[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
WAITING FOR CARE: EXAMINING PATIENT WAIT TIMES AT VA
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, MARCH 14, 2013
__________
Serial No. 113-11
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
MIKE COFFMAN, Colorado, Chairman
DOUG LAMBORN, Colorado ANN KIRKPATRICK, Arizona, Ranking
DAVID P. ROE, Tennessee Minority Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
DAN BENISHEK, Michigan ANN M. KUSTER, New Hampshire
JACKIE WALORSKI, Indiana BETO O'ROURKE, Texas
TIMOTHY J. WALZ, Minnesota
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 14, 2013
Page
Waiting For Care: Examining Patient Wait Times At VA............. 1
OPENING STATEMENTS
Hon. Mike Coffman, Chairman, Subcommittee on Oversight and
Investigations................................................. 1
Prepared Statement of Hon. Coffman........................... 22
Hon. Ann Kirkpatrick, Ranking Minority Member, Subcommittee on
Oversight And Investigations................................... 2
Prepared Statement of Hon. Kirkpatrick....................... 22
Hon. McCarthy (CA-23)............................................ 3
Hon. Jackie Walorski, Prepared Statement only.................... 23
Hon. Jeff Duncan (SC-03), Prepared Statement only................ 23
WITNESSES
William Schoenhard, FACHE, Deputy Under Secretary for Health for
Operations and Management, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 5
Prepared Statement of Mr. Schoenhard......................... 24
Accompanied by:
Thomas Lynch, M.D., Assistant Deputy Under Secretary for
Health Clinical Operations and Management, Veterans
Health Administration, U.S. Department of Veterans
Affairs
Philip Matkovsky, Assistant Deputy Under Secretary for
Health for Administrative Operations, Veterans Health
Administration, U.S. Department of Veterans Affairs
Michael Davies, M.D., National Director of Systems
Redesign, Veterans Health Administration, U.S.
Department of Veterans Affairs
Debra A. Draper, Director, Health Care, Government Accountability
Office......................................................... 7
Prepared Statement of Ms. Draper............................. 27
Roscoe Butler, National Field Service Representative, Veterans
Affairs and Rehabilitation Commission, The American Legion..... 8
Prepared Statement of Mr. Butler............................. 32
WAITING FOR CARE: EXAMINING PATIENT WAIT TIMES AT VA
Thursday, March 14, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 1:00 p.m., in
Room 334, Cannon House Office Building, Hon. Mike Coffman
[Chairman of the Subcommittee] presiding.
Present: Representatives Coffman, Huelskamp, Walorski,
Kirkpatrick, O'Rourke, and Walz.
Also present: McCarthy of California.
OPENING STATEMENT OF CHAIRMAN COFFMAN
Mr. Coffman. Good afternoon. This hearing will come to
order. I want to welcome everyone to today's hearing titled,
``Waiting for Care: Examining Patient Wait Times at VA.''
I would also like to ask unanimous consent that several of
our colleagues be allowed to join us here on the dais today to
hear about this issue that has directly impacted many of their
constituents.
Hearing no objection, so ordered.
We should always be working to ensure veterans have timely
access to quality care. However, today's hearing is necessary
because evidence reviewed by the Subcommittee, the Government
Accountability Office and VA's own inspector general shows
little improvement in that area. GAO recently completed its
study that was appropriately titled ``Appointment Scheduling
Oversight and Wait Time Measures Need Improvement.''
Despite claims of improvement under higher standards, we
will hear today that a lack of reliable information when VA is
measuring patient wait times, VA's own testimony supports that
premise as it discusses what it sees as no reliable standard
and an inability to accurately measure what constitutes a
patient wait time.
While the topic of patient wait times may sound like a very
narrow issue, the problems, inaccurately monitoring improving
wait times for veterans at VA facilities has spread throughout
the whole Department of Veterans Affairs. Schedulers at the
facilities themselves have to use a cumbersome system that
creates a significant chance of error. The problem runs all the
way up to the Veterans Health Administration, which has an
unclear policy on patient scheduling practices and still seems
to struggle to best define its policy on patient scheduling.
I understand that defining these policies is not easy and
that perfecting a process for appointment scheduling is a
significant challenge, but VA has been well behind in this area
for a long time. However, none of this excuses VA from its
obligation to veterans. While I understand the system may not
always be perfect, it does not mean that VA shouldn't make
every effort to ensure veterans receive necessary care.
Backlogs are a fairly common theme at the Department, but
that is no reason for VA to gain the numbers to simply show
better performance instead of providing medical appointments,
sometimes for life-threatening conditions. Sadly, evidence
obtained by this Subcommittee clearly shows that in many cases,
VA did not do the right thing. Instead, that evidence has shown
that many VA facilities, when faced with a backlog of thousands
of outstanding unresolved consultations, decided to
administratively close out these requests. Some reasons given
included that the request was years old, too much time had
elapsed, or the veterans had died. This Subcommittee asked VA
for updates on these consultation backlogs beginning in October
2012.
Despite multiple follow-up requests to VA, no information
was ever provided, and it was only when this hearing was
scheduled that the Department offered a briefing on this
subject.
I would note that the Subcommittee asked for information,
not a briefing. Regardless, we should not be where we are now.
This goes to reinforce that the Veterans Affairs Committee
wants to work with the Department on this and other issues, but
that requires a willingness on VA's side to be forthcoming
about its problem so that together we can identify ways to
solve them.
I now yield to the Ranking Member for opening statement.
[The prepared statement of Chairman Coffman appears in the
Appendix]
OPENING STATEMENT OF HON. ANN KIRKPATRICK
Mrs. Kirkpatrick. Thank you, Mr. Chairman, for holding this
hearing this afternoon on the Veterans Health Administration's
scheduling process and how that affects patient wait times for
veterans.
Improving access to health care is a continuous effort by
VHA, and it is not surprising that we are here today. Excessive
wait times and the failures of scheduling processes have been
longstanding problems with the Veterans Health Administration.
The Government Accountability Office has been reporting on this
issue for over a decade. In 2001, the GAO reported that two-
thirds of the specialty care had wait times longer than 30
days.
In 2007, the VA Office of Inspector General reported that
VHA facilities did not always follow VHA's scheduling policies
and process.
In 2012, the VA OIG reported that VHA was not providing all
new veterans with timely access to full mental health
evaluations. In that same year, the GAO again examined the
issue and found that, among other things, there was
inconsistent implementation of VHA's scheduling policy that
could result in increased wait times or delays in scheduling
timely medical appointments.
In my Arizona district, in the City of Casa Grande, one of
my caseworkers recently met with an Iraq veteran who made the
brave decision to seek VA mental health care after 2 years of
being back in the United States from Iraq. The VA required a
physical exam before this veteran in my district could schedule
an appointment with a mental health care provider.
Unfortunately, they weren't able to schedule him for an initial
physical for 6 months. That is 6 months of waiting before he
could have even an initial consultation with a mental health
care provider, and this was after 2 years of not seeing a
doctor at all.
These situations were able to be resolved by our veterans
caseworker in the district, but the point is veterans should
not have yet another hoop to jump through. Access to health
care should be easy to schedule. I also understand that VHA is
operating with a reportedly outdated system that is cumbersome
and slow. GAO reported numerous work realms that some
facilities are using which may adversely affect timely health
care delivery to veterans.
Delayed care is denied care. This is all too evident with
the rash of recent consult backlogs experienced at some of the
VHA medical centers. It has been reported that thousands of
consults in 2011 and 2012 were backlogged at various facilities
which may have resulted in adverse events due to the delay in
diagnosis and treatment.
This, of course, is unacceptable. Veterans deserve timely
accessible health care. They have earned it. What I would like
to hear about today is a sound plan that will assist VHA in
transforming into a 21st century organization and will
eliminate as much as possible the needless waits, unclear
policies and procedures and frustrating technology that only
serves to slow down the process, and I yield back.
Thank you, Mr. Chairman.
[The prepared statement of Hon. Ann Kirkpatrick appears in
the Appendix]
Mr. Coffman. Thank you.
I ask that all Members waive their opening remarks as per
this Committee's custom. However, I understand that Congressman
McCarthy is going to have to depart early, and he was a main
requester of GAO's work on this issue. I will yield 5 minutes
to him for remarks.
Congressman McCarthy.
OPENING STATEMENT OF HON. MCCARTHY
Mr. McCarthy. Well, thank you, Chairman Coffman, for
holding this oversight hearing for the Department of Veterans
Affairs, specifically the Veterans Health Administration
regarding the scheduling of a timely medical appointment and
for allowing me to make some remarks.
You know, Chairman Miller and I led, along with 28 other
Members, in requesting the GAO to conduct this audit on the VHA
in the scheduling of medical appointments because I was
receiving numerous complaints from veterans in my district who
were waiting months for crucial medical appointments at either
local VA clinic in Bakersfield or the VA medical center in Los
Angeles.
One of the most common and disconcerting complaints for my
veterans is that the VA health care administration lacks a
sense of urgency when scheduling their medical appointments.
This poor customer service mean veterans are forced to wait
months for the care when needed. One horror story a veteran
shared with me was his experience replacing a set of broken
dentures. The VA schedule the veteran for five different
appointments and took 6 months before finally replacing the
dentures. As a result, this veteran had to eat three meals a
day in half a year just in pain.
In addition, veterans stress to me that the VA is
unsympathetic and unhelpful when it comes to ensuring that they
are taken care of from start to finish. When veterans in my
district are scheduled for appointment in the VA medical center
in Los Angeles, they must travel over 2 hours, over mountain
roads and through LA traffic. Smarter scheduling equals fewer
trips to LA for my constituents and more efficient use of VA
staff type.
One veteran who came to me was having difficulty obtaining
appointment with the VA to receive a knee replacement. After
removing the first faulty knee replacement, the VA then
required the veteran to make six different trips--this is a
200-mile round trip from Bakersfield to LA--in order to sign
releases and take tests before the VA would proceed with his
surgery. It was not until our office contacted the Greater Los
Angeles Healthcare System that he was finally scheduled for his
knee replacement, bringing the situation to a close after eight
grueling months.
Finally, when the VA does schedule a veteran for an
appointment, all too often I hear they fail to notify the
veteran in adequate time for he or she to make an appropriate
travel arrangements.
One local veteran, who was waiting for an eye surgery
appointment, was notified that he had been scheduled for his
surgery in Los Angeles less that 24 hours before he needed to
arrive. He was forced to cancel his appointment as he was
unable to find transportation to the surgery on such short
notice. Even though our office attempted to assist him with the
VA-approved surgery, the veteran grew so tired of waiting for
the VA to reschedule, he had the surgery conducted with a non-
VA ophthalmologist having to pay for the procedure himself.
These are just several stories that I have heard from my
veterans and are far from isolated incidents in my district, as
evidenced by the GAO report but are indicative of a larger
systematic problem within the VA medical centers. The
experience these veterans have faced are inexcusable and should
not have to happen to our Nation's finest. I think all of us
here today can agree that this is a problem that needs to be
immediately fixed, especially since we are facing a reverse
surge, due to Department of Defense in reducing the troop
levels and drawing down in Afghanistan.
So I thank you, Chairman Coffman, for your work on this,
Chairman Miller's, and the entire Committee because this is an
issue that is not partisan. This is an issue about the respect
that we give to those that risk their entire lives for all of
us to have our freedom, and how we treat individuals of this
nature is unacceptable and what has gone on.
So I thank this Committee for their work on the GAO study
and I thank them and will pledge to do everything in our power
to make sure we correct this as well, and I yield back.
Mr. Coffman. Thank you, Congressman McCarthy.
With that, I invite the first panel to the witness table.
Mr. Coffman. On this panel, we will hear from Mr. William
Schoenhard, Deputy Under Secretary for Health for Operations
and Management at the Veterans Health Administration. Mr.
Schoenhard is accompanied by Dr. Thomas Lynch, Assistant Deputy
Under Secretary for Health Clinical Operations and Management;
Mr. Philip Matkovsky, if I am saying that right, Assistant
Deputy Under Secretary for Health for Administrative
Operations; and Dr. Michael Davies, National Director for
Systems Redesign.
We will also hear from Ms. Debra Draper, Director of Health
Care at the Government Accountability Office; and Mr. Roscoe
Butler, National Field Service Representative for the Veterans
Affairs and Rehabilitation Commission at the American Legion.
All of your complete written statements will be made part
of the hearing record.
Mr. Schoenhard, you are now recognized for 5 minutes.
STATEMENTS OF WILLIAM SCHOENHARD, FACHE, DEPUTY UNDER SECRETARY
FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER
SECRETARY FOR HEALTH CLINICAL OPERATIONS AND MANAGEMENT, PHILIP
MATKOVSKY, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR
ADMINISTRATIVE OPERATIONS AND MICHAEL DAVIES, M.D., NATIONAL
DIRECTOR OF SYSTEMS REDESIGN; DEBRA A. DRAPER, DIRECTOR, HEALTH
CARE, GOVERNMENT ACCOUNTABILITY OFFICE; AND ROSCOE BUTLER,
NATIONAL FIELD SERVICE REPRESENTATIVE, VETERANS AFFAIRS AND
REHABILITATION COMMISSION, THE AMERICAN LEGION
STATEMENT OF WILLIAM SCHOENHARD
Mr. Schoenhard. Thank you, Chairman Coffman, Ranking Member
Kirkpatrick, Members of the Committee, thank you for the
opportunity to come today to speak regarding a subject that is
important to the care of our Nation's veterans and to their
satisfaction for veterans who have sacrificed all, as
Congressman McCarthy referenced, on our behalf.
Let me first just express regret for the incidents of
breakdown in care that was described by the Ranking Member and
by Congressman McCarthy. Any veteran who goes without timely
care where their care and satisfaction is impacted is one
veteran too many in terms of our commitment to serve those who
have served us.
