More Medical Science and Less Advertising

A recent article appeared in JAMA Open Access reporting that wait times to see a provider in the Department of Veterans Affairs (VA) have improved (1). You might remember that in the not so distant past the VA was embroiled in a controversy for reporting falsely short wait times (2). The widely publicized scandal was centered in Phoenix and led to the firing, resignation or retirement of a number of administrators in VA Central Office, the Southwest Veterans Integrated Service Network (VISN) and the Phoenix VA. What was not as well publicized, but perhaps even more disturbing, was that up to 70% of VA facilities also were reporting deceptively shortened wait times (3). Congress appropriated additional money for the VA to fix the wait times but it is unclear how the money was spent (2).

Now the VA reports that the wait times have shortened and compares favorably to the private sector. The VA’s history has to lead to some skepticism about the data. Is it true? Is it accurate? The short answer is that we do not know because the VA data is largely self-reported. The VA used a different method, the secret shopper approach, for the private sector assessment. In this method a caller requests a routine appointment with a randomly selected care physician in a given health care market. The reported VA data may not be representative of the VA as a whole. Only some metropolitan areas were selected and did not include non-metropolitan facilities and no facilities from the Southwest VISN where there was a known problem. Furthermore, the data is only for new patients requesting a primary care, dermatology, cardiology, or orthopedic appointment. Data for wait times to see other specialties is not reported.

An accompanying editorial by two VA investigators does a good job in explaining the nuances of the study (4). Editorials in response to a specific article are often authored by the reviewers. If these editorial authors were also the article’s reviewers, they can hardly be blamed for saying nice things about the manuscript since “biting the hand that feeds you” is usually a dangerous practice. However, why JAMA published the article in the first place is puzzling. Certainly, lack of timely access to healthcare is very important and lack of access has been associated with higher costs and worse outcomes (4,5). However, this article reports nothing about how the VA achieved this improvement in access. Was it by hiring additional physicians to see the patients or by hiring additional scheduling clerks or additional practice extenders such as physician assistants or nurse practitioners?

The VA data could be easily manipulated. If access by a limited number of new patients is all that is being reported, there may be a tendency to underfund other areas. What about other specialty areas such as oncology, nephrology, pulmonary, neurology, general surgery, ENT, audiology, and ophthalmology to name just a few? What about established patients? What about financial incentives? Were the administrators given bonuses for improving access in these highly selected areas but none or less in others? This is the system the VA used during the wait times scandal and likely contributed to the falsification of data (6).

As it now stands the manuscript represents more advertising than medical science. Medical journals owe their readers better. Hopefully, we at the Southwest Journal are doing a better job of publishing articles that allows the practitioners to better care for their patients and not administrators make their bonus.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Penn M, Bhatnagar S, Kuy S, Lieberman S, Elnahal S, Clancy C, Shulkin D. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. 2019 Jan 4;2(1):e187096. [CrossRef] [PubMed]
2. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening? The Arizona Republic. October 23, 2016. Available at: https://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 1/25/19).
3. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/ (accessed 1/25/19).
4. Kaboli PJ, Fihn SD. Waiting for Care in Veterans Affairs Health Care Facilities and Elsewhere. JAMA Netw Open. 2019 Jan 4;2(1):e187079. [CrossRef] [PubMed]
5. Roemer MI, Hopkins CE, Carr L, Gartside F. Copayments for ambulatory care: penny-wise and pound-foolish. Med Care. 1975 Jun;13(6):457-66. [CrossRef] [PubMed]
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9.

Cite as: Robbins RA. More medical science and less advertising. Southwest J Pulm Crit Care. 2019;18(1):29-30. doi: https://doi.org/10.13175/swjpcc005-19 PDF 

Cite as: Robbins RA

Has the VA Become a White Elephant?

As I write this Dennis Wagner is publishing a series of articles in the Arizona Republic describing his quest to find out if care at VA hospitals has improved over the last 2 years (1). To begin the article Wagner describes the fable of the King of Siam who presented albino pachyderms to his enemies knowing they would be bankrupted because the cost of food and care outweighed all usefulness. A modern expression derives from this parable: the white elephant.

The Department of Veterans Affairs (VA) has prided itself on being a leader in healthcare. It is the largest healthcare system in the US, implemented the first electronic medical record, and more than 70 percent of all US doctors have received training in the VA healthcare system (2). This year the VA is celebrating the 70th anniversary of its partnership with US medical schools. Beginning in 1946, the VA partnered with academic institutions to provide health care and to train physicians, nurses and other healthcare professionals. “We are extremely proud of the long-standing, close relationships built over the past 70 years among VA and academic institutions across the country” said VA Secretary Robert A. McDonald. “These partnerships strengthen VA’s healthcare system, and provide high quality training for the nation’s healthcare workforce. We cannot do what we do without them.” On this Veterans Day these appear to be empty words.

To understand the VA wait list scandal and why it will be difficult to fix, it is important to understand the history of the VA academic affiliations. The VA initially affiliated with medical schools in 1946 because it had trouble attracting enough quality physicians to staff its hospitals. These affiliations led to the formation of "dean's hospitals" (3). These were VA hospitals closely affiliated with medical schools and made the VA hospitals teaching hospitals. The medical school faculty was in charge of patient care and teaching and the dean's committee oversaw it all. Not surprisingly, these dean's committees were largely despised by the non-physician directors of the VA business offices. In the mid-1990's they persuaded Veterans Health Administration undersecretary, Kenneth W. Kizer, to place them in charge of the VA hospitals as hospital directors. The dean's committees were dissolved, freeing the directors from any real local oversight. This set the foundation for the VA to return to 1945 and a culture that makes it difficult to attract sufficient numbers of quality physicians.

