VA Scandal Widens

On Memorial Day, which honors those who died in service to the country, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) is investigating medical facilities in at least 26 cities (1). The scandal started in Phoenix where Sam Foote, a retired VA physician, alleged that up to 40 patients in Arizona died awaiting care in a network where some veterans could not get appointments for more than a year. Foote claimed that Phoenix VA officials were misrepresenting wait times to collect bonus checks while maintaining "secret lists" of patients. These accusations resulted in the suspension of Sharon Helman, the Phoenix VA hospital director, along with her associate director and another unnamed senior administrator. Dennis Wagner in an article in the Arizona Republic listed many of the accusations made against various VA hospitals outside of Phoenix (1). These include:

• Chicago: Germaine Clarno, president of a federal employee union, said secret lists and falsified wait times had been an "everyday practice" at the Hines VA Hospital, and complaints of data fraud were ignored. Hellman was previously at the Hines VA director prior to coming to Phoenix. Clarno also said the inspector general conducted an inquiry, but targeted tangential issues. "The problem is the government covers up for the government — the OIG is a bed partner of VA administration." The OIG had investigated the Phoenix VA in late 2013 but Robert Petzel, then undersecretary for Veterans Healthcare Administration, said the OIG found no evidence to support Foote's claims (2). Petzel later resigned and the White House has nominated Jeffrey Murawsky who previously served as director of VA Veterans Integrated Service Network (VISN) 12 which oversees the Hines VA and who directly supervised Helman (3).
• Walla Walla, WA: VA auditors who visited the Walla Walls VA, where Helman previously served as director prior to coming to Hines VA, identified improper and inconsistent patient-scheduling practices, according to the Walla Walla Union-Bulletin. A psychiatric nurse, who won a whistle-blower settlement after being terminated, told NBC News that intimidation and retaliation were commonplace at the medical center.
• San Antonio, Texas: Dr. Joseph Spann, who retired in January after 17 years with the VA, told federal investigators that physicians were regularly asked to alter the "request date" for medical procedures to hide backlogs for tests. Spann attributed the practice to pressure to meet performance measures that reward administrators bonuses. When told local VA officials had conducted a review and denied the allegation, Spann said, "Central Texas (VA) investigating itself is just worthless." Raymond Chung who was the previous Chief of Staff at the Phoenix VA came to Phoenix from San Antonio.
• Cheyenne, WY: Congressional investigators uncovered an e-mail written by a nurse to other VA employees describing techniques for "gaming the system" by falsifying appointment records to meet goals set by bosses. The nurse was suspended after the e-mail was made public. The director of the Cheyenne VA is Cynthia McCormack who previously was chief of nursing at the Phoenix VA.
• Fort Collins, CO: OIG investigators in December found that medical clinic staffers were trained to make it appear veterans were getting appointments within 14 days, per department guidelines, even though waits were longer. McCormack supervises the Fort Collins clinic.
• Albuquerque: U.S. Sen. Tom Udall, D-N.M., called for an investigation after allegations that  wait-time records were falsified Phoenix. Phoenix and Albuquerque are both supervised by Susan Bowers, the VISN 18 director.

As the above illustrates, the connections between these administrators is striking. Beginning several years ago, according to internal VA records, VA central office in Washington realized medical centers around the country were finding ways to manipulate the numbers. The VA had for several years been the subject of congressional inquiry and criticism not just due to long waits for care, but because of mismanagement but no action was taken.

