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39–648 2008

OUTPATIENT WAITING TIMES 

JOINT HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

AND THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

FIRST SESSION 

DECEMBER 12, 2007 

Serial No. 110–62 

Printed for the use of the Committee on Veterans’ Affairs 

( 


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COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

HARRY E. MITCHELL, Arizona, Chairman 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

CIRO D. RODRIGUEZ, Texas 

GINNY BROWN-WAITE, Florida, Ranking 

CLIFF STEARNS, Florida 

BRIAN P. BILBRAY, California 

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 official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process 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. 


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C O N T E N T S 

December 12, 2007 

Page 

Outpatient Waiting Times ...................................................................................... 1 

OPENING STATEMENTS 

Hon. Michael H. Michaud, Chairman, Subcommittee on Health ........................ 1 

Prepared statement of Chairman Michaud .................................................... 29 

Hon. Harry E. Mitchell, Chairman, Subcommittee on Oversight and Investigations ................................................................................................................ 3 

Prepared statement of Chairman Mitchell ..................................................... 29 

Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on 

Oversight and Investigations .............................................................................. 2 

Prepared statement of Congresswoman Brown-Waite .................................. 30 

Hon. Zachary T. Space ............................................................................................ 4 

WITNESSES 

U.S. Department of Veterans Affairs: 

Belinda J. Finn, Assistant Inspector General for Auditing, Office of Inspector General ............................................................................................. 14 

Prepared statement of Ms. Finn .............................................................. 35 

Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for 

Health, Veterans Health Administration .................................................... 20 

Prepared statement of Dr. Cross ............................................................. 41 

Paul A. Tibbits, M.D., Deputy Chief Information Officer, Office of Enterprise Development, Office of Information and Technology ........................ 21 

Prepared statement of Dr. Tibbits ........................................................... 42 

Jones, Mary C., Licking County Veterans’ Service Officer, Licking County 

Veterans’ Service Commission, Newark, OH ..................................................... 6 

Prepared statement of Ms. Jones .................................................................... 31 

Unum US, Portland, ME, Kevin P. McCarthy, President and Chief Executive 

Officer .................................................................................................................... 7 

Prepared statement of Mr. McCarthy ............................................................. 32 

SUBMISSIONS FOR THE RECORD 

Miller, Hon. Jeff, Ranking Republican Member, Subcommittee on Health, 

and a Representative in Congress from the State of Florida, statement ........ 44 

Stearns, Hon. Cliff, a Representative in Congress from the State of Florida, 

statement .............................................................................................................. 44 

MATERIAL SUBMITTED FOR THE RECORD 

Post Hearing Questions and Responses for the Record: 

Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee 

on Oversight and Investigations, Committee on Veterans’ Affairs, to 

Hon. Gordon Mansfield, Acting Secretary, U.S. Department of Veterans 

Affairs, letter dated December 13, 2007, attached legislative text for 

H.R. 92, the ‘‘Veterans Timely Access to Health Care Act,’’ and response letter from VA dated July 31, 2008 ................................................. 45 


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iv 

Post Hearing Questions and Responses for the Record—Continued 

Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee 

on Oversight and Investigations, Committee on Veterans’ Affairs, to 

Hon. James B. Peake, M.D., Secretary, U.S. Department of Veterans 

Affairs, letter dated January 16, 2008, and response letter dated February 15, 2008. [The attachment to the letter, a breakdown by 

VISN and facility of the outpatient and specialty care waiting 

times for the Department’s major medical centers and the community-based outpatient clinics, will be retained in the Committee files.] ................................................................................................ 48 

Hon. Michael H. Michaud, Chairman, and Hon. Jeff Miller, Ranking 

Republican Member, Subcommittee on Health, and Hon. Harry E. 

Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans’ Affairs, to Hon. George J. Opfer, Inspector General, 

U.S. Department of Veterans Affairs, letter dated February 14, 2008, 

and response letter dated March 17, 2008 .................................................. 51 

Hon. Michael H. Michaud, Chairman, and Hon. Jeff Miller, Ranking 

Republican Member, Subcommittee on Health, and Hon. Harry E. 

Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans’ Affairs, to Hon. James B. Peake, M.D., Secretary, 

U.S. Department of Veterans Affairs, letter dated February 29, 2008, 

and VA responses .......................................................................................... 53 


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OUTPATIENT WAITING TIMES 

WEDNESDAY, DECEMBER 12, 2007 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, Washington, DC. 

The Subcommittees met, pursuant to notice, at 2:50 p.m., in 

Room 345, Cannon House Office Building, Hon. Michael H. Michaud 

[Chairman of the Subcommittee on Health] presiding. 

Present from Subcommittee on Health: Representative Michaud. 

Present from Subcommittee on Oversight and Investigations: 

Representatives Mitchell, Space, and Brown-Waite. 

Also present: Representative Kennedy. 

OPENING STATEMENT OF CHAIRMAN MICHAEL H. MICHAUD, 

SUBCOMMITTEE ON HEALTH 

Mr. MICHAUD. I would like to call to order this joint hearing on 

the U.S. Department of Veterans Affairs (VA) outpatient waiting 

times. 

I would ask unanimous consent that my full statement be included in the record. Hearing no objection, so ordered. 

The focus of this hearing is waiting times for outpatient appointments in the Veterans Health Administration (VHA). Outpatient 

waiting times are one aspect of a much broader focus of the Subcommittee on Health, access to high-quality healthcare. ‘‘Access to 

healthcare’’ is defined as the ability to get medical care in a timely 

manner when needed. We know that access to healthcare is important for veterans. It improves treatment outcomes and the quality 

of life for those who have it. 

Since the beginning of the 110th Congress, the Subcommittee on 

Health has taken broad action to increase veterans’ access to 

healthcare. Today I hope that we will learn more about how the VA 

is doing, in seeing patients in a timely manner for initial and necessary follow-up appointments, and how the VA tracks this information. I would also like to learn how the VA is managing patient 

care to provide necessary preventative medicine. 

In a system that handles 40 million outpatient appointments per 

year, it is clear that efficient and effective policy, training and followup is critical in achieving success. I hope that we can use this 

time to work toward a solution so that we can all achieve our primary goal, to improve the access to healthcare for all veterans. I 

am confident that, by working together, we will be successful. 

Timely access to quality healthcare is something that those who 


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have served our country have earned. We must work together to 

provide it for them. 

I now would like to yield to Ms. Brown-Waite, the Ranking Member of the Subcommittee on Oversight and Investigations, for an 

opening statement. 

[The prepared statement of Chairman Michaud appears on p. 29.] 

OPENING STATEMENT OF HON. GINNY BROWN-WAITE, 

RANKING REPUBLICAN MEMBER, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

Ms. BROWN-WAITE. Thank you, Mr. Chairman. 

I want to thank Ranking Member Miller, who I know is on his 

way, along with the rest of the Members of the Subcommittee on 

Health for joining us for this important hearing on outpatient waiting times at the Department of Veterans Affairs. 

As of October 2007, there were 7.9 million veterans enrolled in 

the VA healthcare system. Today there are more than 153 VA 

medical centers and 724 community-based outpatient clinics—we 

refer to them as ‘‘CBOCs’’—available to serve the needs of our veterans. When a veteran or a physician calls to schedule an appointment in one of these clinics, they should be able to receive an appointment that is timely and appropriate to the medical needs of 

the veteran. 

I am looking forward to hearing from our first panel of witnesses 

today as well as from the other panel as to how they feel outpatient 

wait times at the VA has affected them as well as any possible solutions that we can, as a legislative body, come up with to remedy 

the situation. I am also interested in hearing from the VA Office 

of Inspector General (OIG) on their perspective on the wait time 

issue. Finally, I expect to hear from the VA as to how they monitor 

wait times and what steps they are taking to improve the timeliness of services provided to our veterans. 

On January 4, 2007, I introduced H.R. 92, the ‘‘Veterans Timely 

Access to Health Care Act,’’ which would make the standard for a 

veteran seeking primary care from the Department of Veterans Affairs 30 days from the date the veteran actually contacts the Department. Unfortunately, the bill is needed because current practices do not meet that goal. 

I monitor data in my area, which is part of Veterans Integrated 

Service Network (VISN) 8, from the Department of Veterans Affairs to determine the time new patients and existing patients wait 

to receive an appointment. While established patients wait less 

than 15 days for an appointment, the numbers for new patients 

happen to be much higher. 

