“That’s Crazy!!!” – More Chronicles from the VA Chapter 6

I-CareI promised a follow-up article after Chapter 5; it took me the better part of 48 hours to cool down sufficiently to write coherently to effect an update.  On 18 March 2002, I wrote about an appointment with my Primary Care Provider (PCP) being tardy, unprepared, and bureaucratese in supposedly holding a phone appointment with me.  01 April 2022, not an “April Fools Joke,” at 0731 hours, lasting 9 minutes, my PCP called me to get my approval to have me changed from her PACT team to another provider’s team.  Apparently, in the highly red taped world of PCPs at the El Paso VAHCS, there must be an hour-long handoff call when a provider initiates a change of PACT team.  I have my doubts and smell designed incompetence!

Let me pause here for a moment.  I generally need two hours to write an article after conducting research.  18 March 2002, it took a bit longer to draft that one due to the need to blow off steam with some choice words and choke down the urge to beat a few brick walls with my fists.  I am generally a very controlled person, and the fact that this PCP was so stunningly incompetent, rude, and HIPAA clueless, I admit I lost my cherub-like demeanor!  That the patient advocate was able to get my secure message, upload the comments into the electronic medical record, and contact the provider before the provider had even logged the patient notes, speaks volumes about the ineptitude of the PCP.  Worse, in the call on 01 April, the PCP was still on speakerphone, still disregarding HIPAA security, and quoted lines out of context from my message to the patient advocate.  Speaking volumes about the processes and procedures of the patient advocate’s office to investigate patient claims without breaching confidentiality.  Another topic for another day entirely!PACT_model

28 March 2022, I received the following from the patient advocates office, quoted completely:

We have received your secure message addressing your concerns.  I will be sending a Patient Advocate Tracking notification with your concerns to our Primacy Care Service for review.  They will be contacting you via telephone to discuss your concerns.”

I never heard anything from this mysterious “Primary Care Service” group/team.  01 April 2022 was the first response, and that was from the PCP.  Sourcing the Department of Veterans Affairs (VA) and the Office of Inspector General (VA-OIG), the PCP is the second most important member of the Patient-Aligned Care Teams (PACT) at the VA; the patient is the essential member and an actively engaged and knowledgeable patient is preferred.  I promise the VA-OIG has not even scratched the surface of the problems with recalcitrant, snowflake, and bureaucratic PCPs endangering patient health with the VA.  Not my first run-in with an inept PCP; I sincerely hope it is my last!PACT 3

In returning to the 01 April call, we find another interesting piece of data.  The PCP affirmed that abdominal pain could radiate from, say a hernia, to other parts of the abdomen, but this is for a specialist to diagnose, not a Family Practitioner.  Get that; the PCP is directly reversing all the published documentation by the VA and the VA-OIG by declaring that a specialist is the only person who can adequately decipher and detail why pain is occurring—putting all the PCPs in the VA Health Administration under the bus as merely button pushers and drug dealers.  Then the PCP has the temerity, nay the chutzpah, to suggest a trust deficiency existing between myself and the PCP.  Is it any wonder that people are detested, forlorn, melancholy, madder than a wet chicken with a raging case of hemorrhoids with the care they receive from VA healthcare providers?

Again, I repeat, only for emphasis, when any updates arrive on this issue, I will publish them in their entirety to allow the VA the opportunity to rebut, refute, or explain.  Like the ongoing saga with VISN 22, the Phoenix VAMC, and being arrested and injured three times by the VA Police, I am not holding my breath and awaiting a logical response.  If this were the only problem in the two weeks since the PCP shenanigans, the VA would be in pretty good shape.  Alas, we know, dear readers, that the VA is in dire condition, and the elected leaders need to be scrutinizing the VA a LOT more closely than they are.VA 3

We begin the latest chapter of VA-OIG reports with yet another physician bilking the government:

Robert Clay Smith, a Louisiana physician, pleaded guilty to conspiracy to commit healthcare fraud, wire fraud, and illegal remunerations (taking kickbacks).  According to court documents, the scheme, which ran from 2013 until 2017, involved individuals associated with a medical supply and billing company recruiting Smith to dispense pain creams and patches to his workers’ compensation patients by offering him a split of the profits.  The company acted as the billing agent for Smith, handling all the paperwork and submitting the allegedly fraudulent claims to the US Department of Labor, Office of Workers’ Compensation Programs, and private insurers.  In exchange, the company paid Smith 50 to 55 percent of the profits collected from successfully billing insurers, at markups of 15 to 20 times what the medications cost.”

