Section 1 of 5 [00:00:00 - 00:10:04] (NOTE: speaker names may be different in each section)

Al: From the Center for Investigative Reporting in PRX, this is Reveal. I'm Al Letson. What makes a person risk their job, their reputation, even their freedom, to do the right thing? Throughout American history, whistle blowers have been at the forefront of change. Many of the protections that we have in place are because someone spoke out. Someone raised their hand and said, "This is wrong." They shifted the trajectory, made things better, at least that's the way it's supposed to work. That's what Dr. Katherine Mitchell thought would happen when she put everything on the line to speak out.

Katherine: I've seen many people die.

Al: Two years ago, Katherine was working as a doctor at the veterans hospital in Phoenix.

Katherine: I literally cannot live with myself if I don't come out because the only thing worse than losing my job and my career was having someone else die.

Al: Katherine devoted her entire career to treating veterans. She became the spark that lit the firestorm over the Phoenix VA. Veterans there were waiting so long to see a doctor, that some of them were dying before they ever got an appointment. She had been seeing clues that things weren't right for years, all the way back to 2009 when veterans were coming back from Iraq and Afghanistan by the thousands.

Katherine: At that time, the number of near misses and actual mistakes in nursing triage skyrocketed as our patient flow increased exponentially. There were hundreds and hundreds of cases where patients either had medical bad outcomes or there were near misses. All of those situations indicated that we needed more intense training for our nurses who did triage. Unfortunately administration was unresponsive to that.

Al: That was just the first problem. By 2012, the situation in the ER was even worse.

Katherine: I was in the ER for the third night alone by myself literally swamped with patients. I was so afraid that someone was going to die because I couldn't get to them quick enough and there was no back up personnel to help. Sharon Hellman was the oncoming administrator and she came in and asked me how things were going. I pulled her in the back and told her that we need to be shut down immediately and that we shouldn't be reopened until we had vitally needed resources. About a week and a half later I was called into a meeting and told that the only problem in the ER was my lack of communication skills.

Al: This type of behavior is happening where you're trying to make change and you're facing a lot of resistance. Then when you go further up the chain, you're also being basically ignored.

Katherine: It felt like I was going crazy and I think most whistle blowers will tell you that. You feel a wide range of emotions. You feel frustrated because you know that there's something really dangerous that's jeopardizing patient care and no one is listening.

Al: Katherine kept trying to tell her superiors about the problems. She kept trying to speak up, but her voice fell on deaf ears. Then ...

Katherine: In 2014, there was a specific incident.

Al: There was a marine, a marine Katherine had been working with at the VA for years. Someone she trusted.

Katherine: He's incredibly upstanding by the book guy, and he kept saying that forty people have died. Forty people have died. It isn't right. We have to do something.

Al: The marine pointed Katherine to a list. Printed on it were the names of patients and the dates they had first called the VA for care. This list was kept secret. A different one with much later dates was the one people saw. It seemed like vets were waiting just a couple weeks to see doctors. The real list was proof that they had been waiting for months, and that some of them died before receiving treatment. The marine reached out to Katherine because his bosses were about to destroy this secret document.

Katherine: My first thought was we'll take it to the VA police because we're under orders to preserve evidence. Went to the VA police who I'd known for years, and explained the situation and explained it was almost a thousand names. What we were told was that if we felt that it was that valuable for evidence was that we needed to hide it somewhere in the facility to secure it overnight and turn it into the investigator the next morning. That in itself was ridiculous, because here I was, I have two degrees. I've been a physician for years, and here we were at 10:30, 11:00 at night trying to find a place to hide this list so that it would be safe in the morning. The whole time, thinking it's perfectly possible that we could be watched on video cameras and that someone would come and take the list.

Al: The whole story sounds like a political thriller of some sort. I have to imagine that while all this is going on, your nerves are just frayed. Fear of oh my god, is this it?

Katherine: Yeah, this cannot be happening. We actually made a copy of the list and we hid it in two different places in my clinic so that if they found one location, if someone took it, the chances are they wouldn't fine the second location. That morning, I called my boss and said I needed emergency annual leave, and then I drove strait to the Arizona Republic and walked up to the desk and asked for the reporter I'd been talking to.

Al: The story Katherine and others brought to the Arizona Republic blew up. Investigations into the VA showed that dozens of veterans died before they got a doctor's appointment and the scheduling problems went way beyond Phoenix. More than one hundred and twenty thousand veterans across the country were stuck on waiting lists. The White House, the Justice Department, and the FBI conducted their own investigations. Eric [inaudible 00:05:41], the VA secretary, eventually stepped down. Back in 2014, when Katherine dropped off that list, she had no idea what would happen next.

Katherine: When I went to the Arizona Republic I went home and just cried because as far as I was concerned at that point, my personal and professional life were over. Basically everything that I had cared about my entire professional career was going up in smoke. I work with people in a profession that if you make a mistake, people die. If you over look something, people can die. That if you're busy one day and something slips past you, someone can die. I just didn't want anyone else to die and I didn't know how else to bring it to anyone's attention.

