Manchester VA, Two Years On

Two years ago, VA employees blew the whistle on what they called bad care for veterans at the Manchester VA, kicking off a scandal that made national news. 

This week, we’re taking a look at what happened in New Hampshire’s only VA Medical Center after the scandal.

Thirty years ago, Joseph Maloof underwent spinal surgery after rupturing a disk in his lower back. The procedure left him with back pain whenever he stood straight. “I was never the same after that,” he says. “My back never really regained my vertical posture.” He began to walk with a hunch, as though scanning the ground for a lost contact. “I bought a couple of things you see on TV, back braces and whatnot, which helped me walk a little bit straighter,” he says. “But the more I tried to straighten out my spine, the more it hurt.”

Maloof, a sixty-six-year-old Army veteran, lives in Conway. In 2014, he met a doctor named Ed Kois at the Manchester VA Medical center. Kois had recently been hired as a physiatrist and recommended that Maloof go to a nearby private hospital for a second surgery—nearly three decades after the first. In a matter of months, the pain that had debilitated Maloof evaporated and his posture straightened. 

The surgery, to Kois, was a readily apparent solution, but it was one that previous VA doctors who treated Maloof had missed. It was also one that Maloof wasn’t asking for. “I wasn’t jumping up and down at the VA.” Maloof says, “I wasn’t the squeaky wheel.” In hindsight, he realizes an attentive physician might have spared him years of pain. “If I had jumped up and down, I don’t think the VA would have ignored me,” he says. 

Kois recognized a pattern of cases similar to Maloof. Kois came to the VA after three decades of private practice, where he says spinal cord injuries similar to Maloof’s usually resulted from traumatic incidents—car accidents, gunshots, and the like. At the VA, Kois noticed a different trend. “I started to see a lot of people with an acquired spinal injury,” Kois says, “because of basically non-treatment.”

He began to document what he considered a pattern of insufficient patient care. He kept a list of patient names, a list that eventually reached more than ninety names. It included a young man with a screw mistakenly drilled through his nerve, and a veteran who lost the ability to speak or hold his bladder due to a poorly-managed tumor in his neck. Each case, in the eyes of a physician accustomed to private medicine, raised alarm. 

Two years ago, Ed Kois joined a dozen other VA employees to broadcast their alarm first to their superiors, and then to the public. The group tipped off the Boston Globe Spotlight team, whose article on the condition of the Manchester VA Medical Center caused a brief, national scandal. 

Once the lenses of television cameras retreated, the hospital was left with a challenge faced by VA hospitals all over the country: respond to the needs of patients, listen to the concerns of doctors, and do both while operating within a vast bureaucracy and a constrained budget. 

The Veterans Health Administration is one of the largest healthcare networks in the country, and it’s the closest the US has to socialized healthcare. Military veterans, with a few exceptions, have the option to receive free or nearly-free healthcare. Each year, nine million veterans receive care at 170 hospitals and medical centers. Compared to other VA hospitals, the Manchester VA is small. It offers primary care, pain management, mental health, women’s health, and surgeries that don’t require an overnight stay. 

At the same time that Dr. Kois began to keep his list of names—and scrutinize the workings of this enormous healthcare system—a story broke in Phoenix, Arizona, in 2014. The waiting list for doctor’s appointments had grown so long that numerous veterans, according to CNN, died during the months-long waiting period. 

The VA denied that any of those veterans died as a direct result of lack of care, but the incident became a focal point for public outrage at the VA’s apparent bureaucratic mire. Under pressure, Congress put forth a law called the Veterans Access, Choice, and Accountability Act, often shortened to Veteran’s Choice or Vets Choice, to address the problems.

The goal of the program was to cut down wait times by providing the VA with more money to send veterans to doctors in the private sector, easing the strain on the network of VA hospitals and expanding the range of services available. But Veterans Choice ran into trouble from the start. 

Many doctors didn’t like it. Patients found the process confusing. Vets would be sent to the wrong place. Authorization forms would go missing. A variety of other factors made a mess of the whole Vets Choice system. 

Kois had another problem with Vets Choice—the Manchester VA’s new chief of staff, Dr. Jim Schlosser. Like all chiefs of staff, Schlosser was in charge of authorizing the most cost-effective way to get veterans appropriate care. He started in 2015, when Vets Choice was brand new.

