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Outpatient Cuts at Milwaukee VA

By John Zutz

In a memo dated the day after independence day, the Zablocki Veterans Affairs Medical Center (VAMC) declared itself free of non-service connected outpatients. Follow up memos show that not only will no new patients he admitted into clinics, but established patients will be discharged, and those needing the most service will be the first to go. Unconfirmed reports indicate that service-connected veterans are facing many of the same obstacles.

The cuts, which administrators hint will end with the start of a new budget year, will most likely continue unless the hospital's current $118 million budgets is increased considerably. Though hospital heads have tried to give the actions a low profile in the local media, internal VA memos detail the depths of the service cuts.

After waving the flag on the Fourth of July federal holiday, and welcoming back thousands of newly created Desert storm veterans, VA Center Director Russ Struble, and Chief of Staff Dr. Thomas Garthwaite sent a July 5th memo to all physicians and affiliated department chairmen stating that a "critical budgetary situation" was in effect due to a number of events, including; health care inflation, increased pharmacy costs, removal of pay caps, high requirements of specialty surgery patients from N. Chicago, partially funded cardiac surgery patients from Westside VAMC, and inpatient funding reductions for the coming year, with other fundings not keeping pace with requirements.

The memo contends that, "Traditionally, we have been generous in interpreting VA rules concerning eligibility for care," and though it warns that "this plan alone will be unlikely to save sufficient resources," it continues to outline the far reaching cuts.

The immediate plan is to develop criteria to "enforce strict eligibility for outpatient care." These criteria will "decrease [the number of] veterans who are followed to 'obviate the need for hospitalization.'" (Webster defines "obviate" as "to meet or anticipate and dispose of; make unnecessary. Syn. See Prevent.") Doctors are instructed to "eliminate entry of low priority veterans" into the clinic system, "prevent re-entry of patients," and "turn away veterans who are coming here only for prescriptions."

The memo goes on to hint that staff reductions will be necessary, but states that the center will "continue to provide quality care and maintain its excellent training programs."

This outline would be ominous enough, but shortly after, on July 15th, the Associate Chief of Staff/ Ambulatory Care Dr. James Byrd supplied some of the fine points in a memo to all physicians. He ordered that "Non Service-Connected veterans will not be referred to new clinics whether they are new or established patients."

He goes on to order doctors that "when you consider discharging the patient from your clinic you should consider discharging the patient from all clinics." This seems to indicate that a patient being seen, and subsequently discharged from, say the dermatology clinic, could also be discharged from the orthopedic, cardiac, or other clinics as well.

But Byrd's memo goes further to order that. "In addition to discharging simple patients (1 or 2 problems, 1 or 2 medications), we must also discharge complex patients who are heavy users of VA services." This in effect dumps the veterans who are the sickest and need help the most, out of the hospital supposedly specialized to help them, to search for help in the community. This comes at a time when local resources (read state, county, and city funds) are stretched to the limit. But don't worry, the memo continues, "Additional social workers are being assigned to assist with this process."

In a second July 15th memo, Dr. Byrd ordered Ambulatory Care and Emergency Room physicians to help decrease patient rolls. New Non Service-Connected veterans "should be referred to a community physician and receive limited prescriptions."

These memos would seem to indicate a rather free wheeling approach to deciding who should receive medical care. However, in a July 17 letter to Senator Herb Kohl, Director Struble insisted that "only patients that are considered stable will be discharged." And that "social workers will assist in finding community resources if needed" to take care of discharged vets.

A Sept. 6th Milwaukee Journal front page article, which tended to downplay the cuts, projected that 214,000 outpatient visits, and 10,000 inpatient admissions would be made the same year.

Veterans seeking medical help at the Milwaukee VAMC are in the process of falling through the "safety net." They will soon be needing help from those nebulous "thousand points of light" which are assumed to exist in their community. Veterans at the hospital were reluctant to talk on the record. Veterans groups in general have little hope for increasing the VA budget, they are busily, and somewhat unsuccessfully, trying to keep it from being cut further.