Doctor Shortage Is Cited in Delays at V.A. Hospitals
By Richard A. Oppel Jr. and Abby Goodnough, NY Times, May 29, 2014
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 had in private practice.
What she found was quite different: 13-hour workdays fueled by large patient loads that kept growing as colleagues quit and were not replaced.
Appalled by what she saw, Dr. Hollenbeck filed a whistle-blower complaint and changed jobs. A subsequent investigation by the Department of Veterans Affairs concluded last fall that indeed the Jackson hospital did not have enough primary care doctors, resulting in nurse practitioners’ handling far too many complex cases and in numerous complaints from veterans about delayed care. “It was unethical to put us in that position,” Dr. Hollenbeck said of the overstressed primary care unit in Jackson. “Your heart gets broken.”
Her complaint is resonating across the 150-hospital Veterans Affairs medical system after the department’s inspector general released findings on Wednesday that the Phoenix medical center falsified data about long waiting times for veterans seeking doctor appointments.
Problems with waiting times for veterans seeking medical care have been documented dozens of times by federal agencies over the past 15 years.
In Washington, the number of lawmakers in Congress calling for the resignation of Eric Shinseki, the Veterans Affairs secretary, grew by late Thursday to nearly 100--including almost a dozen Democrats--as President Obama prepared to receive an internal audit on Friday from Mr. Shinseki assessing the breadth of misconduct at veterans hospitals. White House aides declined to say whether Mr. Obama would ask Mr. Shinseki to step down.
At the heart of the falsified data in Phoenix, and possibly many other veterans hospitals, is an acute shortage of doctors, particularly primary care ones, to handle a patient population swelled both by aging veterans from the Vietnam War and younger ones who served in Iraq and Afghanistan, according to 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 Senator Richard Blumenthal, Democrat of Connecticut and a member of the Senate Veterans Affairs Committee. “The exploding workload is suffocating them.” The inspector general’s report also 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 as well as reward strong ones, those reviews and their attendant benefits may have become perverse incentives for manipulating wait-time data, some lawmakers and experts say.
Representative Jeff Miller, a Florida Republican who is chairman of the House Veterans Affairs Committee, said whistle-blowers at several veterans hospitals had told his staff members that they would be threatened if they failed to alter data to make patient-access numbers look good for their supervisors, one reason he has called for a criminal investigation into the Veterans Affairs hospital system.
“Fear was instilled in lower-level employees by their superiors, and those superiors did not want long wait times,” Mr. Miller said in an interview. “Bonuses are tied directly to the waiting times of the veterans, and anybody that showed long wait times was less likely to receive a favorable review.”
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 Veterans Affairs employees to record the first date a doctor was available as the desired date requested by the veteran, even if they wanted an earlier date.
“Yes, it is gaming the system a bit,” one employee at the Veterans Affairs medical center in Cheyenne, Wyo., explained in an email to colleagues. “But you have to know the rules of the game you are playing, and when we exceed the 14-day measure, the front office gets very upset.”
In Jackson, Dr. 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.
And in Albuquerque, an employee at the veterans center said some doctors were shocked when they received a memo a few months ago stating that 20 percent of physician “performance pay” would be doled out only to doctors who found a way to limit patient follow-up visits to an average of two a year--a tactic to reduce waiting times by persuading veterans to make fewer appointments.
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 have leapt 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. He said the department spent too much hiring midlevel administrators and not enough on doctors and nurses, a complaint shared by some lawmakers and veterans groups.
Supporters of the department also note that hospitals everywhere are struggling to find primary care doctors. But some experts say the department has additional hurdles, including lower pay scales. Primary care doctors and internists at veterans centers generally earn from about $98,000 to $195,000, 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.
Many veteran medical center directors tend to make $160,000 to $190,000; according to 2012 data, those directors given performance awards typically received $8,000 to $15,000 more.
Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges, said the department’s 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.”