I am accompanied today, as you said, Mr. Chairman, by two
assistant deputies, Mr. Matkovsky and Dr. Lynch for
Administrative and Clinical Services, respectfully, and Dr.
Michael Davies, the National Director of Systems Redesign.
As I mentioned earlier and as was mentioned by Members of
the Committee and Congressman McCarthy, timely access to care
is important to both clinical care as well as the satisfaction
of our veterans. We are grateful for the oversight of this
Subcommittee. We are also grateful for the report of the GAO
and the IG. We have been on a long journey to see what steps
can be taken to ensure we have reliable and valid measures to
measure wait time and the methods and implementation practices
to ensure consistent implementation of those across our system.
We are also informed by our own study of millions of
veterans' appointments as well as patient satisfaction surveys
that suggests that there is need for improvement, as we
acknowledged if our acceptance of the four recommendations of
the GAO, as we determine how to go forward in better improving
our care to increase patients' experience with our system.
I think it is important to say there are two parts to this
effort going forward: First is to have reliable and valid
measures to measure wait time. And as is indicated in our
written testimony, we have changed the measure for new patients
in order for that to be more valid and reliable, and we have
undertaken a change with regard to the agreed upon date that
the provider and the patient will establish together as a
patient visit is completed.
That is informed, as I mentioned before, by the various
reviews and our own study. It is important that we have
measures that we know will better serve our veterans and
reliably be implemented across this system.
Having said that, as important as that is for a foundation,
execution is the most important part going forward, and I would
offer that in our experience of the past 20 years and what we
have learned from the recent studies is that we need to do a
better job of integrating our administrative and clinical
implementation of this effort going forward. That is why I am
accompanied today by the two assistant deputies.
We need to ensure, as we have for the measure for new wait
times, that we have effectively piloted these measures with
providers in the real world to determine that they work, that
they better serve veterans. We need to ensure that we have
going forward more robust and complete training of our staff,
who actually implement these practices and schedule our
patients.
We need to ensure that we have staffing guidelines for
schedulers to ensure we have sufficient supply and training of
those who do this important work, and I have sat with those who
actually go through the scheduling process, and as mentioned by
the Ranking Member, we need to have better tools for their use
and automated scheduling system to go forward.
Finally, we must have feedback loops to ensure that we have
continuous improvement and reality check on what we do going
forward.
I pledge to you and to the Subcommittee that this is an
effort that will be implemented in an unprecedented way.
As we go forward, this requires joint, administrative and
clinical engagement, and we will ensure, as part of that
process, accountability and oversight to ensure at all levels
of our organization that this is implemented in a way that it
is veteran-centric and important to their care.
We thank you for the opportunity to be here, and my
colleagues and I will be happy to answer questions.
[The prepared statement of William Schoenhard appears in
the Appendix]
Mr. Coffman. Ms. Draper, you are now recognized for five
minutes.
STATEMENT OF DEBRA A. DRAPER
Ms. Draper. Chairman Coffman, Ranking Member Kirkpatrick
and Members of the Subcommittee, good afternoon. I am pleased
to be here today to discuss VA's reported outpatient medical
appointment wait times. The bottom line is that it is unclear
how long veterans are waiting to receive care in VA's medical
facilities because the reported data are unreliable.
Access to timely medical appointments is critical to
ensuring veterans are getting needed medical care. However,
long wait times and a weak scheduling policy and process have
been persistent problems for VA. For more than a decade, both
we and the VA's Office of the Inspector General have reported
on these problems.
In my statement today, I will discuss key findings from a
report we issued this past December that examined the
reliability of VA's reported medical appointment wait times as
well as the scheduling policy and process.
We found that VA's reported wait times are unreliable
because scheduling staff do not always correctly record the
required appointment desired date. That is the date on which
the veteran or provider wants the veteran to be seen. This is
due in part to lack of clarity in the scheduling policy and
related training documents on determining and recording desired
date, a situation made worse by the large number of staff who
can schedule medical appointments, which at the time of our
review was estimated to be more than 50,000 people.
During our site visits to four medical centers, we found
more than half of the schedulers that we observed did not
record the desired date correctly, which may have resulted in a
reported wait time that was shorter than what the veteran
actually experienced. Some staff also told us they change
medical appointment desired dates so that the dates align with
VA's related wait time performance goals.
We found additional problems in how the scheduling policy
was implemented, which may have also resulted in increased wait
times and delays in care. For example, an electronic wait list,
which is required for tracking veterans needing medical
appointments, was not always used, putting veterans at risk of
not receiving timely care. We also found follow-up appointments
being scheduled without communication with the veteran, who
would then receive notification of their appointment through
the mail.
Additionally, the completion of required scheduler training
was not always done, even though officials stressed the
importance of training for ensuring adherence to the scheduling
policies. We also found a number of other factors that
negatively impacted the scheduling process. These included the
VistA system used for scheduling, which officials described as
antiquated, cumbersome and error prone, shortages and turnover
of scheduling staff, and high telephone call volumes without
sufficient staff dedicated to answering these calls.
VA is implementing or piloting a number of initiatives in
an effort to improve veterans' access to medical care. For
example, one such as initiative is Project ARCH, which aims to
provide health care through contracts with community providers
to reduce travel and wait times for veterans who are unable to
receive certain types of care from VA in a timely manner. While
information is being collected on wait times for Project ARCH,
these wait times may not actually reflect how long veterans are
waiting to receive care because the wait times are measured
from the time authorization is received from VA rather than
from the time the veteran first requests the appointment.
In our December report, we recommended that VA take actions
to improve the reliability of medical appointment wait time
measures, ensure the consistent implementation of a scheduling
policy, allocate scheduling resources based on needs, improve
telephone access, including the implementation of identified
best practices. VA concurred with our recommendations and
identified actions planned or under way to address them.
To conclude, while VA officials have expressed an ongoing
commitment to providing veterans with timely access to medical
appointments and have reported continued improvements in
achieving this goal, unreliable wait time measurement has
resulted in a discrepancy between the positive, the wait time
performance VA has reported, and veterans' actual experiences.
More clarity in and consistent adherence to the scheduling
policy, improved oversight of the process, allocation of staff
resources to better match scheduling demands, and resolution of
problems with telephone access are needed to reduce medical
appointment wait times.
VA's ability to ensure and accurately monitor access to
timely medical appointments is critical to providing quality
health care for veterans, who may have medical conditions that
worsen if care is delayed.
Mr. Chairman, this concludes my opening remarks. I am happy
to answer any questions.
[The prepared statement of Debra Draper appears in the
Appendix]
Mr. Coffman. Thank you for your testimony.
Mr. Butler, you are now recognized for 5 minutes.
STATEMENT OF ROSCOE BUTLER
Mr. Butler. Good afternoon, Chairman Coffman, Ranking
Member Kirkpatrick and Members of the Committee. On behalf of
our National Commander, James Koutz, and the 2.4 million
members of the American Legion, I want to thank you for looking
into the problems American veterans are having access in their
health care. Whether it is frustration with repeatedly being
put on hold, waiting three-quarters of a year for a basic
primary care appointment, or being forced repeatedly to adjust
to new primary care providers, the needs of veterans are not
being met.
I want to ask you really to take the time to read through
Appendix A of our testimony. These are real veteran stories,
raw and unfiltered that provide a realistic picture of what is
happening to the people of the system. Time and time again, we
see veterans who love the care they receive when they can get
it. The frustration of the ability to access what is otherwise
excellent care has been a factor we have seen in our System
Worth Saving visits for the 10 years we have been performing
these visits. It is important to remember these veteran stories
because that is the real impact we are talking about.
This is not about meeting targeted numbers or looking at
where results fall on a chart. This is about what happens to
real people who have sacrificed for their country with their
military service and are now frustrated by an otherwise
excellent health care system. Some of the wait time could be
improved if VA did a better job delivering on extended hours
for health services, especially mental health. We know VA is
trying to address this, and they released a VHA directive on
January 9th of this year. Unfortunately, from our experience
with visits in the field, this directive would not go far
enough to meet the needs of veterans.
The new policy states that any facility that treats more
than 10,000 veterans a year has to have an extended session
during the week and one on the weekend end, but the required
sessions are only 2 hours. The American Legion is concerned
that four hours a week simply won't be enough to meet the
demands of veterans at these facilities. We believe VA needs to
continue to refine the policy to make sure they really are
meeting the needs of the veterans.
To address one of the other major problems with wait times,
VA must address the problems with their scheduling system.
After nearly a decade of indecision between off-the-shelf
software and in-house designs, the entire project was dropped
in late 2009. Now, 3 and a half years later, there is still no
fix in place. There is an open call for submission from the
Federal Register to end in July of this year, but our veterans
deserve a clear and better plan in place.
We hope VA can provide details on how they will be able to
implement a 21st Century scheduling software system. The most
frustrating part of the process, something has been since
Commander Conley started the System Worth Saving visits in
2003, is that when veterans can access the VA system, they
really have good things to say about the care they receive. The
American Legion believes VA needs to do a better job getting
veterans to this care and on a more timely basis.
Read through the reports. There is no reason that veterans
should face 9-month delays just to see a primary care provider.
I thank you and the Committee again for looking into this, and
I would be happy to answer any questions you might have.
[The prepared statement of Roscoe Butler appears in the
Appendix]
Mr. Coffman. Thank you, Mr. Butler.
Mr. Schoenhard, GAO reports significant failures in
scheduling appointments that span at least 7 years. In addition
to this, this Subcommittee has identified a backlog of hundreds
of thousands of appointments based on VA's own documentation.
How is VA addressing this tremendous appointment backlog?
Mr. Schoenhard. Sir, we are addressing this in a variety of
different ways, and in terms of new patients, we are creating a
new measure to go to create date to ensure, particularly for
those who are needing access to our system for the first time,
that within 14 days, we would schedule their appointment from
the time the appointment is scheduled, not when the patient
desires to be scheduled, but the clock starts the time the
appointment is being made because we believe that is a more
reliable and valid measure of making sure veterans are able to
access our system, so that is an important first part.
Also, we are in the process of undertaking a complete
review of consultation requests. We have developed new
information system tools to be able to have visibility of this
at all levels, and we are addressing that in a system-wide
review and putting in place work groups that will ensure that
we have better visibility than we have had in the past of these
consult delays and that we are acting on them in a way that
provides proper oversight and audit of that going forward.
Mr. Coffman. Mr. Schoenhard, my concern is that VA has or
will clear this backlog by simply administratively closing
appointments, as they did with 13,000 appointments in Dallas
and approximately 40,000 appointments in Los Angeles. Why isn't
VA using community providers more efficiently?
Mr. Schoenhard. Sir, you touch on a very important aspect
of our care and that is being able to use community providers
in order to better serve our veterans if we are unable to serve
them. I wonder if I could ask Mr. Matkovsky, please, to expand
further on the non-VA care efforts we are making to ensure this
is done.
Mr. Coffman. Please.
Mr. Matkovsky. Thank you.
Mr. Chairman, we have begun in fiscal year 2012 rolling out
a care coordination module for non-VA care. It allows us to
actually be more systematic in how we review referrals to the
non-VA care provider, so the care in the community, rather than
ad hoc, it allows us to collect all of the referrals for non-VA
care, ensure that folks are scheduled timely and that they can
be seen in a timely basis. We do that by actually collecting
the referral request, having a standard form of authorization
for each referral and then being able to monitor how that
referral is worked in the community. What we don't want to do
is have someone who might be experiencing a wait time in the VA
experience the same wait time in the community. This allows us
to monitor them both.
That process will be fully deployed across all of our
medical centers by the end of fiscal 2013. It is an important
change. It may not sound like it, but it allows us to more
strategically and more systematically use our non-VA partners
in delivery of care.
We have also begun a few larger contracting initiatives,
which we have briefed this Committee last year on--
Subcommittee, sorry--that will give us standardized access to
care based on performance.
Mr. Coffman. I am still unclear on how we are talking about
hundreds of thousands of backlog appointments. I mean, what are
you going to do today to get that, to take care of this?
Mr. Matkovsky. We are not going to administratively close
any appointment for care for a veteran. I think you referenced
a couple of instances where there may have been referrals that
were actually completed but simply not closed out, sir.
Mr. Coffman. You mean the 13,000 in Dallas and 40,000 in
Los Angeles, the couple that are the few that I referred to?
Mr. Matkovsky. Sorry, sir. I meant the few examples you
gave, but no, we will not close out any appointment
administratively where a veteran is waiting for care at all.
Mr. Coffman. Mr. Schoenhard, according to VA documentation,
in many instances, veterans were harmed or died due to delays
in getting treatment. How many adverse events nationwide is VA
aware of due to these delays?
Mr. Schoenhard. Sir, we have undertaken review of our
facilities, and we are in the process of completing that
review. We have instances of institutional disclosure that has
occurred throughout our system.
I ask Dr. Lynch to expand on this, but if I could turn to
you and if you could give the report.
Dr. Lynch. Thank you, Mr. Schoenhard.
If I could begin by backtracking for just a second in
discussing the process by which consults have been reviewed
across VA. The VA consult system is not an ideal system, and
unfortunately, it contains not only clinical consults, but also
the consult process that has been used for administrative
purposes. In certain cases, consults have been used to schedule
tests rather than specific patient visits. In some cases,
consults have been used to schedule advanced appointments 3 or
4 years in the future. These are called queuing consults.
The process of reviewing consults has been very careful. We
have looked at the reasons for all of the, what we term
unlinked consults, carefully evaluated whether they are of
clinical significance before making a decision whether or not
they can be administratively closed. Any of the consults that
have been closed to date have been evaluated and there has been
assurance that there has been no risk to patient care or to
patient life, sir.
Mr. Coffman. Ranking Member Kirkpatrick.
Mrs. Kirkpatrick. Ms. Draper, how confident are you that
the Veterans Health Administration will be able to effectively
make improvements in the reliability of the reported medical
appointment wait times, scheduling oversight and initiatives to
improve access to timely medical appointments?
