Reverse incentives of VA health care made fixing the numbers easier than fixing the system


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GWEN IFILL: The Veterans Affairs Department today released a new audit documenting widespread delayed patient care.

It’s based on a nationwide review of 731 of its hospitals and outpatient clinics. According to the internal report, 57,000 veterans have been waiting 90 days or more for their first medical appointment; 64,000 others appear to have fallen through the cracks, after enrolling with the agency and requesting medical care.

And in another major finding, 13 percent of schedulers said their supervisors had asked them to falsify appointment schedules to make the wait times appear shorter. The audit also found that a 14-day target for scheduling appointments wasn’t attainable.

Joining me to discuss the report are Dr. Sam Foote, whose complaints about wait times and bookkeeping in Phoenix led to an investigation in that area’s VA system. He was a VA doctor for 24 years. And Ralph Ibson, national policy director of the Wounded Warrior Project, which provides services to veterans. He previously served as the VA’s deputy assistant general counsel.

Dr. Foote, how dire is this, how widespread? Were you surprised at what you saw in this report?

DR. SAM FOOTE, Former Doctor, Phoenix VA Health Care System: I think what I was surprised at is so many brave individuals came forward, GS4s through GS6s being interviewed by GS14s and 15s.

And we learned from this that 76 percent of facilities had at least one or more employee that had the guts to come forward and say, yes, they were gaming the system on the desired dates on return patients, and 70 percent of facilities had one or more braves employees who came forward and said that they were finding ways around the electronic waiting list.

GWEN IFILL: Were you surprised, Professor?

DR. SAM FOOTE: I’m not. No, I was not surprised that that was happening, but I’m pleasantly surprised that that many people had the courage to step forward and speak up in that situation.

GWEN IFILL: Professor?

RALPH IBSON, Wounded Warrior Project: I was surprised by the scope and gravity of these problems. And I agree with Dr. Foote that it took courage for these men and women to come forward and share those — share those findings.

GWEN IFILL: Is this one of these things that happens that everyone knew it was happening, that everyone understood there was a problem, but it hadn’t happened, Mr. Ibson? Is it that no one had just done anything about it, covered it up?

RALPH IBSON: I think we have been well aware that there’s been a misalignment between patient need for care and the available staffing to provide that care.

Again, I don’t think we realized how widespread it was, nor the extent to which the system was being gamed.

GWEN IFILL: Dr. Foote, I want to talk to you about some of these numbers because they’re quite amazing; 64,000 people were enrolled in the program but not seen, not served over the last decade, in addition to the numbers we were talking about before, and yet, a lot of these veterans actually were served, 96 percent.

So, is it just that the 4 percent was so egregious?

DR. SAM FOOTE: No.

We were doing pretty well until about 2010. And then the demand just ramped up. And rather than own up to the problem, the VA decided to cover it, because there’s no incentive for Washington to get good numbers. If Phoenix turns in good numbers and Susan Bowers is happy as Division 18 director and everybody gets their bonuses, and she turns in good numbers to Washington, when Congress asks them, they say everything is great.

So there is never any incentive. And it was cheaper, and easier and quicker to fix the numbers than it was to fix the problem.

GWEN IFILL: When you first brought — when you first raised these problems, Dr. Foote, how was it received?

DR. SAM FOOTE: Well, you know, I think the San Diego guys when they came out were shocked and appalled, but they basically did nothing.

And from my standpoint, the VA covered it up. I’m so tired of hearing how I was confused about Phoenix handled the electronic waiting lists, how clerks were confused about the desired date, they were confused about how to make appointments.

And one of the things that this study addressed, that people were not confused, that problem is where they were being pressured to falsify data. They didn’t have provider slots to put them in and they didn’t have enough schedulers to do it in a timely fashion.

GWEN IFILL: Ralph Ibson, let’s talk about some of the causes. How much of this was workload?

