'The job's not done yet'

Secretary Bob McDonald is leaving the helm of the Department of Veterans Affairs after taking over 30 months ago in the wake of a medical appointment wait-times scandal. After his Senate confirmation on July 29, 2014, McDonald immediately began working to restore trust in VA among veterans alarmed at reports of comrades dying while waiting to see doctors, facing issues with their own care or experiencing delays in the appeals process.

In an exclusive interview with The American Legion Magazine, McDonald addresses changes made, reforms in process, and advances in care for women and those with PTSD, among other issues. 

How would you rate progress at VA since you became secretary?

We’ve made a lot of progress under the MyVA transformation, but the job’s not done yet. The progress that we’ve made includes 4 million more completed appointments versus the previous year. How have we done that? We’ve done that by adding millions of square feet of new space, of new clinics. We’ve added over 1,200 new doctors, over 2,300 new nurses. We’ve expanded clinic hours. We’ve improved productivity of the staff. Our goal for the end of 2016 is that all our facilities have same-day-access capability. We’re on track.

Secondly, the disability claim backlog is down 90 percent. Those are claims that have been around more than 125 days. It now takes less than 125 days – less than 90 days, even – to get a claim decided. Third, veteran homelessness is down by 47 percent since 2010. The last year was one of the years of the biggest decline, 17 percent, partly because of our focus on Los Angeles.

But we have a lot of things we need to do. We’ve laid out the legislation we need from Congress, none of which really should be political, but legislation to do things like allow us to hire more doctors for emergency rooms. Or legislation that changes the appeals process. We have a backlog of 550,000-plus appeals, and we’re promising to get appeals decided within a year if we can simply get this legislation passed. We’re dependent a lot on what Congress does. So far, they’ve not done enough for veterans.

Employee morale has been a high priority for you over the past year and a half. How is that going?

You’re right, the strategy is to improve the employee experience because that’s the only way you can improve the veteran experience. The No. 1 thing we’ve done is we’ve increased our training. We do a program called Leaders Developing Leaders where the leadership team and I train the top 600 leaders. We then give them a training kit to go back and train the next level of leaders. We cascade that training throughout the organization. One of the things we require is that when you leave that training you work on a project to improve your area of responsibility. Imagine all 360,000 employees working on a specific project to improve their area of responsibility. We then account for those. We measure them, we track them and we make sure that when one project is ended, another one is started.

Ninety percent of veterans love their VA care. It’s that 10 percent that, for some reason, has fallen off the rails. How does VA improve on that 90 percent number?

We have seen an improvement in the outcomes for veterans, and their trust in VA is up about 12 percentage points. I think the most important thing is to make sure the culture is all about veterans so that employees can get that score up. Let’s say we get to 98 percent. There still has to be an outlet for that 2 percent. There has to be some way for that 2 percent to raise their issue and get it adjudicated. That’s why, in September 2014 at my first national press conference, I gave out my cellphone number and email address. Every day I get comments back from the 2 percent or whatever percent it might be, saying they needed help with an item, and I’ve set a team of people who help me get those things resolved. There are going to be some disgruntled people. We need to make sure they get a fair hearing. In the end, they may not agree, but we need to make sure they get a fair hearing.

The Legion and some members of Congress have called for reforming the appeals process – the Appeals Modernization Act, which the House passed. How big of a priority should similar legislation be for the next Congress?

It’s the ultimate priority. As I look back at what has occurred, and the progress we’ve made, this is the one outlier that is a gross injustice to veterans. Veterans aren’t happy about it. I’m not happy about it. As we looked at it, the only way to solve it is to change this 80-year-old law. It’s archaic. We know that if we do that we can make a difference. I think the way claims have been dealt with is a great example. We digitized the system, eliminated 5,000 tons of paper. We’re now able to move those claims around the country to where they can be dealt with, and the number keeps coming down. We’ve got to do the same thing with appeals.

Somewhere between 10 and 15 percent of combat veterans are experiencing PTSD and TBI symptoms. How is VA reacting to the current generation of sufferers and allocating resources differently?

First of all, we’ve allocated research money toward mental health, PTSD, TBI. We’ve also had a conference bringing together the national experts, called Brain Trust, where we try to get researchers to share with each other in order to advance the science. In terms of alternative therapies, we’ve set up an office under Dr. Jennifer Lee; its only mission is to look at alternative therapies and then try to validate them numerically, so we cannot only use them more broadly within VA, because we’ll do that anyway, but also change American medicine. This is one of the roles I think VA has, as the largest and greatest health-care system.

We’re already the largest user of acupuncture in the country, equine therapy, music therapy, creative writing therapy. All these things are things we’re trying, that frankly you couldn’t get a private medical system to do until the insurance company is willing to pay for it.

Some veterans have had success with medical marijuana. Where do you stand on the use of medical marijuana for veterans with PTSD?

Because we’re a federal agency, we have to follow the federal law, which says marijuana is against the law. Having said that, Dr. David Shulkin, our undersecretary for health, has made it clear to doctors within the Veterans Health Administration that they are allowed to, and should, consult on the use of medical marijuana in the states where it’s allowed. Our doctors can be involved in that discussion. There’s no preclusion against that. We just can’t prescribe it yet, given the federal law.

You have talked in the past about genome mapping. Where does that stand now?

There’s some evidence now that understanding the genetic sequencing of an individual can help us determine which post-traumatic stress treatment is more likely to work, and that’s great news. We have well over 550,000 blood samples of veterans. We’re in the process of working with the Department of Energy, and also with IBM Watson, to map the genome of those, and link them with the 20 to 30 years of medical records we have for those veterans.

I’d like to thank all those veterans who are continuing to serve their country by providing this. There’s no other country on Earth that has this capability, and this capability was built by veterans. 

We’re now incorporating it in all our diagnoses in our work with veterans so they understand what they’re susceptible to. It’s an example – just like VA doing the first liver transplant or the first implantable cardiac pacemaker – of VA leading innovation that not only helps veterans, but helps American medicine, helps the American people.

Let’s talk about electronic medical records. What’s keeping VA and DoD from going full bore and implementing this across the board?

Right now, VA and DoD have both certified that they have an interoperable record. VA docs can see the DoD record. DoD docs can see the VA record. The question is, “Why don’t we just go to an identical record?” DoD docs and VA docs have decided that they have different needs in that regard. As a result of those different needs, that’s kept the two agencies away from identicality. I think the future of electronic medical records in this country is something that’s going to be very different from where we are today. It’s probably going to be cloud-based, not server-based. It’s probably going to be agnostic to the medical record software and simply be able to gather data from any kind of record that exists. We’re working with some folks at Georgia Tech to understand that and get ahead of it, so that no matter what doctor the veteran goes to, no matter what medical record that doctor has, we can capture it and bring it up in an easy way for doctors to use.

As you mentioned, one of VA’s greatest successes is reducing homelessness. What else needs to happen to build on that?

Since 2010, homelessness is down about half, by 47 percent. We’ve housed more than 36,000 veterans and family members, or kept them from falling into homelessness. What needs to happen now is, we have less than 40,000 homeless veterans nationally. We literally have them by name. Those left are typically the ones who are in greatest need. Maybe a drug addiction, maybe a mental health issue, maybe incarceration is part of their past. Since we have them by name, we’re working with facilities all over the country to figure out the customized treatment they need.

The American Legion has been involved with many homeless-reduction successes firsthand – U.S.VETS in D.C. and MCVET in Maryland, for example. How significant is that contribution?

The Legion is a great partner. I said this when I came into this job: VA cannot do this job by itself. The idea, for example, of VA alone identifying the risks of suicide in a veteran is nonsensical. There aren’t enough employees. We need the entire community coming together. That’s one of the reasons we set up community veteran engagement boards around the country. It’s one of the reasons we’ve strengthened the relationship with our veterans service organizations like The American Legion. We need help. We can’t do it by ourselves.

The number of women veterans using VA health care has doubled since 2000. How is VA adjusting to meet that demand shift?

We have an office, the Center for Women Veterans. We hired a new leader for that office, Kayla Williams. She was a translator in Iraq and Afghanistan. She walked with the infantry. She’s tough. She’s a great leader. I want her to better embed the growth of women veterans into our strategies. In the past, that office had been mostly outreach to female veterans, and that’s important because women veterans don’t always self-identify.

I want Kayla to go through all our strategies, all  our policies, everywhere we’re active, and build capability so we’re ready for this large influx of women veterans in the future. Are we hiring enough gynecologists? What do we do about child care? What do we do about in-vitro fertilization for those who may have lost their ability to procreate because of battle injury? What do we do about women’s health clinics? Do we have enough? How about when we look at our clinic hours? Are we taking into account women and families? This is a big area for us and it’s got to be a big part of our transformation.

What would help VA better assist those women with military sexual trauma?

I’m not sure we need legislation, because we already have the ability to serve. In terms of military sexual trauma, we’re OK. What we need, obviously, is infrastructure improvement. Sixty percent of our buildings are over 50 years old. Many of them were built with single-gender restrooms. Many were built with communal bays for patients. Those things aren’t amenable to a large influx of female veterans. We need to be changing our buildings to accommodate this. 

After the summer flooding in North Carolina, VA worked with The American Legion and others to establish a mobile medical unit, bringing in veterans and civilians who needed care. How important is it for VA to activate in these crises?

We call it our fourth mission. As the largest integrated health-care system in the country, we are the safety net of health care for the American people. We take that fourth mission seriously. We have disaster drills, just like in the military. In the absence of that practice, and in the absence of a big national disaster, we go to the small ones. We were involved in the floods of North Carolina. We were involved in the shootings at Pulse in Orlando. We had mobile vans on the scene. We were doing counseling. We go wherever the disaster is. It doesn’t get much press, but it’s a very important mission for us.

Do you see those efforts expanding?

I actually think it’s going to expand because of the need. We were deeply involved in the Ebola crisis. We had specific sites with rooms where we could put Ebola-affected patients. I think the discovery of these things, whether it’s Zika, Ebola, whatever – it seems like they’re coming more frequently as science improves, and also as globalization improves. 

As you are about to leave VA, what do you see as some highlights of your tenure?

My purpose in life is to improve the lives of others. On any given day that I can sit with a veteran and have him or her tell me that some change we made improved their life, that for me is the biggest satisfaction. Like the day I talked to Bryant Jacobs, who had our first osseointegration operation in Salt Lake City. Rather than having a prosthetic device with the male-female coupling, we put a titanium rod in the femur, and the prosthetic device snaps on. Bryant told me that for the first time he could feel the grout cracks on the tile in his shower. He talked about his golf score improving by 15 strokes. That kind of opportunity to do the research we then can practice because we’re not encumbered by a for-profit system – that makes my life worthwhile.  

Henry Howard is deputy director of media and communications for The American Legion.