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As Problems Persist At The VA, Clinton Maintains All Is Well

- October 5, 2016

Coming On The Heels Of A Report Showing Up To 40 Percent Of VA Suicide Hotline Calls Going Unanswered, The VA's OIG Found That Wait Time Problems At The Phoenix VA Have Not Been Addressed

TOP TAKEAWAYS

  • Yesterday's report by the VA's OIG found that wait time problems still exist at the Phoenix VA and could have resulted in the death of one veteran.
  • The original Phoenix VA scandal was due to a corrosive culture and employee neglect that resulted in the death of at least 40 veterans.
  • A September report showed that roughly one in three veterans' calls to the VA Suicide Hotline go to backup call centers.
  • Despite continued wait time problems at VA's across the country, Clinton claimed that the problems were not widespread and Secretary McDonald compared VA wait times to Disneyland

Yesterday, The Department Of Veteran Affairs Office Of Inspector General Published A Report Confirming Allegations Of Widespread Misconduct At The Phoenix Veteran Affairs Hospital That Reportedly Led To The Death Of A Veteran Waiting For Care. "The Department of Veterans Affairs (VA) Office of Inspector General (OIG) initiated this review of alleged consult mismanagement at the Phoenix VA Health Care System (PVAHCS) in response to allegations reported to the OIG by the House Committee on Veterans' Affairs in July 2015. These allegations, communicated by a confidential complainant, were received about one year after the OIG published a report confirming allegations of patient care delays, wait times, and problematic scheduling practices at PVAHCS. We reviewed these more recent allegations that PVAHCS staff inappropriately discontinued and canceled consults, management provided staff inappropriate direction, patients died waiting for consultative appointments, more than 35,000 patients were waiting for consults, and other allegations received during our review, to assess the adequacy of managing patient consults at PVAHCS." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

THE VA OIG FOUND ONGOING PROBLEMS AT THE PHOENIX VA TWO YEARS AFTER THE SCANDAL FIRST SURFACED

The Report Found That 24 Percent Of Specialty Care Consult Appointments Were Inappropriately Canceled. "We substantiated that in 2015, PVAHCS staff inappropriately discontinued consults. We determined that staff inappropriately discontinued 74 of the 309 specialty care consults (24 percent) we reviewed. This occurred because staff were generally unclear about specific consult management procedures, and services varied in their procedures and consult management responsibilities." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

  • "Of The 74 Inappropriately Discontinued Consults, 53 Patients Never Received The Requested Care At PVAHCS." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)
  • The Report Found That Chiropractic Service At The Hospital Also Canceled Appointments. "However, we also determined that the PVAHCS Chiropractic Service had inappropriately canceled consults. Canceled consults resulted in patients not receiving a scheduled appointment and, therefore, not receiving the requested chiropractic care. Within the 30 canceled consults we reviewed, 28 patients had not received the requested chiropractic care at PVAHCS." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

At Least One Veteran Could Have Died Due To "Untimely Care." "The OIG's Office of Healthcare Inspections (OHI) reviewed a total of 294 facility consults for 215 individual patients who had open consult requests at the time of their deaths, or had consults discontinued after the date of their deaths. In addition, OHI reviewed nine deceased patients' records with nine discontinued consults from a list of discontinued vascular consults provided by the complainant. Of the 215 individual patients' records reviewed, OHI determined that untimely care from PVAHCS may have contributed to the death of 1 patient." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

Thousands Of Consult Requests "Exceeded 30 Days From Their Clinically Indicated Appointment Date." "We determined that, as of August 12, 2015, more than 22,000 individual patients had 34,769 open consults at PVAHCS. The total open consults included all categories, statuses, and ages of consults. Of all the open consults at that time, about 4,800 patients had nearly 5,500 consults for appointments within PVAHCS that exceeded 30 days from their clinically indicated appointment date. In addition, more than 10,000 patients had nearly 12,000 community care consults exceeding 30 days." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

At Least One Patient Was Waiting Over 300 Days For Vascular Care. "We substantiated that one patient waited in excess of 300 days for vascular care. A patient received vascular care in October 2015 following a consult request from a clinician in Vascular Surgery in June 2013. As of August 12, 2015, we identified 13 open consults of patients waiting for Vascular Lab more than 30 days beyond the clinically indicated date of the provider, ranging from 32 to 157 days." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

The Report Confirmed That Many Of The Problems That Created The Original 2014 VA Scandal Are Still Ongoing

Issues Identified By The OIG In 6 Previous Reports Spanning Two Years Still Remain. "During the past two years, the OIG has reviewed a myriad of allegations at PVAHCS and issued six reports involving policy, access to care, scheduling and canceling of appointments, staffing, and consult management. Although VHA has made efforts to improve the care provided at PVAHCS, these issues remain. This report contains 14 recommendations. The Under Secretary for Health concurred with the recommendation to update VHA's consult policy, and VHA published a new directive on August 23, 2016. The VISN 22 Director also concurred with the remaining recommendations to improve consult management at PVAHCS and submitted acceptable corrective action plans." ("Review Of Alleged Consult Mismanagement At The Phoenix VA Health Care System," Department Of Veterans Affairs Office Of Inspector General, 10/4/16)

