VA Office of Inspector General Releases Scathing Report of Phoenix VA

The long-awaited Office of Inspector General’s (OIG) report on the Phoenix VA Health Care System (PVAHCS) was released on August 27, 2014 (1). The report was scathing in its evaluation of VA practices and leadership. Five questions were investigated:

1. Were there clinically significant delays in care?
2. Did PVAHCS omit the names of veterans waiting for care from its Electronic Wait List (EWL)?
3. Were PVAHCS personnel not following established scheduling procedures?
4. Did the PVAHCS culture emphasize goals at the expense of patient care?
5. Are scheduling deficiencies systemic throughout the VA?

In each case, the OIG found that the allegations were true. Despite initial denials, the OIG report showed that former PVAHCS director Sharon Helman, associate director Lance Robinson, hospital administration director Brad Curry, chief of staff Darren Deering and other senior executives were aware of delays in care and unofficial wait lists.

Perhaps most disturbing is the OIG finding that scheduling deficiencies are systemic throughout the VA. The OIG is currently investigating 90 VA facilities. The findings prompted Rep. Jeff Miller, House Veterans’ Affairs Committee chairman to comment “We have seen no evidence that the corrupt bureaucrats who created the VA scandal will be purged from the department’s payroll anytime soon. Until that happens, VA will never be fixed,” (2).

Though whistleblowers alleged veterans died while awaiting care in Phoenix, acting Inspector General Richard Griffin did not draw any conclusions about criminal culpability and declared that he was “unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.” Phoenix whistleblowers Drs. Sam Foote and Katherine Mitchell, said the OIG standard made no sense because 45 examples described in the OIG report showed that delayed care likely resulted in premature deaths or harm to patients’ quality of life. It is the later standard that is usually applied to physicians.

The day prior to the release of the report the Deputy VA Secretary Sloan Gibson was interviewed noting that more veterans are being sent to private doctors for care reducing waiting times (3). "The fundamental point here is, we are taking bold and decisive action to fix these problems because it's unacceptable," said Gibson. It is unclear whether these reports of improved waiting times are any more reliable than the initial denials of prolonged patient waiting times from both the Phoenix VA and VA Central Office.

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Office of VA Inspector General. Review of alleged patient deaths, patient wait times, and scheduling practices at the Phoenix VA health care system. Available at: http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf (accessed 8/26/14).
2. Wagner D, Lee M. Scathing VA report stirs outcry for accountability. Arizona Republic. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/08/26/scathing-va-report-stirs-outcry-accountability/14665455/ (accessed 8/27/14).
3. Associated Press. Watchdog report details ‘systemic’ problems at VA facilities. Available at: http://www.foxnews.com/politics/2014/08/26/no-proof-delays-in-care-caused-vets-to-die-va-says/ (accessed 8/25/14). 

Reference as: Robbins RA. VA office of inspector general releases scathing report of Phoenix VA. Southwest J Pulm Crit Care. 2014;9(2):140-1. doi: http://dx.doi.org/10.13175/swjpcc112-14 PDF

Banner Health, University of Arizona Health Network to Merge

On Thursday, June 26, the Arizona Board of Regents and the University of Arizona Health Network (UAHN) Board unanimously gave the go ahead to formal negotiations with Banner Health. Under the proposed agreement Banner will acquire the University of Arizona Medical Center and its south campus, which have 624 beds between them, UAHN's faculty practice, University Physicians Healthcare and the system's three health plans. Initial terms of the agreement stipulate that Banner will spend at least $500 million toward capital projects in the next five years, and it will pay $300 million to establish an academic endowment (1). UAHN’s long-term debt, totaling about $146 million, will be absorbed by Banner. UAHN and Banner said plan on reaching a definitive agreement by September.

UA President Ann Weaver Hart was quoted by Tucson News Now as saying, "These 30 years which this agreement anticipates are going to be among the most transformational in health care in America experienced in the last century. And we're absolutely committed to be the leaders in that environment. This is extremely exciting. And I hope you can feel our commitment. We are going to make the future. We are not going to be recipients of the future made by others" (2). We have a solution to expand our capabilities to move care to a higher level, to advance research for our community and our state and to educate the future health care professionals for the state of Arizona," said UAHN President and CEO Dr. Michael Waldrum.

Under the agreement Banner will commit to the "employment of the employees of UAHN and its subsidiaries for at least six months after closing at their current base salaries and retention of their seniority for employee benefits purposes. " (1). The proposal also includes a severance package for any employees who are laid off after that six-month period.

Banner owns 25 hospitals in seven states. In total, the proposed transaction is expected to generate about $1 billion in new capital, academic investments and other consideration and value beneficial to UA and the community, a news release said. The resulting organization will employ more than 37,000 people, after adding 6,300 employees at UAHN's two hospitals, the health plan and the medical group.