Al: All this happened two years ago. Where are we now? Katherine's still working for the VA, just not in Phoenix, but nearby. Part of her job now is to help doctors and nurses report problems. She says she's still running into roadblocks from the system, meanwhile not long after Katherine exposed the problems with wait times, Congress passed a quick fix that was supposed to make it easier and faster for vets to see doctors. Did it work? Are vets getting the healthcare they need? That's what we're looking into today. We're going to hear from veterans, VA staff, and other whistle blowers, and we start by visiting a state that was doing a good job taking care of it's vets. That is until the congressional fix came along. We'll hear that story when we come back on Reveal, from the Center for Investigative Reporting, in PRX.

From the Center for Investigative Reporting in PRX, this is Reveal. I'm Al Letson. In 2014, when whistle blowers like Katherine Mitchel in Phoenix came forward people all across the country saw the news.

Speaker 3: Tonight a 360 Exclusive, the most disturbing example yet of our ongoing investigation of US military veterans dying while they wait for medical care at VA hospitals.

Al: One guy watching was Larry Chapin, a former paratrooper and Iraq war veteran living in Fairbanks, Alaska.

Larry: It's one of those coffee cup moments where you're sitting there with your significant other watching Fox News or CNN and you're like, I kind of find that hard to believe because of my experiences.

Al: See, Larry was lucky. Every local VA system is different. In Alaska, there was no scandal, no secret waiting list.

Larry: I had a great care provider, the front staff were always friendly. I can't say how happy I was.

Al: Larry had been lucky in other ways too. As a heavy engineer, he built military bases in Iraq and was in a convoy driving to [inaudible 00:08:25], just south of Baghdad, when a bomb went off at the front right wheel of his vehicle.

Larry: They either buried it too deep or buried it too far under the pavement, so when it blew up, it actually just blew mud and some asphalt into the air which left us unaffected.

Al: He doesn't have any combat injuries or traumatic stress. Instead, he has something most veterans have, wear and tear. Jumping out of planes and doing construction, all while wearing more than thirty pounds of body armor. It takes a toll. It's one reason why VA healthcare exists.

Larry: VA made this promise that they're going to take care of me.

Al: Lately, Larry says that promise has been thrown into question, by the very thing that was supposed to fix the problems exposed in Phoenix. It's called, Veterans Choice. It's a ten billion dollar program congress created to try to get veterans faster, more convenient healthcare, by making it easier to see doctors outside the VA.

Larry: It's probably the worst thing that's happened to veterans healthcare in Alaska. If it's working somewhere, I don't know where, but it's definitely not working here.

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Section 2 of 5 [00:10:00 - 00:20:04] (NOTE: speaker names may be different in each section)

Al: Lee Romney has been investigating Veteran's Choice for the last five months. She and Reveal's Stan Alcorn went to Alaska in late spring to figure out what happened.

Stan: When we got to Alaska, we kept hearing these surprising facts about the state, like about just how big it is. Remember all those maps we saw.

Lee: They superimpose Alaska on the entire continental US and it takes up the whole middle of the country.

Stan: Helping you sort of visualize this thing that's kind of hard to wrap your mind around. From Barrow to [inaudible 00:10:32], is actually further than from Dallas to Philadelphia.

Lee: There aren't even any direct flights between them.

Stan: Yeah or even roads.

Lee: There's also a statistic we heard a lot. One in ten Alaskans is a veteran. That's higher than any other state.

Stan: Which explains why they offered military discounts at the Walgreen's.

Lee: The Pita Pit.

Stan: Right. On the flip side, there's also no full service VA hospital in Alaska. Not one.

Lee: If you add that all up ...

Stan: Bit state, lots of veterans, no VA hospital.

Lee: It means there are lot of veterans here who qualify for VA care, but they don't live anywhere near a VA doctor.

Stan: So you'd think it would be the worst place in the country for veterans healthcare. According to Lisa Murkowski, Alaska's long time Republican Senator, it used to be pretty bad. When she took office in the early 90's, she says the VA was getting vets into specialty care by flying them outside the state.

Lisa: You were sent outside for what we now would almost consider routine care.

Stan: That means people were being flown to Seattle, place like that.

Lisa: Seattle, or flown to Utah, to Salt Lake.

Stan: This was true even for veterans in Anchorage or Fairbanks, cities that have plenty of doctors. The problem was the Alaska VA was choosing to send veterans to a VA hospital in Seattle, rather than to a non-VA doctor right there in town.

Lisa: I think part of it was a mindset and a culture within the VA that we have our system, don't mess with it.

Stan: She told us about a man in his 70's that was going to have to fly to Anchorage to Seattle to get chemotherapy.

Lisa: we had to move heaven and earth so that he could get his chemo treatment in Anchorage. What we needed to do was take it literally all the way up to the top. I don't recall who our VA secretary was then ...

Stan: But you took it all the way to the VA secretary?

Lisa: Yeah because it was an issue where I was dealing with one constituent, but he was just one of many. He was just one of many that was saying, this just doesn't make sense.

Lee: She says this one constituent got his chemo in Anchorage, eventually. It would take more than a decade to bend the VA's rigid system and make this kind of local healthcare the norm in Alaska.

Stan: The Alaska VA in Anchorage for a government healthcare building, is a surprisingly welcoming place. Everyone seems to know each other. There's a lot of sunlight and bird art. It's here that we meet someone that used to embody Murkowski ‘s more flexible Alaska VA.

Lee: Her name is Cindy Massey. She's this warm, glowing woman who's been a nurse for thirty-five years. She joined the Alaska VA in 2009, right as it was changing it's approach to connect veterans with local doctors.

Cindy: Basically, it was a really good time.

