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Originally published May 29, 2014 at 7:30 PM | Page modified May 30, 2014 at 10:39 AM

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Why the long VA delays? Too few doctors, for starters

At the heart of the falsified data in Phoenix, and possibly many other veterans hospitals, is an acute shortage of physicians, particularly primary-care doctors, to handle a patient population swelled by aging veterans from the Vietnam War and younger ones who served in Iraq and Afghanistan.


The New York Times

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Dr. Phyllis Hollenbeck, a primary-care physician, took a job at the Veterans Affairs Medical Center in Jackson, Miss., in 2008 expecting fulfilling work and a lighter patient load than she had in private practice.

What she found was different: 13-hour workdays fueled by large patient loads that kept growing as colleagues quit and were not replaced.

Appalled by what she saw, Hollenbeck filed a whistle-blower complaint and changed jobs.

A subsequent investigation by the Department of Veterans Affairs concluded last fall that the Jackson hospital did not have enough primary-care doctors, resulting in nurse practitioners’ handling far too many complex cases and numerous complaints from veterans about delayed care.

“It was unethical to put us in that position,” Hollenbeck said of the overstressed primary-care unit in Jackson. “Your heart gets broken.”

Her complaint is resonating across the Veterans Affairs medical system after the department’s inspector general released findings Wednesday that the Phoenix veterans medical center falsified data about long waiting times for veterans seeking doctor’s appointments.

At the heart of the falsified data in Phoenix, and possibly many other veterans hospitals, is an acute shortage of physicians, particularly primary-care doctors, to handle a patient population swelled by aging veterans from the Vietnam War and younger ones who served in Iraq and Afghanistan, say congressional officials, veterans-affairs doctors and medical-industry experts.

The department says it is trying to fill 400 vacancies to add to its roster of primary-care doctors, which last year numbered 5,100.

“The doctors are good, but they are overworked and they feel inadequate in the face of the inordinate demands made on them,” said Sen. Richard Blumenthal, D-Conn., a member of the Senate Veterans Affairs Committee.

The inspector general’s report pointed to another factor that may explain why hospital officials in Phoenix and elsewhere might have falsified wait-time data: pressures to excel in the annual performance reviews used to determine raises, bonuses, promotions and other benefits.

Instituted widely 20 years ago to increase accountability for weak employees and reward strong ones, those reviews and their attendant benefits may have become perverse incentives for manipulating wait-time data, some lawmakers and experts say.

Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, said whistle-blowers at a number of veterans hospitals had told his staff they would be threatened if they failed to alter data to make patient-access numbers look good for supervisors, one reason he has called for a criminal investigation of the VA hospital system.

The precise role incentives and performance reviews might have played in falsifying waiting-list data remains unclear.

In Phoenix, the inspector general’s office said, investigators plan to interview scheduling supervisors and administrators to “identify management’s involvement in manipulating wait times.”

But documents suggest that using the data in annual performance reviews may be commonplace.

One review at a Pennsylvania veterans medical center showed that a significant portion of the director’s job rating was tied to “timely and appropriate access,” which would include waiting times for doctor appointments.

One of those goals would be met only if nearly all patients were seen within 14 days of their desired appointment date, a requirement not found in the private hospital industry.

Schemes to disguise wait times generally followed a handful of approaches, whistle-blowers and officials in Congress say.

In Phoenix, where administrators were overwhelmed by new patients, many veterans were not logged into the official electronic waiting list, making it easier to cloak delays in providing care.

Another strategy, according to documents and interviews, was for VA employees to record the first date a doctor was available as the desired date requested by the veteran, even if the veteran wanted an earlier date.

In Jackson, Hollenbeck reported that hospital administrators created “ghost clinics” in which veterans were assigned to nonexistent primary-care clinics to make it appear that they were receiving timely care.

Most experts agree that soaring demand for veterans’ care has outpaced the availability of doctors in many locations, and that high turnover is a major problem.

In the past three years, primary-care appointments jumped 50 percent while the department’s staff of primary-care doctors has grown by only 9 percent, according to department statistics.

Those primary-care doctors are supposed to be responsible for about 1,200 patients each, but many now treat upward of 2,000, said J. David Cox Sr., national president of the American Federation of Government Employees, which represents nurses and other support staff.

Supporters of the department note that hospitals everywhere are struggling to find enough primary-care doctors. But some experts say the Department of Veterans Affairs has additional hurdles, including lower pay scales.

VA primary-care doctors and internists generally earn from about $98,000 to $195,000 a year, compared with private-sector primary-care physicians whose total median compensation was $221,000 in 2012, according to the Medical Group Management Association, a trade group.

Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges, said the VA doctor shortage came down to a simple fact: “It’s just harder to attract physicians to care for more-challenging patients while paying them less.”

There are long delays for specialty care, too, veterans say. Kent Carson, of Lenexa, Kan., a former Marine with epilepsy, said he had tried to make an appointment with his neurologist at the veterans hospital in Nashville, Tenn., after having five seizures in four days in 2012. But Carson, 29, said he was told he would have to wait more than two months — or go to the emergency room.The Nashville hospital did not respond to a request for comment.



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