Ms. Draper. There is a lot of work to be done, and I think,
as we reported, for more than a decade, there have been a lot
of initiatives started and the problems still persist. So, I
think they have undertaken a number of initiatives to improve
the measurement of wait times. And let me just say the
measurement of wait times is really important for a number of
different reasons, one of which is work load management, so you
don't really know --how much capacity you have which is an
indication of what other resources you might need to get
veterans in to be seen in a timely manner.
So, it remains to be seen. It is a hard question to answer
based upon previous experience. As I said in my testimony, we
have reported on these problems for more than a decade, and
there is a lot of work to be done. And I will say, it is not
just the wait time measurement, but it is having clear policies
and better allocation of staff. We heard that there are a lot
of problems around telephone access, so better management of
the telephone system is needed at the four sites that we
visited, we found evidence of long on-hold times and also of
high call abandonment rate, so it is a very complex issue, and
it is not just one thing that is going to fix this. There are a
lot of things that need to be addressed.
Mrs. Kirkpatrick. In your opinion, what do you believe is
the number one challenge VHA faces as they move forward to
making improvements and moving the scheduling process into the
21st Century?
Ms. Draper. Well, it is very important to have a clear
policy. Right now, there is a lot of ambiguity in the policy,
so it left a lot of discretion resulting in considerable
variation from one facility to another. So, one thing is clear
policy, clear implementation of that policy, and oversight. You
know, one of the things that VA did in 2007 was to require
individual medical centers to do a self-assessment and report
their compliance with the scheduling policy, and I think that
what we saw was more than 80 percent, or close to 80 percent of
the facilities that completed that self-assessment said that
they were in full compliance with the scheduling policy, and we
know from two of the facilities that we visited that said that
they were in full compliance, that was not the case.
Mrs. Kirkpatrick. Again, Ms. Draper, GAO reported that a
scheduler at one of the primary care clinics specifically
stated that she changes the recorded desired date to the
patient's agreed upon date in order to show shorter wait times
for the clinic. Clearly, that should not happen. I think we all
agree with that.
While visiting the facilities and talking to staff, did you
get a sense that the employees were unduly influenced to make
sure that shorter wait times for the clinic were reflected,
even if it weren't true?
Ms. Draper. I can tell you we heard this across several
facilities. So, as you mentioned, in one primary care clinic,
we did hear that the scheduler changed the dates to show that
there were no long wait times. In another specialty care
clinic, we heard that providers were changing dates to make
sure that their data showed that they were within the 14 day
wait time goals of VA.
We also went to one specialty clinic, which reported a
zero-day wait time because they were changing the desired date
to the appointment date. So what happened is, in reality, there
was a 6- to 8-week backlog, at least. So someone in another
part of the facility can look at the scheduling system and it
looked like there was no wait time so they would send someone
over when, in reality, there was a long, long backlog of
appointments.
So, while we weren't specifically told that they were
directed by management, I think the current situation provides
ample opportunity to change dates, whether intentional or not,
to really reflect the results that you want to achieve.
And I just want to say, too, that these measures are used
in a lot of different ways. They are included in the network
and medical director performance plan. They are also included
with VA's budget submissions, and they are also included in the
VA's annual performance and accountability report, so there is
a lot of incentive around these measures.
Mrs. Kirkpatrick. Thank you.
Thank you for your testimony, and I will yield back the
balance of my time.
Mr. Coffman. Thank you, Ranking Member Kirkpatrick.
Mrs. Walorski, Congresswoman Walorski.
Mrs. Walorski. Thank you, Mr. Chairman, and thank you to
the panel. I think, in the State of Indiana, in my district,
have 52,000 veterans just in my district alone, and our little
State of 6.5 million people that sits in the middle of the
country plays a significant role in military operations around
the country and has the fourth largest National Guard.
I find it shocking to sit and to hear these stories time
and time again.
And Mr. Schoenhard, in your testimony today, you talked
about reliable valid measures and you talked about having these
feedback loops, and I am shocked about it. Before I ask you
this question, I am shocked about it because when the military
is in need and our country is in need, Hoosiers to respond in a
rapid form? Our Hoosiers are often the first line of defense
and the first folks to go.
So, when our Nation calls them, they go. When they need
help from our Nation, to have the kind of stories that we hear,
it is very sad and it is shocking to me. So, what feedback
loops have you put in place that are going to try to correct
these problems, given the past of how long it has taken to
actually unveil these issues in the form of hearing?
Mr. Schoenhard. Congresswoman, I would say that the first
feedback loop we have used is to pilot test the new measure for
new patients, moving it from desired date to create date. This
will be a hard timestamp at the time a veteran is making an
appointment until the appointment is actually made.
Part of the problem we have had in the past is that as the
scheduler has asked a new patient when they would like their
desired date, sometimes the veteran may ask to put it out
somewhere in the future. They may be going on a trip or
somewhere and they may want to not feel an urgent need to get
in, and so we have been measuring the wait time around that
desired date. Moving it to the create date will put emphasis on
the day the appointment is being made, is that appointment made
within 14 days or not? And part of what we have experienced in
the past is that veterans, like myself, often are appreciative
of the care VHA renders, and they will ask, well, when do you
have a spot available? They are trying to be accommodating,
unless they have an urgent need, and you get into this circular
conversation. Well, it is not when we are available; it is when
you want to be seen. All of that will go away with the new
create date where we will work to get them in the system
because I couldn't agree more from my visits with veterans and
our own review, the perception of care is higher among those
who use VHA than those who have not. And so we want to get them
in our system and we owe it to Hoosier veterans; we owe it to
veterans throughout this Nation for all that they have
sacrificed, particularly in these wars, to get them in as soon
as we can.
Mrs. Walorski. I appreciate it.
And Ms. Draper, I appreciate the GAO's summary as well and
find it revealing. Is it your belief that the recommendations
that we have talked about today and the recommendations in the
report will suffice in turning some of this stuff around? And
my counter question to that is, is there a competency level at
the staffing level that needs to be addressed, or can this
completely be streamlined through programming?
Ms. Draper. Well, it is interesting you ask about this. I
assume you are talking about scheduling staff. We have heard
that these are high-stress demanding jobs and that they are
really entry level pay grade, so we saw a high amount of
turnover in these positions. We heard in the facilities that we
visited that high performers tend to get promoted quickly out
of their scheduling role, so you have a lot of turnover.
And you know one of the issues is that VA really has not
determined what its scheduling staff needs are. Just to give
you a sense of what happens when you don't have sufficient
scheduling staff, providers are picking up where schedulers are
not completing their responsibility which takes away time from
their direct patient care. So, there is just a lot of issues
that come up and it is not simple and straightforward because a
lot of things happen when you don't have sufficient staff.
Mrs. Walorski. Thank you.
I yield back my time, Mr. Chairman. Thank you.
Mr. Coffman. Thank you.
Mr. O'Rourke, Texas.
Mr. O'Rourke. Thank you, Mr. Chairman.
Ms. Draper, in some of your comments, you touched upon
capacity, and in El Paso, you know, I often hear from veterans
that when they are seen by a doctor at the VA, it is excellent
care and they have no complaints and really are just full of
praise for the quality of care, the professionalism, the
attentiveness. The challenge is getting in a lot of times and
having an appointment set and then canceled and reset, and it
is particularly acute for mental health care.
And we recently found that there are nearly 20 unfilled
positions for mental health professionals in the El Paso VA.
When you look at the fact that we have 80,000 veterans in our
service area, and we don't have a full service VA hospital, we
have this shortfall in our mental health professionals, and if
you want to go see, go to an acute care hospital. It is in
Albuquerque, a 10-hour drive roundtrip. Did you find that
capacity in terms of mental and physical health care
professionals was part of the problem in getting the wait times
that were desired?
Ms. Draper. We did not look at mental health care because
the VA IG addressed that issue, but we did look at specialty
and primary care. What we heard was that part of the reason for
backlogs is not having enough providers. Officials at the
medical centers told us that their providers are often really
stretched. For example, consults are supposed to be triaged
within 7 days of receipt, which typically falls on a clinician.
Some specialty clinics can get 40, 50, 60 consults a day, and
someone has to take care of those. So if you have a short
staffed clinic to begin with and then add on these other
ancillary duties, it really does become a scheduling nightmare.
Mr. O'Rourke. Mr. Schoenhard, how can we work with you? You
know, we met with the VHA director in El Paso, Mr. Mendoza.
Again, they are doing a great job, but I think they are working
with limited resources and they need more help, and they are
challenged by not just having these unfilled positions in their
manning table, but we also have a great active duty full
service hospital at William Beaumont East, which I think at
times poaches health professionals there. Are we not paying
enough for, in this case, mental health professionals or
primary care professionals? Are we having a hard time
attracting and retaining talent at our clinics and VA
hospitals?
Mr. Schoenhard. Congressman, first, I will follow up with
the El Paso situation.
Mr. O'Rourke. Thank you.
Mr. Schoenhard. Look into that personally. We are in a
major effort, as I am sure the Subcommittee is aware, of hiring
additional mental health professionals. We are doing site
visits to our facilities. It is important not only that we
recruit, but that we retain mental health professionals. That
is part of the vacancy. That is part of the turnover situation
going forward. We need to create the best practice environment
for our mental health providers and anywhere in this United
States.
We should lead in that effort in VHA. And it is important
that we not only address new positions, but that we fill
vacancies. As it relates to benefits and salaries, we have had,
historically, some struggle in being competitive in the
recruitment of psychiatrists. Steps have been taken to ensure
that. Psychiatry is a shortage everywhere. Having come from the
private sector, I can say, particularly in rural areas, of
course, El Paso is not that case, it is very difficult to
recruit psychiatrists. And so we use telemental health and
other ways in which to be able to provide care, which actually
has been very well received by our veterans, but we need to
ensure we have the wherewithal to effectively retain and
recruit mental health providers, and we continue to evaluate
that with a major effort in human resources.
Mr. O'Rourke. Thank you, and thanks for your offer to
follow up on these vacancies in El Paso.
Mr. Chairman, I yield back.
Mr. Coffman. Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman, and thank you all for
being here.
Ms. Draper, thank you for your work. I made it no secret in
here I am a big fan of GAO, IG and the oversight.
And Mr. Schoenhard, thank you. I have also made it clear I
am the VA's staunchest supporter and the harshest critic, and
if I am not mistaken, you yourself are a veteran.
Mr. Schoenhard. Yes, sir.
Mr. Walz. As are what percentage of your people who work?
Mr. Schoenhard. Sir, I would need to check, but at least 30
percent.
Mr. Walz. I was just going to say, I wish the distinguished
Whip would have waited for answers today, and I do bristle a
bit at the idea of indifference. I would like to know a name of
which person in the VA was indifferent because I think to paint
with a broad brush the number of people at VA that are out
there doing a good job. I am not going to defend you when you
fall down, and simply think we can do better, but I think
painting with a broad brush.
I have some statistics here. This is a 3-year-old study.
These are average wait times in the civilian sector for a
doctor appointment: 63 days in Boston; 59 days in Los Angeles;
good here, 27 days in Detroit; 47 in Minneapolis. I think many
times what we forget here is comparing apples to apples across
there.
I know, Ms. Draper, that was not your charge to the private
sector, but we pay a lot of money to the private sector in the
form of Medicare and things like that, so when we are talking
best practice and we are adding things, it is certainly not for
the desire to care.
The thing that frustrates me is that I see an unevenness in
application. And Ms. Draper, are all VA facilities created
equal in your mind on how they do this?
Ms. Draper. Are you referring to how they implement their
policy?
Mr. Walz. Yes.
Ms. Draper. No. We found considerable variance from
facility to facility.
Mr. Walz. Are there some that are doing this outstanding,
and it could be made to say that they are doing it world class?
Ms. Draper. I would say in the four facilities we visited,
we found issues in all four.
Mr. Walz. Okay.
Ms. Draper. And they range in size and geographic location.
Mr. Walz. I see it in very small geographic areas between
St. Cloud and Minneapolis, I see a difference in wait times on
there and how that works, so I think it is trying to both
integrate a unified, putting the system in and allowing for
geographic variance, but I think one of the most frustrating
things for me is, is the uneven care that veterans receive at
different facilities.
Mr. Schoenhard, can you talk about that on how you address
that or how you deal with the competing desire of local control
versus a centralized system that provides that uniform quality
care?
Mr. Schoenhard. Well, sir, let me begin with a statement
that veterans should expect the same standard of timeliness,
access, quality in their care whether its Manila or Maine. It
should be throughout our system. We are a national system.
Mr. Walz. And ironically enough, I was just in Manila. It
might be better there than anywhere I have been, just as a side
note to you, but please go on.
Mr. Schoenhard. We will learn from them, but we owe it to
our veterans to ensure more consistent delivery of timely
quality care. That is an expectation we have here in the
central office in Washington of our VISNs. We rely on our VISNs
to ensure that they are providing consistent care within their
regional footprint, and it is our responsibility to ensure
oversight and monitoring of the VISNs doing their work with the
facilities. We have that responsibility.
Mr. Walz. So, these implementations or these corrections
that were given to us, will these help improve system-wide, or
will these help improve these four facilities that were looked
at?
Mr. Schoenhard. It will help the four, and it will help the
others who also are in need of improvement. I would like Mr.
Matkovsky to expand on the plan going forward because I think
it is a more robust effort than we have had in this case.
Mr. Matkovsky. Thank you, Mr. Schoenhard.
And I would indicate that I would agree with Ms. Draper's
analysis. For a program, we require good, clear measurable
policy. So, as we work on the new set of dates, it has to be
clearly defined and we have to be able to relay that to
everybody in the field who we are expecting to hold accountable
to this new set of standards.
Our first step was adjusting some of our policies using a
date that is easy to understand. After we do that, we have to
test this policy. Rather than roll it out system-wide via memo,
it is our responsibility as a program to test it in its
application, make sure that the training we provided staff on
the front line, training we providing the providers was
adequate, that it answered the mail, any changes we made to
systems were easy to use and resulted in a measure that was
reliable in each of the clinics that we applied this change.
