Department of Veterans Affairs
Office of Inspector General

Office of Healthcare Inspections
Report No. 16-01708-340

Healthcare Inspection 

Review of Primary Care Ghost Panels 

Veterans Integrated Service 

Network 23 

Eagan, Minnesota 


August 11, 2016
Washington, DC 20420

 In addition to general privacy laws that govern release of medical
information, disclosure of certain veteran health or other private
information may be prohibited by various Federal statutes
including, but not limited to, 38 U.S.C. §§ 5701, 5705, and 7332,
absent an exemption or other specified circumstances.
As
mandated by law, OIG adheres to privacy and confidentiality laws
and regulations protecting veteran health or other private
information in this report.

To Report Suspected Wrongdoing in VA Programs and Operations:
Telephone: 1-800-488-8244
E-Mail: vaoighotline@va.gov
Web site: www.va.gov/oig

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

Executive Summary 

The VA Office of Inspector General Office of Healthcare Inspections conducted an
inspection in response to a concern raised by Congressman Timothy J. Walz regarding
whether some primary care (PC) panels at facilities within Veterans Integrated Service
Network (VISN) 23 are “ghost panels.” The media has used the term “ghost panel” to
describe patients assigned to PC providers who were not actively providing care, such
as a provider who retired or resigned. Patients who need care and who are assigned to
ghost panels would need to be seen by active facility PC providers, by temporary
providers, or through a combination of efforts. Each PC provider has a limited amount
of time available to see patients, and seeing additional patients would limit the time
available to care for PC patients, which could be a barrier for patients assigned to either
the PC or ghost panels to receive timely health care.
We found that 4 of 674 (0.6 percent) PC panels in VISN 23 were ghost panels.
In total, 2,301 of 287,095 (0.8 percent) of active PC patients in VISN 23 were assigned
to 1 of those panels. The Iowa City VA Health Care System and VA Black Hills
Health Care System each had two ghost panels. We did not identify PC ghost panels at
the other VISN 23 facilities.
The existence of PC ghost panels in VISN 23 is inconsistent with Veterans Health
Administration policy, which requires patients to be reassigned or redistributed to other
PC teams when PC providers discontinue employment. However, we did not identify a
negative impact on patients since the facilities had enacted efforts to ensure ongoing
patient care for patients assigned to the PC ghost panels.
We recommended that the VISN Acting Director ensure that Facility Directors reassign
or redistribute PC patients to other PC teams as required by Veterans Health
Administration policy and monitor compliance.

Comments
The Veterans Integrated Service Network Acting Director concurred with our
recommendation and provided an acceptable action plan. (See Appendix A, pages 7–8
for the Acting Director comments.) We will follow up on the planned actions until they
are completed.

JOHN D. DAIGH, JR., M.D.
Assistant Inspector General for 

Healthcare Inspections


VA Office of Inspector General

i

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted
an inspection in response to a concern raised by Congressman Timothy J. Walz
regarding whether some primary care (PC) panels at facilities within
Veterans Integrated Service Network (VISN) 23 are “ghost panels.”

Background 

VISN 23 serves over 300,000 veterans in the Upper Midwest Region, including Iowa,
Minnesota, Nebraska, North Dakota, South Dakota, and parts of Illinois, Kansas,
Missouri, Wisconsin, and Wyoming.
VISN 23 includes the following eight health care systems (HCSs) and medical center.
  Fargo VA HCS
  Iowa City VA HCS
  Minneapolis VA HCS
  Royal C. Johnson Veterans Memorial Medical Center (Sioux Falls, SD)
  St. Cloud VA HCS
  VA Black Hills HCS
  VA Central Iowa HCS
  VA Nebraska-Western Iowa HCS
The Veterans Health Administration’s (VHA) Primary Care
PC Management.1
Management Module (PCMM) software allows facility staff to track patients and data for
their assigned PC providers (PCPs). The PCMM software allows users to set up and
define a PC team, assign staff to positions within the team, and assign patients to
providers.
Facility staff who are accountable for oversight of PC teams are required to establish
and implement contingency plans for ensuring that patients receive continuity of and
access to appropriate PC during periods of inadequate resources, extended staff
absences, staff turnover, understaffing, and nature-related events (for example, extreme
weather conditions or natural disasters).2 Contingency plans must include the
reassignment or redistribution of patients to other PC teams when the:
  PCP discontinues employment with the clinical service or program accountable
for the PC team;

1

VHA Handbook 1101.02, Primary Care Management Module (PCMM), April 21, 2009. This VHA Handbook
was scheduled for recertification on or before March 30, 2014, but has not yet been recertified.
2
VHA Handbook 1101.10, Patient Aligned Care Team (PACT) Handbook, February 5, 2014.
VA Office of Inspector General