What I also found interesting, in looking over the data, is that 

there appears to be a decrease in the wait times at the major 

medical facilities; however, at the CBOC level, the communitybased outpatient clinic level, wait times actually have increased. In 

the third quarter of fiscal year 2007, new patients had to wait an 

average of 45 to 50 days to receive an appointment at a VA clinic, 

while new patients waited an average of 22 to 25 days to receive 

an appointment at the VA medical centers. This simply is not acceptable. 


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I am also curious as to the dramatic decrease in the wait times 

at the VA medical centers in VISN 8. I question whether patients 

are being redirected to the CBOCs to reduce wait times at the medical centers. If veterans are having problems receiving their care 

within 30 days, then Congress needs to allow them to look for an 

alternative. 

My bill is not—and I underline ‘‘not’’—a scheme to move VA toward privatization. It simply ensures that veterans receive care in 

a timely manner. 

The VA can and does provide a high level of care to all of the 

veterans who are enrolled in the system. However, if a veteran cannot be seen by a physician in a timely manner, what good does that 

do? The Department of Veterans Affairs’ Web site states that it is 

the goal of the VA to, and I quote, ‘‘provide excellence in patient 

care, veterans benefits and consumer satisfaction.’’ This hearing 

today is to determine whether the VA is meeting that goal with 

timely access to care. 

As everyone knows, this issue is tremendously important to 

every American. Our veterans did not wait to answer the call of 

duty. They answered their Nation’s call and took up arms to protect our freedom. They served, and many returned injured and in 

need of care. 

I talk with veterans from my district on a daily basis about the 

issues that they have with the VA, and getting in to see a doctor 

in a timely fashion is at the top of their list. I do not believe that 

veterans’ care should be a political issue. Instead, Members of Congress should work together to improve veterans healthcare so that 

it becomes the model for good governance and excellence in healthcare. 

Again, I thank you, Mr. Chairman, and I yield back the balance 

of my time. 

[The prepared statement of Congresswoman Brown-Waite appears on p. 30.] 

Mr. MICHAUD. Thank you very much. 

I now will recognize Mr. Mitchell, who is the Chairman of the 

Subcommittee on Oversight and Investigations, for an opening 

statement. 

OPENING STATEMENT OF CHAIRMAN HARRY E. MITCHELL, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

Mr. MITCHELL. Thank you, Mr. Chairman. 

You know, the Veterans Health Administration is one of the best 

healthcare providers in the country, yet our veterans can only take 

advantage of this healthcare if they get the appointments they 

need to access it. Unfortunately, too many of our troops are returning home and are encountering long waiting times. 

When I was back in my district this past weekend, I met with 

a group of Arizona veterans. Many of those veterans expressed concerns about the long waiting times they have encountered to get 

doctors’ appointments. One local veteran, John Tymczyszyn, tried 

to make an appointment for treatment for a service-related injury 

he suffered. John requested his appointment in December 2006, 

and his appointment was scheduled in late May of 2007, 6 months 

after his initial request. John told me that he continued to struggle 


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to make appointments with the VA, and because of that difficulty, 

he now relies on civilian providers for his healthcare. This is unacceptable. 

When we tried to look into the problem to see what we could do 

to address it, we were unable to secure verifiable documentation of 

waiting times. According to a recent audit by the Department of 

Veterans Affairs Inspector General (IG), the waiting times reported 

by the VHA are both understated and incomplete. The VA reported 

to the Department of Veterans Affairs fiscal year 2006 performance 

and accountability report in November 2006 that 95 percent of veterans seeking specialty medical care were scheduled for appointments within the required 30-day period; however, the IG audit 

found sufficient evidence to support that only about 75 percent of 

veterans had been seen within 30 days of the requested appointment time. Furthermore, the IG audit found that schedulers were 

not following established procedures for making and recording 

medical appointments. This means that we do not even have a 

clear picture of how many veterans have requested appointments. 

VHA’s schedulers were supposed to act on a veteran’s request 

within 7 days. If this appointment cannot be made within the required 30 days, the scheduler should place the veteran’s request on 

an electronic waiting list. However, the IG found that a majority 

of schedulers are not trained to use this system, so they do not use 

the electronic waiting list. Perhaps more alarming are reports that 

schedulers have been instructed to reduce waiting times by not 

putting patients on the electronic waiting list. This attempt to reduce cases of long waiting times could lead to gaming of the scheduling process. 