After we roll it out, the next thing that we require, you
mention the tension between local care--all care is local--and
oversight. It is our job to pay attention as well, to look at
the performance, to establish measures that allow us to track
the averages, but also allow us to track some of the stories
that Mr. Butler relayed, anywhere where there might be a wait
that is too long. It is our job to actually evolve our
management, our oversight and have that constant feedback that
is always looking at how to improve performance, and that is
what we are doing differently this time.
Mr. Walz. Well, I appreciate that, and with the outrage
that we express, I would just ask you to always ask us this:
how long you have been waiting for us to do a budget and
sequestration? What is fair is fair. Emerson might have been
right, ``how much of life is lost in waiting,'' but thanks.
I yield back.
Mr. Coffman. Thank you, Mr. Walz.
Mrs. Kirkpatrick. Mr. Chairman, may I have just a moment?
Mr. Coffman. Oh, yes. Go ahead.
Mrs. Kirkpatrick. Thank you very much for having this
hearing. I want to thank the panel and the guests. The
Democrats on the Committee are leaving to go meet with the
President, so I didn't want you to think we are just walking
out of the hearing, but we need to meet with him at 2 o'clock,
so thank you.
Mr. Coffman. Thank you.
Dr. Lynch, I believe you stated in your testimony that you
were not aware of any deaths of any veterans due to delayed
care; is that correct?
Dr. Lynch. We were talking about consults to begin with,
and let me, if I may, explain a little bit about how the
consult process works.
There are two sides to a consult. There is the consult
itself, the ask, and there is the response or the physician
reply. There is a third component to that which links the two.
When the team from VHA undertook to assess consults, they did
it in a standardized fashion. We looked, first of all, at all
of the consults over a --
Mr. Coffman. May I rephrase the question?
Are you aware of any deaths of any veterans due to delayed
care?
Dr. Lynch. With respect to the consult look back, no, sir.
With respect to what had occurred in Columbia and Augusta, we
are aware that there were some clinical disclosures made and
that there were veterans who had died with a disease process
that could potentially have been related to consult delay.
Mr. Coffman. Well, yeah, I think you have via the internal
documents here, and you are actually fairly specific. It is in
May that it, in fact, the delay in treatment did cause the
death of a veteran in South Carolina, and another date in May--
another internal document, last year, May 15, speaks to the
Dorn facility, speaks to another death due to delay in care, so
I think that clearly there are, by your own internal documents,
there are issues concerning the quality of care related to
timeliness and, unfortunately, the loss of life unnecessarily
of veterans, and that is particularly alarming.
Mr. Schoenhard, when did you become aware of this problem?
Mr. Schoenhard. The problem being consult backlog or back -
-
Mr. Coffman. The very problem we are discussing here today,
when did you become aware of it?
Mr. Schoenhard. Well, I would say the overall issue of wait
times, I would say, is a matter that I have been concerned
about since arriving when I was appointed in 2009.
Mr. Coffman. In 2009?
Mr. Schoenhard. Yes, sir.
Mr. Coffman. Now, it is 2013, and we are having this
discussion?
Mr. Schoenhard. Yes, sir.
Mr. Coffman. Why are we here today?
Mr. Schoenhard. I think we are here today because of a
number of factors, most of which deal with better execution
going forward and the consistent training, testing and
implementation of our scheduling package with measures that are
more reliable and valid than we have had in the past.
As I said in my opening statement, I think it begins with
the measurement system itself. And I am convinced from what we
have learned from the GAO, the IG, particularly the IG review
of mental health. That was very helpful last year.
Mr. Coffman. Mr. Schoenhard has VA's medical inspector Dr.
John Pierce come to any conclusions as a result of the large-
scale failure to care for veterans?
Mr. Schoenhard. I think that, from Dr. Pierce's report, it
showed clearly that we had the important need to do two things:
Address the delays in the facilities that he had visited in
Columbia, South Carolina and Augusta, Georgia. As important as
it was for us to vigorously respond to that report from Dr.
Pierce and the OMI of those two facilities, it was as important
as that was to ensure we were providing system resources and
VISN resources to those two facilities, it was equally
important that we do a systemwide review to see if this was of
an issue anywhere else. And that is the process that Dr. Lynch
was describing. Because whenever we have a problem arise in a
particular facility, or two facilities, we have a
responsibility to ensure veterans throughout VHA that we are
undertaking a review to see if this is the case anywhere else.
Mr. Coffman. When can the Committee see that report?
Mr. Schoenhard. I would have to take that for the record,
sir. I don't know, but I would certainly take that for the
record.
Mr. Coffman. Well, when can the Committee see that report?
Mr. Schoenhard. Sir, if I could take that for the record, I
will provide an answer as soon as we can.
Mr. Coffman. You will provide the report.
Major Shepard. I would have to check and make sure that I
can tell you the time within which the report would be
rendered.
Mr. Coffman. Is the--well--Mr. Butler, you mentioned that
the Legion's task force had identified a list of 14,000
veterans waiting months for appointments in Bay Pines. Can you
cite other locations?
Mr. Butler. Our System Worth Saving Task Force has visited
a number of VA facilities. And while I can't specifically
identify at this time facilities that have excessive wait time,
I will take that information for the record. But I can tell you
that on as recent as a visit on yesterday, we found that there
are some facilities where when we talk about the electronic
wait lists, we are still finding facilities that are still
using paper lists. So not all the appointments are being
recorded electronically. So, therefore, the wait time is not
accurately being reported as it should be.
Mr. Coffman. Thank you.
Mr. Huelskamp.
Mr. Huelskamp. Thank you, Mr. Chairman. I apologize for any
tardiness in arriving.
I would like to ask Ms. Draper a question of her report and
piecing through that, the one issue in particular that
disturbed me was you note that staff at some clinics told us
they change medical appointment desire dates to show clinic
wait times within performance goals. How widespread was that
pattern of behavior? And can you describe that a little further
for the Committee?
Ms. Draper. We actually found this in several places. So it
was not a one-time occurrence. For example, in one primary
clinic, a scheduler told us that they changed the dates to make
it look like they had short wait times. And at a specialty care
clinic in another facility, a scheduler told us providers
changed the dates to ensure that it reflected wait times within
the 14-day performance goal. We had quite a few examples.
Another specialty clinic in another facility matched the
desired date to the appointment date so that it showed a zero
wait time. In actuality, when we went there it had a 6- to 8-
week backlog of appointments. I think this question came up
earlier. Part of the issue is that there is a lot of confusion
among schedulers about what they are supposed to be doing. No
one specifically told us that they were asked to change the
date by leadership. But I think the situation as it currently
exists provides ample opportunity for dates to be changed,
whether intentional or not, to reflect the results that you
want to achieve.
Mr. Huelskamp. I appreciate that. I apologize.
Mr. Chairman, if the question has been asked before. I want
to follow up a little bit more. Is this, in your understanding,
is this illegal under --
Ms. Draper. Well, it is against scheduling policy, so they
are not in compliance with the policy or the process.
Mr. Huelskamp. I will ask the VA, how do you handle these
employees and what have you done with this information?
Mr. Schoenhard. Sir, gaming the system, if that is what is
being suggested here, by changing dates in order to ensure that
the results look better for performance reviews is entirely
unacceptable. Entirely unacceptable. And we--are visible, when
that is visible to us, we will take appropriate action. And I
will follow up with the GAO report to determine this more
specifically. What we need to be doing is ensuring we are
taking care of veterans.
Mr. Huelskamp. Assuming what we have seen matches up with
what you are seeing, sir, what is the--the penalty for an
employee that is violating this policy? What would you--how
would you handle that?
Mr. Schoenhard. Well, sir, we would review the case in each
individual case to determine what was the facts and the
circumstances and --
Mr. Huelskamp. Let's just establish that the facts indeed
occurred as indicated. What is the penalty for--I wouldn't call
it gaming the system. That is cheating. What is the penalty?
Mr. Schoenhard. The penalty would depend on the seriousness
of the offense.
Mr. Huelskamp. So if they changed it and moved it 6 weeks,
and did this repeatedly, what would be the penalty in those
circumstances?
Mr. Schoenhard. Sir, I would have to say it would depend on
the individual circumstance, but it could lead up to
termination.
Mr. Huelskamp. I look forward for a report on that.
Mr. Chairman, I might note, I want to reiterate a request I
have had to the VA for, I think we are up to 6 or 7 months now
in reference to budget data. I think we have 23 unanswered
questions in reference torch data out of the VA. And I
appreciate you coming forward to this Committee and
Subcommittee and giving some information. But I have had,
again, multiple unanswered questions, basic budget data in
reference to travels and activities by your employees that your
agency has refused to provide information. And it is very hard
to build a level of trust that we need to move forward to help
and achieve the goal of helping our veterans when you refuse to
answer, again, basic budget questions. So I would appreciate it
if you would take that back to the folks in charge. And it has
been a number of months. Certainly, we can figure out what
responses we need to get to the Congressman other than simply
ignoring those.
I yield back, Mr. Chairman.
Mr. Coffman. Thank you.
Mr. Schoenhard, and I'd like to thank the entire panel, Mr.
Butler, for your testimony, and Ms. Draper, Mr. Schoenhard and
your staff.
I just want to say that you have been here since--in this
position since 2009. You came in, obviously, the system was in
chaos and not serving the veterans' community. You have been
there, you haven't made a difference. And I have no reason to
think that, under your leadership, unfortunately, that this job
is going to get done.
With that, Committee is recessed.
[Whereupon, at 2:05 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Mike Coffman, Chairman
Good morning. This hearing will come to order.
I want to welcome everyone to today's hearing titled ``Waiting for
Care: Examining Patient Wait Times at VA.''
We should always be working to ensure veterans have timely access
to quality care. However, today's hearing is necessary because evidence
reviewed by this Subcommittee, the Government Accountability Office,
and VA's own Inspector General shows little improvement in that area.
GAO recently completed its study that was appropriately titled
``Appointment Scheduling Oversight and Wait Time Measures Need
Improvement.'' Despite claims of improvement under higher standards, we
will hear today about a lack of reliable information when VA is
measuring patient wait times. VA's own testimony supports that premise
as it discusses what it sees as no reliable standard and an inability
to accurately measure what constitutes a patient wait time.
While the topic of patient wait times may sound like a very narrow
issue, the problems in accurately monitoring and improving wait times
for veterans at VA facilities is spread throughout the whole Department
of Veterans Affairs. Schedulers at the facilities themselves have to
use a cumbersome system that creates a significant chance of error. The
problem runs all the way up to the Veterans Health Administration,
which has an unclear policy on patient scheduling practices, and still
seems to struggle to best define its policy on patient scheduling. I
understand that defining these policies is not easy, and that
perfecting a process for appointment scheduling is a significant
challenge, but VA has been well behind in this area for a long time.
However, none of this excuses VA from its obligation to veterans.
While I understand a system may not always be perfect, it does not mean
that VA shouldn't make every effort to ensure veterans receive
necessary care. Backlogs are a fairly common theme at the Department,
but that is no reason for VA to game the numbers to simply show better
performance instead of providing medical appointments, sometimes for
life-threatening conditions.
Sadly, evidence obtained by this Subcommittee clearly shows that,
in many cases, VA did not do the right thing. Instead, evidence has
shown that many VA facilities, when faced with a backlog of thousands
of outstanding or unresolved consultations, decided to administratively
close out these requests. Some reasons given included that the request
was years old, too much time had elapsed, or the veteran had died.
This Subcommittee asked VA for updates on these consultation
backlogs beginning in October 2012. Despite multiple follow-up requests
to VA, no information was ever provided, and it was only when this
hearing was scheduled that the Department offered a briefing on this
subject. I would note that the Subcommittee asked for information, not
a briefing. Regardless, we should not be where we are now, and this
goes to reinforce that the Veterans' Affairs Committee wants to work
with the Department on this and other issues, but that requires a
willingness on VA's side to be forthcoming about its problems so that
together we can identify ways to solve them.
Prepared Statement of Hon. Ann Kirkpatrick
Thank you, Mr. Chairman, for holding this hearing this afternoon on
the Veterans Health Administration's scheduling processes and how that
affects patient wait times for veterans.
Improving access to health care is a continuous effort by VHA, and
it is not surprising that we are here today.
Excessive wait times and the failures of the scheduling processes
have been longstanding problems within the Veterans Health
Administration.
The Government Accountability Office has been reporting on this
issue for over a decade.
In 2001, the GAO reported that two-thirds of the specialty care had
wait times longer than 30 days.
In 2007, the VA Office of Inspector General reported that VHA
facilities did not always follow VHA's scheduling polices and
processes.
In 2012, the VA OIG reported that VHA was not providing all new
veterans with timely access to full mental health evaluations. In that
same year, the GAO again examined the issue and found that, among other
things, there was inconsistent implementation of VHA's scheduling
policy that could result in increased wait times or delays in
scheduling timely medical appointments.
In my Arizona district, in the city of Casa Grande, one of my
caseworkers recently met with an Iraq veteran who made the brave
decision to seek VA mental health care after two years of being back in
the U.S. from Iraq.
The VA required a physical exam before this veteran in my district
could schedule an appointment with a mental health care provider.
Unfortunately, they weren't able to schedule him for the initial
physical for six full months. That's six months of waiting before he
could even have his initial consultation with a mental health care
provider. And this is after two years of not even seeing a doctor.
These situations were able to be resolved by our veterans
caseworker in the district, but the point is that veterans should not
have yet another hoop to jump through - access to health care should be
easy to schedule.
I also understand that VHA is operating with a reportedly outdated
system that is cumbersome and slow. GAO reported numerous workarounds
that some facilities are using, which may adversely affect timely
health care delivery to veterans.
Delayed care is denied care. This is all too evident with the rash
of recent consult backlogs experienced at some of VHA's medical
centers.
