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


Mark Sardella/Foter

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."

Note that getting to the front of the line isn't a huge improvement, quality-of-care-wise.

More Reason coverage on the mistreatment of veterans here.