The VA has discounted the IG’s report because it disagrees with 

how waiting times were calculated. This is unacceptable. I am not 

willing to walk away from this audit over a disagreement about 

methodology. This is a real problem that we must look into. 

When our veterans encounter long waiting times, their conditions 

go undiagnosed, and serious diseases go untreated. Furthermore, 

until we have a clearer picture about waiting times, the VA cannot 

improve the situation because we cannot identify problem facilities 

or effectively allocate resources. We should not allow our servicemembers to encounter long wait times for doctors’ appointments. 

I look forward to hearing from our witnesses. 

[The prepared statement of Chairman Mitchell appears on p. 29.] 

Mr. MICHAUD. Thank you, Mr. Mitchell. 

Now I would like to recognize a Member who is a very strong advocate for veterans’ issues to introduce one of our first panelists. 

Mr. Zack Space. 

OPENING STATEMENT OF HON. ZACHARY T. SPACE 

Mr. SPACE. Thank you, Mr. Chairman. 

If I might, very briefly, in advance echo the sentiments of my colleagues from both sides of the aisle. Clearly we have an obligation 

as a Nation to live up to the promises made to veterans and to provide them with the best and most efficient care that we can. Certainly part of what this hearing is about is to ensure that that happens, but part of this hearing is also to determine whether the very 


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numbers that the VA has calculated in terms of the delays are accurate. 

As my Subcommittee Chairman, Mr. Mitchell from Arizona, has 

pointed out, there is a significant discrepancy between what the VA 

has reported compared to what the IG has reported. There is a significant discrepancy. The questions that I am hoping will be answered today are as to whether that discrepancy is the result of 

mere incompetence or is the result of intentional misconduct. To 

me, it would seem reprehensible that our veterans would be shortchanged at the expense of bureaucratic bookmaking. 

So, with that in mind, I am delighted to have with us today our 

first presenter, Mary Jones, from Ohio’s 18th Congressional District. Mary Jones served with the United States Army from May 

1983 to May 1986. She served with the 101st Airborne Division at 

Fort Campbell, Kentucky, and she served with the 2nd Infantry Division at Camp Casey, Korea. Ms. Jones is a graduate of Kent 

State University and is currently serving as a Licking County Veterans’ Service Officer. She has been with the office since 1995, and 

is accredited as a service officer with the American Legion, the Disabled American Veterans, the Veterans of Foreign Wars (VFW), the 

Governor’s Office of Veterans Affairs, and with AMVETS. In that 

capacity, she directs an office of four accredited service officers 

working in a county with nearly 16,000 veterans. 

Ms. Jones is a life member of the Disabled American Veterans 

chapter number 23, of the AMVETS post number 345, of the American Legion’s post number 85, and of the VFW’s post number 1060. 

She is currently serving as the Second Vice Commander of the 

Sixth District of the American Legion Department of Ohio, and is 

serving on the board of directors as the Secretary of the Licking 

County Veterans’ Memorial and Educational Center. A native of 

Ohio, she and her husband Donald reside in Newark, which is in 

Ohio’s 18th district. Ms. Jones, I am very happy to report, is also 

a member of my Veterans Advisory Board. 

I thank you for being here today, Mary, and welcome. 

Ms. JONES. Thank you. 

Mr. MICHAUD. The second panelist is Kevin P. McCarthy, who is 

President and Chief Executive Officer of Unum. 

Since the previous panel cut into about 45 minutes of our time, 

and since we will have votes, actually, within about 45 minutes, 

you will find Mr. McCarthy’s impressive resume in our packets, 

and hopefully you will have a chance to look at that as well. 

So, without any further ado, I will recognize Ms. Jones to begin 

her testimony. I want to thank both of you for coming here today, 

and I look forward to hearing your remarks. 

So, Ms. Jones. 


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STATEMENTS OF MARY C. JONES, LICKING COUNTY VETERANS’ SERVICE OFFICER, LICKING COUNTY VETERANS’ SERVICE COMMISSION, NEWARK, OH; AND KEVIN P. MCCARTHY, 

PRESIDENT AND CHIEF EXECUTIVE OFFICER, UNUM US, 

PORTLAND, ME 

STATEMENT OF MARY C. JONES 

Ms. JONES. Thank you, Mr. Chairman and Members of the Subcommittee. Thank you for providing me with this opportunity to 

testify regarding issues of outpatient waiting times. 

