2014 Veterans Health Administration controversy

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 operations 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. 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. 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. 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 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. 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. 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." Columbia, South Carolina A VA inspector's September 2013 report noted that due to mismanagement, thousands of patients at the VA Medical center in Columbia had their appointments for colon cancer screenings delayed. This resulted in over 50 patients having a delayed diagnosis for colon cancer and some later died from the disease. Additionally, a 2008 report indicated that documents that were critical in the processing of veterans' disability claims had been shredded. Although this had occurred at at least 40 locations nationwide, the Columbia location had the most cases.(1/5 of the overall cases) Also, between 2009 and 2013, the backlog of disability claims in Columbia more than doubled from 33% to 71%. ==Investigations and findings==

Internal VA investigations An audit from the Secretary of Veterans Affairs said, "some front-line, middle, and senior managers felt compelled to manipulate" records to meet performance goals. The manipulation of records was done with the knowledge of senior managers in the Phoenix VA system and possibly those of other VA facilities. Investigations are ongoing as of May 31, 2014. An official report from the VA Inspector General "found that about 1,700 veterans in need of care were 'at risk of being lost or forgotten' after being kept off an official waiting list." Schedulers for the Veterans Health Administration were instructed to change the dates for which veterans had requested an appointment in order to hide delays. At the Phoenix VA, "official data showed (veterans) waited an average of 24 days for an appointment. In reality, the average wait was 115 days." Shinseki called the situation "reprehensible". Former VHA doctors were not surprised by the findings. The VA OIG reported in May 2014 that 17 veteran deaths had occurred while waiting for VHA treatment in the Phoenix VA system, and on June 5, 2014, the Acting Secretary of Veterans Affairs, Sloan Gibson, reported that the VA had identified 18 additional deaths. The 18 deaths were among the group of 1700 identified as "at risk of being lost or forgotten". Griffin said that autopsy reports would need to be investigated to determine if the deaths were caused by the delays in treatment. An internal Veterans Affairs audit released June 9, 2014 found that: • Tens of thousands more veterans who previously reported waiting more than a month for an appointment • Disparities between reported wait times and actual wait times Senator Tom Coburn, (R) Oklahoma, released a year-long investigative report that suggests the number of veterans who died while awaiting delayed care or treatment over the past decade may number as high as one thousand. FBI investigation On June 11, 2014, the Federal Bureau of Investigation opened a criminal investigation of the VA. Obama Administration investigation President Obama's Deputy Chief of Staff, Rob Nabors, reported to Obama on June 27, 2014, that he found "significant and chronic system failures", a "corrosive culture", damaged morale, and a need for additional staff. He reported that the goals for wait times for appointments of no more than 14 days are unrealistic, that data about patient wait times had been falsified by VHA employees, that there are a variety of problems with safety and integrity within the VHA, and that transparency and accountability are lacking. In response to the report, the Republican chair of the House Veterans Affairs Committee, Representative Jeff Miller, said, "It appears the White House has finally come to terms with the serious and systemic VA health care problems we've been investigating and documenting for years" and that he would work with the White House to fix the problems. The independent chair of the Senate Veterans Affairs Committee, Bernie Sanders, said, "No organization the size of VA can operate effectively without a high level of transparency and accountability. Clearly that is not the case now at the VA." Acting VA Secretary Sloan Gibson said that he accepted the OSC's recommendations and had directed a review of the Office of Medical Inspector that was to be completed in two weeks. Gibson said "I am deeply disappointed not only in the substantiation of allegations raised by whistleblowers, but also in the failures within VA to take whistleblower complaints seriously." ==Responses==