The inability to attract physicians is largely responsible for the widely publicized VA wait time crisis. Although the VA blames their inability to recruit on pay below what the private sector pays, this is only part of the story. VA administrators have repeatedly attempted to direct patient care leading to physician job dissatisfaction and poor morale. Rather than quality healthcare, the VA developed a list of largely meaningless metrics that substituted for quality. These so called "performance-measurements" were favored by VA administration in no small part because of the bonuses they generated for the administrators. This created a cycle of increasing numbers of measurements to generate increasing bonuses. Physicians were often pressured to remind patients to wear seat belts, not keep guns in the home, etc. leaving insufficient time to deal with real and immediate healthcare problems. In retrospect, even Kizer himself called the expanding number of performance measurements "bloated and unfocused" (4).

At first VA administrators tried to deny the problem of delayed care due to insufficient staffing. Next VA Central Office tried to make all VA clinics walk-in clinics, essentially shifting the problem to the physicians. When caught in lies about short wait times, VA Secretary McDonald fired a few administrators in Phoenix and then tried to minimize the problem (5). When announcing their progress on the problem, the VA touts the number of people it has hired but usually does not specify the number of physicians or other healthcare providers. Now the VA has decided to let nurses and pharmacists pick up the slack. The VA has proposed removing physician supervision of nurse practitioners and has begun using pharmacists for primary care (6,7).

A number of medical groups have opposed the increased authority for nurses (8). Neither nurses nor pharmacists have the length of training of physicians (9).  However, objections by the AMA and other groups are likely to fall on deaf ears. Unless the VA can recruit physician which seems unlikely without reform, what other choice do they have? It is unclear if the VA and courts will hold these less experienced and lower skilled practitioners to the same high standards they have held physicians. However, given that the VA administrators are knowingly replacing physicians with less skilled practitioners, this would seem reasonable.

Wagner's series in the Arizona Republic seems to suggest that the VA's lack of transparency makes it difficult to determine if care at VA hospitals have improved over the last 2 years (9). The conclusion from the series appears to be that the VA has not. This is not surprising given that no real reform has taken place and McDonald appears not to be in control of the VA. For example, two short years ago McDonald was proposing to downsize the VA administration (10). Like so many reforms, this seems to have fallen by the wayside under opposition from VA administration. In fact, Wagner implies that VA administration may actually have grown beyond what was already a bloated bureaucracy (9).

President-elect Trump has been critical of the VA and McDonald. It seems likely he will be gone this January but the VA administrators will remain. Hopefully, McDonald's replacement will do better in reforming the VA. If not, it might be time to view the VA as what it has become, a white elephant whose cost outweighs all usefulness. Consideration should be given to replacing the VA with care in the private sector. Although care will be more expensive, it is better than no or poor care which is what the VA patients are receiving now.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening?. Available at: http://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 10/27/16).
2. Department of Veterans Affairs. VA celebrates 70 years of partnering with medical schools. Available at: http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2747 (accessed 10/27/16).
3. Department of Veterans Affairs. Still going strong - the history of VA academic affiliations. Available at: http://www.va.gov/OAA/videos/transcript_affiliation_history.asp (accessed 10/27/16).
4. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jul 24;371(4):295-7. [CrossRef] [PubMed]
5. Rein L. VA chief compares waits for veteran care to Disneyland: They don’t measure and we shouldn’t either. Washington Post. May 23, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/23/va-chief-compares-waits-for-veteran-care-to-disneyland-they-dont-measure-and-we-shouldnt-either/ (accessed 10/27/16).
6. Department of Veterans Affairs. VA Proposes to grant full practice authority to advanced practice registered nurses. May 29, 2016. Available at: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793 (accessed 10/27/16).
7. Galewitz P. VA shifts to clinical pharmacists to help ease patients’ long waits. Kaiser Health News. October 25, 2016. Available at: http://khn.org/news/va-treats-patients-impatience-with-clinical-pharmacists/ (accessed 10/27/16).
8. Rein L. To cut wait times, VA wants nurses to act like doctors. Doctors say veterans will be harmed. Washington Post. May 27, 2016. Available at: https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/ (accessed 10/27/16).
9. Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. [CrossRef]
10. Krause J. MyVA re-org likely set to downsize VA workforce, a lot. DisabledVeterans.org. Jan 28, 2015. Available at: http://www.disabledveterans.org/2015/01/29/myva-reorganization-likely-set-downsize-va-workforce-lot/ (accessed 10/27/16).

*The views expressed are those of the author and do not reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Cite as Robbins RA. Has the VA Become a White Elephant? Southwest J Pulm Crit Care. 2016;13(5):235-7. doi: https://doi.org/10.13175/swjpcc108-16 PDF 

The Evil That Men Do-An Open Letter to President Obama

"The evil that men do lives after them; the good is oft interred with their bones". William Shakespeare, Julius Caesar, Act 3, Scene 2

Dear President Obama:

Late in a second term, a President's attention often turns to framing their legacy. I suspect you are no exception and have given this considerable thought. You might wish to be remembered for the Affordable Care Act, even called Obamacare, which brought the US closer to universal healthcare coverage. However, I recall the end of President Clinton's second term a short 16 years ago. During that administration the Federal coffers were full; an unprecedented business boom occurred; and foreign entanglements that might have led to war were avoided. However, most of us do not remember those positives, but recall a White House intern and a certain blue dress. As pointed out by Shakespeare over 400 years ago powerful men are remembered not so much for the good they do but the bad.

Robert McDonald, your Secretary of Veterans Affairs (VA), was brought on board two years ago to deal with concerns about long waiting times for Veterans Administration medical services-concerns and the subsequent lies that were told to cover it up that led you to fire his predecessor, Eric Shinseki. McDonald was talking to reporters in the week leading up to Memorial Day, when attention always turns not just to honoring America's war dead but to whether the government is delivering services it promised living Veterans. The reporters asked McDonald why the VA doesn't publicly report the date when veterans first ask for medical care so as to better measure waiting times (1). His reply:

"The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran's satisfaction. What really counts is: How does the veteran feel about their encounter with the VA? When you go to Disney, do they measure the hours you wait in line?"