Stan: Cindy was putting on a road show, visiting doctor's offices and signing up this network of private healthcare providers. So vets who didn't live near a VA clinic or couldn't get the appointment they needed, they could call Cindy and she could call up the doctor she knew was the right fit.

Cindy: We feel very comfortable with our network of providers, picking up the phone and just saying, we have Sam that needs to get in. This is going on right now. Is there any way you can squeeze them in?

Stan: This is the system that Larry Chapin, the Iraq war veteran, loved.

Larry: it was very simple. If you went in for a doctor's appointment, they would talk about your condition and say this is something we can take care of downtown.

Stan: It was a signature accomplishment for Senator Lisa Murkowski.

Lisa: It wasn't a perfect system, but you know, it was an honest, creative effort to do what needed to be done for the veterans. It was working until somebody decided, hey, we got a great idea. Let's do this choice act thing. That's when everything just started to fall apart.

Lee: What exactly is this choice act thing? The idea is a lot older than the act itself.

Stan: It actually goes back to another senator. Back in 2008, when he was running for President, John McCain talked a lot about his plan to fix healthcare for veterans.

John McCain: Too often a veteran has to drive for an hour or two hours to go to the VA to get an appointment to get an appointment to stand in line to stand in line. My friends, that's not acceptable. What I'm going to do is every time a veteran has a routine healthcare need, I'm going to give them a plastic card, take that card to the healthcare provider of your choice, and get the healthcare you need immediately. That's what we need to do for our veterans. It's what we need to do for them.

Lee: In theory, it's not that different from Alaska's system. Get vets faster care by sending them to local doctors, outside the VA.

Stan: John McCain finally got a chance to put this idea into action, six years after he lost the presidential election. When the Phoenix scandal blew up, he made his card, now called the Choice Card, the center piece of the VA reform bill.

John McCain: Give these veterans a choice card, so they can take that choice card and present it to the healthcare provider.

Stan: Using the choice card isn't as easy as it sounds. It's less like a credit card and more like a business card, because all it really has is a phone number. When you dial that number, you don't get nurse Cindy Massey at the Alaska VA, you get someone in a call center, someone like Lashinda Pulu.

Lashinda: We had to state our name. Somewhere in there had to be what the company was, I guess TriWest Healthcare Alliance. That's what it was.

Stan: TriWest Healthcare Alliance. That's the company the VA hired to run the veterans choice program in twenty-eight states. We'll come back to this later because this is a key decision, but as for what this company's all about, Lee you talked to a bunch of these TriWest workers.

Lee: Yeah.

Stan: Where are they and who are they?

Lee: Well the company set up these big offices full of cubicles and they staffed them mostly with temp workers. Some had medical experience, but a lot of them didn't. One gal, told me the rep sitting next to her thought PET scans were for pets.

Stan: Yikes. By the time we got to Alaska, TriWest had pretty much replaced the work Cindy's team had been doing. Now people in these call centers were scheduling appointments for veterans and very important, sending healthcare providers authorizations, to make sure the VA would pick up the tab. Lashinda who worked at a TriWest call center in Washington, says this did not always go smoothly.

Lashinda: The authorizations was the main complaint. I can't see my provider because there's no authorization.

Stan: So people were trying to see their doctor and they can't get it approved.

Lashinda: Just being the middle man, there was always some kind of communication issue that went on between the veteran and then us and then the provider and then the VA.

Lee: Let's start with the providers. South Peninsula Hospital is up on a hill on the Keen Eye Peninsula with epic views of snow-capped mountains across the bay. Krista Selan coordinates physical therapy here. The way it works is first, someone at TriWest calls to set up an appointment.

Krista: Then they fax us an authorization that is never correct the first time. I say never and I'm not exaggerating because it's never right the first time. Usually it takes us at least four our five phone calls to get a corrected authorization to our office so that we know we can see the person.

Christine: I love how easily you guys say call.

Lee: That's Christine Williamson. She's in charge of billing.

Christine: When we get on the line with the choice program, we're the forty-fifth person in line, so when you say call, it is a huge process to call back.

Lee: Christine and her colleagues say they spend hours each week on hold with TriWest. They've developed a dark sense of humor about it.

Christine: They're phone system had this voice recording. She's hears all the time, if you feel like harming yourself, please call. At about two hours, I'm like, "what's that number?"

Stan: That's the TriWest that medial providers know. For the veterans perspective ... we went to a hotel in Fairbanks for the annual meeting of the Alaska chapter of disabled American veterans. About a dozen vets are in a conference room talking about budgets and bylaws and then Darrell Walker, the commander who's leading the meeting calls us to the head of the table and let's us take a survey of this small group of people who really know veterans healthcare.

How many of you think that the healthcare you're getting now is worse than the care that you were getting before the veteran's choice program? That's one, two, three, four, five, six. It's all but two, eight out of ten. Clarify.

Speaker 11: The care I'm getting is not worse. The process of getting the care, that's what I want to qualify.

Lee: Specifically, it's all the phone calls and all the delays.

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Section 3 of 5 [00:20:00 - 00:30:04] (NOTE: speaker names may be different in each section)

Female: Specifically, it's all the phone calls and all the delays. The commander, Darrell, is a perfect example. After the meeting, we visit Darrell at his house.

Darrell: Hey!

Female: Good Morning!

Darrell: Good Morning!

