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Marion Illinois woes spur VA to widen probe
By Jim Tankersley
November 7, 2007
The Department of Veterans Affairs has limited the surgical privileges of
three doctors at the troubled Marion VA Medical Center in southern Illinois,
and it is reviewing the credentials of 17,000 other health-care providers
for veterans across the country, VA officials told a Senate committee on
The department also announced it is dispatching an "assessment team" to
investigate hiring, personnel and management practices at Marion. It will be
the third investigation launched at the facility since August, when a
computer analysis showed a spike in surgical deaths at Marion and prompted
officials to suspend all inpatient surgeries there.
Testifying before the Senate Veterans
Affairs Committee, VA officials called their response to the Marion deaths
"swift" and their credentialing process for doctors "the envy of the
health-care industry." But the top official present, Dr. Gerald Cross, also
expressed "some concerns" about the agency's ability to keep tabs on doctors
once they've been granted privileges to treat VA patients.
"We're taking the broadest possible look [at credentialing processes] to
make sure that our patients can be reassured," said Cross, the principal
deputy undersecretary for the VA's health department.
Sens. Dick Durbin and Barack Obama of Illinois requested the hearing. The
two Democrats have pushed the VA repeatedly for information about the Marion
facility, 15 miles east of Carbondale, where nine patients died in surgery
from October 2006 to March 2007. That was more than four times the expected
The hearings followed questions about the VA's physician credentialing
procedures first raised in a Tribune story in September about deaths at the
Marion VA hospital. The story revealed that Dr. Jose Veizaga-Mendez, a
surgeon with a troubling professional history, was operating on veterans at
the hospital for more than a year after surrendering his license in
Massachusetts during a disciplinary proceeding.
Officials linked some of those nine surgery deaths to Veizaga-Mendez, whose
medical license was suspended indefinitely last month by the State of
Illinois. Veizaga-Mendez agreed to stop practicing medicine in Massachusetts
last year after a state licensing board there accused him of "grossly
substandard care" leading to serious complications and deaths. The surrender
was dubbed "voluntary" and "non-disciplinary," but Veizaga-Mendez remained
licensed in Illinois and continued to work at the Marion VA facility until
resigning in August.
So far, 8 staffers disciplined
The ongoing VA investigations at Marion have now resulted in five hospital
staffers being reassigned or placed on administrative leave, officials said
Tuesday, along with the three surgeons whose privileges have been limited.
Under questioning from Durbin, the officials said they also have begun to
review the qualifications of all 56,000 independently licensed health-care
providers in the VA system. They flagged 17,000 of those providers, or about
30 percent, for further review because of their answers to questions on
credentialing forms. For example, the director of quality standards for the
Veterans Health Administration, Kathryn Enchelmayer, said her name was
flagged because she once voluntarily surrendered a license in a state -- a
practice she suggested is common for providers licensed in multiple states.
Durbin asked if that review suggests the deaths in Marion could be a sign of
systemic problems in the VA's nationwide network of health-care facilities,
but Cross downplayed the suggestion. "We're cautious people," he said, and
out of caution "we chose to have this broad review."
The top Republican on the committee, Sen. Richard Burr of North Carolina,
said he had asked the committee chairman, Sen. Daniel Akaka (D-Hawaii), to
hold off on the hearing, calling it "premature and inappropriate when
there's an investigation going."
Durbin doesn't sit on the committee but was given permission to ask
questions during the hearing.
"The more I learn about circumstances at the Marion VA hospital, the more
questions I have about how the Veterans Affairs Department manages staffing
and quality control at its hospitals across the country," he said.
Obama sits on the committee but did not attend. "Today's news serves as
glaring evidence that the VA must do more to ensure quality of care for our
veterans, and provide information about the scope of this problem
nationwide," he said in a statement following the hearing.
War veteran's chilling tale
The few senators at the hearing heard a chilling tale of Marion care from an
Iraq war veteran. Marine Lance Cpl. Steven McCarty recounted how, after
returning from active duty last spring, he checked into the Marion hospital
emergency room with several symptoms, including diarrhea and vomiting.
Doctors diagnosed appendicitis and scheduled surgery.
Surgeons found his appendix in better shape than they expected, and after
surgery McCarty's symptoms worsened. Another Marion doctor diagnosed
dysentery and prescribed antibiotics. McCarty eventually was discharged.
Returning home to Texas, he visited another hospital, where doctors
discovered his colon was perforated, removed two parts of it, and told
McCarty he was lucky to be alive. He testified his colon doesn't function
now, and that he can't work or redeploy.
"These wounds are not a result of insurgents," McCarty said, "they are the
result of incompetence on American soil."