Although McDonald later apologized for his remarks, they were offensive to me as a physician who worked in the VA, and I might point out wrong on several fronts. First, Disney does track its wait times. Second, the remark shows a fundamental disconnect between upper echelon management and healthcare. As we pointed out several years ago, satisfaction with healthcare does not mean better healthcare, in fact, it may mean worse care, perhaps because the focus is more on satisfaction than good care (2). Third, McDonald's remark was truly disingenuous. McDonald is concerned about wait times which led you to fire his predecessor. Otherwise, why would the VA lift the supervision requirement for nurse practioners which they did later in the week (3)?

The prolonged wait times occurred because an insufferable VA administration created a hostile work environment for physicians. Many left and the VA was unable to replace them. Although salary is part of this, it is less of a problem than those inside the Beltway believe. The VA abandoned its academic affiliations and created a work environment where physicians seeing patients is largely put in the same category as janitors waxing a floor. Middle level administrators who know nothing about healthcare are now directing physicians on what they should do. The goal has become less about healthcare than the administrators being in charge. The replacement of physicians by nurse practioners is in line with this concept. The goal will not be as much to deliver quality healthcare, a concept that is often nebulous and hard to define, but rather to redefine quality. For example, replacing timely and good care with a measure such as making sure that on each visit the Veteran is reminded to fasten their safety belt (a current requirement), is certainly measurable, cheap and does not require a physician. In most businessmen's minds it matters little whether it does any good or not. It is a measure of someone's concept of quality and the VA will deliver quality as long as it does not cost too much and an administrator can receive a bonus for it. Based on the VA, many physicians are suspicious that this is the long term goal of Obamacare.

So on this Memorial Day, let us remember our Veterans, Mr. President, and consider your legacy. My view is that unless changes are made, your misdirection of healthcare both at the VA and nationally through Obamacare, could be your White House intern in a blue dress.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Capital Gazette editorial board. Our say: McDonald gaffe points to a deeper problem. Capital Gazette. May 30, 2016. Available at: HTUhttp://www.capitalgazette.com/opinion/our_say/ph-ac-ce-our-say-0529-20160529-story.htmlUTH (accessed 5/30/16).
2. Robbins RA, Rashke RA. A new paradigm to improve patient outcomes: a tongue-in-cheek look at the cost of patient satisfaction. Southwest J Pulm Crit Care 2012;5:33-5. Available at: HTU/editorial/2012/7/17/a-new-paradigm-to-improve-patient-outcomes.htmlUTH (accessed 5/30/16).
3. Japsen B. VA would join 21 states already lifting nurse practitioner hurdles. Forbes. May 26,2016. Available at: HTUhttp://www.forbes.com/sites/brucejapsen/2016/05/26/va-would-join-21-states-lifting-nurse-practitioner-hurdles/#2d4e391e9f2cUTH (accessed 5/30/16).

*The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. The evil that men do-an open letter to President Obama. Southwest J Pulm Crit Care. 2016 May;12(5):201-2. doi: http://dx.doi.org/10.13175/swjpcc048-16 PDF

VA Administrators Breathe a Sigh of Relief

On May 30, Eric Shinseki, the Secretary for Veterans Affairs (VA), resigned under pressure amidst a growing scandal regarding falsification of patient wait times at nearly 40 VA medical centers. Before leaving office Shinseki fired Sharon Helman, the former hospital director at the Phoenix VA, where the story first broke, along with her deputy and another unnamed administrator. In addition, Susan Bowers, director of VA Veterans Integrated Service Network (VISN) 18 and Helman’s boss, resigned. Robert Petzel, undersecretary for the Veterans Health Administration (VHA, head of the VA hospitals and clinics), had resigned earlier. You could hear the sigh of relief from the VA administrators.

With their bosses resigning left and right, the VA leadership in shambles and the reputation of the VA  soiled for many years to come, why are the VA administrators relieved? The simple answer is that nothing has really changed. There for a moment it looked like real reform might happen. Even President Obama in announcing Shinseki's resignation said the "There is a need for a change in culture..." (1). Shinseki’s resignation would indicate that any action to change the culture is unlikely. Sure a few administrators, like Helman, will lose their jobs, perhaps a few patients will get outsourced to private practioners, but nothing is being done or proposed to change the VA culture. A new interim VA secretary was named and his tenure is likely to be lengthy since no confirmation appears to go unchallenged in the US Congress, and who would want the job?

I was at the VA, when then undersecretary for VHA, Kenneth Kizer, made the fundamental change that resulted in the present mess. Kizer had come to the VA with a program he called the “prescription for change” (2). Indeed, Kizer made several changes but the one that really counted was that the chiefs of staff, doctors who ran the medical services in VA hospitals, were replaced by the head of the Medical Administration Service, usually a business person. This made the VA director the monarch over their own little kingdom, and we all know “it’s good to be the king”. Furthermore, we all know that power corrupts and now with absolute power, the VA director was absolutely corrupted. The hospital directors eliminated any sources of potential opposition. Physicians who did not “play ball” could suddenly find themselves as a target of an investigation (3). After being found guilty by a kangaroo court, their names would be turned over to the National Practioner Databank as bad doctors making it difficult to find a job outside the VA. Those cooperative physicians were rewarded, often for limiting the care of patients. In other words, putting the VA administrators’ interests before the patients’ (4). Lastly, the long-standing relationship with the Nation’s medical schools was destroyed (remember VA dean’s hospitals?). It was argued that the medical schools used the VA to serve their needs. Although this had some truth, it is part of the two-way street that makes cooperation possible. No VA administrator wanted a bunch of doctors and academics telling them what to do.

