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Growing evidence points to systemic troubles in VA health care system

By David Zucchino, Cindy Caracamo & Alan Zarembo

Los Angeles Times (MCT)

LAST UPDATED: 09:00 a.m. HST, May 20, 2014

NEW RIVER, Ariz. >> Three years ago Edward Laird, a 76-year-old Navy veteran, noticed two small blemishes on his nose. His doctor at the Veterans Affairs hospital in Phoenix ordered a biopsy, but month after month, as the blemishes grew larger, Laird couldn't get an appointment.

Laird filed a formal complaint and, nearly two years after the biopsy was ordered, got to see a specialist - who determined that no biopsy was needed. Incredulous, Laird successfully appealed to the head of the VA in Phoenix. But by then, it was too late. The blemishes were cancerous. Half his nose had to be cut away.

"Now I have no nose and I have to put an ice cream stick up my nose at night . so I can breathe," Laird said. "I look back at how they treated me over the years, but what can I do? I'm too old to punch them in the face."

The Phoenix VA Health Care System is under a federal Justice Department investigation for reports that it maintained a secret waiting list to conceal the extent of its patient delays, in part because of complaints such as Laird's. But there are now clear signs that veterans' health centers across the U.S. are juggling appointments and sometimes manipulating wait lists to disguise long delays for primary and follow-up appointments, according to federal reports, congressional investigators and interviews with VA employees and patients.

The growing evidence suggests a VA system with overworked physicians, high turnover and schedulers who are often hiding the extent to which patients are forced to wait for medical care.

The 1,700 hospitals and clinics in the VA system - the nation's largest integrated health care network - now handle 80 million outpatient visits a year. Veterans Affairs Secretary Eric K. Shinseki promised to solve growing problems with patient access when he took over in 2009, and he has been successful in some respects: Iraq and Afghanistan veterans are using VA health care at rates never seen in past generations of veterans, and a growing number of Vietnam veterans are receiving VA care as they age.

The agency reports it also made substantial progress in reducing wait periods last year, 93 percent of the time meeting its goal of scheduling outpatient appointments within 14 days of the "desired date."

But several VA employees have said the agency has been manipulating the data.

"The performance data the VA puts out is garbage - it's designed to make the VA look good on paper. It's their 'everything is awesome' approach," said Dr. Jose Mathews, chief of psychiatry at the VA St. Louis Health Care System. "There's a 'don't ask, don't tell' policy. Those who ask tough questions are punished, and the others know not to tell."

Mathews was put under administrative investigation in September after he alleged that long wait times led to poor patient care and what he said were two preventable deaths. He said a suicide attempt by a veteran at the facility was covered up by the hospital after a VA psychiatrist failed to provide follow-up treatment.

Several VA schedulers have told investigators that agency staffers were "gaming the system" by making it appear that appointments set for weeks or months in the future were "desired dates" requested by veterans. In fact, they said, veterans grudgingly accepted future appointments because they felt they had no other choice.

"We found people that were told to change the (appointment) dates to make it look like it was in line with VA guidelines," said Debra Draper, who was part of a team from the Government Accountability Office that interviewed 19 appointment schedulers at four VA medical centers in 2012. The team found that more than half of them failed to correctly record the appointment date patients originally requested.

VA officials say that manipulation of wait lists has occurred only in isolated cases and that the majority of patients get timely access to quality care. VA hospitals since 2004 have consistently ranked higher in customer satisfaction surveys than their counterparts in the private sector, they note, with more than 90 percent of patients offering positive assessments of their care.

"As we know from the veteran community, most veterans are satisfied with the quality of their VA care, but we must do more to improve timely access to that care," Shinseki said Friday as he announced the resignation of the VA's undersecretary for health, Dr. Robert Petzel, a departure that had been in the works before the recent revelations.

But veterans and current and former agency employees interviewed last week described a dysfunctional bureaucracy in which turnover is high, the number of doctors is insufficient, and patients may be left dangling even when facing life-threatening health problems.

"The evidence is there. They're never going to be able to hide it," said Brian Turner, a military veteran who has worked as a scheduling clerk in VA facilities in Austin and San Antonio.

In Washington state, Navy veteran Walter "Burgie" Burkhartsmeier, 73, had to wait two months to get an MRI exam at a VA facility in Seattle for shooting pains down his left arm. Eighteen months passed before someone read the MRI results - which showed bony projections on his spinal cord that put him at risk of paralysis if he were struck in the back.

In Texas, Carolyn Richardson, 70, said a VA doctor last year ordered "immediate" chemotherapy for her husband, Army veteran Anson "Dale" Richardson, 66, but a two-month delay robbed him of the chance to fight the throat cancer that killed him Nov. 4.

In Phoenix, Thomas Breen, 71, a Navy veteran with a history of bladder cancer, waited two months last fall for a follow-up appointment at the VA facility there after discovering blood in his urine. His family finally took him to a private hospital that diagnosed him with terminal bladder cancer. He died Nov. 30.

