As accusations of mismanagement, falsified records and preventable patient deaths rock the Veterans Affairs healthcare system, some who are familiar with the VA say the failures are consistent with a pattern of well-documented problems.
For more than a decade, the department's inspector general and the Government Accountability Office have pressed the health administration to address breaches of the requirement to schedule timely appointments and problems with its recordkeeping on wait times.
“It's widespread,” said Darin Selnick, veterans affairs adviser to Concerned Veterans for America. Selnick also served as an appointee at the VA for the Bush administration from 2001-2009.
“Phoenix is just the tip of the iceberg,” Selnick said, referring to last week's announcement that VA Secretary Eric Shinseki had placed three Phoenix veterans' hospital officials on administrative leave after several former employees alleged that as many as 40 patients may have died as a result of treatment delays. Whistle-blowers also claimed that a secret list of patients waiting for appointments had been maintained to conceal how long it took for patients to be treated.
Under a 1996 law, disabled veterans needing care must be seen by a provider within 30 days. But five years after the law passed, the GAO found that two-thirds of the specialty-care clinics they examined had wait times longer than 30 days.
In 2007, an audit by the department's inspector general revealed that Veterans Health Administration facilities did not always adhere to the organization's scheduling policies and procedures. Unexplained differences between the desired dates shown in the scheduling software and the desired dates shown in the related medical records also caused the inspector general to conclude that the VHA's reported waiting times were unreliable.
In one case, a medical provider recommended that a veteran be seen on Jan. 31, 2006. But the scheduler entered a desired date of Oct. 2, 2006, and created an appointment for Oct. 17, 2006, resulting in a reported wait time of 15 days. Based on the provider's desired date, the wait time was actually 259 days, and the veteran was never put on the electronic waiting list.
“We saw no documentation to explain the delay, and medical facility personnel said it 'fell through the cracks,'” the report noted.
That particular patient received medical care from other clinics during that time, the inspector general reported, but other similar cases have resulted in delayed diagnoses, treatment and even some deaths.
Allegations of mismanagement of the gastroenterology clinic at the William Jennings Bryan Dorn VA Medical Center in Columbia, S.C., led the inspector general in 2012 to review whether consult and resource management practices at the facility contributed to or caused delays in care. The review turned up a backlog of 2,500 delayed consults, 700 of which were considered critical. During the period reviewed, 280 patients were diagnosed with GI malignancies, 52 of which were associated with a delay in diagnosis or treatment. Six patients died.
The delays at Dorn were a result of insufficient staffing, failure to use funds as designated, and a lack of oversight for tracking consults, the inspector general reported.
But they aren't isolated problems, according to GAO healthcare team director Debra Draper, who has identified antiquated software systems, lack of adequate training and turnover in scheduling positions as contributing to delays in treatment. “It's not a one- or two-facility issue,” she said.
Last month, the VA distributed a fact sheet based on its own review of the timeliness of GI cancer screenings and care across the system. In it, the VA identified 76 patients requiring an institutional disclosure—notification that the patient had been harmed or may have been harmed during care. And of those 76, the VA reported that 23 had died, but did not directly attribute them to the delays at any of the 13 facilities where there was a death.
“There's inadequate oversight,” Draper said. “The VA relies on self-certification for wait times, but we went in and found they were really not in compliance and a lot of the data that is used for oversight purposes is not reliable. It really creates a lack of accountability.”
But Phillip Longman, a senior research fellow at the New America Foundation and author of “Best Care Anywhere: Why VA Health Care is Better than Yours,” said in an e-mail that it's important to consider amid the current controversy that the VA system generally performs well. “If VA employees engaged in wrong doing, they should be punished, and there may be systematic reforms needed as well. But whenever you hear of bad stuff happening at the VA, and it happens all the time, ask yourself, 'compared to what?'” Longman said. “Because the VA is a public institution, it falls under a much higher standard of political, legal and media scrutiny,” he added.
The level of scrutiny appears to be ramping up as a result of the Arizona allegations.
Rep. Jeff Miller (R-Fla.) and Sen. Marco Rubio (R-Fla.) have introduced the VA Management Accountability Act of 2014 to give the VA secretary greater authority to remove senior executive employees. The American Legion has thrown its support behind the bill, but this week also called for the removal of Shinseki, as well as Under Secretary of Health Robert Petzel and Under Secretary of Benefits Allison Hickey.
“It's become abundantly clear that the dysfunction in the VA extends from the top to the bottom, at the highest headquarters down to local levels in some medical facilities,” Sen. Jerry Moran (R-Kan.) said on the Senate floor Tuesday.
Moran, who likewise asked for Shinseki's resignation, has cited a claims backlog, medical malpractice, mismanagement, lack of oversight and unethical environments in the VA system.
“It's not a failure of resources,” Moran said. Since 2009, funding for the VA has grown nearly 58%. The president's 2015 budget includes $163.9 billion for the VA.
“The problem is not that they don't have the money,” Selnick said. “If you don't know how to spend it wisely and don't know how to manage things, this is what happens.”
Despite mounting pressure from lawmakers and veterans organizations calling for Shinseki's head, the secretary has not indicated any plans to step down, and the White House has continued to stand behind him.
“The president remains confident in Secretary Shinseki's ability to lead the department and to take appropriate action based on the IG's findings,” Press Secretary Jay Carney told reporters Tuesday during the daily press briefing.
In its December 2012 report, the GAO recommended that the VA take action to improve the reliability of its wait time measures, ensure consistent implementation of its scheduling policy, routinely monitor scheduling needs and staffing resources, and improve telephone access for clinical care.
“They've made some progress,” Draper said, “but we expected more to have been done.”
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