Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care

The majority of veterans utilizing VA health care services receive care in VA-operated medical facilities, including 172 VA medical centers and more than 1,000 outpatient facilities. For nearly 20 years, GAO has reported on the challenges VA medical facilities have faced providing health care services in a timely manner. When veterans face wait times at VA medical facilities, they may be able to receive services from VA's community care programs, which VA estimates will be 19 percent of its $86.5 billion in health care obligations in fiscal year 2020.

This testimony focuses on GAO's large body of work on veterans' access to care and the status of VA's efforts to address GAO's recommendations, including those from GAO's June 2018 report on VA's community care programs and from GAO's December 2012 report on VA's scheduling of timely medical appointments that VA has provided information on through July 2019. It also includes preliminary observations on related ongoing work.

GAO has issued several reports recommending that the Department of Veterans Affairs (VA) take action to help ensure its facilities provide veterans with timely access to medical care. VA has taken a number of steps to address GAO's recommendations to improve wait-time measurement and its appointment scheduling policy. However, additional actions are needed to fully address most of GAO's recommendations.

GAO found in 2012 that outpatient appointment wait times reported by VA were unreliable because VA did not ensure consistency in schedulers' definitions of the dates by which wait times were measured. GAO recommended that VA clarify these definitions. VA concurred and has taken a number of actions in response, including improved oversight through scheduling audits. However, VA's first internal audit in August 2018 was unable to evaluate the accuracy and reliability of its wait-time data due to the lack of business rules for calculating them, indicating that additional efforts are needed to address this issue.

GAO also found in 2012 that not all facilities GAO visited used the electronic wait list to track new patients that needed medical appointments, as required by VA's scheduling policy. This put patients at risk for being lost for appointment scheduling. GAO recommended VA ensure consistent implementation of its policy, and that all schedulers complete required training. VA concurred, and with the information VA provided in July 2019 GAO considers VA's actions, including updating its scheduling policy and completing scheduler training, sufficient to fully address the recommendation.

While improvements to VA's scheduling policy and processes will help ensure veterans receive timely access to care, there are other factors that may also affect access that are not currently reflected in VA's wait-time data. For example, GAO found instances in which the time it took the agency to initially enroll veterans in VA health care benefits was more than 3 months.

GAO has also made recommendations to improve appointment scheduling and ensure timely access to care from non-VA providers in VA's community care programs that remain unimplemented. GAO found in June 2018 that the data VA used to monitor the timeliness of the Veterans Choice Program's appointments captured only a portion of the total appointment scheduling process. Although VA had a wait-time goal of 30 days, VA's timeliness data did not capture certain processes, such as the time taken to prepare veterans' referrals and send them to a third-party administrator. GAO found that if these were accounted for, veterans could potentially wait up to 70 calendar days to see a community care provider. VA officials stated that most recommendations will be addressed with new program tools it plans to implement. For example, VA is implementing a system for referral management and appointment scheduling expected to be available in all VA medical facilities by fiscal year 2021. While technology may be an important tool, VA will also need clear and consistent policies and processes, adequate oversight, and effective training to help avoid past challenges.

GAO has made a number of recommendations to VA to address timely scheduling and reliable wait-time data for outpatient appointments and through community care. VA generally agreed with GAO's recommendations. As of July 2019, VA has taken actions to fully implement one recommendation discussed in this statement. GAO continues to believe that all of the recommendations are warranted.

I am pleased to be here today to discuss our work on appointment wait  times for veterans seeking care provided by the Department of Veterans  Affairs (VA) and for those veterans referred to non-VA providers through  VA’s community care programs. Access to timely medical appointments is  critical to ensuring that veterans obtain needed medical care. In  particular, access to timely primary care appointments is essential as a  gateway to obtaining other health care services such as specialty care.

The majority of veterans utilizing health care services delivered by the  VA’s Veterans Health Administration (VHA) receive care in VA-operated  medical facilities, including 172 VA medical centers and more than 1,000  outpatient facilities. For nearly 20 years, we have reported on the  challenges VA medical facilities have faced providing health care services  in a timely manner. Since 2000, we have issued several reports  recommending that VA improve appointment scheduling, ensure the  reliability of wait-time and other performance data, and improve oversight.  Implementing these recommendations would help ensure VA medical  facilities provide veterans with timely access to outpatient primary and  specialty care, as well as mental health care. Due to these and other  concerns about VA’s management and oversight of its health care  system, we concluded that VA health care is a high-risk area and added it  to our High Risk List in 2015, with updates in 2017 and 2019.

