[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
A CONTINUED ASSESSMENT OF DELAYS IN VA MEDICAL CARE AND PREVENTABLE
VETERANS DEATHS
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, APRIL 9, 2014
__________
Serial No. 113-64
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman CORRINE BROWN, Florida
DAVID P. ROE, Tennessee MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
JEFF DENHAM, California DINA TITUS, Nevada
JON RUNYAN, New Jersey ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan RAUL RUIZ, California
TIM HUELSKAMP, Kansas GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
Jon Towers, Staff Director
Nancy Dolan, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
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further refined.
C O N T E N T S
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Page
Wednesday, April 9, 2014
A Continued Assessment of Delays in VA Medical Care and
Preventable Veterans Deaths.................................... 1
OPENING STATEMENTS
Hon. Jeff Miller, Chairman....................................... 1
Prepared Statement........................................... 45
Hon. Michael Michaud, Ranking Minority Member
Prepared Statement........................................... 46
Hon. Corrine Brown............................................... 3
Prepared Statement........................................... 47
Steve Cohen
Prepared Statement........................................... 47
WITNESSES
Barry Coates, Veteran............................................ 4
Prepared Statement........................................... 48
Daniel M. Dellinger, National Commander, The American Legion..... 6
Prepared Statement........................................... 50
Accompanied by:
Edward Lilly, Senior Field Service Officer, The American
Legion
Thomas Lynch M.D., Assistant Deputy Under Secretary for Health
for Clinical Operations, VHA, U.S. Department of Veterans
Affairs........................................................ 23
Prepared Statement........................................... 61
Accompanied by:
Carolyn M. Clancy M.D., Assistant Deputy Under Secretary
for Quality, Safety, and Value, VHA, U.S. Department
of Veterans Affairs
Debra A. Draper, Director, Health Care, GAO...................... 36
Prepared Statement........................................... 64
John D. Daigh, Jr. M.D., Assistant Inspector General for
Healthcare Inspections, Office of the Inspector General, U.S.
Department of Veterans Affairs................................. 38
Prepared Statement........................................... 82
QUESTIONS FOR THE RECORD
Questions From Chairman Miller to VA............................. 90
A CONTINUED ASSESSMENT OF DELAYS IN VA MEDICAL CARE AND PREVENTABLE
VETERANS DEATHS
----------
Wednesday, April 9, 2014
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, D.C.
The committee met, pursuant to notice, at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Jeff Miller
[chairman of the committee] presiding.
Present: Representatives Miller, Bilirakis, Benishek,
Huelskamp, Coffman, Cook, Walorski, Jolly, Brown, Brownley,
Titus, Kirkpatrick, Negrete-McLeod, and O'Rourke.
Also Present: Representative Cohen.
OPENING STATEMENT OF CHAIRMAN JEFF MILLER
The Chairman. The committee will come to order. Before we
begin, I would like to ask unanimous consent that when he
arrives, our colleague from Tennessee, Congressman Steve Cohen,
be allowed to sit at the dais and participate in today's
proceedings. Hearing no objection, so ordered.
Ladies and gentlemen, welcome to today's full committee
hearing, a Continued Assessment of Delays in VA Medical Care
and Preventable Veteran Deaths.
Today's hearing is the fulfillment of a promise I made in
early January to follow-up on delays in care at Veterans
Affairs' Medical Centers in Columbia, South Carolina and
Augusta, Georgia that together resulted in nine preventable
veteran deaths.
I had hoped that during this hearing we could be discussing
the concrete changes that VA had made, changes that would show
beyond a doubt that VA had placed the care of our veterans
first and that VA's commitment to holding any employee who did
not completely embody a commitment to excellence through
actions appropriate to the employee's failure to be held
accountable.
Instead today we are faced with even more questions and an
ever-mounting list of evidence that despite the myriad of
patient safety incidents that have occurred at VA medical
facilities in recent memory, the status quo is firmly
entrenched at the Department of Veterans Affairs.
On Monday, shortly before this public hearing, VA provided
evidence that a total of 23 veterans have died due to delays in
care at VA medical centers. Even with this latest disclosure as
to where the deaths occurred, our committee still does not know
when they may have happened beyond the statement that they most
likely occurred between 2010 and 2012.
These particular deaths resulted primarily from delays in
gastrointestinal care. Information on other preventable deaths
due to consult delays remains unavailable.
Outside of the VA's consult review, this committee has
reviewed at least 18 preventable deaths that occurred because
of mismanagement, improper infection control practices, and a
whole host, of maladies that plague the VA healthcare system
all across this great Nation, yet the department's stone wall
has only grown higher and more nonresponsive.
There is no excuse for these incidents to have ever
occurred. Congress has met every resource request that VA has
made and I guarantee that if the department would have
approached this committee at any time to tell us that help was
needed to ensure that veterans received the care they required,
every single possible action would have been taken to ensure
that VA could, in fact, adequately care for our veterans.
This is the third full committee hearing that I have held
on patient safety. And I am going to save our VA witnesses a
little bit of time this morning by telling you what I do not
want to hear.
I do not want to hear the rote repetition of, and I quote,
``The department is committed to providing the highest quality
care which our veterans have earned and that they deserve. When
incidents occur, we identify, mitigate, and prevent additional
risks. Prompt reviews prevent similar events in the future and
hold those persons accountable,'' end quote.
Another thing I do not want to hear is again, and I quote
from numerous VA statements including a recent press release,
``While any adverse incident for a veteran within our care is
one too many,'' unquote, preventable deaths represent a small
fraction of the veterans who seek care from VA every year.
What our veterans have truly earned and deserve is not more
platitudes and, yes, one adverse incident is one too many.
Look, we all recognize that no medical system is infallible no
matter how high the quality standards may be. But I think we
also recognize that the VA healthcare system is unique because
it has a unique, special obligation not only to its patients,
the men and women who honorably serve our Nation in uniform,
but also the hard-working taxpayers of the United States of
America.
When errors do occur, and they seem to be occurring with
alarming frequency, what VA owes our veterans and our taxpayers
in that order is a timely, transparent, accurate, and honest
account about what mistakes happened, how those mistakes are
being fixed, and what concrete actions are being taken to
ensure accountability.
It seems to me that my staff has been asking for further
details on the deaths that occurred as a result of the delays
in care at VA medical facilities now for months. And only two
days before this hearing did VA provide any information that we
have been asking for. Even then, that information is far from
complete in what VA's effort is to prevent future deaths.
It concerns me even more than that at a briefing that VA
provided on Monday and the testimony that is provided today,
include very few details about what, if any, specific actions
have been taken to ensure accountability for 23 veterans who
lost their lives and the many more who were harmed because they
did not get the care they needed in a timely fashion.
The VA witnesses' testimony that is provided for today is
ridiculous. It answers no questions. It provides no new
information. And I am tired of begging the Department of
Veterans Affairs to answer this committee's questions.
On our first panel today, we are going to hear from a
veteran who sought care through the William Jennings Bryan Dorn
VA Medical Center in Columbia, South Carolina, a facility that
I visited earlier this year.
That veteran, Mr. Barry Coates, is going to tell us that,
and I quote, ``The gross negligence and crippling backlog
epidemic of the VA system has not only handed me a death
sentence but ruined my quality of life.''
Mr. Coates waited for almost a year and would have waited
even longer had he not personally persistently insisted on
receiving the colonoscopy that he and his doctors knew that
they needed. That same colonoscopy revealed that Mr. Coates had
stage IV colon cancer that has metastasized to his lungs and
his liver.
Maybe that is why VA does not want to define accountability
in terms of employees who have been fired. The department is
going to testify this morning that instead we should focus our
accountability efforts on correcting system deficiencies in
order to prevent adverse events from occurring again.
There is nothing wrong with fixing the system, but Mr.
Coates deserves better than that. His adverse event already has
happened and for him, there is no going back.
[The prepared statement of Chairman Jeff Miller appears in
the Appendix]
With that, I yield to the ranking member, Ms. Brown, for
her opening statement.
OPENING STATEMENT OF HON. CORRINE BROWN
Ms. Brown. Thank you, Mr. Chairman, for calling this
hearing today.
We can all agree that veteran safety and quality of care
issues at the VA health facilities are the utmost concern for
this committee. However, it is unfortunate that we must
continually call these hearings to make sure that our Nation's
veterans are receiving the care for which they have already
paid dearly for on the battlefield and in service to protecting
the freedom we all hold most dear.
I also find it disturbing that just two days before this
hearing, the VA has released findings that its healthcare
personnel are not fully trained in the importance of timely
consulting when treating a veteran.
The definition defined a consultant as the act of seeking
information or advice from someone with expertise in a
particular area. The system the VA set up to make these
consults easy obviously broke down and it is possible that at
least five veterans died in Florida because the right
information was not shared with the right health professionals.
I am concerned that in the five years after the colonoscopy
debacle in the Miami VA nothing has changed. To refresh your
memory, in 2009, staff members at a number of VA facilities
noticed improper reprocessing of episcopes contrary to the
manufacturing instructions.
The VA properly ordered all facilities to step up and get
retrained on the procedures. We want employees to feel free to
report questionable issues and procedures without fear of
retribution for trying to save lives. It seems that from the
new consultant problems that the retraining stopped at this one
procedure.
The fact sheet your office put out regarding consults talks
a lot about procedures and adverse events. However, I have
heard that before and again our veterans are suffering. And I
am looking forward to hearing the testimony today and
explanations for this lack of proper care and accountability
for these mistakes.
I yield back the balance of my time.
The Chairman. Thank you very much, Ms. Brown.
[The prepared statement of Corrine Brown appears in the
Appendix]
Joining us today for our first panel is Mr. Barry Coates.
Mr. Coates is a disabled veteran who served in the United
States Army and currently resides in the Palmetto State. As I
stated earlier, he is going to share his very personal story of
attempting to receive needed care from the Department of
Veterans Affairs.
Also on the first panel is Daniel Dellinger, national
commander of The American Legion. The commander is accompanied
by Edward Lilly, senior field officer.
Thank you all for your service both in and out of uniform.
Thank you in particular, Mr. Coates, for being here today
and for agreeing to share what I know is a very painful story.
This committee is honored to have you here before us today, and
you are recognized for your statement, Mr. Coates.
STATEMENT OF BARRY COATES
Mr. Coates. First of all, I would like to thank Chairman
Mr. Miller, Ms. Brown, and other Members of the committee for
the opportunity to be able to come in front of you today and
give you my testimony.
I would like to start, first of all, with the first part of
my paragraph of my testimony, and I think each one of you all
have that.
My name is Barry Lynne Coates. And due to the inadequate
and lack of follow-up care I received through the VA system, I
stand here before you terminally ill today.
I joined the army in February of 1991 anxious to serve my
country. Near the end of basic training, an injury to my back
derailed this plan and I was discharged around the 1st of May
of the same year.
After five years of fight to obtain service-connection
status of my injury and treatment and pain management
requirement as a result of it, I finally became eligible for
medical treatment through the VA system. That was the start of
the long, painful, emotional, and unnecessary journey that
brings me here to you today.
First of all, I appreciate the opportunity to be able to
stand here and testify in front of the committee, one for the
veterans who have died because of this unnecessary tragedy that
occurred that should not have ever occurred to start with.
Also, for the families that have lost those veterans and for
the veterans who have suffered and are still suffering because
of this like myself and their families, I want to be a voice to
them and an advocate to them.
Hopefully this testimony will prove to the VA system the
lack of knowledge or the lack of care that they gave to myself
and to other veterans that need to be changed. Something needs
to be created to change the policy of the way this is done.
I talked to numerous veterans since all this occurred and a
lot of them, I hear the same story like my story, you know, why
didn't we receive help, why didn't I get care earlier, why
didn't it get outsourced. And outsourced is probably a good
thing that needs to be put into policy if it is backed up to a
part they cannot control.
Another thing also that needs to be done for the veterans
that are struggling, for the ones that have lost their husband
or wife, it is hard to even get care and medical.
Another thing, too, to look at, if I am serving in the
military today and I look at what happened to veterans outside
of the VA system and their care and I see what is going on
there like what happened to myself and other veterans, what is
a member of the military service going to think? They are going
to think one thing. Well, they are not taking care of the
veterans outside of this. Well, one day, I will be a veteran
also. Are they going to be there to take care of myself, my
family?
And that is a big question that probably servicemen who are
serving now, they are going to ask the question, why would I
need to serve my country if they are not going to look at me
and protect me after my service and become a veteran?
And I think that is something we need to focus on because
military service is really volunteer. If you look at time and
history dating back to the Revolutionary War, it was all
voluntary. And if it had not been for that voluntary service,
we would not have what we got today in this country. And
without that, we would not be here today and be able to talk to
you all and deal with this matter.
So something needs to be done. Someone needs to be held
accountable for it. And I understand from other sources that no
one has been held accountable for it. And I think someone
should be held accountable for it, whether it be a director of
the Dorn VA Hospital or it be the secretary of the Veterans
Affairs or even the President of the United States.
Thank you.
[The prepared statement of Barry Coates appears in the
Appendix]
The Chairman. Thank you, sir, for your testimony.
And before we go to questions, I do want to ask Commander
Dellinger if he would please proceed with his statement.
You are recognized for five minutes.
STATEMENT OF DANIEL M. DELLINGER, NATIONAL COMMANDER, THE
AMERICAN LEGION, ACCOMPANIED BY EDWARD LILLY, SENIOR FIELD
SERVICE OFFICER, THE AMERICAN LEGION
Mr. Dellinger. Thank you.
As the Nation's largest wartime veteran service
organization, The American Legion dedicates significant
resources towards working with and observing the work of the
VA.
Through the Legion's System, Worth Saving medical facility
visits, Town hall meetings with veterans and the feedback we
receive from the thousands of American Legion certified Veteran
Service Officers across the Nation, we are able to provide you
with the specific details in our written testimony that you
have before you. I will highlight just a few of those details
to you now.
Chairman Miller and Members of the committee, on behalf of
the two and a half million members of The American Legion, I
want to thank you for inviting The American Legion to share our
research and position on the important topics of delay in
medical care and patient deaths.
I am here today because The American Legion has no greater
priority than ensuring that veterans receive timely and quality
healthcare as a result of their service-connected illnesses.
It seems a day cannot pass without a news report about the
problems and challenges the VA faces with delays and quality of
care issues. While we wait for things to get better, hundreds
of thousands of veterans are waiting for their initial
disability claim or appeal which prevents them from receiving
VA healthcare.
While we wait, transitioning servicemembers are falling
through the cracks due to DoD and VA's inability to create a
single interoperable medical record.
While we wait, officials in the VA central offices are
preventing hospitals from being transparent during crisis.
While we wait, veteran suicides continue to plague our Nation
at 22 per day with no clear strategy from VA on addressing
suicides proactively.
And while we wait, veterans are being over-prescribed
medications for pain, TBI, PTSD with reluctance toward looking
at complementary and alternative medicine because giving out
pills is faster than providing veterans the therapy sessions
they need.
In January, The American Legion went to Jackson,
Mississippi where a veteran died as a result of when all the
blood was drained from his body because he was not properly
monitored during a medical procedure.
When our task force members asked the facility director for
a copy of the action plan they were using to address their
problems, the director refused to give them a copy.
Last November, we visited Pittsburgh. At that time, we
believe the Legionnaire outbreak that left six dead and more
than 20 sick was due to equipment failure. The neglect on the
part of the VA to notify local health officials, veterans, and
patients was bad enough, but then later, we learned that CBS
news reported that senior officials at the Pittsburgh VA
actually knew that human error was behind the outbreak and not
equipment failures as officials had suggested to this
committee.