Female: We sit in his living room, surrounded by buzzing fish tanks and old wheelchairs he saves for veterans in need. He served in Panama and in the first Gulf War, and came back with PTSD, problem with his knees, back, neck, you name it. Like a lot of vets we talk to, he moved to Alaska, in part, to get away from other people.

Darrell: We're trained to do an unspeakable thing at a moments notice and be fine with it. That catches up to you after a while. You like the serenity, you like the calm, you like the peace that it brings you.

Male: Lately, he hasn't had a lot of peace. Despite hours of phone calls with TriWest, he's been waiting for nearly 80 days to get seen for a back injury. He's been without physical therapy he needs for his shoulder for even longer. Now, his arm is so weak he can't pick up more than 20 pounds, which is a problem at home, but a disaster for work.

Darrell: I've been an airplane mechanic for 16 years. My job says I should be able to pick up 70 pounds at a minimum, stand on my feet for extended period of time, crawl, kneel, stoop. This, with Choice, has taken me out of my profession.

Male: He says his boss tried to keep him part time doing office work, but ultimately he had to let him go.

Darrell: I can't blame my employer. They have a job to have filled, they have a need, and if I can't fulfill that, they have no use for me.

Male: It's called the Choice program, but veterans like Darrell call it No Choice, because for many veterans all across the country, the VA made this system the only way to see a private doctor. It was supposed to be so quick and easy that many more veterans would do just that, taking the pressure off the VA waiting lists, but it was so cumbersome that hasn't really happened.

Female: In fact, VA data show that veterans in Alaska are getting fewer authorization for private care than before the Choice program began. One question we had was, whose fault is that?

Male: Right, and we put that to the now retired VA official who was in charge of rolling out Veterans Choice, Jim Tuchschmidt and he acknowledged the problem, at least when it comes to Alaska.

Jim: The VA up there had created a stellar purchased care management program that the Choice program clearly disrupted.

Male: But as for why ...

Jim: I would say that was probably one of the casualties of trying to something in 90 days, right?

Male: 90 days.

Female: 90 days.

Male: We heard this a lot.

Female: Right, because the VA and TriWest point to this as the reason for virtually every problem that's come up with the program.

Male: What they're referring to is, Congress gave the VA 90 days to get choice cards in the hands of veterans. Jim says within the first few of those days, the VA decided they just couldn't do it.

Female: At least not on their own.

Male: Right, so Jim, the guy in charge of rolling out Veterans Choice says the VA invited a bunch of big insurance companies to a meeting and asked if they could do it, but ...

Jim: They thought the time frame was unrealistic. They just didn't think it was possible.

Male: Since everyone else said no, the VA turned to TriWest and Health Net Federal services. Two companies they already had contracts with.

Jim: We didn't have a lot of options.

Male: What kind of negotiating position was the VA in?

Jim: Probably not a very good one.

Female: The new contracts reflect that. I got copies, and TriWest got a $72 million fee for rolling out that program, and they get another fee every time they successfully authorize care. Both of those fees are more than triple what they were getting for running a similar but smaller program for the VA.

Male: TriWest CEO, Dave McIntyre, says "The fees are higher because Choice is more complicated."

Dave: Our company actually has yet to make a single dollar in profit due to the cost of constant re-engineering that's been involved, and the investments of infrastructure required to handle the increase in volume of work.

Male: Just because it's expensive for TriWest, doesn't mean it's cheap for tax payers.

Female: Right! I got ahold of an internal cost analysis commissioned by the VA. It shows Choice pays doctors less compared to the old way that worked so well in Alaska. Those savings are outweighed by the high fees to TriWest and Health Net, making Choice more expensive over all.

Male: The VA now says that analysis is overly pessimistic, but there's another significant fee it didn't even include.

Female: Yeah, the phone calls.

Male: The phone calls. Every time TriWest calls a veteran, it makes $10.96. Call center workers told us they had a quota of at least 60 outbound calls per day. CEO, Dave McIntyre, doesn't deny they have quotas, but he says it's not about the money.

Dave: It may appear to some that there is an objective to try and get more fees. The fact of the matter is, the quota we care about is making sure that a veteran gets placed with care.

Female: The call center workers that I talked to said the quotas did shape the culture. They said there was constant pressure to get the numbers up. One veteran told us she got three different calls, from three different TriWest workers, on the same day, about the same thing. [Jacquelyn McElwy Brown 00:25:39] worked for TriWest in San Diego. She said some of her coworkers made appointments with out even talking to the doctors office.

Jacquelyn: I really wanted it to work, because I believe in the purpose and the mission, but we were compromised. Our morals and values was compromised by having to work with a telemarketing mentality.

Male: Today in Alaska, TriWest is taking a step back. National VA officials heard the complaints and so they've picked Alaska to be a guinea pig for what they hope the next version of Choice might look like. In the new pilot program, veteran's phone calls are going back to Cindy Massey's team at the Alaska VA. The official who's now in charge of this stuff, he calls it "a little back to the future."

Male 2: Alaska isn't the only place Veterans Choice is letting veterans down. Congress set up an independent commission to take a deep look at VA healthcare. This summer, it found the Choice program had made long wait times worse, and frustrated veterans, private-sector healthcare providers, and the VA itself, thanks to Reveal's Stan Alcorn and Lee Romney. You can read Lee's full investigation at RevealNews.org. After the break, we'll hear what happened when Choice came to the VA in Cincinnati, Ohio. Whistle blowers say entire departments like Orthopedics and Neurosurgery were slashed, even though that meant turning vets away. That's coming up next on Reveal, from the Center of Investigative Reporting and PRX.

