The Department of Veterans Affairs (VA) provided lawmakers with misleading and inaccurate information when they first detailed the number of veterans who were harmed by long wait times, according to a new report by the Office of Inspector General.
The VA released a "fact sheet" in April 2014 that summarized an internal, system-wide review of unresolved consults or additional requests for services that remained "open or active" after 90 days.
The review was carried out over the course of two years. According to the summary it evaluated "all consults since 1999" and identified 23 deaths of veterans related to delays in gastrointestinal care.
In a report released on Monday, investigators now say the "fact sheet" was filled with misleading information that raises questions as to whether or not the cases were ever "appropriately reviewed or resolved."
"By early May 2014, when facilities were expected to have completed their reviews, the number of unresolved consults had decreased considerably," the report notes. "However, because [Veteran Health Administration] did not implement appropriate controls, we found it lacks reasonable assurance that facilities appropriately reviewed and resolved consults; closed consults only after ensuring veterans had received the requested services, when appropriate; and, where consult delays contributed to patient harm, notified patients as required by VHA policy."
Additionally, inspectors found that "several key statements related to the scope and results of the [agency’s] review were misleading or incorrect," including things as basic as the stated timeframe.
The VA initially claimed that they investigated delayed requests going back to 1999, but months later a review by the Tampa Bay Times questioned the accuracy of that claim. The Times noted that part of the review, which looked at delays specifically for gastrointestinal cancers, "included only cases involving veterans harmed in fiscal years 2010 and 2011."
The VA acknowledged those discrepancies, saying they were an "inadvertent" error and were not meant to "mislead anyone with respect to the scope or findings of these reviews."
The inspector general’s new report confirms a faulty timeframe.
Instead of reviewing cases open since 1999, inspectors found that facility managers were told to "review consults that had been unresolved for more than 90 days but less than 5 years." If a case "had been unresolved for more than 5 years" the managers could "close those without review."
The instructions meant that the VA only reviewed open consults beginning in September of 2007, eight years later than what they wrote in their "fact sheet."
Chairman of the House Veteran Affairs Committee Jeff Miller (R., Fla.) said the latest report is troubling because it suggests that the actual number of veterans negatively impacted by delays in care may never be known.
Miller said in a statement the report shows that cases unresolved for more than five years were "simply closed out … en masse and without proper review," and VA officials made "undeniably false" claims that their review went back to 1999.
"We may never know the actual number of veterans affected by gaps in the VA system that existed for years," Miller said.
The VA did not respond to request for comment by press time.