When an airliner piloted by terrorists slammed into the Pentagon on Sept. 11, Fred Gusman knew he had to get there by any means necessary.
Gusman, a social worker, is the director of the Palo Alto, Calif.-based education and clinical laboratory division of the Department of Veterans Affairs' National Center for Post-Traumatic Stress Disorder. In that role, he works with the military in treating the stress of soldiers deployed overseas and has assisted mental health counselors at such disasters as the 1995 Oklahoma City bombing.
Just hours after the Pentagon attack, and with the nation's air transport grounded, Gusman and five colleagues began heading east in two VA vans, stocked with food to limit stops and with electronic gear to stay in touch with the counselors already working at the Pentagon.
Seventy-nine hours later, they arrived at the disaster scene in Arlington, Va., and were soon at work lending some mental health muscle to overwhelmed counselors helping the families of Pentagon victims. They didn't leave for two weeks.
"I felt I needed to do it, to do the right thing," Gusman says. "It turns out we did the right thing."
Gusman and company's having gone the extra 3,000 miles for the shell-shocked workers at the Pentagon was as notable as an aberration in the VA-military relationship as it was as an act of selflessness.
War, collaboration and bureaucracy
In fact, as the U.S. last week launched the biggest military action since the Persian Gulf War in 1991, the sometimes collaborative, sometimes adversarial relationship between the VA, with its $20.3 billion healthcare system, and the Defense Department, with its $18 billion healthcare system, was on full display.
With the potential for hundreds of casualties returning to the U.S. before they can fully heal from battle wounds, the VA could be called upon to fulfill one of its chief missions: backing up the military's own healthcare system. Some critics, however, say that restructuring of the VA healthcare system, along with advances in treatment and rehabilitation, has made that role superfluous.
Although the overseas military buildup and strikes on military targets in Afghanistan in recent weeks could throw up an administrative barrier to increased sharing, veterans' advocates argue that overseas deployment of military medical personnel should spur greater use of VA facilities by the military-particularly as military casualties return home.
"Resources are going to be flowing elsewhere . . . in particular capital resources," says Kenneth Kizer, M.D., who ran the VA healthcare system from 1994 through 1999. "There's a potential for a need for more services. What's happening right now is kind of prima facie evidence as to why they need to be working more closely together. If we send troops somewhere and they get exposed to chemical agents, biological agents or, God forbid, nuclear agents, (VA hospitals are) going to have to be involved."
"I think that there are clearly more opportunities, and we should work more closely together," Gusman says. "This particular event, this terrorist attack, has made people ask, `What are the assets?' VA is clearly one of the assets that I believe is underutilized."
But one Capitol Hill aide says the VA's mission to back up the Defense Department is an anachronism as the VA has closed inpatient beds and restructured into an outpatient-oriented healthcare system.
"(The beds are) not there, and the beds that VA has in service, they're full because the acuity and the complexity of VA's patients who are actually on an inpatient basis are much higher," says John Bradley, staff director with the House Veterans Affairs healthcare subcommittee.
Bradley notes that during the Persian Gulf War, the VA offered up to 18,000 beds to back up the military that were never used. Had there been a great number of casualties, however, the military had prepared to treat them at government and community hospitals in Europe, not at VA hospitals in the U.S.
"VA's efforts to get itself ready for the receipt of casualties was really an exercise in futility because the military was prepared to forward-deploy healthcare resources in Europe," Bradley says. "God forbid if we do have any major military units on the ground and we have major casualties. I would say we will have a (healthcare) system on the ground responding that looks more like the Persian Gulf War than Vietnam." In Vietnam casualties wound through a series of military hospitals before being placed in VA facilities at home.
Reasons for, barriers to sharing
Congress gave the VA and the Defense Department the authority to share resources in 1982, and that most often took the form of buying or selling services from each other.
The reasons to share resources are simple: VA and military hospitals are federal institutions, serving the same population at different times of their lives. Often, the facilities are near each other. Increased patient volume also allows the facilities to pay for underutilized beds, examination rooms and equipment.
Yet the seemingly simple goal of increased sharing seems to be thwarted by the complexity of the two healthcare systems.
The VA and the military shared some $56.7 million in services in fiscal 2000, equaling less than one-fifth of 1% of the two departments' total healthcare budgets. Although that sharing represents a 14.5% increase over 1996, it is down from $61.3 million in fiscal 1999.
Although nobody will call the two departments' 19-year experiment at sharing a failure, federal officials acknowledge that military-VA collaboration is fraught with challenges, and they express frustration that there isn't more working together.
"I don't think there are any barriers there we don't put there ourselves," says Rose Quicker, director of the VA's medical sharing office. "Sharing is just something else that (healthcare executives) have to do rather than the focus of their entire job."
Defense Department officials did not respond to several requests for an interview.
In fact, this bureaucratic tangle has become so problematic that President Bush has taken notice. In May, Bush announced the creation of a 15-member veterans healthcare task force assigned to identify barriers to increased collaboration and opportunities to expand sharing.
The task force will be led by two co-chairmen: Gail Wilensky, a HCFA administrator under the first President Bush, and Gerald Solomon, a former Republican member of Congress from New York and an ex-Marine who served as senior Republican on the House Veterans Affairs Committee during the 1980s. It scheduled its first meeting for Oct. 10.
