Phoenix 2014: The Secret Wait Lists

The scandal that defined a decade: 3,400+ veterans on unofficial wait lists at Phoenix while 1,400 sat on the official one, 45 patients harmed including 20 deaths in the reviewed cohort, and manipulation the OIG found “prevalent throughout VHA.”

It began with a whistleblower’s allegation that 40 veterans had died waiting for appointments at the Phoenix VA. The OIG reviewed 3,409 veteran patients drawn from wait lists, hotline complaints, congressional referrals and media reports.

It found 45 patients with unacceptable lapses: 28 negatively impacted by delays, including 6 who died, and 17 who received substandard care independent of delays, including 14 deaths. The OIG was careful with causation — it could not assert that timely care would have prevented the deaths — and this page is careful the same way. What it could assert: beyond the 1,400 veterans properly on the Electronic Wait List, more than 3,500 additional veterans sat on unofficial lists, at risk of never obtaining appointments at all.

And Phoenix was not an outlier. Investigations at 93 sites confirmed wait-time manipulation was prevalent throughout the Veterans Health Administration, fueled by staffing shortages, an antiquated scheduling system, and ethical lapses by senior leaders and mid-managers. VHA had even waived the FY2013 requirement that facility directors certify the integrity of their own scheduling data.

The Secretary of Veterans Affairs resigned over Phoenix. The OIG issued 24 recommendations; the VA concurred with all of them. Twelve years later, VA health care remains on GAO’s High-Risk List, and this section exists because the reports kept coming.

"wait time manipulations are prevalent throughout VHA"
— VA OIG, Phoenix review

Source: VA OIG — Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Part of the VA Fraud library — see also the case files for the prosecutions these systems produced.