A Look Inside the VA's Culture of Neglect
| published July 1, 2014 |

By Earl Perkins
Thursday Review associate editor

The southeast region of the United States has rampant problems associated with administering Veterans Administration facilities comparable to issues being faced nationwide, according to several news outlets.

Between Florida and the VA Southeast Network, which includes Georgia, Alabama and South Carolina, numerous horror stories concerning mismanagement, incompetence, waste, mediocrity and falsifying records have been inundating the internet and television news. Management at North Florida VA hospitals is "insanely wasteful," steadily sending patients to private practice physicians, which breeds laziness and mediocrity, allowing doctors to do the bare minimum each day, a North Florida doctor recently told the Florida Times-Union.

He said the problem was not brought on by a lack of money or doctors, because physicians at VA facilities serve about one third to half the number of patients seen at private practices. Veterans are placed on lists and then not seen by a doctor, so they get frustrated and never return to the facility, he said, speaking on condition of anonymity because he feared professional retaliation.

“One thing that kind of kept me there for so long was that I got kind of used to the sedentary, kind of chilled lifestyle and environment, which was not something I was accustomed to going through residency and medical school,” he said. “So I go into the system and I’m kind of like, wow, I don’t have to do this. I don’t have to do that. And I feel bad for saying this, but it’s like the system rewards you for being lazy.”

“You don’t get any more income if you work harder,” the physician said, “you don’t get any less if you work less.”

A national report released this week agrees with the doctor's findings, but Acting Secretary of Veteran's Affairs Sloan D. Gibson told the Times-Union that low caseloads are sometimes caused by the age of patients or type of care needed.

Numerous federal government agencies have been run by incompetent people for decades, and they demand more money to fix the budgetary issues when complaints surface. Things haven't changed today, as the VA scandal broke at the Phoenix facility this spring after 40 veterans died awaiting care while languishing on a secret waiting list that was hidden away in a desk drawer. VA officials and politicians claim more money and doctors are needed to satisfy "ever-growing demands."

The whistleblower doctor trained and worked at VA facilities across North Florida for more than a decade until recently, noting that physicians working at VA enjoy light caseloads.

“In one of the specialties, the VA suggested that the minimum to see is somewhere between 10 to 12 patients for the whole day,” he said, “Whereas the private practice equivalent would be seeing 30 patients per day. If they hire more physicians, it’s not going to make as big of a difference as they think, except for increasing the budget for an already very inefficient, very wasteful system.”

The doctor has spoken for weeks with the Times-Union, outlining problems associated with North Florida VA facilities in Jacksonville, Gainesville and Lake City. His light caseload scenario dovetailed with a 122-page report released by the office of Sen. Tom Coburn, an Oklahoma Republican and doctor.

“An average private-sector primary-care physician has an average caseload (patients under the care of a certain doctor) of 2,300,” the report cited. “Yet, the VA targets panel sizes of 1,200 for its physicians.” The report stated that more than 1,000 veterans may have died because of poor care and almost $1 billion has been paid out in medical malpractice claims during the past decade. After touring the Gainesville facility on Thursday, Gibson claimed there was a shortage of physicians.

“Our average panel size for a primary-care physician is about 1200,” Gibson said. “Think about the patient population we see compared to the private sector. It is older and they have more chronic ailments. The medical system has a way to help us translate that, called ‘RVU’ or relative-value units. What it does is take into account exactly what you’re doing with a patient and assigns a value to that particular treatment. When you look at RVUs, we look a lot more comparable.”

Coburn's report agreed with the north Florida doctor, noting that there was adequate funding, extensive waste and a culture that encouraged mediocrity. “While some believe more money is needed for this to happen, the VA has enough money to institute a much-needed department-wide culture change,” Coburn said in the report.

Doctors in the private sector have moved appointments around at will so they can take off entire days or partial days, allowing them to play golf or enjoy mini-vacations, while VA physicians evidently have discovered even better opportunities. The VA's target panels help schedule doctor workloads, but those figures often have little to do with how many patients are handled.

“If the guidelines are to see 10 patients per day, then 10 patients will be put on the schedule,” the North Florida physician said. “Often times the patients will call days in advance to cancel and nobody is rescheduled into that slot.” This action led to unbelievable complacency at the Jacksonville facility. Think of all the patients who were sitting at home with their cancers or whatever afflictions were visited upon them, with their quality of life almost certainly degrading while the system hid their records so a minimum amount of work was actually performed.