Our System Worth Saving Task Force went to Atlanta in
January where two veterans died of an overdose and one
committed suicide which was attributed to mismanagement and an
inability to get the mental healthcare they needed in a timely
manner.
Last night, there was a daughter that missed her dad saying
goodnight. Today there is a wife who misses her husband.
Tomorrow a father will still regret that he was able to outlive
his son because someone at the VA did not do their job.
Patient deaths are tragic. Preventable patient deaths are
unacceptable. But failure to disclose safety information or
worse, to cover up mistakes, is unforgivable and The American
Legion will not sit quietly by while some VA employees cover up
the truth and the VA should not either.
We need to continue to ask the hard questions. What is VA
doing to fix these problems and are they concerned about
keeping me informed? How is VA holding their leaders
accountable for these errors? And, finally, why is the VA
reducing inpatient long-term care beds, ICU, emergency rooms,
and closing hospitals such as Hot Springs, South Dakota?
The American Legion will not stop asking the hard questions
and we hope you won't either. The American Legion looks forward
to working with this committee as we work together with the VA
to ensure that VA provides the best healthcare anywhere.
Thank you.
[The prepared statement of Daniel M. Dellinger appears in
the Appendix]
The Chairman. Thank you, Commander.
Mr. Coates, in the more or less year that it took for you
to receive a colonoscopy through the Department of Veterans
Affairs, did anybody at any time ever tell you that you could
be authorized to receive the procedure that you needed done
through a private provider in the community enabling you to get
a diagnosis sooner?
Mr. Coates. No, sir. I never was advised during that time
period. During that time period, I seen from January of 2011
when I first complained about it till the day of my colonoscopy
which was December the 9th of 2011, I seen four different
doctors that was in the VA system.
One was Rock Hill Clinic outpatient, Dr. Verna. She was my
outpatient clinic doctor I had in Rock Hill, South Carolina. I
presently moved to the location I live now. I transferred. It
takes roughly anywhere from four to six months to get a
transfer to a different location for outpatient care which
would have been the Florence Clinic.
Upon that, I seen Dr. Verna on January, March, and I think
May of that same year and each time, my problem got worse. And
she made notes in her comments because I retrieved copies of
those from the VA. And she made note of those saying may need
colonoscopy. Never set a consult up for it.
Upon getting transferred to the Florence Clinic in June of
2011, if I remember correctly, Dr. Naumann was my clinic doctor
there. And being a new patient, he done a full exam, looked
over information from Dr. Verna prior to treating me. And he
kind of got upset because she did not have me on a certain
prescription because of taking pills for pain would cause
certain problems and that I should have been on something
already from that from being on those for quite a few years.
But he immediately set me a consult up with a GI surgeon
which I did not ever get an appointment with her until probably
either around the eighth month, maybe the ninth month, if I
remember correctly, Dr. Kim.
And upon seeing her, I seen her twice, she delayed it
another two to three months and I went back to her again around
the tenth month. We did not have a good communication ability
between each other because she kind of made me mad from my
first appointment because of things that she could have done
then that would have resulted earlier and set the consult up
for a colonoscopy earlier if she would have done a couple other
procedures other than a physical exam.
I learned that she could have done a CT exam or a CT scan.
She could have done a lithoscope exam which would have found
the tumor that was only five inches in the area, in the lower
rectum area.
After that appointment with her on the 10th, she set me up
for a consult for the colonoscopy to be done which I received
the appointment in the mail two weeks later. And it was
actually scheduled for April of the following year. We are
talking six more months out and I had already been in pain for
eight months already and suffering because of this. But I did
not let that stand in front of me, so I called the department
that scheduled that appointment and they told me that is the
normal time is usually around six months before you can get a
colonoscopy. There was nothing that she could do to get it done
earlier, that the only way you could get it done earlier is
request your physician to write the chief GI surgeon or either
the gastroenterologist to get it done sooner or you could call
each day and see if anyone dropped off from the appointment
schedule.
And I asked her could she write my name down and call me if
someone dropped off. She said she could not do that. But,
fortunately, due to the Lord's grace, she called me the next
morning at 9:30 and asked me could I come to an appointment
around 2:30 that day which I did. And then that is when I was
set up for the colonoscopy done at the Fort Jackson Military
Hospital on December the 9th.
So from January to December the 9th was a whole year.
The Chairman. One other question. Do you know what an
institutional disclosure is? Have you ever heard that term
before?
Mr. Coates. No, sir.
The Chairman. It is where VA notifies a patient when there
has been an adverse event such as a consult delay that
ultimately resulted in the failure to diagnose an issue.
So you are saying you never received an institutional
notice?
Mr. Coates. Not to my knowledge, no, sir.
The Chairman. Ms. Brown.
Ms. Brown. Thank you.
I think I will ask the first question to The American
Legion, Mr. Dellinger.
During your System Worth Saving visits outlined in your
testimony, did you encounter common themes throughout the VA
medical center and how long have you all been doing this?
Mr. Coates. We have been doing these System Worth Saving
for the last ten years.
Ms. Brown. ten years?
Mr. Coates. Yes, we have.
Ms. Brown. Yes, sir.
Mr. Coates. And we go in. We do a town hall meeting the day
before with the local veterans to learn their concerns and then
we go into the hospitals and we review their procedures and do
visit the hospital.
Ms. Brown. Since you have been doing it for ten years, and
I have been on this committee for 22, have you seen any
improvements over the last ten years in the system?
Mr. Coates. I would say yes, we have seen improvements.
There are still areas that need improving dramatically, but for
the overall system, yes.
I was actually in Salt Lake City a couple months ago and
the director, first thing she had in her hand was a water
quality test to show that she had done it. So they have started
knowing when we are coming to be prepared and they do a better
job.
Ms. Brown. Okay. Thank you very much.
Mr. Coates, let me ask you a couple of questions.
First of all, I want to thank you for your service.
Mr. Coates. Thank you, ma'am.
Ms. Brown. And you are serving today being here. And I also
want you to know that no one can determine when we are going to
leave here. That is in the hands of the Lord. And they have a
lot of new technology and equipment. And I know someone that
they released him, said that you are going to die right away
and four years later, they are still living. So we got to
continue to work to make sure you get the best treatment that
is needed.
When you were going through this process, did you ever talk
to any top officials? You were getting the runaround with the
system it seems, but did you ever try to talk to the head of
the VA at the particular hospital or anything like that?
Mr. Coates. No, ma'am, I did not, which I probably should
have been more aggressive like I was trying to get an earlier
appointment.
Ms. Brown. Uh-huh.
Mr. Coates. And not to discredit what you said, you should
not have to do that.
Ms. Brown. No, you should not. But we do not want you to be
a victim either.
Mr. Coates. No, ma'am.
Ms. Brown. Yes, sir.
Mr. Coates. No, ma'am. And nobody wants to be a victim and
no one wants to be pointing a finger, too, but I should have
but I did not. But a lot of times, you learn from hard things
you do and mistakes that you make and give that advice to other
vets and which I do.
I represent a lot of other veterans around my community and
my state that I help with VA compensation claims and also tort
claims. I help with them also and get them filed, how you file
things, how you get things started because the VA system does
not volunteer any information a lot of times. And a lot of
times, you ask questions and you ask other veterans on how you
get that.
But to answer your question fully, no, ma'am, I did not ask
anybody which I was, I guess, ignorant to that.
Ms. Brown. Let me just ask you one other question. You
indicated that maybe the VA should not farm out, but you could
go to outside--outside the system and that might be more
efficient.
Most of the times when we have testimony, let's say women
veterans, they say, well, we want to be served in the VA, but
we do not like this and that.
So do you think that we should consider maybe giving,
particularly in some areas, an opportunity to go to the
outside? I mean, I know you can, but making sure you know that
you can.
Mr. Coates. Yes, ma'am. I would say I think you should be
able to give more opportunity. I think it should be put in a
form or documentation when you are being treated, as common
knowledge, same way as the handbook, the handout. I think that
should be probably wrote in there somewhere you have options
due to the VA system or you can request outsourced services.
Presently now I have been dealing with the VA system for a
little over two years now going to the oncology department at
the Dorn VA.
Ms. Brown. Yes.
Mr. Coates. I am well satisfied with my doctor I have and I
give him credit. It is Dr. Babcock. He retired from private
practice after 30 years. And I guess he wanted to serve
veterans or either work somewhere that dealt with veterans. And
he goes three days at the Dorn VA and works there as oncology.
When I first started, I actually got him the first week he
came into the system which I think that was something the Lord
had planned all together. And he is a real good Christian man.
He said there is not a night that he does not go to bed at
night and pray for me.
But after all his works and what I have learned through the
VA system medically, they have to request and get certain
medication or certain different treatments to be done for
cancer. I asked what he is doing.
Recently I'm inquiring now after I have been there working
for two years and now from my last scan I had a couple weeks
ago spots on my lungs, liver, and a new spot has came up now in
the abdominal area that they have grown and multiplied.
And I am presently getting ready to go back on chemo in the
next week, but I am looking for outside services now. I have
acquired information now through the MSU--well, the MUSC out of
Charleston which is another cancer research. They have ability
to do--a lot more scientists to research different cancer and
be able to offer more availability to treat me a lot better
than what the VA has.
And I have applied and checked on it and hopefully I can
get payment due from the VA to be able to go to that hospital
and try something new, you know, because I am talking about my
life.
Ms. Brown. Yes.
Mr. Coates. And like you said, no one knows the exact
moment that the Lord is going to call you home.
Ms. Brown. Uh-huh.
Mr. Coates. But you also got sense enough to know that try
your best while you are here and stay as long as you can. And I
am at the process now where I am getting information together
to them so they can look at my case and see what they can do.
And it is always good to have another option because, you know,
I am talking about myself and my life and my family.
Ms. Brown. Yes.
Mr. Coates. And I am sure each one of you all here in this
room now would do the same thing if it was you in my shoe. You
would look for other things because I have been doing this for
two years now and it has worked pretty good, but I think I am
at the end of the line of where I am at now with the VA system.
Ms. Brown. Yes, sir.
Mr. Coates. And I am having to go outside of that.
Ms. Brown. Thank you.
My time is up, but let me just say I want to recommend a
couple of the hospitals in my area. I have a couple of good
ones. Shands and Mayo, they have some excellent work. So let me
yield back the balance of my time, but I will make sure I get
you that information.
Mr. Coates. Yes, ma'am.
Ms. Brown. Thank you.
Mr. Coates. Thank you.
Ms. Brown. Thank you, sir.
The Chairman. Mr. Huelskamp, you are recognized for five
minutes.
Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate the
opportunity to participate in this hearing today.
And, Mr. Coates, I would like to apologize on behalf of the
failed system that has created such pain for you. And I know
words probably do not mean much, but I mean that from the
bottom of my heart. Thank you for coming here today. This
probably was not easy.
But in your testimony, I do note you do mention four
different doctors, Dr. Verna, Dr. Naumann, Dr. Kim, and a Dr.
Sarbah.
Do you know if any of these doctors or related staff have
faced any punishment or discipline for the failures in this
situation?
Mr. Coates. Thank you for the compliment.
And as far as I know, there has not been any discipline. I
would say out of two doctors in that four I mentioned would be
one Dr. Verna. She had three occasions to set me up a consult,
January, March, and May.
Upon seeing Dr. Naumann my first time in that same year, he
immediately looked over the information, set me a consult up
with Dr. Kim, the GI surgeon, which I think he should have set
me up with probably a different department that handled the
colonoscopies. I know it is something to do with
gastroenterology department, but he should have set me up with
someone other than a GI surgeon.
But he did make effort and I give him credit for that
because he is the only one on the first initial meeting.
Dr. Kim was the GI surgeon I mentioned. She could have done
a lot better than what she did if you missed my prior
information about that as far as the procedure she could have
done on my first visit with her and delayed it further.
The last doctor was the one who actually done the
colonoscopy and he done a real good job. And he was the chief
doctor that done that and he was very sensitive to me and my
family about that. And after that, he would see me in the
hospital getting treatment and he would come up and talk to me
and ask how everything is going, you know, everything.
But now I have learned that he has left the system and they
have lost a great man from that down at the VA, at Dorn. He
called me a couple weeks before he left and he said, Barry, he
said I just want to let you know that I am leaving the system
here at the VA. He did not mention where he was going, but he
asked me how I was doing which is very fortunate, you know, for
a doctor to give a rapport like that, but----
Dr. Huelskamp. Mr. Coates, your interaction with other VA
staff other than the doctors, can you describe that and was
that simply taken up with the appointments or were there any
visits with them, any attempts to help you move through the
morass of bureaucracy and can you describe that as well for the
committee?
Mr. Coates. You are referring to appointments as far as
what, set up the consults?
Dr. Huelskamp. Well, any other staff. I mean, you have
mentioned the doctors and those that really went above and
beyond the call of duty and those that perhaps did not.
What about other staff at this center? I mean, were they
helpful? You had to fight your own way through the process? Can
you describe that a little bit more?
Mr. Coates. Well, I will say yes and no to that answer.
There were ones who were helpful, but they only had a limited
source. And the ones that was not trying to be helpful, they
really did not care. And I can say that from knowledge of a
record that I received from the VA upon the GI surgeon from
filling her notes after she learned of the result from my
colonoscopy.
I had a meeting with her that same day at 1:00 or 1:30 and
she came into the office. And that is the same woman that I had
words with on the first initial meeting. And the only thing she
could say was, Mr. Coates, I am so sorry, I did not expect
that. I looked at her and I told her, I said, see there, I told
you I was hurting. I said from now on, you need to start
listening to your veterans and doing more for them on their
first initial visit.
And that way, you know, when you can look back and say I
done the best thing I could do because I told her the same
thing, that I looked up things that she could have done and she
did not do it. And if she had done, it would have been a little
sooner. And the only thing she could say I am sorry. Well,
sorry does not change that. And nothing happened to her. No
punishment came upon her.
Learning from other surgeons in that same department, I
cannot reveal their names, but because they work in that
department and they told me that her policy changed after that
to where now if any veteran comes in that has any bleeding or
pain in the rectum area, that she immediately sets them up for
consult for the colonoscopy.
So I am thankful that, I had to be the one to suffer to get
that done, that other veterans that won't suffer now. But she
has been there. She was a seasoned doctor. And I think the lack
of her ability, not her knowledge because she had the knowledge
to know what was going on, but the lack of care it might be. I
do not really know what it was, but there was a lot of things
that she could have done more than what she did and she did not
do it.
Dr. Huelskamp. Thank you, Mr. Coates. I appreciate it.
I yield back.
The Chairman. Ms. Brownley, you are recognized for five
minutes.
Ms. Brownley. Thank you, Mr. Chairman. And I really want to
thank you for holding this hearing today. It is clearly a very
important one.
And, Mr. Coates, I want to thank you for your testimony
this morning and truly on behalf of this committee and our
Nation, I really want to apologize for the care that you
received or the care that you did not receive.
And clearly you agreed to serve our Nation and we agreed to
take care of you when you came home, and we did not hold up our
end of the bargain. And so I truly want to apologize to you.
And I am the ranking member on the Health Subcommittee here
for veterans. And when I learned of this, I actually wrote a
letter to Dr. Benishek who chairs the Subcommittee on Health
and was very obviously saddened by what I had learned about
nineteen preventable deaths.