I have worked as a County Veterans Service Officer for the past 

12 years, and in that capacity I have had an opportunity to enjoy 

a great relationship with the staff at both the Columbus VA Outpatient Clinic and the Newark Community-Based Outpatient Clinic, and I feel privileged to be able to have this relationship. I use 

the VA healthcare system as my primary provider of medical care 

for my service-connected conditions. 

My concern with outpatient waiting times is our inability to get 

veterans into an appointment in a timely manner. Their appointments are scheduled so far out, often 2 to 3 months, that their 

condition worsens, and they are left angry and frustrated at a 

system that is supposed to be in place to care for those who have 

given so much to our great Nation. As examples of the problems 

created by these wait times, I offer to you some experiences from 

our office. 

We see many veterans shortly after their return home. They 

have been promised dental care within 90 days from their discharge. One veteran’s first available appointment was scheduled almost 90 days from the date of his request. When he got to the dental clinic, he was told that his appointment needed to be canceled 

and rescheduled. They did not have any appointments available 

within that 90-day period, and he was, therefore, not seen. 

Female veterans have unique healthcare concerns and face difficult wait times to see gynecologists, often as long as 6 to 8 

months. Please keep in mind that most of the women who we are 

working with do not have other viable options for healthcare. Many 

are wartime veterans on a nonservice-connected pension and are, 

therefore, very low income. They are unable to get Medicaid treatment for preventative or diagnostic medical care. Pap tests and 

mammograms are increasingly important as we get older and often 

are life-saving diagnostic tools, but waiting as long as 6 months for 

the initial exam, and then often even longer to get the test scheduled, can lead to greater problems if a cancer exists. 

I mentioned earlier that I am a service-connected veteran, that 

I use the VA outpatient clinic myself. I was having health concerns 

and tried to schedule an appointment with my physician and was 

told the earliest appointment I could get was in 6 months. Because 

I am a county employee and have medical insurance through my 

employment, I was able to see a doctor outside of the VA system 

within 3 weeks and ended up needing major medication changes 

and a heart catheterization. I hate to think what would have happened to a veteran without those options. 

We are filing many claims for post traumatic stress disorder 

(PTSD). Usually when we file a claim, we have a veteran who has 


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a diagnosis for a condition, but PTSD is different. Most veterans 

can get into the VA to see a social worker and can get assigned to 

group counseling fairly quickly. Most can see a psychiatrist within 

3 to 4 months for an initial exam, but within the 12 to 18 months 

that a service-connected claim takes to adjudicate, the veteran is 

still left without a diagnosis for PTSD because the wait times prohibit the doctor from seeing the patient often enough to provide a 

definitive diagnosis of any mental health issue. Because no diagnosis exists, the Veterans Benefits Administration must deny the 

claim for service connection. Seeing private psychologists and psychiatrists is beyond the financial reach of most veterans. 

My most memorable experience is a World War II veteran who 

was in receipt of a nonservice-connected pension. He was diagnosed 

with prostate cancer through a prostate-specific antigen test done 

by his primary care. Treatment was scheduled, but the wait time 

was several months. In the meantime, this very gentle man clearly 

understood that he would not survive due to the fact that his cancer had spread and was continuing to spread during this wait. The 

treatment would have only prolonged his life and would not have 

saved his life, but this would have been an excellent opportunity 

to send a positive message of support from our government to this 

World War II vet. That opportunity was missed. He died before his 

appointment with an oncologist. 

This has been an honor for me to have this opportunity to bring 

examples of the difficulties experienced by the veterans who I serve 

caused by the long wait times to be seen at clinics. I did not come 

to criticize the VA, because the care given by our outpatient clinic 

is excellent, but at this time that care comes at a price, and that 

price is patience. 

Thank you, Mr. Chairman. This concludes my testimony. 

[The prepared statement of Ms. Jones appears on p. 31.] 

Mr. MICHAUD. Thank you, Ms. Jones. 

Mr. McCarthy. 