Similar Concerns To The One's Outlined In This Recent OIG Report Originally Prompted 2014 Investigations That Uncovered The VA Scandal. "The VA OIG has conducted six Phoenix inquiries during the past two years. The latest was launched after an employee filed multiple accusations with the House Committee. That included claims that patients died awaiting care and staffers canceled appointments to hide the fact that veterans had died while appointments were pending. Similar Phoenix allegations ignited the 2014 national scandal over veterans' health care that led to the replacement of Secretary Eric Shinseki and passage of a $15 billion reform law." (Dennis Wagner, "Inspectors Rip Phoenix VA Hospital Again For Delayed Care," The Arizona Republic , 10/4/16)

THE WEEK BEFORE A FORMER VA OFFICIAL REVEALED THAT ROUHGLY 40 PERCENT OF VA SUICIDE HOTLINE CALLS GO TO A BACK UP CENTER

A Former Director Of The Veterans Crisis Line Claimed 35 To 40 Percent Of Calls To The Crisis Line Had To Be Handled By The Less Trained Back-Up Center. "Greg Hughes, the former Director of the Veterans Crisis Line, said 35 to 40 percent of crisis calls roll over to back-up centers where workers have less training to deal with veterans' problems." (Matthew Daly, "Official: One-Third Of Calls To VA Suicide Hotline Roll Over," The Associated Press , 9/26/16)

  • The VA Undersecretary For Health, David Shulkin, Said It Was A Public Health Crisis. "David Shulkin, the VA's undersecretary for health, called veterans' suicide a public health crisis and said suicide prevention is a top priority at VA." ("Official: One-Third Of Calls To VA Suicide Hotline Roll Over," CBS News, 9/28/16)

President Obama Forgot To Mention That When Promising There Would Be Someone To Answer A Veterans Call. PRESIDENT BARAK OBAMA: "So we're putting money behind this. We are hiring more mental health professionals. But the fact that there's still 20 a day who are feeling hopeless means that we've got to do more. And, you know, anybody who's watching right now, if you call the, you know, veterans help line, there's going to be somebody there to answer. And unfortunately, the vast majority of the 20 that you're talking about are not people who are receiving services." (Barak Obama, Remarks At CNN's Presidential Town Hall: America's Military And The Commander And Chief , 9/28/16)

The Report Cited Employee Neglect As One Of The Main Issues Plaguing The Hotline

The Suicide Help Calls Were Neglected Due To Worker Laziness And Other Problems At The VA. "More than one-third of calls to a suicide hotline for troubled veterans are not being answered by front-line staffers because of poor work habits and other problems at the Department of Veterans Affairs. That's according to the hotline's former director, who complained in emails that some workers handle fewer than five calls per day and leave before their shifts end even as call volumes increased." (Matthew Daly, "Official: One-Third Of Calls To VA Suicide Hotline Roll Over," The Associated Press , 9/26/16)

  • The Denver Post Editorial Board Called To The VA Hotline Would Sometimes Go To Voicemail Rather Than Providing The Veteran An Immediate Response. "The Associated Press revealed on Monday that one in three calls to the VA suicide prevention hotline are being directed to backup crisis centers where employees have less training and sometimes rely on a voicemail system rather than providing immediate responses." (Editorial Board, "End The VA Suicide Hotline's Busy Signal," The Denver Post, 9/27/16)

The Denver Post Editorial Board Characterized Answering The VA Suicide Hotline As "A Fairly Basic Responsibility." "Fumbling the phone call of a suicidal veteran reaching out to a hotline for help is an unthinkable failure on the long list of dangerous mistakes perpetrated by the Department of Veterans Affairs. Ensuring that veterans teetering on the brink are not met with a busy signal or a voice message when they call a phone number established solely to keep them from falling seems like a fairly basic responsibility." (Editorial Board, "End The VA Suicide Hotline's Busy Signal," The Denver Post, 9/27/16)

A MAY 2016 VETERANS AFFAIRS SENATE REPORT CONFIRMS "SYSTEMATIC FAILURES" AT VETERANS AFFAIRS MEDICAL CENTERS WERE NOT LIMITED TO PHOENIX

In May, A Senate Investigation Revealed Widespread "Systemic Failures" By The Veteran Affairs Inspector General's Review Of The Veteran Affairs Medical Center In Tomah, Wis. " A Senate investigation of poor health care at a Veterans Affairs Medical Center in Tomah, Wis., found systemic failures in a VA inspector general's review of the facility that raise questions about the internal watchdog's ability to ensure adequate health care for veterans nationwide… One of the biggest failures identified by Senate investigators was the inspector general's decision not to release its investigation report, which concluded two providers at the facility had been prescribing alarming levels of narcotics." (Donovan Slack, "Senate Investigation finds 'Systemic' Failures At VA Watchdog," USA Today , 05/31/16)

