IG: Poor VA Care Linked To Hepatitis C Veteran Death

Hepatitis CThe VA OIG confirmed poor health care was linked to the death of one veteran with Hepatitis C at Grand Junction VA Medical Center.

OIG confirmed, “We substantiated the allegation that follow-up care was inadequate and led to further hospitalization.” But allegations that the physician was unqualified to provide specialized care to a Hepatitis C patient was unsubstantiated.

The report continued, “The hepatitis C care provider often did not provide the care or assess the patient thoroughly when seen. The circumstances of discontinuity of care and the lack of a thorough analysis of the patient’s condition may have contributed to his progressive decline and slower recovery.”

RELATED: Veterans Choice Fleeced By Hepatitis C Cure

In a “nothing to see here” moment of denial, the System Director at the facility refused to concur with the IG findings.


IG investigated three allegations:

  1. Follow-up care was inadequate leading to further hospitalization.
  2. A non-qualified physician provided the patient’s Hepatitis C treatment.
  3. The patient should have been admitted earlier to the hospital based on laboratory results.

The Executive Summary of the investigation findings were as follows:

We substantiated the allegation that follow-up care was inadequate and led to further hospitalization. The Hepatitis C Care Provider often did not provide the care or assess the patient thoroughly when seen. The circumstances of discontinuity of care and the lack of a thorough analysis of the patient’s condition may have contributed to his progressive decline and slower recovery. Although not part of the original allegations, we also found that contingency plans were not in place to account for reduced availability of the Hepatitis C Care Provider as he started to decrease his hours.

We did not substantiate that a non-qualified physician provided Hepatitis C treatment.

Neither VA policy nor general practice regarding physicians’ credentialing and privileging, ongoing professional practice evaluations, and documentation of education hours require that clinicians have specific evidence of competency to manage Hepatitis C patients.

We did not substantiate that the patient should have been admitted earlier to the hospital based on laboratory results. We found that the patient had an elevated ammonia level that was acknowledged timely and treated with an appropriate medication.

We recommended that the System Director ensure adequate consultation, formalized back up, and contingency plans for specialties with limited specialty provider availability.

This is one of the first IG inspections to be published publicly under the new management of Inspector General Michael Missal.

RELATED: Hep C Inventor And VA Doctor Reap Huge Profits On VA Contracts

Let’s hope the partial confirmation of wrongdoing is a sign that the agency watchdog will work fast to repair its tarnished reputation for being little more than a dog with no teeth.

The Hepatitis C issue is a matter of great importance for the veteran community, especially since many of those veterans who are ill were made so by DOD’s negligent use of immunization guns that infected young soldiers during Vietnam.

Source: https://www.va.gov/oig/pubs/VAOIG-15-01599-289.pdf

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  1. Ben states in the article “In a “nothing to see here” moment of denial, the System Director at the facility refused to concur with the IG findings.”

    Just have to point out that if by system director he means hospital director, then he might be kind of right since the patient was being treated via tele-med.

    A fact not presented in most of the articles on this death.

  2. TtIt isn’t terribly difficult to verify the qualifications of a physician ESPECIALLY when tracking such things is the responsibility of the employer. All they need do is look in the providers Curriculum Vitae and all of it should be listed if not there are databases that are curated by the AMA there is always a paper trail.

    1. Any veteran who feels they got a bogus C & P exam, should get a copy of the exam and look up the examiners qualifications.
      At the vets site I work at I recently saw a Gynecologist opine on a head injury claim. (WTF)
      If the C & P examiner has no expertise in the claimed condition, the denial can be argued on that basis.
      I had 3 IM0s for a AO DMII death claim( no diagnosis ,no treatment but I filed for direct SC instead of 1151)(They already had awarded 1151 DIC anyhow)
      I raised the issue that my 5103 VCAA letter was illegal. BVA remanded. They agreed with me but remanded for a 3rd VA opinion from a cardiologist.I got a PA’s opinion instead.
      I immediately pointed out how medically inaccurate it was to the BVA and the remand had called for a cardio not a PA and it was too speculate. BVA agreed and shit canned the C & P opinion.
      I won the claim.
      The VCAA legal error did not prejudice me because BVA found I had ample evidence to combat it. (I knew the VCAA regs and wrote a little VCAA letter to myself ).

      Your VAMC might have a web site with a little info on their doctor’s background. Also I have used http://www.healthgrades many times, and by simply googling a doctor’s name you can find out plenty.

      My most recent 1151 HBP posthumous award came from proving to the VA that my sole piece of evidence for it ( dated 1997) came from a VACO doctor, who is still at VACO and a rundown of her credentials showed she was not only still a top VA cardio doc but HBP was one of her main specialties.
      They had denied at first (awarded fast under CUE however) with a VA medical opinion that I still think came from the guy who fills their water coolers paper cup dispenser.

      Also all state Dept H&H Services have disciplined doctor data bases available on line to include any VA quacks who have had FTCA cases won against them.