“Right around that time they also developed budgetary constraints. And that’s where the problems began,” Kois says. 

Kois did not like Vets Choice. He also didn’t like sending patients to the Boston VA, which he thought was providing bad care. For example, he says the Boston VA screwed up Joseph Maloof’s X-rays, essentially masking the problem with his spine. 

The VA had another way to send veterans to private hospitals outside of Veterans Choice. A separate line-item in the VA’s budget. That’s how Joseph Maloof got his surgery. Kois pleaded with Schlosser to let him send patients using that system. 

“After butting heads with Dr. Schlosser a couple of times, I was in a position where I had people with serious injuries and I wasn’t having them adequately taken care of. But he didn’t really care. He made it clear I had to use his hierarchy, which was either Boston or Vet’s Choice or none at all,” Kois says. “What I didn’t realize at the time was that he was having a rough and rocky relationship with multiple physicians. And this was the genesis of what eventually happened.”

Kois, frustrated by red tape, spoke with doctors who shared his hallway, and discovered he was not alone. “We would use the F-word quite a bit,” he says. Kois and his colleagues agreed that a combination of insufficient funding and opaque institutional hierarchy prevented them from providing ideal care to their patients.

For instance, a nurse anesthetist didn’t have basic equipment to sedate patients safely, and administrators couldn’t secure funding to install a much-needed nuclear camera. And then there were the operating rooms, which were frequently closed because of a recurring fly infestation. 

Kois and his colleagues wrote a letter enumerating their concerns to New Hampshire’s congressional delegation. The state’s representatives expressed alarm, though did not take actions as drastic as Kois had wanted, like firing Schlosser. The delegation did order an investigation by the VA Office of Medical Inspector, but Kois believes the investigation was designed to protect rather than look into the VA. 

“They didn’t invite me to the initial investigation,” he says, “I actually forced myself on them because I wasn’t on the list of people to interview, even though I was the one that started the whole process.” The investigators examined patient charts for evidence of negligent care and did not find any, though Kois believes the charts themselves were unreliable and investigators were not thorough enough.

Once the investigation wrapped up, and the leadership of the Manchester VA were seemingly cleared of wrongdoing, Kois says Schlosser tried to remove him from the spinal cord clinic. Kois was not removed, but the attempted retaliation unnerved him. So when he got a call from The Boston Globe, he was eager to talk. Over the course of dozens of phone calls, he listed his concerns, all the while fearing that he would be removed from his position.

On July 15, 2017, the Globe’s Spotlight team published its report, and within 48 hours, the whistleblowers’ first wish was granted. The VA Secretary at the time, David Shulkin, removed Schlosser, Medical Center Director Danielle Ocker, and Nurse Executive Carol Williams from their positions. They were not outright fired: Schlosser and Ocker were reassigned to other positions within the VA while Williams retired. Regardless, to Kois and the other whistleblowers, the move was a signal that change would come. 

To the casual news consumer, it seemed like the VA was cleaning house and fixing the problems. But it’s hard to fix the problem when there’s no agreement on what the problems really are. The whistleblowers had one view. The ousted leaders had another.

Jim Schlosser says he and the entire leadership team were steadily working on all the issues described in The Boston Globe. “The way it was framed in the Boston Globe was really inexact, inappropriate,” Schlosser says. 

Take the flies in the operating room for example. “We had been working on for a number of years. We’d had expert entomologists, both people from VA Central Office and private contractors working on that,” Schlosser says. He says the hospital ensured the issue never affected patients. “No surgeries were delayed or cancelled. No patients were harmed. Our surgical infection rate was zero, in fact. And so to give the impression that the place was rampant with flies or dirt or something like that was just really inaccurate.”

Schlosser says the Manchester VA is an old building prone to such problems. The medical center’s procedure for addressing the problem, Schlosser says, was appropriate and safe. 

The broader complaint whistleblowers raised against Schlosser is that he would not authorize appropriate care because of cost. Schlosser maintains that he needed to operate within a limited budget, and that those budgetary restrictions never forced a patient to receive inadequate care. Schlosser also emphasizes that the underlying process for veterans to request private care was sound. “If a veteran feels that a clinical care has been denied that they think was adequate, they could appeal that,” Schlosser says, acknowledging that very few veterans chose to undertake the appeals process. “They’d much rather go to the press and make an issue about a care decision rather than try to get a clinical appeal to overrule a local decision.”