Al: From the Center for Investigative Reporting and PRX, this is Reveal. I'm Al Letson.

Phoenix and Alaska aren't the only places where the VA is falling short. In Cincinnati, doctors, nurses, and other employees have become so outraged by what they've been seeing, they're going public. More than three dozen whistle blowers have risked their jobs talking to a team of reporters from WCPO-TV, and the Scripps National Investigative Team. Mark Greenblatt is one of those reporters. He's been on the story for nearly a year, talking to hospital employees like Scott [Landrel 00:28:02].

Mark: Hey Scott!

Scott: Hey! How are you? Good to see you Mark.

Mark: Good. How are you?

Scott: Good, good.

Al: The truth is, Scott wasn't so good. I'll let Mark take it from here.

Scott: Come on in.

Mark: This was the second time I met Scott Landrel. It was a Thursday and he invited us into his home. We met his wife.

... the famous wife?

Amy: Nice to meet you.

Scott: Yes, this is Amy.

Mark: Amy, it's a pleasure to meet you. Mark Greenblatt.

Amy: Nice to meet you.

Mark: How's everybody doing? I imagine nerves are on edge a little?

Scott: Just a little bit.

Amy: Yeah, just a little bit.

Mark: For you too?

Scott: Yeah.

Amy: Yeah.

Mark: Amy and Scott are both a little nervous because Scott's decided to speak out about the Cincinnati VA and how it's serving veterans.

You're a veteran yourself?

Scott: I am.

Mark: You served in what branch?

Scott: I served in the Navy from 91 to 93. I'm a disabled veteran and it's one of the reasons I like working at the VA so much. I get to work with my comrades in arms, and I get to take care of the other veterans. I've been in the operating room since 1991, and I've been taking care of just veterans for the past four years.

Mark: Scott's job at the Cincinnati VA was to work as a surgical technician. It meant he was the guy inside the operating room in charge of making sure all the instruments were ready and clean before the procedures began.

Scott: I'm the person, the scrub, who sets up all the instruments, prepares for the case.

Mark: And it's also you're responsibility then, if you see something wrong, to point it out.

Scott: Yes.

Mark: He's gotten used to pointing out a lot of things that haven't been right in the OR. When Scott arrived at the Cincinnati VA in 2012, he says there were already problems with dirty surgical instruments. We heard that from other insiders too. A year later, the hospital brought in a new online system. It was supposed to make reporting and tracking problems in the OR easier, and help fix the problems faster.

Scott: Over the past couple of years, there have just been some serious problems with sterile processing. On several occasions, we found bone on instrumentation.

Mark: The OR team was finding remnants of bone, and even blood sometimes, stuck to the instruments. Scott says some of the debris was even unidentifiable.

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Section 4 of 5 [00:30:00 - 00:40:04] (NOTE: speaker names may be different in each section)

Speaker 1: To the instruments. Scott says some of the debris was even unidentifiable. Other times, the instruments were still wet in the packaging.

Scott: Water harbors bacteria and it means it didn't go through it's proper drying process. Water is your enemy when it comes to sterilization.

Speaker 1: When Scott spotted these problems, he and his team scrambled to solve them. They'd order more instruments, sometimes even anticipate the mistakes by having extra instruments ready to go.

Scott: We went through days where that was just happening over, and over again. I'm talking like entire set ups, where the entire room is already set up, and we have to break everything down and redo everything.

Speaker 1: He remembers when a doctor cancelled an entire day of surgery because of contaminated instruments.

Scott: He says, "We're not doing any more surgeries today," and Dr. Temeck was very upset about that.

Speaker 1: That's Dr. Barbara Temeck. She was hired in July of 2013, as the acting chief of staff, and her name comes up a lot in our investigation of the Cincinnati VA. Scott says he and others were filing reports into the new computer system, every time they found something wrong: a dirty instrument, a broken one. They were hoping the problems would be addressed, but he and others say, that's not how the new boss responded.

Mike: She called all the OR staff together and pretty much laid the law down, that the people were being too picky.

Speaker 1: That's Mike Brooks. He's been a nurse anesthetist at the Cincinnati VA since 2008, and he's one of the whistleblowers who we've been speaking to. Mike says something changed when Dr. Temeck arrived and put new procedures in place.

Mike: The process was put in place that when they found something unsterile, or what they felt contaminated, they had to call Dr. Temeck to inspect that instrument, and she was called to the OR to look at it.

Speaker 4: But you would have to stop the operation until ...

Mike: Until she came to inspect it, and then we moved on. If she was on another meeting or something, could be 20 minutes, half an hour, with the patient under anesthesia.

Speaker 4: Sometimes cut open?

Mike: Yes, usually.

Speaker 4: Waiting for Dr. Temeck to come by and inspect?

Mike: That's correct. She didn't believe the reports from her initial meeting. She felt that these were all fabrications, that we were making up stories about the instruments not being clean. She wanted to see for herself.

Speaker 1: She might not have believed the staff reports but there were other signs of trouble for patients. During Dr. Temecks's leadership, the rate of MRSA infections increased substantially. That's a highly contagious, drug-resistant staph infection commonly associated with surgeries. Over the course of our investigation, we repeatedly asked to speak with Dr. Temeck, but the PR team wouldn't let us near her. One morning in February, we caught up with her in the parking lot outside the hospital.