May and June 2014 Politicians from both Republican and Democratic parties have commented on the scandal. Democratic Representative Steve Israel said that "It's a shame that when Republicans had a chance to help vets get their benefits from the V.A., they blocked a solution", referring to Republican opposition to the 2013 Veterans Backlog Reduction Act. Democrats, led by Senator Patty Murray, have aggressively sought more money for veterans' services since the second term of President George W. Bush. Many Republicans have countered that the problems in the VA are ones of management rather than funding and that Obama Administration officials are responsible for not discovering the patient backlog. Republican Representative Jackie Walorski said that the VA had "bureaucracy run amok" and noted a case in Atlanta where "two top officials were able to retire early and three were reprimanded" over three preventable deaths. At the end of May 2014, bipartisan agreement emerged among Democratic Senator Barbara A. Mikulski and Republican Senator Richard C. Shelby on the Senate Appropriations Committee to include funding for civil and criminal investigations into Veterans Affairs in a veterans spending bill. Democratic President Barack Obama's chief of staff, Denis McDonough, said on May 18, 2014, that Obama was "madder than hell" about the reports of delays in treatment. McDonough said that "At the same time that we're looking at accountability we want to continue to perform to provide our veterans the services that they have earned." On May 21, 2014, in a vote of 390–33, the House of Representatives passed the Department of Veterans Affairs Management Accountability Act of 2014 (H.R. 4031; 113th Congress). The bill would give the Secretary of Veterans Affairs the authority to remove or demote any individual from the Senior Executive Service upon determining that such individual's performance warrants removal or demotion. The House members who sponsored the bill argued that, although federal workers can be fired, the process is extremely lengthy, sometimes taking years, and that the officials who are "under scrutiny for neglecting veterans actually received tens of thousands of dollars in bonuses and positive performance reviews". Florida Republican Representative Jeff Miller, who sponsored the bill, said that "this bill would simply give the VA Secretary the authority to fire or demote VA Senior Executive Service employees based on performance, similar to the authority the Secretary of Defense already has to remove military general officers from command or how I am able to fire someone who works for me on my staff." , Secretary of Veterans Affairs, resigned on May 30 because of the scandal. On May 30, 2014, Shinseki apologized and accepted responsibility for the scandal. Later that day he formally resigned as Secretary of Veterans Affairs. Their legislation was expected to address both the need to improve the healthcare that was being provided to veterans and the poor management of the Department of Veterans Affairs. The Congressional Budget Office estimated that the bill would cost about $620 million over the 2014–2016 period. On June 11, 2014, the Senate voted 93–3 to pass the Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014, the bill written by Senators McCain and Sanders to reform the VA. Chairman of the House Committee on Veterans Affairs Jeff Miller said that "many of the provisions included in today's Senate-passed bill are based on ideas that have already cleared the House, so I'm hopeful both chambers of Congress can soon agree on a final package to send to the president's desk." Miller was referring to the House's Veteran Access to Care Act of 2014 (H.R. 4810; 113th Congress) which contained similar provisions and passed the House on June 10, 2014. In late June 2014, VA General Counsel Will Gunn and VA Acting Undersecretary for Health Robert Jesse stepped down from their positions. • Moving more than $390 million inside the VA budget to fund care for veterans outside the VA system; • Deploying mobile VA medical units; • Ending the goal of providing appointments within the 14-day window that Nabors criticized as unrealistic and said may have "incentivized inappropriate actions"; • Posting twice-monthly public updates of VA wait times; • Banning performance bonuses; • Removing some senior managers from the Phoenix VA system; • Leadership emphasis on protecting whistleblowers from retaliation. July 2014 Appointment of Robert A. McDonald replaced Shinseki as Secretary of Veterans Affairs. President Obama nominated former Procter and Gamble CEO and US Army veteran Robert A. McDonald as the permanent replacement for Shinseki as Secretary of Veterans Affairs. Paul Rieckhoff, CEO of Iraq and Afghanistan Veterans of America, said that "If the president doesn't make VA a priority, Superman can't do this job." House Speaker John Boehner and American Legion national commander Daniel Dellinger also commented that new VA secretary would need Obama's support to make changes in the VA. McDonald was sworn into office on July 30, 2014. His first message to VA employees stressed the importance of integrity. Legislation passed in Congress The Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014 was passed by the House and Senate before their August recess to add $16 billion in supplemental funding for the VA, with $10 billion for allowing some Veterans to receive private medical care at taxpayer expense, and $6 billion for increasing the number of VA staff. The Act also gives the VA Secretary expanded authority to fire managers who perform poorly, and authorized the VA to lease additional facilities. August 2014 Sloan Gibson, who had been Acting Secretary between the time of