Report: VA's Internal 'Watchdog' Ignored Complaints, Downplayed Problems

Posted: Jun 24, 2014 11:26 AM
Report: VA's Internal 'Watchdog' Ignored Complaints, Downplayed Problems

A new independent investigation charges that internal watchers at the corrupt Veterans Affairs agency sanitized and manipulated their reports to protect the bureaucracy, betraying the current and former service members they're charged with protecting. In a parade of horribles -- from the original Phoenix outrage, to endemic abuses to protect administrators' performance bonuses, to tales of systemic whistle-blower retaliation, to egregious standards of care, to discarded warning signs -- this may be one of the most depressing stories to emerge from the VA saga. It's somewhat akin to numerous crime victims calling 911 and running into a brick wall of crooked cops at the other end. The Wall Street Journal reports:

A Department of Veterans Affairs internal watchdog created to safeguard the medical care provided to former service members instead routinely plays down the impact of treatment errors and appointment delays, a federal special counsel alleged on Monday. In a letter to President Barack Obama, U.S. Special Counsel Carolyn Lerner said the VA Office of the Medical Inspector has repeatedly undermined legitimate whistleblowers by confirming their allegations of wrongdoing, only to then dismiss them as having no impact on patient care. The strongly worded critique adds a new layer to the veterans-care scandal that has rocked the VA and President Obama's administration in recent months...The special counsel's allegations are the latest blow to the VA, which was rocked this spring by revelations that some employees doctored records to make appointment wait-times appear far shorter than they really were.

The agency's self-policing mechanism would quasi-confirm whistleblowers' complaints, only to assess that the resulting abuse didn't have any impact. Thus, problems would remain unaddressed, poor practices would remain intact, and (based on last week's Times story), whistleblowers would stand exposed. Click through to read the Office of Special Counsel's withering five-page report on the VA's Office of the Medical Inspector (OMI). The document includes a number of specific incidents, including an instance wherein a patient was "admitted to the facility in 2003, with significant and chronic mental health issues. Yet, his first comprehensive psychiatric evaluation did not occur until 2011, more than eight years after he was admitted." Eight years. CNN's Drew Griffin, who has owned this story, cited that extraordinary example in a segment that aired on Monday and was flagged by Noah Rothman. Be sure to watch through the end. Here's a guy who's followed this scandal as closely as anyone, and he's utterly unconvinced that the VA's toxic culture can be "surgically" reformed. It needs gutting:

"Based on everything I know today, I don't think the VA can fix itself. I don't know how you fix this...I would blanketly throw out every senior manager in the VA. I know that sounds harsh, but I don't know how else you would do this surgically. There is an entire bureaucracy here that has been allowing this to happen for years, and years, and years."

Perhaps bloated, self preservation-minded government bureaucracies shouldn't administer healthcare systems in general -- especially for the people to whom we all owe so much. Buttressing Griffin's core conclusion that the agency is too broken and self-interested to be repaired without sweeping, root-and-branch changes are two new reports. The first, published in the Arizona Republic, reveals that regional VA officials knew full well what was happening -- for years:

Department of Veterans Affairs administrators knew two years ago that employees throughout the Southwest were manipulating data on doctor appointments and failed to stop the practice despite a national directive, according to records obtained by The Arizona Republic through a Freedom of Information Act request. A 2012 audit by the VA's Southwest Health Care Network found that facilities in Arizona, New Mexico and western Texas chronically violated department policy and created inaccurate data on patient wait times via a host of tactics. The practice allowed VA employees to reap bonus pay that was based in part on inaccurate data showing goals had been met to reduce delays in patient care, according to the VA Office of Inspector General. At the Phoenix medical center alone, reward checks totaled $10 million over the past three years...audit findings, based on a review of data from the second quarter of fiscal 2011, show the violations proliferated throughout the Southwest and were common nationwide.

A separate investigation by the Tampa Bay Times uncovered allegations that a 2010 policy change was designed to hide VA facilities' wait time failures: "The VA allowed its hospitals to lengthen to 120 days the time veterans must wait without an appointment before they are put on the waiting list, potentially cutting thousands of veterans across the nation from the list, according to a Tampa Bay Times review of VA records and interviews...Some critics say the changes were a deliberate ploy by VA leaders to make this much-watched measure of hospital performance look better than it actually was," the paper reported. Vets could wait for four months without a scheduled appointment before they even qualified for the "official" wait lists -- which were themselves being abused and falsified in many cases. I'll leave you with this, via CBS news:

Nearly 80 percent of senior executives at the Department of Veterans Affairs got performance bonuses last year despite widespread treatment delays and preventable deaths at VA hospitals and clinics, a top official said Friday. More than 350 VA executives were paid a total of $2.7 million in bonuses last year, said Gina Farrisee, assistant VA secretary for human resources and administration.

Far too many bureaucrats have looked out for themselves and each other, while being incentivized to cook the books. The well-being of the patients -- in this case, men and women who served our country -- were too often shunted aside as an afterthought.

UPDATE - Unconscionable:

Records of dead veterans were changed or physically altered, some even in recent weeks, to hide how many people died while waiting for care at the Phoenix VA hospital, a whistle-blower told CNN in stunning revelations that point to a new coverup in the ongoing VA scandal. "Deceased" notes on files were removed to make statistics look better, so veterans would not be counted as having died while waiting for care, Pauline DeWenter said. DeWenter should know. DeWenter is the actual scheduling clerk at the Phoenix VA who said for the better part of a year she was ordered by supervisors to manage and handle the so-called "secret waiting list," where veterans' names of those seeking medical care were often placed, sometimes left for months with no care at all.