Serious and long-standing problems with veterans’ access to care were  also highlighted in a series of congressional hearings in the spring and  summer of 2014, after several well-publicized events raised additional  concerns about wait times for appointments at VA medical facilities.  Legislation subsequently enacted in 2014 and 2018 established new  community care programs, where veterans have the option to receive  hospital care and medical services from a non-VA provider if certain  conditions are met. VA estimates that community care programs will be  19 percent of its $86.5 billion in health care obligations in fiscal year 2020.  The length of VA outpatient appointment wait times is one of the eligibility  criteria for several community care programs, and in fiscal years 2015  and 2016 about half a million veterans were referred to one of these  programs under the wait-time eligibility criteria.

You asked GAO to testify today on appointment wait times at VA medical  facilities and through community care programs, including the wait-time  information the agency makes available to veterans and the reliability of  these data. My remarks focus on  1.  our work on VA outpatient appointment scheduling and the status of  VA’s efforts to address our recommendations;  2.  our work on community care program appointment scheduling and the  status of VA’s efforts to address our recommendations; and  3.  our ongoing work on one of VA’s efforts to improve access to care.

My remarks today are based on our extensive body of work on veterans’  access to care, including our December 2012 report on VA’s scheduling  of timely outpatient medical appointments and our June 2018 report on  VA’s community care programs, as well as department information  through July 2019 in response to recommendations that we have made.  For a list of our previous work in this area, see the Related GAO Products  page at the end of this report. Those reports provide further details on our  scope and methodology. This testimony also includes preliminary  observations from our current review assessing VA’s efforts to offer  veterans access to routine care without an appointment (known as VA’s  same-day services initiative). That review is based on our review of VA’s  policies, guidance, and requirements related to same-day services, and  interviews with various officials, including from relevant VA offices and six  VA medical centers and affiliated outpatient clinics.

We conducted all of the work on which this statement is based in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Background Scheduling Outpatient Appointments in VA Medical Facilities

Enrollment is generally the first step veterans take to obtain health care  services, within VA or through community care. VA’s Health Eligibility  Center manages the process of accepting applications, verifying eligibility,  and determining enrollment, in collaboration with VA medical centers. VA  requires veterans’ enrollment applications be processed within 5 business  days of receipt, including pending applications that require additional  information from the applicant to process.

Once enrolled, veterans can access VA health services by scheduling an  appointment. VA’s scheduling policy establishes the procedures for  scheduling medical appointments, as well as sets the requirements for  staff directly or indirectly involved in the scheduling process (e.g.,  training). A scheduler at the VA medical facility is responsible for making  appointments for new and established patients (i.e., patients who have  visited the same VA medical center in the previous 24 months), which are  then recorded in VA’s electronic scheduling system. VA scheduling policy  requires patients who have requested an appointment and have not had  one scheduled within 90 days to be placed on VA’s electronic wait list. VA  determines wait times at each facility based on outpatient appointment  information from its scheduling system.

VA’s Public Websites with Appointment Wait-Time Information

VA is required to publish information on appointment wait times at each  VA medical facility for primary care, specialty care, and hospital care and  medical services, which it does through two public websites. In November  2014, VA began posting monthly wait times for scheduling appointments  at all VA medical facilities. One public website provides links to  spreadsheets containing data for each VA medical facility, such as the  average wait times for primary, specialty, and mental health care  appointments and the number of patients on the electronic wait list. In  April 2017, VA created a second public “Access and Quality in VA  Healthcare” website to post both patient access data and information on  VA medical facilities’ performance on various quality metrics. This website  aims to help veterans find wait times at a specific facility. This  information would allow veterans and their family members to use the  wait-time data on this website to determine the best option for obtaining  timely care.

In order to receive needed care in a timely manner, veterans may need to  obtain care outside of VA medical facilities through one of VA’s  community care programs. VA has purchased health care services from  community providers through various community care programs since  1945. Veterans may be eligible for community care when they are faced  with long wait times or travel long distances for appointments at VA  medical facilities, or when a VA facility is unable to provide certain  specialty care services.