And I even question nineteen preventable deaths. I mean,
really, nineteen? I am sure I believe in my heart of hearts
that there are probably more than nineteen, but nineteen that
we know about.
So I am, you know, very, very grateful that we are having
this hearing today and it is incumbent on all of us here to
make sure that the VA is held accountable for what has happened
and is accountable to you, Mr. Coates, and to the other men and
women who have served our country and who have not received the
proper care.
I just wanted to ask you, we have already asked a lot of
questions around this, but during the time that you have gone
through, were you aware of any recourse that you could take or
did anyone suggest to you that there is someone in the VA that
you could reach out to, a patient advocate, anything like that
during the course of these delays?
Mr. Coates. No, ma'am.
Ms. Brownley. And I know that you mentioned just in your
last answer that Dr. Kim ultimately apologized to you for her
lack of diagnosis and care.
But have you had any formal apology from the VA?
Mr. Coates. None.
Ms. Brownley. And in your experience, again, how would you
describe, I guess I want to say sort of the bedside manner in
terms of how you were treated? Clearly there were these delays,
but did you experience from any VA employees or doctors that
you encountered any sensitivity or concern about your
frustration?
Mr. Coates. Yes and no answer to that. No to a couple of
the physicians that I had and yes to a couple of physicians
that I had. I mentioned, I think, briefly those ones that I
mentioned. The lack of concern, I look at this way, and I have
been going to the VA for quite a few years now since early
1990s, same hospital, and you see a lot of different things
going there from different physicians and things like that.
You got physicians that care about people and you got
physicians that look at it as just a job to do. You got nurses
and other officials there that look at it the same way. You got
some that cares for the veteran themself and enjoy what they
do. And then you got some that does it for a job.
And I think that is what happened to a lot of people in
America today. They do not look at the honor of having
something and appreciate it anymore. I am not saying that
anybody does not, but a lot of people do not. They come and go
to work and go home. They want it for one thing and one thing
only and they do it for their self.
And I think if everybody worked together and do something
for each other like it is supposed to and originally was set
up, then we would probably be a lot greater Nation today.
Ms. Brownley. Thank you, Mr. Coates. And, again, I thank
you for your testimony today and it means a great deal. And I
hope that through your testimony today, it will pave the way
for other men and women who serve our country, that they will
not be treated as you were through this process. So I am very
grateful to you. Thank you very much.
Mr. Coates. Thank you, ma'am.
Ms. Brownley. I yield back, Mr. Chair.
The Chairman. The gentle lady yields back.
Mr. Cook, you are now recognized for five minutes.
Mr. Cook. Thank you, Mr. Chair.
Mr. Coates, thank you very much to come here. I know this
is tough on you and your family and everything like this.
Last year, I lost my sister with colon cancer and it is
horrible for the family and everything else. She was much older
than you are.
Can I ask how old you are, sir?
Mr. Coates. Forty-four.
Mr. Cook. You do not have to tell me.
Mr. Coates. Forty-four years young.
Mr. Cook. Okay. And obviously you are expected to live much
longer and that is why this is so tragic.
I want to ask the commander, you know, Commander, you said
that you think the VA has improved in certain areas, but the
culture of the VA in terms of taking care of patients like Mr.
Coates, it seems as though that is lacking.
And do you share my concern about the culture, quite
frankly, taking care of our veterans, taking care of the troops
and that?
And I am not trying to preach here and everything, but, you
know, I spent a long time in the military. We have all had
stories when people that where a grenade was thrown in there,
somebody would land on a grenade, get killed, and save five,
six people for the unit or going out on a battlefield and
somebody was wounded and take them back under fire.
And we have all heard these horror stories and very, very
frustrating. And it seems as though the culture of the VA is
such that there is not a sense of urgency or, hey, we have got
to take care of this veteran. You know, this is general orders.
And if you could just comment. And maybe it is just me, but
I have reached the breaking point on this where, you know,
excuse after excuse after excuse after excuse.
The gentlewoman from Texas talked about, I believe, or
Julia talked about we expect more for somebody that has signed
up to do their duty, the veterans, and return. That is what
they are there for. That is their mission.
So I finally got around to my question. Sorry.
Mr. Coates. That is all right.
You know, it is continuity. As I go around the country
visiting these hospitals, you can tell the ones that are the
caring ones just as Mr. Coates stated. You know, you have where
they are there really for the patients and others are there to
get a paycheck. And that is the difference.
And I think it comes from the top down. VA needs to be
accountable from the top down through the secretary, through
the under secretary, all the way down to the directors and to
the chief of staff. I have seen some great chiefs of staffs and
other ones that are just there biding their time until they
retire.
Mr. Cook. You know, this is probably the most bipartisan
committee, I think, in Congress. And I chaired the Veterans
Committee in California and it was very bipartisan. And I do
not think it is a democrat or republican. I really, really
think it is culture that is not ingrained. You know, all talk
is cheap.
But in terms of actually talking about the suicides, we
talked about all these, and we go on and on and on, and it is
like business as usual and we cannot tolerate that. And maybe,
you know, maybe we do have to fire people, but we certainly
should not give them merit increases and all those things that
go along with it, particularly in the IG investigations and
everything else.
If somebody is not doing what they are supposed to do in
terms of, as I said earlier, taking care of our veterans, not
just on the battlefield, but after they come back, then
somebody deserves to be replaced or fired and have somebody in
there that understands that is the primary mandate.
If you could comment briefly. I know we have a lot of----
Mr. Coates. I agree. I mean, just as in the military, you
disobey an order, you get court-martialed.
Mr. Cook. That is right.
Mr. Coates. Here we have seen instances where there have
been some reprimands, but they are still on the job.
Mr. Cook. That is right.
Mr. Coates. And others are allowed to resign and then there
is nothing. There is no----
Mr. Cook. That is right. You have a rank structure, but
that rank structure, your primary responsibility is to take
care of everyone under you. And if you do not, that is why you
are the first one out the helicopter if you are in command. You
are going to get drilled. That is just the way it is and I am
afraid that it is not carried over.
The Chairman. Thank you much, Mr. Cook.
Mr. O'Rourke, you are recognized for five minutes.
Mr. O'Rourke. Thank you, Mr. Chair.
And for Mr. Coates, your testimony and the answers to the
questions posed so far has been so powerful, so clear, so
honest, really the questions that are left that I have are
really for the VA, for ourselves, for this committee, for this
country.
What are we going to do now that we know the consequences
of lack of access, delay, and ultimately denial really is what
we are talking about in care and lack of accountability?
So I just will use my time to personally and on behalf of
the veterans that I have the honor of representing in El Paso
thank you for your service, for your courage, for your
testimony, and being here today and focusing our attention on
something that we desperately need to fix. So thank you very
much.
Mr. Chair, I yield back.
The Chairman. Thank you very much.
Ms. Walorski, you are recognized for five minutes.
Mrs. Walorski. Thank you, Mr. Chairman.
And, Mr. Coates, I sit here and I think you are an example
of the finest America has to offer. And it seems so petty to
sit here and apologize on behalf of a bureaucratic system that
is broken, but I do apologize. I am so sorry to you and your
family sitting here of what you have gone through and that you
are going to have to stand and be an advocate for the rest of
these veterans.
And I promised my veterans in my district when I ran for
Congress that they answered the call, they did what this Nation
asked them to do, and it was my turn to fight for them. That is
what we do on this committee. We fight for the right of
veterans to get the benefits they were promised, to be treated
with the best care.
I sit here as a freshman lawmaker so frustrated that there
is a bureaucracy that is out of control. And if this happened
in the civilian world where negligence was proven time and time
again, we would be in the streets with signs saying shut them
down. It is an outrage is what it is. This is an outrage.
And so I just join the rest of my colleagues here. This is
not a partisan issue. This is an American disaster that we have
sat here and witnessed for me probably 16 months. And if I
could change your circumstance, I would. I would do it in a
heartbeat.
Mr. Coates. Thank you.
Mrs. Walorski. My dad was a veteran that died of colon
cancer. This is so personal to me. And as a committee, I can
tell you right now what the VA is going to say when they sit
here. They are going to say what the chairman read in his
opening remarks. They are going to give us long dramatic
answers and nothing is going to change unless we in this
Congress on the House and the Senate side decide to stand up
and take on one of the biggest issues in this Nation which is
this negligence toward taking care of the people that fight for
freedom, fought for liberty, and allow us to sit and serve in a
place called the U.S. Congress.
And I just want to say today I hope that your testimony, I
hope that your advocacy, and the truth of what you are saying
changes the culture. It has changed the culture in this room. I
can tell you that. But my prayer is for you and your family----
Mr. Coates. Thank you.
Mrs. Walorski [continuing]. And that together we can stand
and change the culture in this country and say that today was a
different day in the history of this VA. I do not know how they
sleep at night, I really do not. But I can tell you that we are
your brothers and sisters to stand and fight for you in every
way that we possibly can.
Mr. Coates. Appreciate it. Thank you.
Mrs. Walorski. And to The American Legion, sir, you guys
come in here faithfully every single time there are hearings,
you and the many other advocacy organizations for the VA and
for our veterans, and I just want to commend you for
consistently coming, consistently telling the story,
consistently being eyes and ears for all of us that have
decisions to make and hopefully can improve a failed system. I
so much appreciate what you do in your world and standing
consistently for veterans.
But, you know, this is so personal to me today because I
had to advocate for my dad and I could and I did. And we did
everything we could possibly do all the way down to the wire.
And that is what I am going to do for you, Mr. Coates, and for
the veterans in my district. I am going to stand here and
continue to fight every day until we change a broken system.
So God bless you.
Mr. Coates. Thank you.
Mrs. Walorski. And together, let's change this system so no
other veteran ever, ever has to do what you are going through
and your family as well. And you are in our thoughts and
prayers. We will stand with you through this as you continue to
go through this process. But God bless you for being here
today.
Mr. Coates. Thank you, ma'am.
The Chairman. The gentle lady yields back her time.
Dr. Ruiz, you are recognized.
Dr. Ruiz. Thank you very much, Mr. Chairman.
First, Mr. Coates, I apologize again for the missed
diagnoses that occurred in your case. Thank you for your
strength. Thank you for your honor, your dignity. Thank you for
being a voice for all those other missed diagnoses that has
occurred.
I am an emergency medicine doctor, and I see here that the
ER doc recommended a colonoscopy. That was the right thing to
do. It is unacceptable, and as someone who pursues excellence
in medical care, it is very infuriating to know that a
gentleman who comes in with rectal bleeding at any point did
not have a rectal exam or an endoscopy or any other diagnostic
study that would have detected your rectal nodules.
I think that what we need to do now and, you know, I look
at my colleagues, Mr. Cook and Ms. Walorski, and I thank you
for your passion and I am sorry to hear about your father as
well. And Mr. Cook, I can only imagine your memories of those
soldiers who have given up themselves and their lives to
protect others and I thank you for your service. It is very
strong, coming from the heart.
And I believe this to my--I say this to my colleagues, is
that in this individual case we have missed a diagnoses and I
hope that our committee does not miss the diagnoses that we
must pursue in order to remedy this, to determine
systematically whether or not we have more medical errors, more
complaints from patient care and more litigations that were
found successful to the VA versus any private healthcare system
that we would consider the gold standard because we not only
expect the gold standard, we expect our VA system to be beyond
the gold standard because our veterans are beyond the gold
standards of our citizenry in our country.
And so if there is a study or if there is a commission that
we would be able to start as a committee to compare and
contrast, to determine if there is a systematic increase of
maltreatment, misdiagnoses, then I would be very much inclined
to look at that diagnoses and take adequate treatment because
we missed a diagnosis in this individual case. I want to make
sure that the rectal nodule and cancer of our VA system gets
removed as well.
Thank you. I yield back my time.
The Chairman. The gentleman yields back.
Mr. Bilirakis, you are recognized for five minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it so
very much. And sir, thank you very much for your service. You
are an extraordinary individual. Thank you for coming today and
sharing your story.
I wanted to ask, sir, the VA has an ethical and legal
obligation to disclose to patients adverse or potentially
harmful events that have been sustained in the course of the
patient's VA care. I know the gentle lady touched on this and I
want to ask once again, sir, were you notified and informed of
your rights and recourse?
Mr. Coates. To my knowledge, no, sir.
Mr. Bilirakis. Say that again, sir. I am sorry.
Mr. Coates. To my knowledge, no, sir.
Mr. Bilirakis. No, sir, okay. And I know in your statement,
in your testimony you may have mentioned this in your opening
statement, and forgive me, I was a little late for the meeting,
but you state and I quote, ``The gross negligence of my ongoing
problems and crippling backlog epidemic of the VA medical
system has not only handed me a death sentence, but ruined by
quality of life.''
That is simply heartbreaking to hear. So would you like to
elaborate some more? I want to give you the opportunity to, if
you will.
Mr. Coates. As far as ruining the quality of my life?
Mr. Bilirakis. Quality of life, yes.
Mr. Coates. Yes, sir. Thank you for the opportunity. Yes,
it has dampered my quality of life to a great deal. Other than
what I mentioned earlier about still having to go on with the
chemo treatments and for now over two years now, and looking
for other avenues but, you know, I have other family members
other than myself to look at and like any one of us here, you
know, you have children and you have grandchildren. I have
children and I have grandchildren.
The question is, and you don't never know how much longer
you have. You better enjoy them and them enjoy you. You take
one day at a time. That is my philosophy. You live every day as
it is going to be your last day. And once you do that, then the
next day will come and you start again and you live that like
it is your last day.
And this has dampered a lot of what I can do, a lot of
enjoyment. You know, I am 44 years old. I will be 45 in May of
this year, but I am fairly young and a lot of things I can't
do. I can't get out and enjoy playing with my grandchildren. I
can't enjoy doing things that I could as a normal 45-year-old
man.
A lot of things has been taken from me because of that. I
wanted to do things as far as--an example, if I want to get out
there and play baseball with my grandchildren and do running or
anything, I am not capable of doing that. I can't lift but so
much weight because I have a ostomy from that.
If I decided I wanted to--at my age, you know, you probably
look at me and say I am crazy--if I want to have another child,
I can't do that now. That option there is gone. And there are a
lot of other things that, you know, I enjoy doing that I use to
do that I can't do now, and it has affected my life a lot and
my family's life a lot and now I look at what my children and
my grandchildren look at me and they probably look and think,
well, why can't my--why doesn't my dad, can't enjoy himself.
And my grandchildren say, well, why can't you come out and play
with me and do things like the other dads or other granddads do
with them. And so that is something I am going to have to live
with and deal with the rest of my life and hopefully my being
here today, that maybe I am saving another father or another
mother from having to go through the same tragedy that I went
through and have a better quality of life for doing it.
Mr. Bilirakis. I will tell you, sir, you are a tremendous
role model for those children and grandchildren. I know they
are very proud of you.
I have one question for Mr. Dellinger, if I may, Mr.
Chairman.
I understand from your written testimony that The American
Legion has been waiting for five months to receive a report
from VA regarding the Jackson VA Medical Center. Is it common
for your organization to experience lengthy wait times to get
information from the Department?
Mr. Coates. Yes, we do see lengthy delays with the fact
that everything is centralized in Washington, D.C. They try to
do everything out of Washington. We think it is very important
that they empower the medical centers and the directors to be
able to address crisis in a timely and quick manner.
Mr. Bilirakis. Thank you very much. We got to do something
about that, Mr. Chairman.
Thank you very much for your testimony and I appreciate it.
