Rep. Bob Filner (D-Calif.), chairman of the House Veterans Affairs Committee, charged Bush administration officials Wednesday with continuing to downplay the mental trauma and brain injuries suffered by veterans of wars in Iraq and Afghanistan.

Filner said an April RAND Corp. study, “Invisible Wounds of War — Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery,” justifies a tenfold jump in the U.S. casualty count versus the figure of 33,000 American dead and wounded used by the Pentagon.

RAND researchers extrapolated from a survey they conducted of 1,965 veterans to conclude that nearly 300,000 service members and veterans of Iraq and Afghanistan wars are suffering from post-traumatic stress or major depression. Filner told the pair of researchers, who had summarized their findings for his committee, that their work probably understates the problem.

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He was part of a ceremony to install a bell tower in Rising Sun honoring veterans, the first of its kind in the U.S.

“This is refreshing and it renews the soul,” the Vietnam veteran said.

The bell will ring today after a morning “bell breakout,” grinding and polishing.

Davis came from Mooresville, Ind., to be part of the ceremony, which included a parade of more than 900 students from Rising Sun schools and area veterans who loaded 500 pounds of bronze ingots into a mobile bell-casting furnace. In the afternoon the bell was poured and cast.

The talk of this river town of 2,470 Friday was honoring veterans and making history as the first town to get a Veterans Tribute Bell Tower.

“I feel proud that we are the first and feel proud that we have something to honor veterans,” Mayor William Marksberry said. “This helps remind us of the liberties we have.”

Davis spoke for about two hours to the students, telling them about his service as an artillery gunner at a remote fire support base west of Cai Lay, Vietnam. One of those experiences was recounted in the movie, “Forrest Gump.”

Davis suffered severe injuries at Cai Lay during an enemy mortar attack.

Davis disregarded his extensive injuries - and his inability to swim - picked up an air mattress and struck out across a deep river to rescue injured comrades.

“The Forrest Gump movie is not about me, but is about me,” Davis joked Friday. “There were parts of it I didn’t like, but I think the students gave me a new insight. When I asked them what they thought of the movie, they said: ‘It taught us that you don’t lose when you keep trying,’ We were able to see that in the movie.”

Davis explained that the students were referring to when Gump showed great courage under fire as he continued to rescue soldiers while he was hurt. “The emphasis was on keep trying until you fail,” Davis said.
The tower is a project of Rising Sun, the Veterans Coalition, the Commission on the Future for America’s Veterans, the Rising Sun Regional Foundation Inc. and the Verdin Co. of Cincinnati.

They are partnering to raise funds for the commission’s plan that includes a long-term initiative for the health and well-being of veterans, said Edward Sullivan, executive director of the Rising Sun Regional Foundation.

The foundation and the city have raised $250,000 for the project. About $25,000 will go to the commission, a nonprofit organization developing a long-term strategy for the U.S. Department of Veterans Affairs.
James Verdin, president of the Verdin Co., said plans are to build 100 Veterans Tribute Bell Towers across the country in the next 18 months and raise $2 million for the commission.

“We wanted to start close to Cincinnati. If a small town like Rising Sun can do this, any town can do it,” Verdin said. “Our point is to go into cities and set up these towers as a way of saying thank you to our veterans.”

Studies of the VHA for the past six or seven years reveal that it universally gets very high marks for its quality of medical care, while holding down cost-per-patient better than virtually any comparable public or private sector system. Much of this is due to its extensive use of information technology, but there are many other causes, as well. One major asset is that the VA partners with virtually every medical school in the nation, enabling it to benefit from cutting edge teaching facilities and dedicated, but relatively low-cost medical residents for much of its care.

Interestingly, the VHA has even been touted recently as a possible model for national health care in an American Journal of Public Health editorial and numerous professional as well as popular publications have lauded the system’s successes on many levels. Frequent mention includes the development of a national patient safety center, a robust outpatient delivery model, universal access to care, the nation’s only system-wide electronic health record system, and many other industry-leading measures.

This is quite an achievement given that the VHA provides health care services to over 5 million veterans and related patients while operating a national network of 153 medical centers run by 200,000 full-time employees, including 13,000 physicians and nearly 55,000 nurses.

Against a backdrop of Vietnam-era healthcare “horror” stories (some erroneously associated with the recent problems at Walter Reed, which is not part of VA), the Department of Veterans Affairs brought about a remarkable transformation of its healthcare and patient safety programs in the 90’s under the leadership of Dr. Kenneth Kizer. A relentless, dedicated individual, Kizer convinced the Office of Management and Budget to allow VA to retain any savings brought about through efficiencies in order to fund additional measures that further enhanced quality and reduced cost. The system began to “spiral upward” as morale improved and further reforms were brought to bear.

