In one of the most disturbing recent audits of VA health care, a new Government Accountability Office report criticizes medical leaders at all levels of the Department of Veterans Affairs for failing to follow their own policies for reporting incompetent and unprofessional health care providers to state licensing boards and a National Practitioner Data Bank, routine steps to protect patients from harm.
At a House hearing Wednesday, VA officials acknowledged years of lax oversight by VA medical center directors, regional supervisors and top leaders. But Dr. Gerard R. Cox, a retired Navy physician who last month was named VA’s acting deputy undersecretary for health for organizational excellence, told lawmakers the VA accepts the GAO’s findings and recommendations and vowed that reforms are underway.
Randall Williamson, GAO’s director of health care, told the House veterans’ affairs subcommittee on oversight and investigations that auditing teams visited only five of 170 VA medical centers to determine compliance with policies that require directors to report providers subject to adverse actions because of unsafe clinical practices or unprofessional conduct. Medical centers are required to share the names of providers they discipline or fire to the National Practitioner Data Bank and to appropriate state medical licensing agencies.
What GAO found, said Williamson, was a “variety of disturbing problems with how these processes are being carried out.”
Over a four-year period, ending in March 2017, the GAO found that when complaints were lodged against VA providers, medical center reviews of their clinical care often weren’t done or were delayed by months or even years. Collectively, of medical centers audited, a total of 148 providers required clinical reviews based on concerns raised by patients or colleagues.
“For almost half these cases, VA medical center officials could not provide documentation that the reviews were actually conducted,” Williamson testified. “We also found that reviews were not always timely” with 16 cases of reviews delayed more than three months after concerns were raised. “For two providers,” GAO reported, “reviews were initiated three and a half years after concern was raised and then only after we requested documentation on those cases.”
The GAO concluded, from the sample of 148 providers whose treatments were subject to professional scrutiny, that 13 should have had resulting adverse actions reported to the National Practitioner Data Bank, which the VA and non-VA health care entities rely upon to screen providers having histories of substandard care and misconduct. But of the 13, only one was referred to the data bank, and no names had been shared with a state licensing board.
Four of the 13 were VA-contracted providers terminated by a single VA medical center based on clinical performance, which then failed to follow any “required steps for reporting providers” to the data bank or licensing boards.
“Refusing or failing to adhere to reporting requirements” after the VA disciplines or fires a physician “puts not just veterans but all patients across the country at risk of receiving substandard health care,” said Rep. Jack Bergman, R-Mich., subcommittee chairman and a retired Marine Corps lieutenant general.
With the GAO auditing only five medical centers, Williamson couldn’t estimate how many inept physicians or health care providers the VA has allowed to continue to treat patients across 170 centers through its failure to report incompetence or misconduct. He said he was confident his auditing team would have found similar reporting deficiencies across any other group of VA medical centers.
Rep. Ann Kuster, of New Hampshire, ranking Democrat on the subcommittee, recounted some recent high-profile cases including: a doctor fired from Tomah VA Medical Center in Wisconsin for over-prescribing opioids and retaliating against employees who was immediately hired as a VA Choice Program provider; a podiatrist fired from Togus VA Medical Center in Maine for harming patients with botched surgeries who continued to harm patients on leaving VA; and a contract provider who a VA medical center fired for patient abuse just two weeks after hiring him but never shared his name with a state licensing agency or the national data bank.
“VA medical facilities all across the country are failing to protect patients by not reporting providers who do not meet clinically accepted standards of care,” Kuster said. “GAO found that providers who should have been reported were able to continue practicing at the VA, during professional practice evaluations and reviews, and even after being fired by VA or forced to resign.”
Williamson said that not only are VA medical centers lax in conducting reviews of providers when complaints arise, the Veterans Health Administration, the agency with oversight responsibility for VA care, “has no policy governing how soon reviews should occur after clinical care concerns have been raised. That needs to change.”
It will, Cox promised the subcommittee.
“We will report to the National Practitioner Data Bank all privileged providers for adverse privileging actions” including those “who resign or relinquish privileges while under investigation, and any licensed provider who is terminated from a VA facility for substandard care, professional incompetence or … misconduct,” Cox told the subcommittee. That should prevent these inept providers from rebounding into VA community care programs, Cox said.
“We committed to giving interim guidance to our field facilities in December, and then the process of writing the formal policy, getting that approved and signed, will take a little longer but it will be completed this fiscal year,” Cox said.
The VA accepted every GAO recommendation including that reporting adverse actions to state licensing boards should take fewer than 100 days to complete because the boards actually do the investigating of provider clinical practices.
“The National Practitioner Data Bank reports generally take much longer,” Cox said, “because they require more thorough investigation [by the VA] and a final decision about whether an adverse action should be taken.”
Cox also promised to crack down on VA medical center personnel making secret agreements to terminate problem providers’ employment at their facilities on condition that adverse actions not be reported to state licensing boards or the national data bank. GAO said such deals are illegal and result in problem providers being pushed onto other unsuspecting patients, including veterans.
Cox conceded that directors of Veteran Integrated Service Networks (VISNs), which oversee regions of medical centers, as well as the Veterans Health Administration’s central office, have poorly supervised reporting practices at facilities across VA.
“That is one of the reasons why we are on the GAO high risk list. We need to do much better,” Cox said.
Among steps planned is a new electronic auditing tool VISNs will use to monitor timeliness of, and compliance with, provider reporting requirements at all facilities. That will allow a national report by the end of 2018, Cox said, “so we’ll have a much better handle on how things are going out there.”
Cox said VA medical center directors likely have to consider a provider for adverse actions only once or twice in their term leading a facility. So, the issue is important but it has not affected the overall quality of VA care too extensively, he suggested.
But Rep. Jodey Arrington, R-Texas, said the reporting failures are further evidence that veterans need more choice in selecting their providers with private-sector physicians competing to deliver their care.
“Quite frankly we could do well to just outsource the whole thing,” he said.
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