The 2014 Veterans Health Administration controversy is a reported pattern of negligence in the treatment of United States military veterans. Critics charged that patients at the VHA hospitals had not met the target of getting an appointment within 14 days. In some hospitals, the staff falsified appointment records to appear to meet the 14-day target. Some patients died while they were on the waiting list. Defenders agreed that it was unacceptable to falsify data, but the 14-day target was unrealistic in understaffed facilities like Phoenix, and most private insurers did not meet a 14-day target either. By most measures, the VHA system provides "excellent care at low cost", wrote Paul Krugman, who believes that the attacks on the VHA system are motivated by conservatives who want to discredit a government program that works well. Conservative legislators have proposed privatizing the VHA, and legislative reforms that will make it easier for veterans to go to private doctors.
CNN reported on April 30, 2014, that at least 40 United States Armed Forces veterans died while waiting for care at the Phoenix, Arizona, Veterans Health Administration facilities. By June 5, 2014, Veterans Affairs internal investigations had identified 35 veterans who had died while waiting for care in the Phoenix VHA system. An investigation of delays in treatment throughout the Veterans Health Administration system is being conducted by the Veterans Affairs Office of the Inspector General, and the House has passed legislation to fund a $1 million criminal investigation by the Justice Department. On May 16, 2014, the Veterans Health Administration's top health official, Dr. Robert Petzel, retired early at the request of Secretary of Veterans Affairs Eric Shinseki. On May 30, 2014, Secretary Shinseki resigned from office amid the fallout from the controversy. As of early June 2014, several other VA medical centers around the nation have been identified with the same problems as the Phoenix facility, and the investigations by the VA Inspector General, the Congress and others are widening. An internal VA audit released June 9, 2014 found that more than 120,000 veterans were left waiting or never got care and that schedulers were pressured to use unofficial lists or engage in inappropriate practices to make waiting times appear more favorable. On June 11, 2014, the Federal Bureau of Investigation opened a criminal investigation of the VA. President Barack Obama ordered a White House investigation. On June 27, 2014, Obama's Deputy Chief of Staff, Rob Nabors, reported "significant and chronic system failures" and a "corrosive culture" inside the Veterans Health Administration. In August 2014, Obama signed Congressional legislation regarding funding and reform of the Veterans Health Administration.
Background
The Veterans Health Administration, a division of the U.S. Department of Veterans Affairs, is responsible for providing health care to U.S. military veterans, and is one of the largest healthcare operators in the United States, with dozens of hospitals and medical facilities across the nation. It has had a long and troubled history.
Goals for patient wait times
Timeliness of care was an important goal to the VHA. In 1995, VHA established a goal of scheduling primary and specialty care medical appointments within 30 days to ensure veterans' timely access to care. VHA began collecting patients wait time data in 2000 for which the then-General Accounting Office (GAO) reported inaccuracies. By July 2002, VA reported to Congress that over 300,000 veterans nationwide were either forced onto waiting lists or forced to wait over six months for a medical appointment.
Despite questions raised by GAO and the VA Office of Inspector General as to the validity of VA's performance in providing timely care to veterans, VHA shortened the wait time goal to 14 days for both primary and specialty care medical appointments in fiscal year 2011. In fiscal year 2012, VHA added a goal of completing primary care medical appointments within 7 days of the desired date. A .ZIP file containing both the full report and a set of partitioned sections.
VA caseload
Healthcare workload on VA increased substantially from 2007 to 2013. VA experienced an increase of 46% in outpatient visits from 63 million in 2007 to 92 million in 2013. Also, inpatients treated increased 11% from over 811,000 to nearly 902,000. A .ZIP file containing both a four volume report and a PowerPoint slide show.
There are fundamental problems at the Veterans Health Administration of staffing being inadequate for aging Vietnam veterans and for more recent veterans from Iraq and Afghanistan who may have complex health challenges such as traumatic brain injury, multiple limb amputations and prosthetics, diabetes and post-traumatic stress disorder. Testimony Before the Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, House of Representatives, U.S. Congress
VA funding In 2013 the VA spent $41.5 billion on Veterans' healthcare, an increase of 16% from 2007 ($36.2), while the number of individual patients increased by 18% from 5.5 million in 2007 to 6.5 million in 2013. Recent wars in Iraq and Afghanistan increased demands on VA resources with the number of veterans of these wars who went to VA for care increasing 200% from 2007 to 2013, The Veterans Benefits Administration also received an additional $1.2 billion as part of the American Recovery and Reinvestment Act of 2009.
In early June 2014, soon after the scandal became public, the U.S. Senate passed a $500 million aid bill for the VA.
Merit pay bonuses & previous reports of preventable deaths
As of April 2014, the VA had paid approximately "$200 million for nearly 1,000 veterans' wrongful deaths". Agency spokesperson Victoria Dillon said that "any adverse incident for a veteran within our care is one too many", but the deaths were a small fraction of the 6 million veterans which receive VA care each year. The House Committee on Veterans' Affairs held a hearing on preventable patient deaths in VA facilities in September 2013 during which representatives accused the VA of failing to discipline the officials responsible for patient deaths and instead providing performance bonuses. For example, VA regional director Michael Moreland received a bonus of approximately $63,000 and a five-page performance evaluation that made no mention of an outbreak of Legionnaires' disease that led to the deaths of six veterans and illness for 21 others at a Pittsburgh VHA hospital for which Moreland was responsible.
Previous reports of inaccurate data and subsequent manipulation The then-General Accounting Office (GAO) has issued reports since VA started gathering data in 2000 on veterans' wait times to be scheduled for an appointment and these GAO reports have called into question the reliability, and validity, of VA's wait time data.
The VA Office of Inspector General (OIG) reports in 2005, 2007, and 2008 found the reported outpatient waiting times to be unreliable because of data integrity concerns associated with VHA's scheduling system. The discrepancies found by the OIG between requested appointment times documented in medical records and in the databases, and incomplete waiting lists are attributed to patient preference or the scheduler's use of inappropriate scheduling procedures. (rescinded VHA Directive 2009-070, VHA Directive 2006-055) Veterans Affairs officials warned the Obama-Biden transition team in the weeks after the 2008 presidential election that the department should not trust the wait times that its facilities were reporting.
According to a 2010 VA memo, the problem of "gaming strategies" inside the VA to meet performance goals dates to at least 2008. VA Deputy Undersecretary for Health Administrative Operations William Schoenhard wrote, "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..." Schoenhard listed 24 tactics identified in a 2008 study as inappropriately reducing the official measures of patient wait times.
Examples
Phoenix Veterans Health Administration system
In one example, 71-year-old U.S. Navy veteran Thomas Breen was rushed to the Phoenix VA on September 28, 2013, with "blood in his urine and a history of cancer". His family said that he was sent home with instructions that he was to be seen within "one week" by a primary care doctor or urologist, and a note on his patient chart said the situation was urgent. After being sent home, his family said that they were told that there was a seven-month waiting list and that there were other critical patients. Thomas Breen died on November 30, 2013. His death certificate shows that he died from bladder cancer. His family said that the VA called on December 6, 2013, to make an appointment after Breen had died.
Dr. Sam Foote, who retired after 24 years of service with the Phoenix VA system, went public with allegations against the VHA in comments to CNN in April 2014. He said that there was an "official" list at the Phoenix VA that was sent to Washington officials and showed that appointments were timely, and an unofficial list where veterans may wait for care for more than a year. Foote said, "The scheme was deliberately put in place to avoid the VA's own internal rules". He said that workers at the Phoenix VA were intimidated into complying with the deception. "They have families, they have mortgages and if they speak out or say anything to anybody about it, they will be fired and they know that."
Austin Veterans Health Administration system
A scheduler at an Austin, Texas, VHA care clinic said that the practice of "zeroing out" delays in appointments "wasn't a secret at all" at the clinic, and he was instructed by a supervisor in how the process worked. The Austin scheduler said that said "zeroing out" was a practice of falsifying information in the VA's records system that Washington officials used to monitor patient wait times.
Fort Collins, Colorado and Cheyenne, Wyoming VA Deputy Undersecretary for Health Administrative Operations William Schoenhard wrote a memo on March 15, 2013, indicating that the VA was changing its performance measure for appointment wait times. The new goal involved measuring the number of days between a veteran's desired appointment date and the actual date of the appointment. A VA Office of the Medical Inspector report from December 2013 showed a dramatic change in March 2013 of the number of appointments booked within the 14-day window for the Fort Collins, Colorado outpatient clinic. When investigators asked VA employees to explain "what occurred in March 2013" the employees said that "they were instructed by Business office staff to access the appointment schedule, review it for capacity, inform the Veteran of schedule availability, and then enter the Desired Date as the patient appointment date" and "By entering the Desired Date as the appointment date, the wait time ... appears to be zero days." The Fort Collins clinic is overseen by the Cheyenne, Wyoming, Veterans Affairs office. A coordinator at the Cheyenne office sent an email on June 19, 2013, with instructions on how to manipulate the appointment dates. The coordinator wrote, "Yes, it is gaming the system a bit, but you have to know the rules of the game you are playing."