Since 2014, Congress has taken steps to expand the availability of  community care for veterans. The Veterans Access, Choice, and  Accountability Act of 2014 provided up to $10 billion in funding for  veterans to obtain health care services from community providers. The  law established a temporary program—called the Veterans Choice  Program (Choice Program)—to offer veterans the option to receive  hospital care and medical services from a community provider when a VA  medical facility could not provide an appointment within 30 days, or when  veterans resided more than 40 miles from the nearest VA facility or faced  other travel burdens. VA contracted with two third-party administrators  (TPA) to establish networks of community providers, schedule veteran  appointments with those providers, and pay those providers for services  rendered through the Choice Program.

In June 2018, the VA MISSION Act of 2018 was enacted to further  address some of the challenges faced by VA in ensuring timely access to  care. The Act required VA to implement within 1 year a permanent  community care program—the Veterans Community Care Program  (VCCP). The act identified criteria that all veterans enrolled in the VA  health care system would be able to qualify for care through the VCCP;  for example, if VA does not offer the care or service needed by the  veteran or VA cannot provide the veteran with care and services that  comply with its designated access standards. The access standards  include appointment wait times for a specific VA medical facility; for  example, veterans may be eligible for care through the VCCP if VA  cannot provide care within 20 days for primary and mental health care,  and 28 days from the date of request for specialty care, unless veterans  agree to a later date in consultation with their VA health care provider.

VA Has Taken Actions to Address Deficiencies in Appointment Scheduling and Timeliness Identified in Prior Work, but Additional Actions Are Needed VA Has Taken Steps to Address Our Recommendation to Improve Wait-Time Measurement and Has Implemented Our Recommendation to Improve Implementation of Scheduling Policy

VA has taken a number of actions to address our recommendations  regarding deficiencies we found in wait-time measurement and  implementation of its scheduling policy. For wait-time measurement,  these actions included changes to the wait-time measurement definitions,  provision and documentation of scheduler training, and improved  oversight through audits, all of which have been in a state of flux for the  past 6 years. On July 12, 2019, VA provided us additional updates on  efforts to implement our related recommendations. This new information  fully addresses one of our recommendations.

In December 2012, we found that outpatient medical appointment wait  times reported by VA were unreliable, and, therefore, VA was unable to  identify areas that needed improvement or mitigate problems for veterans  attempting to access care. VA typically has measured wait times as the  time elapsed between the ‘start date’—a defined date that indicates the  beginning of the measurement—and the ‘end date’, which is the date of  the appointment. At the time of our 2012 report, VA measured wait times  as the number of days elapsed from the start date identified as the  desired date—the date on which the patient or health care provider wants  the patient to be seen—to the date of the appointment. We found that  the reliability of the reported wait-time measures was dependent on the  consistency with which schedulers recorded the desired date in the  scheduling system, as required by VA’s scheduling policy. However, VA’s  scheduling policy and training documents for recording the desired date  were unclear and did not ensure consistency. We observed that not all  schedulers at VA medical centers that we visited recorded the desired  date correctly. Therefore, we recommended that VA either clarify its  scheduling policy to better define the desired date, or identify clearer wait- time measures that are not subject to interpretation and prone to  scheduler error. VA concurred with the recommendation, which we have  identified as among those recommendations that warrant priority  attention.

Actions VA has taken or is taking to address this recommendation  include:  changes to the start date and definitions for wait-time measurement, provision and documentation of scheduler training, and  improved oversight through scheduler audits.

In addition, we are currently assessing new information VA provided in  July 2019, which will include obtaining additional evidence and  clarification from VA to see whether it has fully addressed our concerns.

VA’s Actions to Change Start Dates for Wait-Time Measurement  While the terminology for the start dates of the wait-time measurement  has changed several times over the past 6 years, we believe that the  current definitions of the start dates are substantively the same as those  we reviewed—and found to be deficient—in our 2012 report. VA  subsequently introduced new terms with similar definitions—from “desired  date” to “preferred date”—without fundamentally addressing the  deficiency. See table 1 for the changes to and definitions of the start  dates for measuring outpatient appointment wait times and wait-time  goals since June 2010.

