In the coming years the veterans’ health care system will be affected by powerful societal and health care industry dynamics. These factors will influence the manner in which the VA accomplishes its mission and they provide the context in which it must operate.
My discussion of the future of the veterans’ health care system is based on the following assumptions:
- The role of the federal government in American society will continue to be reevaluated, and competition for federal government funding will become even more intense.
- Most health care in the United States will continue to be provided by the private sector.
- There will continue to be marked turmoil among and consolidation of medical groups, hospitals, health maintenance organizations, and other elements of the private sector.
- Managed care within integrated delivery systems will become the most common mode of health care delivery in the United States.
- Medical and scientific information will continue to grow at an astonishing rate.
- Technological innovations will continue to revolutionize clinical practice. In addition, the trend of providing care in nonhospital settings will continue, and even accelerate, as concern about health care costs continues.
- Advances in information and communication technology, and imaging systems in particular, will open up many new opportunities for improving the delivery of health care.
- Integrated information systems will be the key to success for future health care systems.
- Nonphysician providers will be increasingly used in health care systems of the future.
- Health care organizations will be increasingly expected to prevent disease and promote community wellness, in addition to treating individual cases of illness.
- There will be increased demand for accountability in health care and increased emphasis on health care outcomes and measurements.
- While the rate of increase of health care costs has diminished in recent years, health care costs will continue to be a major driving force in the industry. Nonetheless, quality of care and customer service will become more important issues.
- The veteran population eligible for care at VA facilities will continue to age and decrease. However, the need for both acute and long-term care services for this aging population will rise disproportionately to the decrease in users due to greater health care needs associated with aging.
- In addition to the “macro” issues, there will be local and regional dynamics impacting individual VA facilities and networks.
In envisioning the veterans’ health care system of the 21st century, it is assumed that the future is unpredictable and that the VA must be flexible enough to rapidly respond to unforeseen circumstances.
The mission of the veterans’ health care system is to serve the needs of America’s veterans by providing specialized care for service-connected veterans, primary care, and related medical and social support services.
To accomplish its mission, the Veterans Health Administration (VHA) should be a comprehensive, integrated health care system that provides excellence in health care value, excellence in service as defined by its customers, and excellence in education and research. It also should be an organization characterized by exceptional accountability.
There are numerous changes underway in the VA which specifically affect optometric education and they present both challenges and opportunities – opportunities for significant gains if optometric institutions are proactive and significant losses if they are passive. The VA is currently:
- Reengineering the operational and management structure of the veterans health care system.
- Implementing the Veterans Integrated Service Network (VISN) management structure. This new structure has resulted in a shift of operational control and some policy development to the local level.
- Management Assistance Councils consisting of external advisors are either operational or being established in all Networks.
- Restructuring VHA headquarters.
- Implementing multidisciplinary “service line” rather than discipline-specific clinical care in recognition of the Transdimensional nature of health care today. Optometry and ophthalmology have been placed in the HQ Primary and Ambulatory Care Strategic Health Group forming the eye care program. This is likely to be emulated in VA field facilities.
- Standardizing clinical processes (e.g., with nationally developed clinical guidelines) and delegating clinical care responsibility to nonphysician providers.
- Exploring ways of improving the accessibility, quality, and cost-effectiveness of VA’s special emphasis programs, e.g., VICTORS.
- Increasing the proportion of the VA’s work force providing primary care.
- Developing tailored training/retraining programs in primary care.
- Reducing the variation in professional staffing that exists among facilities and services having similar missions and work loads.
Although we may experience reductions at certain facilities, overall continued growth in optometry is projected. Since 1990, VA Optometry Service has added 86 FTEE staff and residents. This growth has facilitated our involvement in the following activities:
- Increased sharing of activities with academic affiliates and the Department of Defense.
- Promoting a VHA culture of ongoing quality improvement that is predicated on providing health care value.
- Establishing a VA clinical “Centers of Excellence” program to celebrate and disseminate best practices and to foster studies that identify organizational characteristics that lead to performance excellence.
- Promulgating customer service standards and ensuring that they are known by both staff and patients, e.g., 30 days maximum wait for eye care.
- Decreasing waiting times for appointments. Although reduced from over 100 days in 1990 to the current level of 47, it still is far from acceptable.
- Ensuring the VHA’s educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans today and in the future.
