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VA investigation finds fault with procedures
By MARTIN J. KIDSTON - Independent Record - 07/11/09
http://www.helenair.com/articles/2009/07/11/top/55lo_090711_vadoc.txt
FORT HARRISON — A physician fired from the VA Medical Center in Helena was allowed back to work after an initial investigation cleared him of any wrongdoing, and the medical center’s process of reviewing the fired doctor’s actions have come into question.
The physician, terminated by the VA
in March, was identified Friday by
the Independent Record as Harvey
Casebeer, a 72-year-old ophthal-
mologist who was accused of
improperly conducting patient exams
and fudging medical records to reflect
care that was never provided.
While the hospital would not confirm
or deny the practitioner’s name,
several sources close to the VA
Medical Center confirmed Friday
that Casebeer had been the target
of the investigation and was
subsequently fired as a result.
Files kept by the Montana Board of Medical Examiners show Casebeer with an active medical license that expires on March 31, 2010.
It isn’t currently known if Casebeer is still practicing, but while serving at the VA Medical Center, he saw 5,879 veterans.
A report released this week by the VA Inspector General’s Office found that Casebeer was providing substandard care to patients and engaging in fraudulent medical record documentation practices.
Casebeer was fired from the hospital in March 2009, but not before he was invited to return to the VA on July 21, 2008, after a review held by the Administrative Board of Investigation, or ABI, cleared him of any wrongdoing.
“You have been approved to return to duty,” the board wrote. “The Administrative Board of Investigation has completed its work.”
That flawed investigation by the ABI has drawn criticism from the VA Inspector General’s Office, as well as Sen. Jon Tester, D-Mont., who sits on the Senate Veterans Affairs Committee.
Tester called the ABI’s investigation “absolutely flawed” and said the case should have been resolved much sooner.
The ABI’s review of Casebeer came under
scrutiny when the Office of Healthcare
Inspections began looking at the case
last year.
During its review, the OHI raised concerns
regarding the ABI and its lack of impartiality
when reviewing the allegations against
Casebeer.
“In our review of ABI transcripts, there
appeared to be inappropriate questioning
directed at the complainant, suggestive of
bias,” the report reads. “The complainant told OHI that his interview with the ABI was adversarial, describing it as intimidating and uncomfortable.”
Members appointed to the ABI are bound by VA rules to maintain objectivity, impartiality and professionalism. But transcripts reviewed by the OHI suggest that the ABI failed to act in this manner.
Teresa Bell, spokeswoman for the VA Medical Center, declined to release the names of the ABI board members, or where they were working when asked to serve upon the board.
“When an issue or a matter comes to the attention of the medical center’s management, they form an administrative investigative board,” Bell said. “They’re trained to do investigations and ask questions of witnesses.”
The report, however, said that the ABI’s investigative procedures were flawed, so much so that it affected the board’s ability to properly address the allegations against Casebeer.
Those allegations surfaced on April 13, 2008, when a complainant jumped the hospital’s chain of command and filed his concerns with the Inspector General, accusing Casebeer of providing poor care to veterans and fudging medical records to reflect treatment that was never provided.
“The consequences were not simply a flawed proceeding,” the OHI found. “Resolution of the case was seriously delayed.”
The delays caused a backlog of patients waiting for treatment. By October 2008, there were 118 patients on the waiting list. At the current rate of treatment, the review found, it would have taken seven months to clear the list.
Bell said Joe Underkofler, the director of the VA Medical Center, had been called to Washington on Wednesday — the day the Office of the Inspector General released its report — to address the House Committee of Veterans Affairs.
Underkofler, who will address the House committee next week, will be accompanied by Fort Harrison’s Medical Chief of Staff Foust Alvarez, Chief of Surgery James Nickel, Network Director Glenn Grippen and Chief Medical Officer for the network Leigh Anderson.
“They’re being called there for a briefing,” Bell said. “They haven’t been getting any advanced questions. They’ll be answering questions asked them by the committee.”
Bell said patient care remains the hospital’s top priority. Over the past year, Casebeer had seen 1,173 veterans.
Of those, 359 had already received follow-up care by another physician. The remaining 814 veterans were prioritized into three categories, including those with a potentially serious and progressive condition, those with less serious conditions and those with self-limiting issues.
“We want to make sure the veterans are reassured that we’re addressing concerns,” Bell said. “It’s important to us. Our history shows we really do care.
“We’re here for veterans, and we want to do everything we can to protect them and provide them the highest quality care.”
TIMELINE OF ACTIONS
April 13, 2008
Complainant files a letter with the VA Office of Inspector General, alleging that Harvey Casebeer, an ophthalmologist at Fort Harrison, was providing substandard care and fudging medical records to reflect care never provided.
April 17, 2008
Casebeer is placed in administrative leave as the Inspector General appoints two members from the Office of Healthcare Inspection to review the allegations.
May 2, 2008
Director convenes an Administrative Board of Investigation, recruiting two certified physicians working in the same specialty as Casebeer.
May 21, 2008
The Administrative Board of Investigation begins taking testimony from medical center staff working in Casebeer’s specialty, as well as senior medical center managers.
July 18, 2008
Administrative Board of Investigation issues its report and clears Casebeer of any wrongdoing.