As table 1 shows, for new patients and established patients seeking  appointments without a return-to-clinic date specified by their provider, VA  changed the terminology of the start date to preferred date in its July  2016 scheduling policy from what it had established in its June 2010  policy. However, the definition of preferred date is substantively the same  as the definition of desired date in the previous scheduling policy, the  latter of which we found to be subject to interpretation and prone to  scheduler error in our 2012 report. We continue to believe that the  preferred date is also subject to interpretation and prone to scheduler  error, which poses concerns for the reliability of wait times measured  using the patient’s preferred date.

In its updated July 2016 scheduling policy, VA also changed the  terminology of the start date to the “clinically indicated date” for  established patients whose provider has documented a clinically  appropriate return-to-clinic date in the patient’s electronic health record.  The clinically indicated date is substantively the same as the definition of  desired date for established patients in the previous scheduling directive.

While VA has not clarified the definitions of start dates, VA has taken  actions intended to improve the accurate recording of the clinically  indicated date in three ways:  1.  VA requires clinical leadership (such as the Associate Chief of Staff)  at each VA medical facility to ensure that providers enter the clinically  indicated date in the electronic health record for future appointments;  2.  VA standardized the entry of the clinically indicated date in the  electronic health record to improve the accuracy of the date, which  was implemented across all VA medical facilities as of July 2018; and  3.  VA created a technology enhancement to enable the automatic  transfer of the clinically indicated date from the electronic health  record to the scheduling system. As a result, the scheduler no longer  has to retrieve the date from veterans’ electronic health records and  manually enter it into the scheduling system. VA reported that this  enhancement was implemented at all but three VA medical facilities  as of January 2019.

In July 2019, VA reported to us that the error rate for the patient indicated  date (either the clinically indicated date, or in the absence of that date, the  patient’s preferred date) was 8 percent of about 667,000 appointments  audited in the most recent biannual audit cycle, ending March 31, 2019.  VA cites an almost 18 percent improvement in reducing the number of  errors caused by manual entry of the clinically indicated date due to the  use of the technology enhancements.

VA’s Actions to Provide and Document Scheduler Training  Although VA updated its scheduling policy in 2016, we believe the  instructions, which form the basis for wait-time measurement, are still  subject to interpretation and prone to scheduler error, making training and  oversight vital to the consistent and accurate implementation of the policy.  VA reported that 97 percent of all staff who scheduled an appointment  within 30 days completed the required scheduling training as of July 2,  2019. VA stated that the department will closely monitor compliance with  scheduler training completion for the remaining staff. Given the high  turnover among schedulers, it is important that VA remain vigilant about  scheduler training, ensuring all who need it receive it.

VA’s Actions to Improve Oversight through Scheduler Audits  VA has taken a number of actions to improve oversight of the scheduling  process through biannual scheduling audits at VA medical centers and  second level audits, as well as completion of the first system-wide internal  audit of scheduling and wait-time data.

Biannual scheduler audits. VA’s July 2016 scheduling policy required  biannual audits of the timeliness and appropriateness of schedulers’  actions and accuracy of entry of the clinically indicated date and preferred  date, the start dates of wait-time measurement as identified by the  revised scheduling policy. In June 2017, VA deployed a standardized  scheduling audit process for staff at VA medical centers to use. As part of  our recommendation follow-up in July 2019, VA reported 100 percent  completion of the required biannual scheduling audits in fiscal year 2018.  As noted above, VA reported to us that the error rate for the patient  indicated date (either the clinically indicated date, or in the absence of  that date, the patient’s preferred date) was 8 percent of about 667,000  appointments audited. While VA asserts that errors in the clinically  indicated date have decreased, an error rate of 8 percent still yields errors  in more than 53,000 appointments audited. Given these errors, we remain  concerned about the reliability of wait times measured using preferred  date (one part of the patient indicated date), and have requested  additional information from VA about these errors.

Second level scheduler audits. In November 2018, VA implemented  a second-level scheduling audit (Audit the Auditors program), which is  overseen by the VA integrated service networks tasked with oversight  of VA medical facilities within their regions. Each medical center within  a network region is paired with another medical center and they audit  each other’s scheduling audit. Throughout the cycle, medical centers  share their findings with each other and the network. The goal is to  standardize scheduling audit practices across the network and to  ensure reliability of the scheduler audit results. According to VA, the  first cycle was completed April 30, 2019, by all VA medical centers.