After eliminating any possible oversight from the physicians or the medical schools, an insulating administrative layer had to be placed between the hospitals and VA central office. Therefore, the Veterans Integrated Service Networks or VISNs, were created. Although ostensibly to improve oversight and efficiency (2), only in Washington would they believe that another layer of bureaucracy would do either. As more and more patients were packed into the system, the numbers of physicians and nurses decreased (5). Not surprisingly, wait times became longer and there was no alternative but to hide the truth. The administrators, the VISNs and VA Central office were all complicit in these lies. Their bonuses depended on it and even when it was discovered by the VA Office of Inspector General (VAOIG) nothing was done.

Congress, who supposedly also provides oversight, was swift to propose action that does not change the VA culture and accomplish little. In this election year Congressional cries to throw those VA bums out have been consistent and loud. However, plenty of clues were available to know that the wait time data was false. First, the concept that you can cut the numbers of physicians and nurses and improve wait times defies common sense. Second, the VAOIG had repeatedly reported that wait times were being falsified. Helman had already been accused of this when she was the director at the Spokane VA (6). This week the Senate passed a bill allowing veterans to see private doctors outside the VA system if they experience long wait times or live more than 40 miles from a VA facility; make it easier to fire VA officials; construct 26 new VA medical facilities and use $500 million in unobligated VA funds to hire additional VA doctors and nurses (7). The VA already is able to do the first two, and as the present crisis illustrates, funds can be diverted away from healthcare. It seems likely this is exactly what will happen unless additional oversight is provided.

Kizer and Ashish Jha authored an editorial on this crisis in the New England Journal of Medicine this week (8). They made three recommendations:

1. The VA should refocus on fewer measures that directly address what is most important to veteran patients and clinicians-especially outcome measures.
2. Some of the resources supporting the central and network office bureaucracies could be redirected to bolster the number of caregivers.
3. The VA needs to engage more with health care organizations and the general public.

All these recommendations are reasonable. Outcome measures, not process of care, should be measured (9). Paying bonuses to administrators for clinicians completing these process of care measures should stop. Many of these measures serve mostly to increase administrative bonuses and not improve patient care. By giving administrators supervisory authority over physicians, healthcare providers were forced to complete a seemingly endless checklists rather than serve the patients' interests.

Bureaucracies should be reduced. VA's central-office staff has grown from about 800 in the late 1990s to nearly 11,000 in 2012 (8). VISN offices have reflected this growth with over 4500 employees in 2012 (10). This diversion of funds away from healthcare is the source of the present problem.

The VA needs to re-engage with the medical schools and with its patients. Reestablishment of the Dean's Committee or other similar system that provides oversight of the VA hospital directors and administrators may be one method of achieving this oversight. The association of the medical schools with the VA served the VA well from the Second World War until the 1990s (11).

Poor pay and micromanagement of physicians to perform meaningless metrics makes primary care onerous. Appropriating funds might improve the salary discrepancy between the VA and the private sector but will not fix the micromanagement problem. The VA may find it difficult to recruit the needed physicians and nurses unless a more friendly work environment is created. How do we know that any appropriated money will be spent on healthcare providers and infrastructure unless additional oversight is put in place? Without oversight the VA positions will become VA vacancies and the VA hospitals will become administrative palaces. Local oversight by VA physicians, nurses and patients is one method of ensuring that appropriated monies are actually spent on healthcare.

VA health care is at a crossroads. New leadership can help the VA succeed but only if the administrative structure is fixed changing the VA culture. Until this occurs the same administrative monarchs will continue to rule their realms and nothing will really change.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Cohen T, Griffin D, Bronstein S, Black N. Shinseki resigns, but will that improve things at VA hospitals? CNN. May 31, 2014. Available at: http://www.cnn.com/2014/05/30/politics/va-hospitals-shinseki/ (accessed 6/7/14).
2. Kizer KW. Prescription for change. March 1996. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 6/7/14). 
3. Wagner D. The doctor who launched the VA scandal. Arizona Republic. May 31, 2014. Available at: http://www.azcentral.com/longform/news/arizona/investigations/2014/05/31/va-scandal-whistleblower-sam-foote/9830057/ (accessed 6/7/14).
4. Hsieh P. Three factors that corrupted VA health care and threaten the rest of American medicine. Forbes. May 30, 2014. Available at: http://www.forbes.com/sites/paulhsieh/2014/05/30/three-factors-that-corrupted-va-health-care/ (accessed 6/7/14).
5. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. Available at: /editorial/2012/5/5/va-administrators-gaming-the-system.html (accessed 6/7/14).
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. Available at: /editorial/2014/5/26/va-scandal-widens.html (accessed 6/7/14). 
7. O'Keefe E. Senators reach bipartisan deal on bill to fix VA. Washington Post. June 5, 2014. Available at: http://www.washingtonpost.com/blogs/post-politics/wp/2014/06/05/senators-reach-bipartisan-deal-on-bill-to-fix-va/ (accessed 6/7/14).
8. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jun 4. [Epub ahead of print]. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1406852 (accessed 6/7/14). [CrossRef]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef]
10. VA Office of Inspector General. Audit of management control structures for veterans integrated service network offices. March 27, 2012. Available at: http://www.va.gov/oig/pubs/VAOIG-10-02888-129.pdf (accessed 6/7/14).
11. VA policy memorandum no. 2: policy in association of veterans' hospitals with medical schools. January 30, 1946. Available at: http://www.va.gov/oaa/Archive/PolicyMemo2.pdf (accessed 6/7/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Refence as: Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14 PDF

