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My Turn: VA should not operate as duplicate primary care

As reports regarding the scandal at the Department of Veterans Affairs have emerged, it has become apparent that there is a need for widespread review of this agency and the important medical services it provides.

The VA system is huge and complex, and it is difficult for anyone to gauge the breadth of its challenges. However, my 30 years of experience as a family physician does give me one insight about the problem and maybe affords a partial solution as well.

Among the panel of patients for whom I serve as a family physician are perhaps 50 to 100 veterans, some service members from recent conflicts and the wars in Korea and Vietnam, but others who are members of the “greatest generation,” current seniors who served in World War II.

As they have aged, the same illnesses that affect others of their cohort increase in prevalence, including cardiovascular diseases, diabetes, cancers and the like. They receive primary care services from my colleagues and me in the community just like non-veterans, but with one special exception: They are entitled to “free” medications if they also go to see a VA doctor.

And so many of them, especially those without good pharmaceutical coverage, once they have completed their routine chronic and preventive care with me, schedule parallel and duplicate appointments at the VA, where they must see their “other” primary care doctor. They are given identical monitoring tests and examinations, and then receive free prescriptions from the VA pharmacy.

Most of my patients who go to the VA report that they do it for the free prescriptions. I have often wondered, from my position outside the VA system, whether the requirement for veterans to be seen by duplicative primary care doctors at the VA has been designed to optimize patient care or merely to justify budgetary expenditures of a growing VA system.

Many of my patients, needing the assurance from the long-standing relationship they have with their trusted non-VA family physician, call me after their VA visits to be certain that I am satisfied with recommendations they have received from their VA doctors.

Usually, if I have done my job well, no changes are recommended, and they receive their prescriptions and are sent on their way. Only occasionally, despite the vaunted VA electronic medical record system, do I receive any medical notes or lab and x-ray reports from the VA system. The VA seems to function in isolation, not appreciating the duplication of primary care services it is providing or making any effort to coordinate optimal care for its patients/customers.

Many, including Sen. John McCain and others, have advocated for an approach that would give veterans the right to get care covered outside the VA. All World War II and Korean War veterans, and most Vietnam veterans, are already covered for medical care by Medicare, the insurance program that covers all seniors.

Medicare’s drug coverage program, however, is not “free.”

If the VA wishes to offer free prescription coverage, its rules should be changed to simply eliminate the requirement that patients see a VA doctor in order to obtain the medications. I suspect that, at least in New Hampshire, the volume of patients requesting access to the VA for primary care would dramatically decline, and we would enhance the valued relationship between patients and their community family physicians.

The special services the VA provides to wounded veterans and those with service-connected issues are crucial, and nearly unique, and need our full support. Specialty and in-patient services are another issue, largely provided in southern New Hampshire by contracted private hospitals and specialists, although certain services are available at the VA clinic in Manchester and in hospitals in Vermont and Massachusetts.

But the evolution of the VA into a duplicate primary care system seems ill-advised and wasteful.

While enhancing the budget and power of the VA system, this system may be profoundly distracting from the provision of the important services, which form the core mission of the VA. And recent reports suggest that the access may not be adequate by any standard. I therefore hope our legislative leaders can quickly go beyond the finger-pointing and consider some simple solutions to the issues of access to care for veterans.

(Gary Sobelson lives in Concord.)

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