First internal system-wide audit of wait-time data and scheduling.

In its first internal audit completed in August 2018, VA was unable to  evaluate the accuracy and reliability of scheduling and the wait-time  data. Specifically, VA was unable to determine the accuracy and  reliability of the scheduling and wait-time data, databases, and data  flow from the electronic health record and scheduling system to the  VA Access and Quality website because they were not able to obtain  the rules for calculating wait times. Given our continued concerns  about VA’s ability to ensure the reliability of the wait-time data, we  plan to obtain additional information from VA about its methodology  and assessment of evidence underlying the audit findings.

In December 2012, we also found inconsistent implementation of VA’s  scheduling policy that impeded VA medical centers’ scheduling of timely  medical appointments. Specifically, we found that not all of the clinics  across the medical centers we visited used the electronic wait list to track  new patients that needed medical appointments as required by VA’s  scheduling policy, putting these patients at risk of being lost for  appointment scheduling. Furthermore, VA medical centers’ oversight of  compliance with VA’s scheduling policy, such as ensuring the completion  of required scheduler training, was inconsistent across facilities.  Scheduler training was particularly important given the high volume of  staff with access to the scheduling system—as of July 2, 2019, VA  reported there were approximately 33,000 staff that had scheduled an  appointment within the last 30 days. We also found that VA medical  centers identified the outdated and inefficient scheduling system as one  of the problems that can impede the timely scheduling of appointments  and may impact their compliance with VA’s scheduling policy. We  recommended VA ensure that VA medical centers consistently and  accurately implement VA’s scheduling policy, including use of the  electronic wait list, as well as ensuring that all staff with access to the  scheduling system completes the required training. VA concurred with  this recommendation, which we also have identified as among those  recommendations that warrant priority attention.

VA’s actions to improve implementation of the scheduling policy, including  updated information VA provided in July 2019, fully addresses this  recommendation. VA issued an updated scheduling policy in July 2016  that provided clarification on scheduling roles and responsibilities for  implementing the policy and business rules for scheduling appointments,  such as using the electronic wait list, and required biannual scheduler  audits. VA also ensured almost all schedulers received training on the  updated scheduling policy and improved oversight through audits, as  previously described.

In addition, VA plans to rapidly deploy a single nationwide scheduling  system that is intended to simplify the operating environment for  schedulers and may mitigate challenges identified in our 2012 report. The  new scheduling system will be a resource-based system where each  provider’s schedule is visible on one screen, instead of requiring the need  to toggle through multiple screens as it currently exists. VA plans to roll  out the new scheduling system starting in 2020, which is expected to be  implemented in coordination with the planned modernization of the  electronic health records system across VA facilities. According to VA, the  scheduling system will be available for use in advance of the completion  of the electronic health record implementation at some sites.

VA Has Taken Steps to Address Our Recommendations to Strengthen Enrollment Processes and Management of Initial Requests for Care That Affect Veterans’ Timely Appointments

In addition to the recommendations we made to improve VA’s wait-time  data and implementation of its scheduling policy, we have also made  recommendations to address other factors that affect the timeliness by  which veterans obtain appointments. These recommendations have  targeted VA’s enrollment processes and its management of veterans’  initial requests for care. While VA has taken some steps to address these  recommendations, they have not yet been fully addressed. For example,  we have found that VA’s wait-time measures do not yet capture the time it  takes the agency to enroll veterans in VA health care benefits, or manage  a veterans’ initial request for care.

In September 2017, we found that VA did not provide its medical centers,  who historically receive 90 percent of enrollment applications, with clear  guidance on how to resolve pending applications, which led to delays in  veteran’s enrollment. For example, we found instances in which pending  applications remained unresolved for more than 3 months. We concluded  these delays in resolving pending applications, along with previously  documented delays due to errors in enrollment determinations, may result  in veterans facing delays when obtaining health care services or  incorrectly denied benefits.

