OP-ED

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

VA sealAs your correspondent understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital.  Approximately 1500 vets were assigned to an “off-the-books” waiting list that made the clinics’ official waiting times appear shorter than they really were.

Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command.  If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing.  Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain.  A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General’sinvestigation prejudgment is that none of the deaths can be attributed to delays in care. You can’t make this stuff up.

“Good grief!” says your correspondent.  Numerous articles like thisthis and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

That’s why the implications of this extend far beyond a huge stain on the VA’s reputation.  Once again, taxpayers are witnessing another failure of big government. While this has nothing to do with Obamacare, voters have another reason to doubt Washington’s ability to competently deliver on its health care promises.

In the meantime, your correspondent offers the VA plutocrats one approach to figuring out if the waiting lists were associated with higher death rates.  It’s possible, thinks this correspondent, to use propensity score matching within the VA’s much-admired electronic health record system to retrospectively create a cohort of patients that were similar in every way except for being on the wait list.

A similar death rate in that group – demonstrated by unbiased scientists outside the control of the VA – would go a long way toward reassuring all of us that this debacle was limited to customer service.

Jaan Sidorov, MD (@DisMgtCareBlog) is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Population Health Blog, where an earlier version of this post first appeared.

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38 replies »

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  5. Like I said above, here is a link about the current state of affairs in the VA system, if so wonderful and effective, why the vacancies:

    http://www.foxnews.com/politics/2014/05/26/hundreds-jobs-posted-at-va-hospitals-clinics-as-scandal-grows/

    I’ll leave you all with this from the article:

    “A search of the words “VA” and “physician” yielded 167 jobs openings with top-range salaries of roughly $295,000 a year. There are 18 openings alone in the Phoenix VA Health Care System – the same one facing allegations that up to 40 people died while waiting for treatment.

    One full-time position is for the chief of medicine. The vacancy, posted April 15 and open until June 13, comes with an annual salary up to $235,000.”

    Let’s face it, this is a problem both the Repugnocants and the Democraps played sizeable roles in creating and maintaining! Starting wars we had no business being in, both Nam and Iraq, and then unfortunately having technology save so many lives and bring them home has reinforced the adage “false hope”. But, I am sure the usual apologists and defenders of the indefensible and unacceptable will chime in with the typical lame retorts.

  6. The reason for troops to be sent into war has little to do with the scandal at the VA. Whether one supported a war or not one should still support our children that have paid a permanent price and require care to improve their lives.

    Instead the VA has been taking care of their employees and permitting them not to do their jobs as intended while our soldiers suffer. This is not new and in the prior administration the VA’s budget was radically increased. Frequently the VA makes work for themselves (many veterans are on Medicare) solely to keep VA jobs and promote the building of expensive VA hospitals that remain partially empty. The VA will move incompetent physicians from one state to another when the incompetence is too glaring.

    It is obvious that you don’t know too much about the VA, what they do and their costs. That is OK most people don’t. What you do need to recognize is that the VA system is badly run and needs correction now just like the President said nearly 6 years ago.

    The VA’s problem has less to do with their budget than with the long standing problems that have to do with bureaucracies, unions, etc.

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  8. Joel H., I agree with you wholeheartedly. What gets me are comments about the VA (and those that follow suit) that are basically asking for more proof when the problems in the VA have been apparent for decades. Even Obama noted these deficiencies when he ran for office the first time and said the VA would be a top priority. It wasn’t and we have to recognize that funding for the VA had dramatically increased in the prior administration where waiting times seemed to drop. Funding deficits were being filled before Obama took office so he had time to make sure the money was being spent appropriately and the waiting times continued to drop. Apparently he didn’t so. Iinstead of concern about our veterans we see concern over a President’s reputation.

    Of course some of the stories might be inaccurate, but what we are looking at is the tip of the iceberg so we should investigate the stories while at the same time recognizing the VA is being inappropriately handled. We are being too careful in protecting the jobs and the feelings of those that work at the VA at the expense of our soldiers.

  9. Thanks for the informed facts Barry.

    ” I think we need to know more about exactly what conditions patients who waited an excessively long time for care were seeking treatment for. My gut tells me that the number of patient deaths attributable to excessive wait times is exaggerated.”

    I’m looking forward to the investigation’s findings.

  10. “Stop supporting stupid unnecessary wars and the number of vets requiring care will decrease.”