I yield back the balance of my time.
The Chairman. Ms. Negrete-McLeod, you are recognized for
five minutes.
Dr. Benishek has not returned.
Mr. Coffman, you are recognized for five minutes.
Mr. Coffman. Mr. Coates, thank you so much for your service
to our country. Which branch were you in again?
Mr. Coates. Army.
Mr. Coffman. Fantastic. And again, on behalf of the
American people, I certainly apologize as so many other members
of this committee have to you for the treatment that you got
from the VA system. Let me ask you this question. Do you think,
if you were given an option to be able to go outside the VA
system and have it compensated through the VA for medical care,
would you have taken that option?
Mr. Coates. Knowing what I know now, yes, I would.
Mr. Coffman. Do you think other veterans ought to have that
option that if there are such delays in the system, if they are
unable to do proper diagnosis and something as simple as blood
in the stools, that veterans ought to have choices?
Mr. Coates. Yes, sir, I think they should and the reason
for that is, if you get in a situation like that when you
approach somebody's health and their quality of life or life or
death situation, and even under civilian medicals, you have a
choice of what doctor you want to go to. And under the VA
system, I think you should have the same opportunity there,
what health care you want to use, what physician you want to
use, what specialty physicians you want to use. And especially
when you get in a situation where you have a backlog like there
was and the bad and the sad part of it and I think this comes
from Mr. Miller, I remember hearing, I think there was money
allotted to the VA system at Dorn back in 2011 and it was
misused.
The Chairman. It was over a million dollars.
Mr. Coates. Correct. And no one has asked for that yet. I
don't know where it went. They say it was misappropriated.
Well, what happened to it and who is responsible for that? Why
didn't it go where it went? We can't answer that, but we can
find out why and make sure it doesn't happen again.
Second of all, that was to help the backlog of those
patients and the sad part of it is that was during the time I
was going through that in 2011.
The Chairman. Let me ask you this. The reality is you are
the victim of the system that did not care as much as they
should have about their patients. Do you think that culture or
that system exists because of the fact that they don't see
themselves competing, that you are their only choice, that they
don't see themselves competing with anybody else, so that if
you had an option to go outside the system and they would have
to pay for that and that was your freedom to make that
decision, do you think that they would have handled your case
any differently?
Mr. Coates. I think they probably would have. Any time it
comes down to--and I am not the only one who probably knows
this and anybody across America has known this--when it comes
to spending government money, there are a lot of things that
they like to spend it on and there are a lot of things that
they pinch pennies about. If it is for national defense and it
needs to be done, why, they jump on it. If it something saving
somebody's life, they get in a big debate about it, why does it
need to be spent, where does it need to be spent at, and we
have run across this and here recently in the past year,
debates in the House and debates in the Senate, the debt
ceiling being raised and allocated money for where it goes.
But reality and you look into it, and you look at what we
spend for different small items and you can probably request
this information from somewhere, and I have heard this from
other sources, what we pay for little small things like a
hammer, a toilet seat, you know, $150, $350, when you can go to
anywhere and buy it for $10, $12, we spend money where we think
it needs to be at and where it not needs to go.
And the sad part of it is, we don't get choices like that
of knowing where it goes and where it doesn't go. There are the
people who have the authority to rest upon where it goes at.
Mr. Coffman. Well, Mr. Coates, I again am sorry about your
advanced rectal cancer as a result of substandard medical care
by the VA, and I just want to say that they have received, the
system has received a higher appropriation every single year.
And so it is the question of how that money is utilized.
And with that, Mr. Chairman, I yield back.
The Chairman. I have a bunch of questions, but I am not
going to ask them. You have given of your time today. Your
story is more than compelling. I, like the other members of
this panel, want to say thank you for your service in and out
of uniform.
Ms. Brown. Thank you. My question is really for the
commander. My question is, you know, I have been on this
committee for 22 years as I have mentioned and you have been
here, well, I believe, almost as long as--more than ten years.
But my question, some of the members say that the VA system is
broken. I don't feel like it is broken. I feel like we need to
do what we need to do to fix it.
But I have traveled to, I can't tell you how many
hospitals. I was in one that's going to be one soon yesterday,
all day. But the point is, my feeling is that the VA people
that I met with and talked to, I think they really care and it
can't be just my district. It can't be just those areas in
Florida or Tampa that I have been to or Jacksonville or
Gainesville or Lake City. I mean, I have been to California
and, you know, I have met with the people there and when I went
out there I found out we had 400 units that just was sitting
there and people could be using them.
So the point is, on a one to ten, if you are going to
evaluate the system, and I know we got problems. We are sitting
here listening to the problems and I really think we need to be
able to go outside the system to get certain services.
How would you evaluate the system?
Mr. Coates. It is a great question. I really believe I need
to break that into two aspects. First, being the medical care
that you receive at the medical centers and at the community-
based outreach clinics. I think that is an eight to a nine
because as you mentioned, they really do care. They really want
to help.
But what I think is broken is when you talk about the
oversight and the works of the VA central offices and regional
offices, I would rate that at about a five. They need a lot of
improvement. Where we see most of our problems are at the
regional and the central offices, not at the medical facilities
themselves.
Yes, there are instances just like Mr. Coates, but the
overall system there, I think they are wanting to do better and
just as a director tried to do, you know, wherever you see
blood at this point, you get a colonoscopy. They are addressing
these.
Ms. Brown. That is common sense.
Mr. Coates. It is common sense. But when you have a failure
at the--just like during the Legionella in Pittsburgh when they
had a statement ready to go out and they had to send it back to
Central Office so that they would evaluate the statement. It
never got released. It is such a bureaucracy.
Ms. Brown. Okay. So you are saying the part of the problem
with the culture is that it is too--you don't have enough
responsibility on the regional level?
Mr. Coates. I think regional, central area, yes, across the
area.
Ms. Brown. Okay. Okay. But I really find that this, you
know, maybe in this particular case, the person, it could have
been cultural differences as far as--I mean I just can't
imagine somebody not caring. I mean, I serve on this committee
because I care. And I think the people working in the VA, to
just say that they work for a check is way beyond me because
these people have served us, and what we are doing is giving
back. This is the other opportunity to serve.
Mr. Coates. Ms. Brown, I have with me Field Service Officer
Lilly and he is out there every day. He goes to the System
Worth Saving, he goes to the regional and central offices. I
would like for him to make a comment on this also.
Ms. Brown. Thank you. Thank you.
Mr. Lilly. Thank you, Commander, and thank you, Ms. Brown.
I wanted to comment on what you said earlier about employees
coming forward and trying to address the problem before it
escalates and I completely agree with you there because what
happens is there is this negative stigma of whistleblowers.
That is what those employees become or they are former
employees.
So the local facilities on the local level need to be
empowered to address crises when they happen, and that is not
how it is right now and that is what our commander was
referring to when he was saying that it takes a long time for
these facilities to address what has happened because they have
to get approval from Washington, DC. And that is what we have
seen in Pittsburgh, Jackson, Atlanta, all these different
trips.
The veterans are scared. They are nervous. They are afraid
to go to their own healthcare system because they just don't
know what steps the VA is taking to address the issue.
Ms. Brown. Well, thank you very much, and thanks again,
thank all of you for your service.
Thank you, Mr. Chairman.
The Chairman. Thank you, Ms. Brown. Thank you, Members, for
holding your questions until the next panel.
And thank you very much, Mr. Coates, for being here.
Commander, thank you and you are excused.
Members, we are going to switch up the witnesses and we
will take VA next instead of waiting until the third panel, so
we will be preparing the table for the second panel.
Members, joining us at the second panel is Dr. Thomas
Lynch. He is the Assistant Deputy Under Secretary for Health
for Clinical Operations and Management.
Dr. Lynch is accompanied this morning by Dr. Carolyn
Clancy. She is the Assistant Deputy Under Secretary for
Quality, Safety and Value.
Dr. Lynch, you are recognized for your testimony.
STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER
SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY CAROLYN M. CLANCY, M.D., ASSISTANT DEPUTY UNDER
SECRETARY FOR QUALITY, SAFETY, AND VALUE, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF THOMAS LYNCH
Dr. Lynch. Mr. Chairman, let me begin by saying that we
have heard a compelling story. I need to recognize the fact
that what we have heard is a sad story.
Before I walked up here, I apologized to Mr. Coates. I told
him that I am sorry for what happened. If he did not receive an
institutional disclosure, I initiated that by extending my
apology on behalf of VHA.
I also commit that we will look into what happened so that
we can understand and he can get a better explanation and the
explanation that he deserves.
I was looking around. It appears that he has left the room.
I did and I want to publicly thank him for his service. I want
to thank him for reminding us of what we are here for and for
the people that we are serving through VHA and our healthcare
system.
I am going to go pretty much off script. I want to let you
know that Dr. Clancy and I are here because I think we share a
common value with you, sir, and with the committee, and that
value is to provide quality care to our veterans.
I would also suggest that we are here because we share
common concerns and those are concerns regarding harm that has
occurred to veterans in our healthcare system.
I think it is good that we hear these stories, that we not
ignore when harm has occurred. They are powerful. We need to
learn from them and we need to do better.
I think also I would like to acknowledge publicly that I
think the relationship between VA and Congress has been a
constructive relationship in the past. I think many good things
have occurred in VHA healthcare because of the concerns you
have expressed and because of the actions we have taken.
In the late 1980s there were significant concerns about the
quality of surgical care in the VA. The VA developed what was
then called NSQIP, the National Surgical Quality Improvement
Program. It is now called VASQIP. It gives us a risk adjusted
model to assess outcomes in our surgical programs.
It is so powerful, it has been adopted by the American
College of Surgeons. It is now used to provide oversight and
evidence to healthcare systems and to physicians to allow them
to improve the services that they provide.
In the mid-1990s, there were concerns expressed on behalf
of Congress regarding the quality of our healthcare system. In
response, the VA developed the electronic medical record. This
is an advance that has now been adopted by the private sector.
The VA has also moved towards looking at the way we deliver
care and how we focus care with respect to prevention;
preventing illness, not necessarily treating illness. This
means that we don't necessarily have to put people into
hospitals. We can treat them as outpatients. It is a model that
is now being adopted in the private sector.
I want to go back and make one point from what had been my
prepared statement, Mr. Chairman, and that is that over a third
of our employees are veterans and the fact that everyone in VA
is constantly striving to eliminate the clinical and
administrative errors that may occur.
We strive, sir, to be transparent in disclosing what has
happened. As a system, we have taken a lead in being
transparent, we have taken a lead in clinical disclosure. We
are not perfect, sir. We are a learning organization.
When errors occur, we do try to express apologies to the
involved patients and to their families. I think I will close
with a statement from Ralph Gabarro. He is the former CEO of
the Mayo Regional Hospital in Dover-Foxcroft, Maine. I think he
has said it best, sir.
To paraphrase, preventable patient deaths are a nightmare
for our entire medical community, but our feelings, what we are
going through, pales in relationship to what the families are
dealing with and we understand that, sir.
We are now prepared to take your questions.
[The prepared statement of Thomas Lynch appears in the
Appendix]
The Chairman. Thank you, Dr. Lynch. Your recent National
Consult Delay Review disclosed two deaths in Arizona, but
committee investigation show that it appears that it could be
much worse than you know or if you do know that it is worse
than what the committee has been told, so I want to tell you
about some information that we have received here in the
committee as it relates to Phoenix.
I have been made aware of internal emails from within the
VA that suggest that Phoenix VA may have been using an
unofficial electronic waiting list where veterans were placed
on that unofficial list until an appointment became available.
These lists were supposedly designed to give the appearance
that veterans were only waiting for appointments for 24, 25
days or less and they potentially contain thousands of names.
In cross referencing the two lists, it appears as though there
could be as many as forty veterans whose deaths could be
related to delays in care.
Were you made aware of these unofficial lists in any part
of your look back?
Dr. Lynch. Mr. Chairman, I was not. And Mr. Chairman, I
would say that I have tried to work with your committee. I have
visited with your staff. I was in Atlanta. I was in Columbia. I
was in Augusta when you made those visits. I have tried to
share the information that we have gained as we are obtaining
it. I know it is not perfect information, sir, but I know there
is a desire on your part to know that information as we obtain
it.
I am more than willing to meet with your staffers and take
their information so that I can use it, sir. If I don't have
that information, I can't act on it.
The Chairman. So your people had two lists and they kept it
from your knowledge. So my question is, does that make you even
internally question the validity of the information being
utilized in your look back or your review?
Dr. Lynch. At the moment, sir, it does not, but I am open,
I am happy to meet with your staffers, I am happy to look at
the data so that we can understand it and see what the issues
and the problems are.
The Chairman. I want to provide you with a request for a
preservation order for all potential evidence at Phoenix VAMC
and I would also ask the Inspector General for Health care, Mr.
Daigh, to look into this issue as soon as possible. I will be
putting a letter to you quickly, but I make this as an official
request on the record and we are ready to assist by providing
our evidence and any assistance that Dr. Daigh may need as he
goes forward.
It has been mentioned a couple of times in here about Dorn
being awarded a little over a million, 1.02 million or some
number like that to help in the backlog of fee-basis
colonoscopies and money was provided in September of 2011. I
have still not been able to get a solid answer where that money
went, so I am hoping that you might be able to provide an
insight this afternoon.
Dr. Lynch. Mr. Chairman, I know that that information has
passed through VHA. I took the opportunity to listen to the
Deputy Secretary's hearing the other day. I know he has
committed to increasing the communication with Congress and
with this committee, and I support his efforts and will do what
I can to get you the information that you need, sir.
The Chairman. So, again, another piece of information the
committee awaits. I specifically asked for a complete
accounting of those dollars when I was at Dorn earlier this
year.
On the 22nd of February in a Health Committee hearing, Dr.
Benishek asked Dr. Petzel to provide a list of circumstances
surrounding the removal of six SES employees over the last two
years. Dr. Petzel promised at that hearing that he would
provide that information at the end of that week.
This is April 9th. It has been six weeks since the
committee asked for the information. We have not received it.
This information was referenced in a subcommittee on economic
opportunity hearing that was chaired by Mr. Flores and, by the
way, Mr. Flores is absent today because he is at the memorial
for Fort Hood Texas, and the committee staff has made numerous
requests.
So I would also note that this statistic was also noted in
your written statement for this hearing. So why is VA keeping
this information from the committee when it was an entirely
reasonable request?
Dr. Lynch. Sir, I wish I had an answer for you that you
would find acceptable. I could only repeat that I support the
Deputy Secretary's efforts to get you the information.
The Chairman. I have a bill right now, Dr. Lynch, that
gives the secretary additional flexibility to fire SES
employees. Out of the 320,000 employees at the Department of
Veterans Affairs, we are only talking about 450 individuals.
The secretary is pushing back saying that he has the tools and
that he has, in fact, taken the necessary steps and we are
talking about six people and we have been waiting months now to
get that information, and I just--as the chairman and
subcommittee chairman and the ranking members sit here just
wondering why in the world it takes so long.
In January, following my visit to Columbia and Augusta,
which you were at, to follow up on the delays in care, I wrote
a letter to the secretary asking for specific information
regarding consult backlogs at those facilities and others in
general. And though I requested a response be provided within
thirty days, I have yet to receive a response, an answer from
the department, so I ask you again, as somebody who should be
intimately involved in the preparation of the secretary's
response, when can the committee expect to receive that
information?
Dr. Lynch. I don't want to sound like a broken record, sir.
