VA Investigation: No Proof That Delayed Care Caused Vets’ Deaths
Claims that 40 veterans might have died because of delayed care and manipulated waiting lists at a Department of Veterans Affairs health center in Phoenix, Ariz., are unsubstantiated, according to an internal investigation, the New York Times reports.
According to a letter from VA Secretary Robert McDonald, a VA Office of Inspector General investigation was unable to find any evidence that linked the extended wait times to the veterans' deaths. McDonald wrote in the letter, "It is important to note that while OIG's case reviews in the report document substantial delays in care, and quality of care concerns, OIG was unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans."
However, Deputy VA Secretary Sloan Gibson in an interview said although the investigation did not find proof of a link between care delays and the deaths, VA remains responsible for hiding the prolonged wait times at both the center in Phoenix and others around the country. He said, "I'm relieved that they didn't attribute deaths to delays in care, but it doesn't excuse what was happening." Gibson added, "It's still patently clear that the fundamental issue here is that veterans were waiting too long for care, and there was misbehavior masking how long veterans were waiting for care."
According to the Times, the investigation did find that many facilities used artifices to falsify wait time metrics. The report listed causes for the inappropriate actions, such as:
- Destructive and punitive management culture;
- Perverse incentives for administrators; and
- Physician shortages (Oppel, New York Times, 8/25).
VA Promises Change
According to the AP/Washington Times, VA announced it is firing three executives at the Phoenix center, as well as officials and staff at centers in Colorado and Wyoming that were found to have manipulated wait time data. Gibson also said he expects more VA employees to be fired over the incidents. He noted that VA is "taking bold and decisive action to fix these problems because it's unacceptable" (Ohlemacher, AP/Washington Times, 8/26).
Meanwhile, internal VA documents said the department is "taking vigorous action to ensure that a 'data-driven' approach does not have the unintended impact of diverting attention from our primary goal of providing veterans with ... health care." In addition, the documents noted that VA will:
- Hire outside experts to suggest how to "select and hire ethical leadership and staff (and) how to communicate expectations around ethical behavior";
- Spend $400 million on staff overtime or private care for veterans to ensure they are treated quickly, including nearly $17 million at the Phoenix center for referrals to private physicians;
- Train 8,248 VA employees on how to appropriately schedule patients;
- Create an internal investigation board to identify managers at the Phoenix center that were responsible for misconduct so disciplinary action can be taken;
- Expand mental health resources, primary care physicians and other providers at the Phoenix center; and
- Open new VA health care centers (Zoroya, USA Today, 8/25).