Six days later, a clerk from the VA in Phoenix called Breen's daughter-in-law, Sally Barnes-Breen, to schedule an appointment.

"No. You are too late, sweetheart," Barnes-Breen said she told the clerk. "He's dead."

In Nevada, Sandi Niccum, 78, a blind Navy veteran, was forced to wait five hours for emergency room treatment at a VA facility in North Las Vegas last year. Niccum, who was weeping and pounding the floor with her cane because of intense pain in her abdomen, died less than a month later after a large mass was found. A VA investigation did not link the care delay to her death, but faulted the facility for the long wait and for failing to monitor Niccum.

And in Durham, N.C., two employees were put on administrative leave last week after an internal review uncovered irregularities in appointments, a local VA spokeswoman said.

Some VA employees have said they faced reprisals after they resisted instructions to manipulate appointment books.

Lisa Lee, a medical support assistant at the VA facility in Fort Collins, Colo., said she was transferred and later put on two-week administrative leave when she objected to supervisors' instructions to manipulate appointment times. She said supervisors did not link her transfer and leave to the appointments issue; she was told instead that her performance had delayed patient care.

"They wanted me to cook the books, and I didn't do it," Lee said in a telephone interview from Hawaii, where she now serves with the U.S. Navy. "You're supposed to do your work and shut up."

After Lee was transferred, a VA supervisor in June wrote an email to the Fort Collins staff instructing them to manipulate veterans' appointment requests in order to meet the 14-day directive. In the email, provided by Lee, the official, David Newman, wrote: "Yes, it's gaming the system a bit. But you have to know the rules of the game you are playing, and when we exceed the 14-day measure, the front office gets very upset, which doesn't help us."

In Phoenix, Dr. Katherine Mitchell said she could no longer keep quiet after she got a call from a fellow employee at the VA hospital there on April 27, telling her that patient appointment documents might be in danger of being destroyed that evening.

The call came in the wake of a VA inspector general investigation into the allegations.

Mitchell, who worked in the VA system for 16 years, said she went to the medical center and joined a co-worker in preserving records, including paperwork that she said showed falsified wait times for medical care.

In a six-page letter, Mitchell detailed a series of attempts to voice her concerns about deficiencies at the Phoenix VA through the proper channels. Instead, she was eventually banned from submitting cases to the risk manager at the VA in Phoenix and put on administrative leave last September.

"There has been no significant change in the dysfunctional institutional culture of the Phoenix VA," Mitchell said in a statement last week. "Employees today still risk backlash for bringing up patient care issues, identifying misuse of facility resources and questioning violations of human resource policy."

Phoenix has been at the center of the controversy in the wake of reports over the last several weeks from VA employees and veterans there that as many as 40 patients had died while waiting for medical care. The VA's acting inspector general, Richard J. Griffin, told a congressional committee Thursday that a preliminary review of 17 patient deaths had not shown they were caused by treatment delays.

"It's one thing to be on a waiting list. It's another thing to conclude that as a result . that was the cause of death," Griffin said.

Teams from the VA inspector general's office began visiting VA facilities nationwide last week to look into appointment scheduling practices and other issues. Griffin said federal prosecutors were investigating possible criminal charges at the Phoenix VA.

Officials at several VA facilities said they were committed to rooting out any improper appointment scheduling procedures and to improving patient care.

In a news conference Wednesday, Cynthia McCormack, director of the VA Medical Center in Cheyenne, Wyo. - which has responsibility for the nearby Fort Collins facility - said she and other managers "misunderstood" VA scheduling policies and had improperly administered them.

"We are now correcting our misunderstanding of how to schedule our veterans," McCormack said. She added that all VA employees under her supervision - as well as herself - had been "retrained on the VA scheduling directive."

Paradoxically, independent customer satisfaction surveys have consistently shown that VA patients are as satisfied with their care as patients in private hospitals.

Noble Wilcox, a Vietnam veteran from California, praised the health system for the care he had received the last two decades. He said he had no trouble seeing his primary care doctor at the VA clinic in San Luis Obispo.

"I just call and I get in in a week," Wilcox said.

Ilya Kurbanov, 28, who injured his back in a 2008 bomb blast in Iraq, said he usually has to wait six to eight weeks to see a primary care physician.

"But don't get me wrong," he said. "VA is saving my life."

The VA's internal documents show that the troubled agency has known since at least 2008 that employees manipulate the scheduling system to mask delays in care - what a 2010 memo called "gaming strategies." That memo, written by a VA deputy undersecretary, listed more than a dozen "inappropriate scheduling practices" at medical facilities dating to 2008.

Two years later, in 2012, a Government Accountability Office report concluded that the VA's reporting on its medical appointment wait times was "unreliable," outdated, easily manipulated and in need of complete overhaul.

"The bottom line," said Draper, who was part of the GAO review team, "is that no one really knows how long veterans are waiting to receive care."


Zucchino reported from Durham, Carcamo from New River and Zarembo from Los Angeles. Los Angeles Times staff writers Molly Hennessy-Fiske in Giddings, Texas, Maria L. La Ganga in Seattle and John M. Glionna in Las Vegas contributed to this report.

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Maneki_Neko wrote:
Shinseki has got to go. He didn't cause the problems but in 5 years he never discovered how systemic the problems were and did not act forcefully to correct the problems. Even now we don't hear real outrage and anger from him; all we hear is a bureaucrat talking about studies and reviews.
on May 20,2014 | 09:14AM
bsdetection wrote:
One more example of the damage caused by Bush's decision to fight an unfunded war of choice in Iraq. Over the coming decades, it will cost trillions to provide medical care for Iraq war veterans, but Bush thought he could ignore those costs and let future presidents and generations worry about them. Remember when Paul Wolfowitz, a top Bush adviser and chicken hawk, said that the Iraq war would pay for itself? Well, it didn't and an underfunded and poorly managed VA is incapable of handling the human costs of that war. That war was and remains the major cause of the deficit, and we will be paying for it for decades. The neo-con chicken hawks who got us into this mess love to talk about "supporting the troops" but their actions -- or inactions -- speak louder than their words.
on May 20,2014 | 09:33AM
entrkn wrote:
I totally agree with bsdetection. When mid-level and lower-level administrator civil servants are cheating and hiding it, it's hard to find, hard to prove, and hard to punish because of civil service work rules. Shinseki is one of the best leaders the VA has ever had. These acts are criminal in nature and should be prosecuted as crimes.
on May 20,2014 | 09:53AM
Maneki_Neko wrote:
First action was to can the VA Undrsecretary. Thing is, VA Undersecrertary for Health Dr. Robert Petzel was already scheduled to retire later this summer, but VA Secretary Eric Shinseki asked for his resignation early.

What's that smell?

on May 20,2014 | 11:16AM
DAGR81 wrote:
This is all about Obama's lack of leadership and misguided priorities. The problems were there when he took office, but he chose to ignore them. Instead he hangs with celebrities and hosts lavish parties while he campaigns for himself and his flock.
on May 20,2014 | 10:08AM
serious wrote:
DAGR81--you have gotten it exactly right, just like the IRS, Secret Service, etc, etc. Like Carter, he only has two problems--Foreign and Domestic.
on May 20,2014 | 10:44AM
lee1957 wrote:
Your conclusions are not supported by the facts, but nice rant.
on May 20,2014 | 11:27AM
DAGR81 wrote:
His travels, as well as Michelle's travels, and their lavish functions and parties are well documented as his campaign trips. Have you noticed how few public statements they are making these days...nothing to toot about.
on May 20,2014 | 12:15PM
Winston wrote:
A very ironic web handle, given your post. The blame Bush reflex is powerful. For you guys it's as though time stopped with the Bush presidency and President pants-on-fire is just a poor hapless observer of things presidential, stumbling into one IED after another left behind by Bush.

Well, given that VA funding was bumped up by 20% early in the O's administration and given that O himself raised the very problem we're seeing today as something he was dedicated to fixing, how is it that O bears no responsibility? How is it that he's had five years to fix this, but has not? For that matter, why doesn't O's actions speak louder than his words? Huh?

Well he has been busy, right? Ditching our national interest in Iraq. Flubbing the war he termed as the right war, Afghanistan. Prevaricating his pants off with so many broken Obamacare promises that need air traffic controllers to keep the lies in the holding pattern from crashing into one another.

So busy building a wall of words around his weak presidency that he's just been too occupied to do what he said he'd do, again, and keep veterans from dying while on a secret hospital waiting list.

So have a chicken hawk history festival if you want. Meanwhile, the empty suit you elected continues his hapless second term unmolested by his true believers.

on May 20,2014 | 12:30PM
AhiPoke wrote:
THIS is what obamacare is leading our country to, socialized medicine. When you take away the incentives that drive private industry you end up with people who are less concerned with competing for patients which leads to mediocrity. The VA has been receiving mre and more money each year that obama has been in office. This is not a money issue.
on May 20,2014 | 10:44AM
control wrote:
Red states are notorious for their poor health care ratings, especially in the private sector. Funny how all of the examples above are in red states. Thank the neo-cons and tea party types who work in those facilities. Its been going on long before Obamacare came about.
on May 20,2014 | 02:58PM
dyw001 wrote:
The problem I think reflects the same problems in the private sector nationwide...lack of doctors. Even here in Hawaii, under HMSA, there are not enough primary care physicians (family practice) and certain specialists, such as gastroenterologists.
on May 20,2014 | 11:38AM
KaneoheSJ wrote:
What is really insidious is that congressmen, after serving a term, are given the privilege of veteran's hospitals for life. That, even if they they never served a day in the military for which the veteran's hospitals are meant for. Veteran's hospitals should be for veterans only. This perk given to our congressmen by congressmen is unethical and should be removed.
on May 20,2014 | 11:48AM
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