    There are about 20 million U.S. veterans alive today and that’s with World War II and Korean War vets dying off fairly rapidly. Well before the Iraq war, the VA created eight different tiers to determine which veterans were eligible for VA care and which weren’t because it never had the resources to serve everyone when there were only about 5 million vets in the VA healthcare system. In the top tier were those with service connected disabilities and the lowest tier was made up of people with no service connected or non-service connected disability and annual income above a middle income threshold.

    Though I served in Viet Nam for a year in the late 1960’s, I was never eligible for VA care because I was in Tier 8 (lowest tier). After the VA added ischemic heart disease, which I have, to a list to diseases and conditions presumed to be caused by exposure to Agent Orange for those who served in Viet Nam even for one day, I received a 30% disability rating which suddenly made me eligible for VA care as a member of Tier 2.

    When I got my VA card, I inquired at the local VA clinic what the normal lead time is to see a primary care doctor or NP for routine services. The answer was about one to two weeks. I’ve never accessed the system because I’m eligible for Medicare and can afford supplemental insurance which eliminates copays and deductibles. I think we need to know more about exactly what conditions patients who waited an excessively long time for care were seeking treatment for. My gut tells me that the number of patient deaths attributable to excessive wait times is exaggerated.

    As for the ACA, the two main factors that determine whether or not a provider gets paid for a given service, test or procedures are (1) it must have a billing code, and (2) it must be a covered service. With respect to insurers being unable to sell policies that are not compliant with the ACA, suppose an insurer were willing to sell me a policy for a dollar a year that covered everything above a $1 billion deductible. Should I be able to buy it? Technically, it’s insurance but it really isn’t. That’s why there has to be a mandated benefits package that insurers must cover.

  11. The disingenuous and dishonest dialogue by physician supporters of Obamacare is not only hideous and disgusting, but really shows incredibly poor judgment by those who recited the Hippocratic Oath and then either ignored or dismissed it by supporting this heinous legislation.

    And you wonder why the VA continues to struggle to attract and keep responsible and invested clinicians. But, with the persistent commenters here who blindly support PPACA, well, how do you folks live with yourselves?

    The VA system is the precursor to what Federal control of public care will be, mark these words in the next 5 years if the law stays as is.

  12. Bobby G, I didn’t walk myself back, as you put it, rather used the term ‘free market’ as originally used by Adam Smith and most economists. There was no question in Adam Smith’s mind that some type of government needed to exist for the free market to exist. I must admit that some on the extremes, perhaps anarchists think that a free market precludes any government what so ever, but that is not the way the term is generally used or understood. Perhaps in further discussion should it occur I will refer to ‘Bobby G’s free market adventure’ if choosing the aberrant use of the term ‘free market’.

    “AHIPcare” is a good name and would fall under the category of government care programs like the VA, Medicare and Medicaid. Excellent, BobbyG.

    Have a good Memorial Day Weekend

  13. My answer is that there is no such unconditional thing as a “free market” in the real world (you’ve already walked yourself back a bit by admitting to “degrees”).

    This brief, entertaining pissing contest over the epistemological semantics of the definitions of key terms is over, bro’. That we will never agree is obvious. Have a great day.

    The VA is indeed “government healthcare.” The ACA is not. I call it “AHIPcare,” btw.

  14. BG: It’s a matter of perspective. It is not that I know so much. It is more a matter of what you bring to the table.

    I’ll ask the question again:

    “So let us get to the point of this discussion. You don’t like to call the ACA government healthcare even though the government controls it. What do you wish to call it? Certainly not a free market.”

    You wish to leave this question unanswered and that is understandable from your perspective as you don’t have a good answer.

  15. “It’s that type of thinking that has left our veterans untreated.”

    Really, not sending troops into war reduces funds available to treat veterans? Your reasoning confounds me.

    The situation of having to fudge and lie about wait times is about adhering to budgets and the perverse incentives to stay within budget. But to say the entire VA system is a “failure of big government” is just stupid. It takes “big government” to afford the tax supported system.

    Maybe you think the VA should have no budget and be able to write checks at will.

  16. Peter, The VA failed. There was widespread gaming of the system by VA employees. That cost lives. Correction of the problem was something that Obama ran on in his first race for the Presidency. Instead of focusing on the problem you are focusing on sending troops into wars that you don’t personally agree with. It’s that type of thinking that has left our veterans untreated.

    One of the problems seems to be the inability to fire people at the VA and the refusal of the CEO (the President) to pay attention to his campaign promise.

  17. Gee Allen, I thought the quote was from JAAN SIDOROV and my answer was not intended for anyone in particular.

    You also seem to have little information to go on. I thought, “supporting the troops” was not sending them into personal vendetta wars, as one example.

