Yesterday, May 28, 2014, the House Veterans Affairs Committee hosted three VA witnesses that testified under oath for four hours in an unusual evening hearing regarding the Phoenix VA Medical Center (VAMC) Wait List Times.
VA witnesses were Dr. Thomas Lynch, Deputy Undersecretary for Clinical Operations and Management; Ms. Joan Mooney, Assistant Secretary, Office of Congressional and Legislative Affairs; and Mr. Michael Huff, VA Congressional Liaison Officer.
The hearing was stormy, the members were fired up, well prepared, expressed bipartisan frustration with VA, and concerned that Veterans Health Administration (VHA) Performance Metrics became goals instead of tools to help manage health care delivery.
The VA witnesses appeared to be generally ill at ease, unprepared for the rough questioning they received, offered platitudes and excuses while being evasive during Q and A.
In fact, based on Dr. Lynch’s answers to members’ questions, he stated there was no secret waiting list at Phoenix but rather in traditional VA lingo, “interim work products.”
You might also assume from his answers that VA’s IT architecture, known as VISTA, is the culprit because it created the off-line secret waiting lists.
Obviously VISTA did not create the “interim work product” nor the “secret waiting list,” rather this was an act administered by VA staff in a position of authority.
The most succinct summary of the hearing came from Congressman Mike Coffman (CO-6th) when he stated,
“You are not being forthright.
The impression all three of you give today is that you are here to serve yourselves and not the men and women that have made extraordinary sacrifices defending this country.
I have got to tell you nothing will change at the Veterans Administration until we have new leadership and just from the very top General Shinseki, but all of you, I think, have to find something else to do because you are not here to do your job.”
VA HAS DISPLAYED SERIAL INCOMPETENCE AND HYPOCRISY THAT IS BREATH-TAKING IN SCOPE AND MAGNITUDE.
Yesterday, the VA Office of Inspector General (OIG) also released its Interim Report entitled, Veterans Health Administration Review of Patient Wait Times, Scheduling, Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
The OIG Interim Report confirms some of our greatest fears.
Not only did Phoenix VAMC fail to schedule appointments for 1,400 for primary care patients, it also failed to schedule an additional 1,700 veterans who were waiting for appointments but were not placed on the Electronic Waiting List (EWL).
OIG also disclosed that by not placing veterans on the EWL, Phoenix VAMC, “leadership significantly understated the time new patients waited for their primary care appointment in their 2013 performance appraisal accomplishments, which is one of the factors considered for awards and salary increases.”
The OIG Interim Report reflects significant cheating by purposefully manipulating wait time data in order to help senior VAMC managers change the metrics and thereby yield higher performance evaluations and possible salary “kickers” and bonuses.
The Phoenix VAMC, has been caught red-handed “cooking the books” and delaying health care to thousands of veterans that led to misery, suffering, and untoward consequences for those veterans who languished helplessly while waiting for VA health care that came too late for some.
Adding insult to injury, while the OIG worked this investigation in Phoenix they “received numerous allegations daily of mismanagement, inappropriate hiring decisions, sexual harassment, and bullying behavior by mid-and senior-level managers at the facility.”
THE “GOLD STANDARD” FOR HEALTH CARE DELIVERY TO SOME VETERANS
I will concede that parts of VHA’s massive bureaucracy are indeed the “Gold Standard” when it comes to providing world class specialty care to veterans.
VHA’s Polytrauma, Prosthetics, Spinal Cord Injury, Research and Development units, and others do provide high-quality care and services that are often hard to find in the private sector.
Unfortunately, the good work of these entities as well as the doctors, nurses, technicians, and administrative staff that work very hard every day are overshadowed by the disgraceful scandal that continues to unfold.
RATIONING OF CARE THROUGH WAITING LISTS
Veterans were put on off-line or paper waiting lists because many VAMCs could not, for many reasons, meet the department’s stringent access goals.
These illegal actions by some VAMCs are straightforward rationing of care that reduces patient choices while increasing wait time for often life-saving treatment.
Despite the huge budget increases VA has received over the last decade, VHA seems incapable of providing timely health care to veterans without bilking the taxpayer and more importantly, manipulating patient wait times that caused preventable deaths.
Plain and simple, VHA does not have the resources that are exclusively focused on the provision of timely, high-quality care to all veterans seeking health services.
