VA Caught Denying Care To Sicker Vets To Get Better Performance Ratings
In the seemingly never ending chain of scandals involving the Veterans Administration, the last public relations black eye involves the Roseburg, Oregon clinic turning down health care to veterans who have more serious and complex health issues, all so they can get better ratings reviews from less sick patients who are easier to treat, and in return, reaping rewards for bonus pay.
The push to improve the performance ranking of Roseburg VA pits doctors and caregivers against facility administrators who put veterans lives at risk to improve ratings.
In the chase for higher bonuses through better performance metrics, Roseburg VA administrators are putting veterans lives at risk while interfering with medical decisions made by staff to provide medical care.
The Department of Veterans Affairs uses an internal rating metric from one star to five stars to evaluate the quality of care and other important factors. While the attempt to rate quality seems vital, but VA administrators have figured out how to rig the game. To evade lower ratings or penalties, they refuse to provide certain treatments or even to admit certain patients when doing so puts their rating at risk.
These administrators rig the system by denying care using a death panel called a “utilization management team” that dictates who will be admitted based on the likelihood of positive outcome instead of need or ability to provide care. Needed care for very ill veterans is refused or rationed in favor of less costly and less risky procedures to boost positive outcomes while keeping costs down.
Not only is the scheme at the facility unethical, and a form of medical malpractice, it is intentionally refusing health care VA is required by law to provide in an effort to rig the system for improved performance numbers and higher bonuses.
The act of denying veterans in that manner resulted in the facility climbing from 1 star to 2 stars in 2016. The director, Doug Paxton, earned a bonus of $8,120 as a result.
The New York Times, if you can believe it, actually broke the story. Highlights (lowlights?) include:
An 81-year-old veteran hobbled into the emergency room at the rural Veterans Affairs hospital here in December, malnourished and dehydrated, his skin flecked with ulcers and his ribs broken from a fall at home.
A doctor examining the veteran — a 20-year Air Force mechanic named Walter Savage who had been living alone — decided he was in no shape to care for himself and should be admitted to the hospital. A second doctor running the inpatient ward agreed.
But the hospital administration said no.
Though there were plenty of empty beds, records show that a nurse in charge of enforcing administration restrictions said Mr. Savage was not sick enough to qualify for admission to the hospital. He waited nine hours in the emergency room until, finally, he was sent home.
“The doctors were mad; the nurses were mad,” said Mr. Savage’s son-in-law, Mark Ridimann. “And my dad, he was mad, too. He kept saying, ‘I’ve laid my life on the line, two years in Vietnam, and this is what I get?’”
The denial appeared to be part of an attempt by members of the Roseburg Veterans Administration Medical Center to limit the number of patients it admitted to the hospital in an effort to lift its quality-of-care ratings.
Fewer patients meant fewer chances of bad outcomes and better scores for a ranking system that grades all veterans hospitals on a scale of one to five stars. In 2016, administrators began cherry-picking cases against the advice of doctors — turning away complicated patients and admitting only the lowest-risk ones in order to improve metrics, according to multiple interviews with doctors and nurses at the hospital and a review of documents.
A group of five heroic doctors from the clinic had written a letter to the NYT, blowing the whistle on Doug Saxton’s administrative corruption. The letter, in its entirety, reads:
Mr. Dave Philipps,
U.S. House Representative Peter DeFazio contacted our group of emergency medicine physicians, Emerald Valley Emergency Physicians, and requested we speak with you about concerns regarding patient care at the RVAMC. Therefore, at his request, we write you this summary of matters that are of longstanding concern to our group of emergency medicine physicians. We are all partners and owners of a physician group that has a contract to supply physician coverage to the emergency department at the Roseburg VA Medical Center. The five partners are all Board Certified in Emergency Medicine and continue to additionally work in a busy tertiary care medical center that is a certified stroke, cardiac and trauma center. We also have 12 additional Emergency Medicine Board Certified physicians with vast clinical experience working with us to supply physician services. Five of us have worked at the RVAMC for 7 years.
Over the course of time, worsening over the past 2-3 years, we have seen a very concerning trend of patient care being seriously compromised by the decision making of senior administrative personnel at the RVAMC. The limitations imposed on us and our ability to care for patients is very concerning. As experienced emergency medicine physicians, we understand the complexity of patient needs and have devoted our professional lives to providing the best possible care to our patients. The current processes are being forced onto us by administrative non-practicing physicians, nonphysician positions including nurses and non-clinically trained positions which includes the medical center Director. There has never been any effort to work with us to use our knowledge of emergency medicine patient care to improve care of the veterans. They make patient care decisions without speaking to the patient, without seeing the patient in the ED and without speaking with the physician caring for the patient. The processes are unethical, unsafe and driven by a constant discussion about needing to comply with their misguided efforts to make the “SAIL” report better. Many times, we have been told that the Director demands these artificial processes be used so that certain metrics are met in order to try to increase the “star” rating of the facility. This has gone to such an extreme that there has been an “Exclusion List” created by all these leadership positions that is used to direct how we care for patients in the department. The exclusion list is not one created by nor agreed to by the Board-certified physicians working in the facility.