Bush's executive order requires an interim report within nine months of the first meeting and a final report in two years.
"I think it is an issue that has been looked at and there have been directives to the two departments to increase sharing," Wilensky says. "This is not a new idea. (But) there are different cultures and different way of doing things, and finding out how to make these strategies more compatible is going to be challenging."
Congress also wants to act. House Veterans Affairs Committee Chairman Christopher Smith (R-N.J.) is sponsoring legislation that would require the two agencies to create five new integrated joint venture sites, in addition to the three already in existence.
VA spending legislation passed by the House would require three such hospitals that adopt integrated patient records, billing, treatment and operations. For now, neither department has permanent executives in charge of their healthcare systems. In September, Bush nominated as assistant defense secretary for health affairs William Winkenwerder Jr., a healthcare consultant who has served senior posts with Blue Cross and Blue Shield of Massachusetts, Emory Healthcare in Atlanta and HCFA. The Senate hasn't yet confirmed Winkenwerder.
Bush has yet to name a VA health undersecretary. Thomas Garthwaite, M.D., Kizer's deputy undersecretary, has served as undersecretary since May 2000, but he has announced that he will resign to clear the way for a Bush appointee.
Not for lack of effort
Already there has been no shortage of federal work and congressional directives on increased VA-military sharing, which Wilensky acknowledges. In fact, just two years ago, a government commission headed by now-VA Secretary Anthony Principi recommended joint purchasing of medical supplies and development of compatible accounting and information systems.
The Principi commission's final report, issued in January 1999, estimated that joint purchasing alone could save nearly $374 million in the first year and $1.9 billion in the first five years.
So far, the two departments' efforts at joint purchasing have fallen well short of that estimate. A January report from the General Accounting Office, Congress' investigative agency, says the two departments saved a combined $51 million in fiscal 2000 through joint pharmaceutical purchasing, just 2.1% of their combined pharmaceutical budget.
The report notes, however, that officials from both the VA and the Defense Department believe the prospects for more joint drug purchasing are limited because the two organizations have different patient populations and drug formularies.
It also says sharing is further complicated by VA and Defense Department hospital executives who try to shift to the other department the responsibility for treating military retirees who are eligible for care both at the VA and military facilities.
That GAO report is part of a continuing congressional examination that has questioned why there isn't more sharing. In May 2000, the GAO found that most of the sharing activity was concentrated in direct healthcare services, and most of that activity was focused in three facilities where the VA and Defense Department jointly run facilities.
In 1998, two of them-one at Nellis Air Force Base in Nevada and the other at Kirtland Air Force Base in New Mexico-accounted for $21.5 million of the $29 million in shared direct medical-care services, the GAO said, resulting in at least $3.2 million in savings
That report cited several barriers to further sharing, including:
* Confusion over billing and reimbursement, with some VA and military facilities charging the other department for overhead and capital, rather than offering a discount.
* Budgeting at the joint New Mexico and Nevada hospitals that took into account only the military patient load.
* An inability to negotiate bigger discounts.
* A cumbersome approval process in the Defense Department.
Readiness vs. inertia
The military's own efforts to cover the healthcare needs of retirees, their families and the families of active-duty soldiers and sailors also are getting in the way. In the mid-1990s, the Defense Department responded to downsizing and reduced military hospital capacity by starting a managed-care plan for retirees and beneficiaries called Tricare, which relied heavily on private network providers when services weren't available at military hospitals.
In 1999, the military drove a stake through the heart of some sharing agreements by requiring that Tricare enrollees be first referred to a Tricare network provider, and that referrals to VA partners that aren't part of the Tricare network would constitute breach of the contract with Tricare contractors.
"From VA's point of view, a direct sharing agreement would be more beneficial-no third party," says the VA's Quicker, adding that the VA should have right of first refusal on providing Tricare services.
But in written testimony in June to the House Armed Services military personnel subcommittee, J. Jarrett Clinton, M.D., the Defense Department's acting assistant secretary of health affairs, said the most cost-effective way for the VA to treat military beneficiaries is as Tricare network providers. He said 130 of the 172 VA hospitals are part of Tricare networks.
The Defense Department's need to deploy overseas at a moment's notice-the so-called "readiness" mission-also can interfere with cost-sharing, although veterans' advocates scoff at that argument.
At that same June hearing, subcommittee Chairman John McHugh (R-N.Y.) said that mission shouldn't stand in the way of greater sharing.
"Certainly no action should be taken that would jeopardize the Department of Defense's ability to execute that primary mission," McHugh said. However, he said there is "some concern that the readiness caution" may have been used as an excuse in some circumstances when "the real reason for not moving forward on sharing initiatives was bureaucratic inertia."
Clinton said he agreed. "The constraints of medical readiness have never been raised once in any conversation with me," he told McHugh. "That is not a readiness issue. I think the message is not sufficiently clear in the field."
But former VA chief Kizer says resistance to further sharing is endemic.
"The barrier is primarily turf and the need for top management to make it happen in both agencies," he says. "It's predicated on silos. To break down those silos to create a new culture for collaboration . . . in the absence of major organizational or structural change that requires a sustained effort over a prolonged period of time-not a couple of years but five or 10 years."