“So there can be days—there were days—that I saw one or two patients the entire day,” the doctor said. This inefficient and wrong-headed scheduling system caused light patient loads and led to a shortage of appointments, which meant patients were forced to wait months or longer to be seen by a doctor, he said.

“The recall list we have for the clinic is a list where once a patient comes through and is seen, if there’s no room to schedule that patient at a future (follow-up) appointment, they are put on a recall list,” the doctor said. “They use that in Jacksonville, Gainesville and Lake City. “We had a staggering number of patients on that list and a lot of them were just sitting on this recall list and never being scheduled into a clinic.”

The VA inspector general's audit report from early last month flagged the Gainesville and Lake City facilities for a follow-up investigation into wait-time manipulation. The VA was evidently referring numerous patients to private providers to shorten the list of names.

“It was very difficult to manage that recall list, because there were so many patients on it, some over a year, and no slots available in which to put them,” he said. “So they would take a large number of the recall list and, across the board, send every one of those patients out through the fee-based system.”

The system tossed patients back and forth like hot potatoes—first they would see a VA doctor, then get referred to a private-sector doctor and then back to the VA recall list, with patient improvement results, and suffering, in keeping with such back-and-forth behavior.

“Absolutely the continuity of care is affected because they’re seeing a different provider,” the doctor said. “What’s happening is the taxpayers are getting hit twice—double. Because they’re paying for a VA system and then they’re paying again for a private provider.”

The physician hated the VA actions, but he someday hopes to return if the system is repaired—hence his slight reticence to being exposed as a source. He noted the worst impediment to decent health care was the VA culture, although secret waiting lists, money, doctors and government bureaucracies certainly didn't help matters.

The VA's Gibson may well have understated the problems in his defense of the broken system.

“I think trust is the foundation of everything we have here at VA,” Gibson said. “It’s the trust of our veterans, of the American people and their elected representatives that we’ll be good stewards of the resources they allocate to us. I’m guilty of stating the obvious when I say a lot of that trust has been eroded and we’re going to have to earn back that trust. We have a lot of work to do.”

The North Florida VA scheduling snafus could very well be dwarfed by issues surfacing in the Tampa area, according to the Tampa Bay Times.

A computer scheduling program—Electronic Wait List, or EWL—was created in 2002 to allow the Department of Veterans Affairs to identify those veterans who were forced to wait the longest. New patients with the most severe medical disabilities associated with their military service were automatically flagged after waiting 30 days for an appointment, lining them up for quicker medical care—so the VA said.

Eventually, most new VA patients were added to the list after 30 days, but around 2010 hospital administrators were allowed to stretch the wait times to 120 days, which dropped thousands of patients from the list nationwide. The time frame was recently changed to 90 days. Accusations are flying from critics stating that VA instituted the changes with the specific intent of creating the illusion of improved hospital performance, while veterans either suffered with long-delayed appointments or died.

"This looks to me like just one more of the VA's gaming strategies that have been identified in the last year," said Anthony Hardie, a Bradenton resident on the board of directors of Veterans for Common Sense, a nonprofit advocacy group. "It looks like VA leaders simply gave up on trying to fix the problem."

The inspector general reported 57,000 VA-enrolled veterans were on the list nationally, while 64,000 never reached the EWL list.

Nationally, the epicenter of the controversy is at the Phoenix VA hospital, where a whistleblower brought to light that 40 patients had died awaiting care. However, others have stepped forward on the record, stating that secret waiting lists were used to hide the facility's horrid performance in stemming patient backlogs. The report also said VA employees used unauthorized scheduling tricks to hide patient-care delays.

VA officials said that the lengthened time frames for being included on the EWL were designed to provide "clarity and uniformity" to lists nationwide, and that the practice was not designed to hide rampant incompetence and waste. The VA said the investigation has caused it to "rethink" past practices—whatever that means.

"If there is one message I'd want your readers to get,'' said Dr. Carolyn Clancy, a VA assistant undersecretary of health for quality, safety and value, "is that it is a new day" at the VA.

