Two days after Memorial Day, the Department of Veterans Affairs issued a report admitting that for years one of its own doctors — Robert Morris Levy — misdiagnosed patients, falsified pathology reports, repeatedly reported to work intoxicated, and defeated substance-abuse screens. The Washington Post reports:
When a team of outside pathologists reviewed almost 34,000 cases Levy had diagnosed since his hiring, they found that more than 3,000 had errors, 589 of them major mistakes that caused medical harm to veterans. At least 15 died.
The VA admitted its quality controls were wholly inadequate and multiple veterans died from Levy’s malfeasance before the Department caught wind. The Department wrote:
Dr. Levy’s misdiagnosis of pathology cases resulting in adverse clinical outcomes—suboptimal treatment and patient death—is undisputed…
The OIG determined that the number of major diagnostic discrepancies was the result of Dr. Levy’s failure to interpret specimens correctly that went undetected in part because of his efforts to conceal the errors, and manipulation of pathology quality management data. Deficiencies in quality management processes and managing a potentially impaired provider, as well as facility leaders’ failure to foster a culture of accountability that encouraged reporting without reprisal contributed to Dr. Levy’s errors continuing for many years.
In 2019, I explained why the VA took years to detect and even more years to address the deadly mistakes that doctors like Levy make:
It would have been fairly simple for the VHA to adopt quality‐control measures that Levy could not have defeated and that therefore would have identified his errors earlier and saved lives. But the VHA faces insufficient incentives to adopt such measures. It does not operate in a competitive market and neither the agency nor its employees face the same sort of liability for malpractice that private actors do. In a competitive market, these sorts of horrible consequences would damage a company’s reputation and cause patients to flee. But the VHA is a near‐monopoly government provider with a captive clientele who typically have no other options.
Little has changed since.
