Troubles Continue for the Phoenix VA

According to the Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission, JCAHO), an independent organization that reviews hospitals, the Phoenix VA does not comply with U.S. standards for safety, patient care and management (1). The hospital was at the epicenter of the national scandal over the quality of care being afforded to the nation's veterans where the now notorious practice of double-booking patient appointments was first exposed. The hospital's indifferent management provoked congressional investigations that uncovered still more system-wide abuses leading to the removal of the hospital director and the resignation of then VA secretary, Eric Shinseki. The hospital maintains its accreditation but with a follow-up survey in 1-6 months where it must show that it has successfully addressed the 13 identified problems (1). Inspectors who conducted the review in July found that VA employees were unable to report concerns "without retaliatory action from the hospital." Other alarming deficiencies were that Phoenix administrators did not maintain a "safe, functional environment" or "a culture of safety and quality." They concluded that the hospital does not have adequate policies and procedures to "guide and support patient care, treatment and services."

Elizabeth Eaken Zhani, a media relations manager at the JCAHO, stressed that noncompliance findings do not typically lead to a loss of accreditation (2). Of more than 4,000 medical facilities evaluated each year, she said, less than 1 percent are denied accreditation. The Phoenix VA has a right to appeal and an opportunity to correct failings so the hospital meets national standards. In a written statement October 20, VA officials said plans have been developed with an expectation that compliance issues will be resolved within 120 days. "We are also working diligently to address the cultural issues identified by The Joint Commission and have implemented a number of items to enable employees to raise concerns about safety or quality without fear of retaliation...".

In 2010, the Phoenix VA was among 20 VA medical centers to earn The JCAHO's "Top Performer" honor. The most recent audit, in 2011, showed Phoenix at or above target values established by the commission for every major category of health care and administration. It is unclear if care quickly deteriorated at the VA over three short years or previous JCAHO evaluations were inadequate. JCAHO inspections usually are conducted by a retired hospital administrator, physician and nurse. They usually review policies and procedures and rarely meet with physicians, nurses, technicians or clerks directly involved in patient care.

In an editorial entitled "After ALL THAT, Phoenix VA still fails review?!" the Arizona Republic (3) stated the "Phoenix VA is the hospital the VA would want to get right. The one at which the troubled agency would throw all its resources to assure that, despite all evidence to the contrary, VA leaders really did know what they were doing. And, yet, the Phoenix VA flunked its review". The editorial goes on to say that, "Perhaps the most fundamental flaw in the VA system is the forbidding culture of the organization, which regularly and ruthlessly punished whistle-blowers. You would think that, above all else, the VA's new administrators would strive to assure that that malignant practice was banished. Didn't happen. Failure to assure that a VA worker could 'report concerns about safety or the quality of care to (the reviewing agency) without retaliatory action from the hospital' was at the top of the Joint Commission's list of findings". The Republic goes on to say that "The Joint Commission's audit provides still more evidence of the intransigence [pigheaded] and resistance to change that the VA presents to even the most determined reformers".

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. The Joint Commission. Phoenix VA Health Care System: Summary of accreditation quality information. Available at: http://www.qualitycheck.org/qualityreport.aspx?hcoid=2508# (accessed 10/23/14).
2. Wagner D. Phoenix VA hospital fails outside compliance review. Arizona Republic. October 21, 2014. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/10/21/phoenix-va-hospital-fails-outside-compliance-review/17649623/ (accessed 10/23/14).
3. Editorial board. After ALL THAT, Phoenix VA still fails review?! Arizona Republic. October 22, 2014. Available at: http://www.azcentral.com/story/opinion/editorial/2014/10/22/phoenix-va-downsize/17748023/ (accessed 10/23/14).  

Reference as: Robbins RA. Troubles continue for the Phoenix VA. Southwest J Pulm Crit Care. 2014;9(4):240-1. doi: http://dx.doi.org/10.13175/swjpcc140-14 PDF

Whistle-Blower Accuses VA Inspector General of a "Whitewash"

Yesterday, Dr. Sam Foote, the initial whistle-blower at the Phoenix VA, criticized the Department of Veterans Affairs inspector general's (VAOIG) report on delays in healthcare at the Phoenix VA at a hearing before the House Committee of Veterans Affairs (1,2). Foote accused the VAOIG of minimizing bad patient outcomes and deliberately confusing readers, downplaying the impact of delayed health care at Phoenix VA facilities. "At its best, this report is a whitewash. At its worst, it is a feeble attempt at a cover-up," said Foote. Foote earlier this year revealed that as many as 40 Phoenix patients died while awaiting care and that the Phoenix VA maintained secret waiting lists while under-reporting patient wait times for appointments. His disclosures triggered the national VA scandal.

