Tuesday, April 1, 2008

Good Intentions or Better Methods?

So when this GAO report on VA and DOD joint projects landed in my inbox (thanks BG!), I was expecting some serious inside baseball type stuff, the bureaucratic healthcare version of when to use a left handed pitcher who has a really good cut fastball but whose curve ball occasionally hangs over the plate. Now that I’ve managed to scare away everyone but some bemused Orioles fans and die hard healthcare geeks, let me say that this report did not live up to my expectations. It was surprisingly light on minutia, almost disappointingly so. But there were some interesting and broad points to be gleaned from it (there go the Oriole fans).

    VA Health Care: Additional Efforts to Better Assess Joint Ventures Needed. GAO-08-399, March 28
    Highlights - http://www.gao.gov/highlights/d08399high.pdf

Basically Congress has tasked the VA and the DOD with identifying and cooperating on joint projects that will reduce costs and improve healthcare for veterans and soldiers. Like most such mandates this is one sounds relatively benign and unobjectionable, and like most mandates, this tells us pretty much nothing about what it’s supposed to do or why it’s being done.

Obviously improving care for veterans and soldiers sounds good to me, but I’m skeptical that joint ventures between the DOD and the VA are the best way to improve care. At the macro-level I’ve got concerns about mixing the two cultures, and nothing illustrates those concerns better than the contretemps around the interactions and miscommunications between the Army and the VA at Ft. Drum back in February (link):

    The document summarizes a meeting at Fort Drum between VA workers and members of what the Army calls a "Tiger Team" — an ad-hoc group assigned to investigate, in this case, medical-disability benefits.

    According to the memo, one member of the Tiger Team told the VA not to counsel soldiers on their disability benefits because "there exists a conflict of interest."

Conflict of interest? That’s my Army, always looking out for us soldiers. And that’s the nature of the problem: the Army (and by extension the DOD) have way more pull than the VA. Not to say the people in the VA aren’t going to fight the good fight for veterans, but they’ve got less levers to pull and theirs are way smaller. So commingling the cultures has some drawbacks as the report itself details (p.24):

    VA officials stated that DOD’s readiness mission may be incompatible in certain situations with VA’s mission to provide quality and timely care to veterans. Similarly, VA officials noted that VA and its academic affiliates have different missions and, at times, competing priorities, which has raised concerns among veterans that they may not always receive appropriate access to equipment and services.

And as the report also states, it is possible to manage through these sorts of incompatibilities with careful planning. But then what’s the benefit? In terms of cost reduction, the report describes it this way (p.10):

    Joint ventures are intended to avoid costs by maximizing available resources by jointly using a medical facility. According to VA, joint ventures involve a multi-entity, collaborative and strategic arrangement of at least 5 years in duration and a level of magnitude and scale comparable to VA’s current major capital threshold ($10 million). Joint ventures are complex in that they require an integrated approach because two separate health care systems must develop multiple sharing agreements that allow them to operate as one system at one location. VA currently has eight joint ventures with DOD...

So we’ve got complex projects that have to net at least $10 million in savings; what kind of a track record do we have to date? It seems to be mixed and here’s the kicker: not particularly well understood. Although various VA locations say that they’re able to realize cost savings from collaboration with the DOD, they don’t have a lot of hard data to back these “hunches” up with (p. 26):

    VA and DOD officials told us that they do not use performance measures to assess the extent to which the joint ventures produce the identified benefits, such as improved care or lower costs.

Officials give a number of reasons for not routinely or comprehensively documenting cost savings from these joint ventures, including [emphasis added]:

    VA officials noted that they are not required to conduct assessments.

    • Officials at the VA-DOD sites said that differences in their computer systems and business processes can limit their ability to conduct such assessments.

    • The VA-DOD sites have competing priorities for the limited resources that would be required to conduct such assessments, according to officials from several sites.

    • …several VA and DOD officials said they intuitively knew they were saving money as a result of the joint venture, but they were unable to provide data to support this belief. Without comprehensive, supporting evidence, the extent to which the cited outcomes have been achieved at joint venture sites is largely unknown.

Now I don’t mean to pick on the good people doing the good work that these people are doing, and I think it’s important to pay attention to your hunches when doing analysis (which I do for a living), but you always want to gut-check your hunches with some facts. Unless you aspire to be Paul Wolfowitz or Douglas Feith. But how to put all this ambivalence into context? I mean why is anyone bothering with this? Here’s why I think they’re doing it:

    VA officials said that since all of the existing joint ventures with DOD have been congressionally directed, there is little incentive to document or measure the results of the joint ventures.

Never underestimate the negative impact of top down, hierarchical decrees. One doesn’t have to be particularly skilled at reading between the bureaucratic lines to get a handle on this one: they’re doing it cause they were told to do it. So obviously this raises a whole slew of questions about how this mandate came down from Congress and why it didn’t have some language built in about collecting data to verify results. But that’s a whole ‘nother post. My take away is this:

Since the VA needs to do cost savings to get veterans the care they need, it’s pretty obvious to me that the VA isn’t fully funded. I’m not saying they should be able to spend without oversight, but if they’re being asked to cost save without oversight, how much sense does that make? And how much of priority is this cost savings anyway? Looks like someone got to check off a box without knowing if anything worthwhile was accomplished. So while we have the very real risk of muddying the VA’s mission by forcing it to join with the DOD on various projects, we don’t have a sense of the real benefits in dollars and cents.

But everything about this isn’t negative. This venture has some potential real benefits apart from cost savings. One of the best outcomes (setting aside the issue of adequate care) is making the transition from soldier to veteran a seamless one. As the report states, “Some VA and DOD officials noted that joint ventures support the Presidential Task Force objective for VA and DOD to collaborate at all levels to ensure a seamless transition for eligible military personnel from active duty to veteran status.” This is the best news in the report from my perspective as a veteran. The military generally does a piss poor job preparing their people for life as veterans. And I do mean veterans, not civilians. We’re going to have a lot of people coming back from Iraq and Afghanistan with issues and needs that are specific to people trying to readjust after combat tours. But again, the way to figure out if any of these mandates and the joint ventures that support them are doing any good is to collect data, and that is exactly what isn’t going on. So the question uppermost in mind is why was this mandate sent down without any instructions for follow-up and verification that the joint ventures are actually helping our veterans and service people? I can’t say for sure, but the cynic in me sees a bunch of veterans issues under a rug that Congress is holding the corner of.