Purging veterans from the list who hadn't waited 120 days had a massive impact on the VA's EWL's at the James A. Haley VA Medical Center in Tampa. That number dropped from 4,981 veterans to 1,800 in 2012, while the figure stood at 173 last month, according to the inspector general's audit. Similar figures were discovered at the C.W. Bill Young VA Medical Center in Seminole, where the EWL dropped from 1,408 in December 2010 to 269 in April 2012, then to 103 last month.

The EWLs were designed as a critical tool to help veterans get much-needed care, but somewhere along the way something went terribly wrong. But you really can tell it was designed to improve service, according to a 2002 memo from Laura Miller, then a VA deputy undersecretary, who said agency hospitals created "ad hoc" waiting lists and that "waiting times for new enrollees seeking care are anecdotally reported to be long."

"We will attempt to formalize an 'electronic waiting list' … to more consistently and accurately reflect demand across (the VA) and reduce the risk to enrollees lost to follow-up due to clerical error," the memo said. EWLs were started to measure hospital performance and help leaders allocate resources, but just like any other intimidating bureaucracy, it was prone to manipulation and abuse. The Achilles Heel of the system was probably its choice to link those figures to executive bonuses.

"This is a typical practice of VA hospitals that are not making their numbers," Gordon Erspamer, a San Francisco attorney who represented several veteran advocacy groups, told the Times in 2012. If the VA is late providing care, he said, "The VA redefines the meaning of late."

The VA no longer uses EWLs to measure performance, although it still targets patients who have waited the longest to see a doctor.

VA leaders have known all along that some hospitals used "workarounds" to improve numbers, according to a 2010 memo by VA leadership which stated they (workarounds) "may mask the symptoms of poor access and, although they may aid in meeting performance measures, they do not serve our veterans."

The huge problems exposed in Florida are just the tip of an iceberg, with similar issues surfacing at a South Carolina facility, according to the Washington Times.

Following a confidential complaint against the William Jennings Bryan Dorn hospital in Columbia, S.C., a government audit showed officials not informing patients they were scheduled for surgery, while doctors sometimes planned for surgeries they knew would not happen. They also often cancelled surgeries so they wouldn't have to work overtime, which caused delays for patients who needed surgery. Supply shortages, staffing issues and several instances of contaminated surgical equipment were also discovered.

The facility was evidently extremely disorganized, because staff would just cancel surgeries if they couldn't contact patients, and some surgeries were cancelled on days they were scheduled because pre-operation treatment hadn't been performed. Doctors often scheduled surgeries they knew wouldn't happen so they could work on unplanned "add-on" patients, according to the inspector general. The hospital was also accused of keeping patients under anesthesia longer than necessary so medical students could be trained, but this was unable to be confirmed—probably because of massive staff turnover.

“In the past 3 years, there have been five Medical Center Directors, three Associate Medical Center Directors, eight Chiefs of Medicine (COMs), nine Chiefs of Mental Health, and five Quality Managers,” the watchdog said. The facility is also short-handed in its nursing department. The Inspector General gave 12 recommendations to improve safety and monitoring at the facility. VA officials and hospital leaders agreed with the inspector general's findings associated with the facility, and they're working to fix the problems.

Numerous problems were founds throughout the facility during the inspector general's audit, according to the 31-page report which was released in early June.

The IG took special exception with the Columbia facility's Infection Control program. Dorn ranked 127th out of 128 VA facilities for infections suffered during treatment (healthcare-associated infections) in the 3rd quarter of 2013.

Inspectors noted an orthopedic case cart was returned after surgery containing equipment “still covered with blood and debris,” which the technician evidently didn't "have time" to pre-clean. The IG chose not to substantiate that the issues were a direct cause of the facility's high infection rate. There were also equipment shortages, including surgical mesh, which staffers attributed to supplier disputes concerning payment and billing.

The list goes on and on. Inspectors discovered several issues associated with the hospital's residency program, and they warned that surgery chief residents violated health privacy laws by keeping hard-copy logbooks, including patient health information. They found seven logbooks in a reading room at the facility. Dorn also announced a breach of patient information during the inspection period, but that was left out of the report.

The Atlanta VA Medical Center may have bigger fish to fry than extended wait times and paperwork issues, with the recent federal audit's discovery that three deaths occurred on the facility's watch, according to website Military.com and the Associated Press. The tragedies happened during the past two years after the hospital lost track of mental health patients it referred to an outside contractor, and it also had not been properly monitoring its own patients.

