WASHINGTON, DC—Even though the overall 2012 budget request for VA includes $50.9 billion for medical care— a net increase of $240 million over the 2012 advance appropriations request of $50.6 billion in the 2011 budget—union representatives are worried that cost-cutting measures may be putting too much strain on VA’s already stretched-thin staff.
Much of the increase is the result of the inclusion of a $953 million contingency fund to cover a potential increased reliance on the VA health care system due to economic conditions. That nearly $1 billion fund is offset by a rescission of $713 million due to statutory pay raise freezes on federal employees in 2011 and 2012. VA officials are also estimating an additional $3.7 billion in third-party collections—an increase of almost $1 billion from the latest available actual collection figures from 2009.
That $50 billion breaks down to a little under $40 billion for medical services; $5.5 billion for medical support and compliance; $5.4 billion for medical facilities; and just more than $500 million for medical and prosthetics research—down from $581 million in FY 2010.
Streamlining at the Expense of Physicians
MaryAnn Hooker, MD, a neurologist with the Wilmington, DE VAMC, spoke for the American Federation of Government Employees (AFGE) at the Senate VA budget hearing, and testified that a number of clinical staff and resource realignments in the budget request could have adverse consequences.
AFGA represents more than 200,000 VA employees, including 120,000 who provide direct medical care.
The proposed budget assumes a yearly savings of $151 million in FY 2012 and 2013 based on conversion of selected physician to non-physician providers; conversion of selected RNs to licensed practical nurses (LPNs); and more appropriate alignment of required clinical skills with patient needs.
“Without knowing the specifics of VA’s proposed changes, I can only speak from experience,” Hooker said. “The substitution of other [personnel] for physicians may in some cases have very negative effects of the health care team—patient and provider alike.”
There is already a trend in VA to substitute less experienced healthcare workers for a patient’s primary care provider for the sake of expediency, she noted. “I am seeing patients who have not seen their primary care provider in over two years. They are already lost to the VA system, either through having to repeatedly call for appointments because there are no ‘real’ openings, or through the lack of adequate support staff to notify them of the need to make appointments.”
Hooker also said that VA has made a practice of replacing physicians with other personnel in order to meet the goal of 30-day access to providers. That practice will only become more egregious as VA moves towards a 14-day access goal, she noted, adding. “A realignment leading to fewer primary care providers will only exacerbate these problems.”
“This constant shuffling of patients and care providers leads to high levels of staff turnover, which is very costly,” the neurologist told the committee. “Nurses forced to work at the top of their scopes, such as in the emergency department or in the intensive care unit, frequently are asked to work outside their scope. This leads to more stress, more staff burnout, more turnovers, and more medical misadventures.”
These stresses could have a greater effect on patients utilizing VA services that are traditionally outside of primary care, such as home telehealth, which is not always well integrated with primary care, Hooker noted. “Nurses in this program work from templates and standardized order sets to manage the care of patients with complex problems, such as diabetes, hypertension, and PTSD, all without the direct input of the patient’s primary care provider.”
As for increases in spending for positions at the top level, Hooker said that it is the physicians on the front lines who pay the price. “I can tell you that all those increases in positions come out of our hides,” Hooker said. “If the new initiative is polytrauma, then staff goes into polytrauma. If the issue is women’s health, the staff comes out of polytrauma and goes to women’s health. It’s a constant shifting to meet what the latest performance measure is with no real addition to staff at the lower levels.”
Veterans service organizations, meanwhile, praised VA for what represents a 10% increase overall, but balked at the cut in research funding. The Independent Budget, a document compiled by a collection of the more prominent VSOs, takes aim at this decrease, asking why there is a cut here when other areas see increases, albeit modest ones.
“As the lesson learned from Agent Orange exposure in Vietnam should have taught us, research delayed into developing residuals of war can have devastating economic impact down the road,” the document states. “Money invested now in this research has the potential to not only save this nation money in the long run.”
New Positions at the Top
With the proposed budget including significant staff increases at the top, many in Congress have the VA Central Office in their sights. The proposed budget includes a two-year staffing increase of 34% for the Office of Public and Intergovernmental Affairs; a two-year increase of 44% for the Office of Congressional and Legislative Affairs; and a 7% increase for the Office of the Secretary.
“It raises all kinds of red flags,” declared Rep. Jeff Miller, R-Fla., the newly-elected chair of the House Veterans Affairs Committee.
Sen. Richard Burr of North Carolina., the ranking Republican on the Senate Veterans Affairs Committee, echoed those sentiments at a recent budget hearing. “If this budget were to be approved, both the funding levels and the number of staff will have grown at a very high rate since 2010,” Burr said. “The general administration budget has increased 13% since 2010 and the staff—or FTE’s—request for 2012 reflects a 20% increase.”
According to Burr, the budget represents an increase of 562 general administration employees who are at a GS-12 level or higher. “There’s an inherent commitment [on the part of VA] in hiring them,” Burr said. “There’s a benefits package that extends far past their employment.”
Concern over spending on VA upper management was not limited to Republicans. Patty Murray, D-WA the Senate VA Committee chair, grilled VA Secretary Eric Shinseki over the number of bonuses paid to VA administrators last year. She focused on an $11,000 bonus paid this year to Guy Richardson, director of the Dayton VAMC, where patients at a dental clinic were found to have been exposed to Hepatitis B and C due to lack of basic infection control practices. (Read a related article on page 24 of this issue.)
“Will you be seriously reducing the number of bonuses paid?” Murray asked Shinseki, who responded that he would After examining the role of bonuses over the last two years, Shinseki said he did not find as close a connection between performance and bonuses as his predecessors had.
Concerning Richardson, Shinseki said, “I can’t justify the performance of what happened at Dayton. I think there is a failure of leadership. I can’t describe why a bonus was sensible.”
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