Warnings on ‘gaming' patient waits go back years

WASHINGTON -- The report last week confirming that 1,700 veterans were "at risk of being lost or forgotten" at a Phoenix hospital was hardly the first independent review that documented long wait times for some patients seeking health care from the Department of Veterans Affairs and inaccurate records that understated the depth of the problem.

Eleven years ago, a task force established by President George W. Bush determined at least 236,000 veterans were waiting six months or more for a first appointment or an initial follow-up. The task force warned more veterans were expected to enter the system, and the delays threatened the quality of care the VA provided.

Two years ago, a former hospital administrator told senators during an oversight hearing that VA hospitals were "gaming the system" and manipulating records to make it appear wait time standards, the criteria for awarding manager and executive bonuses, were being met.

Since 2005, the department's inspector general has issued 19 reports on how long veterans have to wait before getting appointments and treatment at VA medical facilities, concluding that for many, sufficient controls don't exist to ensure those needing care get it.

For example, in October 2007, the VA inspector general told the Senate Committee on Aging "schedulers at some facilities were interpreting the guidance from their managers to reduce waiting times as instruction to never put patients on the electronic waiting list. This seems to have resulted in some ‘gaming' of the scheduling process."

That's virtually identical to language in a 2010 VA memorandum, and again in the latest inspector general's report last week that led dozens of members of Congress to call for VA Secretary Eric Shinseki to resign. He abided by those wishes Friday, telling Obama he had become a distraction as the administration tried to address the VA's troubles. The series of reports over the years also raises questions about whether Congress should have done more to solve the problems that have grabbed the nation's attention in recent weeks.

"Anyone in Congress who thinks they've done enough for the VA is simply deluding themselves," Democratic Sen. Jay Rockefeller of West Virginia said in response to Shinseki's resignation. "Year after year, when members of Congress have had the opportunity to provide legitimate funding increases for the VA, they've done just enough to skirt by."

Pointing to the Bush task force report from 2003, Joseph Violante, legislative director for Disabled American Veterans, said the problem of access to health care has been known for a decade.

"In our mind, a lot of the problem that is taking place on the health care side is due to a lack of sufficient funding, and that's Congress's jurisdiction. We think they've fallen short over the years," Violante said.

Rep. Jeff Miller, the chairman of the House Committee on Veterans Affairs, said money is not the problem at the VA. He notes the president has traveled the country touting the spending increases that have occurred in VA's budget during his presidency.

Spending for VA medical care has nearly doubled in less than a decade, from $28.8 billion in 2006 to $56 billion last year.

"They can't even spend the money that we appropriated to them. If money could have solved this problem, it would have been solved a long time ago," Miller said. "It is manipulation and mismanagement that has created the crisis that exists today."

Miller, who became chairman of the House Committee on Veterans Affairs in 2011, makes the case that the investigations that have been undertaken by the VA's inspector general and the Government Accountability Office were generally conducted at the request of members of Congress. When he has sought to follow up on whether the VA was meeting investigators' recommendations, Miller said, he has been stonewalled.

The committee has had an acrimonious relationship with VA leadership and even developed a section on its website called "Trials in Transparency" that list some of the more than 100 requests for information made by the committee that it says are still outstanding.

The problems in Phoenix, Miller said, came to light because of his committee's work with a whistle-blower VA would not pay attention to, Dr. Samuel Foote, who retired after spending nearly 25 years with the VA.

Foote said up to 40 veterans may have died while awaiting treatment at the Phoenix hospital, and staff, at the instruction of administrators, kept a secret list of patients waiting for appointments to hide delays in care. He said he believes administrators kept the off-the-books list to impress bosses and get bonuses. The IG said while its work was not complete, it had substantiated significant delays in access that negatively affected the quality of care at the Phoenix hospital. The IG has not substantiated whether veterans in Phoenix died because of a delay in treatment. But it's clear reports citing a specific number of 40 veteran deaths gave a human element to the story that triggered greater urgency from the public, veterans groups and lawmakers. In a matter of weeks, the American Legion went from being a supporter of Shinseki to asking for his resignation.

"For some reason, something triggered the media's appetite for this story when we've been asking VA to participate and give us information. I don't know if it was the number of 40 veterans," Miller said.

As he gave his final speech as VA secretary, Shinseki acknowledged he once viewed the department's problems concerning wait times as limited.

"I no longer believe it. It is systemic. I was too trusting of some, and I accepted as accurate reports that I now know to have been misleading with regard to patient wait times," he said.