President Trump actually gave President Obama a vote of confidence in his elevating Dr. David Shulkin in rank from Undersecretary for Veterans Health Administration (VHA) to Secretary of the Department of Veterans Affairs (DVA)  last year. Now that Shulkin has been fired, let us all now see how that act of bipartisan comity is going to be repaid with the nomination of Rear Admiral Ronny Jackson USN MD.  Adm. Jackson has said that he will retire from the military upon confirmation, forfeiting as much as $1 million in extra retirement pay that would have followed his pending promotion in rank.

The selection of Admiral Jackson is being attacked on the issue of his lack of significant command qualifications.  In fact, Jackson’s immediate experience will ultimately prove to be a boon for the VA. Navy doctors are trained professionals for big-deal thinking.  I would never typecast a Navy doctor with the rank of Admiral as someone who doesn’t understand how to take command of an organization the size of the VA.

Right now, with an Acting Secretary, pending the confirmation of Secretary-designate  Jackson, it is a perfect time to initiate a GAO audit of the ability of DVA employees to make accurate and timely payments to the providers of private medical treatment for disabled veterans, who had used the “Choice” option.

Basically the current DVA Choice program provides that if a veteran has to wait  longer than 30 days, or needs to travel over 40 miles, the veteran can qualify to be treated by private sector physicians or have medical procedures such as an MRI.  There is a DVA Choice fact sheet that goes into much more detail.

A just completed DVA IG audit, which was very professionally done, focused on “Choice” waiting times and availability.  As did a very professional GAO audit, again focusing on waiting times.  However, many professional Veteran Service Organizations (VSOs) see Choice as a harbinger of the eventual privatization of the VA, while other more recently charted Veteran organizations are asking, “Why not?”

Unfortunately the most important component of the Choice initiative is not well understood.  Before any changes can be made to expand or contract this relatively new (August 2014)  initiative, there is a need for a system wide audit to see if all the dimensions of Choice are good for veterans and their families. It is not just about fixing the all-important waiting time issue.

So far, the DVA competence of having timely accurate payment for services is not well understood, and often reported as going poorly. US private sector medicine is first rate, the envy of the world -- and expensive. The administrative failure in Choice rests on the fact that in most cases the people running and overseeing the current bureaucratic "pay for service" operation are lifetime DVA employees.  So an auditable line of questioning with profound implications would focus on whether DVA career employees, who have been totally socialized into public sector bureaucracy training and thinking, be successfully trained in the skill sets and financial responsiveness of the private sector.

Private sector insurance companies understand the need for both rapid pre-qualification, or if emergency medicine is required, then make a decision that the emergency care is justified.  Either way they are generally consumer-friendly and responsive to quickly pay their insured client’s legitimate medical bills.

So far, anecdotal evidence says those utilizing the Choice option have had both pre-qualification administrative issues, and then sadly, once treated, the current DVA pay out bureaucracy is very weak in rapidly covering their bills.  This unaddressed pay-for-service weakness cannot be allowed; it must be a zero defect system.  This is because some veterans are facing staggering amounts of unpaid private sector medical bills. If they die without bills being paid, their widows and orphans will have a terrible time engaging with the DVA to have all their loved ones’ delinquent medical bills paid.  Creditors hitting a deceased veteran’s estate for legitimate unpaid medical bills is unconscionable.

American Veterans do not deserve to die alone in the dark nor have their loved ones saddled with any financial liabilities from their earned service-connected disability treatment. I have personally experienced billing buffoonery, and also seen other real examples of this type of tragic ineptitude in action.

A comprehensive GAO audit of DVA responsive bill paying is needed before a full Choice commitment can be made. So far, all veterans have seen is years of burning through people, with no indication of progress.

To summarize, President Trump and his Secretary-Designee Admiral Jackson have, in my professional judgment, a one-time generational opportunity to finally "fix" the DVA.

New leadership can begin to start by calling for audit of pay-out times and accuracy, to combine with the earlier GAO and DVA IG work on waiting times.  When the new Secretary is confirmed, a  comprehensive  fact-based total understanding  of all the ramifications of the Choice benefit can be addressed, to see if it is a truly viable option for the veterans and their families, or not.

During this current “strategic pause” prior to confirmation of an new secretary, the Acting Secretary must initiate this most important of all audits.  The old saying, “What gets measured gets managed,” is a true statement. 

Calling in the GAO can early on forge a continuing Executive/Legislative bipartisan partnership that will be a significant move to bring all the necessary fact based evidence to the current debate and perhaps finally get VHA health care right for at least a generation.

Ed Timperlake was the first Assistant Secretary of DVA for Congressional and Public Affairs, and subsequently Public and Intergovernmental Affairs, when the Veterans Administration was elevated to Cabinet Status