Major Surgery: Why the VA Won't Do and Why Patients Must Choose the Hospital and the Surgeon.

By any standards, the VA is a model of success for delivering health care nationwide. Still, it is under tremendous pressure from a rising patient load, not enough doctors and nurses, and lagging funding.

Like many VA clinics and hospitals, the Worcester clinic where I receive care has a doctor shortage. My primary care provider of seven years, Dr. Susan Krantz, left last year primarily because she was being asked to see more and more patients.

"It was clear to me," Dr. Krantz said, "that more and more my compensation was being linked not to the quality of care that I give but how many patients I can see in a day."

And, horror of horrors, the word has it that Dr. Krantz has gone to work for a health insurance company. Besides wishing her happiness in her new career, we can all hope that her patientcentric ways can somehow influence her new employer.

In the process of upgrading and revamping at the Worcester outpatient clinic, physician administrators have been gradually replaced by non-physician administrators who tend to be more at home with systems than with patient care.

A non-physician administrator was installed above the top physician administrator. The longtime physician administrator was not fired. He was stripped of authority, not to mention his office and parking space. Humiliated, the downgraded physician eventually quit.

As more non-physician managers take charge, VA physicians find themselves seeing more patients while systems drive patient care. The systems promote efficiency but sometimes do so at the expense of the traditional VA emphasis on preventive care.

The VA budget has not kept pace with increases in enrollment. The VA spends just 38% of what it spent in 1996. However, this may be changing. By 396 to 0, the U.S. House of Representatives has just approved a broader spending bill that would boost VA funding by $2.9 billion to $25.4 billion for the fiscal year beginning October 1. That is a 12% increase.

"It is a huge turnaround," said Rep. Chet Edwards, Democrat from Texas. "The increase is significant, it is real and it's important."


But the funding is very much catch-up after years of stagnant VA budgets coupled by rising needs, such as caring for military returning from Afghanistan and Iraq. Despite a consensus to step up VA funding, whether it will be enough to deliver top-flight care in the face of rapidly growing demand for care is still a real question mark.

In the best of times, the VA does not deliver excellence in every respect. Based on my own experience and conversations with other VA patients, the VA is not your best choice for major surgery. In such a case, you may be better off with a non-VA hospital. Major fixits are what private hospitals can do well, but are not what the VA system does best.

My younger brother Vic, pictured here, got what can only be described as a runaround from the VA when he was having trouble swallowing and digesting food. He had lost a good part of his stomach from a grenade explosion in Vietnam. He holds a bronze star and other combat decorations and is in the VA's highest-priority category -- service-connected 100% disabled.

Yet he was passed from VA doctor to VA doctor. All were reluctant to recommend the major surgery that Vic felt he needed; that is, opening him up and cutting away built-up scar tissue that was obstructing the passage of food to what remained of his stomach.
Vic had to endure seemingly endless trips to the VA to argue his case. He grew sicker and sicker. His weight dropped to 113 pounds and he began to look more like a cadaver than a human being.

Finally, after weeks of this and with Vic declining rapidly, high-level approval came through for the procedure. The surgery was successful. Vic got his appetite back. A year later, he was back up to 146 pounds and enjoying life.

When my knees, riddled with traumatic arthritis from years of playing ice hockey, finally gave out, I never considered having surgery at the VA. I said to Dr. Krantz, “I think I need two total knee replacements but I don't want them done at the VA.”

“I don't blame you one bit," Dr. Krantz said. "It would probably take a while for the VA to approve it. They'll wait until you can't walk and even then they will drag their feet. The process would be quicker with a private system. You could also choose your surgeon and have more control over your care.”

Dr. Krantz gave me her blessing to see my outside physician, Dr. Daniel Marelli. I called for an appointment and, as usual, quickly got one. Sitting on the examining table in his office, I said, "My knees have finally crapped out. I can't play tennis any more. I can't even stand up straight. I walk like a bowlegged cowboy. I think I need two total knee replacements. Could you give me a referral to see Dr. Dan Berkowitz at Mass General in Boston? He's a joint replacement specialist that I have heard great things about.”

Dr. Marelli had me stand up. "I can see," he said.

"I have already had arthroscopic surgery on both knees and it hasn't helped. I'm at the end of the road on these knees. I don't want the VA. I don't want the surgery to be done locally. I've heard too many horror stories. I want Dr. Berkholtz (not his real name) at Mass General in Boston."

"I'll make the referral."

Why Mass General? Why Dr. Berkholtz? Mass General is a first-class major hospital with an outstanding orthopedic department. Dr. Berkholtz is the department's go-to guy for total joint replacements and does hundreds a year with superlative results.

A couple of guys I knew at the Worcester Tennis Club had their hips replaced by Dr. Berkholtz and I watched them out there running around and playing tennis – and playing well – and feeling great. As far as I am concerned, there's no higher recommendation for a surgeon than to see his outcomes flying around a tennis court.

In addition to his medical degree, Dr. Berkholtz has a master's degree in engineering from M.I.T. He is also a tennis player. I told him that I want to be able to chase down wide balls and lobs, and he did not consider that an unreasonable expectation.