VA Scandal Widens

On Memorial Day, which honors those who died in service to the country, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) is investigating medical facilities in at least 26 cities (1). The scandal started in Phoenix where Sam Foote, a retired VA physician, alleged that up to 40 patients in Arizona died awaiting care in a network where some veterans could not get appointments for more than a year. Foote claimed that Phoenix VA officials were misrepresenting wait times to collect bonus checks while maintaining "secret lists" of patients. These accusations resulted in the suspension of Sharon Helman, the Phoenix VA hospital director, along with her associate director and another unnamed senior administrator. Dennis Wagner in an article in the Arizona Republic listed many of the accusations made against various VA hospitals outside of Phoenix (1). These include:

• Chicago: Germaine Clarno, president of a federal employee union, said secret lists and falsified wait times had been an "everyday practice" at the Hines VA Hospital, and complaints of data fraud were ignored. Hellman was previously at the Hines VA director prior to coming to Phoenix. Clarno also said the inspector general conducted an inquiry, but targeted tangential issues. "The problem is the government covers up for the government — the OIG is a bed partner of VA administration." The OIG had investigated the Phoenix VA in late 2013 but Robert Petzel, then undersecretary for Veterans Healthcare Administration, said the OIG found no evidence to support Foote's claims (2). Petzel later resigned and the White House has nominated Jeffrey Murawsky who previously served as director of VA Veterans Integrated Service Network (VISN) 12 which oversees the Hines VA and who directly supervised Helman (3).
• Walla Walla, WA: VA auditors who visited the Walla Walls VA, where Helman previously served as director prior to coming to Hines VA, identified improper and inconsistent patient-scheduling practices, according to the Walla Walla Union-Bulletin. A psychiatric nurse, who won a whistle-blower settlement after being terminated, told NBC News that intimidation and retaliation were commonplace at the medical center.
• San Antonio, Texas: Dr. Joseph Spann, who retired in January after 17 years with the VA, told federal investigators that physicians were regularly asked to alter the "request date" for medical procedures to hide backlogs for tests. Spann attributed the practice to pressure to meet performance measures that reward administrators bonuses. When told local VA officials had conducted a review and denied the allegation, Spann said, "Central Texas (VA) investigating itself is just worthless." Raymond Chung who was the previous Chief of Staff at the Phoenix VA came to Phoenix from San Antonio.
• Cheyenne, WY: Congressional investigators uncovered an e-mail written by a nurse to other VA employees describing techniques for "gaming the system" by falsifying appointment records to meet goals set by bosses. The nurse was suspended after the e-mail was made public. The director of the Cheyenne VA is Cynthia McCormack who previously was chief of nursing at the Phoenix VA.
• Fort Collins, CO: OIG investigators in December found that medical clinic staffers were trained to make it appear veterans were getting appointments within 14 days, per department guidelines, even though waits were longer. McCormack supervises the Fort Collins clinic.
• Albuquerque: U.S. Sen. Tom Udall, D-N.M., called for an investigation after allegations that  wait-time records were falsified Phoenix. Phoenix and Albuquerque are both supervised by Susan Bowers, the VISN 18 director.

As the above illustrates, the connections between these administrators is striking. Beginning several years ago, according to internal VA records, VA central office in Washington realized medical centers around the country were finding ways to manipulate the numbers. The VA had for several years been the subject of congressional inquiry and criticism not just due to long waits for care, but because of mismanagement but no action was taken.

Although Congress, VA central office in Washington and the local VISNs are all charged with overseeing the VA hospitals, the task of supervising this large, complex bureaucracy is daunting and appears to have been inadequate. A system needs to be put in place where healthcare providers who care for veterans and veteran patients who use the facility have a role in the oversight of their local VA hospital.  Creation of a hospital board of directors consisting predominately of healthcare providers from the facility and veterans might be able to provide the supervision that this ever widening scandal suggests is needed.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Delayed care, fraud point to ailing VA health system. The Arizona Republic. May 25, 2014. Available at: http://www.azcentral.com/story/news/politics/investigations/2014/05/25/va-medical-care-woes/9564605/ (accessed 5/26/14).
2. Wagner D. VA: We found no evidence to support allegations in Phoenix. The Arizona Republic. April 30,2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/30/phoenix-veteran-hospital-deaths-investigation/8518721/ (accessed 5/26/14).
3. O'Dell R, Nowicki D, The Arizona Republic. May 16, 2014. Available at: http://www.usatoday.com/story/news/nation/2014/05/16/top-va-health-official-resigns-under-fire/9182311/ (accessed 5/26/14).

*The opinions expressed are those of the author and do not necessarily represent those of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. doi: http://dx.doi.org/10.13175/swjpcc070-14 PDF

Don’t Fire Sharon Helman-At Least Not Yet

Several developments have occurred over the past few days regarding prolonged wait times and secret lists at the Phoenix VA and its embattled director, Sharon Helman. President Obama has asked for an investigation and several Arizona Senators and Representatives have called for investigations and/or asked for the resignation of Helman and her administrative team (1,2). On 4/30/14, Dr. Robert Petzel, VA undersecretary for health, testified that an administrative team visited Phoenix soon after the controversy erupted and found “no evidence of a secret list… [or] patients who have died because they [were] on a wait list." (3). On 5/1/14 CNN posted an interview with Sharon Helman and her Chief of Staff, Dr. Darren Deering, who denied the allegations. Dr. Sam Foote, who made the original allegations, accused Helman and Deering of lying (4). CNN apparently confirmed Foote’s story with several sources inside the VA including a second physician, Dr. Katherine Mitchell (5). Later the same day, Eric Shinseki, Secretary of Veterans Affairs, suspended Helman and two others (5).

