Editor's note: This is the first of a two-day Union-Bulletin series on staff and service delivery problems within the Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla and its outlying community based outpatient clinics it administers regionally.
Under the U.S. Department of Veterans Affairs’ health system in the Walla Walla regis area — called VISN 20 — most veterans get care in three types of facilities:
Community Based Outpatient Clinic (CBOC)
The Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla oversees these satellite clinics in Richland and Yakima in Washington; LaGrande, Boardman and Enterprise in Oregon; and Lewiston and Grangeville in Idaho.
Services in the Yakima clinic include:
Primary care visits with a physician, physician’s assistant, nurse practitioner, nurse and health technician.
Bladder scans, skin biopsies and basic lung function testing.
Incision and draining of superficial abscesses.
Imaging of the retina, sent to an eye specialist elsewhere for interpretation.
Traumatic brain injury initial screening and secondary assessment.
Mental health assessment, counseling and medication management.
Nutrition and pharmacy counseling.
Vaccinations and some other injections.
Jonathan M. Wainwright Memorial Veterans Affairs Medical Center
The Walla Walla VA provides all the services listed above, as well as:
Post-surgical and diabetes-related wound and skin care provided by home health nurses.
Exams of the esophagus, stomach, colon, bladder.
Optometry consults; some eyewear fittings.
Residential treatment for chemical dependency.
Complete lung function testing.
In-depth imaging via ultrasound, X-ray and CT scans.
Basic lab analysis of blood.
Intravenous infusion of medications.
Scanning of documents into the medical record.
Medications provided on site.
Home-based primary care.
Non-VA treatment determinations.
VA Puget Sound Health Care System in Seattle
Seattle VA provides all the services above. Additional services not available at the Walla Walla VA or Yakima CBOC include:
Gynecologic consultation and procedures.
Nuclear medicine imaging, including nuclear stress tests for cardiac evaluation, cardiac catheterization.
Rehabilitation, including physical, occupational, recreational and speech therapy.
Post-traumatic stress disorder and psychiatric inpatient treatment.
Polytrauma rehabilitation, including traumatic brain injury evaluation.
Cancer chemotherapy, bone marrow biopsy.
Magnetic resonance imaging.
Inpatient hospital care, including critical care.
VA emergency room services 24 hours a day, seven days a week.
Source: U.S. Department of Veterans Affairs, Jonathan M. Wainwright Memorial Veterans Affairs Medical Center officials and Walla Walla VA employees who requested anonymity for fear of workplace retribution.
WALLA WALLA — Dr. Jonathan Hibbs understood what it would mean to walk away last month from an institution like the U.S. Department of Veterans Affairs.
Not being allowed to do his best doctoring for some of the nation’s most vulnerable patients, however, was a final straw in eight years of working for the institution, some of that time spent in medical management at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center.
From believing in the VA’s mission to eventual disillusion, Hibbs said he has come to see the agency is all about policy, not people.
The physician saw the agency trip over its own rules again and again. While he was medical director of the Yakima community-based outpatient clinic (CBOC) — which reports to Walla Walla’s VA as part of that network — Hibbs said he came to regard the health care system as top-down management designed to work against employees and patients.
Take something straightforward, such as a colonoscopy doctors advise for patients age 50 and up.
“Every patient I had has to travel to Walla Walla to get a colonoscopy,” Hibbs explained. “They have to go to the toilet for hours beforehand, they can’t eat. then they want them to travel to Walla Walla, with someone, for the procedure? A lot of my patients lead chaotic lives and they don’t have someone who can come with them.”
Once the procedure is over, those same men and women have to turn around and travel two hours or so back home. They’re in a state of discomfort, partially sedated and unable to drive, Hibbs said, and getting folks to agree to the ordeal has been difficult.
“The point being that colonoscopy is something we want lots of patients to have,” he said. “It’s usually not something the patient initiates, it’s something we ask them to do to prevent a disease they can’t even see nor feel. Yet at the same time we’re trying to persuade them to do it, we make it difficult.
And that difficulty, he added, is unnecessary.
“We do this even though there is a clinic that does many colonoscopies a day right in their hometown of Yakima. That isn’t patient-centered care; it’s facility-centered care — I’m essentially placing the needs of the Walla Walla VA above the needs of my patient, and I’m not OK with that.”
