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Every cloud has a silver lining!

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For years Veteran’s advocacy groups, Veterans, and families of Veterans who have passed away have been trying to bring the problems of the Veterans Administration to light. It would be easy to simply cherry-pick various VA Hospitals and point to specific problems that are well-hidden from public view and confounded with a bureaucratic maze of paperwork. Every VA Hospital has them and the Veterans caught-up in the bureaucratic maze have done their best to bring the many problems to light.

It is impossible to talk about Veterans and the Veteran’s healthcare services at the VA hospitals without having to discuss the federal bureaucracy in general, proposed budget cuts hitting every branch of government, federal waste, fraud, and abuse, lack of Congressional oversight, and a record number of claims that for years have languished in some filing cabinet or on some bureaucrat’s desk for years. There would have to be multi-volume books written to expose the enormity of the problem and a complete re-design of the entire system to finally resolve all the issues.

To those who are not Veterans and to those Veterans who have never needed to use the services of the VA Hospital System, I’ll try to be as brief as possible to highlight a few cases in point which have not donned the headlines in many newspapers or even local news reports, yet are typical of what has become all-too-common problems to those who must rely on the VA for their healthcare. Some cases however have received notoriety, but most drop from public view shortly after they have been exposed.

  • In January, 2013, a CBS News investigation found that a veterans’ hospital in Pittsburgh knew for more than a year that it had an outbreak of Legionnaires’ disease, but kept it secret until five patients died and 21 others became ill. Dave and Bob Nicklas spoke to CBS News after losing their 87-year-old father to the disease in Pittsburgh. The father, William Nicklas, a Navy veteran, caught the deadly pneumonia at the Pittsburgh Veteran’s Hospital. The VA Inspector general found the Pittsburgh facility failed to prevent the outbreak.
  • The Veterans Administration handed out nearly $97 million in bonuses. The man who oversees the Pittsburgh hospital is Regional Director Michael Moreland. Just days after that finding that the Legionnaire’s disease, in most likelihood, could have been prevented, the department gave him a $62,895 service award for saving the government money on a hospital construction project, and for starting a new infection prevention program. Records also show the hospital director, Terry Wolf, got a $13,000 bonus that year and then mismanaged the Legionnaires’ outbreak.
  • Four whistleblowers claim veterans’ health files from the Buffalo and Batavia V.A. medical centers were grossly mismanaged. Five boxes of records were contaminated with mold and mildew. Hundreds more contained mismatched names and social security numbers.
  • The Buffalo Veterans Hospital exposed over 700 patients to hepatitis over a two-year period — by reusing insulin pens. A CBS News Report also learned that during that time, Upstate New York Regional director David West was awarded nearly $26,000 in bonuses.
  • Failure to monitor mental health patients at the Atlanta VA led to three deaths. CBS News found its former director James Clark received over $31,000 in bonuses the years two of those patients died.

According to VA Accountability reports from

  • Diana Rubens, the VA executive in charge of the nearly 60 offices that process disability benefits compensation claims, collected almost $60,000 in bonuses while presiding over a near seven-fold increase in backlogged claims.
  • VA construction chief Glenn Haggstrom collected almost $55,000 in performance bonuses despite presiding over a host of major construction projects plagued by years-long delays and combined cost overruns of $1.5 billion.
  • A December 2012 audit of the Fayetteville VA Medical Center found facility employees did not complete required suicide prevention follow-ups 90 percent of the time for patients at a high risk of suicide. The audit also found the center “non-compliant” in cleanliness of patient care areas, environmental safety, dental clinic safety, training and testing procedures.
  • In July 2012, during an investigation that substantiated patient misdiagnosis complaints, VA’s inspector general found the responsible physician failed to properly review medication information 56 percent of the time, a step that is “critical to appropriate evaluation, treatment planning, and safety.” Fayetteville VA Medical Center Director Elizabeth B. Goolsby received a performance bonus of $7,604 in 2012.
  • Dallas VA Medical Center Director Jeff Milligan and regional director Lawrence Biro have received a combined $50,000 in bonuses since 2011 despite a series of allegations from VA workers, patients and family members regarding poor care at the facility as well as more than 30 certification agency complaints against the medical center in the last three years.
  • Phoenix VA Regional Office Director Sandra Flint has received more than $53,000 in bonuses since 2007 despite a doubling in the office’s backlog of disability compensation claims since 2009.
  • Carl Lowe, the former director of the VA regional office in Waco, Texas, raked in more than $53,000 in bonuses as the office’s average disability claims processing time grew to historic levels, forcing veterans to wait longer than anywhere else in the country.
  • Columbia VA Regional Office Director Carl Hawkins received almost $80,000 in bonuses despite a doubling in the office’s backlog of disability compensation claims and inappropriate shredding of disability claims documents.
  • For nearly 18 years, the dental clinic at the Dayton VA Medical Center allowed unsanitary practices, potentially exposing hundreds of patients to hepatitis B and hepatitis C. Dayton VA Medical Center Director Guy Richardson then collected an $11,874 bonus despite an investigation into the exposures. After nine of the exposed patients tested positive Hepatitis B and Hepatitis C, Richardson was promoted.