Richard Griffin, the acting VAOIG, said that nearly 300 patients died while on backlogged wait lists in the Phoenix VA Health Care System, a much higher number than the 40 listed in his August 26 investigative report (1). However, he defended his office's report and conclusion that the VAOIG could not "conclusively assert" that any veteran deaths were "caused by" untimely care. Dr. John Daigh, Griffin's assistant inspector general, seemed to disagree saying that excessive wait times not only negatively affected veterans, but helped lead to deaths.

Griffin's office has also been accused of allowing VA personnel to "soften" the report-a charge which he denied. Griffin was taken to task by the committee for not providing the original (unaltered) copy of the report which had been requested.

Robert McDonald, the recently appointed VA Secretary also testified. McDonald had come under fire the day before in a letter from Arizona senators John McCain and Jeff Flake for inaction against senior VA officials (3). McCain and Flake said, "Senior VA leaders have ... not been held accountable for delaying and denying patient care, silencing and intimidating whistle-blowers, and enriching themselves by manipulating wait-time statistics to receive undeserved performance bonuses." McDonald and Griffin replied that 19 disciplinary actions are in process and OIG investigators are working with the FBI and Justice Department on possible prosecutions.

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Office of VA Inspector General. Review of alleged patient deaths, patient wait times, and scheduling practices at the Phoenix VA health care system. Available at: http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf (accessed 9/18/14).
2. C Span. Phoenix VA Inspector General's Report. House Committee of Veterans Affairs. September 17, 2014. Available at: http://www.c-span.org/video/?321497-1/hearing-veterans-affairs-inspector-generals-report (accessed 9/18/14).
3. Wagner D. Inspector general: care delay may be factor in VA deaths. USA Today. September 18, 2014. Available at: http://www.usatoday.com/story/news/nation/2014/09/18/inspector-general-care-delay-may-be-factor-in-va-deaths/15814065/ (accessed 9/18/14). 

Reference as: Robbins RA. Whistle-blower accuses VA inspector general of a "whitewash". Southwest J Pulm Crit Care. 2014;9(3):185-6. doi: http://dx.doi.org/10.13175/swjpcc124-14 PDF 

VA Office of Inspector General Releases Scathing Report of Phoenix VA

The long-awaited Office of Inspector General’s (OIG) report on the Phoenix VA Health Care System (PVAHCS) was released on August 27, 2014 (1). The report was scathing in its evaluation of VA practices and leadership. Five questions were investigated:

1. Were there clinically significant delays in care?
2. Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List (EWL)?
3. Were PVAHCS personnel not following established scheduling procedures?
4. Did the PVAHCS culture emphasize goals at the expense of patient care?
5. Are scheduling deficiencies systemic throughout the VA?

In each case, the OIG found that the allegations were true. Despite initial denials, the OIG report showed that former PVAHCS director Sharon Helman, associate director Lance Robinson, hospital administration director Brad Curry, chief of staff Darren Deering and other senior executives were aware of delays in care and unofficial wait lists.

Perhaps most disturbing is the OIG finding that scheduling deficiencies are systemic throughout the VA. The OIG is currently investigating 90 VA facilities. The findings prompted Rep. Jeff Miller, House Veterans’ Affairs Committee chairman to comment “We have seen no evidence that the corrupt bureaucrats who created the VA scandal will be purged from the department’s payroll anytime soon. Until that happens, VA will never be fixed,” (2).

Though whistleblowers alleged veterans died while awaiting care in Phoenix, acting Inspector General Richard Griffin did not draw any conclusions about criminal culpability and declared that he was “unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.” Phoenix whistleblowers Drs. Sam Foote and Katherine Mitchell, said the OIG standard made no sense because 45 examples described in the OIG report showed that delayed care likely resulted in premature deaths or harm to patients’ quality of life. It is the later standard that is usually applied to physicians.

The day prior to the release of the report the Deputy VA Secretary Sloan Gibson was interviewed noting that more veterans are being sent to private doctors for care reducing waiting times (3). "The fundamental point here is, we are taking bold and decisive action to fix these problems because it's unacceptable," said Gibson. It is unclear whether these reports of improved waiting times are any more reliable than the initial denials of prolonged patient waiting times from both the Phoenix VA and VA Central Office.

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Office of VA Inspector General. Review of alleged patient deaths, patient wait times, and scheduling practices at the Phoenix VA health care system. Available at: http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf (accessed 8/26/14).
2. Wagner D, Lee M. Scathing VA report stirs outcry for accountability. Arizona Republic. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/08/26/scathing-va-report-stirs-outcry-accountability/14665455/ (accessed 8/27/14).
3. Associated Press. Watchdog report details ‘systemic’ problems at VA facilities. Available at: http://www.foxnews.com/politics/2014/08/26/no-proof-delays-in-care-caused-vets-to-die-va-says/ (accessed 8/25/14). 

