VA Pittsburgh's new director aims to make health care for vets more convenient, close to home

The week after Donald Koenig took the helm of the VA Pittsburgh Healthcare System, a federal law took effect that ushered in unprecedented competition over veterans care nationwide.

The Mission Act — bipartisan-backed legislation that took effect June 6, the 75th anniversary of D-Day — makes it easier than ever for veterans to go to a non-Veterans Affairs doctor and still have the VA pay for their treatment.

After confronting years of lengthy waits and appointment backlogs, veterans with VA benefits now can opt to make a private appointment close to home for primary or specialty care if the VA is not meeting their needs, or is not doing so quickly enough.

They can also immediately access dozens of urgent care clinics across Western Pennsylvania.

The Trump administration championed the law again last week as poised to transform how veterans get health care and “ensure that veterans receive the highest quality of care and support possible.”

Giving vets the power to shop around

Koenig, 61, a 13-year Navy veteran and lawyer-turned-hospital executive who grew up in Greensburg and Bethel Park, views the policy shift toward giving veterans a broad choice of health care providers as a positive improvement that’s here to stay. With nine years under his belt as chief operating officer at Mercy Health System in Ohio and president of St. Elizabeth Youngstown Hospital, Koenig says he’s been “very frank” with longtime VA employees who have suggested that perhaps the Mission Act will turn out to be a two- or three-year “experiment.” The looming changes were what piqued his interest about taking the job when he applied last August, when he decided he wasn’t quite ready to retire a few months after he left his Mercy Health post in April 2018.

“Once you’ve invested that authority in the veterans, themselves, that you get to choose where you want, you can’t take that away,” Koenig told the Tribune-Review from his office at VA Pittsburgh’s H.J. Heinz Campus in O’Hara, a short drive from Route 28 and UPMC St. Margaret near Aspinwall.

VA Pittsburgh spans two major medical inpatient, outpatient and community living centers — with its main hospital and emergency department in Pittsburgh’s Oakland neighborhood — and five outpatient clinics in Western Pennsylvania and Ohio.

The system served nearly 79,000 veterans last year across its 13-county region.

The system’s freshly installed director — its fifth director in six years — says the increased competition also means it’s more important than ever for the VA to focus on an overarching priority: getting care to veterans “faster and closer to where they live.”

“We have to put the veteran in the middle of this and figure out how we make VA Pittsburgh the easiest choice every time,” Koenig said.

Koenig, who splits his time between Pittsburgh and Youngstown, concedes that VA Pittsburgh has some work to do to keep up with nongovernment health system options such as UPMC, Allegheny Health Network and Excela.

“VA Pittsburgh has made huge progress, but we still have a long ways to go at making sure access to our appointments is as convenient as patients would like,” Koenig said. “Lowering wait times, being able to book your appointment right online for your doctor — we’re slowly getting there, but we’re not quite there. Other health systems are doing a little better job at that.”

Better coordination, personalized “whole health” treatment plans, data-driven improvements and increased use of technology and programs to reach patients — such as via mobile doctor’s units and video appointments — are among Koenig’s priorities for VA Pittsburgh Healthcare System.

It has a roughly $650 million annual budget and nearly 3,800 employees, including 285 doctors and 915 nurses. About one-third of employees are veterans.

Koenig’s first day was May 28. He’s preparing a “state of VA Pittsburgh” report on his first 90 days of observations.

The Tribune-Review sat down with Koenig and discussed some of his top goals and thoughts about what needs to improve about VA Pittsburgh.

Koenig also hit on President Trump’s interest in a Trump-backed, controversial antidepressant prescription drug likened to “Special K”; whether veterans can use medical marijuana to treat PTSD; and how VA Pittsburgh has rebounded and learned from the Legionnaire’s disease outbreak that killed at least five patients several years ago.

Here are some highlights:

Tell us more about the Mission Act, what it means for veterans and what it means for VA Pittsburgh.

Koenig: “Veterans received the power to go to civilian care much more easily. The standards that we have to meet for a new primary care or behavioral health appointment, we have to see them within 20 days of their requested appointment date. For a specialist, it’s 28 days.

“For primary care/behavorial health, you’re not going to drive more than 30 minutes from where you live to get to that appointment and 60 minutes for the specialist.