This all sounded very familiar (6). In 2012 the VA Office of Inspector General (OIG) issued a report on the accuracy of the Veterans Healthcare Administration (VHA) wait times for mental health services (7). The report found that “VHA does not have a reliable and accurate method of determining whether they are providing patients timely access to mental health care services. VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time to see a mental health provider.”

After the 2012 OIG report came the inevitable Congressional hearing (8). Although misrepresenting actual wait times has been known for many years, there has been inadequate action to correct the practice according to the VA OIG. Sen. Patty Murray, then chair of the Senate Committee on Veterans' Affairs, said the findings showed a "rampant gaming of the system." (8). A review of the OIG’s website revealed multiple instances of similar findings dating back to at least 2002 (6). In each instance, unreliable data regarding wait times was cited and no or inadequate action was taken.

The providers at the VA should not necessarily view this as not good news. The VA has usually sought to refocus blame away from the administrators to “lazy” or “poor” doctors. My guess is that we will soon see a number of accusations about Drs. Foote and Mitchell in an effort to administratively circle the wagons. VA administrators usually seize on such opportunities to control physicians. Remember the computer fiasco from several years back when an information technology administrator lost a computer with confidential patient information (9)? This not only resulted in information technology being placed in charge of the electronic healthcare record but a number of restrictions were placed on physician use of data. Furthermore, administrators can now not only regulate a physician’s salary but “black ball” physicians by false accusations through sources such as the National Practioner Data Bank (NPDB). Not surprisingly, physicians are reluctant to speak out when their livelihood can be threatened.

Clearly, the present system is not working. Firing Sharon Helman will solve nothing at the present other than giving some politicians the opportunity to congratulate themselves on weeding out a bad apple in this election year. Furthermore, firing Helman could be an attempt to hide a systemic problem by offering Helman as the “fall guy”. So instead of redoing the OIG investigations and the Congressional hearings which have accomplished nothing in the past, how about doing something else? Here are a few suggestions:

1. Have Helman investigated by an independent source, not the OIG. Examine other VAs for similarly misrepresenting patient wait times. Over thirty years at the VA taught me that if wait times are being "gamed" by one VA, the times are also likely being "gamed" by others.
2. Create a National Healthcare Administrator Data Bank similar to the NPDB with all the same safeguards and checks and balances available to physicians. Helman apparently had a history of misrepresenting data (10). It seems unlikely that she would have been hired if this was publically known.
3. Provide adequate oversight. The local Veterans Integrated Service Network (VISN), VA Central Office in Washington, and Congress is not providing the oversight needed. Create a hospital board of directors consisting predominately of a majority of healthcare providers from the facility and Veterans (not to be appointed by the director) to provide oversight.
4. Quit hiring more administrators while reducing the number of doctors. Inadequate numbers of providers is the root cause of prolonged wait times and has been present for a number of years (6). The numbers of administrators, nurses and doctors should be transparent and publically available.
5. Quit paying administrators bonuses for work done by doctors. This only encourages cheating on reports (6,7). If administrators need a bonus, reward them for achievements in administrative efficiency or similar administrative goals. Both the criteria for and the amount of the bonus should be transparent and publically available.
6. Scrap the VISN system. These local collections of administrators are another source of waste and appear to add no real oversight or patient benefit.

The optimist in me hopes the situation at the Phoenix VA and possibly other VAs is thoroughly investigated. If Helman is the “bad apple” many would like to portray-then fire her. If her actions are more a result of a systemic problem-then fix the problem.  However, the cynic in me fears that Helman will be sacrificed without a thorough investigation and no change will occur.  In that case I will again be writing about an investigation of VA administrators "gaming the system", probably in 2016.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. McCain, Flake call for Senate probe of Phoenix VA. The Arizona Republic. April 23, 2014. Available at: http://www.azcentral.com/story/news/arizona/politics/2014/04/23/mccain-flake-call-senate-probe-phoenix-va/8061141/ (accessed 5/1/14).
2. Harris C, Wagner D. Phoenix VA officials deny there's a secret wait list; doctor says they're lying. The Arizona Republic. April 29, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/29/phoenix-va-director-congressman-call-for-removal/8447131/ (accessed 5/1/14).
3. Wagner D. VA: We found no evidence to support allegations in Phoenix. The Arizona Republic. April 30, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/04/30/phoenix-veteran-hospital-deaths-investigation/8518721/ (accessed 5/1/14).
4. Bronstein S, Griffin D, Black N. Phoenix VA officials deny there's a secret wait list; doctor says they're lying. CNN. May 1, 2014. Available at: http://www.cnn.com/2014/04/30/health/veterans-dying-health-care-delays/ (accessed 5/1/14).
5. Wagner D. Second VA doctor blows whistle on patient-care failures. The Arizona Republic. May 1, 2014. Available at: http://www.azcentral.com/story/news/investigations/2014/05/02/second-va-doctor-blows-whistle-patient-care-failures/8595863/ (accessed 5/1/14).
6. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54.
7. VA Office of Inspector General. Review of Veterans’ Access to Mental Health Care. 1.http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf  (accessed 5-1-14).
8. Vogel S. VA mental health system sharply denounced at hearing. Washington Post. April 25, 2012. Available at: http://www.washingtonpost.com/politics/va-mental-health-system-sharply-denounced-at-hearing/2012/04/25/gIQAXG3mhT_story.html (accessed 5/1/14).
9. Lee C, Goldfarb ZA. Stolen VA laptop and hard drive recovered. Washington Post. June 30, 2006. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2006/06/29/AR2006062900352.html (accessed 5/1/14).
10. Corbin C. Arizona VA boss accused of covering up veterans' deaths linked to previous scandal. Foxnews.com. April 24, 2014. Available at: http://www.foxnews.com/politics/2014/04/24/arizona-va-boss-accused-covering-up-veterans-deaths-linked-to-previous-scandal/ (accessed 5/1/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Don't fire Sharon Helman-at least not yet. Southwest J Pulm Crit Care. 2014;8(5):275-7. doi: http://dx.doi.org/10.13175/swjpcc060-14 PDF

VA Administrators Gaming the System

On 4-23-12 the Department of Veterans Affairs (VA) Office of Inspector General (OIG) issued a report of the accuracy of the Veterans Healthcare Administration (VHA) wait times for mental health services. The report found that “VHA does not have a reliable and accurate method of determining whether they are providing patients timely access to mental health care services. VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time to see a mental health provider.” (1). The OIG made several recommendations and the VA administration quickly concurred with these recommendations. Only four days earlier the VA announced plans to hire 1900 new mental health staff (2).

