Trump Proposes Initial Healthcare Agenda

On Friday, November 11, President-elect Trump proposed a healthcare agenda on his website greatagain.gov (1). Yesterday, November 12, he gave an interview on 60 Minutes clarifying his positions (2). Trump said that he wanted to focus on healthcare and has proposed to:

• Repeal all of the Affordable Care Act;
• Allow the sale of health insurance across state lines;
• Make the purchase of health insurance fully tax deductible;
• Expand access to the health savings accounts;
• Increase price transparency;
• Block grant Medicaid;
• Lower entrance barriers to new producers of drugs.

In his 60 Minutes interview Trump reiterated that two provisions of the ACA – prohibition of pre-existing conditions exclusion and ability for adult children to stay on parents insurance plans until age 26 – have his support (2). Other aspects of the ACA that might receive his support were not discussed.

On the Department of Veterans’ Affairs Trump proposed to make the VA great again by removing corrupt and incompetent individuals who let our veterans down (1).  The website goes on to say that only honest and dedicated public servants in the VA have their jobs protected, and will be put in line for promotions.

Several aspects of healthcare were not addressed. Universal healthcare which Trump has supported in the past was not discussed (3). Trump did not make major policy proposals for Medicare during the campaign and Medicare was not addressed on his website or during his interview.

According to a survey conducted by the Kaiser Family Foundation the top three healthcare issues concerning voters were:

• Ensuring that high-cost drugs for chronic conditions such as hepatitis and cancer become affordable;
• Lowering prescription drug costs in general;
• Making sure health plans have enough physicians and hospitals in their networks (4).

None were addressed on Trump's website or during his interview.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. https://www.greatagain.gov/policy/healthcare.html (accessed 11/14/16).
2. CBS News. President-elect Trump speaks to a divided country on 60 Minutes. November 13, 2016. Available at: http://www.cbsnews.com/news/60-minutes-donald-trump-family-melania-ivanka-lesley-stahl/ (accessed 11/14/16).
3. CBS News. Trump gets down to business on 60 Minutes. September 27, 2015. Available at: http://www.cbsnews.com/news/donald-trump-60-minutes-scott-pelley/
4. Kirzinger A, Sugarman E, Brodie M. Kaiser Health Tracking Poll: October 2016. Available at: http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-october-2016/ (accessed 11/14/16). 

Cite as: Robbins RA. Trump proposes initial healthcare agenda. Southwest J Pulm Crit Care. 2016;13(5):240-1. doi: https://doi.org/10.13175/swjpcc117-16 PDF 

Another Phoenix VA Director Leaves

The Arizona Republic reports that the director at the Phoenix VA Medical Center, Deborah Amdur, will retire after only 9 months for health reasons (1).  Amdur will be replaced by Barbara Fallen, director of the VA Loma Linda Healthcare System. Fallen will be interim director until a permanent replacement for Amdur can be found. This is the fifth hospital director since former Director Sharon Helman was removed in mid-2014 amid the nationwide veterans health-care scandal that was first exposed at the Phoenix VA.

The Veterans Integrated Service Network (VISN) in Gilbert, which oversees the VA Medical Center in Arizona, New Mexico and West Texas has also been through a series of 4 directors since Susan Bowers retired under pressure in the wake of the VA scandal. Marie Weldon, current acting regional director, also oversees the Los Angeles-based VA Desert Pacific Healthcare System. Weldon described Fallen as “an experienced leader who will continue the tremendous effort being made to improve access to high quality health care for veterans in the Phoenix area.”

Amdur's retirement comes just one day after 12 News KPNX in Phoenix reported a taped conversation between a patient and employees at the Southeast VA Clinic in Gilbert (2). During the visit a nurse called the patient phone scheduling system “a nightmare", and a doctor employed by the VA for 3 months said he was “not a fan of the VA” and complained that assigning him 500 patients on May 23rd did not allow him sufficient time with patients. According to the tape the doctor expresses his desire to help but simply states, “It’s just I’m so lost in what to do.” Regarding the audio recording, Director Amdur said before her resignation that "the agency is looking into the matter" and threatened "actions with the providers involved”.