Shinseki's resignation and McDonald's taking office, is now Deputy Secretary. He said on August 6, 2014, that more punishments were planned for VA officials for their roles in the scandal. The VA announced the week prior to Gibson's statement that two supervisors would be fired and four other employees would be disciplined for their roles in falsifying data in Colorado and Wyoming. The VA previously announced plans to fire three executives at the Phoenix VA. "These were the first in what I expect will be a long series of announcements of personnel actions," said Gibson. On August 7, Obama signed the VA funding and reform legislation in a ceremony at Fort Belvoir, an Army installation in the State of Virginia. "This bill covers a lot of ground, from expanding survivor benefits and educational opportunities, to improving care for veterans struggling with traumatic brain injury and for victims of sexual assault," said Obama, and gives the VA Secretary "more authority to hold people accountable... so that he can move quickly to remove senior executives who fail to meet the standards of conduct and competence that the American people demand." As of August 15, VA data showed that the number of veterans who were waiting more than three months for an appointment has declined by half since Spring 2014, but the number who wait at least 30 days remains similar. Reported wait times for repeat patients have increased from 3.5 days to nearly 6 days. The VA paid for nearly 200,000 veterans to see private doctors, and average wait time to see a primary care doctor decreased from 51 to 43 days. August 26, 2014, Obama announces 19 sweeping executive actions aimed at improving access to quality VA healthcare, increasing mental health services, eliminating veteran homelessness and ensuring service members have the employment and education resources necessary to assist with their transition out of the military. September 2014 At a Senate hearing on September 9, 2014, Acting VA Inspector General Richard J. Griffin reported that investigations are continuing into the Phoenix VA, including a review of "possible criminal misconduct by VA senior hospital leadership". Griffin also reported that "Since July 2005, OIG published 20 oversight reports on VA patient wait times and access to care yet VHA did not effectively address its access to care issues or stop the use of inappropriate scheduling procedures. When VHA concurred with our recommendations and submitted an action plan, VA medical facility directors did not take the necessary actions to comply with VHA's program directives and policy changes." In his spoken testimony, Griffin said that in "three-fourths (of the VA facilities investigated for falsification of wait time data), we're pretty confident that it was knowingly and willingly happening, and we're pursuing those." He also said he hopes to complete his office's investigations into possible criminal misconduct by the end of 2014. If his office finds criminal misconduct, it will then refer cases to U.S. attorneys for possible prosecution. Senator Richard Burr said that the "culture that has developed at VA and the lack of management and accountability is simply reprehensible." In his testimony, Secretary Bob McDonald apologized "to all Veterans who experienced unacceptable delays in receiving care at the Phoenix facility, and across the country. We at VA are committed to fixing the problems and consistently providing the high quality care our Veterans have earned and deserve in order to improve their health and well-being." He discussed actions taken at the Phoenix VA facility in response to Inspector General findings, and he discussed national initiatives to change VA's culture, measure patient satisfaction, improve access to care, and improve accountability (including a restructuring of the Office of Medical Inspector). On September 18, 2014, VA published the Federal Register its intention to increase the annual salaries of new physicians and dentists by up to $35,000 as part of a nationwide recruitment effort to hire more doctors and improve veterans' access to care. The notice was to take effect on November 30. VA Secretary Bob McDonald said the department needs new doctors, nurses and clinicians for 28,000 jobs authorized by Congress in the 2014 Veterans Access, Choice and Accountability Act. At a House Veterans Affairs Committee hearing on September 18, Griffin said that delays at the Phoenix VA "contributed to" but did not "cause" the deaths of veterans, an assertion that was challenged by Committee members. Another witness at the hearing, Dr. Sam Foote, said that "This report is at best a whitewash and at worst a feeble attempt at a cover-up", and alleged that the report omitted information about 293 veterans who died waiting for healthcare. Foote also faulted McDonald for allegedly not increasing VA's transparency as he had promised. October 2014 On October 7, the VA announced that it was firing four additional employees, subject to the results of appeals. Deputy Secretary Gibson said that "VA will actively and aggressively pursue disciplinary action on those who violates our values. There should be no doubt that when we discover evidence of wrongdoing, we will hold employees accountable." • The director