Male: Dr. Temeck, Mark Greenblatt I'm with Scripps News. We've been trying to talk to you. We understand that you've written control stuff [inaudible 00:32:56].

Speaker 1: But no luck. She just took off. Our next step was to take everything we'd learned to VA headquarters in Washington, D.C.. Within days, the agency sent inspectors to Cincinnati, but a few weeks later we got a surprise. Headquarters put out a preliminary report saying they, "could not substantiate any allegation involving quality of care for veterans." That didn't stop staff members like Scott Landrum from continuing to report problems.

Scott: Oh yes. I'm an absolute advocate for my veterans that I take care of and fight tooth and nail to make sure they're taken care of and safe.

Speaker 4: You take this very seriously.

Scott: I do.

Speaker 4: When it's not up to par you say something?

Scott: Yes. I've made a lot of enemies at work from reporting these things.

Speaker 1: As we kept digging, we found hundreds of the hospitals own internal records. Records that proved the hospital had been tracking problems in the OR for years. In the fiscal year 2015 for instance, one in every six surgeries at the Cincinnati VA had what they call quality events inside the operating room. Kinds of events no one wants. Broken or rusty surgical instruments, holes in sterile wrappers, a needle holder with a used needle still inside it. In fact we found five of these events documented on the very same day the VA said that it, "Couldn't substantiate any allegations." Turns out the VA had not spoken to a single whistleblower before making the announcement. In June, we finally got to hear from Dr. Temeck, well, at least one of the lawyers she hired. He told us that when she arrived, she discovered a, "whole slew of unsanitary, unhygienic conditions in the operating room." He said though that Dr. Temeck got those cleaned up.

Surgical instruments aren't the only problem in Cincinnati. A lot of the whistleblowers who've stepped forward, said Dr. Temeck started making cuts in staffing. Cuts that just didn't seem to make any sense to the longtime employees like Dr. Richard Freiberg who headed orthopedics.

Richard: What happened was that the three senior people were told that they were going to be reduced to one full time between the three of us.

Speaker 4: What was your take on this when you were told this?

Richard: My take was that this was a disastrous thing to do. There's no way that one part-time attending surgeon, and I was made part-time by the administration, could possibly service that much group of patients.

Speaker 1: At the time, the department had 6,000 visits a year. After the cuts, the hospital was left without a single specialist who could replace a hip, a shoulder, or a knee. The cutbacks weren't just in orthopedics, whole departments were decimated, like prosthetics or neurosurgery, the kinds of services veterans like Bill Hatfield counted on.

Bill Hatfield: This picture here makes my back hurt looking at it.

Speaker 1: Bill's looking at pictures from his time serving in Vietnam. He was stationed deep in the jungle.

Bill Hatfield: I was drafted and I went through basic and then artillery training in Vietnam, and put on a heavy artillery, a thing called an 8 inch howitzer, with shells that were 204 pounds that shot 12 miles.

Speaker 1: Bill would carry those shells.

Bill Hatfield: Yes I did, and I carried many hundreds of them.

Speaker 1: Over the years, it took its toll.

Bill Hatfield: Sitting here it's not too bad, but if I were to try to walk out to the mailbox, I can do it but I would hurt and have to stoup down probably to regroup.

Speaker 1: Bill had already had a couple back surgeries. Those were paid for by his insurance at work, but after he retired, he showed up at the Cincinnati VA looking for help. His timing could not have been worse.

Bill Hatfield: I go to the pain clinic doctor there, looks at my MRI's and is like, "Yeah you have problems here, here, here and here, and you need to see a neurosurgeon," but there wasn't one.

Speaker 4: What did he say to you?

Bill Hatfield: He said, "Right now we don't have a neurosurgeon here at the hospital anymore," which he seemed a bit upset by, and I can imagine that.

Speaker 1: Instead of being treated at the Cincinnati VA, Bill was shown the door and sent into Veterans Choice, the program you heard about earlier in the show. The one that congress put into place after the phoenix scandal. Patients are sent outside the VA if they can't be seen in a timely manner inside the system, but it didn't work out that way for Bill.

Speaker 4: You told the Choice program that you wanted to go to a specific place that did have neurosurgeons.

Bill Hatfield: Yes, but instead was sent to a place that didn't have one.

Speaker 4: Meanwhile a year goes by?

Bill Hatfield: Yeah. I'm very used to pain but it has been getting worse by the week.

Speaker 1: Bill was bounced around in phone calls and visits, 30 times over 19 months, between the VA, private providers, and healthcare administrators, before finally getting a surgery. He's doing better now but feels let down by the VA.

Bill Hatfield: I mean like this is crazy, there're people in far worse shape than I am, and how are they getting their treatment?

Susan: What's happening at the Cincinnati VA is very sad.

Speaker 1: Susan Ware is a nurse practitioner. She's one of several whistleblowers who believe Dr. Temeck, the acting chief of staff, was using Choice to balance the hospitals budget, at the expense of the veterans in her care.

Susan: It was an act passed by congress, so Choice is being provide through a different pot of money. The administration doesn't view it as a cost to our VA.

Speaker 1: Dr. Freiberg says, the people in charge of the Cincinnati VA were taking Veterans Choice, a system meant to supplement veterans care and using it to supplant it.

