Veterans Affairs officials purged 1.5 million unfinished medical orders
By Mark Flatten | MAY 1, 2014 AT 7:36 AM
More than 1.5 million medical orders were canceled by the Department of Veterans Affairs without any guarantee the patients received the treatment or tests they needed, the Washington Examiner has found.
Since May 2013, veterans' medical centers nationwide have been under pressure to clear out 2 million backlogged orders for patient care or services.
They were given wide latitude to cancel unfilled appointments more than 90 days old. By April 2014, the backlog of what the agency calls “unresolved consults” was down to about 450,000.
What happened to other 1.5 million appointments is something that no one, including top officials at the veterans’ agency, can answer.
A review by the Government Accountability Office of the process VA used to close old consult orders found that poor documentation in patient files and the lack of independent verification made it impossible to know whether patients got care they needed before their medical orders were canceled.
“We found they closed consults but there was no evidence as to why it was closed,” Debra Draper, health care director for the GAO, told the Examiner.
“By not having that independent verification or any other controls, there isn’t any way of knowing whether they were appropriately closed out,” Draper said.
“You don’t know whether people received the care or if they received it in a timely manner. There’s no audit trail. There’s no way to know whether they were appropriately closed,” she said.
The Examiner reported in February that the VA did a mass purge of backlogged medical orders that cleared 40,000 unresolved appointments in Los Angeles beginning in 2009 and 13,000 in Dallas during a one-week period in September 2012.
VA officials have since refused to say how widespread is the practice of canceling orders by labeling them “administratively closed” or how many unfilled consult orders were eliminated nationwide.
VA officials have also given conflicting statements about the issue to the media, Congress and the agency's own inspector general.
VA is under pressure to eliminate the long waits patients face when they need potentially life-saving medical tests.
A Veterans Affairs fact sheet released in April said 23 patients at VA medical facilities nationwide with gastrointestinal cancers died after they could not get the colonoscopies or other tests that had been ordered within the deadlines in agency policy. Those tests could have detected the cancers in their early stages, when they are most treatable.
The total number of deaths linked to delayed care from other medical disorders was not revealed.
At least 40 patients in the Phoenix VA health system may have died as a result of delayed care, according to an investigation by the House Committee on Veterans Affairs and reports by the Examiner and other news media outlets.
At a hearing in April, committee chairman Jeff Miller, R-Fla., ordered records at the Phoenix facility to be preserved, while the agency’s inspector general probes allegations that two sets of appointment logs were kept to hide long wait times for medical care.
Allegations that almost 60,000 overdue medical orders were purged in Phoenix to cover long wait times also have been raised by whistleblowers.
It’s not clear how long the VA has been mass-closing backlogged orders for tests and other procedures.
The Los Angeles purge began in 2009, when hospital administrators were under orders from Washington to reduce the backlog of unfilled consults, according to Oliver Mitchell, a whistleblower who formerly worked as a scheduling clerk in the Los Angeles facility's radiology department.
Mitchell filed separate complaints to the inspector general and the U.S. Office of Special Counsel in 2009 alleging thousands of tests were canceled.
Both complaints were closed after investigators did a cursory review and received assurances from VA officials that all patients who needed care got the ordered procedures.
In Dallas, the 13,000 cases were administratively closed in about a week in September 2012.
A consult is an order for follow-up care from a medical provider ranging from a diagnostic test such as a colonoscopy to an order for transportation to a medical facility.
In 2012, officials at the VA headquarters in Washington tried to build a database to track consult orders. But the database proved to be useless because of poor record keeping and the lack of standard procedures for tracking and filling the orders, Draper told the House veterans committee in April.
In May 2013, a directive was sent to medical centers across the country to clean up the records and clear out outdated and unfilled orders that were no longer needed.
Before an order was closed, the case was supposed to be reviewed to ensure the treatment was no longer required.