In knee replacements, who your surgeon is makes a difference. You don't want a surgeon who is not a specialist and who does just a few replacements here and there. You want somebody who does total knee replacements day in and day out and does so many he can do one practically with his eyes closed. That is Dr. Berkholtz.

At the VA, you have to move heaven and earth to get approval for total knee replacements and when you get approval, if you're still alive when you do, you have no say in who you get as a surgeon. You have to take whoever they give you whether good, bad, or indifferent. No thanks.

My health insurer at the time was Harvard-Pilgrim, whose latest increase had brought the monthly premium to more than $800 a month. The insurance was through the retirement plan of my wife, Barbara. She had retired after being a teacher for 26 years. Her old school district picked up half the cost of the health insurance cost. The monthly premium was going up at a breathtaking rate, however.

“You know, dear,” I said to Barbara, “one of these days, the health insurance premium is going to take your entire retirement check.”

True to his word, Dr. Marelli gave me a referral to Dr. Berkholtz and his office notified Harvard-Pilgrim. It took nearly two months to get in to see Dr. Berkholtz. When I finally saw him, accompanied by my wife, Barbara, and brother, Vic, Dr. Burke took one look at the x-rays and said, “You have only one option – replacement of both knees.”

In other words, he agreed with my own diagnosis and prescription. I am not a doctor; I just play one in real life, as we all must these days. “It's what I thought. Can I have both knees replaced at the same time?”

“It can be done and some surgeons do it with good outcomes, but I don't do both knees at once. There is a slight increase of risk and I prefer to avoid unnecessary increased risk. I can give you the name of another surgeon, if you like.”

“No, you're my guy. We do them separately.”

You'd think we were talking about a fender job for a car. That's how fast and routinely patients have to make big medical decisions. Let's be clear: patients and ever-present third parties make the big medical decisions today, not doctors. A patient can ask for total knee replacements and the doctor can agree that this is the right course, but for the procedure to take place, the insurer must agree.

“Okay,” Dr. Berkholtz said. "Stop at the office and they'll set things up."

We shook hands and he was gone, just like that. Dr. Berkholtz sees patients only once a week and is in surgery most other days. On my way out, I passed Dr. Berkholtz's next patient on his way in. He was just like all the other patients packed into the waiting room: old, hurting, face etched with fear.

They sat with drooped heads, some clutching crutches or holding walkers. A couple of elderly men sat dejectedly in wheel chairs. The waiting room was a sad place. Hobbling through it on two bowed and hurting legs, I was also old, bent over, and scared. I fit right in.

The office people explained what was going to happen and what preparations had to be made. It was obvious they had given the spiel hundreds of times, which I liked. I got on the calendar – more than three months away -- for total knee replacement surgery on the first knee. To my utter astonishment, Harvard-Pilgrim quickly approved the major surgery for both knees and assigned me a case worker.

The case worker got in touch with me immediately and stayed in touch every step of the way, from pre-surgery to the lengthy physical therapy. The bill for two new knees plus rehab would exceed $70,000, all of which Harvard-Pilgrim paid promptly and with a remarkable absence of red tape.

In previous posts, I have written a lot of highly critical things about HMO's. I don't take back a word because all of it is true. To my surprise and pleasure, Harvard-Pilgrim was an altogether different animal than the typical HMO.

I had heard many horror stories about health insurance companies refusing to pay this and refusing to pay that and swamping people with paperwork. My own research confirmed the worst. So with Harvard-Pilgrim, I was prepared for the worst and instead got the best.

In a recent report, the National Committee for Quality Assurance ranked Harvard-Pilgrim as the best HMO in the country in both quality of care and member satisfaction. I didn't know Harvard-Pilgrim was this good but I certainly do now. I wrote the company an enthusiastic letter of thanks.

Leaving aside the amazingly high cost, the whole experience of my two total knee replacements was an example of the American health care system at its best. The outcome could not have been better. Today, instead of my wife Barbara pushing me around in a wheelchair, I play tennis three or four times a week.

And, yes, thanks to Dr. Berkholtz's wonderful skills, I chase down those wide shots and lobs. – and comes off the courts sweating like a pig, pooped and happy. In addition to playing tennis doubles two or three times a week, I have begun playing singles tennis a couple of times a week.

This incredible outcome was a combination of planning and plain old luck. It took my knowing where to go for the surgery, how to go about it, my wife Barbara managing the process, Dr. Berkowitz's surgical wizardry, lucking out with Harvard-Pilgrim, and months of brutal rehab.

I was a rehab fanatic. I pushed harder than anyone in my physical therapy group. Everybody else was willing to settle for being able to walk; I was determined to play competitive tennis.

No physical therapist would dare to push a total knee replacement patient the way I pushed myself. I took the suggested exercises and multiplied them two, three, and four times. I asked my therapist -- Iron Mike I called him because he seemed to enjoy being around pain -- for the "toughest regimen you got.”

He gladly complied. I made it even tougher. But in my two-year follow-up with Dr. Berkowitz, coming up in a couple of months, I'm going to show him an outcome that he himself may not even know is possible.

And I, the patient, was in charge from beginning to end. For the best outcome from major surgery, it has to be that way. Don't do it any other way.

So long and keep moving.