Congressman Matt Salmon, who represents Arizona's 5th District which includes the Southeast VA Clinic, told 12 News he was “disappointed” by what the audio recording revealed and does not consider it an anomaly. Salmon said while there are pressing matters facing the agency, he is optimistic new leadership can help turn it around. "I have nothing but praise for Director Amdur who is running the (Phoenix) VA. I think she is a breath of fresh air," Salmon said. "But the problem is so many people who still work there are the people that were there when the problem was created and getting rid of people that don’t do the job the way they are supposed to is almost impossible in the VA." Salmon said the VA's HR system needs to be revamped in order to recruit higher-quality employees. "It needs to be streamlined so that when they find good doctors they are able to hire them quickly," Salmon said.

Amdur's threats and Salmon's comments are in line with the last 2 and a half years of VA excuses for poor care by blaming bad employees rather than mismanagement and lack of oversight. Both the nurse and the doctor are new to the VA and will likely shortly be gone for telling the truth further worsening the shortage of providers. As predicted 2 and half years ago, no fundamental changes have been made at the VA and it is not surprising that problems with patient scheduling persist (3). The last 20 years demonstrate that if the VA wants to provide the best of care, it is time to stop putting VA bureaucrats in charge and replace them with professionals who know something about it, doctors and nurses. Those doctors and nurses need to be overseen by a local committee of professionals to ensure that Veterans get the best of care. Otherwise no real change occurs and VA bureaucrats and politicians will continue to blame bad employees rather than a bad system. If no fundamental change is made, it may be time to scrap the VA system and send patients to outside providers as suggested by both the patient who made the recording and implied by Salmon.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Wagner D. Phoenix VA hospital getting yet another boss. Arizona Republic. August 26, 2016. Available at: http://www.azcentral.com/story/news/local/phoenix/2016/08/26/phoenix-va-hospital-getting-yet-another-boss/89412700/ (accessed 8/27/16).
2. Dana J. VA cancer patient secretly records doctor visit. 12 News KPNX. August 25, 2016. Available at: http://www.12news.com/news/local/valley/va-cancer-patient-secretly-records-doctor-visit/307185216 (accessed 8/27/16).
3. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14.

*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. Dr. Robbins does see VA patients under the Veterans Choice Act.

Cite as: Robbins RA. Another Phoenix VA director leaves. Southwest J Pulm Crit Care. 2016;13(2):95-6. doi: http://dx.doi.org/10.13175/swjpcc084-16 PDF

Patient Deaths Blamed on Long Waits at the Phoenix VA

This morning the lead article in the Arizona Republic was a report blaming as many as 40 deaths at the Phoenix VA on long waits (1). Yesterday, Rep. Jeff Miller, the chairman of the House Committee on Veterans Affairs, held a hearing titled “A Continued Assessment of Delays in VA Medical Care and Preventable Veteran Deaths.” “It appears as though there could be as many as 40 veterans whose deaths could be related to delays in care,” Miller announced to a stunned audience. The committee has spent months investigating patient-care scandals and allegations at VA facilities in Pittsburgh, Atlanta, Miami and other cities. Miller said that dozens of VA hospital patients in Phoenix may have died while awaiting medical care. He went on to say that staff investigators have evidence that the Phoenix VA Health Care System keeps two sets of records to conceal prolonged waits that patients must endure for doctor appointments and treatment. Sharon Helman, director of Phoenix VA Health Care System, said in a written statement: “We take seriously any issue that occurs in our medical center and outpatient clinics. Therefore, we have asked for an external review by the VA Office of the Inspector General [OIG] ... If the OIG finds areas that need to be improved, we will swiftly address them as our goal is to provide the best care possible to our veterans.”

