant. With no local hospital, that means those in town will come calling at all hours, regardless as to whether they are eligible for VA care. So the doctor will essentially be on call 24/7 for patients who need emergency care, such as women who go into labor (no OB around) and need to be attended to until the helicopter arrives. That is, if the weather allows it to fly. Even though it’s not in the contract to take care of patients after 5 PM, on weekends, or those who are not eligible for VA care, who is going to turn those patients away?

The pay scale and benefits for locum tenens doctors are significantly less than those found when practicing at a hospital or group. And there are other downsides, like limited continuing education, vacation has to be scheduled around when (or if) they can find a doctor to replace the vacationer. The doctor has to learn the VA’s policies, medical records system and other things that are specific to the VA, which is a much more worthwhile investment of time and energy for doctors who are likely to stay for more than a year. And, of course, if the doctor needs a doctor they’re out of luck.

Not all locum tenens arrangements are this bad. A few are worse, some are better. But the better ones seem to involve a lot more paperwork, and still put pressure on doctors to see a lot of patients in a limited amount of time. And there are still restrictions on the drugs that can be prescribed, the out-of-VA specialists that can be used, and so on.

It’s no wonder that these positions go unfilled, and have such high turnover rates.

This upcoming go around with Congress looks like it will be acrimonious and its outcome may do nothing to alleviate the squeeze on VA patients, or doctors.  You can read more on the story here.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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  • My husband is a Viet Nam era veteran with a non-service connected disability. He is seen at our local VA once a year by a nurse practitioner. He has NEVER been seen by a doctor there.

  • Spring Texan

    Absolutely! Thanks for the intelligent comment.

  • Bill_Perdue

    Democrat/Republicans always complain that Federal entitlements are full of fraud. In terms of Humana/SKGcare, aka Obama/Romenycare the fraud came early when Obama accepted bribes to drop the public option. “In his analysis accompanying the recently released Annual Report of the Medicare Board of Trustees, Richard Foster, Medicare’s chief actuary, noted that Medicare payment rates for doctors and hospitals serving seniors will be cut by 30% over the next three years. Under the policies of the Patient Protection and Affordable Care Act, by 2019 Medicare payment rates will be lower than under Medicaid. Mr. Foster notes that by the end of the 75-year projection period in the Annual Medicare Trustees Report, Medicare payment rates will be one-third of what will be paid by private insurance, and only half of what is paid by Medicaid.

    Altogether, ObamaCare cuts $818 billion from Medicare Part A (hospital insurance) from 2014-2023, the first 10 years of its full implementation, and $3.2 trillion over the first 20 years, 2014-2033. Adding in ObamaCare cuts for Medicare Part B (physicians fees and other services) brings the total cut to $1.05 trillion over the first 10 years and $4.95 trillion over the first 20 years.http://online.wsj.com/article/SB10001424052748703649004575437311393854940.html

    Humana/SKGcare, aka Obama/Romenycare was born in fraud and corruption by the Obama regime and a corrupt Congress.

    “To navigate the process of health reform, President Obama turned to his chief of staff, Rahm Emanuel, a consummate deal maker, who helped stock the West Wing with an all-star lineup of congressional insiders. …

    The administration’s hopes for reform rested with Sen. Max Baucus (D-Mont.), the powerful head of the Senate Finance Committee, who also happened to be one of the Senate’s top recipients of special interest money from the health care industry. The White House encouraged Baucus to quietly negotiate deals with the insurance lobby, drug companies and other special interest groups, despite promises to run a different kind of White House. But the deals were often controversial. FRONTLINE investigates how, near the start of the health care reform process, Baucus and the White House negotiated a secret $80 billion deal with Billy Tauzin, the former Louisiana congressman who had become the pharmaceutical industry’s top lobbyist.”

    http://www.pbs.org/wgbh/pages/frontline/obamasdeal/etc/synopsis.html

  • If you could ever get that through Congress. We barely got ACA through with Democratic majorities in both houses. Who knows when the Democrats will have the House again.