The Arizona Cancer Center is excluded under the proposed agreement and will remain part of the University of Arizona. The proposal does not affect Banner's existing agreement with the Banner MD Anderson Cancer Center at Gateway Medical Center in Gilbert nor does it affect UAHN's agreement with St Joseph Medical Center in Phoenix.

This would be Banner's first acquisition on an academic medical center which reflects the growing relationship between academia and corporate America (3). Balancing the teaching and research goals of academia and the profit goals of corporations whether profit or not-for profit can be difficult. Some physicians have been troubled by Banner's non-compete clauses on physician contracts as well as Banner's aggressiveness in employing physicians that directly compete with private practice physicians at their hospitals. It is unclear how this agreement might conflict with the academic goals of UAHN as well as affecting the relationship with physicians currently practicing at Banner.

Richard A. Robbins, MD

Editor

References

1. Arizona Board of Regents agenda. Available at: http://azregents.asu.edu/boardbook/Board%20Agenda%20Books/2014-06-26%20Board%20book.pdf (accessed 6/27/14).
2. Ames J, Grijalva B. UA Health Network, UA move forward in negotiations with Banner. Tucson News Now. June 26, 2014. Available at: http://www.tucsonnewsnow.com/story/25880624/ua-health-network-ua-to-move-forward-in-negotiations-with-banner (accessed 6/27/14).
3. Reece EA, Chrencik RA, Miller ED. Fully aligned academic health centers: a model for 21st-century job creation and sustainable economic growth. Acad Med. 2012;87(7):982-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Banner health, University of Arizona health network to merge. Southwest J Pulm Crit Care. 2014;8(6):358-9. doi: http://dx.doi.org/10.13175/swjpcc085-14 PDF

Searchable Database for Physician CMS Payments

Earlier this month the Centers for Medicare and Medicaid Services (CMS), despite the objections of many physicians, released physician payment data for 2012 (1). However, the data on the CMS website is difficult to search and interpret. The New York Times created a searchable database of physician payments from CMS which can be searched by physician name, specialty and/or location (2). The Times points out that payments may cover overhead, such as staff salaries and drug costs. In some cases, when doctors work as salaried employees of group practices, the payments that show up under their names go to their institutions.

Richard A. Robbins, MD

Editor

References

1. CMS. Medicare Provider Utilization and Payment Data: Physician and Other Supplier. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html (accessed 4/24/2014).
2. NY Times. How Much Medicare Pays For Your Doctor’s Care. Available at: http://www.nytimes.com/interactive/2014/04/09/health/medicare-doctor-database.html (accessed 4/24/2014). 

Reference as: Robbins RA. Searchable databse for physician CMS payments. Southwest J Pulm Crit Care. 2014;8(4):238. doi: http://dx.doi.org/10.13175/swjpcc056-14 PDF

Smoking Rates Low in Southwest

The Gallup survey confirms that smoking rates in the US are declining and that smoking rates are lower in the Southwest than the US as a whole (1). Nationally, the smoking rate fell to 19.7% in 2013 from 21.1% in 2008. Among the Southwest states California ranked second (15.0%), Colorado ninth (17.4%), and Arizona tenth (17.5%). Only New Mexico was above the Nation's average at 20.0%. Utah remains the state with the lowest percentage of smokers, 12.2 percent, and Kentucky the highest, 30.2 percent.

Nine of the 10 states with the lowest smoking rates have outright bans on smoking in private worksites, restaurants, and bars, with California allowing for ventilated rooms. Bans are significantly less common in the 10 states with the highest smoking rates. Kentucky, West Virginia, and Mississippi -- the states with the three highest smoking rates -- do not have statewide smoking bans. In addition, these three states have some of the lowest average cost of a pack of cigarettes (2).

The Campaign for Tobacco-Free Kids has identified access to tobacco as a major factor in youth smoking (3). However, tobacco products still remain readily accessible. Recently, CVS, the National chain of pharmacies, announced that it will no longer sell cigarettes (4). A recent New York Times op-ed called for Walgreen’s to do the same (5).

Richard A. Robbins, MD

Editor

References

1. McCarthy J. In U.S., Smoking Rate Lowest in Utah, Highest in Kentucky. Available at: http://www.gallup.com/poll/167771/smoking-rate-lowest-utah-highest-kentucky.aspx?utm_source=rss&utm_medium=rss&utm_campaign=in-u-s-smoking-rate-lowest-in-utah-highest-in-kentucky-smoking-rate-in-alaska-has-dropped-the-most-since-2008 (accessed 4/12/14).
2. Boonn A. Campaign for tobacco-free kids. Available at: https://www.tobaccofreekids.org/research/factsheets/pdf/0202.pdf (accessed 4/12/14).
3. Campaign for tobacco-free kids. Enforcing laws prohibiting cigarette sales to kids reduces youth smoking. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0049.pdf (accessed 4/12/14).
4. CVS quits for good. Available at: http://info.cvscaremark.com/cvs-insights/cvs-quits (accessed 4/12/14).
5. Bach PS. The tobacco ties that bind. New York Times. 4/10/14. Available at: http://www.nytimes.com/2014/04/11/opinion/the-tobacco-ties-that-bind.html?_r=0 (accessed 4/12/14).

