Internal memos show the VA has been playing whack a mole for at least six years with employees who use dozens of different scheduling tricks to hide substantial delays in health care for America's veterans. And whenever the VA tries to stop its staffers from "gaming the system," the staffers come up with new techniques.
Whistleblowers around the country are now accusing the VA of hiding a backlog in patient care with bookkeeping tricks, and a former doctor at a VA facility in Arizona says the delays may have contributed to the deaths of 40 patients.
In an April 26, 2010 memo, the VA's deputy undersecretary for health administrative operations, William Schoenhard said, "It has come to my attention that in order to improve scores on assorted access measures, certain facilities have adopted use of inappropriate scheduling practices sometimes referred to as 'gaming strategies.' … This is not patient centered care."
Schoenhard then listed two dozen different tactics identified in a 2008 study that facilities around the country were using to cut down on the officially recorded time that patients had to wait for care.
The techniques included pretending that appointments cancelled by the clinic were cancelled by the patient, and refusing to schedule appointments for patients when there was no appointment available within 30 days. Patients were told to wait a month and then call back.
Two of the techniques described in the memo closely resemble the methods described by the whistleblowers who have gone public recently with claims that VA facilities have disguised actual patient waiting time.
The 2010 memo discusses how a written appointment log book can be used to avoid entering long wait times into the electronic waiting list system, and forbids the use of any written log. Dr. Samuel Foote, the Arizona whistleblower, now says that as recently as 2013 the Phoenix VA was using paper records with actual patient wait times to avoid entering those wait times into the official electronic system.
The 2010 memo also describes how staffers manipulated the "Desired Date" of a patient's appointment. The date the patient wants to see a doctor is supposed to be entered as the "Desired Date," but those dates are often sooner than a doctor is available. Facilities were able to hide the difference between what the patient wanted and what the patient got, according to the memo, by either entering the wrong date, neglecting to enter any date or entering the earliest available date as the patient's desired date.
The memo reveals that some clerks look inside the electronic scheduling system to see what dates are actually available before filling in the "Desired Date." "[T]he clerk [finds] the availability of future appointments. Once a date/time is found, the clerk exits the system and then starts over using the identified date/time as the Desired Date."
The method closely resembles what whistleblower Brian Turner alleges occurred at VA facilities in Austin and San Antonio within the past year and a half. It also mirrors what a coordinator at a facility in Wyoming seems to be advising schedulers to do in an email from June 2013.
Schoenhard also notes in the 2010 memo that employees continued to come up with new methods for gaming the system.
Wrote Schoenhard, "Please be cautioned that since 2008, additional new or modified gaming strategies may have emerged, so do not consider this list a full description of all current possibilities of inappropriate scheduling practices that need to be addressed. These practices will not be tolerated."
Three years later, after a GAO report spotlighting continuing problems with patient wait times, Schoenhard sent a second memo to VA facilities informing them of more tweaks to the scheduling process for new patients and for patients who were already in the system.
"[Veterans Health Administration] has changed wait time measurement methods as of October 1, 2012," said the March 15, 2013 memo. "New patient wait times will be measured using the date an appointment was created ("create date") as one reference point and completed appointment as the second point."
"Established patient wait times will be measured using desired date as one reference point and the pending future appointment as the second reference point. This change in methodology will impact the reported performance results."
But Dr. Foote alleges that during 2013 the Phoenix VA was able to work around the "Create Date" provision by filling in the data on the electronic system, printing out what was on screen to create a paper record, and then not saving what was on screen. The paper record, he said, was used to build a second, "secret" waiting list.
And whistleblower Brian Turner, who began working at the Austin VA in December 2012, said he was coached on how to game the "desired date" field in the electronic system after his arrival, and that the same method was also used at the San Antonio VA, where he moved in December 2013 and still works.
At a Ft. Collins, Colo., outpatient clinic, the VA's Office of the Medical Inspector report from December 2013 shows a dramatic change after March 15, 2013 - the date of Schoenhard's memo -- in the number of appointments scheduled within 14 days of the patient's desired date. Fourteen days is the VA's target window for providing timely appointments to patients.
Asked to explain "what occurred in March 2013," employees who were interviewed told investigators "they were instructed by Business office staff to access the appointment schedule, review it for capacity, inform the Veteran of schedule availability, and then enter the Desired Date as the patient appointment date."
Employees told investigators that appointments were sometimes unavailable for as long as six to eight weeks, but "By entering the Desired Date as the appointment date, the wait time … appears to be zero days."
The Ft. Collins clinic is overseen by the Cheyenne, Wyo., VA office, which was the source of the June 19, 2013 email from a coordinator providing instructions on how to manipulate the desired date.
"Yes, it is gaming the system a bit," said the email. "But you have to know the rules of the game you are playing."
The VA did not immediately respond to a request for comment.