FOLLOWING THEIR CALL FOR ACCOUNTABILITY FOR FAILURES AT BUFFALO VA, SCHUMER, GILLIBRAND, KENNEDY, LANGWORTHY ANNOUNCE NATIONWIDE REVIEW TO IDENTIFY & INVESTIGATE SYSTEMIC ISSUES WITHIN THE VA’S COMMUNITY CARE PRACTICES

Investigation Will Help Ensure That No Veteran – In Buffalo Or Anywhere Else In The Country – Fails To Receive Desperately Needed Treatment Again 

Following their call for accountability after egregious failures at the Buffalo VA left veterans waiting weeks or months to receive care, U.S. Senate Majority Leader Chuck Schumer, Senator Kirsten Gillibrand, Representative Tim Kennedy, and Representative Nick Langworthy today announced a nationwide evaluation of the VA’s community care consult practices to root out systemic issues within the VA’s health care network.

At Schumer, Gillibrand, Kennedy, and Langworthy’s request, the Government Accountability Office (GAO) will be conducting a comprehensive review of the VA’s community care consult practices. The investigation will include a review of the VA’s practices around scheduling patient treatment, particularly for high-risk and complex conditions. It will also review practices around handling concerns raised by patients and health care providers in the case of delayed treatment. 

“No veteran, in Western NY or anywhere in America, should experience failures like those that occurred at the Buffalo VA. We must make sure this unacceptable failure to provide the care our veterans need never happens again. This new independent investigation by the Government Accountability Office will conduct a top-to-bottom review of the VA’s nationwide practices,” said Senator Schumer. “We must put better infrastructure and oversight practices in place to protect veterans in Western NY and across the country. We will be watching the VA like a hawk to ensure changes are made and VA centers across the country deliver on their promise to our vets to provide them the top-notch care they have earned and deserve.”

“What happened at the Buffalo VA was unacceptable. Nothing should ever get in the way of veterans receiving desperately needed care,” said Senator Gillibrand. “I am glad that the Government Accountability Office is investigating the VA at my urging and I look forward to seeing the results of their investigation. I will continue to monitor this situation closely and fight to ensure that no veteran slips through the cracks.”

“I am pleased that the Government Accountability Office is moving forward with reviewing VA community care practices to ensure our heroes receive the quality and timely medical services they deserve,” said Congressman Kennedy. “I will continue to do everything in my power to uphold our duty of care and get the Buffalo VA back on track.” 

“We must keep our nation’s promise to our veterans that when they get home, they get the care they earned and deserve — the failures that caused critical delays in care at the Buffalo VA are absolutely unacceptable,” said Congressman Langworthy. “This new investigation led by the Government Accountability Office will help us identify the problems that allowed this to happen and ensure it never happens again. I’ll be actively involved to make sure we hold the VA accountable and deliver real results for our veterans.”

According to a report from the Department of Veterans Affairs Office of Inspector General, critically ill patients at the Buffalo VA had their treatments postponed for months or even canceled entirely, despite concerns raised by patients and health care providers. In one case, a patient waited nine weeks for radiation therapy for a new cancer malignancy, despite efforts by the chief of oncology to get the community care team to schedule treatment. In another, a veteran died waiting for palliative radiation therapy that would have eased severe pain from stage 4 cancer. Following the shocking revelations of the report the lawmakers requested an independent investigation by the GAO into the VA community care practices that led to these failures to ensure better care for veterans both in Western NY and across the country.

Specifically, the GAO review will include: 

1. Oversight of medical centers’ adherence to Veterans Health Administration (VHA) requirements for processing consults for conditions considered high-risk or complex; 
2. Whether consults are appropriately prioritized and consistently processed within VHA’s timeliness requirements;
3. Reviewing how medical facilities, VISN leaders, and the VHA Office of Integrated Veteran Care respond to concerns regarding delays in consult scheduling from providers, staff, patients, and their families and how this is built into VHA’s quality and risk management programs;
4. Best practices to prevent and address leadership deficiencies within the community care scheduling process, including the prioritization of patient safety.

The full text of Senator Schumer, Gillibrand, Kennedy, and Langworthy’s original letter requesting this investigation by the Government Accountability Office is available below:

Dear Mr. Dodaro:

            On Friday, September 27th, the Department of Veterans Affairs Office of Inspector General (“OIG”) released its findings following its inspection of the VA Western New York Health System in Buffalo, New York. The report – Leaders Failed to Address Community Care Consult Delays Despite Staff’s Advocacy Efforts at VA Western New York Healthcare System in Buffalo – found a shocking pattern of apathy and incompetence on the part of Department facility and community care leaders in addressing the needs of patients with complex and high-risk conditions.

            As the report indicates, these delays caused or led to an increased risk of harm to the patients. One veteran passed away while waiting months to receive palliative care that would have helped manage cancer pain in their final months. Another patient waited nine weeks to schedule radiation therapy for a new cancer malignancy, despite efforts by the chief of oncology to get the community care team to schedule treatment. Another veteran in their twenties continued to suffer from seizures for another 10 months as they waited for a consult to be scheduled, the delay partially caused by a referral being canceled by the community care medical director. These are only some of the cases highlighted by an OIG report that identified incompetence and bureaucratic red tape that failed the veterans in Buffalo again and again.

            The failure by the leadership at the Buffalo VA Medical Center must never occur again, and veterans across the United States must be reassured that they can receive timely and high-quality health care across the VA health care system.  Therefore, I request that the Government Accountability Office (GAO) conduct a review of Veterans Integrated Services Networks’ (VISN) community care consult practices. The review should include, but not be limited to: 

1. Oversight of medical centers’ adherence to Veterans Health Administration (VHA) requirements for processing consults for conditions considered high-risk or complex; 
2. Whether consults are appropriately prioritized and consistently processed within VHA’s timeliness requirements;
3. Reviewing how medical facility, VISN leaders, and the VHA Office of Integrated Veteran Care respond to concerns regarding delays in consult scheduling from providers, staff, patients, and their families and how this is built into VHA’s quality and risk management programs;
4. Best practices to prevent and address leadership deficiencies within the community care scheduling process, including the prioritization of patient safety;

I request a briefing on the preliminary findings with final results to be submitted on a date and in form mutually agreed upon. Please include recommendations, as appropriate, for agency or congressional action in your evaluation.

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