Plus the following:

Robert Schneiderman of Langhorne, Pennsylvania, admitted to participating in a massive compounded-medication kickback scheme that he and others ran out of a pharmacy in Clifton, New Jersey.  Schneiderman pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to violate the Anti-Kickback Statute.  From 2014 through 2016, Schneiderman and his coconspirators used Main Avenue Pharmacy, a mail-order pharmacy with a storefront in New Jersey, to run a fraud and kickback scheme involving compounded drugs like scar creams, pain creams, migraine mediation, and vitamins.  Schneiderman was the president of Main Avenue Pharmacy and was a founder and CEO of its corporate parent.  Main Avenue Pharmacy received over $34 million in reimbursements from healthcare benefit programs on compounded medications alone.  Approximately $8 million of that total was paid by federal payers.  Schneiderman himself earned over $400,000 through the course of the scheme.  This case was investigated by the VA OIG, FBI, Department of Defense OIG, Defense Criminal Investigative Service, and Department of Health and Human Services OIG.”

Don’t forget this one:

Dr. Harry Doyle, a psychiatrist from Philadelphia, Pennsylvania, and his wife, Sonya Doyle, have agreed to pay $3 million to resolve alleged violations of the False Claims Act.  The alleged violations include submitting false billing to the US Department of Labor Office of Workers’ Compensation Programs (OWCP) for psychiatric services that were not provided and upcoding and double-billing patient claims.  The Doyles have also agreed to be voluntarily excluded from federal healthcare programs for 25 years as part of the settlement.  This is the largest recovery against a single psychiatrist in the history of the OWCP.  A multiagency investigation of Dr. Doyle’s practice revealed that from January 2013 through April 2021, the Doyles allegedly billed for services not rendered, some of which occurred when they were not physically present in the United States.  This case was investigated by the VA OIG, the Department of Labor OIG, and the United States Postal Service OIG.”

More is coming on this one:

Ten Texas doctors and a healthcare executive have agreed to pay more than $1.68 million to resolve False Claims Act allegations involving illegal remuneration in violation of the Anti-Kickback Statute and Stark Law.  According to a multiagency investigation, from 2015 to 2018, the doctors allegedly received thousands of dollars in illegal remuneration from eight management service organizations (MSOs) in exchange for ordering laboratory tests from Rockdale Hospital doing business as Little River Healthcare, True Health Diagnostics LLC, and Boston Heart Diagnostics Corporation.  Little River funded the illegal remuneration to the doctors in the form of volume-based commissions paid to independent contractor recruiters, who used the MSOs to pay numerous doctors for their referrals.  The MSO payments to the doctors were disguised as investment returns but were based on and offered in exchange for the doctors’ referrals.  As part of their settlements, the defendants have agreed to cooperate with the Department of Justice’s investigations of other parties involved in the alleged law violations.  To date, 17 doctors and two healthcare executives involved in this scheme have agreed on settlements totaling more than $2.7 million.  The civil settlements resulted from a coordinated effort between the VA OIG, Department of Health and Human Services OIG, Defense Criminal Investigative Service, and the US Attorney’s Office for the Eastern District of Texas [emphasis mine].”

Elected officials, the next time you are asked about the incredible amounts of fraud in government-provided healthcare and insurance, do not buy the media talking points that the fraud is minimal, contained, or anything but designed incompetence on the part of the bureaucrats to act as a jobs program for investigators!  The same investigators who are refused sufficient tools to investigate shenanigans by employees in the Federal Government adequately.?u=http2.bp.blogspot.com-fGEUjJsJ2h4VcJgswaisnIAAAAAAAABcsoFqEewPF_E4s1600quote-if-the-freedom-of-speech-is-taken-away-then-dumb-and-silent-we-may-be-led-like-sheep-to-the-george-washington-193690.jpg&f=1&nofb=1

Frankly, all of these cases need the government workers to be held accountable, and the myriad of red tape loopholes CLOSED!  I remember an election; I forget who and the exact when, but a significant election plank in the platform was healthcare reform, promising to clean up the swamp and bring accountability to Washington and the government.  The public is still waiting, and I know enough of you have run on this topic from both parties to repaper the walls (inside and outside) of the White House.