Like I said, the above represents the tip of the iceberg when looking into administrative problems at the VA. As I been pounding on in many recent articles, the government bureaucracy at all levels, in all departments, and in all programs, do not suffer from lack of funding. They suffer from lack of oversight, and accountability. The Veterans Administration is no exception, and after years of abuse, Congress is finally succumbing to the pressure of the millions of Veterans trapped in the system and the taxpayers footing the bill. This should come as no surprise as we are headed into election time once again.

While the above examples only relate to the administration of a healthcare system covering up to 25 million citizens (approximate Veteran population in the US), it would take a year’s worth of articles to begin to cover the unfortunate mistakes that are made in medical procedures. In the civilian world, those mistakes are called malpractice.

In 2010, Korean War veteran Gary Willingham, 80, went to the VA hospital in Dallas for what his family believed would be a short operation to remove a tumor from his neck. But the doctors accidentally clamped off his carotid artery and starved his brain of oxygen for 15 minutes. He had a massive stroke, which rendered him paralyzed and unable to eat or drink on his own. He died a year later.

A simple Internet search will turn up thousands of such examples in far great numbers than in the public sector, which one would except due to the fact that many Veterans seeking care are fighting healthcare problems that were contracted (i.e. Agent Orange, Depleted Uranium, PTSD, etc) while serving. This is not to suggest that all care in the VA system is substandard, but the care provided from Hospital to hospital varies greatly and most likely doesn’t stand up to the quality that is provided by the leading university medical teaching hospitals where medical teams provide state-of art treatment protocols. Anyway, here are a few examples of some of the problems you will find doing a Google search:

  • A Florida Veteran filed a claim against his VA Hospital, claiming he underwent months of unnecessary radiation and chemotherapy treatments when after he received a misdiagnosis of lymphoma.
  • In 2011, a VA Hospital was forced to temporarily close its operating rooms when investigators found rust stains on surgical equipment. The hospital eventually spent $7 million dollars on a new sterilization center, hired additional nursing staff and reopened the surgical suites after cleaning and replacing faulty surgical equipment.
  • Investigators discovered that a VA intensive care nurse injected a patient with a potentially lethal dose of painkillers. The nurse was banned from treating patients when other “egregious acts resulting in death or near death of patients” were confirmed by the VA Office of Inspector General.
  • A 58 year old veteran died during a five-hour kidney dialysis treatment. An investigation revealed that his nurse did not notice or report that the patient had become unresponsive over the five hour treatment period.

The title of today’s article is that every cloud has a silver lining. This goes hand-in-hand with the fact that history repeats itself, and has since the beginning of time. The problems with the government run Veterans Administration Hospitals, is in no small way, what happens anytime government is involved. If one were to doubt the fallacy of giving government control over the nation’s healthcare system with Obamacare, which involves one-sixth of the US economy and encompasses 330 million Americans, look at the mess they’ve made serving the US military healthcare system and that deals with only 25 million or so Veterans.

In the part two next week, we’ll compare the Veteran’s Hospital system to what the government is planning to deliver to the rest of the country through the Affordable Healthcare Act. If you are among the millions who are being served by the Veterans Administration, the 49.5 million enrolled in Medicare, the 4.6 million seniors on Medicaid, those sitting on the sidelines waiting to enroll in one of the government subsidized plans, one of millions currently covered under a company sponsored healthcare program, or one of the young adults being asked to off-set the cost of Obamacare, you won’t want to miss next week’s article.



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