I realize that you take this seriously. I realize that your
committee takes the responsibility seriously, and I accept the
fact that there can be a constructive relationship between the
committee and the VA, and I hope to be part of that solution,
sir, and not the problem.
The Chairman. Ms. Brownley, you are recognized.
Ms. Brownley. Thank you, Mr. Chair. And I wanted to ask, I
know we skipped over a panel, but I wanted to refer back to
some of the testimony that I reviewed from Dr. Daigh who spoke
specifically around the problems in Columbia, around the
consult backlog, and one of the indications that he gave was
the availability of fee-based care, that it had been reduced.
I wanted to just hear your comments on that and why fee-
based care was reduced in Columbia.
Dr. Lynch. I don't have the full explanation for that,
Congresswoman. I believe the facility felt at the time they had
the resources to solve the problem. In retrospect, they did
not. I think, however, Congresswoman, that in the process of
looking back over what happened, we have developed a tool that
gives the facility, that gives the network and it gives VA
Central Office eyes on delays and helps us ask critical
questions of a facility in terms of should they be using fee-
basis care.
We have improved our fee-basis process. We have implemented
the PC3 process which helps us interact with the community to
obtain services. I think we have the ability to identify where
our demand exceeds our capacity, to understand why that may be
occurring, and as we move forward, to effectively use fee
basis.
Ms. Brownley. Thank you. And this tool that you are
speaking of, can you give me some more details about what that
is? What triggers you to begin to look at it? How long do the
backlogs have to be before you begin to put your eyes on the
problem and try to rectify it?
Dr. Lynch. I think, first of all, the answer is that it is
individualized, but let me explain the tool to you. As we began
to look back at our consults after the incidents in Columbia
and Augusta, we observed that there were flaws in our consult
process that allowed consults to remain open or unresolved.
That put noise in our system and it prevented us from
trying to identify those facilities where there was need for an
alternative, such as fee-basis care.
Over the past year, after the incidents in Columbia and
Dorm, we went back. We examined over 250 million consults since
1999 in VA. We identified where there were delays. We had to
resolve those consults and make sure that they were closed
appropriately and that services were provided. And in the
process of doing that, we implemented new business rules that
helped us separate our clinical consults from what had become
some administrative uses of that consult system.
We are in the process of completing that review. It should
be completed in the next month or two. With that and with new
business rules, we will have the ability to look at a facility,
to look at individual specialties within a facility, to take a
look at trends in delays and to ask critical questions; whether
the facility has the resources to address those delays, whether
the facility thinks those delays are temporary, transient, or
whether the trend is an indication of increasing delays, and to
then work with the facility to decide do we need to add more
staff or do we need to use fee-basis services.
Ms. Brownley. Thank you. Are you collecting any data as we
speak, looking ahead--we talked a lot about looking to the past
and what needs to be done for the future--but looking ahead,
are you collecting data and benchmarks vis-a-vis consult
backlogs throughout the VA. Obviously, we have determined there
was some VISNs, there have been some real problems, but are we
going to collect that data to understand the data that data
gets shared with the committee and where are the trigger points
that we can make an immediate fix to what potentially could be
a very, very serious problem.
Dr. Lynch. I think the answer to that is yes,
Congresswoman. In fact, about six months ago, using some
initial data that we were beginning to collect, we sent over a
$100 million out to the field for facilities to use to contract
for fee-basis services. We reduced the wait time, the backlog
at that point, by almost 50 percent or 50,000 patients.
So we have begun to use that tool. I think we can also
begin to use that tool to look at what I think is the critical
issue when we look at access, and that is delayed care. We
focus on fourteen day access, but really, importantly, we need
to look at where care is delayed. And we can set the filters on
this system to look at delays at variable lengths of time, and
as we get control of the system, slowly reduce backlog from
ninety days to sixty days to thirty days based on the
information that we will get.
Ms. Brownley. Thank you. I yield back.
The Chairman. Mr. Huelskamp, you are recognized for five
minutes.
Dr. Huelskamp. Thank you, Mr. Chairman. Just a couple of
follow questions if I might. First, in reference to our
previous speaker, Mr. Coates, are you familiar with the
specifics of his situation?
Dr. Lynch. I have not reviewed the specifics of his
situation. I assure you, I will.
Dr. Huelskamp. And Dr. Clancy, have you any familiarity
with this situation?
Ms. Clancy. Not before what I heard this morning. Not
before what I heard this morning.
Dr. Huelskamp. Okay. I would ask if you could also follow
up on the situation in prior discussions with Mr. Coates that
currently VA is requiring him to drive almost four hours for
some follow-up treatments instead of being able to receive it
right close to home. Would you please follow up on that and see
if that is indeed that case?
Ms. Clancy. Absolutely.
Dr. Huelskamp. Okay. Additionally, I would like to ask a
couple of questions of Dr. Lynch. What specific person at the
VA Medical Center level is responsible for ensuring timely care
is delivered to veterans?
Dr. Lynch. Ultimately, it is the Medical Center director,
sir, working with his quadrad, the director, the chief of
staff, the chief of nursing and the associate director who
often deals with engineering and environment of care.
Dr. Huelskamp. And what specific person or position at the
VISN is responsible for ensuring timely care?
Dr. Lynch. Ultimately, it is the network director, sir. He
or she works with the chief medical officer and with the
quality medical officer.
Dr. Huelskamp. And then at the VA Central Office level, who
is responsible for timely care?
Dr. Lynch. Ultimately, that would go to the office of the
deputy under-secretary for operations and management and to Dr.
Petzel.
Dr. Huelskamp. And out of the people in positions you have
just named and anywhere from twenty to forty deaths by delay of
veterans, do you know if anybody at all has received any
disciplinary action whatsoever?
Dr. Lynch. I believe that Dr. Petzel discussed disciplinary
action the last time he was here. I believe we have identified
two physicians in Memphis, which is another issue, where there
was discipline. There was discipline in Augusta, as well as
Columbia, and there was discipline in Atlanta.
Dr. Huelskamp. And did anybody lose their job?
Dr. Lynch. I can't answer that specifically, sir.
Dr. Huelskamp. You don't have the information or is it a
refusal to----
Dr. Lynch. No, I don't have the information, sir. If I did,
I would share it with you. I guess I would say, maybe in
response--I understand your concern. I understand the
chairman's concern regarding accountability and I think that is
important and I think VA has some very prescribed purposes for
that.
I am troubled a little bit by whether or not firing
somebody is necessarily the answer. I think, as I mentioned
earlier, almost a third of our employees are veterans.
Dr. Huelskamp. Would you be opposed to taking away their
bonus?
Dr. Lynch. Pardon?
Dr. Huelskamp. Would you be opposed to taking away their
bonus?
Dr. Lynch. Could I just continue for just a second?
Dr. Huelskamp. I don't have time for that answer.
Dr. Lynch. I think we need to be careful about punishing
everybody for what may have occurred at one or two medical
centers. I think by and large, sir, we have good people who
care for veterans, who deliver quality care. And I think in
those circumstances they should be rewarded. I don't think we
should punish the system for what may be incidents that
occurred in individual medical centers.
Dr. Huelskamp. Lastly, Dr. Lynch, I am looking at your
handbook that provides the procedures for disclosure of adverse
events to patients.
Dr. Lynch. Yes, sir.
Dr. Huelskamp. And it is pretty clear of the ethical
requirements: ``Unwavering ethical obligation to disclose to
patients harmful adverse events that have been sustained in the
course of their VA care.'' Has this been disclosed to Mr.
Coates?
Dr. Lynch. It would appear from his testimony that it
hasn't, sir. I think VA has taken a lead in this area. I don't
think we are perfect, but I think we have a good system and it
can be better.
Dr. Huelskamp. And if one failed to disclose this as
apparently it is the case to Mr. Coates, what is the
punishment? Who is punished for failure to meet an unwavering
ethical obligation?
Dr. Lynch. Sir, at this point I don't know. I need to
understand the circumstances that occurred and I will be
looking into that.
Dr. Huelskamp. Yeah, I would appreciate the specifics on
Mr. Coates, but the general question is who is responsible for
meeting this unwavering, ethical obligation?
Dr. Lynch. The handbook would tell you that it is the
executive team of the hospital. It is the director. It is the
chief of staff. It is the chief of nursing.
Dr. Huelskamp. Thank you, Mr. Chairman. Yield back.
The Chairman. Mr. O'Rourke, five minutes.
Mr. O'Rourke. Thank you, Mr. Chair.
Dr. Lynch. Mr. Coates made a very powerful case that the
delay of service to a veteran can effectively mean denial of
life-saving care to a veteran, and I think you have made the
commitment to look at his case specifically; find out what you
can learn from that; apply those lessons to improving the VA,
and specifically what happened with those specific doctors and
he relayed an anecdote or anecdotes of poor performance on
behalf of the doctor, but he also showed us that there are some
truly terrific public servants working for the VA. He mentioned
the doctor who retired from private practice and is spending
time within the VA because he cares about veterans and he wants
to make sure that they get the best care.
I have found that to be the case in El Paso, that we have
really wonderful doctors, terrific care for veterans who can
get in my community, and far too often in other parts of the
country is that it is very hard to get into the VA and get an
appointment and see a doctor. Anecdotally, I have heard from
veterans who served as back as World War II, who need simple
procedures like cortisone treatment who have to, as Mr.
Huelskamp just described, travel four or five hours to the
nearest VA hospital in Albuquerque to get that care. They
decide not to get the care and they end up either suffering,
choosing an alternative or just going without.
I have spoken to countless veterans who just delay or just
do not receive appropriate treatment, procedures, or surgeries
for the same reasons. That anecdotal information has been borne
out by the recent SAIL report that the VA OIG recently produced
that showed that El Paso is arranged 123 out of 128 VHA
facilities for access to care, and when we drilled down into
the numbers a little bit further, we found that as recently as
six months ago, only 18 percent of veterans seeking to make an
appointment were actually able to get an appointment within a
reasonable period of time, a standard that you all set for
yourselves. So for those 82 other out of every 100 veterans
trying to make an appointment, they can't get in and find care.
So, you know, Mr. Huelskamp approached this, I think
rightfully so from a perspective of accountability, and what do
we do when people don't perform, when veterans don't get access
and we have these poor outcomes?
To look at the other side of the question: What are you
missing in resources to be able to provide the access that we
need to hire the very best doctors, or in El Paso's case,
enough doctors so that veterans can get in and get an
appointment? What are we not providing to you and to the VA
that you need to be able to turn this situation around?
Dr. Lynch. Dr. Clancy.
Ms. Clancy. So first, I want to say to you and your
colleagues here that we very much appreciate the privilege and
opportunity and honor of serving the men and women who have
effectively written a blank check to this country; there is no
higher calling, really, in medical care delivery.
The issue of timely access is one that we take seriously,
so to the extent that you have additional information that we
haven't seen, we would love to see and work on that with you.
Mr. O'Rourke. Here's the thing--and I appreciate what you
just said, but I have spoken to Dr. Petzel about this. You all
had measured it and seen the outcomes and the lack of service.
I am with Ms. Brownley and others who question whether the
number of preventable deaths is really accurate. Who knows how
many of those in El Paso who are not able to get an appointment
or who were told they had to make a ten-hour roundtrip and
those not to have the procedure, who knows who their outcomes
were. I don't know if we are effectively measuring that.
What I want to know--and I have tried to do this in the
most cooperative, polite, diplomatic fashion I can think of--
what I want to know is what you are going to do to turn that
situation around, and if you need something additional from me,
as a Member of Congress, from us as a committee, from the
House, the Senate, in terms of appropriating resources, what
are you missing that is preventing you from delivering the
standard of care that our veterans should be able to expect?
Ms. Clancy. What we are working on right now are new
programs to improve our ability to schedule appointments in a
timely fashion. In addition to that, particularly for folks who
live in rural areas where traveling great distances often is a
big challenge, we are looking into other options when it is
feasible. Obviously, if you need an injection or a procedure,
you can't do that remotely, but we are looking at a variety of
telehealth options sometimes for video consultation. It seems
to be a very, very effective way to improve access for people
who have mental health appointments, and other venues so that
we can be able to get people in faster, and I will personally
follow up with Dr. Petzel about your request.
I wanted to make one other comment, just about rankings. If
you have 152 hospitals or centers in a system, there will be a
number one and a number 152. I think the real question is: Is
123, how does that stack up against the private sector and what
is the gap between best possible care and----
Mr. O'Rourke. And use the other metric that I gave you,
which is 82 out of every 100 veterans trying to make an
appointment in El Paso cannot get in, in a reasonable amount of
time, a standard in which you set. And I have asked Mr. Petzel
publicly. We have talked to the office privately.
When can we get something in writing that will tell us when
you will be able to meet the standard of care that you,
yourselves, have set for the veterans in El Paso, and the
veterans all around this country, and I am still waiting for
the reply. So I am going to ask you, again, publicly, to please
work with Dr. Petzel and our office to get us that reply.
Mr. Chair, thank you.
Ms. Clancy. I will do that.
The Chairman. The gentleman's time has expired.
Dr. Benishek----
Dr. Benishek. Thank you.
The Chairman [continuing]. Chairman of the health
subcommittee, you are recognized for five minutes.
Dr. Benishek. Thank you very much, Mr. Chairman.
I thank both of you for being here this morning. Frankly,
this makes me really angry, all right. I mean Mr. Coates is
here testifying about this care at the VA where he has going to
die and as far--I am a general surgeon. I do colonoscopies. I
do colonoscopies at the VA.
This man did not receive the standard of care and it is
very frustrating for me to be here and have people calmly
explain to me how they are working really hard to make things
happen when there is not an emergency. This is an emergency.
This gentleman did not receive the standard of care, all right.
He did not receive an apology.
It is hard for me to understand, you know, when I ask Dr.
Petzel for what are you doing for this kind of stuff?
And it was six people have been disciplined and then I
can't even get an answer from him as to which people and why.
So how can I believe that the VA is serious about putting a
stop to this stuff when I ask a simple question and I can't
even get an answer to it. It is very frustrating to me that we
have to come up with some sort of legislative fix for how you
people manage your department.
I mean it should be a management decision that, you know, a
physician who is not giving a colonoscopy when people have
rectal bleeding or blood in the stool. This has been the
standard of care for 30 years. And, you know, for not even
getting a consultation for a colonoscopy for a year and then to
get six months before he is--from what I can understand from
the timing--six months.
This is an emergency. If I see somebody in my office with
rectal bleeding, they get a colonoscopy like the next day or
within the week. And I don't know--you know, I just get so
frustrated by people like you that come here and calmly say we
are going to fix it and it never gets fixed.
Dr. Lynch. Congressman, I am a surgeon by training. I have
spent the last 30 years working in the VA system working with
veterans, training residents, working with medical school
students. I am angry, as well, sir. I share your anger.
I have been working for the last year since I have been
here in central office to put together the tools that give us
what we need to manage our system in a fashion so we can
identify where there are delays and----
Dr. Benishek. No, I understand.
See, you calmly answer me----
Dr. Lynch. I am not calmly answering you, Congressman. I am
angry like you are angry.
Dr. Benishek. But I don't see any progress, Dr. Lynch. I
don't see any progress.
I mean all I asked of Dr. Petzel was for some things here.
We don't see where you are actually fixing it. All we get is
calm responses from people that are assuring us that we are
actually doing it, but we don't see any progress and, you know,
when I see a case like that case that was presented here
earlier by Mr. Coates, I just can't stand--what are you doing?
