Janaury 2004, Vol. 87, No. 1
The agency is about to embark on a comprehensive overhaul of its health
care facilities.
By Tom Philpott
After years of study and analysis, the Department of
Veterans Affairs is poised to launch a far-reaching restructuring of its
mammoth, $26 billion-a-year health care system. The impact will be felt by
veterans and communities nationwide.
The new organizational plan is titled “Capital Asset
Realignment for Enhanced Services,” or CARES. It shapes up to be the most
comprehensive overhaul of veterans’ health care facilities ever conducted.
The government has not yet reached decisions about every
aspect of the CARES plan. In fact, VA officials and members of a blue-ribbon
outside review commission were still struggling with key issues late in 2003.
The expectation was the panel’s findings would be decisive in VA decisions this
year.
Even so, the question is not whether there will be dramatic
change, only when and in what specific ways.
At present, the VA operates 163 major hospitals and some
5,000 other buildings on almost 20,000 acres of land.
It was during the Clinton Administration years that the
Department of Veterans Affairs recognized it had no choice but to restructure
these facilities. The agency began transforming itself into a more modern
health delivery system by emphasizing outpatient care and setting up many more
clinics in veteran-population areas.
Even so, the changes did not go far enough. According to a
1999 report by the General Accounting Office, a Congressional watchdog agency,
VA still was wasting up to $400 million a year by maintaining old, decrepit,
and underused facilities.
This was duly noted by VA Secretary Anthony J. Principi.
That money, said Principi, “can buy a lot of health care and state-of-the-art
ambulatory clinics and sophisticated bed towers and surgical suites and more
digital technology so a doctor on the West Coast can be diagnosing a patient on
the East Coast.”
In June 2002, Principi formally launched the CARES process,
and VA officials went to work. The draft national CARES plan was completed last
August. It makes hundreds of recommendations to realign and modernize VA health
facilities over the next 20 years.
Among the highlights is the VA’s determination that it
should shut down seven aged inpatient hospitals. They are in
Under the CARES plan, the VA would also build large new
facilities. These include new hospitals in Las Vegas and Orlando, Fla., new
centers for the blind in Biloxi, Miss., and Long Beach, Calif., and new spinal
injury centers in Denver, Little Rock, Ark., Minneapolis, and either Albany or
Syracuse, N.Y.
The VA would open at least 48 new outpatient clinics and
close or consolidate many other small facilities.
The aim of all this activity, said Principi, is not mere cost-cutting,
as wary veterans suspect, but, rather, to make VA’s care more efficient and
accessible by closing older, underused hospitals and opening modern units where
needed most. According to Principi, the redistribution of VA resources should
reflect veteran-population shifts in recent years (and projected shifts) and
allow VA to take full advantage of new treatments and technologies.
“We’ll either be on the cutting edge of
medicine in the 21st century” via restructuring, said Principi, or “on the
trailing edge of the past century.”
He went on, “We have a responsibility to make changes, ... much like the private sector has to its systems,
and to make sure the extraordinary amount of dollars the American people send
us are being spent wisely.”
After Principi launched CARES, health officials in each of
the VA’s 21 regions, now called Veterans Integrated Service Networks or VISNs (pronounced “visens”), were
to review facility needs and recommend moves to dispose of underused buildings
and property and to propose new ones. Computer models were available to help
predict veteran-population trends and demand for services.
In June 2003, however, VA officials decided the VISN
recommendations were not aggressive enough. They ordered changes aimed at
closing and consolidating even more facilities.
Every lawmaker or community resists closing the local VA
facility. Such closures affect not only care for veterans but also the state of
the local economy. As the CARES process reached its summer conclusion, many
lawmakers who thought they knew how it would affect their districts were
unpleasantly surprised. The final draft, prepared by Robert H. Roswell, VA
undersecretary for health, was different from what they had been led to believe
in the VISN briefings.
In hindsight, VA chief Principi conceded, “I might have
directed [
Release of the draft plan (http://www.appc1.va.gov/cares/)
moved the CARES process into a new phase. With Congress critical of the VA
action, Principi created an independent panel that would review the plan and
give it more credibility within the veterans
community.
