Sentences to ponder

by on June 16, 2014 at 6:29 am in Current Affairs, Medicine, Political Science | Permalink

Staff members at dozens of Department of Veterans Affairs hospitals across the country have objected for years to falsified patient appointment schedules and other improper practices, only to be rebuffed, disciplined or even fired after speaking up, according to interviews with current and former staff members and internal documents.

An intrinsic problem with government bureaucracy, or just the result of having the wrong people in charge?  I say the former.  The story is here.

david June 16, 2014 at 6:42 am

An intrinsic problem with the design of bureaucracy, surely – a problem which also regularly impacts corporate for-profit and nonprofit bureaucratic structures?

It does seem a bit odd that there are complaints that it is both too difficult and too easy to fire DVA employees.

andrew' June 16, 2014 at 6:50 am

Motivation. I noticed a while back that nearly if not all espionage cases of late are against whistleblowers.

handle June 16, 2014 at 7:17 am

Total nonsense. Everyone in prison claims they’re innocent. Everyone who intentionally discloses classified information without authorization claims they’re a whistleblower. Only a fool believes either without strong evidence.

Rahul June 16, 2014 at 7:33 am

In their circumstance it’d be somewhat hard to disclose classified information with authorization.

Imagine asking your CO for permission to declassify a potentially illegal torture manual?

dkfj June 16, 2014 at 11:19 am

> Everyone who intentionally discloses classified information without authorization claims they’re a whistleblower.

Not everyone. Some never need to make such claims, because they never face any repercussions. A Deputy Secretary of State, Special Assistant to the Chairman of the Joint Chiefs of Staff, or White House Deputy Chief of Staff can do an 8 hour interview with Bob Woodword, give away all of the family jewels and face zero repercussions.

dbg June 16, 2014 at 1:32 pm

you’re not very well informed. Chelsea Manning is a whistleblower serving a 35 year prison sentence for disclosing classified documents to wikileaks without authorization. She plead guilty.

gab June 16, 2014 at 2:47 pm

Isn’t Chelsea Manning a “he?”

al June 17, 2014 at 11:58 am

No, bigot.

Andrew' June 16, 2014 at 4:06 pm

handle June 16, 2014 at 7:17 am
Total nonsense

No, handle, I’m not making a speculation.

Andrew' June 16, 2014 at 4:07 pm

I’m feeling a renewal of my old policy coming on.

Ted Craig June 16, 2014 at 7:24 am

Yes, the VA scandal and the GM ignition switch recall show that bigger is rarely better. But those at different ends of the political spectrum view those not as the same, but as examples of how the other side is bad.

dearieme June 16, 2014 at 7:49 am

The VA stories are reminiscent of many NHS stories.

Of course, if you have a dispersed system rather than a centralised one, it’s easier for the scale of a problem to avoid detection.

8 June 16, 2014 at 8:30 am

More and more its the same group of people who defend the VA and GM.

F. Lynx Pardinus June 16, 2014 at 8:45 am

I think you confuse “defend” with “understand the incentives in order to propose reforms, but don’t want to burn the whole VA to the ground.”

Z June 16, 2014 at 10:32 am

The modern Left is reactionary. There’s no reason for them to defend this nonsense on ideological grounds. But, they see the face of the critics, recoil in horror and begin stacking sandbags around the nearest VA hospital.

gregorsam June 16, 2014 at 2:52 pm

“they see the face of the critics, recoil in horror ”

Just like all the racists became ardent proponents of a color blind society (in order to oppose any type of redress) after the passage of the Civil Rights Laws, the critics of the VA just want reform of the bureaucracy.

Z June 16, 2014 at 3:17 pm

Just as all liberals gave up on fascism once the picture from Auschwitz were made public….

If you want to call me names, you fascist little prick, just do it like a man.