Yet, even if only outside providers and executives were scheming, the VA might not be in too bad a condition.  Except for the employees of the VA, VHA, and VBA, which continue to be caught up in ethics violations at a minimum:

The VA-OIG conducted an administrative investigation that included a congressional request to look into allegations that Charmain Bogue, former executive director of the Veterans Benefits Administration’s Education Service, committed ethical violations arising from her spouse’s consulting work for Veterans Education Success (VES).  VES is a nonprofit advocacy group that regularly had business before the Education Service.  The allegations also pointed to possible incomplete financial disclosures by Ms. Bogue concerning her spouse’s consulting business.  In their work, investigators uncovered evidence of other potential conflicts of interest and related misconduct by Ms. Bogue [emphasis mine].”

VA-OIG finding:

    1. Bogue participated in Education Service matters involving VES without considering whether it raised an apparent conflict of interest and acted contrary to the ethics guidance she received from her supervisors.
    2. Bogue sought résumé feedback from the president of VES to aid in her search for career advancement without considering whether this raised apparent conflict of interest concerns in subsequent VES matters. VES also endorsed Ms. Bogue for presidential nominee positions.
    3. Bogue provided insufficient detail about her spouse’s business in 2019 and 2020 public financial disclosures; VA ethics attorneys had found them compliant. She remedied the subsequently identified deficiency in her 2021 disclosure.
    4. The OIG found that Ms. Bogue refused to cooperate fully in the OIG’s investigation by refusing to complete her follow-up interview. Her husband and VES president also refused to participate in OIG interviews, and the OIG lacks testimonial subpoena authority over individuals who are not VA employees.   Bogue resigned from VA in January 2022.VA 3

UPDATE: 14 April 2022Sen. Grassley was hoodwinked by the VA on this issue and The Daily Signal (linked) has more of this report.  I covered this before, I repeat only for emphasis, when you are discharged from the VA, you lose your ability to be a “whistle-blower.”  As a point of fact, this is how the VA is able to hide a lot of their shenanigans, get rid of the person rocking the boat, invent the paperwork, cover the whole incident over as a “bad-apple” and keep you collective heads down and mouths shut until the VA-OIG investigation concludes.  The VA’s ability to abuse whistle-blowers is further compounded by Federal Attorneys who cherry-pick the cases they know they can win.  Which further protects the VA’s shenanigans and disheartens and mystifies those who have been wrongly terminated.  The Daily Signal reflects this pattern of corruption perfectly citing the records obtained by Empower Oversight.

Some commentators have claimed that blaming elected officials for not scrutinizing or not providing tools to investigate entirely is unduly unfair to the congressional representatives.  Really?!?!?!  The VA-OIG conducts an investigation, the people being investigated refuse to comply, and the VA-OIG is toothless to enforce a full and complete investigation to initiate Attorney General and FBI investigations and actions to recompense the defrauded taxpayer.  Ms. Bogue and the VES have invalidated any trust the taxpayer should have in their respective activities, but this, like so many other investigations into VA employees, will die of apathy before anyone is held accountable.  Even though a congressional representative demanded an investigation, nobody is being held liable.  Nobody is forced to compensate the defrauded taxpayer, yet the taxpayer is still expected to elect the same old representatives to their jobs.  Blaming the congressional representatives (legislative branch) for not scrutinizing the executive branch, one of only two jobs these people have, is somehow unfair?  NO!Exclamation Mark

Remarkably, between the 18 March disaster with the PCP and 01 April’s compounding idiocy, the VA-OIG published an ironically titled investigation report.

Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints.”

