NY Times – 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.
Administrators at Roseburg VA are no different.
The practice is generally referred to as “unauthorized practice of medicine” and is generally regarded as the practice of medicine without a license. It occurs when someone gives medical advice or treatment without a professional license. It can also occur when a nonlicensed person dictates the medical care a person receives.
At Roseburg VA, one of the poorest rated VA medical centers in the country, veterans lives are put at risk by hospital administrators trying to score points for promotions and bonuses.
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.
While the NY Times stopped short of calling this spade a spade, I did it for them – Roseburg VA Medical Center is overtly engaged in rationing healthcare using a death panel that overrules decisions made by facility medical doctors treating the actual veteran.
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.
As you read the following excerpt, please note over half Roseburg VA’s beds sit empty and the facility director received a substantial bonus for improving Roseburg’s star rating in 2016.
NY Times Case Of Rejected Veteran
According to the NY Times:
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?’”
Savage later sought care from VA but was denied, again. Ultimately, a doctor admitted the man against the will of the facility administrator. Shortly after admission, Savage was transferred off to a nursing home to avoid negative marks in the rating system.
How The Ranking System Works
VA administrators at Roseburg VA cherrypick patients by admitting primarily low-risk cases while turning away veterans who are high risk in an effort to boost numbers:
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.
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.
Paxton says the veterans benefit by VA turning them away because it allows the agency to focus its resources on the neediest veterans.
“The numbers are indicators of the quality of care for the veterans, so, sure, we’re worried about the numbers,” he said. “But if you improve the care to veterans, in turn your numbers are going to improve. That’s the bottom line.”
Whistleblowers Speak Out
These failures were called into question by five whistleblowers, medical doctors at the facility, who wrote to the NY Times to expose the problems plaguing the facility.
All five disagree with what Paxton says. “When we voice concern that a process is dangerous and not good for patient care,” they wrote, “we are met with the response that ‘this is what the director wants.’”
“We cannot express strongly enough how detrimental this process has been for patient care and how unacceptable it would be anywhere else,” the letter noted.
“It’s a numbers game. The leadership has figured out the hospital can actually do better by seeing less patients,” said Dr. Steven Blum, a doctor there who said he has seen patients regularly turned away or transferred to private hospitals. “These numbers show up on the director’s report card, so it is very important they look good.”
Some Strategies To Rig System
The NY Times article also included numerous other strategies VA uses to rig the system.
Congestive Heart Failure Penalty
Misdiagnose veterans with congestive heart failure (CHF) as being hypervolemia. A CHF diagnosis counts against the facility as a sign of poor preventative care. By misdiagnosing that condition as hypervolemia, a condition where too much fluid is in the blood, the misdiagnoses actually hides the problem and results in the veteran not receiving the healthcare they need and not receiving the medical information they are legally entitled to.
Death In Hospital Or 30 Days Post Discharge
To bypass this penalty, hospital administrators encourage forcing veterans to be admitted as “hospice patients”. According to whistleblowers, veterans are sometimes switched to hospice status without knowing.
One whistleblower, Dr. Blum, was pressured to do this.
“It’s extremely unethical, extremely,” Dr. Blum said. “I was asked to do it and so were the emergency department doctors. And we refused, so the administration just did it.”
A Condition “Exclusion List”
To rig the game, Roseburg VA also created an “exclusion list.” This was for conditions administrators deemed too severe for Roseburg VA to treat.
Utilization Management Team (aka Death Panel)
The NY Times also indicated Roseburg VA is making use of a “utilization management team” of administrators to help them decide which patients to admit or to refuse.
Doctors would have to call an off-site nurse to ask permission to admit a patient. Patients with higher risks of death were turned away from VA care to other hospitals or just sent home. Some lower-risk patients would also be sent home such as those with pneumonia who needed inpatient care.
This is a very real death panel that decides who will and will not get healthcare. It is curious that medical doctors are forced to subjugate themselves to an offsite nurse who then gives a thumbs up or thumbs down on who is admitted even if the doctor onsite disagrees with the nurse.
Canada makes use of death panels, a group of government-appointed adjudicators who can make decisions about refusing lifesaving healthcare if they deem it appropriate. Sarah Palin brought this topic to the forefront of political debate in 2009 when she said Obamacare would result in using death panels to ration care.
VA is well-known for using death panels within certain circles, but most journalists and policymakers refuse to call VA’s use of rationing care by offsite administrators as part of a utilization management team as a death panel, but that is exactly what it is.
VA is required to provide all necessary care to qualified veterans in need, but it frequently uses backroom decisionmaking by bean counters to decide who gets the care.
Typical VA Denial
VA denies its Roseburg facility engages in manipulations, “All admission decisions are based on the hospital’s ability to provide the care patients require and are made by clinicians, including the facility chief of staff and her clinical chiefs of service — nonclinical administrators have nothing to do with these decisions.”
What are some other ways VA uses death panels to ration healthcare to boost performance numbers while ignoring its fundamental duty to provide for sick or injured veterans?
It never ceases to amaze me how career VA employees fail to connect the dots between VA administrators failing to properly administer healthcare and benefits and the decrease in the likelihood that VA will exist as a healthcare provider in 10 years – at least not in its current form.
How can they be so blind?
VA recently lowered Roseburg VA in its rating system from 2 stars to 1 star.
Whistleblower Letter From Roseburg VA To NY Times
The following is the letter from 5 Roseburg VA doctors to NY Times about the schemes at the facility. It is included in its entirety in italics below:
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