ThomasH June 16, 2014 at 7:07 am

I’d place the blame more on politicians, mainly in Congress, not wanting to hear that veterans were not being attended to as well as they’d like. If it is just “bureaucratic structure” then we’d have scandals about FDA falsifying the numbers of how may drugs were approved or the Park service about how many visitors, etc.

8 June 16, 2014 at 8:34 am

The IRS targeted political enemies, the EPA targets political enemies, and Justice Department is involved in major scandals, the Pentagon always has a scandal or two floating around. Congress is to blame for creating these beasts and not reigning them in, but the bureaucracy is also a problem.

ThomasH June 16, 2014 at 11:42 am

I know what the writer means by the reference to the IRS, although I don’t necessarily agree. I have not heard any allegations of politicization in EPA, DOJ or DOD administrative actions.

Z June 16, 2014 at 10:30 am

I’m betting that if stretch face was still running Congress, you would have a different “snowball” to blame.

foosion June 16, 2014 at 7:18 am

The care for veterans is some of the best in the US. The problem is getting the care, due to a shortage of doctors, etc.

The fix for this, as well as many of the problems with the US healthcare system, is to increase supply (i.e., cut back on limits to competition), whether through training more doctors, encouraging non-US doctors to immigrate, relaxing licensing so that nurses, etc., can do more or the like. This would, of course, lower the pay of doctors, and we can’t have policies that hurt the incomes of some of the highest paid, can we?

Ted Craig June 16, 2014 at 7:34 am

Increasing the number of physicians probably won’t solve the problem. The number of licensed physicians is actually growing. Doctors don’t want to work for the VA, just like they don’t want to work in rural areas.

fwiw June 16, 2014 at 9:11 am

My dad is a doctor who was offered extremely generous compensation to go work for the VA.

He quit after a month. The bureaucracy was too much to deal with.

Cliff June 16, 2014 at 11:12 am

Wow! It’s ACTUALLY GROWING!! Amazing. There can’t be any problem at all with supply then. I guess it would be impossible to get those $400,000 starting salaries down no matter how much competition we allow.

ThomasH June 16, 2014 at 11:46 am

There is a very simple solution for imbalances between where people “want to” work and where there is work to be done. It’ just like teachers who don’t like to teach poor students in unsafe schools. Pay them a differential.

Ricardo June 16, 2014 at 1:07 pm

Check out http://www.usajobs.gov to see VA physician compensation rates. They are not very high, relative to private practice.

Ted Craig June 16, 2014 at 1:51 pm

Yes, the bureaucracy is greater, the pay is less and the patients are worse. From the NIH: “Large differences in sociodemographic status, health status, and subsequent resource use exist between the VA and the general patient population.” Since there’s nothing you can do about the third factor, you’d have to increase the pay a lot to compensate. And even then there is no guarantee it will attract more doctors. ThomasH uses the example of inner city schools, but the evidence from there doesn’t support the “Pay them and they will come” strategy (http://educationnext.org/the-revolving-door/). You could flood the market, as Cliff and foosion suggest, but then you run the risk of complaints about quality rather than wait time.

Jan June 16, 2014 at 9:50 pm

Yes, and the per patient cost in the VA is well below the private sector, despite the worse health status of the patient panel. The reason is simply that not enough money flows into the system. The VA has in some ways been the victim of its own success. Congress refused to adequately fund it when more people came into the system, because they had gotten so used to getting a high-quality, cheap product.

BenK June 16, 2014 at 7:21 am

Its an interesting question of what motivates this kind of corruption – where there is loyalty to the organization over and against the mission of that same organization.

8 June 16, 2014 at 8:35 am

The mission of the organization is to expand its power and funding.

Yancey Ward June 16, 2014 at 9:21 am

And, it is apparently working. Congress is set to double the budget.

andrew' June 16, 2014 at 4:46 pm

Maybe bureaucracy is half as efficient so a doubling is appropriate /[close Cowen]

Jan June 16, 2014 at 9:54 pm

Expand its power? What the hell are you talking about? The VA health system has a responsibility to deal with the health care for a certain segment of veterans. How exactly shall a single payer health system like that expand its power?