Imagine that, more designed incompetence negatively impacting the veterans seeking care at a VA medical facility, stating the obvious by the investigators.  Who on earth would be responsible for seeing that regulatory agencies had the tools needed to scrutinize and demand corrective action?  Calling all elected officials, did you notice that one of the prima facia tools a veteran has to report problems, conveniently called “patient advocates,” does not have the sufficient authority, adequate oversight, and tools to execute their jobs?  The VA-OIG reports the following:

The Patient Advocacy Program helps advance the Veterans Health Administration’s (VHA) efforts to improve customer service, support veterans’ access to quality care, and provide a mechanism to resolve healthcare issues.  Patient advocates document veterans’ concerns, communicate the resolution, provide follow-up and feedback, and identify trends for potential opportunities to improve medical facilities.  In FY 2020, VHA tracked about 162,000 serious complaints in its patient advocate tracking systems.”

Angry Wet ChickenOn a side topic, VA-OIG, how do you define a “significant complaint” and separate it from other types of complaints?  Honest question, the information was, to quote my PCP, “remarkably” missing from your investigation report!  Would the VA-OIG like to know why so many veterans’ complaints have risen to a “serious” level?  You reported the exact problem:

A complaint is considered resolved when the complainant communicates the outcome, and the record is closed in the tracking system.”

Maybe, the VA-OIG merely overlooked the logic problem, but complaints increase when the solution pushed down the throats of the veterans does not fix the actual situation.  Honest question, no sarcasm involved.  Is a “serious” complaint one where significant harm or death to the patient has occurred?  Is a serious complaint one that breaks federal laws, EMTALA, comes readily to mind??u=https3.bp.blogspot.com-fYRTNk48SCwT8ua0IRDWPIAAAAAAAAFZUpexSmJsN2Kos1600overcoming-adversity-help-yourself-believe-cubby-motivational-1289878102.jpg&f=1&nofb=1

Having had “solutions” forced down my throat, speaking only for myself, I am thoroughly sick of having the patient advocates bureaucratize my complaint, then fail to act, and then compound the problem by quoting policy to me as a reason to close the complaint, when the VHA never have written policies and procedures!  Maybe, you might want to look into the root causes of some of those “closed” complaints and ask root causation questions!

What did the VA-OIG find when they investigated the patient advocates?

    • VHA lacked adequate governance of the Patient Advocacy Program.
    • VHA did not effectively issue and implement adequate policy, monitor complaint practices, and provide guidance to medical facility directors responsible for local program management.
    • Patient advocates did not always enter complaints into the system.
    • Even though complaint records generally appeared to be closed on time, patient advocates did not always document the communication of the outcomes to the complainants.
    • The VA-OIG substantiated an inadequate program policy to identify clear expectations and responsibilities.
    • The VA-OIG found that they (patient advocates) did not always adhere to the documentation requirements to show full complaint resolution.
    • At the local and VISN levels, responsible personnel did not consistently analyze patient advocate tracking system complaints about trends.

Feel free to read the complete abomination of designed incompetence for yourself.  Essentially the VA-OIG concluded that the VHA has been burning taxpayer money in a patient advocacy program, and the designed incompetence is so apparent it can be tracked from L2, where the James Webb telescope is located!  Worse, you won’t need the James Webb telescope to see the designed incompetence!James Webb Space Telescope

Unfortunately, I could have guessed the first three findings without looking.  Every VA program is designed so ineptly, reprehensibly led, criminally incompetent, and with such dastardly deceptive doings that fiction writers’ storylines have to be written better to sell books.  You cannot make this stupidity up and make a profit.  Hollywood would run screaming into the night if they made a true story about the ineptitude found at the VA!

Knowledge Check!Elected officials, where are you?  The VA-OIG presents copies of their findings to you, and I have yet to witness a single one of you holding the VA Leadership criminally responsible for the failures at the VA.  Even when the VA is killing hundreds of veterans, the US Congress refuses even to act upset, let alone scrutinize for a change!  Remember how many veterans were intentionally killed in Phoenix waiting for treatment?  How many VA employees lost their jobs and pensions or were forced in front of a judge for murder?  It is a fair question, where are the elected officials in the legislative branch working to end the criminal “fraud, waste, abuse,” and designed incompetence in the executive branch?

© Copyright 2022 – M. Dave Salisbury
The author holds no claims for the art used herein, the pictures were obtained in the public domain, and the intellectual property belongs to those who created the images.  Quoted materials remain the property of the original author.