  • The Probe Found The VA's Inspector General "Discounted Key Evidence And Witness Testimony, Needlessly Narrowed Its Inquiry And Has No Standard For Determining Wrongdoing." "The probe by the Senate Homeland Security and Governmental Affairs Committee found the inspector general's office, which is charged with independently investigating VA complaints, discounted key evidence and witness testimony, needlessly narrowed its inquiry and has no standard for determining wrongdoing." (Donovan Slack, "Senate Investigation finds 'Systemic' Failures At VA Watchdog," USA Today , 05/31/16)

"One Of The Biggest Failures" Was That The VA IG Failed To Release An Investigative Report That Would Have Forced VA Officials To Publicly Address The Excessive Prescription Of Narcotics At The Facility. One of the biggest failures identified by Senate investigators was the inspector general's decision not to release its investigation report, which concluded two providers at the facility had been prescribing alarming levels of narcotics. The facility's chief of staff at the time was David Houlihan, a physician veterans had nick-named 'candy man' because he doled out so many pills. Releasing the report would have forced VA officials to publicly address the issue and ensured follow up by the inspector general to make sure the VA took action. Instead, the inspector general's office briefed local VA officials and closed the case." (Donovan Slack, "Senate Investigation finds 'Systemic' Failures At VA Watchdog," USA Today , 05/31/16)

  • The Chief Of Staff At A VA Facility Was Nick-Named "Candy Man" For Prescribing So Many Pills. "The facility's chief of staff at the time was David Houlihan, a physician veterans had nick-named 'candy man' because he doled out so many pills. Releasing the report would have forced VA officials to publicly address the issue and ensured follow up by the inspector general to make sure the VA took action. Instead, the inspector general's office briefed local VA officials and closed the case." (Donovan Slack, "Senate Investigation finds 'Systemic' Failures At VA Watchdog," USA Today , 05/31/16)

The Investigation Raised Concerns That The VA's Watchdog Is Able To Ensure "Adequate Health Care For Veterans Nationwide." "A Senate investigation of poor health care at a Veterans Affairs Medical Center in Tomah, Wis., found systemic failures in a VA inspector general's review of the facility that raise questions about the internal watchdog's ability to ensure adequate health care for veterans nationwide." (Donovan Slack, "Senate Investigation finds 'Systemic' Failures At VA Watchdog," USA Today , 05/31/16)

According To The Report, In Three Months "The VA Investigated And Substantiated A Majority Of The Allegations That The VA OIG Could Not Substantiate After Several Years." "'In just three months, the VA investigated and substantiated a majority of the allegations that the VA OIG could not substantiate after several years,' the committee report notes." (Donovan Slack, "Senate Investigation finds 'Systemic' Failures At VA Watchdog," USA Today , 05/31/16)

EVEN AS PROBLEMS AT THE VA HAVE CONTINUED TO PERSIST, NEITHER CLINTON NOR SECRETARY MCDONALD APPEAR TO TAKE THESE ISSUES SERIOUSLY

In An October Interview, Clinton Said The VA Scandal Has "Not Been As Widespread As It Has Been Made Out To Be ." CLINTON: "Yeah, and I don't understand that. You know, I don't understand why we have such a problem, because there have been a number of surveys of veterans, and overall, veterans who do get treated are satisfied with their treatment. Now…" MADDOW: "Much more so than people in the regular system." CLINTON: "That's exactly right." MADDOW: "Yeah. Right." CLINTON: "Now, nobody would believe that from the coverage that you see, and the constant berating of the VA that comes from the Republicans, in part in pursuit of this ideological agenda that they have." MADDOW: "But in part because there has been real scandal." CLINTON: "There has been. And - but it's not been as widespread as it has been made out to be." (MSNBC's " The Rachel Maddow Show," 10/23/15)

  • Clinton Accused Republicans Of "Constant Berating Of The V.A. That Comes From The Republicans, In Part In Pursuit Of This Ideological Agenda…" CLINTON: "Now, nobody would believe that from the coverage that you see, and the constant berating of the V.A. that comes from the Republicans, in part in pursuit of this ideological agenda that they have." (MSNBC's "The Rachel Maddow Show," 10/23/15)

Click To Watch

Secretary McDonald Callously Compared VA Wait Times To Disneyland

VA Secretary Compares Hospital Wait Times To Disneyland "'The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran's satisfaction,' McDonald told reporters at a Christian Science Monitor breakfast in Washington, according to The Hill newspaper. 'When you go to Disney, do they measure the number of hours you wait in line?' he asked. 'What's important is what's your satisfaction with the experience.'" (Rebecca Shabad, "Veterans Affairs Secretary Compares Wait Times To Lines At Disneyland," CBS, 5/23/16)

Click To Watch

Clinton: "I Think Secretary McDonald Is Doing A Great Job…" CLINTON: "I think Secretary McDonald is doing a great job, but there is a lot more that needs to be done." (Hillary Clinton, Remarks At A Campaign Event, 11/10/15)


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