Richard: The number of cases in the operating room, the number of physicians who were being paid to care for the patients, all expenses for the hospital per se go down dramatically. The expenses for the government go up.

Speaker 1: Those expenses can go up by a lot. Let's take neurosurgery as an example. Dr. Temeck ordered a cost benefit analysis in 2014, she found that it cost up to $7 million more to send patients outside the hospital for services. A hospital would have to pay the extra expense, so she didn't do it, that is until Choice came online. After that program, congress set up a separate fund, that would pay the bills when vets were sent outside the VA system. In the spring of 2015, when Dr. Temeck effectively shut down neurosurgery at the Cincinnati VA, all those patients who needed care, would have to find it outside the hospital now. Whistleblowers like Dr. Freiberg and Susan Ware say Choice made it possible for the hospital to cut staff, and cut its budget, by cutting service.

Section 4 of 5 [00:30:00 - 00:40:04]

Section 5 of 5 [00:40:00 - 00:51:05] (NOTE: speaker names may be different in each section)

Speaker 1: The hospital to cut staff, and cut its budget by cutting services.

Speaker 2: There's no question that the expenses go down if you don't take care of people.

Speaker 1: It seemed like a hospital in disarray. To us, and to the whistle blowers who weren't getting answers from Dr. Tomek, so, we went to her boss.

Speaker 3: Do you want to have a seat right here, Mr. [inaudible 00:40:23]?

Speaker 1: Sure.

Jack [Het-ric 00:40:27] took charge of all of the A facilities in Ohio in November of 2006. When we sat down to speak with him, he was proud of what he'd done for the Cincinnati VA.

Jack: I'm pretty satisfied with the way things have been going.

Speaker 1: Budgeting had been a problem in Cincinnati, and Hetric had applied serious pressure on the hospital to balance its books. He sent an email to the staff, warning of a potentially large budget deficit, and said, "The status quo is not an option." Hetric says the staff took action, and it worked.

Jack: They met their budget last year, actually, by a little bit of an excess.

Speaker 1: We also asked Hetric about complaints from the whistle-blowers that the hospital's leadership was cutting services to veterans, and pushing them into choice to save money.

Jack: Absolutely not. I don't know why that's being said. I do know that me, personally, I devoted a lot of time and energy to save the neurosurgery program here.

Speaker 1: Many of the whistle-blowers brought their concerns about Dr. Tomek right to Jack Hetric, asking him about the staffing cuts and the on-going problems with sterilization, but they say they go nowhere, so we asked Hetric about Dr. Tomek, too.

What's your opinion of how Dr. Barbara Tomek has performed, and is performing, as acting chief of staff?

Jack: I don't supervise Dr. Tomek on a day-to-day basis, but basically, what I look at is how an organization is performing over a period of time. The Cincinnati VA has been regularly improving. They've struggled with some resource challenges in the past. I've wanted to make sure that this organization was set solid for the future. I took a personal interest in it.

Speaker 1: Perhaps too personal an interest. According to documents obtained by Scripps, Dr. Tomek had a history of prescribing pain medications, opioids such as hydrocodone, to Hetric's wife, even though she didn't have a license to write those prescriptions privately. I asked him about that.

Dr. Tomek is not licensed to prescribe controlled substances as of 2011. Why was she prescribing controlled controlled substances to your wife after that fact?

Jack: I am not going to comment on this. We have talked, and you're not going to ...

Speaker 1: Is [crosstalk 00:42:39] ...

PR Guy: That's the end of the interview, thank you.

Speaker 1: That last voice was the PR guy. Hetric walked out of our interview. We wondered what his bosses in Washington would make of all this, so we showed them what we found. Everything, including the actual prescriptions for opioids. That's when their eyes widened, and they leaned in, and just a few weeks later, headquarters told Hetric he was going to be fired. He retired instead, and Dr. Tomek? She had all her medical privileges at the Cincinnati VA taken away. She was reassigned to a desk job in the basement of the hospital.

The whistle-blowers were ecstatic about the changes in leadership, but after the dust settled, they realized that the issues that mattered most to them, the dirty surgical instruments, staff cuts, and the quality of care for the vets, all that was still unresolved. The Scripps Washington and WCPO in Cincinnati held a town hall meeting in April to bring the community together. The vets, the whistle-blowers, and the VA.

Robert: We're here tonight really to listen and to learn from the veterans in the room, from the employees in the room, and I can tell you, we have note-takers, we have staff from the Cincinnati VA here.

Speaker 1: Robert McDivet is on stage. He's representing the VA. He's also the guy who replaced Jack Hetric as regional director. He's been on the job about a month. Scott Landrum, the surgical technician we met at the beginning of the story is 1 of about 100 vets and VA employees in the crowd.

Scott: I wanted to see what everybody had to say about what was going on at the VA. There were going to be 3 whistle-blowers there, the news crews were going to be there, other veterans were going to be there, and I just wanted to see what was going to happen, and what was going to be said.

Speaker 1: Scott takes a seat in the front row, and listens quietly as other vets voice their complaints.

Speaker 8: My complaint really isn't about my care, it's about gross neglect of care of other veterans.

Bob: My name is Bob [Malum 00:44:40], you guys saw me retire. Sometimes it takes too long to get things done.