Officials at the Walla Walla VA, however, said some colonoscopies are provided to veterans at non-VA providers in their communities. As well, veterans from Yakima can come to Walla Walla the night before.
“We lodge them and they can do the prep here,” said Brian Westfield, who came on board as director in 2008.
But for Hibbs, the final straw came when he was no longer allowed to treat the VA’s vulnerable patients responsibly and with honor. He left the Yakima CBOC on July 25.
The departure terminated a practice he always hoped would make a difference, he said.
“I can’t live with the policies we are pursuing at this time,” said Hibbs. “I can’t stay here any longer. I want the VA to succeed but it’s failing.”
Leading by “intimidation”
Hibbs’ residency training in internal medicine in Minneapolis included rotations at that VA facility. Later he worked for Walla Walla’s VA as an infection-control specialist and part of the ethics committee.
By his second year or so here, Hibbs realized it would not be an easy place to work.
“I was talking about redesigning the clinic, changing the way the work was organized to be rational,” he said. “I was heavily involved, listening to staff members. We had meetings, we spent a lot of time processing what needed to be done.”
Hibbs said he believed it made good sense to involve employees in finding solutions and addressing their unhappiness at not being listened to in the past.
“But while we were doing all this,” he said, “one of the nurses told me ‘You know, Jon, this is great but it’s going nowhere ... you are giving people false hope. Nothing is going to happen.’”
The doctor refused to believe that. Now he knows exactly what that nurse meant. When the new plan — flow charts, the whole works — was scrapped by his superiors, he was appalled.
“They told me ‘If we want ideas, we’ll ask you.’”
It was further suggested Hibbs had intimidated people into going along with the redesigned approach, an allegation that didn’t fit with his “new kid on the block” position at the time, he said. “But administration rules that way, it’s the language they speak. I have seen that in Walla Walla and other places. They lead by intimidation.”
It was his first experience with the disillusion of running up against policy, Hibbs recalled. There would be countless more before his VA career was over.
Whether situations are crises or routine, the organization’s mindset is harming veterans, he maintains, “and it’s not seen by the public.”
Policy before procedure
Start with crises. Veterans who first go to the Yakima CBOC with an emergency situation, like bleeding gut or a heart attack, are sent to hospital emergency rooms as protocol demands, the doctor explained. “The VA will usually pay for that.”
But should that same veteran go directly to either of Yakima’s two hospitals, without passing “go” at the CBOC, the VA often balks at paying those bills, especially if the chest pain turns out not to be a heart attack. Even though the more direct route to care is medically safer, VA payment system encourages veterans to waste steps and time in getting help, Hibbs said.
“And the VA is following its own rules in doing that. They say it was not an emergency. But the veteran doesn’t know that.”
Surgeries that can be planned — hip replacement and gall bladder removal, for example — are routed to Portland, Seattle and Spokane VA hospitals, Hibbs said. “Or, God help us, Boise. It’s a long way to get to Boise, and if you’re miserable, it’s a really long drive.”
Hibbs calls the situations horrendous. The veterans he’s cared for generally do not have the resources for such trips: Gas, lodging, meals for themselves and often for someone who has come along to help add up, he pointed out.
Most diagnostic tests, for example, require travel to Walla Walla or elsewhere to meet policy, according to Hibbs and VA officials.
And when veterans are put on the road for care, that policy has resulted in highway collisions — some fatal — involving veterans in Washington and other states over the past few years, Hibbs said.
He supplied a number of news reports, including one about a 51-year-old veteran who died when a VA van driven by a volunteer drifted off the road and crashed while en route to a VA clinic in White City, Ore., in 2011.
In winter of 2008, five veterans from Yakima were headed to Seattle for appointments over Snoqualmie Pass when the van transporting them skidded on an icy road and struck a median. At least one suffered injuries, and responders had difficulty getting to the scene.
“The veterans involved in these crashes were traveling to central VA facilities in service vans to receive scheduled services that could have been offered by non-VA facilities closer to home,” Hibbs pointed out. “Nobody makes a fuss about it because each crash is treated like a sad but isolated accident. The systems problem doesn’t appear until you put a bunch of the incidents together.”
