Dennis Wagner, The Republic | azcentral.com
3:22 p.m. MST September 10, 2014
A Department of Veterans Affairs inspector general's report on delayed health care at the Phoenix VA medical center used a standard to evaluate patient deaths that would be virtually impossible to meet, according to medical experts.
Inspector General Richard Griffin, who oversees the VA's internal watchdog agency, stressed in his Aug. 26 report that investigators were "unable to conclusively assert that the absence of timely quality care caused the deaths" of Arizona veterans who died while on secret wait lists for appointments.
Media outlets widely reported that whistle-blower allegations were exaggerated and that veterans were not severely affected by wrongdoing at the Phoenix VA medical center.
But health-care experts say Griffin's report used a measure that is not consistent with pathology practices because no matter how long a patient waits for care, the underlying "cause" of death will be a medical condition, rather than the delay.
Put simply, people die of pneumonia, heart conditions and bullet wounds — not waiting to see the doctor.
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"I think that would be a standard that is very difficult to meet," said Dr. Gregory Schmunk, chief medical examiner in Polk County, Iowa.
Schmunk, past head of the National Association of Medical Examiners, stressed that he was not speaking in that capacity but from his expertise on mortality.
"Delay of care may not have been the proximate cause of death," he said, "but the real question is: Did delay of treatment cause the patient to die earlier than necessary?"
Dr. Gregory G. Davis, current head of the association and chief medical examiner in Jefferson County, Ala., also questioned the standard used in the Office of Inspector General report.
"I can't imagine a circumstance where someone would word it that way," he said.
Both doctors said delays in care could be linked to death in an extreme case, such as a patient who developed bed sores leading to sepsis and fatal pneumonia as a result of negligence.
Even then, they said the cause of death would be pneumonia, while lack of treatment would be identified as a contributing factor.
During a Senate Committee on Veterans' Affairs hearing Tuesday, Sen. Dean Heller, R-Nev., challenged the language in the OIG report, suggesting it downplayed the effects of long-standing VA delays in delivering care to ailing veterans.
"I don't want to give the VA a pass on this, and that's exactly what this line does," Heller said to Dr. John Daigh, assistant inspector general for health-care inspections. "It exonerates the VA of any responsibility in past manipulation of these ... wait times."
Heller grilled Griffin about whether the cause-of-death standard was in initial drafts of his report or was inserted after VA administrators reviewed the findings and urged changes. Griffin acknowledged the changes were not in early drafts, but he added emphatically, "No one in VA dictated that sentence go in the report, period."
Untimely care is not among the recognized causes of death published by the World Health Organization or the Centers for Disease Control and Prevention.
In e-mail correspondence, The Arizona Republic asked VA officials to point out a previous inspector general report that listed untimely care as the cause of a patient's death. Griffin did not identify any such report or respond to questions about why he used the unprecedented standard in Phoenix.
He also would not discuss why his investigative findings did not address how many deceased patients might have lived longer if timely treatment had been available, or the hundreds of surviving veterans whose medical conditions could have been improved — or suffering reduced — if not for inappropriate delays in care.
Inspectors did not interview any veterans or family members before reaching their conclusions, according to a spokesman for the House Committee on Veterans' Affairs.
The OIG report said that more than 3,400 Arizona veterans were subjected to delays while on unauthorized wait lists and that at least 28 patients were affected by "clinically significant delays in care." Six of them died. The report also criticized the Phoenix VA Health Care System for "unacceptable and troubling lapses in follow-up, coordination, quality and continuity of care" and said managers knew about the scheduling misconduct.
Based on the OIG's cause-of-death conclusion, many media outlets cast the investigative report as vindication for the VA and as refutation of Arizona whistle-blower claims.
A Washington Post article was headlined, "Overblown claims of death and waiting times at the VA." The Associated Press report, which appeared in publications nationwide, was titled, "IG: Shoddy care by VA didn't cause Phoenix deaths."