August 18, 2008
Casebeer is permitted to return to modified duty at the medical center, but is not permitted to see patients. New accusations arise as Casebeer’s patients begin to see other practitioners.
Sept. 2008
Medical center management removes Casebeer from reading imaging studies and again places him on administrative leave.
Nov. 19, 2008
Peer review report finds “serious quality of care deficiencies” by Casebeer in 7 of the 8 cases it reviewed. The ABI, which cleared Casebeer, had found problems in just 3 of 38 cases reviewed.
Jan. 9, 2009
Casebeer submits detailed case-by-case rebuttal to the medical center.
March 4, 2009
Peer review firm submits detailed case-by-case rebuttal to Casebeer’s rebuttal.
March 13, 2009
Casebeer is terminated from VA employment.
July 8, 2009
Office of Inspector General releases its report.
Incompetence in care
By MARTIN J. KIDSTON - Independent Record - 07/10/09
FORT HARRISON — A doctor at the VA Medical Center accused of improperly conducting patient exams and fudging medical records to reflect care that was never provided was fired by the hospital based upon the findings of an investigation that started back in 2008.
The VA Medical Center at Fort Harrison
declined to confirm the doctor’s name
to the Independent Record, but a
spokesperson with the hospital said
veterans once under the doctor’s
care were notified of the findings
and assigned to another practitioner.
The doctor was terminated in March.
“If veterans are concerned about
their individual care, and they would
like to talk to someone, they can
speak to our patient representative,”
said Teresa Bell, the hospital’s
spokeswoman. “We’ve been very
proactive in this. We pride ourselves in
giving the highest care to our veterans.”
A report released Wednesday by the VA’s Inspector General’s Office said the allegations first appeared in a letter dated April 13, 2008.
In that letter, a complainant accused the doctor of providing poor care to veterans and engaging in irregularities when documenting treatment in their medical records.
The complainant accused the physician of practicing in an “incompetent manner” and of not performing the proper physical examinations on the patients he saw. This falsely documented treatment, the complainant added, led to misdiagnoses, which led to delays in treatment and prolonged suffering by patients.
“At best, I believe that you will find gross incompetence on the part of the (subject physician),” the complainant wrote. “At worst, some cases will lead you to believe that sham examinations are performed and therefore fraud is taking place.”
The complainant, who also is not identified in the report, provided the VA’s Inspector General’s Office excerpts from the medical records of 28 hospital patients.
Bell said the physician’s patients were
notified that their doctor had come under
investigation.
“Any allegations the VA gets we take very
seriously,” Bell said. “This report we take
very seriously. We address all concerns.”
On April 17, 2008, after receiving the
complainant’s letter, two senior physicians
from the Office of Healthcare Inspections
reviewed the allegations and brought them
to the attention of the VA Central Office in
Washington, D.C.
A panel known as the Administrative Board of Investigation, or ABI, was created to review the allegations while the physician was placed on administrative leave.
“Through our internal ongoing review process, we discovered the potential that one of our providers may not have met standards of care,” Bell said. “The provider was removed from patient care and an action plan was put in place.”
The review by the ABI “did raise patient care concerns,” the report notes. It adds, however, that the evidence reviewed by the panel “largely did not substantiate the allegations.”
Of the 38 cases reviewed, the ABI found evidence supporting the allegations in just three of the cases. In those three cases, the panel wrote, “all appear to be missed diagnoses by (the subject physician).”
But as the ABI completed its review, additional allegations surfaced against the doctor. The report said the ABI’s own investigation had failed to sufficiently address the complainant’s allegations.
The hospital hired an external doctor practicing in the same field to re-examine one of three cases. It was this external doctor and not the ABI who “identified serious quality of care deficiencies by the subject physician.”
Bell could not say how many patients the doctor was seeing at the Helena-based hospital. Nor could she release the physician’s name, saying instead that the VA’s Inspector General’s Office did not include the doctor’s name in its report and, therefore, the hospital was only following the Inspector General’s lead.
Sen. Jon Tester, D-Mont., who is a member of the Senate Committee on Veterans Affairs, expressed disappointment in the hospital’s internal review process and the time it took to reach a conclusion.
“This should have been taken care of earlier,” Tester said. “The internal investigation was absolutely flawed. If they need to do a better job of peer review, we will encourage them to do that.”
Tester also said the VA is a large organization that, overall, has seen improvements in recent years.
By and large, Tester added, veterans across Montana speak positively about the VA and the quality of care they received at the hospital. In 2005, the hospital was ranked as the top VA medical facility in the country.
The Inspector General reached several conclusions in Wednesday’s report, saying the hospital’s managers complied with current policies in pursuing its actions.
It also noted that the ABI impeded the task by failing to fully address the complainant’s allegations.
Also, the report suggested that the undersecretary of health create a panel of specialists and administrators to review the care in the specialty once filled by the terminated doctor.
Bell would not confirm the doctor’s specialty, saying again that such information was not included in the Inspector General’s report.
The Independent Record will continue to press for the confirmation of the doctor’s name.
Veterans concerned about their individual care at the Montana VA should call patient representative Susanne Corbette at 447-7990, or toll free at 1-877-468-8387.
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