There is also the hardship of patients being away from friends and family, plus getting care from physicians they have no prior relationship with, he said.
Hibbs said it boils down to this — Walla Walla and other centers get the equipment and Yakima’a clinic doesn’t.
Westfield said he has field discretion to purchase community care for a veteran if it’s in the best interest of the patient.
“We do purchase care when it makes sense,” he said.
Westfield said he uses a 60-driving-minutes radius from VA facilities as a guideline when determining where to purchase non-VA care for veterans.
In 2013, Jonathan M. Wainwright Memorial Veterans Affairs Medical Center officials authorized $21.6 million for non-VA services, including home health, dental and vision care.
That’s about 25 to 30 percent of the total budget for the Walla Walla center’s region, which included CBOC’s in Richland and Yakima in Washington, LaGrande, Boardman and Enterprise in Oregon, and Lewiston and Grangeville in Idaho.
Caution must be taken any time a patient goes outside the VA health system, however, Westfield said.
“I think it could potentially disrupt the care process,” he said. “It can create care that is not well coordinated, so partnerships need to be developed to make this an effective program.”
An unsent letter
Dr. Don Hill is a Yakima physician who worked with Hibbs from 2008 to 2011 before also quitting the VA. He, too, can be counted in the demographic of the disillusioned.
A Navy Reserves corpsman who served in Vietnam from 1969-71, Hill then became a doctor and served in the U.S. Air Force from 1990-1994. After he left the Air Force, he said, he intended to bring what he could to the Veterans Health Administration.
Like many physicians, Hill trained within the U.S. Department of Veterans Affairs health care system. When an opening was advertised for Yakima CBCO, Hill recalled being eager yet realistic about doctoring while operating in a government system.
Three years inside that perimeter found Hill discouraged and pessimistic, he wrote in a 2012 letter to Rep. Doc Hastings, R-Pasco, a letter Hill said he regrets never mailing.
Hill said problems for providers in the Walla Walla VA system are numerous. Despite a conscientious clinic staff, patient care is too often thwarted by demands from those in authority at Walla Walla.
His list of hurdles includes:
• Results — labs and imaging, for example — for patients sent to Walla Walla were often delayed in getting back to the Yakima clinic.
“Those had to be scanned in Walla Walla; we were not permitted to do that in Yakima for some reason,” Hill said. “Then I would not have the report for when the patient came back in.”
• Referrals for diagnostic testing and specialty care often reflect more of a concern for preserving equipment and specialists within the parent facility — Walla Walla, Spokane, Seattle, etc. — than for the safety and benefit of the patient.
• Patients with established non-VA providers are required to be seen in the Yakima clinic to get approval for prescriptions ordered by that outside doctor, Hill said. Those prescriptions would then be entered into the computer system under the VA provider’s name so they could be dispensed by a VA pharmacy service, usually through the mail from the Walla Walla VA hospital.
It’s a process Hill described as unnecessary and wasteful.
“Why not allow a local pharmacy to bill the VA for the same prescription?” he said.
• Patients, many sick and elderly, are mandated to attend group visits for chronic disease management.
“We are asking them to drive 100 miles in some cases, asking them to come in and be seen just for their blood pressure problem, for example,” Hill said. “These are people with cancer, arthritis, hypertension, all kinds of health issues and we are asking them to come all that way for one of those things. It’s all about making your numbers look good. I refused to do it.”
Yet no one at the top ever asks for solutions from those at the bottom, he said. It’s like being in a war zone surrounded by a giant and entrenched bureaucracy.”
“It’s us-against-them. We have to struggle against these administrators,” said Hill. “If we can’t get it right for the veterans who have sacrificed to preserve our freedoms, what will it be like for the rest of our citizens?”
To Hibbs, too many VA employees believe federal investigations will save the system.
“They think, ‘It will be painful but they will shine the light in the corners,’” he explained. “But the (Office of Inspector General) inspects us for our own policies and most of our problems are caused by our own policies. Policies are made by people who don’t see patients.
“We think the rules are here to protect us and they do, but not from all problems. Some rules, and the ways they are implemented, are actually hurting us and they are hurting veterans.”