The Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) is filling my inbox by mid-week again, and the volume never ceases to amaze and mystify. Over the last 10+ years of reporting on the VA-OIG reports, I have learned that when the volume is exceedingly high by mid-week, there are reports the VA-OIG is hoping to get overlooked in the crush. Luckily for them, I am here to ensure nothing gets overlooked; you’re welcome!
We begin with more fiscal insanity and the failure to comply with regular auditing and business financial practices that would see a private company’s owners in prison. Let’s be clear; Congress passed specific legislation to single out government agencies to demand they comply. One of these unique pieces of legislation is called the Payment Integrity Information Act (PIIA), which audits the VA regularly fails.
Please note, last year, the VA failed two programs on the PIIA; for the fiscal year 2020, the VA failed two of the programs, consistent failure is a leadership problem. Yet, the VA-OIG claimed the following:
“To VA’s credit, it noted a decrease in improper payment estimates two years in a row and a decrease in its improper payment rates for nine programs and activities.”
Consistent with the previous fiscal year’s PIIA reports, yes; still a leadership problem, yes. But I am not so generous as the VA-OIG, for I know many a non-profit and for-profit organization that has been fined heavily, bankrupted, and put into conservatorship over the same actions. Nothing ever happens to the leaders at the VA failing to do their jobs! 12 programs and activities totaling $11.37 Billion, and never are the leaders held accountable for failure; let that sink in for a minute or two. Read the report, you tell me, should real people be held responsible for failing to follow the law?
The VA-OIG conducted a comprehensive healthcare inspection (CHIp) of the Roseburg VAHCS in Oregon; for the regular readers, I bet you can guess what was found. Yup, the employees feel morally distressed in how they are being pressured to treat the veterans. Are you surprised; I am not, but there still might be some people, somewhere in America, surprised that the VA abuses the veterans they are honor-bound to serve. The most tenured leaders have been in place since 2016. I wonder if the moral distress and the leadership hiring are correlational data points, for I know that from 2012 to 2017, there was a lot of shuffling of VA leaders at the local VAMC/VAHCS level due to dead veterans in Phoenix from death list scandals.
The VA-OIG claimed the following:
“The VA-OIG identified concerns with root cause analysis action implementation and outcomes measurement. Leaders were knowledgeable about employee satisfaction and patient experiences. However, they had opportunities to improve their knowledge of VHA data or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures.”
Tell me something, how can you have a job for more than four years, be rated as knowledgeable about the measurement analytical methods, but not be knowledgeable about root cause analysis, action implementation, and systems-level factors contributing to poor performance? To gain your position, you had to grow professionally through the bureaucracy and the various sub-levels of VA leadership to lead a VA Hospital. Yet, somehow, after all this time and experience, you have inadequate knowledge about the essential functions of your job. Quoting Colonel Potter here: “HORSE HOCKEY!” Does this sound remarkably akin to designed incompetence to anyone else?
Meaning, I do not believe your lies!
Traveling to Fayetteville, Arkansas, and the case of Dr. Robert Dale Bernauer Sr. (74), who has pled guilty to workers comp fraud and four other charges of fraud, where the total amount of fraud existed from 2011 to 2017 and more than $1 Million. Co-Conspirators and the insurance company are not named but should be. Worse, this scheme involved workman’s compensation insurance for Federal and State employees, Federal agencies, State agencies, and private employers. While the lawyers and attorneys all crow about catching a doctor who committed fraud, and I am glad he was caught, where are all the state and federal employees who had to know this was going on and did not do their jobs?
Through the insurance company, the doctor was charging 1500-2000% higher for medication marked up. Indeed, this should have raised some eyebrows and questions somewhere in the six years this fraud lasted. Who is asking why this did not raise red flags at the state and federal levels?
Weep America, another veteran, has died by suicide, and the VA is culpable due to bureaucrat inertia and outright failure to follow the guidelines and rules as established.
“The VA-OIG found that staff did not adequately evaluate the patient’s condition when reviewing the patient’s high-risk status. Facility staff did not assign a Mental Health Treatment Coordinator (MHTC) prior to discharge or establish a facility MHTC policy, as required. The Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET) provider did not outreach the patient as required. Facility staff did not comply with Veterans Health Administration suicide risk assessment procedures and did not notify facility leaders or suicide prevention staff of the patient’s death by suicide” [emphasis mine].