STATEMENT OF KEVIN P. MCCARTHY 

Mr. MCCARTHY. Thank you, Mr. Chairman and Members of the 

Subcommittee. I would like to thank you for the opportunity to testify before you. My name is Kevin McCarthy. I am the President 

of Unum. I have submitted written testimony, which has been 

made available to you, but I will briefly present an overview. 

Unum’s involvement was generated by our company’s wanting to 

explore how we could assist with sharing best practices that might 

be useful in caring for our veterans. Recently, Representative 

Michaud visited Unum and viewed firsthand how the combination 

of our people and technology are integrated together in a way that 

reduces delays in every aspect of claims processing and case management, including appointment scheduling. 

As a result of this visit and our meetings this summer and fall 

with House and Senate Congressional staff, with the Department 

of Veterans Affairs and with the U.S. Department of Defense (DoD) 

on the sharing of best practices between the private and public sectors, I am here today to discuss how we use these smart systems 

and our people not only to reduce waiting times in setting up independent medical examinations, but also to discuss how these are 


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aspects of a larger, integrated case management and claim management approach that include everything from regular contact 

with our insureds so they know what is happening in real-time 

on their claims to assisting them with vocational rehabilitation. 

This integrated approach actually speeds not only wait times on 

individual specific issues, but on the entire case management 

process. 

With regard to the specific issue before you of outpatient wait 

times, we work closely with our insureds, and with their physicians, to make sure that they are receiving appropriate and regular 

care, and we follow up shortly after scheduled visits. As a function 

of our followup and prompting system, we track our insureds’ medical visits and revisits, and we record new medical information. 

As one of the world’s leading employee benefits providers, Unum 

helps to protect more than 21 million working Americans and their 

families in the event of illness or injury. In 2006, we responded to 

more than 420,000 newly filed claims and replaced $4 billion of lost 

income to help provide support to our insureds and to their families. These benefits are paid directly to our insureds. 

Obviously, the management of disability claims differs from 

health insurance, but when circumstances warrant, we do follow up 

in person with our customers and with their providers to determine 

if they have kept medical appointments. Also, we typically follow 

up shortly after appointments to determine if their medical status 

has changed. 

Our ability to pay our customers billions of dollars annually with 

these high levels of satisfaction is due to our highly trained people 

supported by the right technologies. Specifically, we deploy experienced people and technologies with a comprehensive claims management process that applies the most accurate and appropriate 

resources to each claim and decision making supported by expert 

systems and resources with an emphasis on consistent quality and 

regular tracking. 

While a person’s disability can be a complex, ongoing and everchanging life event, our goal is to make the claims process simple 

and transparent for our customers during what is a trying time in 

their lives, so we make it easy to submit a claim. It can be done 

by Internet, telephone, fax or mail. At any time after a claim has 

been submitted, our customers can speak regularly with a skilled 

specialist. We handle more than 4.5 million calls a year. 

While our goal is to make it easy for customers to reach us, we 

also understand that many need our help. Thus, we regularly reach 

out to our insureds and to their healthcare teams. We view it as 

critically important to speak with our insureds and their physicians, and we frequently help our patients follow up with their doctors. We are able to do this because we have invested in an innovative technological process which sorts claims by complexity and 

severity, and it allows all case and claim management activities to 

be conducted real-time in one place. This technology is supported 

by hundreds of highly trained benefits specialists, physicians, 

nurses, and vocational rehabilitation specialists. Our technology allows our people, for example, to make appointments, to schedule 

exams and follow-up calls, to manage workloads, to review claim 

documents, and to provide real-time management access and roVerDate Aug 31 2005 02:26 Oct 04, 2008 Jkt 039648 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 E:\HR\OC\39648.XXX 39648

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bust quality assurance and continuous improvement. Each one of 

the activities the benefits specialist does is scheduled and tracked 

to ensure that the right resources are applied to the right claims 

at the right time. 

The claim status is viewable on the Web so our customers can 

access their claim status. Privacy safeguards are in place. For the 

more complex claims, each customer is called, and we set individual followup action plans in place with the insured based on the 

dynamics of their specific medical condition. 

Our contribution here today is to provide you with insight into 

our best practices, and we welcome the opportunity to continue to 

be a resource for public- and private-sector sharing as you continue 

to evaluate claim processes. 