Even more impressive is the fact that during and immediately after this transformation, the number of veterans accessing healthcare from VHA more than doubled. Clearly veterans voted with their feet.

With data-driven, evidence-based principles combined with customer-driven measures for access and quality, a new VHA healthcare delivery model was developed. It shifted the VHA from hospital-based care to a community-based healthcare system brought together by an integrated electronic information system.

But, as is often the case, Kizer suffered the fate of many change agents and was sent packing by Congress after six years because he tinkered too extensively with what many considered their sacred cow. Much needed change was left undone, however, and the system now is in danger of unraveling due to a “perfect storm” brewing in the not-too-distant future. With enormous federal financial challenges for Medicare and Social Security looming, and with thousands of new wounded warriors from Iraq and Afghanistan adding to the millions of Vietnam, Korean and World war II veterans, a confluence of financial, practical and political issues could be disastrous for a system that some would rather see dismantled in favor of “vouchering out” care in the future.

The system faces challenges on many fronts. The infrastructure of VHA’s system needs major help; the age of an average hospital in the system is over 55-years-old compared to an average of less than 20 in the private sector. The demographics of the veteran population has shifted dramatically to the South and Southwest but no new facilities are being built due to tight budgets caused in large part by political pressure requiring old facilities be kept up even if the veteran population has drifted downward in a catchment area. Urgent needs get constantly pushed out into the future: a desperately needed Orlando hospital has been on the drawing board for over 25 years, and the last major hospital built anywhere in the nation was over 17 years ago. A critical poly-trauma center to treat badly wounded soldiers in Tampa has been in need of sinks in each of its outdated rooms so care-givers can wash their hands before handling wounds, and the $13 million fix has not been approved. The system is fraying at the edges, despite the best efforts of well intending VA officials.

Meeting the obvious, urgent needs of the antiquated, overly bureaucratic system becomes nearly impossible when its top leaders move in and out every two years, as has been the case since 1999. Planning for the future (or even the current year) is an exercise in futility when Congress passes the budget for this largest health care system in the country anywhere between two and twelve months late, every year. At a minimum it takes two years to fund important projects that are needed now, but many never make the cut. Most importantly, these kinds of challenges make it very difficult to train and maintain the highly skilled personnel necessary to continue VHA’s reputation for excellence. The system is losing many of its best people because they cannot deal with the uncertainty.

What can be done? The Commission on the Future for America’s Veterans, an independent, non-partisan panel established by major veteran’s service organizations, respected research institutions and a range of corporate and philanthropic entities assembled a “who’s who” of experts. They have studied the healthcare needs of veterans for the past two years and developed a long-range plan to bring about the needed changes to ensure a robust system into the future. Dr. Kizer, the author of the VHA’s transformation of the 90’s was one of the first to be selected. All agreed that the solutions to present and future challenges for VHA can be distilled into a few words, “dramatically increase operational flexibility, and allow the system access to capital.”

The commission’s recommendations for ensuring the continued quality of VHA healthcare in light of the looming federal financial meltdown and increasing demands on the system begin with these:

Create a federally chartered public/private entity with rigorous oversight and professional management, taking lessons from other federal entities used to address pressing social needs for our country (housing, education, communications); Give the new entity access to federal financing in order to flexibly address critical problems like the aging VHA infrastructure;

Place VHA physical infrastructure and personnel into the new entity and guarantee funding for the care of veterans eligible for care as described by Congress, and; Create new funding streams for the system by expanding coverage to all veterans and their families who can bring their private insurance or medicare funds, or subscribe to VA health insurance.

These changes would not only provide the flexibility to create a dynamic entity that could meet veterans’ healthcare needs far into the future, but also provide stability of leadership and fiscal management to ensure the system is capable of meeting the range of challenges it faces routinely.

Studies of the VHA for the past six or seven years reveal that it universally gets very high marks for its quality of medical care, while holding down cost-per-patient better than virtually any comparable public or private sector system. Much of this is due to its extensive use of information technology, but there are many other causes, as well. One major asset is that the VA partners with virtually every medical school in the nation, enabling it to benefit from cutting edge teaching facilities and dedicated, but relatively low-cost medical residents for much of its care.

Interestingly, the VHA has even been touted recently as a possible model for national health care in an American Journal of Public Health editorial and numerous professional as well as popular publications have lauded the system’s successes on many levels. Frequent mention includes the development of a national patient safety center, a robust outpatient delivery model, universal access to care, the nation’s only system-wide electronic health record system, and many other industry-leading measures.

This is quite an achievement given that the VHA provides health care services to over 5 million veterans and related patients while operating a national network of 153 medical centers run by 200,000 full-time employees, including 13,000 physicians and nearly 55,000 nurses.

