What the Department of Veterans Affairs–which just lost its chief, Eric Shinseki–needed was not haphazard incentives to cut corners on patient wait times. It needed publicly funded alternatives to conventional, local options.
Thankfully, one system provides exactly this model: charter schools, which give parents alternatives when their district school fails.
We could start with veterans over 65, who represent a huge portion of the VA’s current problem. Vets who are eligible for Medicare should be given a special Medicare card. When a patient is unable to obtain a VA appointment within a specified period of time – 30 days for most procedures – he or she could use his special Medicare card to obtain the services of any participating provider in the United States.
If the matter were more urgent, like depression or PTSD, the waiting period might be reduced to say, seven days. And if a particular treatment could be readily deferred without substantial risk or discomfort to the patient, the waiting period might be somewhat longer. Finally, the standard deductible and co-pay for Medicare – normally collectible from the patient unless there is a Medigap policy in place – would be waived.
To activate the special Medicare card so that it could be accepted by a Medicare provider, the veteran would be given a certificate from his or her local VA hospital, specifying the service for which an appointment could not be obtained within the maximum waiting period.
A national hotline could be established to police the (hopefully rare) times when patients were not provided either a timely appointment or the certificate. Veterans or their families could report such cases either by telephone or online. Suitably scrubbed of patient identifying information, the list of recalcitrant VA hospitals or providers, and the dates and circumstances of the complaints, could be made public. That way the media, the President, and Members of Congress could not claim to be unaware of any problems.
Officials could also collect records of the number of certificates issued by each facility and the treatments for which they were provided, obviously scrubbed of patient identifying information. That would also be a warning of potential mismanagement or underfunding.
Critics worry that Medicare reimbursement rates might exceed the VA’s actual service costs. But this would incentivize the government to improve the VA’s efficiency, or to obtain more resources from Congress. We mightdiscover that for certain services, the VA’s single-provider approach is the most efficient and effective option. At the same time, for selected services or periods of high demand, the Medicare system might prove to be the least cost, effective provider.
By providing both choice and transparency, we would be able to determine, after a period of time, whether the VA itself had outlived its usefulness and should be replaced with a voucher system. If the opposite is the case, more publicly funded medical services should perhaps be moved into single-provider operations like the VA. Whichever way the VA evolves, the veterans themselves would no longer be hostages to that ideological or policy debate.