Bill June 16, 2014 at 7:37 am

They should have talked to an insurance company about how to deny care.

TMC June 16, 2014 at 9:53 am

I work for one, and we couldn’t get away with half the sh*t the VA, Medicare or Medicaid does if we tried. You would not believe the things we go through to help people through the process. Our customer service people win awards for figuring out how to get people treatment.

Bill June 16, 2014 at 11:57 am

really

ZZZ June 16, 2014 at 2:21 pm

I work with a physicians office and they agree that the VA is the worst to work with, hard to get records from, hard to refer to, just a general pain in the ass.

Jan June 16, 2014 at 9:55 pm

What do you mean you couldn’t get away with it? You’d lose customers?

Chris S June 16, 2014 at 7:41 am

My pet theory based on limited experience and evidence is the combination of being ill-informed and intractable at the policy implementation levels – the department heads and their staff – plus a willful disregard, perhaps as a survival mechanism, of the next few levels.

Shinseki sees and issue with VA wait times. He decrees that no wait times will be longer than 30 days. The lower level managers know this is impossible, so come up with schemes to make it appear that way. It starts as a temporary expediency, but real-life pressures – more people want treatment than there are doctors – make it expand. Once the lower-level managers start down that road, there is no turning back. What a tangled web and all that.

Bill Harshaw June 16, 2014 at 7:52 am

I’d blame Congress–where was their oversight, why didn’t they follow up on GAO reports, why didn’t they fund a good system. And I’d blame the media–more interested in big scandals than whether the bureaucracy is doing its job. And I’d blame the people, they’re the ones who elect Congress and read the media.

dkfj June 16, 2014 at 11:22 am

Congress is rightly terrified of pissing off the very active veterans’ lobby. There’s no upside to going against their every whim, and those groups don’t really want dramatic reform.

Ed June 16, 2014 at 8:20 am

Maybe having the wrong people in charge IS the instrinsic problem with the design of bureaucracy?

Anyway, I think Chris S gets what was happening in this particular instance.

Turpentine June 16, 2014 at 8:43 am

“An intrinsic problem with government bureaucracy…”

An intrinsic problem with any bureaucracy, whether it is public or corporate. I’ve worked in a large private company and this whole VA story sounds like it could have happened there, without any doubt.

enoriverbend June 16, 2014 at 11:04 am

@Turpentine
“An intrinsic problem with any bureaucracy”

I understand your point and halfway agree. But you should admit that the incentive structure is considerably different. The first meaningful response from Congress for the VA problems is to hand them a bunch more money. Now, the GM problem with switches, for example, may reflect similar problems with large bureaucracies, but I didn’t see the whole host of GM customers rising up to volunteer to pay an additional $5K for each GM car they bought.

The typical reward for failing government bureaucracies is more money. This may sometimes happen with private enterprise but it is not the rule.

rayward June 16, 2014 at 8:49 am

The “government” did it! That’s always the explanation of those who oppose public benefits, whether it’s the VA or social security. As for the crisis at the VA, it’s a combination of three factors: the Gulf wars and thousands of vets injured in those wars, the aging of the Vietnam era vets, and inadequate funding. Of course, inadequate funding is mostly a political problem. As for vets, I suggest that the large number of Vietnam era vets entering the VA system was unexpected, as Vietnam era vets, who have mostly been in the private health care system with jobs that come with group insurance, have “retired” in large numbers but are not yet eligible for Medicare. I put “retired” in quotes because many aren’t choosing that status voluntarily. Of course, we could be in for another ten year war, but most likely the current crisis won’t last as the Vietnam era vets qualify for Medicare. What can be done? The simple solution would be to lower the age of eligibility for Medicare, not just for vets but everyone. The nearly old (disclosure: that includes me) face loss of jobs with group insurance, premiums for health insurance that are three times what are charged younger insureds (it’s permitted under Obamacare), and a higher risk of illness. Allowing the nearly old to qualify for Medicare would solve the VA problem and the problem faced by the nearly old.