Why was the staff allowed to fail so severely here; they were not appropriately trained. Staff failures and training failures are symptoms of leadership failures, and a veteran is dead! Which staff has been fired for their failures? Which leaders have been fired without retirement or potential for rehiring for a deceased veteran as the final act in a chain of events that began with failing to perform their job? How many times will this story have to repeat before Congress acts to reflect the interest and the responsibility invested in their office by the electorate? How many times is this story repeating without the benefit of the VA-OIG doing a full-blown investigation?
Unfortunately, the following report involves the abuse of an intimate partner and bureaucratic inertia. While the complete record is not revealed (thankfully), what is revealed is detestable to the Nth degree and includes 214 days of spousal abuse, bureaucratic inertia, and mental health failures to protect the spouse and help the veteran, ending with the veteran’s suicide. The saddest part of this story, it took almost three years for this suicide to be investigated by the VA-OIG (2019).
“The VA-OIG found that despite the patient’s and spouse’s intimate partner violence (IPV) reports, inpatient mental health unit staff did not consult with the IPVAP point of contact or ensure the spouse felt safe with the patient returning home upon discharge. The inpatient psychiatry resident did not timely complete a progress note addendum, which resulted in other clinicians not having access to critical IPV-related information for 34 days. Facility staff failed to consider a consultation with the Office of Chief Counsel, although the Veterans Health Administration (VHA) advises employees to “work with your Office of Chief Counsel” regarding state reporting requirements for victims of IPV. Outpatient mental health staff did not consult with the IPVAP point of contact or document discussion of IPV resources or treatment options, as the OIG would have expected. The Facility Director did not ensure the development of an IPVAP protocol, as required. Although a licensed independent provider was appointed as the IPVAP coordinator, facility staff and leaders did not identify the assigned IPVAP coordinator as a resource at the time of the patient’s care in 2019. The VA-OIG also found that VHA guidance about IPV training responsibilities was unclear.”
Let’s talk about some realities of mental health.
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- 50% of the patients seeking mental health see no improvement.
- 10% of the patients seeking mental health support will be injured by the mental health provider.
- 33% of the mental health patients choosing a pharmacological solution experience harm or no relief.
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If you add these numbers up, that’s 93% of the population seeking mental health support not being helped or being harmed by mental health providers. This does not mean that mental health providers need to give up, but they need to work harder to find solutions and meet their patient’s needs. It means timely provider notes are mandatory! It requires providers to have a plethora of options for treatments, obtain patient buy-in, and follow up with the patient. It involves treatment facilities to write procedures and operating policies that allow for rapport between a patient and a provider that is not disturbed as long as that relationship is healthy and progress occurs.
America, it is time, and past time, for the Department of Veterans Affairs to be overhauled from stem to stern. To be held up to scrutiny, transparent audits and the leaders held accountable and responsible for the failures and abuse of veterans, their spouses, and dependents. These last two stories, especially, have left me spiritually sick and mentally angry! There is no excuse for the inertia evidenced, no excuse for the designed incompetence, and no excuse for the abuse to continue! Where is Congress? Where is the US President? Where are the House and Senate speakers (Major and Minor) raising a rhubarb and demanding hearings, opening Department of Justice inquiries into misconduct and malfeasance when these egregious VA-OIG reports are brought before them? Where is the media in demanding the politicians pay attention?
Weep America! Those who have defended you and me are being fed into the machine of bureaucratic inertia and spat out as broken or dead constructs — bereft of hope, lost in red tape, and denied solutions and care. Pets and farm animals are treated better than veterans, and I cannot help but wonder if this was designed purposefully to satisfy the whims and fancies of the politicians currently in office. Treat an animal like a veteran is treated, and you will be publicly shamed on national TV faster than a snake can shed its skin. You will receive more media attention, more lawyers and politicians will hound you, and consequences galore will fall all over you. Shameful! Utterly shameful!
References
American Psychological Association. (2012, August). Recognition of psychotherapy effectiveness. Retrieved from http://www.apa.org/about/policy/resolution-psychotherapy.aspx
Corbett, L. (2013, December 17). Psychotherapy based on depth psychology is a superior approach [Video file]. Retrieved from https://youtu.be/e4JQamcq24c
Lilienfeld, S. (2007). Psychological Treatments That Cause Harm. Perspectives on Psychological Science, 2(1), 53-70. Retrieved from http://www.jstor.org/stable/40212335
Smith, B. L. (2012). Inappropriate prescribing. Monitor on Psychology, 43(6), 36. Retrieved from http://www.apa.org/monitor/2012/06/prescribing.aspx
© 2021 M. Dave Salisbury
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