Excerpt: Betrayal of Valor by Eric Gang

The Deadly Wait

Dangerous Flaws in Medical Care Access

In Indianapolis, disabled veteran Ralph Patterson was made to wait nearly seven hours to get results from an X-ray for severe knee pain. Patterson left the Army in 1984 with an honorable discharge after injuring his left leg. Years of relying on his right leg to get around had taken their toll. He ended up falling and injuring his right knee, which caused constant pain and limited his mobility.

Two days after the fall, Patterson ended up at the ER. He was promptly scheduled for an MRI, which revealed severe trauma to his knee. He needed to see an orthopedic specialist. The VA Orthopedic Services division told him they had an opening in 29 days. Since his appointment was one day under the established 30-day deadline, he wasn’t able to seek out an orthopedic specialist outside of the VA under the Veterans Choice Program.

During his wait, he returned to the VA emergency room in serious pain. After an X-ray, doctors told him to wait in the emergency room for the results. He spent a total of nearly seven hours before the emergency doctor told him, “They're not going to come down. They're just going to discharge you.” He was handed a prescription for painkillers and dismissed.

In another disturbing example of our nation’s unacceptable medical care access for veterans, on September 28, 2013, a doctor examined 71-year-old Navy veteran Thomas Breen who was seeing blood in his urine. Breen’s physician decided the situation was urgent and asked that a urologist evaluate Breen within one week. Breen and his wife called the VA daily for two months trying to get an appointment, but Breen lost his life to bladder cancer on November 30. Six days later, the VA called to schedule his “urgent” appointment.

A History of Medical Access Problems

Reports claim veterans have faced difficulties trying to get timely medical assistance since at least John F. Kennedy’s presidency, but the true answer is difficult. Investigation results suggest VA clinics have hidden away or falsified records to conceal the problem for decades.

In the 1990s, medical access got particularly rough. With thousands already receiving care and surges of veterans set to return home from the Gulf War, legislators decided to expand veteran eligibility for medical care at VA clinics to include all veterans—no income restraints or service connection requirements. Unfortunately, VA hospitals weren’t prepared. The move resulted in a bottleneck of patients and severe delays in medical care. By October 1993, the U.S. General Accounting Office (GAO) reported that many veterans were waiting eight to nine weeks to obtain appointments in specialty clinics.

In 1996, to help alleviate the problem, Congress started requiring all nonurgent primary and specialty care VA clinics to schedule appointments within 30 days of the request. Patients had to be seen within 20 minutes of their scheduled appointment time. The timeliness standard also required that veterans have access to urgent care 24 hours per day. But by 2001, the GAO was still reporting excessive VA clinic wait times. An inspection of 54 specialty care clinics revealed that just 33 percent were meeting the VA’s 30-day standard, while 66 percent had wait times ranging from 33 to 282 days.

The GAO emphasized that many of the delays in both primary and specialty care clinics were “the result of poor scheduling procedures and inefficient use of staff,” adding that, “Given the inefficiencies that we found, it was difficult to determine the extent to which clinics would have benefited from additional staff.”

Over the years, as medical technology and access to battlefield care improved, many more veterans were able to return home alive—but with permanent disabilities that require years of consistent medical care. Even though the U.S. veteran population dropped by 5.8 million between 1986 and 2012, the number of service-connected disabled veterans increased by about 1.3 million. Veterans struggling with PTSD and Agent Orange exposure continued to fight for their right to VA benefits. And as eligibility expanded, VA healthcare clinics struggled to meet demand.

The VA health care system has long blamed scheduling failures and unsafe wait times on staff shortages. However, the problem appears to be more one of incompetence and indolence. In 2012, the GAO reported that poor training, inconsistent scheduling systems, deficient staff guidelines, and faulty staff utilization were leading to extended wait times—not low staff numbers, stating, “Outpatient medical appointment wait times reported by the Veterans Health Administration, within the Department of Veterans Affairs, are unreliable.”

The Phoenix Scandal

At this point, even VA employees were starting to be concerned about veteran safety. In early 2012, VA emergency room physician Dr. Katherine Mitchell took incoming Phoenix VA Health Care System Director Sharon Helman aside to tell her the Phoenix emergency room was “overwhelmed and dangerous.” In response, Mitchell says the administration transferred her out of the ER for her “deficient communication skills.”

