Patients in a Southeast Texas Department of Veterans Affairs medical system faced denials or long delays in getting routine colonoscopies and other medical tests because of bureaucratic cost-cutting, a former top administrator told the Washington Examiner in an exclusive interview.
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Dr. Richard Krugman, former associate chief of staff at the Veterans Affairs health care system based in Harlingen, Texas, said his boss implemented a policy in 2010 that colonoscopies would only be approved if the patient tested positive in three successive screenings for bloody stools.
“By the time that you do the colonoscopies on these patients, you went from a stage 1 to a stage 4 [colorectal cancer], which is basically inoperable,” said Krugman.
“That was done because of dollars and cents. For the VA, they have to be bleeding out of their rectum before they would authorize a colonoscopy. That was the standard of care,” he said.
Since the Harlingen VA health center couldn't do colonoscopies at that time, all referrals had to go to local private providers.
The cost-cutting order came from Dr. Raul Aguilar, chief of staff at the VA Texas Valley Coastal Bend Health Care System, Krugman said.
As many as 15,000 patients who should have gotten the colonoscopies either did not get them or were examined only after long and needless delays, Krugman said.
That estimate is based on the demographics and total number of veterans treated in the Texas Valley network, about 40,000.
Many likely died, Krugman said. But, since there is no VA hospital in the area, their final days would have been spent in a private hospital or at home, where they would not appear in VA statistics, he said.
Another directive was issued in January 2011 requiring that patient referrals to private providers be cut by 10 percent.
That order was sent by Jeffery Milligan, then director of the Texas Valley health network, according to an internal email obtained by the Examiner.
Krugman also told the Examiner that an office secretary deleted about 1,800 orders for medical tests or other services to eliminate a backlog that threatened a certification inspection from an outside group.
Krugman reported his allegations to the U.S. Office of Special Counsel in a whistleblower complaint filed in July 2011.
Krugman was put on administrative leave for a year after he complained to higher-ranking VA officials that patients' lives and health were being put in jeopardy by ill-conceived policies and a poorly designed surgical center. Though he was still being paid, he was not allowed to do his job.
He was fired in May 2012, but is appealing to the federal Merit System Protection Board, claiming his termination was in retaliation for being a whistleblower.
Krugman's allegations are consistent with deficiencies at other veterans' hospitals across the country identified by the agency's inspector general, the Government Accountability Office, congressional investigations and media reports.
VA has acknowledged 23 patients with gastrointestinal cancers died while in its care after long delays in receiving colonoscopies or similar tests.
An internal investigation by VA acknowledged that some of Krugman's allegation were true, but downplayed any harm to patients.
The investigative panel appointed by VA Under Secretary for Health Robert Petzel cited Aguilar's “emphatic” denials that there was a policy requiring three screenings before a colonoscopy was authorized.
Petzel’s team did say fecal occult blood tests, which detect blood in stools, are an appropriate screening method if that is what the patient prefers.
VA’s investigators found no evidence the patient was given the choice. But that doesn’t mean the VA’s policy requiring patient consultation was not followed, the team concluded.
“On record review, however, no chart was found that indicated a veteran was informed of his or her choice of type of screening tool,” the agency’s investigators said.
“Complete documentation of all education and information given to patients is not required and the lack of it in the patient record does not suggest that the conversation/education did not take place,” the report said.
The Harlingen medical center is now equipped to perform colonoscopies in-house.
Regarding the mass purge of 1,800 medical orders, Petzel's team concluded they were closed appropriately after each was individually reviewed to ensure medical care was properly delivered or no longer needed, consistent with VA policies.
But that never actually happened, according to Krugman. Instead, the chief of staff's secretary mass-deleted virtually all of those cases in a single afternoon in May 2011, he said.
The Examiner reported earlier this month that more than 1.5 million VA medical orders nationwide were canceled in the past year without any guarantee the veterans received the care that had been ordered.
Many of those orders for tests, specialist visits or other services were closed without any evidence in the case files that they had been individually reviewed, or that the patient or doctor was contacted.
In February, the Examiner reported that 40,000 VA medical orders were canceled in Los Angeles and another 13,000 in Dallas to make it appear those facilities reduced long backlogs for delivering services.
Milligan, who was director of the Texas Valley health network when Krugman worked there, has been director of VA's North Texas Health Care System in Dallas since 2011.
More recently, it was disclosed that two sets of appointment books were kept at the VA hospital in Phoenix to conceal long waits patients faced when seeking care, and that documents were destroyed to conceal the practice.
The VA inspector general and the GAO are investigating allegations of mass purges of medical appointments and that bogus records were kept in other facilities across the country.
VA Secretary Eric Shinseki last week ordered a nationwide review to determine if fraudulent wait lists were being kept at other medical centers to hide backlogs, an allegation that was raised by GAO more than a year ago.
Krugman was hired as associate chief of staff at the Texas Valley health network in September 2010. The new system was being split from the region based in San Antonio.
At the time, a $40 million surgical center was being built in Harlingen to allow minor surgeries to be performed locally, sparing veterans long drives to the nearest VA hospital.
Krugman, an anesthesiologist who had overseen development of similar facilities in the private sector, immediately saw problems with the building’s design that threatened patient safety.
The heating and air conditioning systems were not appropriate for maintaining a sterile surgical environment, and there was no backup generator to ensure power during one of the area's frequent outages.
Krugman's initial complaints to his bosses about those design deficiencies soon turned to issues directly affecting patient care.
A March 2011 email agenda for a staff meeting sent by Aguilar called for a “temporary reduction in screening colonoscopies for low risk patients by using fecal occult blood testing.”
The agenda says the policy would be to allow “colonoscopies for cause.”
“A fecal smear only delays the colonoscopy,” Krugman told the Examiner. “So that was a business move. They just put different hurdles for the veteran patient to jump before they had to spend money.”
Making matters worse, the Harlingen facility frequently ran out of fecal blood screening kits, so even when a veteran did show up for a follow up screening it could not be done, Krugman said, an assertion he documented with repeated emails sent at the time.
After frequent and intense complaints that patient care was being compromised, Krugman was stripped of his duties in January 2011.
The medical orders were purged in late May 2011, just prior to an inspection by the Joint Commission, a nonprofit organization that accredits health care facilities nationwide.
If the commission found the backlog, it would have jeopardized the Texas Valley split from the San Antonio network, Krugman said.
No attempt was made to contact the doctors or patients to determine if the tests were still needed, he said.
Krugman was put on administrative leave and escorted from the building in June 2011. He hired a lawyer, who filed his complaint with OSC a month later. Krugman's termination was effective in May 2012.
The OSC report does not draw conclusions, but rather documents the whistleblower's allegations and the agency's response.
That is standard procedure for that type of whistleblower complaint to OSC, said spokesman Nick Schwellenbach.
Sending the reports to the White House and congressional oversight committees is also routine procedure, he said.
Shinseki is scheduled to testify before the Senate Committee on Veterans' Affairs Thursday.
Milligan and Aguilar could not be reached for comment.