Why so many delays in VA? Too few doctors, for starters

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Phyllis Hollenbeck, a primary-care doctor, took a job in 2008 at the Veterans Affairs medical center in Jackson, Miss., expecting easier hours and a lighter patient load than she 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 department investigation 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 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 in the wake of findings Wednesday by the department's inspector general that the Phoenix veterans medical center falsified data about long waiting times for veterans seeking doctor's appointments.

At the heart of the falsified data in Phoenix, and possibly many other veterans hospitals, is an acute shortage of doctors, particularly primary-care doctors, to handle a patient population swelled both by aging veterans from the Vietnam War and younger ones who served in Iraq and Afghanistan, congressional officials, veterans affairs doctors and medical industry experts say. 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 problem facing the VA in terms of not having the number of primary-care doctors and nurses it needs is part of a national crisis," said Sen. Bernard Sanders, I-Vt., the Senate Veterans Affairs Committee chairman.

With many veterans flocking to VA medical centers, and with the department clearly struggling to hire enough doctors, the department "simply does not have the staff of doctors and nurse practitioners they need," he said.

But 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 to provide rewards for strong ones, those reviews and their attendant benefits may have become perverse incentives for manipulating wait-time data, some lawmakers and experts say.

Rep. Jeff Miller, R-Fla., the House Veterans Affairs Committee chairman, said whistle-blowers at a number of veterans hospitals had told his staff 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 of the VA 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."

Experts point out that performance reviews and incentives were a crucial element in transforming the Veterans Affairs medical system, considered a medical backwater right after Vietnam, into a national health care system that, for all its problems, is generally highly regarded for its care.

Debra Draper, a Government Accountability Office official, said performance-contract incentives were only one possible explanation for inaccurate wait-list data, and that other factors included lack of oversight and training. "It's an environment where, if you wanted to manipulate the system, it would not be hard to do," Ms. Draper said.

But delays in care come back to the central question of whether the system has enough doctors to handle its growing patient lists. Most experts agree that soaring demand for VA care has outpaced availability of doctors in many locations.

The department's critics and supporters agree that many facilities do not have enough physicians. But they disagree about whether that is because the department has poured too much of its hefty federal budget increases into hiring midlevel managers instead of clinicians, or whether the system simply does not have enough funding -- or a large enough pool of doctors to hire from -- to keep up.


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