Schlosser declined to comment on Dr. Kois or his list of more than 90 patients. 

“I think the whistleblowers’ intention to open up issues of concern is appropriate and can be constructive,” Schlosser says. “It’s one way to make change. Is it the best way? Is it most effective? Is it the best service to the veterans and our citizens who fund the enterprise, to manage the system in that way? I think a more progressive or constructive approach is to make sure there’s voice for concerns, whether from veterans and their families or from staff of various levels, so that their concerns can be brought to light, evaluated as judiciously as possible. And because it’s a big system, we can’t change everything at once. We only have so much. Congress allocates funds and we’re tasked to use them as effectively as we can.”

In September 2017, two months after the Boston Globe report, a congressional field hearing was held in Pembroke. Around this time, the whistleblowers’ public focus shifted from identifying faulty metrics to targeting individuals they thought would prevent meaningful change. One of those individuals was Michael Mayo-Smith, who led New England’s regional group of VAs.

At the hearing, Mayo-Smith praised the whistleblowers. When he pushed back, it was gentle. He didn’t argue or get defensive. “There was sort of a gag order,” he says. “We weren’t allowed to speak to the press directly. It was being handled in Washington. And there was very much a feeling of not being adversarial with the whistleblowers. And so that was the direction that was taken at the hearing.”

And in the months following the hearing, whistleblowers lambasted him in the press. He never fought back. Eventually, he was pressed into retirement. “I think the actual patient concerns could’ve been addressed very thoroughly without these, in some cases, very personal attacks against a number of people.” Mayo-Smith agrees with Jim Schlosser that VA leadership, at the local as well as regional level, were doing the best they could with limited resources.

Mayo-Smith also says medical center staff cooperated with and supported the investigations into the Manchester VA, noting that one of the eventual reports from these investigations commended Manchester leadership on their cooperation. “Really I view it as a complete exoneration of local leadership in terms of the allegations brought against them,” he says. The VA has declined requests for comment on the investigation.

A report on the Manchester VA issued by the Office of Accountability and Whistleblower Protection focused on leadership performance, and it found no fault with Danielle Ocker, Jim Schlosser, or Carol Williams. Mayo-Smith says the VA rushed to remove those leaders under pressure from whistleblowers, the public, and Congress, before investigations could be conducted. “In the military it’s a pretty standard procedure,” he notes. “If there’s a senior leader, and there are serious allegations, they take them out of that position of command, and complete an investigation, and then make a decision about putting them back in or not. That wasn’t the process that was followed at the VA.”

Earlier this month, the Manchester VA hosted a town hall meeting. If you want to learn about the particular shortcomings of any given VA hospital, these events will reveal them. Veterans more often show up with complaints than praise. They are not shy.

At this town hall, a 30-year-old Army veteran from Brookline, New Hampshire, Shawnasey Madison, spoke up. “I have been coming here since 2011. I love it here. I tell all my friends that are veterans that this is the place to go, with one exception.” Shawnasey said she arrived earlier that day seeking mental health counseling. “So, walked in and said, I don’t have an appointment, but my medication isn’t working appropriately and I’d like to talk to someone.” Shawnasey choked up as she described being turned away. 

At this point, Al Montoya steps forward and begins to address her experience. Montoya’s the newly appointed director of the Manchester VA. “I’ll tell all veterans who are here, at the end of the night, I’ll give out my cell phone number just like in every case. You may run into a barrier, and I walk around this medical center a lot, always checking with veterans, but I may not see what you see, so I need you to pick up the phone and call me.” Montoya’s message, throughout the night, was that he was listening. 

Evaluating the effect of a change of leadership is difficult, though some veterans who attended the town hall that night praised what they considered an improvement in waiting times for appointments as well as the duration and quality of those appointments. “I just find that there’s been more training,” one person in attendance said, “more behind the scenes push to make the individuals that work here to be more sensitive to the needs of the veterans who come here.”

“If you recall back in the Boston Globe article where it mentioned that flies were coming into the OR and all of those things, we’re working on some physical things to make sure that doesn’t happen,” Montoya says, adding that “you have to have a process in place so when an insect does come in, you stop the line, you terminally clean the room.”

Montoya’s argument is the same one used by his predecessor, Jim Schlosser. Montoya does have one thing previous leadership did not: more money. Some of that money is going toward major renovations.