Thank you very much for the opportunity to testify before your 

Subcommittees. 

[The prepared statement of Mr. McCarthy appears on p. 32.] 

Mr. MICHAUD. Thank you very much, Mr. McCarthy. 

As you mentioned, I have seen your system and your facility in 

Portland, and I am very impressed with your system. Patients see 

specialists very quickly. 

What is the average time that it actually takes them to see a 

specialist or to see a doctor? 

Mr. MCCARTHY. Typically we handle all claim inquiries within 3 

to 5 days. The scheduling process, of course, depends on the availability of physicians and their responsiveness to the claimants, but 

we resolve all short-term disability claims within 3 to 5 days and 

all long-term disability claims typically within 45 days. 

Mr. MICHAUD. As you mentioned, patients can view their cases 

online. They can see their care plan, their next appointment, future 

appointments, et cetera, and you follow up with the patients, as 

you mentioned, to make sure that they understand what they need 

and to make sure that they are getting it. 

Can you go into a little more detail on how Information Technology (IT) manages your cases and how that could be implemented 

within the VA system? 

Mr. MCCARTHY. Our systems are designed to assist our claimants and the specialists who manage and work with those claimants to make sure that care is delivered in a high-quality and consistent fashion. 

So, for example, in the case of a patient’s requiring an independent medical examination, our disability specialist will contact 

that claimant, will record the conversation, will log the requirement for an independent medical examination. Simultaneously, 

that information is available to one of our in-house physicians also 

online. We are able to then work with an outside physician to 

schedule that appointment. That information is then logged in the 

system. The disability benefits specialist then can see the activity. 

He knows when to follow up with the claimant to ensure that the 

appointment was kept and that care was delivered. All through the 

process, this information is available real-time to anyone managing 

and supporting our claimants. 

Mr. MICHAUD. You also mentioned that you receive 4.5 million 

calls a year. How many staff handle those calls? Is there a waiting 

list? Is it an automated list, or can they get a live person? 


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Mr. MCCARTHY. They get a live person. Every call is answered 

within 20 seconds. We have 300 people answering these calls. 

Mr. MICHAUD. Twenty seconds? 

Mr. MCCARTHY. Twenty seconds. 

Mr. MICHAUD. Three hundred people? 

Mr. MCCARTHY. Three hundred. 

Mr. MICHAUD. What is the availability if someone calls in? Can 

they call in during the evening, or is it during the daytime? 

Mr. MCCARTHY. Twenty-four/seven. 

Mr. MICHAUD. Twenty-four/seven. Thank you. 

Mr. MCCARTHY. Thank you. 

Mr. MICHAUD. Ms. Brown-Waite. 

Ms. BROWN-WAITE. Thank you very much, Mr. Chairman. 

Ms. Jones, I am very familiar with the great work the veterans 

service organization officers do, and my hat is off to you. 

You mentioned in your testimony the difficulty in getting veterans appointments for specialty care, including dental, gynecological and oncology services. Is this a problem with the scheduling 

of appointments, or is it a specific problem with staffing in these 

specialties in the Ohio area where you are? 

Ms. JONES. I have to think it is within the staffing. There is just 

not enough staff available. 

Ms. BROWN-WAITE. Okay. So there are not enough of the specialty care physicians available. Am I understanding your response 

correctly? 

Ms. JONES. Yes, ma’am. 

Ms. BROWN-WAITE. Okay. How about primary care? What is the 

length of time with a veteran getting primary care? 

Ms. JONES. An initial call is usually 2 to 3 months still. 

Ms. BROWN-WAITE. So it is 2 to 3 months? 

Ms. JONES. Yes, ma’am. 

Ms. BROWN-WAITE. I mentioned in my opening statement the bill 

that I have that basically says if veterans cannot get medical care 

within 30 days, if they cannot get the appointments from the time 

that they ask for the appointments, that they would be able to seek 

care in the private sector, because the issue, really, is the timeliness of care. 

Could you give me your view of whether this is a good idea or 

a bad idea or how you think your veterans would react? 

Ms. JONES. That is a tough question. 

I have to say that it is encouraging for me to think that we are 

looking outside of the box. I know that a lot of the veterans organizations are not pleased with that, so I have to make it clear that 

I do not speak for them. 