      VA successfully fails to report some of them to the NPDB(per GAO and my personal investigation on that) so they can commit severe negligence ,enough to warrant a FTCA malpractice settlement and just go on being a VA doctor, if VA fails to fulfill the NPDB mandate and thus , they don’t get on these state disciplined doctor’s data bases,
      as there is no paper trail in that respect.

  3. As far as the new VA OIG having teeth, he’s limited by the Ring Knockers Code, as a ring wearing member he is limited to the amount of grief he can cause a fellow Ring Knocker.

    1. The West Point Protection Society. One thing I have noticed is they one, will throw non-ring knockers under the bus lightening fast. And, two, even ring knockers will turn on each other if you can get them fighting against each other. Image means more than morals at West Point.

      And, most Special Ops I know think Ring Knockers are a liability on a team. Most likely to be fragged. Being a perfumed prince is not helpful to real men fighting for their lives.

  4. Using VAOIG is like hiring the same attorney as the guy who t-boned you at a red light. Nothing objective will materialize.

    What’s wrong with this picture? Look at page 4. “After reviewing the medical history and completing a physical exam, the Hepatitis C Care Provider (HCCP) initiated a three-drug treatment regimen that included interferon.” By 2014, Interferon was considered sure death with a 39% success rate. Worse, it’s accepted medical acumen that if Interferon didn’t work the first time out, the chances of a later success are between zero and none. The new regimen of Harvoni has been around for over two years. Anybody still using the old Bocepravir/Interferon/ Ribavirin cocktail in 2014 shouldn’t even be allowed to “practice” medicine on a dummy.. VA bought six trainloads of it just as Gilead Science came out with the new NS5A Protease Inhibitors. Bocepravir, an old NS3A, was already known to be a dud. Ribavirin is almost as toxic as Interferon. instead of turning around and dumping it on some unsuspecting third world country, they kept using it on us.

    Saying that his quality of care was good to go with Interferon in the same sentence is like exorcising the devil out of you using cyanide and expecting you to survive it.

    1. I had a clinical social worker diagnose and enter into my record that I suffer from TBI. I later asked my psychiatrist why I had been diagnosed with this and had it entered i to my record by a social worker and what the treatment was? He said he had no idea why this had been done and he had no treatment answer. If a LCSW in Eugene is passing out TBI diagnosis, and the LCSW beside her was literally passing out VA drugs on the corner of 7th and Pearl st in Eugene while also practicing medicine, why would it shock anyone to learn that there are diagnosis being tossed around by anyone.

      Here in Eugene Oregon we have LCSW’s tossing around TBI diagnosis in our records and handing out psychiatric drugs on the street corner. As a matter of fact, absolutely nothing stops ANY VHA emoloyee from putting anything in hour record.Think about that for a minute….I have three places in my medical record where they quote my home answering machine which informs callers all incoming calls are monitored, but the last part of my home voice mail jests and informs politely, “…and if you work for the federal government, you can go to hell.” In three places in my medical record they note this message and their unwillingness to communicate. THE MESSAGE IS A HUMOROUS MESSAGE, yet the butt hurt VHA employees enter the message into my medical record??? Then refuse treatment because of it!

      VHA is a rogue agency that is no longer in control by The People. The are horribly incompetent, but they are not stupid. I am a jerk, but do I not have a right to say what I choose on my own home,phone without fear of,repurcussions? Nope. The VHA has a core value system of unaccountability.This will never change unless tigers start to grow spots – then some LCSW will diagnose and treat the with whatever pills they have laying around…

  5. Hmmm. So the director does not concur with the findings at the Grand Junction VA. Having experienced both first-hand, I am not at all surprised.
    It makes me wonder if the American Legion who was here pushing their System worth Saving crap thinks the veteran in the report got adequate care and is just a whiner.
    I am not surprised they used any provider for care, but I am surprised the veteran actually knows their test results. The Grand Junction VA often just calls and leaves a voice mail with test results…then bill your insurance hoping nobody catches them.
    I filed a FOIA request to them for a few documents, including copies of their patient contact reporting log. Their response was that my request was overly broad or burdensome. Gee, wrongly bill my insurance over $10,000.00, refuse to provide answers, McDonald’s office refuses to respond to multiple emails, but I am the burden?
    It is interesting that I filed the same FOIA with the VA billing facility in KS, and their response was that they are gathering what I requested.

    Meanwhile, the Grand Junction VA wants to know if I will pay over a certain amount for them to find the records I requested.

  6. How did you know Bob McDonald sent them. I have been threaten by the Denver chief of staff to have me arrested and federal charges.

    IF it’s ever reported that I again am accused of disruptive behavior. They are unable to provide proof of the disruptive behavior in the first place.

    Why because it never happened !

    Bob McDonald’s office lieing to me. About the employee not working for the VA anymore and cut off all communications with me. After I advised his employes Stephanie.that she was lied to or she was lieing to me !

    Guess they both were lieing. This tactics of sending the police to someone’s house.is Nazi tactics.