It has been reported that thousands of consults in 2011 and 2012
were backlogged at various facilities which may have resulted in
adverse events due to the delays in diagnosis and treatment.
This of course is unacceptable. Veterans deserve timely,
accessible, health care.
What I would like to hear about today is a sound plan that will
assist VHA in transforming into a 21st Century organization and will
eliminate, as much as possible, the needless waits, unclear policies
and procedures, and frustrating technology that only serves to slow
down progress.
Prepared Statement of Hon. Jackie Walorski
Mr. Chairman, it's an honor to be here today.
I thank you for holding this hearing on an issue that is very
important to current and future veteran care.
Indiana's Second Congressional District is home to over 50,000
veterans. \1\
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\1\ There are an estimated 53,318 veterans in IN-02. This data was
compiled on 09/30/2012, based on the district lines from the 112th
Congress. http://www.va.gov/vetdata/Veteran--Population.asp
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These men and women have served their country and endured the
struggles and triumphs that come with wearing the uniform. I am proud
of these Hoosiers and indebted to them for their sacrifices.
When the Hoosier veterans were called for duty, they promptly
responded. It is saddening and disgraceful that our Veterans
Administration fails to respond to the needs of these veterans with the
same timeliness. Veteran calls for help should not go unanswered.
I appreciate the time the panelists have taken today. I know my
colleagues share the same commitment, as I do, to ensuring the veterans
of this great Nation receive the care they have rightfully earned.
Thank you.
Prepared Statement of Hon. Jeff Duncan
It was once said that ``the legacy of heroes is the memory of a
great name and the inheritance of a great example.'' In our country,
some of our greatest heroes are our veterans; individuals who answered
our Nation's call to protect and defend our freedom. Our veterans are
one of our Nation's greatest treasures and as such our country has
given them a firm promise:
Because of their willingness to protect us through their service,
when their service ends we promise to look after them. Unfortunately,
when I talk to veterans today, they don't believe that our government
is living up to our promises. When we made the commitment to take care
of troops when they return home we never said anything about making
them jump through hoops or navigate a complicated a bureaucracy. We
promised our veterans the moon but instead we have failed in many
instances to provide our veterans with the most basic of care.
When I heard this Committee was holding this hearing, my staff
reached out to our veterans in our district to hear their perspective.
The VA testifies here today that its ``wait time goal'' is 14 days.
Well, I spoke to my constituents. As of Monday, March 4, 2013, the
Columbia VA Regional Office has 22,565 claims pending. The current wait
time is an average of 282.6 days. Survivor benefits for veteran's
spouses can between 10 and 18 months to be dispersed, and sometimes
even longer depending on the health status of the beneficiary.
My staff spoke with the Oconee County Veterans Affairs office last
week, and they tell me that up until a few weeks ago, the local
Veterans Affairs office hadn't been able reach the Columbia Regional
Office by telephone since early November. In fact, the staff of this
particular Veterans Affairs office told us that they often have to take
files home with them, so they can call down to Columbia at 10 or 11
o'clock at night just so they can leave a message, which they aren't
even able to get through to do during the day!
Last year, my office assisted a constituent who contacted us
because he has had 12 claims pending before the Veteran's
Administration which dated all the way back to 2004.
Tommy Wilbanks, a Vietnam and Gulf War Veteran from Oconee County,
currently has five cases pending before the VA dating back to June of
2010. He told us that veterans constantly feel like they're getting the
run around from the VA.
Another constituent who we've worked with had her claims delayed
over 18 months because she has been told by the Veteran's
Administration that they didn't have her medical records, this is
despite the fact she sent the VA her medical records twice by certified
mail.
When we connect these disabilities claims backlogs to the wait
times for appointments that veterans are currently experiencing in my
district, the lack of doctors and inefficiency in the system, we see a
large systemic problem that the VA has failed to address. This is
utterly unacceptable.
I've heard frequently from a younger veteran, a marine, who served
two tours in Iraq. He's concerned about the cleanliness of the
facilities in Columbia, and angered at what he's described as
disrespect shown by some of the staff directed towards veterans. He's
also deeply troubled by the wait times of support hotlines for veterans
with PDST.
The VA has failed our veterans in these ways, and you must do
better. You say the problem is resolved. Veterans in my district
disagree. You say that you've fixed it. I want to know how. We know
that in other facilities you have administratively closed cases, and
veterans have died. What are you going to do to fix these problems?
Prepared Statement of William C. Schoenhard
Good afternoon, Chairman Coffman, Ranking Member Kirkpatrick, and
Members of the Subcommittee. Thank you for the opportunity to discuss
an important topic that impacts every Veteran's experience with
Department of Veterans Affairs (VA) health care services - the
reliability and timeliness of outpatient medical appointments. I am
accompanied today by Thomas Lynch, M.D., Assistant Deputy Under
Secretary for Health for Clinical Operations; Philip Matkovsky,
Assistant Deputy Under Secretary for Health for Administrative
Operations; and, Michael Davies, M.D., National Director of Systems
Redesign
The Veterans Health Administration's (VHA) mission is to honor
America's Veterans by providing exceptional healthcare that improves
their health and well-being. Providing timely access to that care is a
critical aspect of our mission. Access enables VHA to provide
personalized, proactive, patient-driven health care; achieve measurable
improvements in health outcomes; and, align resources to deliver
sustained value to Veterans. VHA is continually assessing wait times
and making adjustments as needed to ensure that Veterans have access to
the best care anywhere.
VHA Wait Time Determination: Early Efforts
VHA has been transforming its health care delivery system for two
decades, moving from a hospital-based system to an ambulatory care
model. The ability of Veterans to access health care at the right time
and in the right place is at the heart of keeping our promise to
America's Veterans. For this reason, VA's effort to manage timely
access is critically important.
We know timeliness of appointments has improved since we began
tracking it, but determining a reliable and valid way to measure
timeliness has been difficult. In the 1990s, VHA started measuring wait
times using capacity measures, such as next available appointment date
that are widely used in the health care industry today. VHA found that
capacity measures proved inadequate to portray each individual
patient's experience because they showed clinic availability rather
than what occurred for the individual patient. In the absence of an
effective industry standard, VHA has had to develop, test, and refine
new methods for measuring wait time that align with our goal to provide
patient-centered care. Much of this work has been iterative and is
reflected by the numerous wait time measures VHA has developed over the
past ten years.
In retrospect, we now know that some of our reporting on wait times
was not as reliable as our Veteran patient and stakeholders deserve.
For instance, while the information VHA submitted for the President's
annual Performance and Accountability Reports did provide the current
level of performance against the existing measures, these measures did
not accurately capture the experience of Veterans. Measuring outpatient
medical appointment wait times was uncharted territory and we relied on
the best information and experience available at the time.
In 1999, Veterans waited an average of 60-90 days for a primary
care appointment. In 2011, VHA established a wait time goal of 14 days,
rather than 30 days, for both primary and specialty care appointments.
VHA challenged itself to provide more timely care to increase patient
satisfaction since most patients were being seen within the earlier
established 30 day goal. Currently, approximately 40% of new patients
and 90% of established patients meet this 14 day goal.
Over the past few years, the U.S. Government Accountability Office
(GAO) and VA's Office of Inspector General (OIG) have assessed VHA's
outpatient medical appointment wait times. OIG made multiple
recommendations to improve scheduler accuracy and ``establish
procedures to test the accuracy of reported wait times.'' VHA
acknowledges the shortcomings in our past approaches and appreciates
these findings and recommendations. Through these analyses, we are
better able to understand the gaps in our processes and incorporate
best practices into future policy and operations.
VHA's Wait Times Study
In 2009, VA commissioned a retrospective study partly in response
to concerns raised by GAO and OIG to assess the association between
multiple measures of timeliness and patient satisfaction. Using data
from 2005 - 2010, researchers obtained and analyzed information from
nearly 400 million VHA appointments and over 220,000 patient
satisfaction surveys. VHA received the study's results in 2012.
The study showed that new and established patients have different
needs and require different approaches for capturing wait times. Also,
the data identified that the Create Date, the date that an appointment
is made is the optimal method for new patients, since most new patients
want their visit or clinical evaluation to occur as close to the time
they make the appointment as possible. For established patients, VHA
has determined that using the Desired Date is the most reliable and
patient-centered approach. Desired Date is the ideal time a patient or
provider wants the patient to be seen. Although not perfect, this
measure provides the best association with patient satisfaction for
established patients. VHA's Wait Time Study, consistent with the
literature in this area, shows that shorter wait times are associated
with better clinical care and positive health outcomes. Armed with
evidence that the Create Date and the Desired Date best predict patient
satisfaction and health outcomes for new and established patients
respectively, VHA adopted these methods on October 1, 2012.
In December 2012, GAO issued its report urging VA to improve
oversight of the reliability of reported outpatient medical appointment
wait times and scheduling for outpatient appointments. VA concurred
with GAO's findings and their four recommendations that are important
to improving VHA's wait time measures. We will discuss in more detail
VHA's action plan to address GAO's recommendations below.
The Way Forward
With the recent evidence from our wait time study, ongoing VHA
performance measures, as well as findings and recommendation from
oversight entities, VHA believes it now has reliable and valid wait
time measures that allow VHA to accurately measure how long a patient
waits for an outpatient appointment. VHA's action plan is aimed at
ensuring the integrity of wait time measurement data so that VHA has
the most reliable information to ensure Veterans have timely access to
care and high satisfaction.
VHA is focused on implementing new wait time measurement practices,
policies, and technologies along with aggressive monitoring of
reliability through oversight and audits. VHA is working to implement
the action plan and expects to have the majority of the efforts in
place in the next 12 months. Following is a discussion of VHA's efforts
to implement reliable measures so that we can ensure that Veterans
receive the care they need when they need it.
In response to the first GAO recommendation, identifying weaknesses
in scheduler procedures for accurately and reliably establishing the
patient's desired appointment date, VHA is both establishing more
accurate wait time measures and revising its scheduling policy. The old
scheduling policy relied on the scheduler to ascertain and correctly
record the Desired Date for established patients. The new policy
requires the provider to record the patient-provider decision on the
projected next appointment date. This `Agreed-Upon-Date' (AUD) process
provides clear documentation and will improve the reliability of the
recorded desired appointment date. AUD also includes the patient
actively in the decision-making process and more accurately portrays
the patient expectation. VHA piloted these new procedures and found
them to be feasible to implement.
In order to improve the accuracy of wait time measures, VHA is
using methodology that relies on recorded time stamps. For new
patients, VHA will report the length of time that elapses between
appointment creation and completion. For established patients, VHA will
report the time between the AUD and the scheduled appointment. The VA's
wait time study that began in 2009 demonstrated that of all possible
measure combinations, these particular methods best reflect patient
satisfaction.
Regarding GAO's second recommendation to improve scheduling policy
and procedures for the use of the Electronic Wait List (EWL), VHA is
updating policy and training. Also, VHA is ensuring all staff with
access to the Veterans Health Information Systems and Technology
Architecture (VistA) appointment scheduling system completes required
training. The EWL is used to keep track of patients waiting to be
scheduled with a provider in Primary Care, Specialty Care, or Mental
Health. When the new process goes into effect within the next year,
only new patients will be placed on an EWL if they cannot be scheduled
within 90 days. In the past, VHA did not specify the 90-day standard.
Patients on the EWL will continue to have their wait times tracked from
the time they are entered on the list. Standardizing all clinics to
this procedure will allow managers to better understand clinic
operations and resource needs.
VHA has updated its training program for the more than 50,000 staff
that uses the VistA scheduling system. Schedulers are trained on how to
properly record the AUD in VistA. VHA acknowledges that the VistA
scheduling system is outdated and inefficient. Schedulers must open and
close multiple screens to check a providers' availability. It can take
a scheduler between 30 seconds and five minutes and many keystrokes to
make an appointment in VistA, compared to a point and click process in
modern scheduling programs. This cumbersome process leads to user
error. To optimize scheduler efficiency, VHA requires training of
schedulers making appointments. VA medical centers are able to track
schedulers' compliance with training requirements.
While training ensures that staff know the proper scheduling
procedures, VHA also requires audits to ensure compliance with these
procedures. The implementation of new AUD procedures enables more
comprehensive auditing capabilities. In the future, supervisors will
have the capability to electronically audit proper entry of the AUD by
the scheduler. For a typical Patient Aligned Care Team (PACT) practice,
this could range from 1,000 to 2,000 appointments per year for every
provider. Supervisors will not need to pull and review charts, but
rather more efficiently retrieve reports from central databases. This
process will audit appointment requests generated internally from
health care providers, where the majority of appointments are made.
These procedures do not apply to patients who call-in or walk-in from
``outside'' the practice. VHA will continue to require manual audits of
these cases.
Complying with GAO's third recommendation, to ensure adequate
scheduling staff is present in VHA facilities, VHA is working to ensure
that each medical center has adequate scheduling staff. Schedulers are
entry-level positions with high turnover rates and may have multiple
responsibilities. VHA has launched efforts to study and select the best
way to track staff occupying these positions. In addition, VHA has made
progress in developing analytical tools that will help schedulers and
managers select the best methods to manage access based on individual
clinic patterns of operation. For instance, clinics have differing
amounts of no-shows, cancellations, and different utilization and
revisit rates.
GAO's fourth recommendation to VHA is to improve responsiveness to
Veterans accessing services by phone. To improve telephone service for
Veterans calling into health care facilities for appointments, VHA will
require facilities to complete a standardized telephone assessment and
implement improvements. VHA will monitor the progress quarterly and
align resources as needed.
In addition to actions taken to comply with GAO's recommendations,
VHA continues to develop technology for improving the scheduling
system. VHA has completed programming for version 1.0 of the Veteran
Appointment Request Application that is currently being pilot tested.