This sounded familiar and so a quick search on the internet revealed that about a year ago the United States Court of Appeals for the Ninth Circuit issued a scathing ruling saying that the VA had failed to provide adequate mental health services to Veterans (3). A quick review of the Office of Inspector General’s website revealed multiple instances of similar findings dating back to at least 2002 (4-7). In each instance, unreliable data regarding wait times was cited, VA administration agreed, and no or inadequate action was taken.

Inadequate Numbers of Providers

One of the problems is that inadequate numbers of clinical physicians and nurses are employed by the VA to care for the patients. In his “Prescription for Change”, Dr. Ken Kizer, then VA Undersecretary for Health, made bold changes to the VA system in the mid 1990’s (8). Kizer cut the numbers of hospitals but also the numbers of clinicians while the numbers of patients increased (9). The result was a marked drop in the number of physicians and nurses per VA enrollee (Figure 1).

Figure 1. Nurses (squares) and physicians (diamonds) per 1000 VA enrollees for selected years (10,11).

This data is consistent with a 2011 VA survey that asked VA mental health professionals whether their medical center had adequate mental health staff to meet current veteran demands for care; 71 percent responded no. According to the OIG, VHA’s greatest challenge has been to hire psychiatrists (1). Three of the four sites visited by the OIG had vacant psychiatry positions. One site was trying to replace three psychiatrists who left in the past year. This despite psychiatrists being one of the lowest paid of the medical specialties (12). The VA already has about 1,500 vacancies in mental-health specialties. This prompted Sen. Patty Murray, Chairman of the Senate Committee on Veterans Affairs to ask about the new positions, "How are you going to ensure that 1,600 positions ... don't become 1,600 vacancies?" (13).

Administrative Bonuses

A second problem not identified by the OIG is administrative bonuses. Since 1996, wait times have been one of the hospital administrators’ performance measures on which administrative bonuses are based. According to the OIG these numbers are unreliable and frequently “gamed” (1,4-7). This includes directions from VA supervisors to enter incorrect data shortening wait times (4-7).

At a hearing before the Senate Committee on Veterans' Affairs Linda Halliday from the VA OIG said "They need a culture change. They need to hold facility directors accountable for integrity of the data." (13). VA "greatly distorted" the waiting time for appointments, Halliday said, enabling the department to claim that 95 percent of first-time patients received an evaluation within 14 days when, in reality, fewer than half were seen in that time. Nicholas Tolentino, a former mental-health administrative officer at the VA Medical Center in Manchester, N.H., told the committee that managers pressed the staff to see as many veterans as possible while providing the most minimal services possible. "Ultimately, I could not continue to work at a facility where the well-being of our patients seemed secondary to making the numbers look good," he said.

Although falsifying wait times has been known for years, there has been inadequate action to correct the practice according to the VA OIG. Sen. Murray said the findings show a "rampant gaming of the system." (13). This should not be surprising. Clerical personnel who file the data have their evaluations, and in many cases pay, determined by supervisors who financially benefit from a report of shorter wait times. There appears no apparent penalty for filing falsified data. If penalties did exist, it seems likely that the clerks or clinicians would be the ones to shoulder the blame.

The Current System is Ineffective

A repeated pattern of the OIG being called to look at wait times, stating they are false, making recommendations, the VA concurring, and nothing being done has been going on for years (1, 3-7). Based on these previous experiences, the VA will likely be unable to hire the numbers of clinicians needed and wait times will continue to be unacceptably long but will be “gamed” to “make the numbers look good”. Pressure will be placed on the remaining clinicians to do more with less. Some will become frustrated and leave the VA. The administrators will continue to receive bonuses for inaccurate short wait times. If past events hold true, in 2-5 years another VA OIG report will be requested. It will restate that the VA falsified the wait times. This will be followed by a brief outcry, but nothing will be done.

The VA OIG apparently has no real power and the VA administrators have no real oversight. The VA OIG continues to make recommendations regarding additional administrative oversight which smacks of putting the fox in charge of the hen house. Furthermore, the ever increasing numbers of administrators likely rob the clinical resources necessary to care for the patients. Decreased clinical expenses have been shown to increase standardized mortality rates, in other words, hiring more administrators at the expense of clinicians likely contributes to excess deaths (14). Although this might seem obvious, when the decrease of physicians and nurses in the VA began in the mid 1990’s there seemed little questioning that the reduction was an “improvement” in care.

Traditional measures such as mortality, morbidity, etc. are slow to change and difficult to measure. In order to demonstrate an “improvement” in care what was done was to replace outcome measures with process measures. Process measures assess the frequency that an intervention is performed.  The problem appears that poor process measures were chosen. The measures included many ineffective measures such as vaccination with the 23 polyvalent pneumococcal vaccine in adult patients and discharge instructions including advice to quit smoking at hospital discharge (15). Many were based on opinion or poorly done trials, and when closely examined, were not associated with better outcomes. Most of the “improvement” appeared to occur in performance of these ineffective measures. However, these measures appeared to be quite popular with the administrators who were paid bonuses for their performance.