    But we can all cheer Memorial Day and enjoy the holiday while using it to flog some merchandize while draping ourselves in the flag.

  18. Peter 1, how does one answer another that doesn’t recognize that there is a difference between supporting wars and supporting our troops when injured. You don’t know what I believe with regard to any war yet you are foolish enough to draw conclusions without any facts.

    I guess that foolishness is one of the reasons you don’t seem to understand what the debate is all about.

  19. Yes, BG there are different degrees of freedom, but you can nit pick almost anything and get nowhere. We have laws to prevent theft and fraud. You might believe they eliminate what you think is a free market, but a free market doesn’t exist without some type of government that recognizes contracts and the law.

    As government places more burdens on those that willingly wish to contract with each other we become less free. Did you know that? I see don’t see any recognition of that in your replies.

    So let us get to the point of this discussion. You don’t like to call the ACA government healthcare even though the government controls it. What do you wish to call it? Certainly not a free market.

  20. “Lois Lerner decided who got 501c status”

    And who lost 501c status? One liberal watchdog group. Big scandal.

  21. “Once again, taxpayers are witnessing another failure of big government.”

    Really?

    “The Veterans Health Administration is America’s largest integrated health care system with over 1,700 sites of care, serving 8.76 million Veterans each year.”

    Stop supporting stupid unnecessary wars and the number of vets requiring care will decrease.

  22. allan says: May 22, 2014 at 2:02 pm

    “we haven’t had a free market in the healthcare sector since WW2. It has become less and less free.”
    __

    There’s no such thing as a “free market.” Human socioeconomic affairs get regulated one way or another. By laws and regulations, by corporate rule of the powerful and rapacious, or at gunpoint. Those are in fact the choices. Maybe private market mechanisms suffice for trading in cheap trinkets, but administration of health care is quite another matter, many orders of magnitude more complex in terms of effective, rational, and just means.

    None of which is to justify the PPACA — neither am I a big fan. My issue is simply with your simplistic, fits-on-a-bumper-sticker mischaracterization of it.

  23. The VA medical system is simply overwhelmed. Well-meaning VA leadership instituted systems and measures to track and improve performance on a key metric (wait time). And local administrators gamed the systems and measures. Should VA leadership have expected some to game the system and audited reports to keep everyone honest? Absolutely. And that’s a big problem.

    What’s unfortunate here is that this situation helps those who seek to discredit the VA (and/or President Obama) to put forth the narrative that the VA delivers poor care, has antiquated computer systems and is poorly led. That the VA is far inferior to the care being delivered in the rest of the US healthcare system.

    This is, of course, just the opposite of the reality.

    Let’s hope that this false narrative doesn’t result in ignoring all of the lessons, best practices and innovations coming out of the VA that could – and should – inform our broader healthcare system. That it doesn’t paint everyone who works at the VA as some kind of a cold, useless bureaucrat. And that it doesn’t result in a collective effort to give up on the VA (“Let’s privatize it. HCA can run it better than the VA!).

    Is the VA perfect? Far from. Nor is the rest of the US healthcare system.

    The VA has been put to the test with the influx of new veterans. And the problems that we see are a predictable result. Thank God that they’ve come out and we can fix them.

    We’re going to find out how the healthcare system performs when millions of people gain health insurance and then seek medical care. Delayed care, denied care, deferred care and cost rationing in the broader healthcare system occur on a daily basis in many forms…before the influx. What will the future hold? It ain’t gonna be pretty.

    Ron

  24. BG, I have no doubt that you put a lot of effort into reading the bill and checking all the other federal legislation that this bill refers to along with all the new rules that have come out since the ACA’s passage. I am sure you have been more diligent then those members that actually passed the bill. I would however, advise you to do a search for certain key words such as ‘the secretary shall decide’ or anyone of the key variants. The bill was a skeleton left open for executive decision making.

    I don’t disagree with what Kleinke observes since we haven’t had a free market in the healthcare sector since WW2. It has become less and less free. The ACA expanded the status quo which is government involvement and now we can call this newest bill government healthcare.

    You don’t wish to use that term. What term would you like to use? The ACA certainly doesn’t represent the free market. I am not free without penalty to carry no insurance. An insurer that can come up with a better plan that is outside of the government guidelines cannot offer his insurance to me despite the fact that we might have a willing buyer and the insurer being a willing seller.

    You see choice and I see a Hobson’s choice, ‘choose the horse in the stall closest to the door’.

