VA Investigation: No Proof That Falsified Data Led to Vets’ Deaths

August 26, 2014 in News

Claims that 40 veterans might have died because of delayed care and manipulated waiting lists at a Department of Veterans Affairs health center in Phoenix, Ariz., are unsubstantiated, according to an internal investigation, the New York Times reports.


In April, Sam Foote, a retired physician at the Phoenix VA Health Care System, claimed that employees at the practice inaccurately used the center’s electronic health record system and “deliberately” created a secret waiting list to hide documentation of delays in care. According to Foote, up to 1,600 patients were placed on a secret electronic waiting list at the Phoenix center, sometimes waiting months to over a year to have an appointment scheduled.

The waitlist scandal resulted in the resignation of VA Secretary Eric Shinseki and spurred several investigations.

Earlier this month, President Obama signed into law a $16.3 billion bill (HR 3230) to overhaul the VA and improve veterans’ access to care in part by extending telehealth services through its mobile VA centers (iHealthBeat, 8/7).

Investigation Findings

According to a letter from VA Secretary Robert McDonald, a VA Office of Inspector General investigation was unable to find any evidence that linked the extended wait times to the veterans’ deaths. McDonald wrote in the letter, “It is important to note that while OIG.’s case reviews in the report document substantial delays in care, and quality of care concerns, OIG was unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.”

However, Deputy VA Secretary Sloan Gibson in an interview said although the investigation did not find proof of a link between care delays and the deaths, VA remains responsible for hiding the prolonged wait times at both the center in Phoenix and others around the country. He said, “I’m relieved that they didn’t attribute deaths to delays in care, but it doesn’t excuse what was happening.” Gibson added, “It’s still patently clear that the fundamental issue here is that veterans were waiting too long for care, and there was misbehavior masking how long veterans were waiting for care.”

According to the Times, the investigation did find that many facilities used artifices to falsify wait time metrics. The report listed causes for the inappropriate actions, such as:

  • Destructive and punitive management culture;
  • Perverse incentives for administrators; and
  • Physician shortages (Oppel, New York Times, 8/25).

VA Promises Change

According to the AP/Washington Times, VA announced it is firing three executives at the Phoenix center, as well as officials and staff at centers in Colorado and Wyoming that were found to have manipulated wait time data. Gibson also said he expects more VA employees to be fired over the incidents. He noted that VA is “taking bold and decisive action to fix these problems because it’s unacceptable” (Ohlemacher, AP/Washington Times, 8/26).

Meanwhile, internal VA documents said the department is “taking vigorous action to ensure that a ‘data-driven’ approach does not have the unintended impact of diverting attention from our primary goal of providing veterans with … health care.” In addition, the documents noted that VA will:

  • Hire outside experts to suggest how to “select and hire ethical leadership and staff (and) how to communicate expectations around ethical behavior”;
  • Spend $400 million on staff overtime or private care for veterans to ensure they are treated quickly, including nearly $17 million at the Phoenix center for referrals to private physicians;
  • Train 8,248 VA employees on how to appropriately schedule patients;
  • Create an internal investigation board to identify managers at the Phoenix center that were responsible for misconduct so disciplinary action can be taken;
  • Expand mental health resources, primary care physicians and other providers at the Phoenix center; and
  • Open new VA health care centers (Zoroya, USA Today, 8/25).

VA Announces Search for new Scheduling System Contractor

On Monday, VA officials announced that the department soon will begin searching for a contractor to develop the agency’s new scheduling system, Modern Healthcare reports.

VA plans to release a formal request for proposal by the end of September, and vendors will have 30 days to respond.

McDonald said, “When we can put a solid scheduling system in place, this will free up more human resources to focus on direct veterans’ care.”

In the meantime, VA is making changes to its current VistA electronic health record system. Specifically, VA is working on:

  • Changing the system’s view from a text-based, multiscreen view to a calendar view; and
  • Developing mobile applications for veterans to request specific types of care, including mental health appointments.

The calendar view is expected to be implemented in January 2015 (Dickson, Modern Healthcare, 8/25).

Obama Outlines Executive Actions To Improve Military Mental Health

At the American Legion’s national convention on Tuesday, Obama announced new executive actions aimed at improving the mental health of service members, veterans and their families, the New York Times reports (Baker, New York Times, 8/26).

In his speech, Obama outlined 19 executive actions, which include:

  • Allocating $78.9 million in funds as part of the BRAIN Initiative toward a five-year research program on developing minimally-invasive neurotechnologies to increase the brain and body’s ability to induce healing with the goal of managing diseases such as post-traumatic stress disorder;
  • Automatically enrolling individuals leaving military service who have mental health conditions into VA’s inTransition program to connect them with VA or community mental health treatment programs;
  • Compiling and analyzing data on the effectiveness of care delivery models that are forward-located for improving key outcomes, such as behavioral health, and designing a study to compare such models to standard care; and
  • Expanding to all branches of the military the Behavioral Health Data Portal, an automatic and secure system currently used by the Army to allow patients, providers and clinical leaders to access patient-centered data on clinical outcomes for substance misuse and mental health conditions (VA and Department of Defense Fact Sheet, 8/26).

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