Cooking the Books at the VA

Dr. Joseph Kelley is a guest blogger this week.

Recent news stories have been exploring accusations that many veterans died while waiting many months for care at the Veterans Administration (VA) hospital in Phoenix, Arizona.. What makes this particularly onerous is that the leadership there received rewards for outstanding performance, including exceeding the appointment waiting time standard of 2 weeks or less. It is alleged that secret lists were kept for those needing appointments that could not be given within the required time and the patients were only entered into the official system when appointments could be made within the standard. Therefore when metrics were measured, the facilities met or exceeded the standards. While this was first identified at the Phoenix VA, there is evidence it has occurred at multiple other sites. The investigations and reviews are not yet complete so we should withhold our final judgment, but we can all agree that it is tragic if preventable deaths occurred because of administrative tomfoolery.

These reports seem to be a microcosm of health care and raise numerous ethical concerns at many levels. There are issues from the national level to the local level. Some are more governmental (business) ethics but others are more bioethical. Just off the top of my head there are issues of justice (distributive, procedural, restorative, and retributive), politics, keeping promises, medical budgeting and costs, leadership, stewardship (managing for others rather than selfishness), prioritizing care and access, trust, deceit and others. We could discuss the value of metrics, some of which appear to improve care while others have no observable effect on outcomes. In this case the measure appears to be worthy (timely access to care) but actually was useless because the data input was not reliably entered, thereby becoming a source of ill-gotten bonuses.

To someone like myself who has spent most of his career in military service, this story is especially troublesome. No one has admitted wrongdoing, yet people have died. Many people in the account seem to have been trying to do the right thing (developing metrics that encourage proper care and acting on those metrics). However, it appears that others were “cooking the books” to make their performance appear better than it was for selfish gain. I am not implying that we should not follow and reward appropriate metrics. However, when non-virtuous individuals are given the opportunity for self-rewarding gain, we can expect greed and deceit and a lack of focus on the person who should really be at the heart of our thoughts in medicine—the patient.

We have not heard the end of this story. However, this calamitous report reinforces the importance of virtue in the entire health care team. Unfortunately, when we as a nation move further away from Hippocratic ideals to business models for patient care, I fear there will be more similar events.

(Major General (retired) Joseph Kelley, Medical Corp, USAF spent his career as a military surgeon and also serves as the coordinator for the Trinity Bioethics blog.)

For Further Study

“VA wait-list scandal: Senate, veterans to finally hear from Shinseki,” CNN, May 14, 2014

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