This writer knows patients who have dealt with this facility, and it has been inundated with emergencies and troubled veterans for decades, but these things should not happen at a government hospital. People evidently would rather commit suicide than continue getting the runaround from healthcare providers. The IG report found that many of 4,000 patients the hospital referred to the DeKalb Community Service Board "fell through the cracks."

One died of an apparent drug overdose after the community service board did not provide him with a psychiatrist, although he languished with a referral for almost a year. Another wished to speak with the facility's Health Care for Homeless Veterans psychiatrist, but the person was unavailable. Staff told the man to take public transportation to the emergency room, but he instead ended up committing suicide the following day.

More mismanagement was discovered in the hospital's mental health ward, with staff members losing track of a suicidal patient for two hours one afternoon. He was supposed to be closely monitored, but he died that night from an overdose of drugs he acquired from a fellow patient.

The audit list just continued to grow. One patient with a history of substance abuse and domestic violence wandered the halls for four hours unsupervised, eventually injecting himself with testosterone. Another vet who was diagnosed with schizophrenia disappeared for eight hours and he told nurses he "got lost" going back to his room.

Hospital officials did not dispute the audit's findings and are presently implementing its recommendations, which included new policies concerning contraband, better drug screenings and a new patient tracking system.

"We want to express our heartfelt condolences to the families and friends of the three veterans cited in the reports who died," said Dr. David Bower, hospital chief of staff. "All suicides are tragic events and VA, including this VA, has placed a huge emphasis on suicide prevention. One suicide is one too many. Providing the best health care possible to our nation's heroes is our goal and we are committed to it."

Michael Zacchea, a Marine veteran on the board of directors at Veterans for Common Sense, wondered why the hospital has just now started tracking patients, and he was not impressed with the director's press release.

"It's inexcusable," he said. "I don't think it's an indication that they are finally getting it. I think it's the opposite." The 26-acre Decatur center has the ability to house 405 patients, but also works with eight Atlanta-area outpatient centers to serve 86,000 patients. The IG report, sparked by an anonymous tip last year, condemned hospital policies which allowed mismanagement and understaffing.

From 2011 to 2012, the waiting list for mental health treatment rose from 53 to 397 patients, while there were 66 vacant full-time staff positions. The VA report attributed the disparity to a lack of space and low pay for psychiatrists. Thomas Bandzul, legislative counsel for Veterans and Military Families for Progress, was as kind as possible when noting the facility is one of the nation's most overworked. Also, the wait time for new patients at the hospital averages 64 days.

"They're just overwhelmed," he said. "The system is not designed to handle the numbers that they have in the region."

Bower, the hospital's chief of staff, chose not to demand additional funding at this time. He probably heard about the public's reaction after other VA hospital administrators sought more money on the heels of the audit's excoriating comments.

"The Atlanta VA Medical Center is one of the fastest-growing facilities across the VA, with over 1 million outpatient visits last year," he said. "We are confident that we have the necessary resources to provide all our veterans the care they deserve and earned."

The Atlanta VA's issues actually mirror problems found throughout America, as we continue to deal with veteran suicides and their mental health issues.

U.S. Rep. Sanford Bishop, an Albany Democrat, called the report "disgusting" but said the majority of VA patients are happy with the system. Bishop is the leading Democrat on the U.S. House Appropriations subcommittee that oversees VA funding.

"I don't think that there's anyone who can say that the VA has been underfunded since 2007," he said. "Money is not the issue here. It is management, oversight and accountability, and we are going to do our best to make sure that those measures are taken, that these kinds of incidents will not be recurring."

Finally, we need to take a look at statistics for facilities in Alabama, where Montgomery and Tuskegee show some of the nation's longest wait times for veterans seeking care, according to the Montgomery Advertiser. Central Alabama has an average wait time of 75 days, which stands as seventh-worst nationally, while delays are shorter elsewhere in Alabama.

The average wait time in Tuscaloosa is 47 days, while the Birmingham VA is only 31 days for new patients. You might want to leave the state if you're a first-time mental patient, because central Alabama has one of the nation's worst average wait times at 57 days. Birmingham weighs in at 30 days, Tuscaloosa at 19.

Ten locations in the VA Southeast Network were singled out for further review and investigation into suspected misconduct, with Montgomery and Tuskegee on the initial audit list. It depends on which veterans you talk to as to whether they like or hate the VA and its service. James Milton, who suffers from diabetes, would fall under the negative heading.