But an ongoing review by GAO found lax procedures and the lack of independent verification left VA unable to prove that all patients got the care they needed before the appointment was closed.
At one facility reviewed by GAO, patients in three of the 10 cases examined did not get the ordered procedures before their consults were closed.
At another, 18 consult orders were canceled on the day the facility was required to have the cases resolved.
GAO reviewed three of those cases and “found no indication that a clinical review was conducted prior to the consults being discontinued.”
Some of the 1.5 million backlogged consults were probably closed appropriately, Draper told the Examiner.
In some cases, the patient received the test but the verification was not correctly entered into the patient’s file. In those cases, closing the consult order would be appropriate.
Some of the closed consults were administrative tasks, such as transportation orders, and in others the medical procedure was no longer required because the patient’s treatment plan had changed or the patient died.
But there is no way to tell how many of the orders were appropriately filled or canceled, Draper said. A large proportion were simply “administratively closed” without any sign the appropriate review was done or the patient ever received the needed care that had been ordered, she said.
VA officials refused to be interviewed for this story.
They have issued a variety of statements in the past both acknowledging and denying mass cancellations of backlogged consult orders.
In response to Mitchell's whistleblower complaint, VA officials in Los Angeles told the inspector general they were ordered by Dr. Charles Anderson, then national radiology director at VA, to “mass purge all outstanding imaging orders” that were more than six months old.
An internal VA memo from Dallas in September 2012 said medical staff would “aggressively address this backlog of unresolved consults and reduce the number to an acceptable level.”
However, after the Examiner reported on the Los Angeles and Dallas purges, Robert Petzel, under secretary for health at VA, said only a few hundred cases in the Los Angeles facility had been administratively closed.
Petzel also said he had never heard the 40,000 figure cited by the Examiner, which was initially raised during a congressional hearing a year earlier.
The same day, Dr. Dean Norman, chief of staff for the VA Greater Los Angeles Healthcare System, said in an agency blog post that several hundred old orders had been closed in Los Angeles after careful administrative review.
“At no time were ‘group’ close-outs of imaging studies completed,” Norman said.
The one consistency in VA’s explanations has been that cases were closed only after careful, individual reviews, and that no patient who needed care was denied care.
Draper said that is not a claim VA can back up.
Reviewing cases individually, as GAO did, is tedious and time-consuming, Draper said. It is unlikely such a careful analysis could have been done on 13,000 cases in Dallas in about a week, much less 1.5 million cases nationally in a year, she said.
GAO is still investigating the large-scale closing of unfilled consult orders and its findings should be published this summer.
The VA inspector general is also conducing an investigation into allegations first raised by the Examiner of the Los Angeles and Dallas mass purges.
After the Examiner's story was published, Republican Reps. Kevin McCarthy of California and Dan Benishek of Michigan asked for in an internal agency investigation.
Benichek is chairman of the House Veterans subcommittee on health and a former VA surgeon.
A similar request was sent by Rep. Pete Olson, R-Texas.
Petzel responded in an April 9 letter to Benishek that the inspector general would handle the investigation. Petzel did not respond to questions on the accuracy of the Examiner's reports or if the mass-purge practice was being used at other VA medical facilities.
“It’s unacceptable,” Benishek said of the response he’s gotten from the VA. “It’s a 'CYA' philosophy.”
Prior investigations by the GAO and inspector general found hospital administrators had an incentive to show steep declines in appointment backlogs. Performance reviews and bonuses are tied in part to meeting agency goals for reducing patient wait times.
GAO also identified several ways local facilities manipulated appointment lists to show it was meeting agency rules for wait times.
Sharon Helman, the director of the Phoenix VA health system, got a $9,345 bonus last year.
Draper said the bonus incentives and weak oversight make it easy for VA hospitals to manipulate their statistics.
“There are incentives that may encourage bad or unwanted behaviors,” she said. “There are weak system designs that really allow for manipulation if that’s what’s desired.”