Mr. Doug Paxton and his Executive Leadership Team have come under public and congressional scrutiny regarding alleged mismanagement and alleged “cooking” of Strategic Analytics for Improvement and Learning quality measures.
Mr. Paxton is aggressively denying the allegations that have been levied against him and his ELT. In his letter to all-hands, he contends the care delivered at the Roseburg VA is good and “the New York Times story is absolutely false.” During his Oregon Public Broadcasting interview, he repeatedly asked the article author, Dave Philipps, for the evidence.
To respond to Mr. Paxton’s statement and request, I present the following. I agree with Mr. Paxton — front line staff and middle management in Roseburg and Eugene work very hard and provide good care. This occurs in spite of bureaucracy, staffing deficiencies and the ELT. And, I would contend good care only occurs because the employees (doctors, midlevel providers, nurses, technicians and aids) make it so. I also would state that bad care is provided to veterans in Roseburg and Eugene. This occurs in spite of the employee efforts. Logically it follows that the poor care would then be due to bureaucracy, staffing and the ELT. Ultimately, all the good care and all the bad care provided in the Roseburg VA and in the Eugene VA rests solely on Mr. Paxton’s shoulders. After all, Mr. Paxton is the captain of this ship.
Health care, like any business, has a volume to quality ratio. If a hospital is caring for too many patients, the “human” part of health care is sacrificed for the technical and technical errors occurring because of system fatigue. On the opposite side, if a hospital is not busy enough, then time spent with a patient is plentiful. Yet, the care that is delivered is worse because underutilized skills erode and underutilized processes break down resulting in higher death rates. This is the “Goldie Locks” principle of health care; the volume of patients being cared for needs to be “just right.”
Under Mr. Paxton’s leadership, the average daily inpatient number was intentionally limited resulting in a drop from eight patients/day to four patients/day. This occurred without a change in population number and during a time when Roseburg ER visits were increasing. Mr. Paxton indicates he is limiting admission to his facility in the best interest of his veterans. He states Roseburg VA Health Care System “admits patients based on Inter-Qual criteria.” Mr. Paxton also implies that because the Roseburg VA HCS is a one-star SAIL facility they could not be manipulating the data. Further, he attributed his recent SAIL rating reduction to two unexpected deaths.
What Mr. Paxton does not do is appropriately represent how Inter-Qual is to be used. Inter-Qual’s purpose is to advise physicians on the care level typically necessary for a diagnosis, not whether a patient should be admitted. This distinction is subtle but very important to understand. The Centers for Medicare and Medicaid and the Emergency Medical Treatment and Labor Act regulations place the admission decision with the emergency room and consulting physician and not with a panel of non-clinical nurses and non-clinical physicians. The only question a facility must make regarding a physician’s decision to admit is: “Do we have an available bed, do we have the nursing?” With an average daily census of four, Mr. Paxton had available beds. CMS is very intentional in its decision to limit a facility’s choice. CMS, through application of EMTALA regulations, wants to prevent facilities from “cherry picking” patients to enhance reimbursement or enhance quality scores.
Mr. Paxton may argue the VA is exempt from following EMTALA. This argument would be false, as VA Secretary David Shulkin signed VHA Directive 1101-05 in March, which states: “While not technically subject to EMTALA and the regulations implementing the Act issued by CMS, VHA complies with the intent of EMTALA requirements.” If Mr. Paxton is to comply with the intent of EMTALA, the emergency room physicians and consulting physicians decide who is admitted to Roseburg VA HCS.
Did Mr. Paxton attempt to regulate admissions to enhance his SAIL score and monetary reward? Did he limit admissions to improve health care? Only Mr. Paxton knows the answers to these questions. But, if he didn’t manipulate the SAIL data, his decision to limit admissions did expose veterans to worse processes of care and increased mortality. One has to wonder what Mr. Paxton means when he states his SAIL rating was reduced because of two unexpected deaths. Was his limiting admission for two years a contributing factor to these deaths?
No matter Mr. Paxton’s answer, he has harmed veterans. In the first instance, he has harmed veterans for personal gain. In the second, Mr. Paxton and his ELT have harmed veterans because they do no understand health care.