Jeff June 16, 2014 at 12:47 pm

If there are a bunch of rabid libertarians out there who oppose wounded or sick veterans getting medical care at public expense, I haven’t met any of them. The question is simply what is the most efficient way to provide said care. Is pumping more money into the VA system the answer? Based on your answer about how you’d like to see veterans shift over to the Medicare system, it sounds like you actually agree with us rabid libertarians to some extent.

The Other Jim June 16, 2014 at 8:58 am

The guy who ran the VA, who was either entirely complicit in this lethal fraud or the most incompetent dope in human history, was a member of the President’s Cabinet. He sat across the table from Obama on countless occasions to report on the VA. Obama was either complicit in this lethal fraud or entirely disinterested in veterans to the point of shrugging off their deaths (tough call on that one).

But sure, blame Congress. Or generic “bureaucracy.” Makes perfect sense. Whatever makes you sleep better, guys.

MR Troll Alert Services June 16, 2014 at 9:15 am

Move along, folks; nothing to see here.

Willitts June 16, 2014 at 11:54 am

Yes, Shinseki was an ineffective leader, but there is a lot of sober, well-informed opinions that the VA was broken for decades and it is too large a job for one boss. In addition to medical care, the VA administers disability compensation, home loans, employment programs, GI bill payments, burial services, etc.

Are there other government agencies with such a broad scope of duties?

Frankly, I think we promise veterans too much. Anyone who served for a few years, not even in combat and without service-connected conditions, can qualify for medical care. IMO, they need to be cut loose, and that group includes me.

mike June 16, 2014 at 9:20 am

Why didn’t VA use backlog data as justification for increased budgets? That’s what competent bureaucrats would have done. So I’m voting for incompetent bureaucrats.

Willitts June 16, 2014 at 11:48 am

Without even checking, I’m quite sure the VA requested a larger budget and more resources. This is a large government, and politicians hear clamoring for funds daily.

Medical care is expensive. Medical professionals are rationed. Administrative staff are unionized. What could possibly go wrong?

JWatts June 16, 2014 at 11:59 am

I agree with Willitts on this one. The bureaucrats probably were incompetent. But I’m confident they routinely asked for much more money.

prior_approval June 16, 2014 at 9:26 am

So, I guess this belongs in the government bureaucracy category, and not the military spending in response to threats as growth engine post –

‘Despite years of tinkering and vows to fix technical shortcomings, the system’s performance has gotten worse, not better, since testing began in 1999. Of the eight tests held since GMD became operational in 2004, five have been failures. The last successful intercept was on Dec. 5, 2008. Another test is planned at Vandenberg, on the Santa Barbara County coast, later this month.

The GMD system was rushed into the field after President George W. Bush, in 2002, ordered a crash effort to deploy “an initial set of missile defense capabilities.” The hurried deployment has compromised its effectiveness in myriad ways.

“The system is not reliable,” said a recently retired senior military official who served under Presidents Obama and Bush. “We took a system that was still in development — it was a prototype — and it was declared to be ‘operational’ for political reasons.’ http://www.latimes.com/nation/la-na-missile-defense-20140615-story.html#page=1

And here is a sentence to ponder – ‘Navy Adm. Timothy J. Keating, then head of the U.S. Northern Command, was even more emphatic when he told the Senate Armed Services Committee in 2007: “I appear before you today as confident as I know how to be in the employability and efficacy of that system.”‘

So, either military spending in response to threats is an engine of growth, or its the nature of government bureaucracy to be a burden to any successful response to ongoing circumstances.

Thankfully, this web site has never been bothered by the need for consistency in what it highlights.