Root Causes of the Problems

The root causes go back to Kizer’s Prescription for Change. The VA decreased the numbers of clinicians, but especially specialists, while increasing the numbers of administrators and patients. The result has been what we observe now. Specialists such as psychiatrists are in short supply. They were often replaced by a cadre of physician extenders more intent on satisfying a checklist of ineffective process measures rather than providing real help to the patient. Waiting times lengthened and the administrative solution was cover up the problem by lying about the data.

VA medical centers are now usually run by administrators with no real medical experience. From the director down through their administrative chain of command, many are insufficiently medically trained to supervise a medical center. These administrators could not be expected to make good administrative decisions especially when clinicians have no meaningful input (10).

The present system is not transparent. My colleagues and I had to go through a FOIA request to obtain data on the numbers of physicians and nurses presented above. Even when data is known, the integrity of the data may be called into question as illustrated by the data with the wait times. 

The falsification of the wait times illustrates the lack of effective oversight. VA administration appears to be the problem and hiring more administrators who report to the same administrators will not solve the problem as suggested by the VA OIG (3-7). What is needed is a system where problems such as alteration of wait times can be identified on the local level and quickly corrected.

Solutions to the Problems

The first and most important solution is to provide meaningful oversight by at the local level by someone knowledgeable in healthcare. Currently, no system is in place to assure that administrators are accountable.  Despite concurring with the multitude of VA OIG’s recommendations, VA central office and the Veterans Integrated Service Networks have not been effective at correcting the problem of falsified data. In fact, their bonuses also depend on the data looking good. Locally, there exists a system of patient advocates and compliance officers but they report to the same administrators that they should be overseeing. The present system is not working. Therefore, I propose a new solution, the concept of the physician ombudsman. The ombudsman would be answerable to the VA OIG’s office. The various compliance officers, patient advocates, etc. should be reassigned to work for the ombudsman and not for the very people that they should be scrutinizing.

The physician ombudsman should be a part-time clinician, say 20% at a minimum. The latter is important in maintaining local clinical knowledge and identifying falsified clinical data. One of the faults of the present VA OIG system is that when they look at a complaint, they seem to have difficulty in identifying the source of the problem (16). Local knowledge would likely help and clinical experience would be invaluable. For example, it would be hard to say waiting times are short when the clinician ombudsman has difficulty referring a patient to a specialist at the VA or even booking a new or returning patient into their own clinic.

The overseeing ombudsman needs to have real oversight power, otherwise we have a repeat of the present system where problems are identified but nothing is done. Administrators should be privileged similar to clinicians. Administrators should undergo credentialing and review. This should be done by the physician ombudsman’s office.  Furthermore, the physician ombudsman should have the capacity to suspend administrative privileges and decisions that are potentially dangerous. For example, cutting the nursing staffing to dangerous levels in order to balance a budget might be an example of a situation where an ombudsman could rescind the action.

The paying of administrative bonuses for clinical work done by clinicians should stop. Administrators do not have the necessary medical training to supervise clinicians, and furthermore, do nothing to improve efficiency or clinically benefit Veterans (14). The present system only encourages further expansion of an already bloated administration (17). Administrators hire more administrators to reduce their workload. However, since they now supervise more people, they argue for an increase in pay. If a bonus must be paid, why not pay for something over which the administrators have real control, such as administrative efficiency (18). Perhaps this will stop the spiraling administrative costs that have been occurring in healthcare (17).

These suggestions are only some of the steps that could be taken to improve the chronic falsification of data by administrators with a financial conflict of interest. The present system appears to be ineffective and unlikely to change in the absence of action outside the VA. Otherwise, the repeating cycle of the OIG being called to look at wait times, noting that they are gamed, and nothing being done will continue.

Richard A. Robbins, M.D.*

Editor, Southwest Journal of Pulmonary

            and Critical Care

References

1. http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf  (accessed 4-26-12).
2. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2302 (accessed 4-26-12).
3. http://www.ca9.uscourts.gov/datastore/opinions/2011/07/12/08-16728.pdf (accessed 4-26-12).
4. http://www.va.gov/oig/52/reports/2003/VAOIG-02-02129-95.pdf (accessed 4-26-12).
5. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf (accessed 4-26-12).
6. http://www.va.gov/oig/54/reports/VAOIG-05-03028-145.pdf (accessed 4-26-12).
7. http://www.va.gov/oig/52/reports/2007/VAOIG-07-00616-199.pdf (accessed 4-26-12).
8. www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 4-26-12).
9. http://veterans.house.gov/107th-congress-hearing-archives (accessed 3/18/2012).
10. Robbins RA. Profiles in medical courage: of mice, maggots and Steve Klotz. Southwest J Pulm Crit Care 2012;4:71-7.
11. Robbins RA. Unpublished observations obtained from the Department of Veterans Affairs by FOIA request.
12. http://www.medscape.com/features/slideshow/compensation/2012/psychiatry (accessed 4-26-12).
13. http://seattletimes.nwsource.com/html/localnews/2018071724_mentalhealth26.html (accessed 4-26-12).
14. Robbins RA, Gerkin R, Singarajah CU. Correlation between patient outcomes and clinical costs in the VA healthcare system. Southwest J Pulm Crit Care 2012;4:94-100.
15. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med 2005;353:1860-1 [letter].
16. Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3.
17. Woolhandler S, Campbell T, Himmelstein DU. Health care administration in the United States and Canada: micromanagement, macro costs. Int J Health Serv 2004;34:65-78.
18. Gao J, Moran E, Almenoff PL, Render ML, Campbell J, Jha AK. Variations in efficiency and the relationship to quality of care in the Veterans health system. Health Aff (Millwood) 2011;30:655-63.

*The author is a former VA physician who retired July 2, 2011 after 31 years.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Reference as: Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. (Click here for a PDF version of the editorial)