  • Periodically there will be a few doctors in every town who announce loudly that they won’t be taking any new medicare patients. And then a month later those same doctors take them anyway. This has been going on for decades. Some doctors operate under the delusion that they can stop accepting medicare as if there are enough patients with gold-plated health plans or rich people who can just pay out of pocket to keep their practice running. They learn that lesson quickly, however.

  • Right. Like dealing with the shameful backlog of veterans’ benefits claims. Hire some temps for six months to do the routine part of the job (most of it) and let the regular employees deal with any special cases that require more attention and get caught up. This is easy and not really that expensive and yet no fix. Some of these things ought to be quick and easy. No one disagrees about what needs to be done. There’s no partisan issue so what the fuck? Oh right, it’s not something billionaires care about so it doesn’t happen. It would serve Congress right if every fucking one of them got replaced.

  • Indigo

    Where is that? I’m not experiencing any problems. Although I’ve heard people make that claim, I don’t know of any cases of it happening. I suspect it’s a Fox myth.

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  • Mike_in_the_Tundra

    What are they gutting? Fraud? Waste? Subsidized health care to the 1%? Over payment to the Advantage programs? I have no problem with those.

    Nursing homes receive very little money from Medicare already. Most of their money comes from private pay or Medicaid. The feds may cut Medicaid, but most states pick up the difference (red states may not). I can also see why they would reduce payment to teaching hospitals. It’s almost like they are double dipping. If someone can afford to buy premium supplemental health insurance, they can also afford to pay a nice little surcharge.

    I really don’t want to see Medicare damaged. I know very little about Medicaid, but I’m certain I don’t want it to be damaged. There can be cuts made to both of them that won’t affect the recipients.

  • dave3137

    Our Congress these days simply seems to get “outraged” over things that don’t matter, and when media interest forces them to get “outraged” about things that DO matter, like the VA healthcare system, they fume and spout and then forget to do diddly. When the media get off their backs, they find other things to worry about, like the “Mosque at Ground Zero” or “Benghazi, Benghazi, Benghazi.” Fact is, they NEVER bother to factor in the cost of care in the cost of war. They are gung ho about “getting those bastards,” but NEVER consider the human costs (if they even bother considering the financial). As a Vietnam era vet, and a disabled vet, I am part of that system, and except for the initial years, when I got “if we did it for you (i.e., schedule an appointment in less than a year) we’d have to do it for everybody.” (And that is a verbatim quotation from a “Veterans Benefits Adviser” I called Jack Murtha, and suddenly they COULD do it for me.) However, once that was past, I’m pleased with my care, though I do seek out civilian doctors under my Medicare Advantage plan when I’m hesitant about the things I hear — like the Legionnaire’s Disease outbreak that was covered up at Pittsburgh, etc. AND the doctoring of computer records so supervisors could collect bonuses, etc., etc., etc. But between Congress’ “yellow ribbon car magnet” attitude, and the “corrupt” bureaucracy, it’s a mess. But then again, so is the entire US “non-system” for healthcare.

  • Bill_Perdue

    It’s a small fraction of the amounts that will be gouged out of Medicare/Medicaid.

    Why do you think gutting Medicare/Medicaid is good?

  • Mike_in_the_Tundra

    I have to ask in what county do you live? I’m in Hennepin County, Minnesota, and we don’t have a problem with Medicare. Minnesota calls our Medicaid Medical Assistance and there has been a cutback in the number of doctors, although it seems to still work out.

  • Mike_in_the_Tundra

    “The president’s budget would collect $66 billion over 10 years by charging higher premiums to higher-income Medicare beneficiaries, for coverage of doctors’ services and prescription drugs.”

    Why is this part bad?

  • Bill_Perdue

    Medicare and Medicaid are being gutted to provide more money for Humana/SKGcare, aka
    Obama/Romenycare.

    “WASHINGTON — In his new budget, President Obama proposed on Monday to squeeze $399 billion over the next 10 years out of Medicare, Medicaid and other programs run by the Department of Health and Human Services.