“If the VA can’t meet those standards, we now present them the option — we can give you the paperwork, you are free to go to the civilian hospital or doctor of your choice if you prefer, and VA will pay for it.

“The veterans will appreciate it. Some will say, for whatever reason, the rest of my life, ‘Forever VA.’ Some will, because of convenience … give UPMC a try. Some will try UPMC and then immediately the next time they need something they’ll start with the VA again. Some may go to UPMC and decide they like it and remain there.

“That’s just the reality of when you put the power into the shopper of making the informed choices. That’s why we need to make sure that the VA is always the easiest, the best choice, the one that puts the veteran at the middle of every decision.”

Critics and advocacy groups such as the Veterans of Foreign Wars have cautioned that while perhaps beneficial to veterans, opening up access to private providers could threaten the viability of VA programs should too many veterans veer away from VA facilities. (Last year, VA Pittsburgh served 78,652 patients, up 6.4 % from 2017.) How many veterans are taking advantage of the option to see private doctors so far?

“We’re still waiting to see some of the data, but we understand that (the urgent care option) is very popular with veterans.

“We certainly think that our commitment to taking care closer to the veterans and where they live, whether it’s in Erie or Altoona, will help us weather the Mission Act.”

Give me some examples of how you’re making care more convenient.

Koenig: “So when you go to our Oakland campus, you pull into the parking garage, it’s probably a football-field-and-a-half-long designated parking for all the big buses that come from Erie and Altoona and Clarksburg and other sites, bringing veterans to Pittsburgh for their Pittsburgh appointments.

“They ride the bus for hours, come and get all their appointments and then get back on that bus and go back home. That’s been the way it has worked with big hub hospitals for many, many years.

“We’re saying, ‘Well, how do we change that?’ Can we change out those big buses for small, WiFi-enabled vans and send the doctors and the nurses from Pittsburgh to go take care of patients in Altoona, in Erie, in Butler, in those outlying areas, and so we’ve begun doing that. …

“One of the most amazing, innovative programs was that Altoona did not have a capacity at the VA to treat their cancer patients for their chemotherapy. … So we worked with the staff there, a great collaboration, we said, ‘Let’s build the space necessary so your pharmacist can custom-mix the drugs just as the patient arrives. We’ll train the staff, and then we’ll use a video tele-presence with their oncologist here in Pittsburgh.’ And now they don’t have to do five hours on the bus three times a week. So it absolutely thrilled the patients, what an improvement to their lifestyle. It gets the care closer to where our patients are.”

”We opened new ones (community outpatient clinics) in the past year in Rochester, Pa., which is Beaver County, a brand-new one in Washington, in St. Clairsville, in Fayette, and we’re getting ready to let the contract go for the new replacement one in Westmoreland. … Each of them has a dedicated tele-medicine room. … It could be a cardiologist, a pulmonologist, someone back in Pittsburgh, they can do that from the comfort of the outpatient care center that’s close to where they live.

“We’re also the behavioral health tele-network for about a third of the country … if people need to reach out to psychology or mental health training or suicide hotline.”

What are the VA’s goals in terms of wait times, and how does VA Pittsburgh stack up?

“We’re getting much better, we are offering same-day appointments at a number of clinics. … We will offer tele-medicine visits same day … Even for World War II veterans in their 80s, it’s no harder than Facetiming the grandkids. …

“The ER has (a typical wait time from arrival to release of) about 3½ hours. The goal is to get patients treated and released within 2½ hours and to admit patients in 3½ hours. Some days it will run 4½. We keep a very close tab on any patients who leave without being seen.”

Last year, the average wait was six days for primary care and two days for mental health at the VA campus in Pittsburgh’s Oakland neighborhood; and five days for primary care and three days for mental health at VA Pittsburgh’s O’Hara campus, according to VA Pittsburgh’s annual report.

President Trump last week made another public lobby for Johnson & Johnson’s prescription drug Spravato, a nasal spray antidepressant that uses ketamine, known as the street drug “Special K,” as a way to prevent veteran suicides. A team of VA clinicians failed to add the drug to its fully approved medication list in May, despite Trump’s repeated statements in support of it.

Koenig: “All I know is that the medical folks, I think, are still looking at it, at least (at) preliminary review, they were not quite ready to approve it, but I’m sure they will work it out.