TMC June 16, 2014 at 9:59 am

Wow, a political tool used for politics.
I guess your link for the VA scandal and this is that the Vets are political tools?

platypus June 16, 2014 at 9:39 am

Having worked in both the public and private sector, this sort of thing is a product of hierarchical organization, and happens in both public and private sector organizations (and in the military as well). Managers are frequently faced with a set of contradictory imperatives: like ship the product on the announced date vs. making sure it actually works. The ethical thing to do is to present the contradiction to your boss and get relief. Or resolve the contradiction yourself and dare your boss to fire you. Or lie. Or, more commonly, deceive yourself until the contradiction disappears.

Of course, bad bosses get lied to a lot, and eventually there are consequences. The people who are unwilling to lie or to drink the kool-aid of self-deception depart, creating an ever-more-pervasive culture of corruption, and eventually the organization collapses from its own incompetence. the real differece between the public sector and the private sector is that in the public sector, the consequences may take longer to arrive–though a big, profitable company can take a long time to die.

JWatts June 16, 2014 at 12:00 pm

“though a big, profitable company can take a long time to die.”

And a big, unprofitable company will get government money and still take a long time to die.

Jon June 16, 2014 at 9:42 am

It is an intrinsic problem at all human institutions–government or non-government. Leaders of private companies have been known to belittle or fire people who disagree with them.

The only difference is that a monopoly such as a government bureaucracy can survive more of this stuff.

Willitts June 16, 2014 at 11:08 am

The difference is that there are laws specifically prohibiting arbitrary personnel actions or reprisal in federal government. Government employees have a property interest in their jobs.

The fact that this happens in government despite the unambiguous, specific prohibition by Congress shows that government is even more ineffective. With additional safeguards, they still fail.

Why are we wasting money on the Merit Systems Protection Board, EEOC, OIG and Office of the Special Counsel if those bodies don’t recognize and timely correct deficiencies?

In my view, sovereign immunity of government and qualified immunity of government officials are the sources of the worst abuses. How would the average person act if no laws constrained their actions?

Jon June 16, 2014 at 9:45 am

The time a private company could benefit from this behavior is if the dissenter is trying to stop the private company from breaking or evading regulations or do something that benefits the firm but causes social harm. This holds until the whistleblower goes public or the government.

Unfortunately when the culprit is the government there is no higher authority to go to.

ummm June 16, 2014 at 9:55 am

I guess my question is why can’t they go to a regular hospital where the care obviously seems superior. Electrical engineers don’t go to an electrical engineer hospital, etc

dkfj June 16, 2014 at 11:25 am

Because it’s free, and the regular hospitals are a massive rip us. It’s bad enough that we get cheated by the medical industrial complex for old people’s care, we don’t need also do so for professional killers.

Willitts June 16, 2014 at 11:42 am

Most of the doctors at the VA have appointments at other hospitals as well.

Military injuries can be quite unique, and thus specialization has its virtues.

The main issue with the VA is not the quality of care, but rather the timeliness. The problems are mainly with the front office staff and management having to deal with too many patient needs relative to resources available. The blatant misconduct is the consequence of trying to squeeze water from a stone.

This is a classic case of low marginal cost creating excess demand, and the firm unwilling or unable to raise price. The VA rations by queuing.

We could probably privatize funcrions of the VA, but it would still face restrictions of rationing by price. I don’t see how that improves things.

platypus June 16, 2014 at 10:16 am

here is a private sector example–Miniscribe, the firm that gained a certain fame for making its quarterly financial targets by shipping bricks to its customers in lieu of disk drives that the customer hadn’t even ordered. . In what universe was that a good idea? Yet it actually happened.

http://www.bobbarr.biz/pdf%20Files/MiniScribe%20Corporation%20Case%20Study.pdf

TMC June 16, 2014 at 12:03 pm

And they went out of business. If it were a government agency they would be further subsidized.

TallDave June 18, 2014 at 9:39 am

Companies like Solyndra Miniscribe are the true engine of economic growth.