I mean what mechanism do you have to find out about stuff like
this?
What happened to that doctor? Why wasn't she working on--at
the standard of care? I mean these are the kind of questions
that we need answers to and we don't ever get them, and so I am
very disappointed with the quality and the management of the
VA. I mean I worked at the VA for 20 years myself. I think that
the VA has made tremendous improvements over the last 20 years,
there is no doubt about it, and I applaud you for doing your
career there, but, you know, coming from that system, where I
worked as a physician, and I come here, and knowing, you know,
how the bureaucrats work there, the physicians, to me, didn't
have enough input as to how things were done; it was the
bureaucrats that decided about a lot of this stuff.
So I would be happy to work with you to give you my insight
as to how to do this better. You know----
Dr. Lynch. Congressman----
Dr. Benishek [continuing]. Like I said, it is great----
Dr. Lynch [continuing]. I would be happy to meet with you.
Dr. Benishek. What is the second half of that?
Dr. Lynch. Dr. Clancy and I would both be happy to meet
with you, sir.
Dr. Benishek. I will yield back my time and hope----
Ms. Clancy. And I do want to be clear that we both share
your anger and are very, very upset and we know that we can't
take that back; it can't be undone. So, a young man who will
die prematurely, we get that. But what it inspires us to do is
to work harder to make sure that we don't do it again and we
have a system in place to make it foolproof so that we don't--
--
Dr. Benishek. Well, my frustration is how can I tell what
is happening when I can't even get a simple answer to a simple
question from Dr. Petzel? Thank you.
The Chairman. Ms. Titus, you are recognized for five
minutes.
Ms. Titus. Thank you, Mr. Chairman.
I want to ask Dr. Lynch, I am sure you are aware that the
IG is currently investigating the death of Sandi Niccum at the
VA hospital out from Las Vegas. That investigation came at the
request of the chairman and myself. It is taken awhile, and we
hope to get the results soon, but just wonder when the results
come to this investigation or any, what you do to follow up;
how you assure us that you have made the changes; implemented
the recommendations.
Could you comment, maybe, specifically about the Las Vegas
case or--and also generally?
Dr. Lynch. I can't comment specifically about the Las Vegas
case. I have not seen the OIG's report yet. I can tell you that
when those reports come in, I do read them. I do look at the
recommendations and we do have a process for tracking to make
sure that those recommendations are acted upon and closed.
Ms. Titus. Can you elaborate on that process for tracking
them so that we can be sure that there is transparency and
accountability and I can go back to my constituents and say
this was the problem and this has happened to correct it.
Dr. Lynch. There is an office in VHA whose specific
responsibility is to work with the OIG. They obtain those
reports and they work with the OIG until such time as he
accepts the actions that have been taken and closes the
recommendation.
Ms. Titus. And that is public?
Ms. Clancy. Yes, that is public information in terms of
what was the response of the VA Health System and the follow-up
and so forth. So I think we can both commit to you that we will
follow-up with you when that report is done.
I want to stress, though, that we don't wait for the
Inspector General. The Inspector General is a very valuable
resource and a source of information for us, but we have many
internal processes. So our National Center for Patient Safety,
for example, routinely is collecting information about adverse
events and near misses; in other words, circumstances that set
people up for errors.
I have heard a lot of concern from all of you this morning,
and we share that, about harms to patients and patient safety.
And I would love to tell you that we can build an error-free
system and that is not possible.
What we can do, and are strongly committed to doing, is
identifying things at the earliest possible phase so they can
be fixed and the much longer-term consequences and more serious
consequences can be prevented. So, we pay a lot of attention to
the IG reports to reports by the GAO, but we also have our own
internal processes where we are relying on every single
employee who works at VA to let us know; it is called Stop the
Lying. If you see something, say something. If you see
something that could be unsafe, we need to hear about it and
you need to let people know so that we can act on it, and
together, across the system can learn about it.
Ms. Titus. Can you tell us then--and I appreciate that, I
think that is a good thing that you have--but if something is
being done to follow up on the Sandi Niccum case independent of
the report that we are waiting on?
Ms. Clancy. I can get back to you with that. I am not
familiar with the specifics of that, but we will definitely get
back to you.
Ms. Titus. Thank you very much.
And I yield back, Mr. Chairman.
The Chairman. Could you tell me why the video, the
surveillance video that day in the hospital that showed Ms.
Niccum, who was an elderly lady, was in severe pain and ended
up dying, was erased, deleted, how did that occur?
Dr. Lynch. The only explanation I have heard is that after
30 days, the videotapes are overwritten and we don't have that
information; and I understand that I don't know the
relationship between your request and when that tape was
erased.
I think from our standpoint, it is unfortunate; we would
like to have seen what happened as well.
The Chairman. Wouldn't you think, though, as a matter of
principle and good business practice, that if a death occurred
in your facility and you had a video of that death--30 days--
man, I can understand if it was 24 hours, maybe it got
deleted--but 30 days before it got taped over?
Dr. Lynch. If I recall the case, which is now coming back,
I don't believe that Ms. Niccum died that day. I believe she
died subsequently, following hospitalization. So I think the
concern was that her care was delayed in the emergency
department and there was a delay in her receiving radiology
service. She went home and was subsequently admitted to another
facility and died at that time.
So it wasn't that we had a death in the facility at that
time, which I absolutely agree with you, Congressman, would
have required that we review those videotapes and look at them.
The Chairman. The GAO, in their written testimony for this
morning's hearing, alleges that oversight of the implementation
of VHA's business rules has been limited and has not included
independent verification of VAMC actions. So my question to you
is: Would the Department be willing to increase oversight of
the new business rules and pursue independent verification of
VA Medical Center implementation?
Dr. Lynch. I did read the GAO's testimony, sir. I am not
sure that we agree that there is value to auditing of the
facilities. We think that we have provided adequate training.
We think that we have provided the education that the
facilities need to implement those. We know that the facilities
have begun to implement and use consult management teams. We
feel very strongly that the consult tool that is resulting from
this review will give us that individual oversight by facility
and by specialty.
The Chairman. And they also allege in their statement that
the Department did not require medical centers to document how
they address unresolved consults that were opened greater than
90 days; is that true?
Dr. Lynch. That is true, sir.
But we felt we had a process defined that identified which
consults could be closed. When there were individual patient
consults which remained unresolved that resulted--that related
to clinical care, that we had a process and an expectation of
our medical centers, that those would be reviewed individually.
The Chairman. In their written statement this morning, GAO
references one VA Medical Center where specialty care providers
have allegedly been instructed to discontinue consults for
appointments that are not needed within 90 days and to track
these consults outside the consult system and to resubmit them
closer to the date that they are needed.
Is this an acceptable practice?
Dr. Lynch. We have a process, as we implement new business
rules that will identify consults for what we term ``future
care.'' Future care would be somebody who perhaps had an
endoscopy----
The Chairman. So the answer to that question is: Yes, it is
an acceptable practice?
Dr. Lynch. The answer to that is: Yes, we have a process in
place to be able to identify those and be sure that we have
eyes on those future care consults, sir.
The Chairman. So we have a dual track list?
Dr. Lynch. No, sir. We have an electronic process that
follows those and kicks them out at the appropriate time back
into our system so that we are aware that an endoscopy or a
consult needs to be scheduled at the appropriate time.
The Chairman. Can you respond to the comment made in the
IG's written statement that there seems to be a lack of focus
on healthcare delivery as priority one at VA medical
facilities, as evidenced by the length of time that it takes to
fill a vacant position. I think that any one of us that goes to
a VA Medical Center for a visit are often not surprised anymore
by the number of people that have the word ``acting'' before
their name or that there are positions that are important that
are vacant.
Can you respond to those comments?
Dr. Lynch. Yes, sir.
First of all, I think if we look back through VHA, the
system that we currently have was initially developed around
1940 by Omar Bradley, and by Dr. Paul Holly. It focused on
clinical care. It focused on academic affiliation and the
education of medical school students and residents, and it
focused on the value of research.
I realize that healthcare has changed. I respect the IG's
recommendations and thoughts. I think we do need to re-examine
our system, but I would disagree that I think we are ignoring
clinical care in favor of research or education. I think they
are both critical components of what we do in VHA. The research
that we have done has helped to improve patient care and the
care that we deliver. I can give you two recent examples.
There was VHA research on the treatment of PTSD that has
resulted in new treatments for patients with PTSD, as well as
tools for identifying TBI. There was a study on the use of the
drug Prazosin and its value in patients with PTSD that has been
implemented, not only in VA, but also in the private sector. I
think that research plays a critical role in helping us assure
that we have quality care for our veterans.
The Chairman. Final question from me: Does the VA have
every legal authority it needs to pay for a veteran's care
whose care is delayed, to receive care outside of the VA
system?
Dr. Lynch. To my knowledge, sir, yes.
The Chairman. So, would it be correct to say that failure
to deliver care in a timely fashion is simply a question of
poor leadership at VA?
Dr. Lynch. I think that would be a stretch, sir. I think
that our system strives to treat patients within VHA because we
think we do provide good care. We think we provide quality
care. I hope that we can identify those circumstances where it
may be necessary to send somebody into the private sector. I
think we have to use all the resources that we have, sir.
The Chairman. Ms. Brownley. any further questions?
Ms. Brownley. I don't have any further questions, but I do
have a comment that I would like to make, and to say, I, too,
share the frustration of the committee that we are not able to
get the answers that we want.
And I think, you know, we are looking for specifics, data,
metrics, et cetera, and, feel--I always feel as though we never
get them. We get answers like ``We have a system that provides
eyes on the process''; ``We have tools.'' But we are really
looking for the specifics.
Our staffs assure us that you know the questions that we
are going to ask and what we are interested in knowing through
these hearings and it is just my feeling and my only conclusion
that I can come to, if you are not willing to reveal the facts,
that there is something that you don't want the public to hear,
and I just want to make that statement. I don't know what else
to conclude when we don't get the facts and the information
that we are specifically asking for.
Dr. Lynch. Congresswoman, I would point out that, in fact,
one of your staff members of the HVAC did meet with Dr. Mike
Davies of our staff and did go over the consult tool that we
are developing and was shown how it works.
The Chairman. Mr. O'Rourke or Ms. Titus, any further
questions?
Thank you very much for being here with us, and the second
panel is dismissed.
Members, joining us on the third and final panel--and thank
you very much for your indulgence in allowing VA to give their
testimony before you--is Deborah Draper, Director of Healthcare
for the Government Accountability Office, and, Dr. John Daigh,
Assistant Inspector General for Healthcare Inspections for the
VA Office of the Inspector General. The committee appreciates
both of you for being here today and thank you for your hard
work and advocacy on behalf of America's veterans.
Ms. Draper, we will begin with you, you are recognized for
five minutes for your opening testimony.
STATEMENT OF DEBRA A. DRAPER
Ms. Draper. Chairman Miller and Members of the Committee, I
am pleased to be here today to discuss access problems in VA
that may delay needed medical care for veterans. GAO and
others, including VA's Inspector General, have continued to
report that VA medical centers do not always provide timely
care, and in some cases, these delays have resulted in harm to
veterans.
My statement today covers two access-to-care concerns.
First, I will highlight preliminary observations from our on-
going work related to VHA's management of outpatient specialty
care consults. Second, I will discuss concerns regarding VHA's
medical appointment wait times, and scheduling, including
progress VHA has reported making in implementing our December
2012 recommendations.
VHA providers request and manage consults for specialty
care using VHA's clinical consult process, which is supported
by an electronic system. Clinical consults include both
clinical consultations, such as an evaluation of a patient's
clinical concern, as well as specialty procedures, such as a
colonoscopy. The specialty care provider who receives the
consult request is to review it within 7 days of it being sent
to determine whether it is needed and appropriate. VHA's
guideline is for consults to be completed within 90 days.
In 2012, VHA created a database to capture all consults
systemwide; however, the data were deemed inadequate for
monitoring purposes. One issue was the lack of standard
processes and uses of the electronic consult system. For
example, in addition to requesting consults for clinical
concerns, the system was also being used to request a variety
of administrative tasks, such as requesting veterans' travel to
appointments. Additionally, VHA could not accurately determine
whether veterans actually received the care requested or
received it in a timely manner. At the time the database was
created, there were approximately two million consults open for
more than 90 days.
In May 2013, VHA began an initiative to standardize aspects
of the consults process with the goal of developing consistent
and reliable systemwide consult information. Among other tasks,
VA medical centers were to complete a clinical review as
warranted, and as appropriate, close all consults open for more
than 90 days.
Through our on-going work on outpatient specialty care
consults, we found examples of delays in care at each of the VA
medical centers included in our review. For example: For three
of ten gastroenterology consults reviewed in one facility, up
to 210 days elapsed from the dates the consults were requested
to when they were completed.
In another facility, for three of ten physical therapy
consults reviewed, more than 100 days elapsed with no apparent
actions taken to schedule appointment. These consults were
eventually sent back to the requesting providers without the
veterans involved receiving the requested care. According to
the patients' files, no non-service connected evaluations were
being accepted due to resource constraints.
We also found variation in how VHA's consult initiative is
playing out at the local level. For example: VA medical centers
have developed different strategies for clinical consults that
are needed beyond the 90-day completion guideline. Some
facilities are managing these future-care consults outside of
the electronic system, and consequently, these consults do not
appear in VHA's systemwide data.
VA medical centers are also not required to document how
they address consults open for more than 90 days. None of the
facilities in our review were able to provide us specific
documentation in this regard. VHA officials estimated that as
of April 2014, of the two million open consults that existed
when the systemwide database was created in 2012, 450,000
remained unresolved.
Additionally, oversight of VHA's consult initiative has
been limited, and has not included independent verification of
VHA medical centers' actions. Without this verification, VHA
cannot be assured that the actions have been implemented
correctly. Furthermore, VHA's consult data may not accurately
reflect whether veterans received the care needed, or if they
received it in a timely manner.
The second access-to-care concern that I wanted to
highlight today relates to our December 2012 report and
subsequent Congressional testimony. We reported that VHA's
outpatient medical appointment wait times were unreliable, and
that there were problems in the implementation of VHA's
scheduling policy. We recommended VA take actions to: Improve
the reliability of medical appointment wait time measures,
Ensure the consistent implementation of a scheduling policy,
Allocate scheduling resources based on needs and Improve
telephone access for medical appointments.
VA concurred with our recommendations and has reported
continued actions to address them. For example, VHA officials
told us they have implemented new wait time measures, which
they say are more reliable. We believe that work needs to
continue to fully implement our recommendations. It is
essential that VHA also assess the actions taken to ensure that
they are achieving the intended improvements.
Mr. Chairman, this concludes my opening remarks, I am happy
to answer any questions.
[The prepared statement of Debra Draper appears in the
Appendix]
The Chairman. Thank you very much.
Dr. Daigh, you are recognized for five minutes.
STATEMENT OF JOHN D. DAIGH, JR., M.D.
Dr. Daigh. Chairman Miller, Members of the Committee, it is
an honor to be able to testify before you here today. I would
like to recognize the courage of Mr. Coates for his testimony
this morning. It was extremely important to hear and I think
very sad.
My staff works tirelessly to try to ensure that these
events don't occur and this is a failure for us to see a story
like this. I believe the VA has lost its focus on the
importance of providing quality medical care as its primary
mission. In the day-to-day decisions that managers at all
levels make, that they take for granted often times, and assume
that quality medical care will be provided.