Uncomfortable Truths – An Open Letter to the Department of Veterans Affairs and the Congressional and Senatorial Representatives of the United States of America

I-Care

I write by way of greeting; I write by way of exhortation to action, as the current status quo is reprehensible and unacceptable.  Uncomfortable truths are those realities where bureaucracy has superseded logic and leadership, creating situations where the harm of the patient/customer is the first and only business.  There are good people at the Department of Veterans Affairs; but, these people are being crushed by the bureaucracy, the stifling mental inertia, and the lack of actionable leaders to propel change at the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemetery.

An example of uncomfortable truths: I witnessed a veteran enter the emergency room of the VA Medical Center, and be actively, but passively, abused.  Because he was a regular, and sometimes came in and was obstinate, and because he was homeless, he had a history with this emergency room and staff.  The staff actively overlooked him, they talked bad about him, they cussed him out behind his back, and his service was suboptimal at best when he was finally treated.  As this veteran was not the only one being treated in this manner, this was brought to the attention of hospital leadership; the person reporting the abuse was terminated without cause.  This is a leadership issue, a process problem, and an excuse not to change.

Another example of uncomfortable truths: the VBA needs/wants “New and Material Evidence” to process/review/correct a claim.  The Primary Care Provider and all specialty clinics at the VA cannot provide “New and Material Evidence,” as they are not diagnosticians.  Thus, the veteran is left stuck between two bureaucracies that refuse to help, because the rules do not allow the providers to help; this a leadership problem and a process issue.  How can the veteran afford outside insurance to obtain the “New and material evidence?”

Earlier this month, the OIG sent out a report over death at the VA due to leadership inefficiencies and can be found here, VA-OIG report.  Over the last week, three more incident reports have been discharged from the VA-OIG.  Report 1: Has a veteran dying of suicide, because the decision-making process, a process designed specifically to improve communication to aid high-risk patients were not implemented, tracked, and reported properly.  The decision-making process is expected to employ a full patient-care team (PACT) in evaluating and making decisions that affect the patient’s care.  The process was not followed, and the veteran who is already at high-risk for suicide and known to the PACT was deactivated, leading to a veteran’s death.  The VA-OIG made a recommendation to improve the process, the same process that was disabled, leading to a dead veteran.  How does this make sense?

The uncomfortable truth is multi-faceted in this case.  Leadership does not do record audits to ensure the deactivation of high-risk patients does not become “lost” in the bureaucracy.  Leadership is not flagged when the PACT disagrees with the treatment of a patient.  Finally, the VA-OIG has no teeth to reprimand, insist, and improve compliance; they can only make recommendations after the fact.  Congressional representatives and Senators, you allowed the VA to have its own dedicated inspector general, why?  What will you do to enhance the leadership at the VA?  Do not tell me again; we will hold “Committee Meetings.”  These committee meetings have been, and continue to be a feckless waste of taxpayer time, money, and never addresses the core issues apparent.

Report 2: Covers a veteran needing an appendectomy and had to wait for three hours for the surgeon to become available to perform the surgery.  The VA-OIG confirmed the delay in care, but essentially settled for, “Well, the patient lived, so no problem here.”  If that statement seems overly simplified of the process, tell me why the patient had to wait.  Why pay records and timekeeping records were messed up for a single month (May 2018), and how pay and timekeeping records got messed up in the first place.  The VA uses a national system for reporting time worked, but not all employees use the same payment system.  If true, why aren’t all employees, to include residents, surgeons, and staff using the same pay system?  The wait is blamed on poor communication, communication in scheduling surgery, communication between resident and surgeons, and communication because the “appropriate documentation” was insufficiently maintained.

I know from sad experience that there are nurses and doctors who write things down in notebooks, on scrap paper, and on paper charts, when the computer on wheels (COWS) is readily available.  The excuse is always, “I am too busy to use that thing.”  I know the VA has spent an excessive amount of money to get digital records, installing digital records, getting digital records to work when needed, and delivering the digital record available to mobile stations to document what is happening with the patient.  I have some grave concerns for checkbox medicine; but, blaming a surgical delay on improperly maintained documentation remains a wholly inexcusable and unacceptable statement in an official investigation.  Why was this lame excuse allowed to stand?

