Letter to Acting Secretary of Veterans Affairs Re: Deaths at Marion VA Medical Center

Letter

By:  Barack Obama II Dick Durbin
Date: Oct. 11, 2007
Location: Washington, DC

Durbin, Obama Question VA Oversight

U.S. Senators Dick Durbin (D-IL) and Barack Obama (D-IL) today sent a letter to the Acting Secretary of Veterans Affairs, Gordon Mansfield asking questions regarding the background check that was performed on Dr. Jose Veizaga-Mendez who has been linked to some extent to the recent spike in deaths at the Marion VA Medical Center. A cursory check of publicly available information by staff members from both Senate offices uncovered questionable information that should have raised red flags and prompted additional investigation by the VA.

"It appears the VA's efforts to discover the truth about Dr. Veizaga-Mendez, his past professional history, and the circumstances surrounding his license forfeiture were far from adequate and may have put the veterans seeking care at Marion in danger," the Illinois Senators wrote. "This is an extremely alarming revelation that calls into question the adequacy of the oversight exercised by the VA as it evaluates and monitors those who provide care to our veterans."

On September 14, the Department of Veterans Affairs suspended all inpatient surgeries at the medical center due to an unusual increase in deaths. Four top hospital officials have been reassigned until an Inspector General investigation is completed. During the investigations, questions have arose about a surgeon, Dr. Jose Veizaga-Mendez, who was allowed to practice medicine at the facility until August 2007 despite having to surrender his license in Massachusetts after numerous cases of malpractice.

In an October 3 meeting with Senator Durbin, Dr. Michael Kussman, Under Secretary of VA for Health and Dr. Gerald Cross, Principal Deputy Under Secretary insisted that the VA could not have known that Dr. Veizaga-Mendez had surrendered his license under circumstances that were more troubling than the non-disciplinary and voluntary conditions he claimed.

Both Senators Durbin and Obama have actively pressed the VA for information on the situation at the Marion VA Medical Center. Last month, they sent a letter to Jim Nicholson, who was serving as the Secretary of Veterans Affairs, asking specific questions about the VA's response to the increase in deaths at the center. They also asked why Dr. Veizaga-Mendez, who had been barred from practicing in another state, continued to practice at the Marion VA Center until August.

This followed a September 17 letter to Secretary Nicholson, sent by Durbin and Obama, asking for more information on the ongoing investigation. In the letter, they also sought assurances that the travel and scheduling needs of any veterans who must now be redirected to other facilities to receive their needed surgeries will be facilitated.

Text of letter appears below:

October 11, 2007

The Honorable Gordon Mansfield
Acting Secretary of Veterans Affairs
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420

Dear Secretary Mansfield:

We are writing to follow up on two previous letters we sent to Secretary Nicholson last month with regard to the situation at the Marion, IL, Veterans Administration Medical Center (VAMC) and specifically on the hiring and employment of Dr. Jose Veizaga-Mendez. Continued revelations about Dr. Veizaga-Mendez's record both before and during his employment at the Marion VAMC have raised serious concerns about the adequacy of the VA's credentialing and quality control systems.

In our letter to Secretary Nicholson of September 24, we asked him to explain the background check process that is conducted by the VA before hiring medical staff. Additionally, specific concerns regarding Dr. Veizaga-Mendez's employment were raised directly with Undersecretary Kussman and Deputy Undersecretary Cross in a meeting last week. Dr. Kussman and Dr. Cross both insisted that the VA had conducted due diligence when it became aware that Dr. Veizaga-Mendez had surrendered his medical license in Massachusetts. They asserted that there was no way the VA could have known that Dr. Veizaga-Mendez had surrendered his license under circumstances that were more troubling than the non-disciplinary and voluntary conditions he claimed. However, a cursory check by our staff of publicly-available information has cast doubt on the validity of that claim. Although our staff did not have access to the full range of information that hospitals and state medical boards have, we were still able to uncover questionable information about Dr. Veizaga-Mendez of sufficient magnitude that it should have raised red flags and prompted additional investigation before the VA continued to entrust the lives of our veterans to his care.

It appears the VA's efforts to discover the truth about Dr. Veizaga-Mendez, his past professional history, and the circumstances surrounding his license forfeiture were far from adequate and may have put the veterans seeking care at Marion in danger. This is an extremely alarming revelation that calls into question the adequacy of the oversight exercised by the VA as it evaluates and monitors those who provide care to our veterans.

We have specific questions regarding the background check that was performed on Dr. Veizaga-Mendez and on the oversight of care givers throughout the VA Medical System.

1. An October 5, 2007, Associated Press article cites Pete McBrady, acting director of the Marion VAMC, as saying that the VAMC "has a board consisting of a group of practicing physicians at the hospital who vet each candidate for hire" and that "there was no evidence that would set off any alarms about Veizaga-Mendez with the Marion panel when they reviewed the doctor." Prior to hiring Dr. Veizaga-Mendez, what inquiries did the VAMC make to public or private sources concerning his qualifications? What specific evidence did the VAMC obtain when it reviewed Dr. Veizaga-Mendez prior to his hiring?

2. Did the VAMC contact the Massachusetts Board of Registration in Medicine (Massachusetts Board) regarding Dr. Veizaga-Mendez's qualifications prior to his hiring?

3. We have been informed by the Massachusetts Board that the Board operates a publicly-accessible internet site featuring profiles of physicians licensed in Massachusetts. We also have been informed that when he was hired by the Marion VAMC in January 2006, Dr. Veizaga-Mendez had a profile on the Massachusetts Board's internet site that would have disclosed, at minimum, that he had been the subject of a hospital disciplinary action in 2004, and that he made two medical malpractice payments (one in 2004 and one in 2005). Did the VAMC access the Massachusetts Board's internet profile of Dr. Veizaga-Mendez before hiring him? If so, what was the VA's response to the information contained in the profile?

4. Dr. Veizaga-Mendez voluntarily surrendered his Massachusetts license in July 2006. How was the VA notified he had surrendered his license? What investigation was undertaken by the VA to determine the cause and circumstances? Was the VA informed about allegations of professional misconduct against Dr. Veizaga-Mendez that were made by the Massachusetts Board?

5. Did Dr. Veizaga-Mendez provide any written representations regarding the surrender of his Massachusetts license? If so, what were those representations?

6. We have been informed that Dr. Veizaga-Mendez has filed an appeal before the Massachusetts Division of Administrative Law Appeals in response to allegations raised by the Massachusetts Board. Was the VA aware of any such appeal?

7. According to regulations governing the Massachusetts Board, the VA is not explicitly included on a list of "designated agencies" that are entitled to request and view non-public information from the Massachusetts Board. Why is the VA not included on this list? Are there other states in which the VA is not entitled to request and review non-public information from state medical licensing boards? What steps, if any, has the VA taken to address this flaw in the VA's access to information about physicians?

8. What assurances can you provide us that there are not other cases of similar circumstances at the Marion VAMC and at other VA hospitals?

9. What steps are you taking to ensure that troubling information about VA physicians is not overlooked in the future?

Due to the seriousness of this issue, we would appreciate a prompt response.

Sincerely,

Richard J. Durbin
United States Senator

Barack Obama
United States Senator

Cc:
Dr. Michael Kussman
Dr. Gerald Cross