VA health system workers who asked not to be named because they fear retribution, said patient access data incorrectly show vets are able to see physicians within days when actual waits may be months. Dr. Sam Foote, who retired from the Phoenix VA in December, filed complaints with the VA inspector general seeking investigations of alleged medical care failures and administrative misconduct. In a Feb. 2 letter to the inspector general, Miller, Sen. John McCain and Rep. Ann Kirkpatrick, Foote said the Phoenix system is afflicted by “gross mismanagement of VA resources and criminal misconduct” that produced “systemic patient safety issues and possible wrongful deaths.” According to Foote, VA IG investigators came to Phoenix late last year and verified allegations he’d made in an October complaint, but no action was taken. In an interview, he said patients “were deliberately being held off the lists” to misrepresent the speed of health services for vets, but it remains unknown how many of the deaths may have been preventable. Foote went on to allege hostile working conditions that caused an exodus of quality doctors and nurses, producing backlogs in both primary care and specialty areas. One example was urology, where resignation of several of the staff urologists forced patients to be referred to out-of-state VA centers or private physicians for treatment. Foote described elaborate techniques that were used to mischaracterize system responsiveness, estimating that up to 30,000 patient charts have been altered. He said thousands of new patients must wait up to a year for assignment to primary-care physicians who are overbooked.

Allegations of falsifying wait times or retaliation against whistle-blowers are nothing new at the VA. A Senate hearing in 2011 found similar falsification of wait times (2). Review of the Office of Inspector General’s website revealed multiple instances of similar findings dating back to at least 2002 (3-6). In each instance, unreliable data regarding wait times was cited and no action was taken.

Fear of retaliation was cited by Foote as a reason for retirement and other employees asked that their names be withheld (1). These fears appear to be realistic. Recently, a VA employee was demoted after providing testimony about financial mismanagement at the Phoenix VA (7). In contrast, it appears that VA administrators have little to fear from whistle blowers, the OIG, or Congress. If recent history is any guide, it seems likely that the delays will be blamed on lazy providers and VA administrators will create another layer of bureaucracy ostensibly to solve the problem. However, the outcome will be further repression of any whistle blowers and depletion of already short patient care resources.

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Deaths at Phoenix VA hospital may be tied to delayed care. Available at: http://www.azcentral.com/story/news/politics/2014/04/10/deaths-phoenix-va-hospital-may-tied-delayed-care/7537521/ (accessed 4/10/14).
2. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54.
3. http://www.va.gov/oig/52/reports/2003/VAOIG-02-02129-95.pdf (accessed 4/10/14).
4. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf (accessed 4/10/14).
5. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf  (accessed 4/10/14).
6. http://www.va.gov/oig/52/reports/2007/VAOIG-07-00616-199.pdf (accessed 4/10/14).
7. Wagner D. VA official in Arizona demoted after her testimony. Arizona Republic. Available at http://www.azcentral.com/news/arizona/articles/20130314va-official-arizona-pedene-demoted-after-testimony.html (accessed 4/10/14).

Reference as: Robbins RA. Patient deaths blamed on long waits at the Phoenix VA. Southwest J Pulm Crit Care. 2014;8(4):227-8. doi: http://dx.doi.org/10.13175/swjpcc050-14 PDF 

In Aftermath of Financial Investigation Phoenix VA Employee Demoted after Her Testimony

A previous Southwest Journal of Pulmonary and Critical Care Journal editorial commented on fiscal mismanagement at the Department of Veterans Affairs (VA) Medical Center in Phoenix (1). Now Paula Pedene, the former Phoenix VA public affairs officer, claims she was demoted for testimony she gave to the VA Inspector General’s Office (OIG) regarding that investigation (2). In 2011, the OIG investigated the Phoenix VA for excess spending on private care of patients (3). The report blamed systemic failures for controls so weak that $56 million in medical fees were paid during 2010 without adequate review. The report particularly focused on one clinician assigned by the Chief of Staff to review hundreds of requests per week and the intensive care unit physicians for transferring patients to chronic ventilator units (1,3). After the investigation, the director and one of the associate directors left the VA and the chief of staff was promoted to chief medical officer in one of the VA’s networks. The other associate director was appointed as director of another VA medical center in 2010 before the investigation.

According to the Arizona Republic, Pedene was interviewed in May 2011 by the OIG to probe the misspending along with allegations of sexual harassment and a hostile workplace (2). Pedene testified that the Phoenix VA suffered from “leadership run amok” (2). She said that agency bosses intimidated employees and that then-Director Gabriel Perez threatened her with banishment to a basement workspace, making it clear he did not want a woman — or someone with a service-connected disability — as the VA’s public-affairs officer. The OIG report makes no mention of intimidation, sexual harassment or a hostile workplace in their report (3).