    Under the proposals, many Medicare beneficiaries would have to pay more for their care and coverage. The president would, for example, introduce a co-payment for new Medicare beneficiaries who receive home health care services, and he would collect $4 billion over 10 years by imposing a surcharge on premiums for new beneficiaries who buy generous private insurance to supplement Medicare.

    In addition, Mr. Obama’s budget would reduce scheduled Medicare payments to teaching hospitals, hundreds of small rural hospitals, nursing homes and health maintenance organizations that care for older Americans and people with disabilities.” http://www.nytimes.com/2015/02/03/us/politics/under-obama-budget-many-medicare-recipients-would-pay-more.html?emc=edit_th_20150203&nl=todaysheadlines&nlid=25790019

  • Doctors make more money in other areas. Pay them more and they might go into the VA. However that might require spending more money in the VA and Republicans will not allow that anytime soon.

  • docsterx

    Exactly. That wouldn’t fix everything, but it would be a good start.

  • docsterx

    I’ve done some rotations at VA hospitals. You’re right, some personnel are extremely motivated and caring and work with (and sometimes against) the system to get better results. But, like anywhere, there are the slugs who work slowly, make errors, aren’t professional and just don’t care. It seems as if the VA has a hard time replacing the latter group.

    I think a good deal of the problems stem from the government underbudgekting the VA and, when problems arise, the VA gets the blame, not those who are demanding miracles and paying pennies. There does seem to be an area of bureaucratic ineptitude in place at the VA where some administrators don’t have a solid background in healthcare and try to run things like a pure business. That adds to the problems. In addition there is understaffing in a lot of patient-care areas, some lower than average-salaries and other factors contributing to the problems that the VA has.

    For once, we need to be willing to spend as much on our vets as we promise to do. If we spent a fraction on the VA, and other services for veterans, as we do in a year of war, the problems would be much less. We often SAY that we’ll take care of vets, and we do, but the reality is how we take care of them is at much, much lower level of care than we promised them and ourselves. It’s a national shame.

  • “With no shared sacrifices being asked of civilians after Sept. 11″ {And Still None nor Demand There Should Be, Just Attacks on VA Personal, Conservative media hyped ‘scandals’, nothing done from previous hearings!!}

    Not the VA, the People Served Broken Promises!!
    The ‘Veterans Administration’ is the People Served Responsibility, that includes veterans, now civilians, of previous conflicts and military service!! Long list, decades and wars from, of ignored issues or outright denied issues even exist!!

    Through their elected representatives, in congress and the ideologies of the executive branches and their cabinets, decades of obstructed under funded budgets unfunded poser patriotic legislation’s used to attack VA personal in hearings, in states the legislatures and the chief executive the governors administrations, and especially those with obstructive conservative ideologies seeking to privatize for corporate profit, decades long wants!!

    Facts: Matthew Hoh {former Marine and foreign service officer in Afghanistan}: “We spend a trillion dollars a year on national security in this country.”
    “And when you add up to the Department of Defense, Department of State, CIA, Veterans Affairs, interest on debt, the number that strikes me the most about how much we’re committed financially to these wars and to our current policies is we have spent $250 billion already just on interest payments on the debt we’ve incurred for the Iraq and Afghan wars.” 26 September 2014

    Bob Herbert * Losing Our Way * : “And then the staggering costs of these wars, which are borne by the taxpayers. I mean, one of the things that was insane was that, as we’re at war in Iraq and Afghanistan, the Bush administration cut taxes. This has never been done in American history. The idea of cutting taxes while you’re going to war is just crazy. I mean, it’s madness.” Bill ‘Moyers and Company’: Restoring an America That Has Lost its Way 10 Oct. 2014

    ProPublica and The Seattle Times Nov. 9, 2012 – * Lost to History: Missing War Records Complicate Benefit Claims by Iraq, Afghanistan Veterans *
    “DeLara’s case is part of a much larger problem that has plagued the U.S. military since the 1990 Gulf War: a failure to create and maintain the types of field records that have documented American conflicts since the Revolutionary War.”