of the Pittsburgh VA is being fired for "conduct unbecoming a Senior Executive" after an outbreak of Legionnaires' disease in 2012 and a subsequent investigation. "VA officials knew about problems and dangers with the medical center's water system, but did not disclose that information for almost a year." • The director of the Dublin, Georgia VA is being fired after "the hospital's staff closed out more than 1,500 patient appointments to hide long wait times." • The director of the central Alabama VA system is being fired after a variety of problems were found by the VA Inspector General, including long wait times that some schedulers were instructed to conceal. • The Deputy Chief Procurement Officer is being fired. According to the Inspector General, she "improperly disclosed non-public VA information to unauthorized persons, misused her position and VA resources for private gain, and engaged in a prohibited personnel practice." Rep. Jeff Miller, Republican, of Florida, chairs the House Veterans Affairs Committee. He said that the new VA law gives agency officials five days to respond to notices of intent to fire them. The director of the Georgia VA retired four days in advance of VA's announcement that he would be fired, and the procurement official also retired in advance of her firing. The procurement official was nearly hired by the U.S. Department of Energy before that department learned of the findings against her at the VA. Miller said that "If any current laws or regulations are impeding the (VA)'s ability to swiftly hold employees accountable, VA leaders must work with Congress so those laws and regulations can be changed", and "VA appears to be giving failing executives an opportunity to quit, retire or find new jobs without consequence." He said he opposed allowing officials who had committed misconduct being allowed to "slip out the back door with a pension". November 2014 The official in charge of the Phoenix VA facility, who had been on administrative leave for almost seven months, was fired. While on administrative leave, she was paid over $90,000. Rep. Kyrsten Sinema, D-Ariz, said that the payments were "a completely unacceptable use of taxpayer dollars that should instead go to providing care for veterans". Dr. Sam Foote said that the firing was "a good first step" and that "I think there are a lot of others who need to follow her out the door." The VA temporarily appointed a new manager for the southwest region of the United States. The southwest region includes the Phoenix VA facility. The new manager was previously involved in clandestinely placing a camera inside the hospital room of a patient in Florida. She later said that the manner of the camera's placement was "wrong". The Republic reported that "(she) at first said she authorized the videotaping because nurses were upset and wanted to prove family members were committing medical sabotage. Moments later, she said there was no intention to keep the filming secret from the Carnegies, and the camera was really approved for patient safety." She said that she has previously been assigned to problematic hospitals during her career, including those with ethics violations or financial problems, and has been successful at fixing the problems. February 2015 Secretary McDonald made two controversial statements in February. On a February 15, 2015 airing of Meet the Press, McDonald claimed that 60 U.S. Department of Veterans Affairs employees had been fired due to the VA's wait time scandal. Later, he backtracked and clarified it was only 8 employees that lost their jobs. On February 23, 2015, McDonald admitted he misspoke to a homeless veteran on January 30, 2015, about his serving in the U.S. Army special forces, a conversation that was recorded by a CBS television news crew accompanying him during a nationwide count of homeless veterans. "I have no excuse, I was not in the special forces" he told The Huffington Post, which first broke the story. The Huffington Post reported that "special operations forces" includes the Army Rangers and that McDonald "...completed Army Ranger training and took courses in jungle, arctic and desert warfare" and "...While he earned a Ranger Tab designating him as a graduate of Ranger School, he never served in a Ranger battalion or any other special operations unit." April 2017 On April 27, 2017 President Trump signed Executive Order 13793, titled "Improving Accountability and Whistleblower Protection at the Department of Veterans Affairs." ==Comments from management experts, health care experts, and economists==

Management experts said that the source of the problem was setting an unrealistic goal of a 14-day wait. This was compounded by not including provisions for measuring how well the system was working. Experts said that having high-stakes goals, especially without checks and balances, encouraged "gaming the numbers" and cheating, in the private and public sector. Managers at the Federal level should have had data about times and costs for basic services throughout the VA system. That would have identified the Phoenix facility as anomalous. "Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable," wrote Longman. "But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there." ==See also==