Against a backdrop of Vietnam-era healthcare “horror” stories (some erroneously associated with the recent problems at Walter Reed, which is not part of VA), the Department of Veterans Affairs brought about a remarkable transformation of its healthcare and patient safety programs in the 90’s under the leadership of Dr. Kenneth Kizer. A relentless, dedicated individual, Kizer convinced the Office of Management and Budget to allow VA to retain any savings brought about through efficiencies in order to fund additional measures that further enhanced quality and reduced cost. The system began to “spiral upward” as morale improved and further reforms were brought to bear.

Even more impressive is the fact that during and immediately after this transformation, the number of veterans accessing healthcare from VHA more than doubled. Clearly veterans voted with their feet.

With data-driven, evidence-based principles combined with customer-driven measures for access and quality, a new VHA healthcare delivery model was developed. It shifted the VHA from hospital-based care to a community-based healthcare system brought together by an integrated electronic information system.

But, as is often the case, Kizer suffered the fate of many change agents and was sent packing by Congress after six years because he tinkered too extensively with what many considered their sacred cow. Much needed change was left undone, however, and the system now is in danger of unraveling due to a “perfect storm” brewing in the not-too-distant future. With enormous federal financial challenges for Medicare and Social Security looming, and with thousands of new wounded warriors from Iraq and Afghanistan adding to the millions of Vietnam, Korean and World war II veterans, a confluence of financial, practical and political issues could be disastrous for a system that some would rather see dismantled in favor of “vouchering out” care in the future.

The system faces challenges on many fronts. The infrastructure of VHA’s system needs major help; the age of an average hospital in the system is over 55-years-old compared to an average of less than 20 in the private sector. The demographics of the veteran population has shifted dramatically to the South and Southwest but no new facilities are being built due to tight budgets caused in large part by political pressure requiring old facilities be kept up even if the veteran population has drifted downward in a catchment area. Urgent needs get constantly pushed out into the future: a desperately needed Orlando hospital has been on the drawing board for over 25 years, and the last major hospital built anywhere in the nation was over 17 years ago. A critical poly-trauma center to treat badly wounded soldiers in Tampa has been in need of sinks in each of its outdated rooms so care-givers can wash their hands before handling wounds, and the $13 million fix has not been approved. The system is fraying at the edges, despite the best efforts of well intending VA officials.

Meeting the obvious, urgent needs of the antiquated, overly bureaucratic system becomes nearly impossible when its top leaders move in and out every two years, as has been the case since 1999. Planning for the future (or even the current year) is an exercise in futility when Congress passes the budget for this largest health care system in the country anywhere between two and twelve months late, every year. At a minimum it takes two years to fund important projects that are needed now, but many never make the cut. Most importantly, these kinds of challenges make it very difficult to train and maintain the highly skilled personnel necessary to continue VHA’s reputation for excellence. The system is losing many of its best people because they cannot deal with the uncertainty.

What can be done? The Commission on the Future for America’s Veterans, an independent, non-partisan panel established by major veteran’s service organizations, respected research institutions and a range of corporate and philanthropic entities assembled a “who’s who” of experts. They have studied the healthcare needs of veterans for the past two years and developed a long-range plan to bring about the needed changes to ensure a robust system into the future. Dr. Kizer, the author of the VHA’s transformation of the 90’s was one of the first to be selected. All agreed that the solutions to present and future challenges for VHA can be distilled into a few words, “dramatically increase operational flexibility, and allow the system access to capital.”

The commission’s recommendations for ensuring the continued quality of VHA healthcare in light of the looming federal financial meltdown and increasing demands on the system begin with these:

• Create a federally chartered public/private entity with rigorous oversight and professional management, taking lessons from other federal entities used to address pressing social needs for our country (housing, education, communications);
• Give the new entity access to federal financing in order to flexibly address critical problems like the aging VHA infrastructure;
• Place VHA physical infrastructure and personnel into the new entity and guarantee funding for the care of veterans eligible for care as described by Congress, and;
• Create new funding streams for the system by expanding coverage to all veterans and their families who can bring their private insurance or medicare funds, or subscribe to VA health insurance.

These changes would not only provide the flexibility to create a dynamic entity that could meet veterans’ healthcare needs far into the future, but also provide stability of leadership and fiscal management to ensure the system is capable of meeting the range of challenges it faces routinely.

In over seven decades of serving veterans returning from war, the VA has experienced many operational challenges. In most cases, these challenges were met with practical and capable solutions such as General Omar Bradley’s alignment of VA medical centers with the nation’s medical universities following WWII. Bradley’s solution brought a lasting partnership that has produced generations of US medical professionals and served VA patients capably and efficiently for sixty years.

More recently, a dramatic cultural change in the 90’s ushered in new regional health service networks and established many innovations that catapulted VA into what is now regarded as one of the highest quality and lowest cost systems in the nation. Developments established under the leadership of then-Under Secretary for Health, Dr. Ken Kizer, included universal primary care, a major shift to outpatient care and system “right sizing,” a capitation-based resource allocation system, adoption of a world-class electronic health record, industry-leading patient safety practices, and a new emphasis on wellness, disease prevention and health maintenance that is unmatched in the private sector.