Willitts June 16, 2014 at 11:01 am

It is both.

See Pournelle’s Iron Law of Bureaucracy:

http://www.jerrypournelle.com/reports/jerryp/iron.html

Mark June 16, 2014 at 11:54 am

Tyler, I am speaking as a Federal manager, although of course for myself alone.

You and the commenters are failing to distinguish between the failure — slow delivery of care to veterans — and the dishonesty. The failure could have happened in any bureaucracy. Congress didn’t appropriate enough money to care for veterans of Iraq and Afghanistan, given the cost structure in American health care. No bureaucracy would have succeeded in treating them all.

The *dishonesty* could not have happened at just any bureaucracy. The shocking part is the choice of a metric that large numbers of managers’ bonuses depended on; that was easily gamed, was widely known within the system for years to be actively gamed. This is high-level malfeasance. It is like Westmoreland and the body count in Vietnam. People at the top should be held accountable for having kept that metric for years, knowing what was wrong with it, and people in the middle should be held accountable for having robbed an open till.

Willitts June 16, 2014 at 12:01 pm

I agree, but the incentive structure itself was designed to address a problem with no feasible solution. The fact that anyone met the goals should have been met with skepticism. Miracle or fraud?

Reminds me of the woman who won the NYC marathon by taking the subway. Extraordinary claims require extraordinary proof.

andrew' June 16, 2014 at 4:55 pm

Relative not absolute targets, whistleblower bonuses, clawbacks, next?

andrew' June 16, 2014 at 4:58 pm

At my last employer I heard the stories of how they would target weight of product out the door with obvious results. They quit doing that, somewhere around the mid-to-late-seventies.

TallDave June 18, 2014 at 9:37 am

Socialism doesn’t work, but incentives still matter.

JKB June 16, 2014 at 12:19 pm

Intrinsic.

It’s been quite few years now, but I was admonished in writing to not worry so much about the Code of Federal Regulations. I had been vocal about several serious safety issues. Issues that were we private sector, the controlling government agency would have shut us down for violating the CFRs.

I do not believe my bosses were bad people. But fixing the old infrastructure isn’t near as fun as building new toys. Besides, as I was oft told, nothing bad has happened even though the condition has persisted for years.

genauer June 16, 2014 at 12:27 pm

Why dont I ever read about such problems in Germany’s “socialized medicine” ?

andrew' June 16, 2014 at 4:59 pm

Too lazy to learn German?

prior_approval June 17, 2014 at 1:02 am

Or he has the disadvantage of living there. And paying a third less for health care that is at least as good as that found in the U.S. – health care that is essentially available to everyone.

Willitts June 17, 2014 at 10:19 am

Don’t confuse expenditures with costs.

TallDave June 18, 2014 at 9:36 am

Germany has a two-tier system, the people who can afford it buy private insurance.

Bob from Ohio June 16, 2014 at 3:16 pm

“The Veterans Health Administration (VHA) has issued a Directive to all of its facilities establishing a policy of respectful delivery of healthcare to transgender and intersex veterans who are enrolled in the Department of Veterans Affairs (VA) healthcare system or are otherwise eligible for VA care. ”

I have been assured that this is vitally important.

Jan June 16, 2014 at 10:15 pm

Good thing FreedomWorks was out there demanding that Republicans not fund an increase in VA funding in February. Money for the war, but not the vets. This despite the fact the VA is probably the most cost effective health systems in this country. Oh well. http://www.freedomworks.org/content/key-vote-no-using-emergency-funding-expand-broken-va-health-care-system

TallDave June 18, 2014 at 9:35 am

the VA is probably the most cost effective health systems in this country.

Death lists for all!

TallDave June 18, 2014 at 9:34 am

I think the big story here is that no one knew about this until this year.

How can that happen in a country with thousands of newspapers and magazines? Simple: they never looked for what they didn’t want to find.

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