Veterans

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

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Veterans
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.

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  1. 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.

    What difference at this point does it make?

  2. Shocker the gov. can’t determine if it’s at fault or not.

    1. First rule of bureaucracy – check all of the boxes so no blame can be assigned.

  3. Would someone please explain why, since the dawn of time, veterans (and soldiers) get treated like shit yet there is never a shortage of kids willing to volunteer and put their lives — and limbs — on the line for these hucksters?

    I understand how an 18 year old can be ignorant of history, but why don’t parents spend 10 minutes to tell their kids that they’re suckers for joining the military?

    1. Probably because some of those kids (and a not-inconsiderable number of adults) see some value in serving their country, and they’re not embittered and cynical about what’s going to happen to them if/when they get out.

    2. I dunno. How common were volunteer armies prior to the modern era (serious question). As for the modern era, they’re fed a steady diet of bullshit patriotic propaganda.

      1. In the US, the military was always volunteer until the later part of the Civil War (see NYC draft riots, etc) – the mass Industrial Armies of WWI and WWII saw a draft, and then it kept up until 1973.

        I hate slave armies.

    3. Never considered or cared about the VA when I joined – in fact, both my parents were medical people who had interacted with VA at some point 1940s-1950s and told me it was a horror.

    4. People suffer all kinds of romantic illusions and delusions. Military service is just one of many, IMO. Just because people get older, doesn’t always mean they also get wiser.

      But then, I’m a cynic, so there’s that.

      1. So nobody joins except out of romanticism or delusion?

  4. 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.

    Oh, how about a stab at a *probability*, then? 80%? 90%?

  5. I knew it!
    Fake Scandal #467! Down for the count!

  6. 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

    Unless you are an attorney in which case you know for a fact that it was the doctor’s negligence.

  7. Bending the health care cost curve downward, one veteran at a time.

    It’s not a Death Panel, it’s an Oopsie We Bungled the Paperwork Panel!

  8. We so need a Republican in the White House, like a flaming, bible-thumping, gay-hating socon, and we need her now. So many government abuses starved for sunlight and attention. Pulitzer would have to start issuing multiple awards in the same year if the president had a R next to their name right now.

    1. That’s basically why, given two terrible choices (and I’m assuming Rand doesn’t get the nomination here), I’d rather Team Red win in 2016. At least then the media and the populace would start giving a damn again about government abuses.

      1. And the vicious cycle continues…

        God help us if Rand isn’t elected POTUS in 2016!

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