This ``App'' resides on a Veteran's handheld device or desktop computer
and accepts up to three preferences for each appointment request. VHA
databases will capture the Veteran-entered first choice as the Desired
Date. VHA has also contracted for the development of a Scheduler
Calendar View. This ``overlay'' to the VistA scheduling system is
envisioned as a way to decrease user error that can occur during the
scheduling process. The Scheduler Calendar View will be a more user-
friendly, point-and-click interface. VHA continues to pursue efforts to
replace VistA scheduling with a commercial off-the-shelf product. The
Department has issued a challenge on Challenge.gov for a medical
patient scheduling solution.
Conclusion
In conclusion, VHA is aggressively addressing access for patients
in many ways. In 2011, VHA raised the bar for the industry by setting a
wait time goal of 14 days for both primary and specialty care
appointments. Last year, VHA added a goal of completing primary care
appointments within 7 days of the Desired Date. The intent is to come
as close as possible to providing just-in-time care for patients. The
ultimate goal is same day access. VHA is making improvements in
delivering timely care to our Veterans and in the reliability of
reporting wait time information. We have identified the issues and are
taking steps to address them. We recognize that there is more to do,
and we will continue to make this a priority.
VA is committed to honoring America's Veterans by providing them
the health care they have earned and deserve. Thank you for the
opportunity to speak to you about this issue. My colleagues and I are
ready to respond to any questions you might have.
Prepared Statement of Debra A. Draper
Chairman Coffman, Ranking Member Kirkpatrick, and Members of the
Subcommittee:
I am pleased to be here today to discuss improvements needed in the
Department of Veterans Affairs' (VA) outpatient medical appointment
scheduling oversight and wait time measurement. \1\ In fiscal year
2011, the Veterans Health Administration (VHA), within VA, provided
nearly 80 million medical appointments to veterans through its primary
and specialty care clinics, which are managed by VA medical centers
(VAMC). \2\ Although access to timely medical appointments is critical
to ensuring that veterans obtain needed medical care, long wait times
and inadequate scheduling processes at VAMCs have been persistent
problems, as we and the VA Office of Inspector General have reported.
\3\ Most recently, in December 2012, we reported that VHA's medical
appointment wait times are unreliable and problems with VHA's oversight
of outpatient medical appointment scheduling processes impede VHA's
ability to schedule timely medical appointments. \4\
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\1\ Throughout this statement, we will use the term ``medical
appointments'' to refer to outpatient medical appointments.
\2\ Outpatient clinics offer services to patients that do not
require a hospital stay. Primary care addresses patients' routine
health needs, and specialty care is focused on a specific specialty
service such as orthopedics, dermatology, or psychiatry.
\3\ See GAO, VA Health Care: More National Action Needed to Reduce
Waiting Times, but Some Clinics Have Made Progress, GAO-01-953
(Washington, D.C.: Aug. 31, 2001). See also Department of Veterans
Affairs, Office of Inspector General, Audit of the Veterans Health
Administration's Outpatient Waiting Times, Report No. 07-00616-199,
(Washington, D.C.: Sept. 10, 2007). Finally, see Department of Veterans
Affairs, Office of Inspector General, Veterans Health Administration:
Review of Veterans' Access to Mental Health Care, Report No. 12-00900-
168, (Washington, D.C.: Apr. 23, 2012).
\4\ GAO, VA Health Care: Reliability of Reported Outpatient Medical
Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-
13-130 (Washington, D.C.: Dec. 21, 2012).
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VHA has a scheduling policy designed to help its VAMCs meet its
commitment to scheduling medical appointments with no undue waits or
delays. \5\ The policy establishes processes and procedures for
scheduling medical appointments and ensuring the competency of staff
directly or indirectly involved in the scheduling process. It includes
several requirements that affect timely appointment scheduling, as well
as accurate wait time measurement. \6\ For example, the policy requires
schedulers to record appointments in VHA's Veterans Health Information
Systems and Technology Architecture (VistA) medical appointment
scheduling system; schedulers also are to record the date on which the
patient or provider wants the patient to be seen--known as the desired
date. \7\
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\5\ VHA medical appointment scheduling policy is documented in VHA
Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures
(June 9, 2010). We refer to the directive as ``VHA's scheduling
policy'' from this point forward.
\6\ VHA has a separate directive that establishes policy on the
provision of telephone service related to clinical care, including
facilitating telephone access for medical appointment management. VHA
Directive 2007-033, Telephone Service for Clinical Care (Oct. 11,
2007).
\7\ VistA is the single integrated health information system used
throughout VHA in all of its health care settings. There are many
different VistA applications for clinical, administrative, and
financial functions, including the scheduling system.
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At the time of our review, VHA measured medical appointment wait
times as the number of days elapsed from the patient's or provider's
desired date, as recorded in the VistA scheduling system by VAMCs'
schedulers. According to VHA central office officials, VHA measures
wait times based on desired date in order to capture the patient's
experience waiting and to reflect the patient's or provider's wishes.
In fiscal year 2012, VHA had a goal of completing primary care
appointments within 7 days of the desired date, and scheduling
specialty care appointments within 14 days of the desired date. \8\ VHA
established these goals based on its performance reported in previous
years. \9\ To help facilitate accountability for achieving its wait
time goals, VHA includes wait time measures--referred to as performance
measures--in its Veterans Integrated Service Network (VISN) directors'
and VAMC directors' performance contracts \10\ and VA includes measures
in its budget submissions and performance reports to Congress and
stakeholders. \11\
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\8\ In 2012, VA also had several additional goals related to
measuring access to mental health appointments specifically, such as
screening eligible patients for depression, post-traumatic stress
disorder, and alcohol misuse at required intervals; and documenting
that all first-time patients referred for or requesting mental health
services receive a full mental health evaluation within 14 days of
their initial encounter. As noted earlier, in its Report No. 12-00900-
168, the VA OIG found that some of the mental health performance data
were not reliable. VA is dropping several of these mental health
measures in 2013.
\9\ In 1995, VHA established a goal of scheduling primary and
specialty care medical appointments within 30 days to ensure veterans'
timely access to care. In fiscal year 2011, VHA shortened the wait time
goal to 14 days for both primary and specialty care medical
appointments. In fiscal year 2012, VHA added a goal of completing
primary care medical appointments within 7 days of the desired date.
\10\ Each of VA's 21 VISNs is responsible for managing and
overseeing medical facilities within a defined geographic area. VISN
and VAMC directors' performance contracts include measures against
which directors are rated at the end of the fiscal year, which
determine their performance pay.
\11\ VA prepares a congressional budget justification that provides
details supporting the policy and funding decisions in the President's
budget request submitted to Congress prior to the beginning of each
fiscal year. The budget justification articulates what VA plans to
achieve with the resources requested; it includes performance measures
by program area. VA also publishes an annual performance report--the
performance and accountability report-- which contains performance
targets and results achieved compared with those targets in the
previous year.
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My statement today highlights key findings from our December 2012
report that describes needed improvements in the reliability of VHA's
reported medical appointment wait times, scheduling oversight, and VHA
initiatives to improve access to timely medical appointments. \12\ For
that report, we reviewed VHA's scheduling policy and methods for
measuring medical appointment wait times and interviewed VHA central
office officials responsible for developing them. \13\ We also visited
23 high-volume outpatient clinics at four VAMCs selected for variation
in size, complexity, and location; these four VAMCs were located in
Dayton, Ohio; Fort Harrison, Montana; Los Angeles, California; and
Washington, D.C. At each VAMC we interviewed leadership and other
officials about how they manage and improve medical appointment
timeliness, their oversight to ensure accuracy of scheduling data and
compliance with scheduling policy, and problems staff experience in
scheduling timely medical appointments. We examined each VAMC's and
clinic's implementation of elements of VHA's scheduling policy and
obtained documentation of scheduler training completion. In addition,
we interviewed schedulers from 19 of the 23 clinics visited, and also
reviewed patient complaints about telephone responsiveness, which is
integral to timely medical appointment scheduling. We interviewed the
directors and relevant staff of the four VISNs for the sites we
visited. We also interviewed VHA central office officials and officials
at the VAMCs we visited about selected initiatives to improve veterans'
access to timely medical appointments. We performed this work from
February 2012 through December 2012 in accordance with generally
accepted government auditing standards.
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\12\ GAO-13-130.
\13\ We did not include mental health appointments in the scope of
our work, because this issue was already being reviewed by VA's Office
of Inspector General.
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In brief, we found that (1) VHA's reported outpatient medical
appointment wait times are unreliable, (2) there was inconsistent
implementation of certain elements of VHA's scheduling policy that
could result in increased wait times or delays in scheduling timely
medical appointments, and
(3) VHA is implementing or piloting a number of initiatives to
improve veterans' access to medical appointments. Specifically, VHA's
reported outpatient medical appointment wait times are unreliable
because of problems with correctly recording the appointment desired
date--the date on which the patient or provider would like the
appointment to be scheduled--in the VistA scheduling system. Since, at
the time of our review, VHA measured medical appointment wait times as
the number of days elapsed from the desired date, the reliability of
reported wait time performance is dependent on the consistency with
which VAMC schedulers record the desired date in the VistA scheduling
system. However, aspects of VHA's scheduling policy and related
training documents on how to determine and record the desired date are
unclear and do not ensure replicable and reliable recording of the
desired date by the large number of staff across VHA who can schedule
medical appointments, which at the time of our review was estimated to
be more than 50,000. During our site visits, we found that at least one
scheduler at each VAMC did not record the desired date correctly,
which, in certain cases, would have resulted in a reported wait time
that was shorter than the patient actually experienced for that
appointment. Moreover, staff at some clinics told us they change
medical appointment desired dates to show clinic wait times within
VHA's performance goals. Although VHA officials acknowledged
limitations of measuring wait times based on desired date, and told us
that they use additional information, such as patient satisfaction
survey results, to monitor veterans' access to medical appointments,
reliable measurement of how long veterans wait for appointments is
essential for identifying and mitigating problems that contribute to
wait times.
At the VAMCs we visited, we also found inconsistent implementation
of certain elements of VHA's scheduling policy, which can result in
increased wait times or delays in scheduling timely medical
appointments. For example, four clinics across three VAMCs did not use
the electronic wait list to track new patients that needed medical
appointments as required by VHA's scheduling policy, putting these
clinics at risk for losing track of these patients. Furthermore, VAMCs'
oversight of compliance with VHA's scheduling policy was inconsistent
across the facilities we visited. Specifically, certain VAMCs did not
ensure the completion of scheduler training by all staff required to
complete it even though officials stressed the importance of the
training for ensuring correct implementation of VHA's scheduling
policy. VAMCs also described other problems that impede the timely
scheduling of medical appointments, including VA's outdated and
inefficient VistA scheduling system, gaps in scheduler staffing, and
issues with telephone access. The current VistA scheduling system is
more than 25 years old, and VAMC officials reported that using the
system is cumbersome and can lead to errors. \14\ In addition,
shortages or turnover of scheduling staff, identified as a problem by
all of the VAMCs we visited, can result in appointment scheduling
delays and incorrect scheduling practices. Officials at all VAMCs we
visited also reported that high call volumes and a lack of staff
dedicated to answering the telephones impede the scheduling of timely
medical appointments.
---------------------------------------------------------------------------
\14\ In October 2012, VA announced a contest seeking proposals for
a new medical appointment scheduling system from commercial software
developers.
---------------------------------------------------------------------------
VHA is implementing or piloting a number of initiatives to improve
veterans' access to medical appointments that focus on more patient-
centered care; using technology to provide care, through means such as
telehealth and secure messaging between patients and their health care
providers; and using care outside of VHA to reduce travel and wait
times for veterans who are unable to receive certain types of
outpatient care in a timely way through local VHA facilities. For
example, VHA is piloting a new initiative to provide health care
services through contracts with community providers that aims to reduce
travel and wait times for veterans who are unable to receive certain
types of care from VHA in a timely way. Although VHA collects
information on wait times for medical appointments provided through
this initiative, these wait times may not accurately reflect how long
patients are waiting for appointments because they are counted from the
time the contracted provider receives an authorization from VA, rather
than from the time the patient or provider first requests an
appointment from VHA.
In conclusion, VHA officials have expressed an ongoing commitment
to providing veterans with timely access to medical appointments and
have reported continued improvements in achieving this goal. However,
unreliable wait time measurement has resulted in a discrepancy between
the positive wait time performance VA has reported and veterans' actual
experiences. More consistent adherence to VHA's scheduling policy and
oversight of the scheduling process, allocation of staff resources to
match clinics' scheduling demands, and resolution of problems with
telephone access would potentially reduce medical appointment wait
times. VHA's ability to ensure and accurately monitor access to timely
medical appointments is critical to ensuring quality health care to
veterans, who may have medical conditions that worsen if access is
delayed.
To ensure reliable measurement of how long veterans are waiting for
appointments and improve timely medical appointment scheduling, we
recommended that the Secretary of VA direct the Under Secretary for
Health to take actions to (1) improve the reliability of its medical
appointment wait time measures, (2) ensure VAMCs consistently implement
VHA's scheduling policy, (3) require VAMCs to routinely assess
scheduling needs for purposes of allocation of staffing resources, and
(4) ensure that VAMCs provide oversight of telephone access and
implement best practices to improve telephone access for clinical care.
VA concurred with our recommendations and identified actions planned or
underway to address them.
Chairman Coffman, Ranking Member Kirkpatrick, and Members of the
Subcommittee, this concludes my prepared remarks. I would be pleased to
respond to any questions you or other members of the subcommittee may
have at this time.
For questions about this statement, please contact Debra A. Draper
at (202) 512-7114 or [email protected]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this statement. Individuals making key contributions to this
testimony include Bonnie Anderson, Assistant Director; Rebecca Abela;
Jennie F. Apter; Lisa Motley; Sara Rudow; and Ann Tynan.