We made several recommendations to address these deficiencies, two of  which we determined to be priority recommendations for VA to clearly  define roles and responsibilities for (1) resolving pending applications and  (2) overseeing the enrollment process. VA has made progress in  addressing these priority recommendations by beginning to update, but  not yet finalizing, its policies, procedures, and guidance on enrollment  processing. In 2017, VA’s Health Eligibility Center began conducting  secondary reviews of enrollment determinations. However, in fiscal year  2018, Health Eligibility Center staff found that 18 percent of rejected  enrollment determinations and 8 percent of ineligible enrollment  determinations that underwent secondary reviews were incorrect. These  recommendations remain unimplemented as of July 2019.

Once enrolled, we have found that VA’s management of veterans’ initial  request for care have led to delays; and although VA has clarified  timeliness requirements, it has yet to fully capture the wait veterans  experience in scheduling initial appointments. In a number of reports from  2015 to 2018, we found instances in which newly enrolled veterans were  not contacted to schedule initial primary care appointments, and did not  complete initial primary care appointments and mental health evaluations  according to VA timeliness requirements. These delays may be  understated in VA data, because VA’s wait-time measures do not take  into account the time it takes VA medical center staff to contact the  veteran to determine a preferred date (the starting point for wait-time  measurement) from the veteran’s initial request or referral. We found that  the total amount of time it took for veterans to be seen by providers was  often much longer when measured from the dates veterans initially  requested to be contacted to schedule an appointment or were referred  for an appointment by another provider than when using the veterans’  preferred dates as the starting point. See figure 1 for an example of how  the two wait-time calculations differ for an initial primary care  appointment.

We made several recommendations to VA, including a priority  recommendation to monitor the full amount of time newly enrolled  veterans wait to be seen by a provider. VA has taken several steps to  address the priority recommendation, including revising an internal report  to help identify and document newly enrolled veterans and monitor their  appointment request status. The report is intended to help VA and its  medical centers oversee the enrollment and appointment process by  tracking the total time from application to appointment. However, VA is  still in the process of enhancing its electronic enrollment system to  capture the application date for all newly enrolled veterans. Until the  enhancements are implemented, VA may not consistently capture the  start date for newly enrolled veterans, which, in turn, affects the reliability  of its wait-time data. The priority recommendation remains  unimplemented as of July 2019.

VA Has Not Implemented Recommendations to Address Wait Times and Other Choice Program Issues That Could Affect VCCP Implementation

VA has not implemented several of our recommendations related to the  Choice Program that could impact veterans’ timely access to care under  the VCCP. These recommendations address (1) establishing achievable  community care wait-time goals and a scheduling process consistent with  those goals, (2) collecting accurate and complete data to systematically  monitor veteran community care wait times, and (3) other factors that  could adversely affect veterans’ access to community care. VA has begun  taking steps to address these recommendations as it implements the  VCCP.

VA Still Needs to Establish Achievable Wait-Time Goals and a Scheduling Process Consistent with Those Goals to Ensure Veterans’ Timely Access to Care under the VCCP

Our review of the Choice Program in June 2018 found that despite having  a wait-time goal, VA developed a scheduling process for the Choice  Program that was not consistent with achieving that goal. The Veterans  Access, Choice, and Accountability Act of 2014 required VA to ensure the  provision of care to eligible veterans within 30 days of the clinically  indicated date or, if none existed, within 30 days of the veteran’s  preferred date. However, we found that those veterans who were referred  to the Choice Program for routine care because services were not  available at VA in a timely manner could potentially wait up to 70 calendar  days for care. Under VA’s scheduling processes, this potential wait time  included VA medical centers having at least 18 calendar days to prepare  veterans’ Choice Program referrals to TPAs and another 52 calendar  days for appointments to occur as scheduled by TPAs.

Based on this finding, we recommended that VA establish an achievable  wait-time goal for the VCCP that will permit VA to monitor whether  veterans are receiving community care within time frames that are  comparable to the amount of time they would otherwise wait to receive  care at VA medical facilities. We also recommended that VA should  design an appointment scheduling process for the VCCP that sets forth  time frames within which (1) veterans’ referrals must be processed, (2)  veterans’ appointments must be scheduled, and (3) veterans’  appointments must occur that are consistent with the wait-time goal VA  has established for the program. VA agreed with both recommendations,  which remain unimplemented, and officials stated that they are in the  process of finalizing metrics to capture wait-time performance and  designing an appointment scheduling process. Without specifying wait- time goals that are achievable, and without designing appointment  scheduling processes that are consistent with those goals, VA lacks  assurance that veterans are receiving care from community providers in a  timely manner.