Report 2, exemplifies a multi-faceted problem presenting a need for a multi-faceted approach to correction.  Leadership at the hospital must be actively engaged, ensuring processes and procedures are optimized to deliver the “I-CARE” customer promise.  Communication chains are a leadership tool, and when broken, correction demands accountability and responsibility to resolve correctly.  Reporting is a leadership function to ensure liability and corrective action as a normal operating procedure.  Did anyone ask why the documentation was not maintained?  Was this lack of documentation maintenance a design flaw to hide what happened during this incident as an extension of designed incompetence?

Report 2, demands answers on two distinct issues double-dipping, and the continued practice of collective design incompetence. Double-dipping by providers working for the VA at the same time they are working at other medical institutions, is this occurring?  Why?  I understand there is a provider shortage at the VA.  I know doctors need to make money, and doctors make money by seeing patients, surgeons make money performing surgery.  The VA-OIG report appears to gloss over the practice of double-dipping e.g., on-call from one hospital while working at another, or working at another hospital while the VA expects you to be at their hospital.  Senators and Congressional representatives, are you investigating the potential for double-dipping?  Will it take a dead veteran before you even care about double-dipping occurring?  I make no accusations; I am asking honest questions on this issue in an attempt to learn more.  Will you do the same?

One of the most egregious problems at the VA is designed incompetence to allow a malefactor the ability to hide behind bureaucracy to avoid accountability and responsibility.  Designed incompetence remains a significant problem and I do not see any of the mid-level managers, leaders, supervisors, trainers, etc. acting to eliminate designed incompetence to the improvement of the Department of Veterans Affairs.  During President Obama’s Administration, I watched a Congressional Committee meeting where whistle-blowers were invited and testified about the designed incompetence that allows for an individual to pass the buck, duck responsibility, and protect their jobs and power at the VA.  I keep discussing design incompetence, because the mid-level managers, directors, and supervisors at the VA refuse to address and correct this issue.  Senators and Congressional Representatives, why do you allow this practice to continue?  Did you know that this is the primary method for discriminating and harming whistle-blowers?  Of course, you did.  I have seen several committee meetings where this exact issue was discussed, and the bloviation from the committee does nothing.  You are the leaders in our Republican Society, when are you going to act, in concert with Secretary Wilkie (who’s doing an exceptional job), correcting and insist these practices cease?

Report 3: Involves 60,000+ veterans, is this number sufficient to warrant permanent action on the proper billing of insurance companies and veterans, or does this number need to exceed some other level before it warrants your attention.  If a different level is required, what is that magical number?  I guarantee that veterans from all states and territories are involved here, as their representatives, what will you do?

Directly from the VA Website, we find two different uses for funds collected:

  • “VA is required by Public Law 87–693; 42 USC. 2651, commonly known as the Federal Medical Care Recovery Act, to bill the health insurance carrier that provides health care coverage for Veterans to include policies held by their spouse. The money collected goes back to VA medical centers to support health care costs provided to all Veterans.
  • Funds that VA receives from third party health insurance carriers go directly back to VA Medical Center’s operational budget.”

You, the elected officials of the Republic of the United States of America, enacted these laws and improper billing of veterans and insurance companies, causes financial harm and distress; this is your problem!  Do you understand that even if money is returned to a veteran, the financial injury has been done?  Those veterans who have paid a bill, or the insurance company that paid a statement, they didn’t need to pay is an interest-free loan to the government, and this is wrong!

There are literally tons of money at stake here; I know my local VA Hospital said, “The funds collected when we bill insurance companies come directly to this hospital for construction projects, renovations, new equipment, and so forth.”  Report 3 is but one of how many VA-OIG reports where improper billing is occurring. Incorrect billing drives the cost of healthcare up.  Hence, Obamacare costs more because the VA is not accurately billing.  Medicare costs more because of improper billing.  You the elected officials are directly responsible for ensuring proper billing occurs as an aid in reducing the costs of healthcare.

Where are you? Will you act?

 

© 2019 M. Dave Salisbury

All Rights Reserved

The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.