We have tried every manner possible within the VA system to address these concerns. We have personally met with these people in leadership roles to discuss our concerns. We have made it clear that we hope to be included in any processes that might discuss clinical care within the medical center so we could offer our experience to assist the VA. We are available at all times to meet with and discuss any clinical concerns. We have participated in formal investigative processes conducted by the VA. We have attempted to develop processes to collaborate with leadership. Despite our efforts, we are not involved with nor consulted about clinical decision making. Often when we voice concern that a process is dangerous and not good for patient care, we are met with the response that “this is what the Director wants”. For many months the Chief of Staff, the Chief of Surgery, the medical center Director, the previous Chief of Medicine and a previously employed physician who is part of the “Bed Control Team” who all direct how we should be caring for patients in the ED have been unwilling to discuss these items with us. Of importance is that the RVAMC is a small facility and our group of emergency medicine physicians is by far the largest physician component there. Yet, we are completely excluded from all patient care discussions and our concerns are continually ignored.
Nowhere in a non-VA facility have we ever heard of this type of admission/care process being discussed, suggested as a standard of care, nor forced upon physicians. Physicians within our group hold many high level medical staff positions in a large tertiary care private hospital system and trained at highly respected training programs around the country giving us years of experience and context for our comments. We cannot express strongly enough how detrimental this process has been for patient care and how unacceptable it would be anywhere else. It is in our opinion a gross misuse of positions of power in a complex government hierarchy to allow those people to misrepresent the quality of care being provided to the veterans. Reasons for this process being so adamantly defended by these few in power seem to be desire for promotion, financial compensation and protecting their current salaries and positions.
It has become evident that a driving force behind restrictive processes and compromised care in the RVAMC is an effort to meet a variety of metric measurements, one of which is the SAIL report. The manner in which these metrics are discussed and change is approached differs from any experience we have previously had in non-VA medical centers. Although the metrics are purportedly to be used as a measurement of quality, unfortunately the all-consuming drive to make spreadsheets look better by senior leaders such as the Director Mr. Paxton , the Chief of Staff Dr. Ratnabali Ranjan, the Chief of Surgery Dr. Dinesh Ranjan, other physicians Dr. William Stellar and Dr. Bilal Chaudhry as well as RN staff Mr. Cowan and non-clinical staff Mr. Beiring has created a nepotistic cartel of power that completely prohibits sound clinical decision making by the emergency department staff and hospitalist physicians. Veterans are suffering. Unethical practices are being promoted. We have no recourse within the VA system to try to address these safety issues because every senior position above us refuses to consider perspectives other than their own. It has become clear that the senior positions starting at the Director level do not value the knowledge and experience of the committed, educated, experienced staff physicians and nurses.
Our group has never before spoken with anyone outside of the VA system about our concerns because we had tried to maintain faith that given time, the process for improvement within the organization would correct these dangerous patient care problems. It has become evident that there is no functioning process within the VA system to improve care for these veterans and subsequently the health and safety of the veterans is compromised. At this point we maintain some hope that speaking out publicly might be the last hope for veterans to get the quality and compassionate care they deserve. We feel we are placing our contract at risk by speaking to you at the request of Mr. DeFazio but at this point it is simply not possible for us to find any other means to address the malfeasance of the senior administrative positions in the RVAMC.
We would have liked to work collegially with the staff and administrators to correct the many issues of concern but there is unfortunately a very antagonistic, unprofessional, unethical and deceitful relationship fostered at the RVAMC.
We hope that by speaking with the New York Times some of these issues might finally be addressed to allow our group of dedicated physicians to provide the quality care that the United States Veterans deserve and were promised for their service to our country.
Thank you for your professional consideration of the information we present to you. To demonstrate how seriously we consider these issues, we are willing to allow these statements to be used by you “on the record” if necessary as well as any other comments in any possible follow up discussion with you that we explicitly discuss in that context.
Dr. Christoffer Poulsen, President, Emerald Valley Emergency Physicians
Dr. Charlotte Ransom, Secretary/Treasurer, Emerald Valley Emergency Physicians
Dr. Bradley Anderson, Partner, Emerald Valley Emergency Physicians
Dr. Michael Day, Partner, Emerald Valley Emergency Physicians
Dr. Ann Cooley, Partner, Emerald Valley Emergency Physicians