Although Congress, VA central office in Washington and the local VISNs are all charged with overseeing the VA hospitals, the task of supervising this large, complex bureaucracy is daunting and appears to have been inadequate. A system needs to be put in place where healthcare providers who care for veterans and veteran patients who use the facility have a role in the oversight of their local VA hospital.  Creation of a hospital board of directors consisting predominately of healthcare providers from the facility and veterans might be able to provide the supervision that this ever widening scandal suggests is needed.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Delayed care, fraud point to ailing VA health system. The Arizona Republic. May 25, 2014. Available at: http://www.azcentral.com/story/news/politics/investigations/2014/05/25/va-medical-care-woes/9564605/ (accessed 5/26/14).
2. Wagner D. VA: We found no evidence to support allegations in Phoenix. The Arizona Republic. April 30,2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/30/phoenix-veteran-hospital-deaths-investigation/8518721/ (accessed 5/26/14).
3. O'Dell R, Nowicki D, The Arizona Republic. May 16, 2014. Available at: http://www.usatoday.com/story/news/nation/2014/05/16/top-va-health-official-resigns-under-fire/9182311/ (accessed 5/26/14).

*The opinions expressed are those of the author and do not necessarily represent those of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. doi: http://dx.doi.org/10.13175/swjpcc070-14 PDF

Don’t Fire Sharon Helman-At Least Not Yet

Several developments have occurred over the past few days regarding prolonged wait times and secret lists at the Phoenix VA and its embattled director, Sharon Helman. President Obama has asked for an investigation and several Arizona Senators and Representatives have called for investigations and/or asked for the resignation of Helman and her administrative team (1,2). On 4/30/14, Dr. Robert Petzel, VA undersecretary for health, testified that an administrative team visited Phoenix soon after the controversy erupted and found “no evidence of a secret list… [or] patients who have died because they [were] on a wait list." (3). On 5/1/14 CNN posted an interview with Sharon Helman and her Chief of Staff, Dr. Darren Deering, who denied the allegations. Dr. Sam Foote, who made the original allegations, accused Helman and Deering of lying (4). CNN apparently confirmed Foote’s story with several sources inside the VA including a second physician, Dr. Katherine Mitchell (5). Later the same day, Eric Shinseki, Secretary of Veterans Affairs, suspended Helman and two others (5).

This all sounded very familiar (6). In 2012 the VA Office of Inspector General (OIG) issued a report on the accuracy of the Veterans Healthcare Administration (VHA) wait times for mental health services (7). The report found that “VHA does not have a reliable and accurate method of determining whether they are providing patients timely access to mental health care services. VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time to see a mental health provider.”

After the 2012 OIG report came the inevitable Congressional hearing (8). Although misrepresenting actual wait times has been known for many years, there has been inadequate action to correct the practice according to the VA OIG. Sen. Patty Murray, then chair of the Senate Committee on Veterans' Affairs, said the findings showed a "rampant gaming of the system." (8). A review of the OIG’s website revealed multiple instances of similar findings dating back to at least 2002 (6). In each instance, unreliable data regarding wait times was cited and no or inadequate action was taken.

The providers at the VA should not necessarily view this as not good news. The VA has usually sought to refocus blame away from the administrators to “lazy” or “poor” doctors. My guess is that we will soon see a number of accusations about Drs. Foote and Mitchell in an effort to administratively circle the wagons. VA administrators usually seize on such opportunities to control physicians. Remember the computer fiasco from several years back when an information technology administrator lost a computer with confidential patient information (9)? This not only resulted in information technology being placed in charge of the electronic healthcare record but a number of restrictions were placed on physician use of data. Furthermore, administrators can now not only regulate a physician’s salary but “black ball” physicians by false accusations through sources such as the National Practioner Data Bank (NPDB). Not surprisingly, physicians are reluctant to speak out when their livelihood can be threatened.

Clearly, the present system is not working. Firing Sharon Helman will solve nothing at the present other than giving some politicians the opportunity to congratulate themselves on weeding out a bad apple in this election year. Furthermore, firing Helman could be an attempt to hide a systemic problem by offering Helman as the “fall guy”. So instead of redoing the OIG investigations and the Congressional hearings which have accomplished nothing in the past, how about doing something else? Here are a few suggestions:

1. Have Helman investigated by an independent source, not the OIG. Examine other VAs for similarly misrepresenting patient wait times. Over thirty years at the VA taught me that if wait times are being "gamed" by one VA, the times are also likely being "gamed" by others.
2. Create a National Healthcare Administrator Data Bank similar to the NPDB with all the same safeguards and checks and balances available to physicians. Helman apparently had a history of misrepresenting data (10). It seems unlikely that she would have been hired if this was publically known.
3. Provide adequate oversight. The local Veterans Integrated Service Network (VISN), VA Central Office in Washington, and Congress is not providing the oversight needed. Create a hospital board of directors consisting predominately of a majority of healthcare providers from the facility and Veterans (not to be appointed by the director) to provide oversight.
4. Quit hiring more administrators while reducing the number of doctors. Inadequate numbers of providers is the root cause of prolonged wait times and has been present for a number of years (6). The numbers of administrators, nurses and doctors should be transparent and publically available.
5. Quit paying administrators bonuses for work done by doctors. This only encourages cheating on reports (6,7). If administrators need a bonus, reward them for achievements in administrative efficiency or similar administrative goals. Both the criteria for and the amount of the bonus should be transparent and publically available.
6. Scrap the VISN system. These local collections of administrators are another source of waste and appear to add no real oversight or patient benefit.

The optimist in me hopes the situation at the Phoenix VA and possibly other VAs is thoroughly investigated. If Helman is the “bad apple” many would like to portray-then fire her. If her actions are more a result of a systemic problem-then fix the problem.  However, the cynic in me fears that Helman will be sacrificed without a thorough investigation and no change will occur.  In that case I will again be writing about an investigation of VA administrators "gaming the system", probably in 2016.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. McCain, Flake call for Senate probe of Phoenix VA. The Arizona Republic. April 23, 2014. Available at: http://www.azcentral.com/story/news/arizona/politics/2014/04/23/mccain-flake-call-senate-probe-phoenix-va/8061141/ (accessed 5/1/14).
2. Harris C, Wagner D. Phoenix VA officials deny there's a secret wait list; doctor says they're lying. The Arizona Republic. April 29, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/29/phoenix-va-director-congressman-call-for-removal/8447131/ (accessed 5/1/14).
3. Wagner D. VA: We found no evidence to support allegations in Phoenix. The Arizona Republic. April 30, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/30/phoenix-veteran-hospital-deaths-investigation/8518721/ (accessed 5/1/14).
4. Bronstein S, Griffin D, Black N. Phoenix VA officials deny there's a secret wait list; doctor says they're lying. CNN. May 1, 2014. Available at: http://www.cnn.com/2014/04/30/health/veterans-dying-health-care-delays/ (accessed 5/1/14).
5. Wagner D. Second VA doctor blows whistle on patient-care failures. The Arizona Republic. May 1, 2014. Available at: http://www.azcentral.com/story/news/investigations/2014/05/02/second-va-doctor-blows-whistle-patient-care-failures/8595863/ (accessed 5/1/14).
6. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54.
7. VA Office of Inspector General. Review of Veterans’ Access to Mental Health Care. 1.http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf  (accessed 5-1-14).
8. Vogel S. VA mental health system sharply denounced at hearing. Washington Post. April 25, 2012. Available at: http://www.washingtonpost.com/politics/va-mental-health-system-sharply-denounced-at-hearing/2012/04/25/gIQAXG3mhT_story.html (accessed 5/1/14).
9. Lee C, Goldfarb ZA. Stolen VA laptop and hard drive recovered. Washington Post. June 30, 2006. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2006/06/29/AR2006062900352.html (accessed 5/1/14).
10. Corbin C. Arizona VA boss accused of covering up veterans' deaths linked to previous scandal. Foxnews.com. April 24, 2014. Available at: http://www.foxnews.com/politics/2014/04/24/arizona-va-boss-accused-covering-up-veterans-deaths-linked-to-previous-scandal/ (accessed 5/1/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Don't fire Sharon Helman-at least not yet. Southwest J Pulm Crit Care. 2014;8(5):275-7. doi: http://dx.doi.org/10.13175/swjpcc060-14 PDF