As a very general rule, once VA patients are established at a facility, they do receive fairly good care.
However, if a veteran lives in a highly rural area or near a VAMC that cannot recruit and hire critically needed clinical staff, the use of private sector health care may not be an option either.
INFIGHTING IS A VA BLOOD SPORT
VA Secretary Eric Shinseki is now into his 6th year of being in charge at VA, a monolithic organization with a well-earned reputation for being one of the most political departments in the federal government.
From all appearances, General Shinseki is either personally hesitant or incapable of grappling with the entrenched bureaucracy to force the kind of change he says must be made to the VA’s health care and benefits delivery systems.
With a flood of returning warriors from the Global War On Terror (GWOT), VA needed a leader that has the “vision thing” and the proverbial “fire in the belly” to compel VHA’s leadership to prepare and preposition resources to successfully meet the onslaught of veterans seeking VA benefits and medical care.
Instead, many veterans got excuses, delays, incompetence, and blatant cheating so some Directors at VAMCs and managers at the 21 Veterans Integrated Service Networks (VISNs) could look good statistically and capture financial bonuses.
THE VA WAIT LIST AND PREVENTABLE DEATHS SCANDAL DID NOT DROP OUT OF THE SKY
As a Vietnam veteran who sought care and benefits from VA, General Shinseki knows better than most, that the health and benefits systems were inundated with Vietnam veterans as that war wound down to a final conclusion.
VA knew, or should have been aware from past experience, that this phenomenon would repeat itself and, once again, the system would be tested as the GWOT veterans returned to civilian life seeking health care and benefits they earned as war fighters.
The root problem is not the “awareness” of the mismatch between available health care and the demand for services by veterans – the root problem is that competent VA leaders were at a premium.
When the Undersecretary for Benefits and Health both fail, that equals mission failure by the Chief executive, Secretary Shinseki. General Shinseki did not root out or solve the VA’s health care access problem nor did he or his team work with congress to identify problems and find solutions that would help mitigate the tsunami of veterans flooding VA.
Consequently, systemic malfeasance, corruption, cheating, and unethical behavior became acceptable in some quarters of VHA. VAMC Directors felt intense pressure to force staff to “hit the numbers” or face negative consequences.
Thus, some VAMC Hospital Administrative Services forced their schedulers to cut corners or simply manipulate the scheduling of patients so that it appeared as though the VAMC met VHA’s timeliness standards.
If a VAMC could not meet the stringent time lines dictated by VA Central Office in Washington, DC, they often times reverted to cheating as a form of self preservation.
Unfortunately, this cheating was at the patient’s expense.
WHAT THE TALIKING HEADS ARE SAYING
It is President Bush’s fault – after all, he started these two wars.
Response: Maybe so but that was then and this is now.
The Obama Administration has had 5+ years to work on and solve VA’s health care access problems and VBA’s backlog.
Congress has failed in their oversight responsibility.
Response: For several years, the House Veterans Affairs Committee has held hearings in Washington and across the country via field hearings regarding lengthy wait times, backlog of disability claims, VA construction delays, cost overruns, stonewalling of congress, bonuses for senior VA managers.
Additionally, much time was spent on another egregious VA scandal where taxpayer money to the tune of $6.1 million was spent on VA conferences in Orlando, FL. Congressional offices receive complaints about VA from their constituents and then interact with VA’s Office of Congressional Affairs to resolve these matters. Unfortunately, VA’s Office of Congressional Affairs is many times unresponsive and congressional inquiries go unanswered.
VA has not been responsive and therefore is derelict in its duty when VA will not provide answers to the Chairman of the House Veterans Affairs Committee for months or years.
VA has the executive oversight responsibility for VA’s problems, not the congress.
Sure congress gets involved but cannot force VA to do much of anything except call hearings and subpoena information.
Secretary Shinseki should stay at VA to fix the problems.
Response: How can anyone expect Shinseki who has exacerbated this scandal by inaction be expected to satisfactorily resolve this matter? To date, he has had over 5 years to fix many of these problems and failed.
It will take months to find a replacement for Secretary Shinseki and get Senate confirmation.
Response: Possibly, so start the process immediately since time is of the essence.
President Obama has sent a trusted senior adviser to “assist” Secretary Shinseki.
Response: Wise up and snap out of it!
