Posted on Sun, Oct. 21, 2007

Iraq and Afghanistan war veterans suffering traumatic brain injury, grave wounds or serious illnesses often wait longer for outpatient appointments than the 30-day VA standard, according to an Observer analysis of two internal VA reports.

The analysis of 283,000 recent outpatient appointments showed that the VA scheduled 93 percent within 30 days, a key measure of the agency's ability to meet demand. That left 20,500 waiting longer.

At issue: Patients needing critical care accounted for 10.5 percent of total appointments scheduled, but 20 percent of those with longer waits.

The Observer's findings could signal that the VA is struggling to care for the neediest of the new veterans. Critics and veterans advocates say the system is overwhelmed, poorly managed and lacks medical specialists.

The Department of Veterans Affairs disputed the analysis, saying the reports are not an accurate measure of total service. The agency has said it can serve patient needs.

Most VA hospitals, including all six in the Carolinas, showed lags in delivering outpatient care for serious problems, according to the newspaper's analysis. For example:

• Twenty-four percent of appointments nationwide for traumatic brain injury care exceeded the 30-day mark this summer.

• At the Salisbury VA hospital, 61 percent of appointments for the seriously wounded were scheduled more than 30 days out this summer, one of the worst records nationwide.

• At the Charleston VA in South Carolina, 13 of 14 patients slated to be seen for brain injury waited more than a month. At 93 percent, that was the worst record nationwide.

"It says that we are disgracefully failing to care for some of the most grievously wounded young men and women coming back from Iraq and Afghanistan," said Linda Bilmes, a Harvard professor who has researched VA care and testified before Congress. "There is a good-faith intention, but ... as a country, we're allowing some of them to fall through the cracks."

The VA, like any full-service hospital, promptly cares for patients who are bleeding or in emergency distress. Many badly wounded veterans arriving at VAs have already been treated at military hospitals. Once home, they may face a lifetime of outpatient care. They queue up with the nearly 6 million patients swelling VA ranks.

The nation's largest health care system says the newest veterans will be seen quickly or sent to private doctors.

To help monitor service, the VA generates reports twice a month that list scheduled outpatient appointments for Iraq and Afghanistan veterans. The reports show whether veterans will be seen within 30 days or wait longer. That means the reports can be a red flag of delays.

Paul Sullivan, a veterans advocate who worked with similar reports while a VA project manager, called the Observer findings "the strongest evidence so far that the VA has a capacity crisis."

Sullivan, who resigned from the VA last year, leads one of two veterans groups that in July sued the VA on behalf of Iraq and Afghanistan veterans. The lawsuit alleges delays in disability payments and health care. Sullivan said he hopes the findings will help the VA improve care. He praised VA medical expertise and employees.

"We really do want veterans to go there for quality help -- and get it quickly," he said.

In e-mail responses to the Observer, the VA says it uses the reports as a "management tool" to identify and analyze delays. But the agency says they can't be used to judge service because they don't show all appointments. For example, the records don't reflect appointments made and completed between the reporting dates, the 1st and 15th of each month.

The VA also said about one-third of the appointments are canceled or rescheduled, or the patient doesn't show up. And some veterans choose to wait.

"The use of this data to characterize VA wait times is a gross misrepresentation of the facts," said the VA's Phil Budahn.

Some problems being fixed

The two reports obtained by the Observer list scheduled appointments for Iraq and Afghanistan veterans at 128 VA hospitals.One report is from midsummer, the second from two months later. All hospitals had few or no appointments beyond 30 days for some services.

There's no way to say how many veterans were waiting because some have multiple appointments. The Observer did not have access to patient records, which would indicate whether veterans with longer waits suffered or became sicker.

"Is anyone monitoring the status of these veterans?" asked Sullivan, head of Veterans for Common Sense, a Washington nonprofit. "Is their health deteriorating while they're waiting?"

The reports list a total of 185 types of care. The Observer, with medical consultation, identified 13 treatments for potentially critical needs, such as neurosurgery, urology and brain injury. These services also could be among the most costly and time-consuming for the VA to deliver.

The VA acknowledged problems providing some types of care the Observer analyzed.

The Salisbury VA, for example, is hiring to "help eliminate appointment backlogs," provide faster care for the most seriously wounded and "meet the projected need for traumatic brain injury assessment within the 30-day timeframe," according to an Oct. 5 e-mail.

The Salisbury VA handles evaluations for polytrauma -- multiple, serious wounds -- for its patients and those from the Asheville and Fayetteville VA hospitals, the agency said.

Following Observer inquiries last month, the VA said its Fayetteville hospital found report coding errors. That hospital also is calling veterans "scheduled for an appointment beyond the 30-day standard ... to expedite their appointment."

The VA didn't explain how, but Charleston turned around its dismal summer showing on brain injury waits and had none on the second report.

The problem is "huge demand for VA care," said Bilmes, a Harvard public finance professor. "Then you have regional pockets where you just have a real shortage of some specialists."

Discrepancy in data

Delays might be a bigger issue than the reports suggest.

VA investigators said last month that the agency overstates how quickly it cares for veterans. The VA's investigative arm examined care wait times for veterans of all eras.

They said 75 percent of veterans were seen within the required 30 days, not the 95 percent the VA claims.

The VA expects to treat 5.8 million people this year, about 5 percent Iraq and Afghanistan veterans -- both an increase.

The VA's patient load is growing because of rising health care costs and an aging veteran population. Reports of improved care quality also have attracted more patients.

"They're just overwhelmed by the demand," Bilmes said. "It's not easy for them, as a government bureaucracy, to quickly respond to the need for change."

The VA disputes that it is overwhelmed, especially by Iraq and Afghanistan veterans and their often complex needs.

The VA is under congressional and public pressure to deliver.

Scandal this year over conditions at Walter Reed Army Medical Center ramped up attention on all military care, including the separate VA system. The Observer has reported past care problems, including patient deaths, at the Salisbury and Asheville VA hospitals. Both have said problems are fixed.

The VA's e-mail said veterans with health care needs "should seek VA care -- where they will be welcomed and receive compassionate care in thanks for their service to our nation."

-- Database editor Ted Mellnik contributed.

-- Stella M. Hopkins: 704-358-5173