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Highlights
VA HEALTH CARE
Appointment Scheduling Oversight and Wait Time Measures Need
Improvement
Why GAO Did This Study
VHA provided nearly 80 million outpatient medical appointments to
veterans in fiscal year 2011. Although access to timely medical
appointments is important to ensuring veterans obtain needed care, long
wait times and inadequate scheduling processes have been persistent
problems.
This testimony is based on a December 2012 report, VA Health Care:
Reliability of Reported Outpatient Medical Appointment Wait Times and
Scheduling Oversight Need Improvement (GAO-13-130), that described
needed improvements in the reliability of VHA's reported medical
appointment wait times, scheduling oversight and VHA initiatives to
improve access to timely medical appointments. To conduct that work,
GAO made site visits to 23 clinics at four VAMCs, the latter selected
for variation in size, complexity, and location. GAO also reviewed
VHA's policies and interviewed VHA officials.
What GAO Recommends
In its December 2012 report, GAO recommended that VHA take actions
to (1) improve the reliability of its medical appointment wait time
measures, (2) ensure VAMCs consistently implement VHA's scheduling
policy, (3) require VAMCs to allocate staffing resources based on
scheduling needs, and (4) ensure that VAMCs provide oversight of
telephone access and implement best practices to improve telephone
access for clinical care. VA concurred with GAO's recommendations.
What GAO Found
Outpatient medical appointment wait times reported by the Veterans
Health Administration (VHA), within the Department of Veterans Affairs
(VA), are unreliable. Wait times for outpatient medical appointments--
referred to as medical appointments--are calculated as the number of
days elapsed from the desired date, which is defined as the date on
which the patient or health care provider wants the patient to be seen.
The reliability of reported wait time performance measures is dependent
on the consistency with which schedulers record the desired date in the
scheduling system. However, aspects of VHA's scheduling policy and
training documents for recording desired date are unclear and do not
ensure consistent use of the desired date. Some schedulers at VA
medical centers (VAMC) that GAO visited did not record the desired date
correctly, which, in certain cases, would have resulted in a reported
wait time that was shorter than the patient actually experienced for
that appointment. VHA officials acknowledged limitations of measuring
wait times based on desired date, and described additional information
used to monitor veterans' access to medical appointments; however,
reliable measurement of how long patients are waiting for medical
appointments is essential for identifying and mitigating problems that
contribute to wait times.
While visiting VAMCs, GAO also found inconsistent implementation of
certain elements of VHA's scheduling policy that impedes VAMCs from
scheduling timely medical appointments. For example, four clinics
across three VAMCs did not use the electronic wait list to track new
patients that needed medical appointments as required by VHA scheduling
policy, putting these clinics at risk for losing track of these
patients. Furthermore, VAMCs' oversight of compliance with VHA's
scheduling policy, such as ensuring the completion of required
scheduler training, was inconsistent across facilities. VAMCs also
described other problems with scheduling timely medical appointments,
including VHA's outdated and inefficient scheduling system, gaps in
scheduler staffing, and issues with telephone access. For example,
officials at all VAMCs GAO visited reported that high call volumes and
a lack of staff dedicated to answering the telephones impede scheduling
of timely medical appointments.
VHA is implementing a number of initiatives to improve veterans'
access to medical appointments such as use of technology to interact
with patients and provide care, which includes the use of secure
messaging between patients and their health care providers. VHA also is
piloting a new initiative to provide health care services through
contracts with community providers that aims to reduce travel and wait
times for veterans who are unable to receive certain types of care
within VHA in a timely way.
Prepared Statement of Roscoe Butler
A veteran in crisis, suffering from mental health problems, became
so furious with the telephone delays he faced while trying to make a
mental health appointment at the VA, assaulted his wife and dog after
being repeatedly placed on hold. Veterans are struggling to access
their healthcare across the country, and in Richmond, Virginia
appointments for mental health (PTSD) issues are at least a six to
eight month wait. Further, when calling for assistance, veterans are
placed on hold before being asked whether the call is regarding an
emergency, or whether the veteran is currently a danger to them self or
to someone else.
Chairman Miller, Ranking Member Michaud and distinguished Members
of the Committee: On behalf of National Commander James Koutz and the
2.4 million veterans of The American Legion, thank you for the
opportunity to address this critical issue affecting veterans across
the nation.
In VISN 21, a veteran has informed us that it takes approximately
twelve weeks to obtain primary care appointments at the VAMC.
Addressing wait times within VA is nothing new to The American Legion.
Our System Worth Saving Task Force, the renowned third party oversight
of VA medical facilities, was created, in part, as a response to
growing wait times at VA facilities. When Past National Commander
Ronald F. Conley of Pennsylvania became National Commander in 2002, he
helped create two initiatives: First was the year-long ``I Am Not A
Number'' campaign which sought to put faces on the veterans waiting
months and years for appointments and service from VA, and second was
the annual System Worth Saving report - designed to address the fact
that, as Commander Conley noted,
``Among veterans, I heard profound gratitude voiced for the quality
of care they receive. But from nearly everyone, I also found acute
frustration over the lack of timely access to VA health care.''
That year the System Worth Saving Report found that over 300,000
veterans were waiting for health care appointments. Of those, over half
were waiting more than eight months for primary care appointments. At
Bay Pines, Florida the VA Medical Center had a list of 14,000 veterans
waiting longer than six months for an appointment, and 14,000 was a
celebrated improvement!
It's been more than 10 years, and The American Legion continues to
make System Worth Saving Task Force visits to dozens of medical
facilities across the country every year. We have determined that many
of these scheduling problems remain, and veterans are still being
delayed and denied access to otherwise excellent care. VA needs to
begin implementing real solutions to its problems and these solutions
need to start with an improved appointment scheduling system.
Unfortunately, the only metric we have to track whether veterans
are being seen on time relies on self-reporting from VA, and according
to the Government Accounting Office (GAO), VA is a poor barometer of
whether or not they are meeting appointment time guidelines. GAO
specifically noted problems with VA schedulers repeated erroneous
recording the ``desired date'' for appointments, and explained `` . . .
schedulers changed the desired date based on appointment availability;
this would have resulted in a reported wait time that was shorter than
the patient actually experienced.'' \1\ Because the figures are being
manipulated by employees to look better, statistics such as VA's
reported 94 percent of primary care appointments within the proper
period, mean very little.
---------------------------------------------------------------------------
\1\ GAO-13-130, Reliability of Reported Outpatient Medical
Appointment Wait Times and Scheduling Oversight Need Improvement,
December 2012
---------------------------------------------------------------------------
The real measure, of whether VA is meeting the needs of veterans is
how long the ACTUAL veterans have been waiting for appointments. For
example, a veteran in VISN 18 told the Legion that they were waiting
more than 8 months for a primary care appointment, and when he finally
went in for the appointment, he was not seen, but rescheduled to return
a month later. A three quarter of a year wait for a primary care
appointment is not meeting the needs of veterans.
As we are now a decade into the 21st Century, The American Legion
believes that VA should also begin implementing 21st Century solutions
to its problems. In 1998, GAO released a report that highlighted the
excessive wait times experienced by veterans trying to schedule
appointments, and recommended that VA replace its VistA scheduling
system. \2\ To address the scheduling problem, the Veteran's Health
Administration (VHA) solicited internal proposals from within VA to
study and replace the VistA Scheduling System, with a Commercial Off-
the-Shelf (COTS) software program. VA selected a system, and about 14
months into the project they significantly changed the scope of the
project from a COTS solution to an in-house build of a scheduling
application. After that, VHA ended up determining that it would not be
able to implement any of the planned system's capabilities, and after
spending an estimated $127 million over 9 years, The American Legion
learned that VHA ended the entire Scheduling Replacement Project in
September 2009. \3\ We believe that this haphazard approach of fits and
starts is crippling any hope of progress.
---------------------------------------------------------------------------
\2\ U.S. Medicine Magazine, VA Leadership Lacks Confidence in New
$145M Patient Scheduling System, May 2009
\3\ GAO-10-579, Management Improvements Are Essential to VA's
Second Effort to Replace Its Outpatient Scheduling System, May, 2010
---------------------------------------------------------------------------
It has now been over three years since VHA cancelled the
Replacement Scheduling Application project, and as of today, The
American Legion understands that there is still no workable solution to
fixing VA's outdated and inefficient scheduling system. In 2012 The
American Legion passed Resolution number 42 that asked the VA to
implement a system ``To allow VA patients to be able to make
appointments online by choosing the day, time and provider and that VA
sends a confirmation within 24 hours''. Last December, VA published an
opportunity for companies to provide adjustments to the VistA system
through the federal Register - all submissions are due by June 2013.
While this is laudable attempt to address the problem, it hardly seems
sufficiently proactive given that the problem has been identified for
over fifteen years, and the persistence of excessive wait times still
experienced by many veterans across the nation.
The American Legion recognizes that over the past decade, VA has
taken some steps aimed at to improving its scheduling and access to
care, we believe that there is still much to be done. In order to
adequately address the problems of veterans, The American Legion
believes VA should adopt the following steps towards a solution:
1. Devote full effort towards filling all empty staff positions.
The problems with mental health scheduling clearly indicate how a lack
of available medical personnel can be a large contributing factor to
long wait times for treatment. Despite VA's efforts to hire 1,600 new
staff, as recently as last month VA was noting only two thirds of those
positions had been filled. This does not even address the previous
1,500 vacancies, and stakeholder veterans' groups are left to wonder if
VA is adequately staffed to meet the needs of veterans.
We believe they are not.
If VA needs more resources to address these staffing needs, The
American Legion hopes they will be forthright and open about their
need, and ask for the resources they need to get the job done. The
Veteran Service Organizations and Congress have been extremely
responsive to get VA the resources they need to fulfill their mission,
but VA must be transparent about what their real needs are.
2. Develop a better plan to address appointments outside
traditional business hours. With the growing numbers of women veterans
who need to balance family obligations and other commitments hamper our
veterans' abilities to meet appointments during regular business hours.
The American Legion believes VA can better address the community's
needs with more evening and weekend appointment times. American
Resolution number 40 calls on the VA to provide more extended hour
options, and believes VA should recruit and hire adequate staff to
handle the additional weekend and extended hour appointments for both
primary and specialty care.
3. Improve the IT solution. Last year The American Legion also
passed resolution number 44 , that called on the VA to create a records
system that both VBA and VHA could share to better facilitate
information exchange. A common system could even synchronize care
visits in conjunction with compensation and pension examinations. We
had hoped such a system might be included in the improvements brought
by the Virtual Lifetime Electronic Record, however VA and DOD appear to
be content to pursue individual legacy systems for that project, so
veterans must continue to contend with VBA and VHA systems that do not
communicate as well as they should. In any case, as VA looks outward
for a solution to their scheduling program, all can agree that the
current system is not serving the needs of veterans and needs to be
updated.
Tragically, the end result is that although VA has a truly first
rate standard of care, veterans aren't able to access it with anywhere
near the ease with which they should. Even the best care in the world
is of little service to veterans if they cannot easily schedule timely
appointments. If these problems with scheduling and appointments can be
remedied, and veterans can access the care VA is delivering through the
system, there would be little to complain about.
The American Legion thanks the committee for their diligence to
pursue these failings of oversight, and while these are solvable
problems, the solutions will require the participation and input from
all community stakeholders. The outstanding care veterans receive in VA
is, and should be, a point of national pride. Let's not tarnish the
good work the VA accomplishes because we insist on wrestling with
legacy IT systems.
For additional information regarding this testimony, please contact
Mr. Shaun Rieley at The American Legion's Legislative Division, (202)
861-2700 or [email protected].
List of attachments;
Attachment A Statements from veterans as reported to us through our
Department Service Officers
Attachment B The American Legion Resolution #40
Attachment C The American Legion Resolution #42
Attachment D The American Legion Resolution #44
Attachment A:
Statements from veterans as reported to us through our Department
Service Officers
VISN 1
Generally the access to healthcare in the VISN is excellent when
everything goes right, weather and vacations hamper the process though
and there are a few issues. Scheduling continues to be tricky for
certain specialties and the clinics are cancelling appointments if the
veteran is not checked in prior to the assigned time. In the winter
months that is tricky . Vets ( including myself) were listed as missing
an appointment on the day of the big snow storm earlier in the month.
My rheumatology clinic was rescheduled four months from now. VHA has
expanded the capacity at one of the CBOC's as it has moved to a larger
facility and they have in turn brought on additional providers. This
eases the strain at the VAMC's, although I cannot say without checking
the numbers if they are seeing more veterans then last year at this
time, or if the load has been spread out across more providers. Mental
Health Care at the CBOC's is getting good reviews , both on access and
availability to Psychologists and Psychiatrists. In VHA the problem
appears to be, as was mentioned at the Washington Conference in DC,
that only about half of the enrolled vets are using the services. I
cannot say what the functionality would be if 80-90% of enrollees began
to actively seek health care, or if a higher percentage of eligible
veterans enrolled.
VISN 6
Appointments for Mental Health, i.e Ptsd. Veterans are having to
wait at least 6-8 months to be seen. When calling this clinic for
assistance, you are immediately placed on hold, before being asked ``Is
this an Emergency'' Are you in any danger to yourself, or someone else.
One Veteran, after he was placed on hold, became so furious, he beat
his dog and wife, then they both went to the emergency room outside the
VA.
Another concern is Veterans being sent for QTC exams, and because
the doctors are not clear as to the test VA wants, they are given
options to decline the tests.
Female Veterans are not seeing, nor getting the treatment, or time
spent as males are. Story- Two married veterans with Diabetes. Her
husband (takes pills only), VA doctor took 20 minutes with him,
observed his feet, spoke to him about nutrition, shoes, socks
medication and so on. Her doctor, crossed his legs, asked what can he
do for her, took 10 minutes, made one or two notes, and said I refilled
your medicines and I will see you in six months. This veteran is
Insulin dependent, takes Medformin (pill), had recently stepped on a
thumb tack, and her feet and ankles were swollen. She asked him to
check her feet, doctor asked why, what's going on and reminded her that
other patients are time slotted, she may have to reschedule. Last - VHA
-Interns are telling the veteran, they are not experienced enough to
write nexus letter to support claim, diagnoses or justify conditions.