    ‘Yes, government care the ACA is.’ _ET

  25. According to the SCOTUS it is a tax bill. It also is a law requiring policies to include certain benefits they previously did not have, making some beneficiaries winners and some looking for new coverage t higher cost. It also will have consequences yet to be seen, I suspect some are intended…fewer docs playing the game will lead to de facto rationing, thereby cutting rate of spending. The unintended consequences likely will be amazingly bad.

  26. I read EVERY draft of the bill that became law. I have a pdf copy here. I refer to it often. It is nhot “government healthcare.” The fact that ~half of payments come from public monies doesn’t change the fact that the PPACA, as noted medical economist J.D. Kleinke has observed, is “a radical expansion of the status quo.” The actual delivery of health care services remains as it was.

  27. You might want to believe that, but the chief executive of the ACA happens to be the President. If you read the law you will note ‘the secretary shall decide’ on numerous occasions and that means that an arm of the President shall decide much like the IRS scandal where Lois Lerner decided who got 501c status. The government is determining how the fee should be determined and what should be offered. It is controlling both sides of the Adam Smith equation the buyer and the seller. The ACA most definitely is government healthcare. One is even ‘fined’ for not going along with the government’s plan.

  28. This makes one want to review their notes with regard to the ACA. The VA and the ACA have one thing in common. They both represent government healthcare. My bet is that The future is grim for either the patient or the ACA in the future. One of the two will be discarded. It looks like it might be the patient. Think of those gallant soldiers that died on the VA waiting list. Now think of all those on Medicare that likely will be facing the same fate. Think of the disabled and think of anyone with a costly, time consuming illness.

    The government is focusing on the wrong set of problems and blaming physicians etc., but not leveling the blame where it belongs… on the government itself and its CEO, the President.

  29. Excellent comment. What a CusterFluck. Shinseki is now the new Sebelius, and will likely jump/be pushed after a “decent interval.”

    My late Dad was disabled WWII (left a leg behind in Europe). His VA experience was excellent, but, that’s because of old-timers in VA administration who looked out specifically for that cohort. During his dementia years, I was his legal guardian and had to interact with the VA on his behalf. I never had any problems. But, that probably came at the expense of the younger vets.

  30. As a VA physician, here’s what I know anecdotally:

    1. The middle management (both nurse, physician and non-clinical administrators) is accountable for much of the waste and political inefficiencies in the system. There is nepotism, union rules and inability to manage staff appropriately, egos and serving of self interest to keep advancing in the VA system.

    2. The EMR is fabulous in many ways and has served as a model for other systems. But much like EPIC, which is truly painful to deal with on a busy clinic day, it does not help in efficiently taking care of patients. The more information you throw at a provider, the more they are theoretically responsible for knowing and there is simply not enough time in a 15 or 20 minute visit to cover it all.

    3. Which leads us to issue #3…if you slow the system down with technology that is fabulous for extracting information but overwhelming in the level of detailed input, you decrease the number of patients you can see OR you start to increase burnout at a truly unsustainable rate (before you guffaw at lazy doctors and nurses, think about how rushed and frazzled they may have seemed at your last visit – it’s because they are going full tilt every day, and that does impact their productivity).

    The focus of this article is about implications for the broader ACA and about how to measure whether or not the wait list truly made any difference in care by comparing to a matched population. I think both are important theoretical points. It’s important to have some data to assess prior impact to help determine possible future outcomes.

    But anyone on the ground will tell you that they already know – this is extremely relevant to the ACA because two of the key tenets are increase in the volume of patients and the use of technology for management, both of which absolutely impact the care at the VA. And, like with the studies which say that fears of litigation don’t impact practitioners or lead to defensive medicine, anyone who actually practices will tell you that this theoretical assessment just isn’t true in reality.

    By all means, let us collect and analyze data to come up with appropriate conclusions. But as a wise colleague of mine used to say about life – most of our problem isn’t that we don’t know what we need to know, but that we aren’t willing to do what we need with that information.

  31. Amazing that they waited this long to bring this up.

    Anybody who knows anything about the way the bureaucracy inside the VA works understands why this happened and knows what will be coming next. Getting things done in a system dominated by red tape and petty political infighting invovles working around the bureaucracy.

    Two predictions: 1. This is not going to go away. It is only going to get worse. 2.Shinseki is history and he knows it. The White House is looking for ways to avoid getting taken out by this, this is bad and they know it. Another significant revelation: documented evidence of widespread patient deaths, evidence of fudged outcomes data on a larger scale, or the emergence of a highly placed whistleblower will have the critics inside the White House gates.

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