Another key point about VA Pittsburgh that you may not know — we employee 300 people doing clinical research. We are one of the major clinical research hospitals for the VA. So we have a number of wonderful people who are working on next-generation medicines and trying novel approaches to caring for different disease processes.

Tell me about VA Pitttsburgh’s expanded efforts regarding suicide prevention.

Koenig emphasized that even veterans with dishonorable discharges ineligible for most medical benefits are eligible to receive VA-funded mental health and suicide prevention programs: “If you are a veteran, and you are feeling at all suicidal, reach out to the VA, and we will get you hooked up.

“Because of the generational differences, the things you would use to reach out to a depressed World War II veteran are very different than what the 29-year-0ld who has just come back from Afghanistan is going to think of. We’re certainly moving much more to have a presence on social media. … Whether it’s a person on a hotline to talk with them, a fellow veteran to talk with them, up to we’ve got a safe place for you to come and we will help you deal with those feelings … and help you avoid making that costly decision.

“There are still too many dying every day. That statistic of about 20 a day — about four are active-duty, 16 are veterans. Of the 16 veterans, less than half are enrolled in VA health care.

“No one is able to measure how many did we save … but we know that our behavioral health, our suicide prevention classes and support groups are quite full, so we’re reaching lots of folks.”

Q: PTSD now is on the state-approved list of conditions for Pennsylvania’s medical marijuana program, but marijuana in any form remains illegal under federal law. What does that mean for VA patients interested in trying medicinal cannabis? Koenig: That’s a tough one, right? A tough one for the federal government. … They can (get medical marijuana cards). They can pay for it themselves.

“Because it’s an illegal controlled substance, we can’t prescribe it. But what we want veterans to understand is, do tell your doctor. … Don’t feel that you have to hide it from the VA, we just are not going to be able to provide it to you.”

At least five patients’ deaths were linked to a Legion­naires’ outbreak at the VA Pittsburgh Healthcare System from February 2011 to November 2012. Tell me about what has been done since to prevent hospital-borne contamination from ever happening again.

Koenig: “That was a period of time for Pittsburgh VA. Patients died. (Legionella) is a bacteria that is present at some extent in all municipal water systems, and what happens is in older buildings or in buildings where you add on, if you end up with dead-end pipe runs and water sits, it can begin to reproduce. Water that sits in an evaporation tower on the roof for your cooler system, water in a fountain, it will reproduce, and then the fountain aerosolizes it and so it’s caught by breathing in. And so it was a horrible, horrible event.

“But Pittsburgh has dedicated itself to fixing the problems, monitoring it like nobody’s business, becoming the national experts for the VA on legionella prevention and water safety programs. We are the experts that many call upon to say, ‘We’re having an issue, can you come help us?’

“We monitor our water every month and we put it on our web page. We want everyone to see: ‘Here are the monthly reports of all of our legionella testing, our water temperature testing.’

“I get a report every Friday morning from my chief of infectious disease — about how many pneumonias developed this week at VA Pittsburgh, how many legionella cases and were any of them in-house. We have not had an in-house (legionella) case in quite awhile, in well more than several years.”

Tell me about your leadership and management style.

Koenig: “I like the saying, ‘Culture eats strategy for lunch.’ If you have the right people with the right mindset doing the right things for the right reason, strategy and everything else will take care of itself.

“You’ve got to visit the night shift. They’re either a third or a half of your crew. … They need to know you care; you need to see how everything’s going. Particularly when you pop in unannounced, you send that very nice, subtle message of ‘Hey, the boss could come in at any time; we really do need to be paying attention to what we’re supposed to be doing.’

What made you apply to run VA Pittsburgh?

“I knew the VA was looking for new leaders that didn’t necessarily come out of the VA mold. They wanted people with greater experience running civilian health systems who had to compete for the loyalty of their patients because of the new programs the VA was implementing, (since) they were planning on putting a lot more discretion in the hands of the veterans. I decided maybe I should check it out to see what’s available.

“The very first day I look on the jobs list (in August 2018), the Pittsburgh (VA director job) had just opened up. I was like, ‘That’s my hometown.’ I think that’s the sign I needed that this is where I’m supposed to be.”