1

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

  PCP is not permitted by state or federal law or VHA or local policy to provide
health care to patients; or
  PCP’s absence is expected to last longer than 6 months.
VHA collects data regarding patients assigned to PCPs in PCMM software and
publishes selected information on the Active Panel List report.3 The Active Panel List
documents the number of active PC patients assigned to PC teams and providers,
teams’ capacity, and teams’ PCP full-time employee equivalent by facility. This report is
useful for PCMM and facility staff required to maintain the currency of information in
PCMM software and to reassign or redistribute patients to PC teams when PCPs
discontinue employment.
Ghost Panels. The media has used the term “ghost panel” to describe patients
assigned to PCPs who were not actively providing care, such as a provider who retired
or resigned. In this scenario, patients who need care and who are assigned to
ghost panels would need to have been seen by active facility PCPs, by temporary
providers, or through a combination of efforts. As a result, the active facility PCPs’
panel size could seem artificially low since these patients would not be included in the
active PCPs’ panel totals. Further, each PCP has a limited amount of time available to
see patients, and seeing additional patients would limit the time available to care for
PC patients, which could be a barrier for patients assigned to either the PC or
ghost panels to receive timely health care.
Allegation. On November 16, 2015, Congressman Timothy J. Walz contacted
VA OIG to request a review of whether the practice of using “ghost panels” in PC care
was taking place within the VA system. Subsequent to that request, Congressman
Walz revised the request to determine whether this practice was occurring in VISN 23.

Scope and Methodology 

We conducted our work from December 29, 2015, through February 11, 2016. The
period of review was from December 29, 2015, through February 11, 2016.
We reviewed PCMM data and Active Panel List reports available through VHA Support
Service Center. We also reviewed selected electronic health record data in the
VA Corporate Data Warehouse and employment data available through the
VA Personnel and Accounting Integrated Data (PAID) system.4

3

Active Panel List Data Definitions (Last Updated January 14, 2016), VSSC (http://vssc.med.va.gov/), accessed
February 11, 2016.
4
The PAID package records payroll data including time and attendance records and a continuously updated
employee master record database. Available PAID data was current through pay period 22 (ending
November 14, 2015). See Department of Veterans Affairs Personnel and Accounting Integrated Data (PAID) User
Manual, Version 4.0, May 2012.
VA Office of Inspector General

2

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

We identified PC ghost panels using the following three steps:
  We identified PCPs on the Active Panel List reports as of January 4, 2016, who
did not appear to be clinically active.5 We concluded that PCPs might not be
clinically active if they did not enter any progress notes in the
electronic health record during the previous month (December 2015).
  For PCPs who did not appear to be clinically active, we reviewed PAID to
determine if the PCPs were employed by the facilities.
  For PCPs who did not appear to be clinically active and were not employed by
the facilities, we interviewed selected facility staff with knowledge of PC staffing
at the respective facilities. We asked those staff for alternate explanations for
what appeared to be the presence of ghost panels. We also asked about the
steps taken, if any, to ensure patients assigned to the ghost panels received
ongoing patient care.
In the absence of current VA/VHA policy, we considered previous guidance to be in
effect until superseded by an updated or re-certified Directive, Handbook, or other policy
document on the same or similar issue(s).
We conducted the inspection in accordance with Quality Standards for Inspection and
Evaluation published by the Council of the Inspectors General on Integrity and
Efficiency.

5

We did not flag associate provider panels, such as panels assigned to medical residents, if the supervising PCP was
clinically active.
VA Office of Inspector General

3

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

Inspection Results 

We found that 4 of 674 (0.6 percent) PC panels in VISN 23 were ghost panels. In total,
2,301 of 287,095 (0.8 percent) active PC patients in VISN 23 were assigned to
1 of those panels.
The Iowa City VA HCS and VA Black Hills HCS each had
two ghost panels. We did not identify PC ghost panels at the other VISN 23 facilities.
(See Table.)
Table. Number of PC Panels and Active PC Patients in VISN 23, by Facility

Facility
Fargo VA HCS
Iowa City VA HCS
Minneapolis VA HCS
Royal
C.
Johnson
Veterans
Memorial Medical Center
St. Cloud VA HCS
VA Black Hills HCS
VA Central Iowa HCS
VA Nebraska-Western Iowa HCS
Total

PC Panels
PC
Total
Ghost
Panels
34
0
100
2
193
0
40
0
37
35
52
183
674

0
2
0
0
4

Active PC Patients
Assigned
Total
to Ghost
Panels
28,872
0
42,954
1,245
69,921
0
24,754
0
32,607
16,523
26,969
44,495
287,095

