While the Inspector General of the VA did not draw a direct link between substandard care and the deaths of as many as 40 veterans at the Phoenix VA, a new report showcases what the IG labeled "unacceptable and troubling lapses in follow-up, coordination, quality and continuity of care" for veterans at that facility.
You can read the 143 page report on the website of the VA Inspector General.
The report delves into 45 different patient cases, raising questions about how the VA system dealt with these patients, and whether the person's death could have been blamed on VA shortcomings.
Just a few examples:
Case 1 - "Given the patient's homelessness and uncontrolled diabetes, hospitalization would have been optimal. In that he was not admitted, a more urgent scheduling effort than a "Schedule an Appointment" consultation (consult) was required."
Case 2 - Staff at the Phoenix VA called this patient to schedule a primary care appointment 'more than 3 months after the patient's death'
Case 3 - "Given the size and location of the tumor at the time of diagnosis, the delay in care for this patient was unlikely to have had a negative effect on his overall prognosis. However, his care might have been improved if palliative care had been implemented sooner."
Case 6 - A patient shows up for emergency care "at which significant symptoms and laboratory abnormalities were noted" related to diabetes; that patient was not scheduled to see primary care physician for almost four months after that.
Case 19 - "The patient was an amphetamine abuser and had dangerously elevated blood pressure during his initial visit. His wait for Primary Care was excessive, and while waiting, he suffered a stroke."
Even with numerous examples of care that didn't do enough for veterans, the IG did not directly link that to the deaths of several dozen veterans.
"While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans," the report stated.
What does come through in this 143 page report more than anything is that the VA health system is a very large undertaking, and unfortunately, a number of patients seem to get left behind by the system when it comes to further care.
There are several examples listed of where a patient isn't getting the care that was needed, until a doctor or other medical worker decides on their own to help ensure they get a new test or review.
The recommendations in the report emphasize the need to improve the overall continuity of care for veterans, the method of providing primary care and access to that care.
The report also includes internal VA emails showing that some inside the VA were trying to push hard to resolve delays in getting appointments for veterans, but faced administrative and bureaucratic obstacles.
Others raised questions about why vets couldn't get appointments, even though primary care physicians in Phoenix were "very sparsely scheduled."
"Every so often I look at random PCP [Primary Care Physician] schedules to see how far out they are scheduled with new pts [patients] and I have consistently found that in the timeframe of T+30 [within 30 days] to T+90 [within 90 days] days they are very sparsely scheduled. I bring it up with HAS and they tell me they are working on it," one doctor wrote to a superior in February of 2014, worried that vets were going without appointments for no good reason.
In Congress, the reaction to the details of the report was a bipartisan call for even more oversight by lawmakers in the future.
"Even though the IG says it can’t conclusively assert that deaths were caused by VA negligence, the report does link 20 deaths to substandard care," said Rep. Jeff Miller (R-FL), the Chairman of the House Veterans Committee.
"This report details extremely disturbing findings about what was going on in Phoenix," said Rep. Mike Michaud (D-ME). 'It confirms our worst suspicions about the systemic failures plaguing the VA system."
"We are deeply troubled by the findings in the report," said Arizona Senators Jeff Flake and John McCain in a joint statement about the review of their home state VA facility.
"It is unbelievable to us that months after the scandal broke, Phoenix VA officials responsible for it remain on the federal payroll," the two Senators stated.
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