- Convening Residency Realignment Advisory Committees for physicians and other health professionals to provide guidance in ensuring the VA’s postgraduate training programs are responsive to the needs of the VA and the nation. Possible overall reduction in optometry positions could result from general downsizing. Also, the lack of formal requirements for optometric residency training increases the vulnerability of the program. Most likely there will be a reduction in multiple resident placements.
- Increasing the proportion of trainees in primary care disciplines.
- VA facilities are reevaluating their affiliation(s) in light of VHA’s restructuring and vision of the “new VA,” and the present educational role of VA. Affiliation agreements should defend the prerogatives of VA, control the use of VA resources, and protect the interest of VA patients.
- Initiating review and renegotiation of all academic affiliation agreements.
- Reassessing the role and function of Deans Committees in light of today’s changed health educational environment and effect changes where needed.
- Academic affiliations and residents are likely to be negotiated on a Network basis.
- Clinical credentialing and privileging will probably be conducted on a Network basis.
The VA’s Current Contributions to Optometric Education
There are currently 155 academic affiliation agreements at 103 facilities. Five hundred thirty optometry students annually rotate through VA facilities. Seventy-five residents and 9 WOC are currently funded at 44 program sites. A significant increase in requests for “without compensation placements” (WOC) has been noted. There is a potential of 400,000 annual clinical teaching encounters. Research opportunities abound with currently over 7.0 million in funded optometric research.
There is a corps of well-qualified clinical preceptors with some VA optometrists released to teach at affiliates. VA clinicians are also active contributors to the literature and national continuing education programs.
What Can Individual Schools and Colleges Do to Preserve VA Affiliations?
- Above all, be an active partner.
- Assist VA facilities with Quality Improvement activities.
- Assist VA facilities in improving staff productivity and reducing waiting times for appointments. Low productivity will likely result in loss of residency funding and possibly staff FTEE. Chronic long waiting times could result in local frustration and contracting out to commercial providers. This is already a reality in one Network.
- Seek appointment of school-based optometric faculty as consultants at VA facilities.
- Enter into contractual “sharing’ arrangements, e.g., VICTORS, Eye Care Centers of Excellence.
- Seek appointments to Network Management Assistance Councils. Already, Drs. Haffner, Hopping, and Walls have been appointed and I have received positive feedback on their contributions.
- Increase awareness of VA affiliations by publicizing your institution’s activities.
- Seek new academic affiliations within your Network.
- Prepare thoroughly for COE accreditation visits and address problems before COE visits. Less than full accreditation will likely result in loss of VA funding.
- Seek cooperative research projects with VA affiliates.
- Consider WOC residency programs as a means to initiate new programs.
- Understand the new JCAHO accreditation standards and survey process and their implications to optometry.
What Can ASCO Do Collectively?
ASCO should implement the recommendations agreed to in the 1992 AOA/ASCO/NAVAO Strategic Plan. For example:
- In cooperation with the VA, assist in the development of and implementation of a system wide Total Quality Improvement Program.
- Improve management of affiliations programs by: participation on Network Management Assistance Councils. (Originally the Deans’ Committees.)
- Stimulate research proposals in cooperation with VA medical centers.
- Review faculty appointment procedures and benefits for VA preceptors and enhance them wherever permitted by institutional governance.
- Residency expansion in VA should be carefully managed to assure well-balanced clinical educational programs nationwide.
- ASCO should endeavor to publicly promote its relationship with the VA, increasing positive support of VA activities and accomplishments and increasing the public and the government’s knowledge of optometry.
- Monitor affiliations through the ASCO Committee on Residencies and Externships and through COE reports.
This is a time of great change in the VA. It presents many challenges, but also many opportunities. The shift of control to the Networks (local) level makes it more important than ever that every affiliated optometric institution be an active partner with its VA affiliated facilities and Network leadership. There is the possibility for significant gains if there is local initiative and likewise the possibility for significant losses if the schools and colleges of optometry are inactive.
At the time this article was written, Dr. Mullen was Director of the Optometry Service, Veterans Health Administration. This article is based on the VA’s new strategic plan entitled Prescription for Change. Dr. Mullen is currently the president of the Illinois College of Optometry.
The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education, Volume 22, Number 3. Spring 1997.
Charles F. Mullen, O.D.