0
1,056
0
0
2,301

Source: OIG analysis of VHA Support Service Center, VA Corporate Data Warehouse, and PAID data, and
interviews with knowledgeable staff

Iowa City VA HCS
The two Iowa City VA HCS PC ghost panels represented 2 percent of PC panels at the
HCS. As of January 4, 2016, 609 and 636 (1,245 total) active PC patients were
assigned to the affected panels, representing 2.9 percent of the system’s active
PC patients.
Staff we interviewed from Iowa City VA HCS confirmed that the panels were from
two PCPs who accepted positions at other VA facilities (one in August 2015 and the
other in November 2015) and were not employed at Iowa City VA HCS. Recruitment
efforts to fill these vacancies were not expected to exceed 6 months.
Staff told us that they employed several different strategies to meet ongoing patient care
needs for patients assigned to those PC panels. Efforts included reassigning acutely ill
patients to other PCPs with panel capacity, assigning surrogate providers to receive and
manage electronic health record alerts on a weekly basis, and using a pool of providers
to see patients assigned to these PC panels. A locum tenens provider6 and a newly
recruited provider were scheduled to begin employment and fill these vacancies on
February 18 and 21, 2016, respectively. Staff also stated that the PC panels assigned
6

A locum tenens provider is a provider hired to temporarily fill in or substitute for another provider.

VA Office of Inspector General

4

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

to providers no longer employed at the respective facilities were maintained in order to
facilitate the assignment of these patients to replacement providers.
VA Black Hills HCS
The two VA Black Hills HCS PC ghost panels represented 6 percent of PC panels at the
HCS. As of January 4, 2016, 337 and 719 (1,056 total) active PC patients were
assigned to the affected panels, representing 6.4 percent of the system’s active
PC patients.
Staff we interviewed from VA Black Hills HCS confirmed that the panels were from
two PCPs who were no longer employed at VA Black Hills HCS (one left in September
and the other in October 2015). Since September 2015, the HCS has used fee-basis,
intermittent, and/or existing HCS providers to assist in managing patients assigned to
these panels.
One newly hired provider was scheduled to begin employment on February 1, 2016,
while a second provider was undergoing credentialing and privileging and was expected
to begin employment in early March 2016. Staff we interviewed also stated that the
PC panels assigned to providers no longer employed at the respective facilities were
maintained in order to facilitate the assignment of these patients to replacement
providers.
We did not identify a negative impact on patients since the facilities had enacted efforts
to ensure ongoing patient care for patients assigned to the PC ghost panels.

Conclusions 

We found PC ghost panels in VISN 23; however, we did not find evidence that the use
of ghost panels was pervasive across VISN 23.
We determined that 4 of 674 (0.6 percent) PC panels and 2,301 of 287,095
(0.8 percent) active PC patients were assigned to PCPs who were no longer employed
at the respective facilities, as of January 4, 2016.
At Iowa City VA HCS, 2 percent of PC panels were ghost panels and 2.9 percent of
active PC patients at the HCS were assigned to those panels. At VA Black Hills HCS,
6 percent of PC panels were ghost panels and 6.4 percent of active PC patients at that
HCS were assigned to those panels. No PC ghost panels were found among the
remaining 539 PC panels at the other VISN 23 HCS.
Although we found that the facilities had employed efforts to ensure ongoing patient
care for patients assigned to the affected PC panels, VHA requires patients to be
reassigned or redistributed to other PC teams when PCPs discontinue employment.

VA Office of Inspector General

5

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

Recommendation 

1. We recommended that the Veterans Integrated Service Network Acting Director
ensure that Facility Directors reassign or redistribute primary care patients to other
primary care teams as required by the Veterans Health Administration and monitor
compliance.

VA Office of Inspector General

6

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN
Appendix A

VISN Acting Director Comments
Department of
Veterans Affairs
Date:
From:

Subj:

To: 

Memorandum

March 30, 2016
Acting Director, VA Midwest Health Care Network (10N23)
Healthcare Inspection—Review of Primary Care Ghost Panels,
Veterans Integrated Service Network 23, Eagan, Minnesota
Director, Dallas Office of Healthcare Inspections (54DA) 

Director, Management Review Service (VHA 10E1D MRS Action) 

VISN 23 concurs there were four primary care panels in which the Primary Care
Provider (PCP) had discontinued employment with the VA. All panels have had a
coverage provider assigned or the patients have been reassigned to other PCP
panels as per PACT Handbook 1101.10.
On 11 January 2016 Primary and Specialty Medicine Service Line (PSMSL)
leadership and on 8 February 2016 Primary Care Management Module (PCMM)
coordinators at all Facilities in VISN 23 were instructed to remove primary care
providers from PCMM graphical user interface that have discontinued employment
with the VA. PSMSL leaders and PCMM coordinators were given the option to
assign a coverage PCP to the panel or reassign patients to other PCP panels.
VISN 23 will monitor compliance by two mechanisms:
1) 

On a monthly basis Facility PCMM coordinators will submit a PCP Time
Allocation spreadsheet to the VISN 23 PCMM Coordinator. The spreadsheet
includes a list of all PCPs and their separation effective date. The list of PCPs
listed in PCMM graphical user interface who have separated from the VA.