    Part Two: * A Son Lost in Iraq, but Where Is the Casualty Report? *

    * Army Says War Records Gap Is Real, Launches Recovery Effort *

    Add in the issues of finally recognizing in War Theater and more Veterans, by the Shinseki Veterans Administration and the Executive Administrations Cabinet, what the Country choose to ignore from our previous decades and wars of: The devastating effects on Test Vets and from PTS, Agent Orange, Homelessness, more recent the Desert Storm troops Gulf War Illnesses, Gulf War Exposures with the very recent affects from In-Theater Burn Pits and oh so so much more! Tens of Thousands of Veterans’ that have been long ignored and maligned by previous VA’s and the whole Country and through their representatives!

    * Push For VA Privatization, for Corporate Profit, Back on Table *
    Conservative Think, American Enterprise Institute, Tanks Own: “Sally Satel Still Selling Care for PTSD Veterans is Waste of Money”. Long Time, Vietnam, Veterans Nemesis and Denier
    Giving long time, Veterans nemesis Sally, from the Conservative Think Tank ‘American Enterprise Institute’, another big smile! Giving Conservatives their talking points and the citizens served whole heartedly following their lead as the decades long, wars from, obstruction to the peoples responsibility, the VA budgets, continues! She’s made herself quite infamous and wealthy over the decades with her writings and speeches doing what the country, especially conservatives, wanted in ignoring or out right denying the many issues of Veterans, especially from our, poser, patriotic wars!

    USN All Shore ’67-’71 GMG3 Vietnam In Country ’70-’71 – Independent**

  • What Veterans Get in Privatizing the Veterans Administration

    * Push For VA Privatization, for Corporate Profit, Back on Table *

    6
    May 2015 report – {Poser Patriot} Deanna Dutting with her website
    ‘Healing 4 Heroes’: >” “If you want to feel bad or do your own
    research, you can do just like the rest of us did, but we got over it
    real quick once we started making our money, you know what I mean?” said
    Dutting. ” “There’s no free lunch here,” said
    Thomas. “These individuals, their patriotism is directly tied to their
    paycheck. They’re not helping these soldiers.”
    May 6, 2015 – “They’re getting providers, doctors or whomever to write
    scripts, fill in scripts without even seeing the patient,” said Thomas.
    Dr.
    Bolger told us he’s sent prescription requests like ours by a service
    that pays him to review patient files from states where he’s licensed —
    New York, the state of our request, is not one of them. <

    "If
    military action is worth our troops’ blood, it should be worth our
    treasure, too — not just in the abstract, but in the form of a specific
    ante by every American." -Andrew Rosenthal 10 Feb. 2013

    * “With no shared sacrifices being asked of civilians after Sept. 11" *

    Chris
    Hayes : "If you can run a deficit to go to war, you can run a deficit
    to take care of the people who fought it" In response to Republican,
    long ago lost as the party of Lincoln and not just as to us Veterans,
    opposition to expanding Veterans' benefits on fiscal grounds

    USN All Shore '67-'71 GMG3 Vietnam In Country '70-'71 – Independent**

  • nicho

    Of course, single-payer universal health care would solve that problem — with the stroke of a pen.

  • nicho

    If the VA doctors really looked like the guy in the photo, I would enlist this afternoon.

  • bkmn

    While I am not a veteran I have seen the VA system from a couple of different sides, as a former medical device representative who covered a VA hospital and as my partner’s mother and best friend received care in their later years from the VA. The people that work there are good at what they do and they care deeply. Truly inspiring.

  • bkmn

    An overhaul of Medicare reimbursement rates could go a long way to helping with this problem. However the panel that sets the rates is controlled by interventional specialists that set high reimbursement rates for angioplasty/stents/surgery while underpaying generalists/internists/gynecologists for the bulk of their work.

  • 2karmanot

    This is becoming a potential national crises. In our county most doctors are not accepting Medicare or medicaid and the impact on low income seniors is devastating.

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