VA’s Monitoring of Care under VCCP Could Still Be Compromised by Incomplete and Inaccurate Data

In June 2018, we reported that VA could not systematically monitor wait  times for veterans accessing care under the Choice Program due to  incomplete and inaccurate data. Without complete and accurate data, VA  was not able to determine whether the Choice Program was achieving its  goals of (1) alleviating the wait times veterans experienced when seeking  care at VA medical facilities, and (2) easing geographic burdens veterans  may have faced when accessing care at VA medical facilities. We made  three recommendations to address VA’s incomplete and inaccurate data  related to the Choice Program, and VA is taking steps to implement two  of those recommendations.

We found that the data VA used to monitor the timeliness of Choice  Program appointments captured only a portion of the total appointment  scheduling process. Though VA had a 30-day wait-time goal to provide  veterans with care under the Choice Program, VA’s timeliness data did  not capture (1) the time VA medical centers took to prepare veterans’  referrals and send them to the TPAs, and (2) the time spent by TPAs in  accepting the referrals and opting veterans into the Choice Program. For  example, we found that it took VA medical center staff an average of 24  calendar days after the veteran’s need for care was identified to contact  the veteran, compile relevant clinical information, and send the veteran’s  referral to the TPAs. For those same authorizations, it took the TPAs an  average of 14 calendar days to accept referrals and reach veterans to opt  them into the Choice Program.

In 2016, VA also conducted its own manual review of appointment  scheduling times and found that wait times could be longer than the 30  days (see fig. 2). Specifically, out of a sample of about 5,000 Choice  Program authorizations, VA analyzed (1) the timeliness with which VA  medical centers sent referrals to the TPAs, and (2) veterans’ overall wait  times for Choice Program care. VA’s analysis identified average review  times when veterans were referred to the Choice Program to be greater- than-30-day wait time for an appointment at a VA medical facility. For  example, for overall wait times (i.e., the time veterans’ need for care was  identified until they attended initial Choice Program appointments), wait  times ranged from 34 to 91 days across the 18 VA integrated service  networks. The national average was 51 days.

In September 2017, VA began implementing an interim solution to  monitor overall wait times, but this solution relied on VA medical center  staff consistently and accurately entering data on referrals, a process that  is prone to error. In June 2018, we recommended that VA establish a  mechanism to monitor the overall wait times under the VCCP. VA agreed  with this recommendation, and stated that it is developing a monitoring  mechanism that will be incorporated into a new system that will be fully  implemented across all VA medical facilities by fiscal year 2021.

We also reported that the clinically indicated dates included on referrals  that VA medical centers sent to the TPAs, which are used to measure the  timeliness of care, may not have been accurate, further limiting VA’s  monitoring of veterans’ access to care. Our review of 196 Choice  Program authorizations found that clinically indicated dates were  sometimes changed by VA medical center staff before they were sent to  the TPAs, which could mask veterans’ true wait times. We found that VA  medical center staff entered later clinically indicated dates on referrals for  about 23 percent of the 196 authorizations reviewed. We made two  recommendations to improve the accuracy of the Choice Program data.  For example, we recommended that VA establish a mechanism under the  VCCP that prevents clinically indicated dates from being modified. VA  agreed with our recommendation, and stated that a new system will  interface with VA’s existing referral package to allow a VA clinician to  enter in a clinically indicated date while restricting schedulers from  making alterations to it.

VA Has Not Addressed Other Factors That Could Adversely Affect Veterans’ Access to Care under the VCCP

In June 2018, we also reported that numerous factors adversely affected  veterans’ timely access to care through the Choice Program and could  affect access under the VCCP. These factors included the following: (1)  administrative burden caused by complexities of VA’s referral and  appointment scheduling processes; (2) poor communication between VA  and its medical facilities; and (3) inadequacies in the networks of  community providers established by the TPAs, including an insufficient  number, mix, or geographic distribution of community providers.