When addressing the competing demands to provide medical
education, research, support to our nation in time of national
disaster, comp and pen exams, the fight against homelessness,
managers have lost focus on the importance of making quality
medical care delivery their number one priority.
In my written statement, I addressed three events that we
have recently published that have occurred at more than two
institutions. One is the colon cancer issue that we discussed
here previously, the second would be veterans at Miami and
Atlanta who died in VA hospitals from overdoses of street
drugs, and in both cases, basic policies were not followed.
In Buffalo and Salisbury, North Carolina, insulin pens
designed to be used for one patient to take multiple doses
were, instead, used on the ward for multiple patients, putting
hundreds of veterans at risk for the risk of blood-borne viral
infections. There is no good explanation for these events. They
are not consistent with good medical practice. They are not
consistent with common sense, and they are not consistent with
VA policies that exist.
The most important factor in preventing these events, in my
view, is excellent leadership that instills a culture of safety
and accountability. In addition, I believe that a review of
VHA's organization and business rules is appropriate to
determine if there are changes that would support the singular
importance of quality of care and improve the ability of
leadership to deliver that high quality medical care across the
system.
For example, one might identify positions within the
medical center that are deemed essential for the delivery of
medical care, and should one of those positions become vacant,
for instance, the nurse in the colonoscopy suite or the GI
nurse, that job would automatically be refilled. It wouldn't
have to compete for being refilled within the administration
for medical education or a technician who might want to be
hired for research. So, again, a way to try to focus the budget
and resources on healthcare.
In addition, VISN and hospital instructions are not
standardized. It is not possible to look at--the position
descriptions are not the same. The areas of responsibility are
not the same. So if you ask the simple question: Who owns the
operating room? You are not really sure if it is the chief of
surgery; is it the chief of anesthesia; is it the chief of
surgical care line; is it the head nurse?
So I believe that these rules that currently exist which--
and I will be the first to admit that the VISN system and the
mantra that all healthcare is local has served the VA very
well. I believe that these systems ought to be looked at to see
if it is time to change some of these rules.
With that, I will end this portion of my testimony and be
pleased to take questions.
[The prepared statement of John Daigh, Jr. appears in the
Appendix]
The Chairman. Thank you, both.
I was looking at the written statement for the GAO and you
talked about, and the IG talks about it, too, that VA
experienced difficulty in hiring and retaining specialists for
gastroenterology and physical therapy. And the question is: Did
you find any reason for that?
Dr. Daigh. I guess----
The Chairman. Either can answer on it.
Ms. Draper. Yeah, I think what we heard in some locations
was that for some high volume specialities, there is a national
shortage of some specialists, so it is difficult to hire. I
think we heard, generally, that there was an increased volume
of requests for certain specialty services which is
complicating providing care. So, you know, if you have a
shortage of providers, you can't backfill and, you know,
increase the capacity that you have within the specialty
clinics, so we did hear some of that.
The Chairman. I would suspect that if you had a shortage of
providers or you had vacancies that you couldn't fill, then the
obvious thing would be a fee-for-service if possible, and then
the question begs to be answered: Do you think VA makes
adequate or even maximum use of fee-bases resources when those
specialists are not available?
Ms. Draper. We have not looked at this in any great detail.
I mean it varies considerably from facility to facility. And at
one facility, for example, they fee-based two to three hundred
GI consults a month. In other facilities, they do very little.
It is hard to understand what the variation is, but it does
vary considerably from one facility to another.
Dr. Daigh. I would say, sir, that this is not a new
problem. We published, you know, a similar report in 2006 that
outlined the difficulty that VA had in following up on patients
who were being screened for colonoscopy and needed tests to
look for the presence of colon cancer on a regular basis. And
so I think, A, you have to have a system in place, but, B, you
are just talking about a procedure and the procedure can be
done by a variety of people trained to do that procedure.
So the question is: If you need a colonoscopy done, well,
maybe a PA could do that or maybe a nurse could do that--to
have the training and to assist the physicians and other staff
to make sure that this simple procedure got done adequately,
and where a physician needed to impart additional insight into
what one should do, you could schedule visits for that. So I
think this is just not a new problem.
The other point I would make is that many VAs, probably 100
of them, are affiliated with medical schools, so you have right
there a whole set of physicians that are in the community that
are available, so that if you could work with that group of
patients, a group of facilities, one could probably construct
solutions that would be worthwhile.
So, I think fee-basis consults, creative uses and training
of your resources and your people to plan for what you know are
going to be on-going problems; they are all parts of the
solution here.
The Chairman. Ms. Draper, have you ever seen an instance or
instances where a VISN director or a medical center director
restricted the use of fee-basis care funds or diverted those
funds to be used in other programs?
Ms. Draper. I have not, but for this work we have not
looked at that in any great detail.
But I do want to say one thing about fee-basis, as well, is
that these are not tracked the same way, so you don't know what
the wait times are. So when you fee-base something out there,
you lose that tracking ability to see, so you may not really be
accomplishing something--you may not be getting the care in a
timely way, it is just that VA doesn't--they don't really track
that.
The Chairman. And, again, they should.
Ms. Draper. They should, and we pointed that out in our
previous report.
The Chairman. We found this issue in Atlanta, in
particular, where mental health care was an issue where
basically once VA fees something out, it appeared that they
just dropped off the radar screen and they weren't watching it
or tracking it again.
Just because they are not getting care in a VA facility
doesn't mean that they are not VA's patient or America's
patient and VA had darn sure better----
Ms. Draper. Right. And VA is paying the bill, so--I mean
that was one of the issues that we pointed out in our 2012
report is that is was not tracked.
The Chairman. Actually, a grateful American taxpayer is
paying the bill and I think VA forgets that sometimes; it is
the taxpayers' funds, not theirs.
Ms. Brown.
Ms. Titus.
Ms. Titus. We have been here a long time. Thank you, Mr.
Chairman.
I just keep hearing a theme over and over that these things
seem to vary have facility to facility, and I understand
perhaps the need for some flexibility because some hospitals
may be associated with the medical school, different
demographics, different geography, and all of that. But it
seems to me there is some need for some kind of standardized
policy to some extent.
I know at the Las Vegas hospital, they are flying in
emergency room doctors from all over the country on contract
for a few day schedules. That doesn't seem very practical to
me. I mean there must be all of the Las Vegas Valley, some
emergency room doctors who could do that. It seems like you
would save money and get more of a buy in from the medical
community than these kind of flying in doctors.
I would like that addressed, but I also would like to go
back to the Sandi Niccum case. Dr. Lynch kind of got his memory
back in the course of answering that question, but I would like
to ask ya'll if you can give us some kind of progress report so
we can find out if that is moving and when we are able to get
some results.
Dr. Daigh. Yes, the research on that has been done. The
report has been written. It is in draft phase, and it will be
out within a couple--three or four weeks. So we are--we will be
ready.
In the normal process, I would like to clarify a little bit
what was said previous. We would write a report and lay out the
facts as we see them. We would then send a report to VHA at
multiple levels, including the hospital in Las Vegas, ask them
to read the report and verify they think the facts are correct.
We would then make recommendations in the report and ask them
to respond to the recommendations and they would, in writing,
respond to those recommendations.
At that point, we would offer the Committee and you a
briefing on the findings and we would publish the report to the
web where it would be public, that would be our report, plus
their response.
The response sometimes takes awhile for VA to follow back
up on, so we then have a part of our office that does follow-
up. Usually, it is that we ask for records to prove that X and
Y were done, and if they provide records that X and Y were
done, then we usually close it.
Occasionally, we say this is so important an issue that we
personally will go back and re-visit the facility and try to do
a follow-up. The follow-up documents, though, are not made
public unless they are requested, so they are internal to us. I
see them, you ask for them, you can get them. We do provide a
list to Congress multiple times a year of those recommendations
that have not been filled within a year.
So where we have not been unable to close a recommendation
on one of our reports within a year, we make that available to
you as an item and we are happy to talk about those.
Ms. Titus. Okay. So when you say the report will be
finished within three weeks or so, is that the stage in which
you send it to the hospital or----
Dr. Daigh. No, I think this should be publishable within
three weeks or so, three to four weeks.
Ms. Titus. Well, I will look forward to getting that.
And it seems to me that sometimes these reports that focus
on a specific problem in a specific hospital are used to
address just that and not taken in the broader, I don't know,
perspective, so that they can be used to solve problems at
other facilities.
Dr. Daigh. Well, I think in terms of just producing a
report and making sure it is accurate, I have to narrow the
scope often times to what I can be accurate about.
Ms. Titus. Uh-huh.
Dr. Daigh. But if one looks at the reports that we put out
or you ask us to talk about it--I am familiar with the reports
that we put out--we are happy to try and talk about patterns
that we see.
Certainly, VHA gets the reports and they can look for
patterns and we are aware of patterns, so I think you are
right; there is a difficulty in that they don't all talk to the
universe, but I can't do that and get it out timely.
Ms. Titus. I understand that.
Mr. Chairman, thank you. I yield back.
The Chairman. Mr. O'Rourke.
Mr. O'Rourke. Thank you, Mr. Chair.
Dr. Daigh, a couple things that you said really struck home
in terms of trying to figure out what is going wrong and how we
fix it. You said it was a question of leadership and you also
said it is a question of having a culture that prioritizes
safety and accountability. And those issues are so big and so
tough to address in a five-minute question and response.
But I will just tell you that I have had the chance to meet
Secretary Shinseki. I have heard him testify here. I have no
question whatsoever that he has the highest and deepest
commitment to improving the service of the VA--and if he were
here, I am sure that he would agree and share everyone's
frustration--and say that the results that we described today
are unacceptable, and I also have no doubt about Dr. Lynch and
Dr. Clancy and their commitment.
The people that I meet within the VA are good people who
are trying, and yet, the awful numbers that I gave for El Paso
earlier are not new. In 2008 we had the worst access not
country to be able to get in to see a doctor and it has
improved only marginally since then. So, despite good people
doing good work and assuring us of their efforts, it is not
getting better--certainly not quickly enough for the veterans
who need to see care.
Let me ask you this: In assessing the job that I am doing
and the job that Congress and this Committee is doing, you
know, the primary responsibility for these veterans is within
the VA. The ultimate responsibility is within Congress. We have
the power and responsibility of authorizing, appropriating, and
oversight, and so I will ask you the question that I asked Dr.
Lynch: What could we be doing that we are not doing now to
change the outcome and to get veterans the care that is being
delayed and ultimately denied, as we heard with Mr. Coates and
as I see every single day in El Paso?
Dr. Daigh. I have watched this system for awhile; I would
agree that the people who work in it are excellent. They are
committed. Many of them are veterans and they are of the
highest quality when you sit and talk with them. That is why I
expressed the frustration over the events that I talked about
when you say ``Well, what really happened?''
And often, I think--so let me go to your point. I think
that serious thought needs to go into the business model that
VA uses now to deliver care. So if you are in the middle of
Manhattan and you have multiple medical schools and many
hospitals, you have a different group of folks to deal with in
terms of trying to resource and provide care. You would make
different decisions about how you provided care. You may decide
that cardiac surgery is so great at this hospital that why
shouldn't I get into that business, why wouldn't it use it all
the time.
And if you are a different facility someplace, you have
entirely different business needs, and I think that the VA
structure has not morphed over the last number of years, as I
think it should. In the past, I think most veterans lived in
the shadow of the hospital. If they drove and could get there,
they were enrolled in that facility.
If the goal is deliver one standard of care to all veterans
who are eligible for that particular piece of care, the ones
that live on the other side of the mountain and across the
river, I think you have to rethink a little bit how you are
doing that. And so I would take a serious look at, given that
the information flow has changed; data requirements have
changed; data is available--the capabilities of computing are
different. I think it is time to take a look and fix what needs
to be fixed bureaucratically to drive efficiency and drive
standardization, but try very hard to preserve the mantra that
all healthcare is local, so that local folks can make important
local decisions.
Mr. O'Rourke. And I appreciate the fact that
representatives from the VA are here listening to this, and I
am sure at headquarters, they are listening as well, and to a
certain degree, they can choose to adopt these recommendations
administratively, but just to put a finer point on the question
that I am asking: Are you suggesting that, again, despite the
best efforts within the VA and current leadership, we are not
seeing the kind of change that we need? That the recommendation
that you are making needs to come in the form of a legislative
proposal, a bill that would force the VA to change how it
delivers cares?
Dr. Daigh. So how change occurs, I am not quite the expert
on, whether it needed to be law or discussion. But, certainly,
if you were to change business structure, I am assuming that
you would need to change some law.
But what I am pointing to is in a GI clinic where you are
scheduling colonoscopies and you have people who need
colonoscopies, you know what the demand is. If you lose a
critical player in that clinic, then you know that you can't do
the work that you did before. So the people in that clinic, the
doctors, the nurses, everybody, needs to have an easy conduit
to drive change and make it happen.
If the complaint is that at the local level within a
hospital, they can't get the positions filled, they need filled
to ensure that what gets done gets done, and those people who
are not bureaucratically responsible for the delivery of care
are somehow able to drive resources outside of the delivery of
primary care, I think that needs to be fixed.
I think there ought to be a study. I think there ought to
be a good look at how VA is currently set up and see if there
are not better ways to manage this system in 2014 and forward.
Mr. O'Rourke. Thank you, Dr. Daigh, and, Ms. Draper, I
thank you for your answers.
Mr. Chair, I yield back.
The Chairman. The gentleman yields back.
Ms. Titus, do you have a request?
Ms. Titus. I do, Mr. Chairman, thank you.
I would like to submit Mr. Michaud's written statement for
the record because he couldn't be here.
The Chairman. Without objection.
The Chairman. Being no further questions from the
Committee, we will be submitting some questions for the record.
We would appreciate a timely response from all the witnesses
today.
I do ask unanimous consent that all members would have five
legislative days with which to revise and extend or add
extraneous material to their remarks.
Without objection, so ordered.
And, once again, thank you to all of the witnesses for
being here today.
This hearing is adjourned.
[Whereupon, at 12:41 p.m., the Committee was adjourned.]
APPENDIX
Prepared Statement of Chairman Jeff Miller
Good morning.
The committee will come to order.
Before we begin I'd like to ask unanimous consent for our colleague
from Tennessee, Congressman Steve Cohen to sit at the dais and
participate in today's proceedings.
Hearing no objection, so ordered.
Welcome to today's full committee oversight hearing, ``a continued
assessment of delays in VA medical care and preventable veteran
deaths.''
Today's hearing is the fulfillment of a promise I made in early
January to follow-up on delays in care at department of veterans
affairs (VA) medical centers in Columbia, South Carolina, and Augusta,
Georgia, that, together, resulted in nine preventable veteran deaths.
I had hoped that during this hearing, we would be discussing the
concrete changes VA had made--changes that would show beyond a doubt
that VA had placed the care our veterans receive first and that VA's
commitment to holding any employee who did not completely embody a
commitment to excellence through actions appropriate to the employee's
failure accountable.
Instead, today we are faced with even with more questions and ever
mounting evidence that despite the myriad of patient safety incidents
that have occurred at VA medical facilities in recent memory, the
status quo is still firmly entrenched at VA.
On Monday--shortly before this public hearing--VA provided evidence
that a total of twenty-three veterans have died due to delays in care
at VA medical facilities. Even with this latest disclosure as to where
the deaths occurred, we still don't know when they may have happened
beyond VA's stated ``most likely between 2010 and 2012.'' These
particular deaths resulted primarily from delays in gastrointestinal
care. Information on other preventable deaths due to consult delays is
still unavailable.