RALPH IBSON: I think workload is a piece of it. And I think, as Dr. Foote suggests, it’s a culture that discouraged candor and even in some cases encouraged ethical lapses.

GWEN IFILL: How about physician shortages?

RALPH IBSON: Yes, I would agree. Many of these facilities have more patients needing care than they have staff to take care of those patients.

GWEN IFILL: Why?

RALPH IBSON: We have both an aging veteran population and a compelling need on the part of veterans returning from war in large numbers with multiple medical problems and a system that just wasn’t equipped at all facilities to handle that.

GWEN IFILL: Let’s talk about the system, Dr. Foote. How much of this is dated technology?

DR. SAM FOOTE: The computer is not the problem.

VistA works quite well, if you’re trying to do it honestly, but it was never designed to try to prevent people who were going to do things incorrectly to do it. And as far as the medical thing, you have got — the Vietnam veterans pretty much drive the medical side of the house, as the aging baby boomers and the younger returning vets are putting a huge strain on mental health.

And if you look at the Phoenix situation, only about half our primary care providers are physicians, and maybe a little more than half of those are actually internists. And there’s a real shortage of supply of primary care physicians. And I think this is a nationwide problem that is only going to get worse, but the VA is feeling it first.

GWEN IFILL: Ralph Ibson, part of the problem apparently was that one of the fixes the last time this came up was to put in this 14-day scheduling, that someone would actually see a doctor within 14 days, and instead it turned into a reverse incentive for people to make up scheduling times.

How do you know that any fix right now won’t result in the same kind of problem?

RALPH IBSON: I think we have a long way to go, and I think, certainly, certainly VA central office has — understands the gravity of the problem.

I don’t think these are easy solutions. And, as Dr. Foote indicates, we have shortages of primary care physicians. We have shortages of psychiatrists across the country. So this is going to take time, and we need to keep at it.

GWEN IFILL: I want to ask you both about the solutions, the VA suggesting today among them creating a patient — what they call a patient satisfaction matrix, changing scheduling and access, hiring — putting in place a hiring freeze to get some of the people who have been doing these things wrong out of the office.

First with you, Ralph Ibson, do these sound like the kinds of solutions which can work?

RALPH IBSON: Well, I think they are steps in the right direction.

I don’t want to suggest that these are a panacea. And I think, again, what really is important is leadership and changing that culture. And, again, that doesn’t take — that doesn’t — you know, building trust in the employees to have the courage, as Dr. Foote indicated, to come forward and say we are so short-staffed.

GWEN IFILL: Dr. Sam Foote, what do you think about these solutions that the VA put out today?

DR. SAM FOOTE: The fundamental problem is a mismatch between demand and supply. And the VA is going to really need to turn to the private sector, primarily for urgent and emergent care and for hospitalizations.

VA does a great job of chronic care on scheduled appointments, things like diabetes, high blood pressure, getting your medications, but they fall down terribly, especially out West and in sparsely populated areas, where there isn’t any appropriate hospital, let alone a VA one. I would definitely favor something like a Medicare card that’s run very similar to Medicare.

I would not reinvent the wheel. I would look at how Medicare does things and issue these patients that live far away, like more than 40 miles, which Senator McCain has suggested, and give them a Vet-I-Care card that is valid for urgent and emergent care.

And don’t use the VA fee basis system now called for the non-VA care system. That takes months to get approval from the center and maybe six, 12, 18 months for Austin to pay it. You need something where they can bill the Vet-I-Care immediately, because, otherwise, unless you have a senator on one arm and an investigational TV crew on the other, they’re not going to pay that bill when you go into a hospital for emergent care that you need.

GWEN IFILL: Well, some of that is what’s the legislation that is making its way through Congress right now.

Dr. Sam Foote, former VA doctor and Ralph Ibson of the Wounded Warrior Project, thank you both very much.

DR. SAM FOOTE: Thank you.

RALPH IBSON: Thank you for having us.

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