For its chairman, Principi selected Everett Alvarez Jr., a
retired Navy aviator, eight-year
Alvarez has faulted the draft CARES plan for including so
many last-minute changes. “It caught everybody off guard,” he said, “including
the political people on the Hill.” He went on, “What came out of headquarters
were proposals counter to the VISN plan. They should have handled it with a
little more sensitivity. I guess they were pressed for time.”
The Alvarez commission began work in August. It held 38
public hearings, visited 68 VA medical facilities, and received 175,000 written
comments from anxious veterans and community leaders. They drew crowds of
thousands to meetings held in areas where hospitals are set to be closed, Alvarez
said, attesting to the level of concern. These individuals want their hospitals
to remain open. However, said Alvarez, what they really need is more
information.
“When they first hear about it, it’s ‘Oh, they are closing
up our hospital! They are going to throw us to the wolves!’ ” said Alvarez,
“but the whole objective is to increase and enhance their care, with tomorrow’s
medicine—not [by keeping open] 70-year-old facilities. It doesn’t help that
Congressmen and Senators are up there leading the charge.”
Alvarez said that even the draft CARES plan addresses the
real health care needs of veterans far more thoughtfully than one would
conclude just by reading newspaper articles about hospitals “on the chopping
block” and so forth.
The unease felt by veterans and politicians lessens, he
said, once the facts are known. As an example, he pointed to plans to close the
VA hospital in
In October, as the commission held its hearing in
What the VA sees at Waco, said Alvarez, is an old, large
hospital and surrounding campus, built in 1932, delivering far more outpatient
than inpatient care, and with only 109 beds, most of which are for psychiatric
patients. When one of those patients becomes physically ill, VA must transfer
him immediately to a nearby civilian hospital. There he stays until he is
stable or until he is sent to the Olin E. Teague Veterans’ Center in
The VA wants to transfer those 109 beds to
“All the rest of the care—93.5 percent of the workload of
that facility—will stay in
The veteran population in both
“When you build a hospital today, it should be right-sized
and it should be for today’s research, today’s medical training, [and able to
handle] complex cases,” he said.
In Canandaigua, the 23-building VA campus has its own fire
department, bowling alley, and laundry, even though the hospital has only 200
inpatient beds, down from 1,700 at one time. Most are for psychiatric patients.
Outpatient services won’t be affected by closing the hospital, Alvarez said.
“The question is, in the next 10 to 15 to 20 years, when do you take the small
number of inpatients beds you have, consolidate them,
and unload a major [campus] that is draining you?”
Principi seconded
that statement.
“Some facilities, we inherited from the Army at the turn of
the 20th century,” Principi said. “At their peak, these facilities may have had
2,000 patients [apiece]. Today, there may be fewer than 200 patients, and we’re
maintaining 200, even 350, acres of land.”
Alvarez agrees that expansive campuses are anachronisms,
suited to an era when almost all surgical procedures entailed a hospital stay.
Today, he said, 70 percent of surgeries nationwide are outpatient procedures.
Alvarez said that, while the panel agreed with much of the
draft national plan, it is not without flaws, and the commission decided to
propose changes.
The commissioners questioned the reliability of the models
used to project demand for care, had concerns about proposed uses of vacant
space, and questioned whether community-based outpatient clinics can provide
the required level of services.
Commissioners strongly supported greater sharing of Defense
and VA medical support services.
Alvarez noted that the job of the commission was “to look at
the strategic plan in terms of whether or not it makes sense, whether or not
the recommendations can withstand scrutiny, are defensible, and to make sure
quality of health care does not fall as we go through the process.” He added
that the plan would take years to execute.
Careful Review
Principi promised a careful review of commission
recommendations and could send some back for further work and consideration. He
hoped to announce the final restructuring plan within a month of receiving the
commission’s work.
How successful that CARES plan becomes in restructuring VA
health care ultimately will depend on VA budgets, year to year, and how well
Congress funds initiatives to close, consolidate, and build facilities.
“Money is very important,” said Alvarez.
“I have the authority” to execute a plan, Principi said. “I
don’t perceive Congress blocking me. I may be wrong.”
The VA chief is optimistic that through the CARES process,
VA will reshape health care for the future. Reaction overall has “gone as well
as one could hope for, given the gravity and comprehensive nature of this
report,” Principi said.
Meanwhile, he said, veterans service organizations “are
keeping an open mind and have not tried to sabotage this effort in any way.
They recognize that health care has changed, and the demographics of the veterans population have changed.”