Speaker 10: We have a question from Jesse, from Twitter, for director McDivet. He asks, "Are you and your team developing a plan for change? What is your timeline for noticeable change?"

Speaker 1: At one point McDivet is asked, "When will the VA rebuild after so many departments had been decimated?

Robert: I don't know that off the top of my head, to be honest. Recruiting and retaining good healthcare staff is a challenge across the nation. Orthopedic surgeons, neurosurgeons, and so on are a very special commodity.

Speaker 1: Then, the dirty surgical instruments come up. McDivet says there's an on-going investigation, but echoes the position of headquarters, that so far there's no evidence to support the claims.

Robert: There have been at least 3 reviews looking at sterile processing. They have preliminary conclusions, some of which were published, but the final reports have not come out.

Speaker 1: This just isn't sitting well with Scott, who becomes visibly agitated. He's so upset, he can't stay in his seat any more.

Scott: I just now understand that the investigations showed that there was no bone, or nothing was wrong with the instruments. I'm the person who found the instruments and what was wrong with it. How in the world can they say that? I'm the one who filled out the reports. Where did the reports go?

Speaker 1: After a long, uncomfortable silence, McDivet responds. He says he'd be happy to learn more from Scott.

Robert: I think that's the strength of the VA system, that we are an open, transparent system. We have an inspector in general, an office of the medical inspector, and others that will fairly and equitably look into any allegation.

Speaker 1: After the formal Q&A session ends, McDivet, his staff, and the veterans hang around for another hour or so, chatting, exchanging contact information, and promising to follow up with each other. Then, just 2 days after the town hall meeting, I hear from Scott again. He says he'd just been called into the front office of the Cincinnati VA, and when he got there, he was told the VA wanted to fire him. He had to fire a pricey lawyer to fight the VA's decision. I went over to Scott's house to hear how he was dealing with things.

I've got to ask you, though. The night that you go home, after you're told that they plan to fire you, and you tell your wife ...

Scott: I had cried earlier that day, and you know I'm a big guy, that's hard for me to do sometimes. Just really took a lot out of me. I felt betrayed by the VA, because the truth is, I just really wanted things to be better. Rather than want things to be better, they just want things to be status quo, even though the status quo is not even up to par where it should be.

Speaker 1: We went back to headquarters one more time, and asked about the agency's treatment of employees like Scott who speak up. James Hutton, director of media relations, read us a statement.

Speaker 11: Whistle-blower retaliation is unacceptable and intolerable at the VA. We are working hard to create and sustain a climate that embraces constructive dissent.

Speaker 1: Scott believes there's no question the VA was retaliating. He said they wanted to send a message to other whistle-blowers.

Scott: If they follow through with what they're trying to do to me, and they terminate me, it is going to scare off every person who actually has an issue at the VA that wants to come forward, and maybe has some more serious issues than even I brought forward, and they're not going to want to do that for fear of retaliation by the senior nursing management that will take it out on them.

Speaker 1: Do you think that this was a shot across the bow to all the whistle-blowers that have been speaking out?

Scott: Oh, yes, very much so. I think it's made some other people nervous.

Al: Here's where things stand now. Instead of waiting for the VA to fire him, Scott Landrum left the hospital for a new job. He says he just had enough. Dr. Barbara Tanek turned in her license to write prescriptions for controlled substances, and is still under investigation by the VA. She remains working in the basement of the hospital, and filed her own whistle-blower complaint, alleging that she was a victim of retaliation. We're still waiting to see the VA's final report on what was going on inside the hospital. Thanks to Mark Greenblatt of Scripps National Investigative Team and WCPO in Cincinnati for bringing us this story.

After hearing about Cincinnati, Alaska, and Phoenix, you might be wondering what's next for the VA. Veteran's Choice expires next summer, but the VA is already working on its replacement. Call it Choice 2.0. It's not clear how it'll all work, but the commission advising Congress, the VA, and a bunch of veteran's groups all agree on the same thing, it's going to take new federal legislation and a lot more money than the $10 billion set aside for Choice. If it doesn't come together, a million veterans being treated by private doctors now could lose that access.

For more on what you just heard, plus the latest stories, go to RevealNews.org, and tell us what you thought. Send along your story tips, leave us a message on Facebook. We're at Facebook.com/ThisIsReveal, or find us on Twitter. Just plain old @Reveal. Amy Walters and Stan Alco were our producers. Thanks to Ellen Weis, [La-wan 00:50:15] Hamilton, Dan Monk, [Aar-on 00:50:17] Kesseler, and Megan Wesley of Scripps. Today's show was edited by [At-ki Tel-e-ne-tis 00:50:21]. Our sound design team is the Wonder Twins, my man Jay Breezy, Mr. Jim Briggs, and Claire C. [Note-mul-len 00:50:28]. Our head of studio is Christa [Shar-fen-burg 00:50:29], Amy Pyles is our editor in chief, Susanne [Reev-ers 00:50:32] our executive editor, and our executive producer is Kevin Sullivan. Our theme music is by [Ka-mar-a-do 00:50:37], Lightning. Support for Reveal is provided by the [Reeve 00:50:30] and David Logan Foundation, the Ford Foundation, the John D. And Katherine T. MacArthur Foundation, the John S. And James L. Night Foundation, and the Ethics and Excellence in Journalism Foundation. Reveal is a co-production of the Center for Investigative Reporting and PRX. I'm Al Letson, and remember, there is always more to the story.