2) 

On a quarterly basis, each Facility Director will be asked to certify that all
PCMM data is accurate, up-to-date and does not include PCPs that have
discontinued employment with the VA.

VA Office of Inspector General

7

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN

Comments to OIG’s Report 

The following Acting Director’s comments are submitted in response to the
recommendations in the OIG report:
OIG Recommendations
Recommendation 1. We recommended that the Veterans Integrated Service Network
Acting Director ensure that Facility Directors reassign or redistribute primary care
patients to other primary care teams as required by the Veterans Health Administration
and monitor compliance.
Concur
Target date for completion: August 31, 2016
VISN response:
VISN 23 concurs there were four primary care panels at the VA Black Hills Health Care
System and the Iowa City VA Health Care System in which the Primary Care Provider
(PCP) had discontinued employment with the VA. The panels of these providers have
had a coverage provider assigned or the patients have been reassigned to other PCP
panels as per PACT Handbook 1101.10.
In addition, beginning April 1, 2016, the VISN 23 Primary Care Management Module
(PCMM) Coordinator will ensure that each VISN 23 facility Director reassigns or
redistributes primary care patients to other primary care teams (VHA PACT Handbook
1101.10) by monitoring compliance on a monthly basis with the following:
1) Name and separation date for all PCPs that have discontinued employment with
the VA;
2) A timely “position inactivation date” for the PCP was entered into PCMM Graphic
User Interface (GUI) or PCMM Web (new PCMM software to be implemented in
VISN 23 in May 2016);
3) The name of the coverage PCP and date that he/she was assigned to the panel
or the names of the PCPs to whom the patients were reassigned.
When a facility demonstrates 100% compliance with all of the audit criteria (above), it
will continue to be monitored until it demonstrates 100% compliance for 3 consecutive
months or 90 days.

VA Office of Inspector General

8

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN
Appendix B

OIG Contact and Staff Acknowledgments
Contact
Contributors

For more information about this report, please contact the OIG at
(202) 461-4720.
Larry Ross, Jr., MS, Team Leader
Cathleen King, MHA, CRRN
Melanie Krause, PhD, RN
Roneisha Charles, BS

VA Office of Inspector General

9

 Review of Primary Care Ghost Panels, VISN 23, Eagan, MN
Appendix C

Report Distribution
VA Distribution
Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Midwest Health Care Network (10N23) 

Director, Fargo VA Health Care System (437/00) 

Director, Iowa City VA Health Care System (636A8/00)

Director, Minneapolis VA Health Care System (618/00) 

Director, Royal C. Johnson Veterans Memorial Center (438/00) 

Director, St. Cloud VA Health Care System (656/00) 

Director, VA Black Hills Health Care System (568/00) 

Director, VA Central Iowa Health Care System (636A6/00) 

Director, VA Nebraska-Western Iowa Health Care System (636/00) 

Non-VA Distribution
House Committee on Veterans’ Affairs
House Appropriations Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies
House Committee on Oversight and Government Reform
Senate Committee on Veterans’ Affairs
Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies
Senate Committee on Homeland Security and Governmental Affairs
National Veterans Service Organizations
Government Accountability Office
Office of Management and Budget
U.S. Senate: Tammy Baldwin, John Barasso, Roy Blunt, Richard J. Durbin, Joni Ernst,
Michael B. Enzi, Deb Fischer, Al Franken, Chuck Grassley, Heidi Heitkamp,
John Hoeven, Ron Johnson, Mark Kirk, Amy Klobuchar, Claire McCaskill,
Jerry Moran, Pat Roberts, Mike Rounds, Ben Sasse, John Thune
U.S. House of Representatives: Brad Ashford, Cheri Bustos, Rod Blum, Kevin Cramer,
Sean Duffy, Keith Ellison, Tom Emmer, Jeff Fortenberry, Sam Graves,
Tim Huelskamp, John Kline, Ron Kind, Steve King, Adam Kinzinger, Darin LaHood,
Dave Loebsack, Cynthia Lummis, Betty McCollum, Kristi Noem, Rick Nolan,
Erik Paulsen, Collin C. Peterson, Adrian Smith, Timothy J. Walz, David Young
This report is available on our web site at www.va.gov/oig.

VA Office of Inspector General

10