They are telling the veteran, it's in their records, tell who ever is
processing your claim to read it.
VISN 8, 10, 18
I've been enrolled in three different VISN's and health care
facilities in the last twenty some odd years. The first was at the VA
OPC, in VISN 8. The care there was second to none and I could get
appointments within two to three weeks. My second experience was with A
medical center in VISN 10. Although overcrowded, I received excellent
care and appointments within two to three weeks. I am now residing in
VISN 18. It took me eight months to get my initial appointment, when I
arrived, they had given me the wrong time and cancelled the
appointment. It took another four or five weeks to reschedule their
error. My appointment was in early January. They were supposed to set
up upper-GI and audiology appointments. Also, I asked for more pain
medications (non-narcotic) for my service connected back. I am still
waiting for the appointments and the meds. I do not intend to go back
to this medical center. It appears to be poorly managed. I should not
have had to wait 8 months for my first appointment, and they should
have made arrangements to see me that day when I reported late for the
appointment, as it was their error which caused me to be late. I lost
one hour of sick leave because of their error.
VISN 10
Treatment - The mental health department seems to have a cookie
cutter method for treating all veterans. As a result veterans have
stopped seeking Mental Health treatment. This makes veterans not want
to seek help.
VHA Phone - When you do get through on the phones, you are
transferred to the wrong department or told you will be called back,
and never get a call back.
VISN 17
We do not receive too many complaints and about my facility in VISN
17, but a few more complaints about another VAMC in VISN 17 with regard
to scheduling appointments. Some of the veterans indicate that it is a
bit difficult to schedule an appointment, especially with the
outpatient clinics. Most of the complaints seem to center around being
timely notified of the date and time of the appointments. Additionally,
there have been complaints about the length of time it would take to
get into a specialty clinic, especially PTSD at the clinics. Of course,
the majority of the complaints about the VA healthcare facilities come
from those individuals using the medical center.
VISN 18
Here in VISN 18 we have a great VA hospital. However, medical
personnel is an issue. We have a great women's clinic but because of
staff shortages it takes sometime for our women veterans to have an
appointment. In addition, the east side CBOC is also experiencing staff
issues. One primary care physician at a medical center in VISN 18 has
not been replaced and since his departure last summer, his patients
have a difficulty being seen.
VISN 19 & 22
Another major issue is having to wait up to 12 weeks to get a
primary care appointment. Fortunately, the individual can go to triage
for emergent issues but we don't want triage to become primary care.
Another issue would be obtaining a diagnosis of PTSD or mental health
issue. It can take weeks for a WWII or a Viet Nam vet to get a
diagnosis as the only priority care for PTSD issues is the OEF/OIF
office. Now these WWII and Viet Nam and Korea vet who begin to
experience issues at this later time in life after retirements etc,
have to first get to primary care (12 weeks) and then obtain a referral
to mental health which can take weeks to months due to loading.
While I hear great things about the staff and care in VISN 19 AND
22, the wait times and availability for appointments and issues are
approximately 8-12 weeks out.
We are not considered `rural' but `frontier', which means we are
even more remote than rural. We have an approximate population of 50K
and are 4 hours drive from the nearest VAMC. The local CBOC does not
have a full time nor even part time doctor on site which means 4 hour
trips one way. Emergency and urgent care and coordination there of for
veterans seems to be an issue with the local hospital also.
VISN 23
One of the biggest complaints I hear time and time again is when a
veteran wants to call in (or the doc has asked them to contact them)
and they call up the Clinic to leave message or etc and they cannot be
connected to the doctor. Either they get a triage nurse or someone in
another clinic and they are not sure the provider even got the message
to start with. This is a huge problem. Many times the vets get seen in
the ER or the doc says call me and let me know and they can't get that
message back to them. This makes the vets feel like they have no
connection to the doctor they just saw.
My other issue is this: I am soooooo tired of getting a provider
and 2 months later having to start from scratch with yet another
provider. I hate hashing and rehashing my medical concerns time and
time again or something that was so far in the past that it's no longer
an issue but since we are starting from scratch we have to go back to
it. That means the quick appointment I thought I was going to get to
refill my meds now takes 2 hours and there is absolutely no reason for
it.
We hear a lot about the inability to provide certain medications
for veterans as they are not authorized on the list. For example
certain medications for Diabetes control.
Attachment B
NATIONAL EXECUTIVE COMMITTEE OF THE AMERICAN LEGION INDIANAPOLIS,
INDIANA
OCTOBER 17 - 18, 2012
Resolution No. 40: Extended Hours & Weekends for Veterans' Health
Care
Origin: Veterans Affairs and Rehabilitation Commission
Submitted by: Veterans Affairs and Rehabilitation Commission
WHEREAS, The Department of Veteran Affairs' (VA) mission is to
provide for those who have borne the battle; and
WHEREAS, Veterans employed in the civilian workforce may require
more flexible hours to meet their health care needs, because they have
not accrued an adequate amount of personal leave to use for health care
appointments; and
WHEREAS, Eligible veterans should not be denied access to VA
healthcare due to a lack of flexible health care appointments; and
WHEREAS, Veterans with children also may require flexible hours to
meet their health care needs; and
WHEREAS, Extended hours such as early mornings, evenings and
weekend appointments should be made available at all VA facilities to
include primary and specialty care; and
WHEREAS, Offering extended hours for veterans may reduce no-show
rates by providing flexible appointments; and
WHEREAS, Additional clinic hours are not possible due to chronic
short staffing; and
WHEREAS, Staffing limitations would affect patients from receiving
health care on a timely basis; and
WHEREAS, The VA's premium and overtime compensation should be
competitive with the private sector for employees who contribute
overtime and weekend work; and
WHEREAS, The Veterans Health Administration developed Directive
2012-023, Extended Hours Access For Veterans Requiring Primary Care
Including Women's Health and Mental Health Services At Department Of
Veterans Affairs Medical Centers And Selected Community Based
Outpatient Clinics on September 5, 2012; and
WHEREAS, The directive was rescinded on September 11, 2012 by VHA
Notice 2012-13; now, therefore, be it
RESOLVED, By the National Executive Committee of The American
Legion in regular meeting assembled in Indianapolis, Indiana, on
October 17-18, 2012, The Department of Veteran Affairs (VA) provide
extended hours and weekend appointments for both primary and specialty
care at all VA medical facilities in addition to their regular hours of
operation; and, be it finally
RESOLVED, That the VA recruits and hires additional staff to
accommodate the rising need of weekend and extended hours for
appointments in both primary and specialty care.
Attachment C
NATIONAL EXECUTIVE COMMITTEE OF THE AMERICAN LEGION INDIANAPOLIS,
INDIANA
OCTOBER 17 - 18, 2012
Resolution No. 42: Virtual Lifetime Electronic Record
Origin: Veterans Affairs and Rehabilitation Commission
Submitted by: Veterans Affairs and Rehabilitation Commission
WHEREAS, On April 9, 2009, President Obama provided direction to
the Department of Defense (DoD) and Department of Veterans Affairs (VA)
to develop a Virtual Lifetime Electronic Record (VLER), which would
create a unified lifetime electronic record for members of the Armed
Services; and
WHEREAS, The VLER plans to include administrative and medical
information for service members from when they first join the service
throughout their lives until they are laid to rest; and
WHEREAS, The VLER plan seeks to expand the departments' health
information sharing capabilities by enabling access to private sector
health data as well; and
WHEREAS, VLER is a federal, inter-agency initiative to provide
portability, accessibility and complete health, benefits and
administrative data for servicemembers, veterans and their
beneficiaries; and
WHEREAS, DoD and VA for years have yet to fully implement a
bilateral medical record between both agencies with no target end date
in sight; and
WHEREAS, Approximately 2.1 million members of the military have
served in Operation Enduring Freedom, Operation Iraqi Freedom, and
Operation New Dawn and are returning home in unprecedented numbers
needing care for their injuries and illnesses sustained in service to
our nation; and
WHEREAS, Failure to implement a bilateral medical record and VLER
to date has caused significant delays in the veterans' treatment
process from DoD to VA because the VA treatment team does not have full
access to the patient's DoD records and have to rely on a patient's
self report of their medical history and symptoms; and
WHEREAS, Servicemembers and veterans are forced to make copies of
their records at their last duty station or submit a request to the
National Personnel Records Center in St. Louis, which can take months
to process; and
WHEREAS, Veteran service organizations, such as The American
Legion, have not been invited to VLER meeting to provide stakeholder
input and sharing of mutual concerns; and
WHEREAS, The American Legion has over 2,000 accredited department
(state) and county veteran service officers that will continue to need
access to Veteran Benefit Administration databases in order to file for
VA benefits and claims for those claimants represented; and
WHEREAS, The American Legion is concerned that within VA's three
branches - Veterans Health Administration (VHA), Veterans Benefits
Administration, and National Cemetery Administration - there are
numerous computer-based programs that are inoperable between these
branches which are not addressed in the VLER plan; and
WHEREAS, Because a bilateral medical record is not currently
available, there is not an ability for a patient's record to be flagged
at the time of injury/illness occurred during military service, which
makes it difficult and more time-consuming for DoD/VA physicians and
raters to find proof of service connection; and
WHEREAS, Currently VA has the ability to send patients encrypted
email messages and a VHA program, Myhealthyvet, allows patients to
refill their VA prescriptions, view their labs and receive VA wellness
reminders but does not allow VA patients to schedule appointments
online; now, therefore, be it
RESOLVED, By the National Executive Committee of The American
Legion in regular meeting assembled in Indianapolis, Indiana, on
October 17-18, 2012, That The American Legion urge Congress to provide
oversight to the Department of Defense (DoD) and Department of Veterans
Affairs (VA) to ensure that the Virtual Lifetime Electronic Record
(VLER) is fully implemented by Fiscal Year 2013; and, be it further
RESOLVED, That The American Legion urge DoD and VA to implement
VLER no later than FY 2013 to ensure returning servicemembers' medical
records are able to be accessed by both agencies which will improve the
timeliness and delivery of VA health care and claims benefits; and, be
it finally
RESOLVED, That The American Legion recommend the following be
included in design and implementation of VLER:
Include veteran service organizations, such as The
American Legion, in VLER meetings to offer stakeholder input and
sharing of mutual concerns;
Allow servicemember records to be flagged at the time of
injury/illness in the military to speed up processing of VA benefits
(health care and claims) during and after discharge;
Ensure computer systems and programs within the Veterans
Health Administration, Veterans Benefits Administration, and National
Cemetery Administration are interoperable and able to communicate with
each other;
Allow VA patients to be able to make appointments online
by choosing the day, time and provider and that VA sends a confirmation
within 24 hours.
Attachment D
NATIONAL EXECUTIVE COMMITTEE OF THE AMERICAN LEGION INDIANAPOLIS,
INDIANA
OCTOBER 17 - 18, 2012
Resolution No. 44: Decentralization of Department of Veterans
Affairs Programs
Origin: Veterans Affairs and Rehabilitation Commission
Submitted by: Veterans Affairs and Rehabilitation Commission
WHEREAS, The Department of Veterans Affairs (VA) has been gearing
towards a centralized model of decision-making within the Veterans
Health Administration (VHA) and Veterans Benefits Administration (VBA);
and
WHEREAS, Centralization of contracting has created problems for
individual facilities such as a two-day pileup of hazardous waste
outside a Boston VA Medical Center (VAMC) due to a lapse in contract
that could have been prevented by local contracting officers; and
WHEREAS, Centralization of Internet Technology (IT) removed the
ability of individual facilities to be flexible with their programming
needs; and
WHEREAS, Centralization of information leads to siloing among the
Administrations; for example when processing a claim, the VBA and the
VHA do not have the ability to access or view the other
administration's records in their entirety; nor can the Appeals
Management Center (AMC) view images in records that might be useful in
rating decisions; and
WHEREAS, According to an article published in the Annual Review of
Public Health in 2009 called ``Extreme Makeover: Transformation of the
Veterans Health Care System'' by Drs. Kizer and Dudley, centralization
of decision-making authority markedly slows down the process; and
WHEREAS, Centralization fosters animosity between agencies that are
forced to compete for IT funding; for example the Office of Research
and Development (ORD) reported that it was unable to finance select
projects because all resources went to the VBA claims IT program
programs; and
WHEREAS, The VistA computer program that the VHA uses to track
medical records was created by doctors at local facilities, and is now
regarded as one of the best IT systems in the world; and
WHEREAS, If the VBA and VHA shared a common appointment scheduling
system for Compensation and Pension (C&P) exams, their respective
employees would be able to schedule and reschedule appointments as
needed; and
WHEREAS, If VBA liaisons were placed within VAMCs, communication
between administrations, namely the communication between raters and
physicians, would be increased, therefore reducing error and turnaround
time for processing claims; now, therefore, be it
RESOLVED, By the National Executive Committee of The American
Legion in regular meeting assembled in Indianapolis, Indiana, on
October 17-18, 2012, That The American Legion supports decentralization
of programs associated with the Veterans Benefits Administration (VBA)
and the Veterans Health Administration (VHA); and, be it further
RESOLVED, That the Department of Veteran Affairs (VA) decentralizes
its decision making, accompanied by a demarcation of responsibilities
and a plan for holding its decision-makers accountable; and, be it
further
RESOLVED, That the VA restores contract-making authority and
Internet Technology programs to VA Medical Centers at the local level
and Regional Offices (ROs); and, be it further
RESOLVED, That VBA and VHA structure their relationship using a
bottom-up approach similar to Baldrige's Model of Excellence, which
will allow for a rapid model of change to occur at the operator level;
and, be it finally
RESOLVED, That VBA and VHA share a common records system and
increased access to one another's programs in order to facilitate
information exchange and process claims more efficiently.