Reference as: Robbins RA. VA office of inspector general releases scathing report of Phoenix VA. Southwest J Pulm Crit Care. 2014;9(2):140-1. doi: http://dx.doi.org/10.13175/swjpcc112-14 PDF

Banner Health, University of Arizona Health Network to Merge

On Thursday, June 26, the Arizona Board of Regents and the University of Arizona Health Network (UAHN) Board unanimously gave the go ahead to formal negotiations with Banner Health. Under the proposed agreement Banner will acquire the University of Arizona Medical Center and its south campus, which have 624 beds between them, UAHN's faculty practice, University Physicians Healthcare and the system's three health plans. Initial terms of the agreement stipulate that Banner will spend at least $500 million toward capital projects in the next five years, and it will pay $300 million to establish an academic endowment (1). UAHN’s long-term debt, totaling about $146 million, will be absorbed by Banner. UAHN and Banner said plan on reaching a definitive agreement by September.

UA President Ann Weaver Hart was quoted by Tucson News Now as saying, "These 30 years which this agreement anticipates are going to be among the most transformational in health care in America experienced in the last century. And we're absolutely committed to be the leaders in that environment. This is extremely exciting. And I hope you can feel our commitment. We are going to make the future. We are not going to be recipients of the future made by others" (2). We have a solution to expand our capabilities to move care to a higher level, to advance research for our community and our state and to educate the future health care professionals for the state of Arizona," said UAHN President and CEO Dr. Michael Waldrum.

Under the agreement Banner will commit to the "employment of the employees of UAHN and its subsidiaries for at least six months after closing at their current base salaries and retention of their seniority for employee benefits purposes. " (1). The proposal also includes a severance package for any employees who are laid off after that six-month period.

Banner owns 25 hospitals in seven states. In total, the proposed transaction is expected to generate about $1 billion in new capital, academic investments and other consideration and value beneficial to UA and the community, a news release said. The resulting organization will employ more than 37,000 people, after adding 6,300 employees at UAHN's two hospitals, the health plan and the medical group.

The Arizona Cancer Center is excluded under the proposed agreement and will remain part of the University of Arizona. The proposal does not affect Banner's existing agreement with the Banner MD Anderson Cancer Center at Gateway Medical Center in Gilbert nor does it affect UAHN's agreement with St Joseph Medical Center in Phoenix.

This would be Banner's first acquisition on an academic medical center which reflects the growing relationship between academia and corporate America (3). Balancing the teaching and research goals of academia and the profit goals of corporations whether profit or not-for profit can be difficult. Some physicians have been troubled by Banner's non-compete clauses on physician contracts as well as Banner's aggressiveness in employing physicians that directly compete with private practice physicians at their hospitals. It is unclear how this agreement might conflict with the academic goals of UAHN as well as affecting the relationship with physicians currently practicing at Banner.

Richard A. Robbins, MD

Editor

References

1. Arizona Board of Regents agenda. Available at: http://azregents.asu.edu/boardbook/Board%20Agenda%20Books/2014-06-26%20Board%20book.pdf (accessed 6/27/14).
2. Ames J, Grijalva B. UA Health Network, UA move forward in negotiations with Banner. Tucson News Now. June 26, 2014. Available at: http://www.tucsonnewsnow.com/story/25880624/ua-health-network-ua-to-move-forward-in-negotiations-with-banner (accessed 6/27/14).
3. Reece EA, Chrencik RA, Miller ED. Fully aligned academic health centers: a model for 21st-century job creation and sustainable economic growth. Acad Med. 2012;87(7):982-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Banner health, University of Arizona health network to merge. Southwest J Pulm Crit Care. 2014;8(6):358-9. doi: http://dx.doi.org/10.13175/swjpcc085-14 PDF

Searchable Database for Physician CMS Payments

Earlier this month the Centers for Medicare and Medicaid Services (CMS), despite the objections of many physicians, released physician payment data for 2012 (1). However, the data on the CMS website is difficult to search and interpret. The New York Times created a searchable database of physician payments from CMS which can be searched by physician name, specialty and/or location (2). The Times points out that payments may cover overhead, such as staff salaries and drug costs. In some cases, when doctors work as salaried employees of group practices, the payments that show up under their names go to their institutions.

Richard A. Robbins, MD

Editor

References

1. CMS. Medicare Provider Utilization and Payment Data: Physician and Other Supplier. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html (accessed 4/24/2014).
2. NY Times. How Much Medicare Pays For Your Doctor’s Care. Available at: http://www.nytimes.com/interactive/2014/04/09/health/medicare-doctor-database.html (accessed 4/24/2014). 

Reference as: Robbins RA. Searchable databse for physician CMS payments. Southwest J Pulm Crit Care. 2014;8(4):238. doi: http://dx.doi.org/10.13175/swjpcc056-14 PDF