Horror: VA failed to stop pathologist who misdiagnosed thousands -- and showed up drunk for work

It took more than three thousand misdiagnoses, a dozen or more patient deaths, and multiple alerts before the Veterans Administration caught up with its chief pathologist Robert Morris Levy. The Washington Post offers a lengthy exposé of the VA’s internal inertia as well as the ineffectiveness of its quality controls, all of which took a terrible human cost on thousands. And the worst part is that VA officials got warned repeatedly that Levy was a problem before finally getting fired last year … over a DUI.


At least that’s not the biggest legal issue Levy’s facing now:

On the Fayetteville campus, rated one of VA’s best, Levy’s supervisors failed to heed early warnings that he was endangering patients and then were slow to act, according to internal VA documents, court filings and interviews with 20 congressional officials, veterans and current and former VA employees.

Federal prosecutors charged Levy, 53, last week with three counts of involuntary manslaughter in the deaths of three veterans. VA officials now acknowledge that he botched diagnoses of at least15 patients who later died and 15 others whose health was seriously harmed.

The number of those affected, however, is much greater, and the full repercussions of Levy’s actions may not be known for years. VA officials say Levy made 3,000 errors or misdiagnoses dating to 2005.

If Levy’s on trial for involuntary manslaughter, others should be charged as accomplices. VA officials got several warnings that Levy was working while intoxicated, records indicate, starting as early as 2012. One incident in 2016 showed Levy with a 0.4% blood alcohol reading, which is five times higher than needed in most states to get a DWI. Rather than put this together with all of the other alerts, the VA paid for a three-month inpatient treatment center and then put Levy back on the job.


It never occurred to anyone, apparently, to double-check Levy’s work after finding out that he showed up to work drunk. Supposedly Levy had a very low incidence of mistakes in his work, but the system used to determine competency was absurdly easy to game. The VA used a peer-review system to sample work by specialists, which meant that Levy’s work was spot-checked by the deputy who reported to him. Levy simply changed the conclusions of his deputy’s reports in order to maintain a very low error rate — and was rewarded with large bonuses based on those ratings.

When Levy began showing up impaired for work in 2017 and 2018, the VA finally did an independent check of his work. It turned up red flags — which the VA ignored until after he got dismissed:

In January 2018, after multiple staff reports that he was still impaired, the hospital’s professional standards board continued Levy’s suspension. Spot checks of his cases showed “no evidence of patient harm,” according to the minutes.

Still, Worley brought in a pa­thol­ogist from VA’s division headquarters for another review of Levy’s work. She found more than a dozen misdiagnoses.

“Dr. Levy’s actions have negatively impacted patient care outcomes,” Worley and the medical director at the time wrote in a memo on Jan. 11, 2018.

It would be six more months before VA began a deeper review of his work.


Even when the VA finally did get around to checking Levy’s work, it initially limited the review to his last year in the system. Only after the inspector general intervened did the VA conduct a full review and find the thousands of misdiagnoses Levy produced. The VA also waited months to alert medical boards in three states to Levy’s incompetence.

Unfortunately, this hardly qualifies as a shock. The VA has had so many scandals surrounding incompetence and corruption that it’s tough to keep track. This episode, as with others, demonstrates the lack of accountability in government-run single-payer systems, and the instincts of government bureaucracies to protect themselves rather than their patients. A dozen or more patients are already dead, and hundreds more might have had their lives shortened because VA apparatchiks couldn’t be bothered to deal with the obvious problems Levy was creating, and didn’t think to double-check their own metrics for bonuses.

It’s long past the time when we should offer our veterans more choice than to remained locked into this single-payer horror show. This serves as yet another example of the need to have government as an enforcer of law than a provider of services, especially in a monopoly.


Update: I neglected to say this in the original post, but kudos to the Washington Post for an outstanding effort in reporting this.

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