Reference as: Robbins RA. Smoking rates low in southwest. Southwest J Pulm Crit Care. 2014;8(4):233. doi: http://dx.doi.org/10.13175/swjpcc051-14 PDF

Patient Deaths Blamed on Long Waits at the Phoenix VA

This morning the lead article in the Arizona Republic was a report blaming as many as 40 deaths at the Phoenix VA on long waits (1). Yesterday, Rep. Jeff Miller, the chairman of the House Committee on Veterans Affairs, held a hearing titled “A Continued Assessment of Delays in VA Medical Care and Preventable Veteran Deaths.” “It appears as though there could be as many as 40 veterans whose deaths could be related to delays in care,” Miller announced to a stunned audience. The committee has spent months investigating patient-care scandals and allegations at VA facilities in Pittsburgh, Atlanta, Miami and other cities. Miller said that dozens of VA hospital patients in Phoenix may have died while awaiting medical care. He went on to say that staff investigators have evidence that the Phoenix VA Health Care System keeps two sets of records to conceal prolonged waits that patients must endure for doctor appointments and treatment. Sharon Helman, director of Phoenix VA Health Care System, said in a written statement: “We take seriously any issue that occurs in our medical center and outpatient clinics. Therefore, we have asked for an external review by the VA Office of the Inspector General [OIG] ... If the OIG finds areas that need to be improved, we will swiftly address them as our goal is to provide the best care possible to our veterans.”

VA health system workers who asked not to be named because they fear retribution, said patient access data incorrectly show vets are able to see physicians within days when actual waits may be months. Dr. Sam Foote, who retired from the Phoenix VA in December, filed complaints with the VA inspector general seeking investigations of alleged medical care failures and administrative misconduct. In a Feb. 2 letter to the inspector general, Miller, Sen. John McCain and Rep. Ann Kirkpatrick, Foote said the Phoenix system is afflicted by “gross mismanagement of VA resources and criminal misconduct” that produced “systemic patient safety issues and possible wrongful deaths.” According to Foote, VA IG investigators came to Phoenix late last year and verified allegations he’d made in an October complaint, but no action was taken. In an interview, he said patients “were deliberately being held off the lists” to misrepresent the speed of health services for vets, but it remains unknown how many of the deaths may have been preventable. Foote went on to allege hostile working conditions that caused an exodus of quality doctors and nurses, producing backlogs in both primary care and specialty areas. One example was urology, where resignation of several of the staff urologists forced patients to be referred to out-of-state VA centers or private physicians for treatment. Foote described elaborate techniques that were used to mischaracterize system responsiveness, estimating that up to 30,000 patient charts have been altered. He said thousands of new patients must wait up to a year for assignment to primary-care physicians who are overbooked.

Allegations of falsifying wait times or retaliation against whistle-blowers are nothing new at the VA. A Senate hearing in 2011 found similar falsification of wait times (2). Review of the Office of Inspector General’s website revealed multiple instances of similar findings dating back to at least 2002 (3-6). In each instance, unreliable data regarding wait times was cited and no action was taken.

Fear of retaliation was cited by Foote as a reason for retirement and other employees asked that their names be withheld (1). These fears appear to be realistic. Recently, a VA employee was demoted after providing testimony about financial mismanagement at the Phoenix VA (7). In contrast, it appears that VA administrators have little to fear from whistle blowers, the OIG, or Congress. If recent history is any guide, it seems likely that the delays will be blamed on lazy providers and VA administrators will create another layer of bureaucracy ostensibly to solve the problem. However, the outcome will be further repression of any whistle blowers and depletion of already short patient care resources.

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Deaths at Phoenix VA hospital may be tied to delayed care. Available at: http://www.azcentral.com/story/news/politics/2014/04/10/deaths-phoenix-va-hospital-may-tied-delayed-care/7537521/ (accessed 4/10/14).
2. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54.
3. http://www.va.gov/oig/52/reports/2003/VAOIG-02-02129-95.pdf (accessed 4/10/14).
4. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf (accessed 4/10/14).
5. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf  (accessed 4/10/14).
6. http://www.va.gov/oig/52/reports/2007/VAOIG-07-00616-199.pdf (accessed 4/10/14).
7. Wagner D. VA official in Arizona demoted after her testimony. Arizona Republic. Available at http://www.azcentral.com/news/arizona/articles/20130314va-official-arizona-pedene-demoted-after-testimony.html (accessed 4/10/14).

Reference as: Robbins RA. Patient deaths blamed on long waits at the Phoenix VA. Southwest J Pulm Crit Care. 2014;8(4):227-8. doi: http://dx.doi.org/10.13175/swjpcc050-14 PDF