Montoya declined to gauge how much of that new money could be attributed to whistleblowers, but he says they deserve some credit. “I’m actually appreciative that they came forward and brought their concerns because it gave an opportunity for us to make these improvements, for us to really go out there and invest in the organization, invest in the services. And so I think if that had to come from them coming forward, then so be it.”

The disagreements between whistleblowers and administrators were rooted in conflicting visions for how patients should be cared for. Previous leaders kept citing the budget when they denied requests for care the whistleblowers thought was non-negotiable. Montoya points out the tension between frugality and thorough treatment remains. “We still have to run this place like a business,” he says. 

Ed Kois says his referrals are approved faster now, and that Montoya and other leaders seem to care about his concerns. Under previous leadership, Kois complained of an over-emphasis on performance metrics that did not accurately represent the condition of the hospital, and he says Montoya has improved on that practice. “Al comes out of his office. Al talks to people. Al listens to patients. If someone makes a complaint, Al fixes it. If I walk into Al’s office and say ‘Al, something’s broken,’ he says, ‘I’ll have someone come down today.’ That never used to happen.”

Former Chief of Staff Jim Schlosser, too, agreed that the hospital’s period of upheaval—including his own ouster—ultimately benefited the hospital. “I think it is better off, because there’s been a clearing of the air. There’s been new funding and attention to the work of the Manchester VA. And the current leadership is really trying to engage staff, empowering staff, and build new programs that serve veterans.”

Schlosser says certain policy changes would help the VA as a whole address concerns. One is greater flexibility in budget allocation. The VA gives each medical center money separate pools of money for separate budgetary needs, such as administrative costs, medical care, or construction, “which can’t be used very efficiently,” Schlosser says. “They have to be kept separate and accounted for separately. And if one runs out, another one can’t replenish it. You can’t just move money where it’s needed most.”

Schlosser also thinks the VA should be less political. It’s good that the VA is accountable to the public, he says, but it’s also susceptible to the whims of politicians. “So you have the countervailing needs of a healthcare system that needs thoughtful, long-term building of engagement with patients and staff to develop the systems that will serve them the best, and the shorter cycle time and the more media-sensitive issues of politics.”

In June, a hearing in Washington, D.C. addressed VA whistleblower retaliation. Chris Pappas, a U.S. Representative for New Hampshire’s first district, argued that that VA “seems to have a culture problem. In some instances, VA leadership and supervisors have turned a blind eye to those in VA’s workforce who have attempted to expose bad actors who have abused their positions or broken laws. In even more concerning examples, VA leadership and supervisors have actively worked to stamp out these voices.”

But, Pappas says, retaliation has not happened at the Manchester VA. “This is good news, that Dr. Kois says he has not experienced retaliation as a result of speaking out. And I urge the VA to follow the path of New Hampshire’s example when other whistleblowers express their concerns.”

At the hearing, Dr. Minu Aghevli, a whistleblower from the Maryland VA system, spoke up about the retaliation she faced when she called out her VA’s secret waiting lists in 2014. Over the last  five years, she’s fought off several VA attempts to silence her.

“Since my privileges have been suspended for the last two months, I’ve been forbidden to talk to any patients or engage in patient care and I’ve been assigned menial administrative tasks in a situation that seemed chosen to be as stressful and publicly humiliating as possible,” Aghevli says. Aghevli says VA administrators even informed her in June she’d be removed from her job. That came just a day after she told them she’d been invited to speak at this subcommittee hearing. “This feels obviously retaliatory. But worse than that, I feel like I’m being used as a threat against other employees who might think about speaking up.”

Skeptics remain concerned that retaliation similar to that experienced by Dr. Aghevli could happen at the Manchester VA. Because of this fear, some whistleblowers no longer want to speak on the record to the press. Meanwhile, the extra funding allocated to Manchester is not permanent, and critics remain wary of the medical center’s future. 

Editor’s note: On Tuesday, July 23rd, Ed Kois was driving home from the Manchester VA when he crashed into a guardrail. Nobody else was hurt, and Dr. Kois was taken to the hospital, where he was pronounced dead. He was 62 years old. 

"He was the kind of person that a person like me would take a bullet for,” said Joseph Maloof. “He was a patient's doctor. He was the doctor you wanted to have at the helm."