His mission is to staunch the hemorrhaging and keep the scandal from widening. The first step in solving a problem is realizing there is one. Unfortunately, this Administration perceives “problems” as something to be shaped and massaged instead of fixing. Fixing VA is hard work.
President Obama should work with Shinseki to solve the myriad problems.
Response: On the contrary, the President should “count coup” by firing the Secretary to rebuild confidence in VA and his leadership. A demonstration such as a visible manifestation of empathy for veterans who suffered and those that died due to VHA ‘s “gaming the system” would be a smart move for the President and good for future veterans’ health care options.
Firing General Shinseki would also mean that the long tail of VA political appointees on that kite would also go. The people who have a vested interest in covering up the facts should not be allowed to stay in place and run interference.
VA should switch to vouchers or privatization.
Response: Vouchers have been tried in the past and were fraught with so much waste, fraud, and abuse the program had to be terminated.
Privatization is currently being used by VHA to augment care by private sector providers if the Fee Basis dollars are available, if the outside providers have excess capacity, and if VA leaders are willing to fully accept outside augmentation, something they have heretofore resisted.
Construct more Community Based Outpatient Clinics (CBOC), Super Outpatient Clinics (SOPC), and VAMCs to handle the work load.
Response: Building new health care facilities is neither a short- nor long-term solution for the current VA access problem. In fact, VA should have a moratorium on further construction projects until they prove the department can handle what they have in the pipeline.
To date, cost overruns and significant construction delays for VAMCs, in the works for over a decade, have overwhelmed VA’s ability to handle the construction projects they current oversee.
The President’s loyalty to his cabinet Chiefs is laudable.
However, the President’s first loyalty should be to the veterans who served our country and especially those who suffered disabilities during that service. Political appointees are expendable, not the veterans they are supposed to serve.
THE FACTS ABOUT VA AND THE OBAMA ADMINISTRATION
When Senator Obama was in the senate, he was a member of the Senate Veterans Affairs Committee.
As a presidential candidate, he ran on a platform of “fixing” VA’s problems exacerbated by America’s involvement in two wars.
VA’s overall budget has tripled since 2000.
In 2008, President-elect Obama’s VA Transition Team was specifically warned in a written Transition document that paraphrased the VA Office of Inspector General stating, “VHA has made only limited progress in addressing the longstanding and underlying causes of problems with outpatient scheduling, accuracy, of reported wait times , and completeness of electronic waiting lists(EWLs).” [emphasis added].
The Transition Document goes on to state that in the 2008 OIG report that wait time scheduling procedures were not followed and affected the reliability of reported wait times and caused inaccuracies;
“This report and prior reports indicate that the problems and causes associated with scheduling, waiting times, and waiting lists are systemic throughout VHA. Moreover, VHA has not ensured compliance with its policy that patients’ preferences for desired appointment dates are documented and that veterans receive appointments within the required timeframes.” [emphasis added]
ANOTHER SMOKING GUN?
The problems at VHA with scheduling practices, delayed health care, and preventable deaths are systemic and demonstrate gross negligence.
The big question asks “are there any VAMCs that are not “gaming the system” and putting veterans’ health in jeopardy?”
On April 26, 2010, Deputy Under Secretary for Health for Operations and Management (DUSHOM) William Schoenhard wrote a 1-page memo with an 8 page attachment sent to all 21 VISN Directors. Schoenhard stated that, “The purpose of this memorandum is to call for immediate action within every VISN to review current scheduling practices to identify and eliminate all inappropriate practices including but not limited to the practice specified below.”
He further opined that, “It has come to my attention that in order to improve scores on assorted access measures, certain facilities have adopted use of inappropriate scheduling practices sometimes referred to as “gaming strategies.”
The 8-page attachment drafted by the VA’s Systems Redesign Office specifically describes the numerous ways VAMCs “game” the system and notes that “additional new or modified gaming strategies have emerged, so do not consider this list a full description of all current possibilities of inappropriate scheduling practices that need to be addressed. These practices will not be tolerated.”
Notwithstanding the terse warnings contained in both the Obama Transition Team documents and DUSHOM Schoenhard’s “gaming memo” VA Secretary Shinseki, Undersecretary for Health Petzel, various other senior staff, VISN, and VAMC Directors ignored specific warnings, condemning thousands of veterans to needlessly suffer and leaving scores to die.
FACTS ABOUT MISCONDUCT BY VA SENIOR LEADERS
According to recent reports, approximately 15,000 VA employees owe $150 million in back taxes.
