New York Times: The V.A. Prepares to Back Up a Health Care System Threatened by Coronavirus

WASHINGTON – The Department of Veterans Affairs, legally designated as the backup health care system in national emergencies, is preparing to absorb the overflow of coronavirus patients from private hospitals if – or when – they become strained to the breaking point. It would be the biggest test the sprawling and sometimes troubled government hospital system has faced.

The department is experienced in managing an older and vulnerable population, and in many ways, it could be better prepared than the rest of the health care system to take on the task. It has a surplus of beds in many of its 172 hospital centers and a robust number of special rooms for patients with breathing disorders. Leaders at the agency say they have a surplus of supplies that they have been ordering since the beginning of the year.

“Nobody has asked for our help at this point, but the American people should know we are ready,” said Dr. Richard A. Stone, who is in charge of the Veterans Health Administration.

But several current and former officials said they feared that in this case, the department would be hampered by its highly centralized and often opaque management culture, which has left some critical players unsure of how the department is preparing and what is expected of its tens of thousands of employees.

In 1982, Congress added what is known as a fourth mission to the department – which otherwise focuses on patient care, training and research – to back up the nation’s entire health care system.

The private-sector health care system has 2.8 hospital beds per 1,000 people and an estimated 45,000 intensive care unit beds, and it could be overwhelmed with an explosion in the number of new, acutely ill patients.

The department has, in theory, the capacity to fill its mission. In addition to its central medical facilities, it has 1,074 outpatient sites and more than 330,000 full-time employees across the country. The veterans’ system has 13,000 acute care beds, including 1,800 intensive care beds, and has far more equipment and specialized care facilities – such as negative pressure rooms meant to isolate those with an infection like the coronavirus – than many private hospital systems.

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It has played a significant and often vital role in recent years, backing up the strained health care system in Puerto Rico after a hurricane – it had intravenous therapy solutions that other centers did not – and providing mobile units after the 2016 mass shooting in the Pulse nightclub in Orlando, Fla. The department is one of the many federal coordinating centers that respond to emergencies; it even played a role in the Ebola outbreak.

Its problem, though, may be management.

When the department decided last week to bar visitors from its nursing homes to protect against a coronavirus outbreak, some were unprepared. The police force of the department, strained by its diminished numbers, is concerned about how to manage situations like a recent visitor to a veterans’ hospital who had to be physically removed under protest after an initial screening showed he was possibly infected with the coronavirus.

Some workers said they were not clear if veterans would be prioritized over civilians in an emergency at their medical centers, and there were mixed messages in the department as to whether it would be called on at all.

“There is not a unified plan of action,” said Bob Fetzer, the president of the Fourth District of the American Federal of Government Employees National Veterans Affairs Council, which represents thousands of workers from the department. He said he had received complaints from members who said they were not receiving communications from Washington.

Robert L. Wilkie, the secretary of veterans affairs, was added belatedly to the White House coronavirus task force this month and is rarely visible, other participants said.

He was not among the many officials and corporate executives who spoke on Friday at a news conference with President Trump in the Rose Garden. The department was not even mentioned at that event. Several current and former employees at the veterans department and Capitol Hill staff members said they hoped Mr. Wilkie, who does not have a background in public health, would not be sidelined.

A senior administration official familiar with the task force’s meetings said that Mr. Wilkie’s role in the group, thus far at least, had mostly included offering reassurances that the veterans’ medical system was ready to help. “To my knowledge he was been at all the meetings,” Dr. Stone said.

Lawmakers in both parties, who have long complained about opacity at the department, are carefully watching.

“We recognize that the Covid-19 outbreak is an evolving situation, with a growing impact on the United States and global community, and want to ensure that the V.A. has all of the resources needed to keep veterans, staff and communities safe,” Senator Jon Tester of Montana, the ranking Democrat on the Senate Committee on Veterans’ Affairs, said in a statement, referring to the disease caused by the virus.

A group of senators has requested information on the agency’s efforts to increase its response time and preparedness as cases are expected to climb among veterans, who tend to be older and have underlying medical conditions that put them at greater risk.

Dr. Stone has been the department’s lead official speaking to Capitol Hill, the White House and the news media. Congressional staff members receive daily updates on the number and location of veterans who test positive – 16 as of Friday – and have begun weekly conference calls with Dr. Stone.

The department’s medical centers are far-flung and operate largely independently. They vary greatly in capacity and quality. During a national emergency, local officials would have to explain their needs and abilities to Washington while seeking guidance. The questions would include: How do they prioritize care between veterans and nonveterans? How should workers telecommute?

Mr. Wilkie has in the past expressed concern that the department cannot keep proper track of its number of employees or their functions.

Older veterans, who make up a large portion of the department’s patient base, as well as those with very difficult injuries and illnesses like spinal cord injuries and kidney failure, need special and acute care and sometimes rely on private contractors for things like dialysis. Those patients are likely to be the department’s focus if supplies dwindle in the American health care system.

About 60 percent of the department’s medical staff have affiliations with other medical centers, and some workers worry about staff shortages in an extreme situation like those faced in China and Italy, although many of those doctors weight their time heavily toward the department’s facilities. During a hurricane in the Carolinas, medical staff worked overtime to personally move fragile spinal cord injury patients from the area to other states and bunked with department employees there.

“The V.A. has some very talented people who work on emergency preparedness,” said David J. Shulkin, a former secretary of veterans affairs. “This is their time to shine.”

Unlike many other urban hospital centers, the Department of Veterans Affairs has dozens of centers across the nation with excess capacity, especially in the Northeast and the Rust Belt, where the veteran population has greatly declined. It can offer backup beds and care when private hospitals become overwhelmed. But a 50-bed center operating at only 30 percent capacity may not have the extra medical staff standing by to handle the influx, some officials cautioned. That may make the capacity less useful than it could be.

Epidemiologists fear that medical professionals will also be infected by the virus, depleting their numbers.

“I think we all need to recognize that in a heavy penetration of this virus, we are all going to be looking for providers,” Dr. Stone said. “But we are well staffed and well trained for what we need to do today.”

Dr. Stone said the department had been ordering large quantities of supplies that could prove vital if those resources at other hospitals become depleted.

“We are certainly not the first line of defense,” Dr. Stone said, but should the department be called on to assist with a civilian crisis, he was confident that it would step up.

https://www.nytimes.com/2020/03/15/us/politics/veterans-affairs-coronavirus.html