Phoenix Veterans Given ‘Poor Quality of Care,’ But Inspector General Can’t ‘Conclusively Assert’ It Killed Them

One of the things about sending
really sick people to a crappy sawbones is that you never really
can be sure if it was Dr. Shakes that did them in or the ailments
they hoped to have treated. That’s the gist of a report from the
Department of Veterans Affairs Office of Inspector General on
“allegations of gross mismanagement of VA resources, criminal
misconduct by senior leadership, systemic patient safety issues,
and possible wrongful deaths at the Phoenix VA Health Care System,”
as the report
summary puts it. Specifically, officials have been accused of
shuffling waiting lists and choking off access to care in order to
polish up their performance reports and reap bonuses.

The Inspector General finds that “The 45 cases discussed in this
report reflect unacceptable and troubling lapses in follow-up,
coordination, quality, and continuity of care.” But while some of
the patients so mistreated did die, the report is
unable to directly connect the crappy medical care to those
deaths.

Our analysis found that the majority of the veteran patients we
reviewed were on official or unofficial wait lists and experienced
delays accessing primary care—in some cases, pressing clinical
issues required specialty care, which some patients were already
receiving through VA or non-VA providers. For example, a patient
may have been seeing a VA cardiologist, but he was on the wait list
to see a PCP at the time of his death. While the case reviews in
this report document poor quality of care, we are unable to
conclusively assert that the absence of timely quality care caused
the deaths of these veterans.

That’s no surprise. Unless you find a drunk doctor straddling a
body and brandishing a bloody scalpel, the cause and effect leading
to death in any individual case is hard to demonstrate. But there’s
no doubt that the quality of care provided by the Phoenix VA system
was not good.

As of April 22, 2014, we identified about 1,400 veterans waiting
to receive a scheduled primary care appointment who were
appropriately included on the PVAHCS EWL. However, as our work
progressed, we identified over 3,500 additional veterans, many of
whom were on what we determined to be unofficial wait lists,
waiting to be scheduled for appointments but not on PVAHCS’s
official EWL. These veterans were at risk of never obtaining their
requested or necessary appointments. PVAHCS senior administrative
and clinical leadership were aware of unofficial wait lists and
that access delays existed. Timely resolution of these access
problems had not been effectively addressed by PVAHCS senior
administrative and clinical leadership.

It’s not hard to conclude that, if you’re delaying the delivery
of medical care to over 3,500 people, you’re going to get bad
outcomes. And if you’re hiding that delay with unofficial waiting
lists, it’s probably because you expect bad outcomes, but don’t
want others to make the connection.

Interestingly, Phoenix facility executives had been told by the
Veterans Integrated Service Network 18 Director in 2012
and 2013 to stop with the shenanigans, but continued
anyway.

And the report acknowledges that such “Inappropriate scheduling
practices are a nationwide systemic problem.”

More Reason coverage on the mistreatment of veterans here.