VA spent $500 million on furniture, drapes, and other sundry items.
During Secretary Shinseki’s tenure, in one year VA spent $86.5 million on conferences and workshops.
On September 30, 2012, VAOIG reported that VA’s Human Resources spent $6.1 million for two training conferences in Orlando, FL where 11 VA employees improperly accepted gifts in conjunction with their conference management responsibilities.
The OIG found that VA leadership failed to provide proper oversight in planning and executing the conferences. The GSA scandal for spending taxpayer money for their conference pales in comparison to VA’s activities.
WHAT SHOULD SECRETARY SHINSEKI DO?
He should immediately admit the real scope of the problem and tender his resignation. This would give President Obama the opportunity to find a new VA Secretary and senior team to begin the long-term effort to rebuild the belief and confidence veterans deserve.
New leadership, especially political appointees, is required in order to restore a modicum of trust between VA and the veterans they are supposed to serve.
All VAMC, VISN, and VACO staff that failed to follow DUSHOM Schoehard’s April 26, 2010, Memorandum regarding “gaming the system” should be asked to immediately resign or be fired and referred as appropriate to DOJ for potential criminal prosecution.
VA must be redesigned and streamlined to make patients and beneficiaries the centerpiece of all work effort.
VA should finally begin to collaborate with Republicans and Democrats on the Hill. New leadership at VA’s Congressional Affairs Office must immediately occur to end the lack of communication and ongoing politicization of VA.
VA must immediately work with congress to modify VA Fee Basis Program to ensure funding and access to private sector health care is available to all enrolled veterans when timely or high-quality health care (within a reasonable distance from their homes) is not available.
Begin work on a new IT system that removes the ability of VAMCs to manipulate wait times for health care delivery.
VA must begin to timely pay all Fee Basis invoices from private sector providers that lag many months behind, especially in VISN centralized Fee Basis Programs. To continue to delay Fee payments to private sector providers will ensure they do not take care of referred patients in the future.
VA should seek legislation to lift the salary cap on all hard to recruit VA medical staff.
Primary Care clinician’s panel size of veteran patients must be significantly increased and the average number of patients seen per day must be substantially enlarged in keeping with private sector health care professionals.
The VHA Scheduling Package must be improved so that routine primary care appointments are not expanded from 20 minutes to 40 or 60 minutes except under specific circumstances.
Regular Saturday hours of operation must be instituted to increase access for veteran patients. A triage function must be established at all VA facilities in order to handle walk-ins, drug refills, and urgent care.
Performance pay for physicians is based on Stretch Goals that can be as high as $15,000 per annum. This payment must be based on patients treated and not on continuing education or other endeavors that actually reduce the number of patients seen. Continuing education for VA physicians must be accomplished “off clock” and not interfere with patient access and treatment.
All Hospital Admin Service employees must receive a high degree of scheduling training that precludes any form of data manipulation.
Without delay, President Obama should pull back the Intent to Nominate Jeffery Murawsky, MD as Undersecretary for Health.
VA is at a critical juncture in its history.
The department is at a tipping point where what is good with the system could be lost. That means a “house cleaning” is required and strong replacement management and leadership teams must be installed to begin the process of restoring faith in government generally and faith in the VA specifically.
VA’s Gang That Couldn’t Shoot Straight needs to start Shooting Straight with America’s veterans they serve and the taxpayers who foot the bills.
From Ed Timperlake, the Editor of the Second Line of Defense Forum:
Al Poteet is one of America’s top leading experts on the Department of Veterans Affairs. He has written a series of articles on the Forum focusing on the issues facing DVA .
This is his latest which provides an insightful look at the Congressional DVA Oversight Hearings held on May 28, 2014.
He is a former Army gunship pilot with two tours in the Republic of Vietnam; a registered lobbyist for the Veterans of Foreign Wars (VFW);Deputy Assistant Secretary for Congressional Affairs; Director of three VA Regional Offices; a VA Medical Center Director; and Executive Director of the President’s Task Force To Improve Health care Delivery For Our Nation’s Veterans.
Ed Timperlake First Assistant Secretary Public and Congressional Affairs, then Assistant Secretary Public and Intergovernmental Affairs DVA. Editor Sldforum.com
To view the hearings see the following:
For earlier columns by Al Poteet on The Forum see the following: