Inspector General Finds Problems at US Department of Veterans Affairs’ Medical Facilities

Since 2005, the Office of the Inspector General (OIG) has issued 18 reports indicating scheduling issues, long wait times, and subpar patient care at US Department of Veterans Affairs (VA) facilities throughout the United States. None received as much attention or led to as much political scrutiny as the interim report from May 28.

That day, the OIG concluded that scheduling practices at the Phoenix VA Health Care System were not compliant with VA policy, confirming issues raised by multiple parties in previous weeks. Investigators discovered that there were multiple lists used to manipulate wait times and hide the problems from government officials and the public. The inadequate scheduling negatively affected patients’ quality of care.

Two days later, VA secretary Eric Shinseki resigned and apologized for the scandal. Still, reports indicated that the problem was not only limited to Phoenix. At VA hospitals in other states, employees did not disclose the long wait times that may have led to preventable deaths and adverse patient outcomes. The OIG is currently conducting further investigations to examine allegations and is expected to release the final results in August. The FBI also announced in early June that it opened a criminal investigation of the VA.

“I cannot explain the lack of integrity among some of the leaders of our healthcare facilities,” Mr. Shinseki told the Washington Post shortly before he resigned. “This is something I rarely encountered during my 38 years in uniform. I cannot defend it because it is indefensible. But I can take responsibility for it, and I do.”

Origins of a Scandal

The issue first gained national attention on April 9 during a House Committee on VA hearing. Committee chairman Jeff Miller, a Republican Congressman from Florida, mentioned then that he had hoped the VA had made changes following delays at facilities in Columbia, South Carolina, and Augusta, Georgia, that resulted in 9 preventable deaths. Two days earlier, the VA released information indicating 23 people had died due to delays at its facilities, although Mr. Miller criticized the VA for not revealing more information. He added that the Committee had reviewed cases of 18 other preventable deaths that the VA did not disclose.

“Congress has met every resource request that VA has made, and I guarantee that if the department would have approached this committee at any time to tell us that help was needed to ensure that veterans received the care they required, every possible action would have been taken to ensure that VA could adequately care for those veterans,” Mr. Miller said. “When errors do occur—and they seem to be occurring with alarming frequency—what VA owes our veterans and our taxpayers, in that order, is a timely, transparent, accurate, and honest account about what mistakes happened, how they are being fixed, and what concrete actions are being taken to ensure accountability.”

Later in the hearing, Mr. Miller said that Committee investigators had evidence that the Phoenix VA Health Care System kept 2 sets of records to hide the long wait times. Thomas Lynch, MD, assistant deputy undersecretary, clinical operations and management, VA, testified that day that he was unaware of the cover-up.

The next day, the Arizona Republic revealed more allegations. Sam Foote, MD, who retired from the Phoenix VA in December 2013 after 24 years, gave the newspaper documents that he claimed to have filed with the VA inspector general. On February 2, Dr. Foote wrote a letter to the inspector general and indicated the Phoenix VA is “afflicted by gross mismanagement of VA resources and criminal misconduct that produced systemic patient safety issues and possible wrongful deaths,” according to the Arizona Republic report. He also sent a copy of the letter to Mr. Miller, Republican Senator John McCain from Arizona, Democratic Representative Ann Kirkpatrick from Arizona, and the United States Attorney’s Office.

Dr. Foote said investigators from the OIG visited Phoenix and verified his allegations, but he claimed no changes were made in staffing or practices. The Arizona Republic mentioned that multiple requests made for documents and data from VA were denied.

On April 23, the scandal grew after CNN reported that 1400 to 1600 sick veterans in Phoenix waited months to see a doctor and at least 40 had died, including several who were placed on a falsified waiting list. CNN obtained emails from within VA that revealed top executives shared a secret waiting list with government officials that indicated there were timely appointments even when people had to wait for days. Dr. Foote told CNN VA requires hospitals to see patients within 14 to 30 days. “The scheme was deliberately put in place to avoid VA’s own internal rules,” Dr. Foote said.

Katherine Mitchell, MD, who worked for 16 years at the Phoenix VA Health Care System, also claimed that there were 2 lists and described her experience to the Arizona Republic in an article published on May 2. She alleged that a coworker feared that patient records were about to be destroyed at the same time that a House Committee had requested documents. The coworker later delivered the documents to the VA inspector general, according to Dr. Mitchell. Dr. Mitchell said she warned hospital administrators for a few years about delays in care before making her accusations public.

“I am violating the VA ‘gag’ order for ethical reasons,” she wrote in a statement to the Arizona Republic. “I am cognizant of the consequences. As a VA employee, I have seen what happens to employees who speak up for patient safety and welfare within the system. The devastation of professional careers is usually the end result, and likely is the only transparent process that actually exists within the Phoenix VA Medical Center today.”