Pedene, the Veterans Day Parade coordinator since 1997, was accused of having her husband take photographs of the Veterans Day Parade. Pedene, who is blind, then allowed her husband to upload the photos onto the VA website using her password (2). Pedene’s legal advisers and VA records indicate the dispute stems from a larger controversy involving years of mismanagement, squandered funds, discrimination, sexual harassment and retaliation at the Phoenix VA. Pedene was notified of her transfer in a Dec. 10 letter from Associate Director Lance Robinson. He wrote that she was the subject of a “very serious” allegation, and he issued a gag order prohibiting public disclosures.  

Former Maricopa County Attorney Rick Romley, who chairs the parade-sponsoring Veterans Commemorative Committee of Phoenix, said he authorized Pedene to hire her husband as a photographer and cannot understand VA administrators’ response to a seemingly minor transgression  (2). “Quite frankly, this is peanuts in the security world,” said Romley, who in 2006 served as special security adviser to the secretary of Veterans Affairs in Washington (2).

Pedene had been called as a witness in the case. The investigation was initiated after complaints by employee Sheila Cain, who in 2010 was assistant chief of the Phoenix VA’s Health Administration Services. Cain had sought to repair problems with the Phoenix VA’s budget and fee-payment systems. According to VA reports, her efforts led to infighting over blame and responsibility. Cain filed a series of grievances alleging that she was subjected to false accusations, denied due process, stripped of authority and isolated in a basement workspace for six months. Cain endured sexual remarks, threats, improper touching, public humiliation and other abuse more than 30 times. In one instance, she alleged that Dr. Christopher Bacorn, then Phoenix VA Associate Director, hit her rear end with a spatula in front of a fellow employee (2).

Documents obtained independently by the Arizona Republic show Cain also was victimized by unlawful access to her medical records (2). An investigation of that patient-confidentiality breach resulted in the discipline of at least nine employees of the health system, some of whom left the VA. Cain remains with the VA but not under the supervision of Phoenix administrators. In the meantime, Pedene became a target of similar treatment under new bosses. Her reassignment to the hospital library, initially set at 30 days, is in its third month.

Employee-relations consultant, Roger French, who at one time represented Pedene and has represented about 40 VA employees in grievances, said he has seen a pattern of abuse, discrimination and retaliation in the Phoenix VA (2). He said Pedene was criticized for her blindness, and administrators dismantled a public-relations program once considered among the nation’s best. Recently, he added, Pedene’s name was redacted from the VA’s online employee directory, and her awards were removed from a display case at the Phoenix VA. “She stood up and told the truth,” French said. “It cost (administrators) their jobs, and they threatened to destroy adversaries and families.”

French has asked Department of Veterans Affairs Secretary Eric Shinseki to launch a new inquiry. French’s Feb. 12 letter accuses the present Phoenix VA administration of nepotism, retaliation and improper downgrading of evaluations. “I have never seen the hostility, cavalier violations of regulations and laws (or) lack of dignity and respect for employees,” French wrote to Shinseki. Shinseki did not respond, French said.

Unfortunately, if Shinseki does act, it will likely be through another investigation by the OIG which inadequately investigated the previous allegations of mismanagement (1). Instead of focusing on the administrators responsible for budget control, the OIG attempted to place the blame on clinicians acting in the best interests of the patients (1). Furthermore, if the Arizona Republic report is correct, the OIG ignored accusations of sexual harassment and a hostile workplace made at the time of their original investigation. If French’s accusations regarding the present Phoenix VA administration are true, a whitewashing with resignation of some and promotion of other present Phoenix VA administrators is likely to result, as it did in the original investigation (1).

Richard A. Robbins, MD*

References

1. Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3.
2. Wagner D. VA official in Arizona demoted after her testimony. Arizona Republic. Available at http://www.azcentral.com/news/arizona/articles/20130314va-official-arizona-pedene-demoted-after-testimony.html accessed 3/29/13.
3. http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 3/29/13).

*Dr. Robbins was the Chief of Pulmonary and Critical Care at the Phoenix VA from 2003-11.

Reference as: Robbins RA. In aftermath of financial investigation Phoenix VA employee demoted after her testimony. Southwest J Pulm Crit Care. 2013;6(3):151-3. PDF