That spin on the story first circulated a day earlier when a copy of the VA's response to the OIG investigation was leaked before release of the report. The key talking point: "It is important to note that OIG was unable to conclusively assert that the absence of timely quality care caused the death of these veterans."
Inspector general reports are typically circulated to agency bosses prior to publication, providing an opportunity to correct errors and suggest changes.
More than a week before the Phoenix investigation was released, TheRepublic learned that a dispute had arisen over standard-of-proof language that was being pushed by VA administrators to downplay deaths in Phoenix.
Under the Freedom of Information Act, The Republic requested OIG report drafts and e-mail records showing whether the OIG's questionable phrasing was inserted at the request of VA Secretary Robert McDonald or other agency leaders. Those materials have not been made available to the newspaper.
Under pressure last week, however, Griffin supplied a copy of the draft document to the House Committee on Veterans' Affairs. According to correspondence obtained by The Republic between the committee and the OIG, the sentence in question was inserted after VA administrators reviewed the findings.
Records show that the House committee was concerned about the OIG's death analysis a week before release of the report. On Aug. 19, Rep. Mike Coffman, R-Colo., chairman of the Subcommittee on Oversight and Investigations, wrote to Griffin pointing out that the VA determines whether a veteran's medical problems are service-connected based on a greater-than-50 percent standard, or "more likely than not."
Coffman suggested the same measure should be used to evaluate whether veteran fatalities in Phoenix were related to untimely care. Among his other questions:
• Did anyone at VA headquarters "attempt to persuade OIG not to use the greater than 50% threshold?"
• "Were there VA cases that did not meet the greater than 50% threshold, but reviewers concluded that the wait may have contributed to the death?"
House records show that Griffin sent letters back advising, "I can assure you that minimal changes were made to the draft report following receipt of VA's comments." He wrote that a "more likely than not" standard is not appropriate for linking delayed care to deaths.
Griffin also contended that committee staffers asked the OIG to review Phoenix cases "in order to 'unequivocally prove' that the deaths occurred due to delays in care." That characterization is false, according to committee records, which show that Griffin was asked to determine whether deaths were "related to" untimely care.
Finally, Griffin informed Coffman that his office did not evaluate Phoenix VA medical care for medical negligence or malpractice "because that is not the role of the OIG."
In a statement to The Republic, Rep. Jeff Miller, chairman of the House committee, said significant changes were made to the inspector general report after viewing by VA administrators and were "selectively leaked" by the agency. He concluded: "This matter deserves further study and review. We will ensure that happens."
The House Committee on Veterans' Affairs has scheduled a hearing Sept. 18, with Dr. Sam Foote and a Phoenix VA employee, Dr. Katherine Mitchell, both Arizona whistle-blowers, mong the witnesses.
OIG investigators corroborated virtually every major allegation of wrongdoing submitted by the two whistle-blowers. Nevertheless, the report and congressional briefing papers contain passages that appear to criticize Foote and his credibility, emphasizing that "the whistle-blower did not provide us with a list of 40 patient names." The passage referred to VA patients Foote said died while awaiting care in Phoenix.
According to the House committee, OIG staffers acknowledged during a briefing that the sentence jabbing Foote was not in the original draft of the Phoenix report but was inserted in response to comments by VA administrators during a review.
In interviews and a written rebuttal, Foote said the portion of the report about him is "false and misleading" because he and other whistle-blowers provided 24 names to inspectors and explained where in VA records to identify 16 more.
Another part of the VA report acknowledged that Foote had supplied at least 17 names and that others could not be traced because documentation had been destroyed by VA employees.
ON THE BEAT
Dennis Wagner has been a beat reporter, columnist and investigative journalist at The Arizona Republic for 31 years. He focuses on watchdog stories involving public money and corruption. His April story about a Phoenix VA whistle-blower's allegations ignited the national VA furor.
How to reach him