On May 23, Dr. Foote wrote an op-ed article in the New York Times explaining his decision to go public with his allegations. He said he sent letters to the inspector general in October 2013 and again in February without receiving a response. After Dr. Foote spoke with the Arizona Republic, VA opened an investigation, although he wrote that he would have preferred US Department of Justice (DOJ) officials examine the issues instead of employees from the Veterans Integrated Service Network who do not have as much power as the DOJ.

According to Dr. Foote, VA excels at treating patients with chronic conditions such as diabetes and has a top-notch computerized records system. However, he noted that the VA systems in sparsely populated areas of the country struggle because their residents live far from a hospital. He suggested possibly providing veterans with a card to use for urgent and/or emergency care and hospitalizations, although he was concerned that the White House and top VA officials would not take his recommendations seriously.

“I am worried about the patients whose care is entrusted to the VA, and I am skeptical about our chances of creating real, long-lasting reform—but I hope that this time we will,” Dr. Foote wrote.

Inspector General Report and Fallout

The VA OIG began investigating allegations of manipulated wait times at VA medical facilities in late April. It compiled a group of physicians, special agents, auditors, and healthcare inspectors to examine the charges and determine if the wait lists were compromised and if veterans had died because of delays in care.

The VA OIG’s preliminary report on the Phoenix VA Health Care System was released on May 28 and found that 1700 veterans were waiting for a primary care visit but were not included on the waiting list. The report mentioned that the 1700 people may never receive treatment. By not including those people on the waiting list, the report indicated that executives at the Phoenix VA Health Care System had “significantly understated the time new patients waited for their primary care appointment in their [fiscal year] 2013 performance appraisal accomplishments, which is [1] of the factors considered for awards and salary increases.”

The investigators also examined 226 appointments at the Phoenix VA Health Care System. According to data released to the national VA office, veterans waited an average of 24 days for their first primary care appointment, while 43% waited >14 days. However, the VA OIG found that veterans waited an average of 115 days for their first primary care appointment, while 84% waited >14 days.

“Most of the wait time discrepancies occurred because of delays between the veteran’s requested appointment date and the date the appointment was created,” the investigators wrote. “We noted in at least [25%] of the 226 appointments reviewed, patients received some healthcare in the Phoenix [VA Health Care System], such as the emergency department, walk-in clinics, or mental health clinics.”

Soon after the report’s release, Mr. Miller, Mr. McCain, and >100 lawmakers from both political parties called for Mr. Shinseki to resign as VA secretary, a job he had held since 2009. After accepting Mr. Shinseki’s resignation on May 30, President Barack Obama referred to the conditions at VA facilities as “totally unacceptable,” although he praised Mr. Shinseki for serving in Vietnam and for his work at VA.

“[Mr. Shinseki] has worked hard to investigate and identify the problems with access to care, but as he told me this morning, the VA needs new leadership to address them,” President Obama said. “He does not want to be a distraction, because his priority is to fix the problem and make sure our [veterans] are getting the care that they need. That was [Mr. Shinseki’s] judgment on behalf of his fellow veterans. And I agree. We do not have time for distractions; we need to fix the problem.”

President Obama replaced Mr. Shinseki on an interim basis with Sloan Gibson, former head of the United Services Organization, who joined VA in February as Mr. Shinseki’s deputy.

“We are going to do right by our veterans across the board, as long as it takes,” President Obama said on May 30. “We are not going to stop working to make sure that they get the care, the benefits, and the opportunities that they have earned and they deserve.

Further Investigations

In early June, VA released reviews of 731 facilities conducted from May 12 through June 3 that included 3772 interviews with clinical and administrative staff. Of the scheduling staff interviewed, 13% said “they received instruction (from supervisors or others) to enter a date different than what the veteran had requested in the appointment scheduling system,” according to the report. In addition, 8% of the scheduling staff said they used alternatives to the official waiting list, and some were pressured to make the waiting lists seem shorter than they actually were.

As of May 15, there were >6 million appointments scheduled at VA facilities, while 57,436 veterans were waiting to be scheduled for a visit. Later that month, at the behest of President Obama, VA launched the Accelerating Access to Care initiative to improve access to care for veterans.

More information on the problems at VA facilities is expected to be released in August. Richard Griffin, acting inspector general, VA, testified before the Committee on VA on June 9. He acknowledged his office was reviewing 56 VA medical facilities for allegedly manipulating data and inaccurately reporting wait times.

“Our reviews at this growing number of VA medical facilities have thus far provided insight into the current extent of the inappropriate scheduling issues throughout the VA healthcare system and have confirmed that inappropriate scheduling practices are systemic throughout [VA],” Mr. Griffin said. “One challenge in these reviews is to determine whether these practices exist currently or were used in the past and subsequently corrected by VA managers. We will work diligently and complete our work and publish the results in August.”