Critical Challenges Facing VA Today

Despite significant improvements, a number of critical issues today threaten the future viability of VA health care. These issues revolve around historic inequities that threaten to strangle the nation’s largest health system due to completely inadequate management and financial controls and under funding for mission tasks. Some of the most challenging concerns, such as the looming federal financial crisis described in GAO and CBO reports[i], lie beyond VA’s control but have enormous implications for the discretionary funding program the Department depends on Congress to provide (consistently late) each year.

In reality, most major problems facing VA defy internal reform due to the structural or legal constraints imposed on the system. These issues include the inability of the system to strategically manage capital assets, conduct long range or strategic planning, or restructure services to meet shifting demand. The annual unknowns in how much and when a changing congressional budget will be provided exacerbate all of these. Not once in the past eight years has the VA been able to implement a budget at the beginning of the year.

Some would liken the VA health system to an antique auto that has been “souped up” with modern improvements, but its chassis is rusting and in danger of falling apart. One of the most vexing problems is the many highly resource-intensive, aging facilities. Average age of VA’s 153 medical centers is over 55 years (compared with less than half that in the private sector). What is more challenging, however, is that facilities cannot be built, closed or refurbished without specific congressional approval, which creates a virtual impossibility for addressing VA’s target population. The last VA medical center was built over 10 years ago, despite major geographic shifts in veteran population and patient demand over recent decades. Demographically stranded hospitals with more staff than patients remain open due to local political pressures while facilities in areas with high veteran populations are literally bursting at the seams and appointments can take months to obtain.

Further exacerbating VA’s structural challenge is the difficulty in maintaining continuity of leadership due to rapid turnover of administrators. For example, since 1999, four individuals were appointed Under Secretary for Health, with each serving an average of two years. Subordinate positions change with similar frequently. In government such movement may not seem unusual, but it effectively eliminates critical strategic planning and proactive management in a massive health system.

The net effect of these complex system and infrastructure problems is that despite the dedicated and heroic efforts of thousands of individuals the VA is highly inefficient and not capable of meeting veterans’ needs into the 21st century. In fact, the looming federal financial crisis may undo the system, as it exists today. It is time for new thinking in order to address what have become intractable issues and it is in that light that the independent Commission on the Future for America’s Veterans (CFAV) was formed to conceive solutions to the problems.

A Necessary Solution

Following nearly two years of study, the Commission concluded that the best solution for providing the highest quality, most efficient and effective health care to the nation’s veterans is for a new structure to be established that would encompass the best characteristics of existing government entities and programs today. Such a new entity would be much more capable of long range planning and strategic activity, while also functioning dynamically to manage its assets and ensure the financial stability needed to operate a major health organization in an increasingly difficult financial environment.

Structure

The specific recommendation is to create a new government chartered organization with specific provisions detailing its structure. It could be called the Veterans Healthcare Service (VHS). It’s charter would detail a carefully organized mission for serving veterans and their families, while providing for a governance structure that would allow for internal management of its assets, its funding (to include a long-term capitated government funding stream for disabled and poor veterans) and its personnel. An appointed, and congressionally confirmed board of governors would oversee it. The existing VA health care resources would be transferred through the legislation creating the entity, and that legislation would describe the specific provisions of management and oversight. The board of governors would meet specific skill requirements, but be selected principally from the veterans and health community with nominations coming from VSO’s, academic medicine and labor. Governors would serve terms sufficient to supercede administrations, and among their duties would be the responsibility to select and oversee professional management of the system. The board would be responsible for governing the Veterans Healthcare Service under the oversight of the Secretary of Veterans Affairs, and it would receive funding through VA.

Finance

To increase the system’s financial stability it will need multiple income streams in the coming times of increasingly difficult finances. Resources would include funds associated with enrollment of all veterans and family members desiring to use VHS. This would be on a means-tested basis (with service-connected disabled and indigent veterans subsidized as today by appropriated funds) and new enrollees would either bring health insurance or purchase graduated low cost coverage through the system. As it benefits the government, lower cost VHS care could be reimbursed on a per capita basis by other state or federal programs for those veterans or family members preferring to use VHS. A business plan detailing financial specifics will accompany the Commission’s May 2008 report.

Precedence

Over the years, a number of federal agencies have successfully restructured to meet changing demands and priorities. For example, the Post Office Department’s assets were transferred into a newly created US Postal Service in the 80’s and the resulting entity has become much more effective and efficient, managing its resources and successfully operating in a highly competitive marketplace.

It is time that our nation’s veterans receive the best care possible through a system capable of operating at its best. Business as usual is not an option with so much at stake.