VA has taken steps to help address these factors; however, none have  been fully addressed. For example, to help address administrative burden  and improve the process of coordinating veterans’ Choice Program care,  VA established a secure e-mail system and a mechanism for TPAs and  community providers to remotely access veterans’ VA electronic health  records. However, these mechanisms only facilitate a one-way transfer of  necessary information. They do not provide a means by which VA  medical facilities or veterans can view the TPAs’ step-by-step progress in  scheduling appointments or electronically receive medical documentation  associated with Choice Program appointments. We made five  recommendations to VA to address the factors that adversely affected  veterans’ access to Choice Program care. VA agreed or agreed in  principle with all five recommendations and has taken some steps in  response to these recommendations. However, our recommendations  remain unimplemented.

As It Implements the VCCP, VA Has Taken Some Steps to Address Community Care Wait- Time Data and Monitoring Issues

On June 6, 2019, VA began implementing the VCCP, which created a  consolidated community care program. Under the VCCP, VA began  determining veteran eligibility based on designated access standards,  such as wait-time goals of 20 days for primary and mental health care  and 28 days for specialty care and other criteria identified in the MISSION  Act. According to VA officials, the implementation of the VCCP also  included the use of the new Decision Support Tool—a system that  combines eligibility and other information to help veterans, with  assistance from VA staff, decide whether to seek care in the community.  VA officials previously identified the Decision Support Tool along with  another new system—known as the Health Share Referral Management  system—as key efforts in addressing many of our recommendations  related to VA’s community care wait-time data and monitoring issues. VA  expects the Health Share Referral Management system, which will  manage community care referrals and authorizations as well as facilitate  the exchange of health information between VA and community  providers, to be fully implemented across all VA medical facilities in fiscal  year 2021. We began work in May 2019 to review VA’s implementation of  the VCCP, including how it will address issues such as appointment  scheduling.

Preliminary Observations on VA’s Provision of Same- Day Services— Another Access Initiative

In addition to the actions described above, VA has taken other steps to  improve veterans’ access to care by, for example, offering veterans  access to routine care without an appointment. We have ongoing work  related to same-day services provided in VA primary care and mental  health clinics. In order to improve access, VA implemented the same-day  service initiative in 2016, and by 2018 offered same-day services in over  1000 facilities. As part of the initiative, VA medical facility staff are  directed to address veterans’ primary care and mental health needs that  day through a variety of methods, including face-to-face visits, telehealth,  prescription refills, or by scheduling a follow-up appointment. Our ongoing  work indicates that the six VA medical facilities we visited were generally  providing same-day services prior to the initiative; however, according to  VA officials, ongoing staffing and space shortages created challenges  implementing the initiative. Our ongoing work also indicates that VA does  not have performance goals and measures to determine same-day  services’ impact on veterans’ access to care. We plan to issue our report  on VA’s same-day services initiative in August 2019.

In closing, we have identified various weaknesses in VA’s wait-time  measurement and scheduling processes over the years. These  weaknesses have affected not only VA’s internal delivery of outpatient  care, but also that provided through community providers. As we have  highlighted here, we have made a number of recommendations to  address these weaknesses. VA has taken actions to address our  recommendations, but additional work is needed for some. The  implementation of enhanced technology, such as a new scheduling  system, is crucial and will provide an important foundation for  improvements. However, this is not a panacea for addressing all of the  identified problems. Moving forward, VA must also continuously ensure  that it has clear and consistent policies and processes, adequate  oversight, and effective training.

Chairman Takano, Ranking Member Roe, and Members of the  Committee, this completes my prepared statement. I would be pleased to  respond to any questions that you may have at this time.

If you or your staff have any questions about this testimony, please  contact Debra A. Draper, Director, Health Care at (202) 512-7114 or  DraperD@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this  statement. GAO staff who made key contributions to this testimony were  Sharon Silas (Acting Director), Ann Tynan (Assistant Director), Cathy  Hamann, Aaron Holling, Akbar Husain, Kate Tussey, and E. Jane  Whipple. Also contributing were Jacquelyn Hamilton and Vikki Porter.

Most veterans using VA health services receive medical care in VA-operated facilities, including 172 medical centers and over 1,000 outpatient facilities.

For years, we have documented VA’s struggle to provide timely medical care. We testified about VA’s efforts to address some of our recommendations on how to improve.

For example, veterans may be referred to a non-VA provider from the community if timely care is not available. However, we found that VA was not measuring wait times for this community care. We recommended VA compare community care wait times with those at VA facilities.

VA health care is a topic on our High Risk List.