    What did the police tell you.did they make any threats against you and did they provide any proof or is the VA just using once again hearsay !

    Write senators congressmen and the news paper and your local news. These people are plain crazy and must be stopped.

    Enough innocent people are arrested for no reason. Someone can say anything and the police act. Without evidence and then the VA. Will drop the charges.

    But not until the veterans were arrested.forced to pay bail and have their mug shot and a police record.

    Hope this IG.will put some of these employees behind bar’s and make them wear a sign. I falsely accused a veteran of wrongdoings and they were innocent !

    1. The police insist it came out of Northport NY VA. On Thursday the Director got an email from a top person at VACO telling the Director to get face time with John. Since he refuses to go anywhere near a VA they had to come to the house. VACO knew she was coming today. I think someone had the brainiac idea of riling him up by calling in a false police report. So did the cops. Unfortunately they managed to run the call thru Northport and it cannot be traced. Seems the pussy did not use a real name associated with his call.

  7. This IG report is some very carefully worded VA spin for sure…..
    They probably killed him.
    The family should obtain an independent medical opinion.
    VA pulled all sorts of spin on me when I FTCAed them.
    I had no IMO and no lawyer…but I had a brain and studied the medical records and autopsy very carefully.And Cardiology, neurology, endocrinology too.
    I don’t advise that however unless you have a medical and legal background and….
    a BIG PAIR…if you catch my drift…
    I settled with the VA under auspices of the USA for wrongful death.
    Then subsequently won 2 additional DIC awards for direct SC ( on other conditions they malpracticed on.)
    Alex Graham ( ASKNOD)who some of you know, won a BIG Hep C case against them.
    It took years but Evidence coupled with Perseverance ,and the ability to last long enough to see the b—–ds pay, is worth the effort.

    If they FTCA the VA , this report will help but not much. IG reports like this are not legal claims such as FTCA .
    The survivors have to take action with an SF 95 and an IMO.

  8. Off topic but necessary. Baghdad Bob called the cops on us again last night. I showed them my video of Rep Lee Zeldin taking Dr. David Shulkin to task and some of my emails and memes.
    It was supposed to be over an email sent to the Northport VA. Only problem is I don’t use or email them.
    Bite me Bob. Bite me big time.
    The case manager from Northport is supposed to come to the house at 1 to see John. I have to go get ready for her visit now.

    1. @Robin Mitchell
      What did the cops say when you showed them the video? And for what (criminal) activity did VA say you did?

      I’m waiting for someone to show up at my doorstep due to my wife and I being so vocal about the incompetence of VA’s healthcare system! Let em come. They know the the truth!

      1. The local social workers were pretty nice. I showed them a ton of evidence and they seemed confused as to why my husband is not being approved for aid and attendance. He is determined he is going back to Alaska June 2nd. With or without Bob signing the equitable relief paperwork.

        That will be 23 vets dead the day he dies. This one on Bob personally.

  9. “Poor care”, “lack of knowledge by (an alleged) physician”, “not following up on ‘what might have been a cause’ for a veterans death”, even though my friends wife was a nurse, is the main cause of a “Former Marine’s” Death!
    I’m still unsure of ‘WHY’ VA healthcare professionals refuse to listen! Is it possible they just don’t care? Is it possible they don’t have a medical degree?
    When a healthcare professional is confronted with undeniable proof while the vet is still alive, from the vet AND his/her family members, that disputes all diagnoses. Then WHY can’t that healthcare professional be held accountable?
    That’s exactly what happened to my “brother”!

    So, in my opinion, if this new head of the OIG doesn’t start “bitting” instead of just softly “barking”, nothing will change.
    This OIG needs to get these incompetent healthcare professionals out of various VHA’s. If their found incompetent and/or are committing criminal activities, then criminal charges should be brought against them.
    Here’s the problem. McDonald doesn’t care. The DOJ won’t do a damn thing. All VA will do is “settle out of court” if they feel they will lose!

  10. So…the VA robbed $$$$$$$$$ from Choice Program for this Hep C “cure”, yet the VA could not provide “adequate care” nor “a contingency plan for Specialist Provider’s (cut) hours”?????
    This folks, is WHY I do not use VA Deathcare, I have to go to Specialists and my local VA makes patients with Hep B, C, and HIV drive a couple HOURS to Dayton because my local major metro area VAMC, a brand new facility, refuses to put in place Specialists at this location, stating Veterans can simply go to Dayton…assholes, some people are actually TOO SICK to either drive or even take a VA Van that long in our conditions!!!!!!!!!!!! BasTURDs!!!!!!!!

    Don’t you just love how the VA OIG will find a problem, even a Veteran’s death caused by said found problem but in same breath claim they cannot substantiate whether the Specialist’s availability contributed…quite a mixed-bag of toothless dog crap there:

    “[…“We substantiated the allegation that follow-up care was inadequate and led to further hospitalization.” But allegations that the physician was unqualified to provide specialized care to a Hepatitis C patient was unsubstantiated…]”

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