At a September 2014 hearing before the House Veterans Affairs Committee, the assistant inspector general for health care inspections admitted that delays at the Phoenix VA Health Care System had contributed to deaths, revealing that 293 veterans had died out of the 3,409 cases it reviewed in Phoenix. A July 2015 OIG investigation reported that:

87 patients died waiting for appointments with 116 open consults
Non-providers canceled consults for vascular patients (potentially to hide a patient’s death while waiting for an appointment)
Waitlists for consults contained over 35,000 patients
Patients waited over 300 days for vascular care
1,100 veterans waited over 30 days for a doctor’s appointment

The OIG stated that one veteran died while waiting for a cardiology appointment that could have saved his life. Regarding canceled chiropractic consults, the report stated, “We analyzed 30 consults canceled from January through March 2015 and found that the staff responsible for scheduling inappropriately canceled all 30 consults.”

In at least one case, staff members sent a letter to the patient informing them they should schedule the consult, and then sent a consult cancellation on the same day. According to regulations, staff should make three attempts to contact patients before canceling a consult. The OIG also found that, “Nearly 4,800 patients had open consults for PVAHCS care for more than 30 days, and 10,000 Patients had open consults for community care exceeding 30 days.”

In March 2016, the Chief of Specialty Care Clinics and Scheduling Operations at the Phoenix VA Health Care System and former Army infantry officer, Kuauhtemoc Rodriguez, filed a whistleblower complaint claiming that physicians were blocking off valuable appointment times and making themselves unavailable to patients for between three and five hours per day. Rodriguez also alleged physicians were canceling veteran appointments at rates of up to 35 percent—causing veteran wait times to exceed 400 days.

Failed Efforts to Improve

In the light of the Phoenix scandal, the White House and Congress launched an investigation and a temporary solution, the “Veterans Choice Program,” which aimed to expand community care to increase veterans’ access to medical care and diminish scheduling delays. The government also asked the Commission on Care, a board of specialists formed under the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), to investigate the VHA in more detail and identify chronic problems in its organizational culture. The Commission released the results of its investigation on June 30, 2016.

The report said the Choice Program hadn’t solved the wait times issue. It also shed light on many problems that required urgent attention—problems that may have been the most important consequence of the past VA scandal. In relation to the Choice Program, the 300-page report informed that it only "aggravated wait times and frustrated veterans." Among the issues identified by the Commission, “chronic management and system failures, along with a troubled organizational culture” were some of the most critical.

To ensure that there is no doubt about the VHA’s critical situation, the report’s authors did not shy before calling its organizational structure “chaotic” and pointing to “staffing shortages and vacancies at every level of the organization and across numerous critical positions.”

But in spite of these warnings and numerous proposals for reform, little seems to have changed since. On March 22, 2017, the Department of Veterans Affairs supplied data on two Iowa medical centers showing zero patient wait times of over 90 days—a claim that appeared suspect right off the bat. Committee staff immediately questioned the data, and in June 2017, Iowa Republican Senator Chuck Grassley said the VA was still trying to hide just how bad the wait times were.

A whistleblower produced data revealing that more than 1,500 veterans had indeed waited longer than 90 days to receive care—with hundreds waiting as long as two years. The former employee of an Iowa City VA hospital supplied documents showing that:

537 veterans waited 91-180 days for appointments
539 veterans waited 181-365 days for appointments
232 veterans waited one-two years for appointments

In August 2017, Kuauhtemoc Rodriguez filed a second whistleblower complaint against the Phoenix VA system claiming VA doctors were refusing to see patients during available work hours—contributing to the dangerous appointment wait times. Rodriguez also filed an anti-retaliation suit against executives who he claimed were threatening termination in response to his complaint. He alleged that veterans were still waiting over 150 days for mental health care and that executives were continuing to permit VA psychiatrists to schedule large blocks of time off or cancel appointments.

It is incredibly frustrating to observe that so little has changed after years of reform efforts. The Phoenix scandal and later reports furnished proof that too many veterans have died because of the VA’s inefficiency and lack of ethics across its bureaucratic system.