Outside of the VA's consult review, this committee has reviewed at
least eighteen preventable deaths that occurred because of
mismanagement, improper infection control practices, and a host of
other maladies plaguing the VA health care system nationwide. Yet, the
department's stonewall has only grown higher and non-responsive.
There is no excuse for these incidents to have occurred.
Congress has met every resource request that VA has made and I
guarantee that if the department would have approached this committee
at any time to tell us that help was needed to ensure that veterans
received the care they required, every possible action would have been
taken to ensure that VA could adequately care for those veterans. This
is the third full committee patient safety hearing we have held since I
have been chairman and I am going to save our VA witnesses some time by
telling them what I don't want to hear from the department this
morning.
I don't want to hear the rote repetition of--and I quote from
several prior VA statements, including the written testimony that was
provided for this hearing--``the department is committed to providing
the highest quality care, which our veterans have earned and deserve.
When incidents occur, we identify, mitigate, and prevent additional
risks. Prompt reviews prevent similar events in the future and hold
those responsible accountable.''
Another thing I don't want to hear is--and, again, I quote from
numerous VA statements, including a recent press statement--``while any
adverse incident for a veteran within our care is one too many,''
preventable deaths represent a small fraction of the veterans who seek
care from VA every year.
What our veterans have truly ``earned and deserve'' is not more
platitudes and, yes, one adverse incident is indeed one too many. We
all recognize that no medical system is infallible, no matter how high
the quality standards might be. But I think we all also recognize that
the VA health care system is unique because it has a special obligation
not only to its patients--the men and women who honorably serve our
nation in uniform--but also to its financers--the hard-working American
taxpayers.
When errors do occur--and they seem to be occurring with alarming
frequency--what VA owes our veterans and our taxpayers, in that order,
is a timely, transparent, accurate, and honest account about what
mistakes happened, how they are being fixed, and what concrete actions
are being taken to ensure accountability.
It concerns me that my staff has been asking for further details on
the deaths that occurred as a result of delays in care at VA medical
facilities for months and only two days before this hearing did VA
provide the information we have been asking for. Even then that
information is far from a complete description of the problem and VA's
efforts to prevent future deaths.
It concerns me even more that VA's briefing Monday and testimony
today include very few details about what, if any, specific actions
have been taken to ensure accountability for the twenty-three veterans
who lost their lives and the many more who were harmed because they
didn't get the care they needed in a timely manner.
On our first panel today, we are going to hear from a veteran who
sought care through the William Jennings Bryan Dorn VA medical center
in Columbia, South Carolina. That veteran--Mr. Barry Coates--is going
to tell us that, and I quote, `` . . . the gross negligence . . . and
crippling backlog epidemic of the VA [health care] system has not only
handed me a death sentence but ruined my quality of life . . . ''
Mr. Coates waited for almost a year and would have waited even
longer had he not actively, persistently insisted on receiving the
colonoscopy that he and his doctors knew he needed. That same
colonoscopy revealed that Mr. Coates had stage four colon cancer that
had metastasized to his lungs and his liver. Maybe that is why VA does
not want to define accountability in terms of employees who have been
fired.
The department is going to testify this morning that, instead, we
should focus our accountability efforts on correcting systems
deficiencies in order to prevent adverse events from occurring again.
There is nothing wrong with fixing systems. But Mr. Coates deserves
better than that. His adverse event already happened and, for him,
there is no going back. With that, I now yield to acting ranking member
Brown for any opening statement she may have.
__________________
Prepared Statement of Michael Michaud, Ranking Member
Thank you, Mr. Chairman, for holding this hearing today. We all
agree that patient safety and quality of care issues remain top
priorities for this Committee.
I read with concern the testimony provided by our first two panels.
All too often, members of this Committee hear the same issues raised
again and again in reports by agencies such as the Government
Accountability Office and the VA's Office of Inspector General.
Findings such as inadequate training, improper oversight, lack of
guidance, no accountability, and failing to follow proper procedures
already in place, are too common.
Mr. Chairman, I understand that the Department is a very large
agency and not without its challenges. I also understand that mistakes
are going to be made. I also believe no matter how transparent the
Department is, something clearly has to change.
My frustration lies in the fact that findings are made and plans
are implemented, but the situation does not seem to get better.
Veterans, like Mr. Coates from our first panel, have suffered terribly
from these ongoing mistakes. As Mr. Coates states in his testimony:
``I am not here today for me. I am here to speak for those to come,
so that they might be spared the pain I have already endured and know
that I have yet to face.''
Mr. Chairman, we owe it to the veterans of this nation to do
everything we possibly can to improve the processes that will help
prevent such incidents' happening in the future, and ensure proper
accountability for those who are responsible.
Veterans are not statistics, a number or a column on a spreadsheet.
They are people who have fought for the freedoms we so enjoy today. We
need to remember that and the Department needs to make much stronger
efforts to turn this issue around.
In today's day of advanced systems and rapid technology
development, there is no excuse for ``losing track'' of vital consults
and appointments. Ensuring proper tracking and timely appointments is
critical.
Mr. Chairman, I do not want to revisit this issue in six months. It
is time to stem the tide of rationalizations and excuses. Let's get
this done.
I look forward to hearing from our panelists today and want to
thank everyone for being here.
Mr. Chairman I yield back the balance of my time.
Prepared Statement of Hon. Corrine Brown
Thank you, Mr. Chairman, for calling this hearing today. We can all
agree that veteran safety and quality of care issues at the VA health
facilities are of utmost concern for this Committee.
However, It is unfortunate that we must continually call these
hearings to make sure that our nation's veterans are receiving the care
for which they have already paid dearly for on the battlefields and in
service to protect the freedoms we all hold most dear.
I find it disturbing that just two days before this hearing, the VA
has releases findings that its healthcare personnel are not fully
trained in the importance of timely consults when treating a veteran.
The dictionary defines a consult as the act of seeking information
or advice from someone with expertise in a particular area.
The system the VA set up to make these consults easier obviously
broke down and it is possible that at least ficve veterans died in
Florida because the right information was not shared with the right
health professionals.
I am concerned that in the five years after the colonoscopy debacle
at the Miami VA, nothing has changed.
To refresh your memory, in 2009, staff members at a number of VA
facilities noticed improper reprocessing of endoscopes contrary to the
manufacturer's instructions. The VA properly ordered all facilities to
Step-Up and get retrained on the procedures. We want employees to feel
free to report questionable issue and procedures without fear of
retribution for trying to save lives.
It seems that from this new consult problem that the retraining
stopped at that one procedure.
The fact sheet your office put out regarding the consults talks a
lot about procedure and adverse events. However, I have heard that
before and again our veterans are suffering.
I look forward to hearing the testimony today and explanations for
this lack of proper care and accountability for these mistakes.
VA we have appropriated much money over the years to overhaul your
computer system, and yet, you could not separate that heart consults
are of a higher priority than a ride across town?
What kind of training did employees get before and how is the
training different now?
____________________
Prepared Statement of Hon. Steve Cohen (TN 9)
Thank you, Chairman Miller, for allowing me to submit a statement
into the record for today's hearing on preventable veteran deaths.
While I do not sit on the VA Committee, today's hearing touches on an
issue that unfortunately has affected veterans and their families in my
home of Memphis, Tennessee. I appreciate the Committee for accepting my
statement.
In October 2013, the VA Office of Inspector General released a
concerning report regarding three deaths at the Memphis VA Medical
Center Emergency Department. The report, which was based on a May 29-
31, 2013 site visit, found that certain actions and inactions taken by
physicians at the VA may have contributed to the death of the veterans
mentioned in the report. I do not dispute the report's findings but
instead am interested in learning what Congress and our VA medical
centers can do to help prevent incidents like these from reoccurring in
my home and at VA medical centers across America.
As soon as this report was released, I sent a letter to VA
Secretary Eric Shinseki raising my concerns about its findings as well
as those of my constituents. In the same spirit of learning what can be
done to prevent avoidable deaths at VA medical centers, in my letter I
also invited the Secretary to visit the Memphis facility to meet with
Memphis veterans and hospital staff. I asked that he offer any
suggestions that would improve care at the Memphis VA center--whether
it be increased funding, personnel, technology or equipment.
While I am waiting to hear back from the Secretary's office
regarding my invitation, I hope that the witnesses present at this
hearing will offer corrective actions that can be taken to improve care
at VA medical centers. I am also interested in their suggestions for
incorporating standards of care at these facilities so that preventable
deaths do not occur in the future.
I have been in close contact with Director C. Diane Knight at the
Memphis VA Medical Center, who was appointed in July 2013. While the
deaths and the IG site visit occurred prior to her leadership, I am
confident that the reforms she has put into place since becoming
director and in light of the report will greatly improve patient care
at the facility. I hope that the witnesses' testimonies will reflect
this and again, offer constructive suggestions for how we all can work
to improve conditions at the VA medical center in Memphis and across
America. Our veterans bravely risked their lives for us and we owe them
the very best care we can offer.
Mr. Chairman, again, thank you for accepting my statement and I
look forward to reviewing the testimonies.
____
Prepared Statement of Barry L. Coates
My name is Barry Lynn Coates and due to the inadequate and lack of
follow up care I received through the VA system, I stand before you
terminally ill today. I joined the Army in February of 1991 anxious to
serve my country. Near the end of basic training an injury to my back
derailed those plans and I was discharged around the first of May that
same year.
After a five year fight to obtain service connection status for my
injury and the treatment and pain management required as a result of
it, I finally became eligible for medical treatment through the VA
system. That was the start of the long, painful, emotional, and
unnecessary journey that brings me to you.
On November 22, 2010 severe abdominal pain sent me to Carolina
Pines Regional Medical Center in Hartsville SC, where a spinal CT
showed that my lungs were clear and my liver were normal however, there
was blood seen in the stool so a follow-up was recommended and
consideration of a colonoscopy was suggested. That follow-up
recommendation was completed at the Rock Hill Clinic with Dr. Anuradha
Verma on January 20, 2011. No rectal exam was done, I was basically
told to continue taking my medications previously prescribed and to
come back if things did not improve or things got worse.
Due to increased pain and constipation, on February 25, 2011 I
requested to be seen by a doctor or to be referred to a GI Specialist.
I saw Dr. Verma again on March 3, 2011 because of increased pain and
rectal bleeding. I reminded her of the suggestion made by the ER doctor
that a colonoscopy might be needed. I was sent home with hemorrhoidal
suppositories and the promise that a colonoscopy might be done at some
point. I was not seen until May of 2011 and the results were the same.
I had relocated in October 2010 but had to continued to be seen at
the Rock Hill, SC Clinic due to the back log at the Florence, SC
Clinic. I was first seen by Dr. Eric Naumann at the Florence Clinic in
June 2011. He started by putting me on 100 mg of the stool softener
``Docusate'' in order to counteract the constipation caused by
narcotics necessary to treat the ongoing back pain to my previous
injury. He also expressed dismay that this had not be done previously.
Most importantly, he agreed that a colonoscopy needed to be done.
However my first GI consult did not occur until August 2011 with
Dr. Sylvia Kim. I informed Dr. Kim of the ongoing pain, constipation,
and bloody stools that I had been dealing with for over a year only to
repeatedly have it dismissed as hemorrhoids. I was simply told to
return in two months, still no referral for colonoscopy despite my
request. In a conversation with Andy Pigge, Rn at the Florence Clinic,
I made it known that my requests were being ignored and I felt it was
jeopardizing my health.
On September 1, 2011 after ample time on the Docusate I sent Dr.
Naumann a message via my healthyvet.com informing him that I was still
bleeding every bowel movement and still experiencing pain. As of
September 15, 2011 I began having trouble urinating in addition to the
other problems and only found some relief sitting in warm water. Dr.
Naumann was informed of these new symptoms at this time. He stated that
I may need to see a surgeon and may need to be considered for a
colonoscopy. Dr. Naumann requested for the second time a colonoscopy
October 4, 2011.
I saw Dr. Kim October 12, 2011 and told her that the pain was now
constant as well as the rectal bleeding and that my stools have become
smaller and bright red in color. I was finally scheduled to have a
colonoscopy consultation in April of 2012, which would be approximately
a year and a half after the beginning of this journey.
Tired of living in constant pain and knowing that my problems were
bigger than hemorrhoids, I persistently called on the chance that there
might be an earlier opening or cancellation. I was able to secure an
opening for consultation appointment for November 30, 2011 and finally
had the colonoscopy done December 9, 2011. The procedure was done at
the Fort Jackson Hospital by Dr. Steedman Sarbah which found that I had
a 5.5 mm nodule located six to eight centimeters from the anal verge
with almost total luminal obstruction. I was diagnosed with stage four
colon rectal cancer. Further tests revealed metastatic nodules on the
right lung in the upper lobe along with liver lesions. It was stated
that because of the post proximity of the nodules to anal verge a
proper rectal exam would have easily found it and prompted treatment
sooner.
I saw Dr. Kim days later on the 14 of December 2012 and expressed
to her sentiments of the doctor that performed the colonoscopy along
with my own that a doctor should take time to listen to her patients as
they know their bodies and can often sense when something is wrong.
After ``supposedly'' not being able to feel the tumor during prior exam
after seeing the images she was suddenly able to locate it easily.
I had surgery on December 16, 2012 for a post diverting loop
colostomy and started chemotherapy in January of 2012 followed by 26
radiation treatments. The tumor was removed July 22, 2012 with a total
anal recession. I have since had to endure a permanent colostomy which
requires multiple bag changes per day along with catherization several
times daily because of the bladder nerves being severed in order to
remove the tumor. I am totally and permanently impotent as well as
incontinent. The extensive chemotherapy has resulted in permanent
neuropathy in both my hands and feet causing constant discomfort and
pain.
A follow up exam on April 2, 2014 has shown even further spreading
of cancer with new lesions on my liver, multiple new lesions on both
lungs, plus growth of the existing lesions and a referral for a MRI as
the doctor fears it may have spread to my brain. Another round of
Chemotherapy would have been started immediately but was postponed so I
would be able to come and speak to all of you.
It is likely too late for me, the gross negligence of my ongoing
problems and crippling backlog epidemic of the VA medical system has
not only handed me a death sentence but ruined the quality of my life I
have for the meantime. I am not here today for me, I am here to speak
for those to come so that they might be spared the pain I have already
endured and know that I have yet to face.
My situation is made even more unnecessary knowing that a 1.2
million dollar grant was given to the Dorn VA Center to reduce backlog
and improve care and treatment of veterans only to learn that the money
was misallocated by diverting it to other uses instead of using it for
the intended purpose. Only 1/3 of those funds were used properly.
Men and women across this country volunteer every day to serve in
the armed forces. The fact that our military stays well-manned and
strong solely on the willingness of those volunteers to risk their
lives for the protection of the nation as a whole is truly awe-
inspiring. Other nations have to force service in order to maintain a
strong military. The very least this country should do is to ensure
that those volunteers are taken care of after they have made sacrifices
to take care of our country. I am not a unique case in the VA health
care system as 19 others have already died and 60 more are in the same
terminal status. I am here because proper care was not given exams were
not performed properly, and diagnostic tests were either postponed or
not done at all.
In the civilian world, these doctors would face malpractice suits
and medical review boards. As the saying goes ``heads would roll.'' In
the VA system oversight is not as clear cut and complaints are often
either lost or covered up by bureaucracy. So I ask you today, how many
more vets will be allowed to suffer and die before someone is held
accountable?
Thank you for your time,
Barry Coates
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