"This VA, all I can say is it's sorry and like most vets say, it sucks," he said. "Mind you, I've been here three years and I've seen a VA doctor twice."

Then there's Chuck Manikas, a Vietnam veteran, who has nothing but good things to say about his dealings with the local VAs.

"I've had excellent benefits from the VA. Excellent service from the VA, the local VA. I haven't had any problems with the doctors, with the pharmacy, X-ray, all departments. I've had really good appointment scheduling, patient affairs," he said. Manikas says some of the negativity might be surfacing because the system is strained by more soldiers becoming veterans, while other vets continue to age.

"There's a lot of people in the area that use the VA," he said. "There's a lot of people in the Montgomery area that use the VA regional office that file claims. There are more and more veterans coming back from overseas and then other veterans are getting older every year. I can line up 20 veterans and you might have one or two of the 20 that will say something negative about this VA."

Alabama Congressman Mike Rogers recently issued a strongly-worded statement concerning the VA Audit.

"I am appalled to learn that certain employees at Alabama VA facilities have been a part of this," he said. "To know that any of our Veterans experienced artificially extended wait times is deeply disturbing. No matter how many employees are involved, all implicated in this scandal should be terminated."

WSFA, an NBC affiliate in Montgomery, has a social media site which has been receiving messages and e-mails from veterans and their family members, seeking to have their voices heard concerning their treatment at the facilities in Montgomery and Tuskegee. There were mixed reviews scattered among those who responded to the topic.

"I have good primary care coverage in Tuskegee. I couldn't ask for anything better. The only delay I've found is if you need a specialist," said Robert Boleware, a disabled Army vet.

Another WFSA viewer, Mike Renegar wrote: "I am a combat Vietnam veteran. I receive care from the Montgomery and Tuskegee V A hospitals. I have been very pleased and impressed with the care that I have received and the caring attitude I have received from the staff members employed at these facilities...There may be some areas locally that need to be addressed however I would give high marks to the director of our VA facilities, Dr. Stokes, and all staff members that look after me and my medical care."

Eric Menefee said his 91-year-old grandfather, a WWII veteran, waited more than two years to receive an appointment for cataract surgery, and he's gone blind while waiting for the Montgomery eye clinic staff to schedule him.

"Based on his age and condition, he's expecting the VA to fully honor its obligation to its veterans," Menefee said. "The fraud has been going on for many years and many decades."

A Marine Corps veteran spoke on the condition of anonymity, having undergone spinal fusion surgery at 22 following an injury during his first tour in Iraq. He has been visiting the Montgomery VA Medical Center for care.

"When I ask for more help and tell them I'm having more problems, they just want to give me x-rays and send me on my way just to give you the minimal care so they can say they didn't blow you off when it took you six months to get that appointment in the first place," he said. "They do as little as possible to say they've done something and I just think we deserve more than that. In my opinion, it's our right to get this medical service back to us, especially when we get hurt doing our jobs for the government."

A Vietnam vet also asked to remain anonymous, although he hopes the VA system and local facilities will be overhauled.

"All they want to do is give you medicine and tell you to go on. They don't want to solve the problems. This has been happening since I've been going there in 1972," he said. "I'd like to see the facility change. I'd like to see the doctors care. I'd like to see the nurses care. I'd like to see that we as veterans who fight for the freedom of everybody else that somebody cares about us. And I feel like now that nobody cares about us."

Former Army senior aviator Carol Varner survived combat and the 9/11 attack on the Pentagon.

"I would like to see everyone in the VA system become accountable for their actions and realize how precious it is for them to have the freedom to even work at the VA. That freedom was granted by our military and they should give back by doing the very best they can for our veterans," she said.

American Legion National Commander Daniel Dellinger claims the problems are widespread but fixable.

"The fact that more than 57,000 patients ... have waited more than 90 days for initial appointments is disgraceful," he said. "Even worse is that an additional 64,000 enrolled over the past 10 years have been unable to get appointments. This is not just 'gaming the system.' It's Russian Roulette and veterans are dying because of the bureaucracy."


Related Thursday Review articles:

Truth & Lies at the Veterans Administration; Earl Perkins; Thursday Review; June 14, 2014.

The VA's Long Road Ahead; Earl Perkins; Thursday Review; June 13, 2014.