For me, to see the possibility of our being able to use outside 

physicians might be a good idea. What I like about that is that 

maybe outside physicians who are already treating our veterans 

anyway would then get some kind of training about dealing with 

veterans issues. Right now most doctors do not even ask, ‘‘Are you 

a veteran,’’ let alone, ‘‘Are you a combat veteran?’’ That is critical 

to their care that they are getting outside of the VA because they 

cannot get into the VA. 

Ms. BROWN-WAITE. I appreciate your candid response to that. 

Ms. JONES. Thank you. 


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Ms. BROWN-WAITE. I think that it is a mixed blessing. People 

want to receive the services in the VA because, when they do get 

the services, overall they are happy. I see you are shaking your 

head in agreement. 

Ms. JONES. Yes, ma’am. 

Ms. BROWN-WAITE. If there is a long delay in getting those services, you certainly do not want someone who has an ongoing problem, such as the one that you pointed out with the fellow with the 

prostate cancer—you do not want that going on without receiving 

the proper medical care. I know some veterans groups are adamantly opposed to this. If our goal here is to provide quality care, 

then care not rendered in an expeditious manner is not quality 

care, so we do have to, I think, think outside the box. If we cannot 

provide that in the VA, then I think that we need to throw that 

gauntlet down to the VA and say, if you cannot do it in 30 days, 

then the veteran would have the option to go elsewhere. That is 

why I put the bill in. It is not that I do not believe in the VA system; I do believe in the VA system, but we also want to make sure 

that there is a timeliness of that care. 

I have just one other question, and that relates to—you mentioned the difficulty of the veterans that you are trying to assist 

getting their PTSD claims adjudicated in a timely manner—— 

Ms. JONES. Yes, ma’am. 

Ms. BROWN-WAITE [continuing]. Because of the problem in obtaining an appointment with a psychiatrist, which, obviously, then 

delays the diagnosis needed to adjudicate the claim. 

Do you feel that a joint VA/DoD/Benefits Delivery at Discharge 

physical may reduce the amount of time that it would take to obtain a diagnosis for PTSD and would allow a claim to be processed 

more rapidly? 

Ms. JONES. If the veteran is going to start talking about what the 

issues are at that time. 

What bothers me is that if they are still involved in DoD, they 

may not be open to discussing mental health issues. 

Ms. BROWN-WAITE. Thank you. 

I yield back, Mr. Chairman. 

Mr. MICHAUD. Thank you very much. 

Mr. Space. 

Mr. SPACE. Thank you, Mr. Chairman. 

My first question, really, is for both of the panelists. The VA has 

reported that 95 percent of outpatient appointments are scheduled 

within 30 days of the desired date. My question is: Based upon 

your experience, is that consistent with your own observations and 

experiences? 

Ms. JONES. Absolutely not. 

Mr. MCCARTHY. I would not have any experience, actually, directly with respect to veterans appointments, but in general in the 

private sector, that would be quite a common occurrence to be 

within that timeframe. 

Mr. SPACE. Okay. Well, I want to follow up a little bit on what 

Congresswoman Brown-Waite referenced. 

By the way, Mary, I want to commend you for the diplomatic 

fashion in which you responded to her inquiries. 


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Given that you have been involved in the system yourself as well 

as in your extensive experience with helping others navigate the 

system, is there any means—let us take the example of the gentleman whom you referenced in your testimony who suffered from 

prostate cancer. Is there any means by which a veterans service 

officer can intervene to expedite an outpatient scheduled appointment in the event that there are exigent or compelling 

circumstances? 

Ms. JONES. We absolutely call in all the chips that we can when 

there is a circumstance where we have someone. Sometimes the VA 

can be responsive, but sometimes there simply just is not an available appointment. I have had experiences similar to what we are 

talking about where the VA is able to contract services out. It is 

what we saw when we had a large number of troops coming into 

our community from a maintenance company that was coming back 

from Iraq and was scheduled for dental care. They contracted out 

dental care for a period of time, and they did it locally rather than 

having them all try to fight their way into the VA clinic in Columbus. So I have seen them do some contracting when we call and 

say, ‘‘Look, we have a large number of people who are needing the 

same treatment,’’ but that is not across the board, and that is not 

always available. 

Mr. SPACE. So those are instances in which you have seen or 

have observed the active contracting out because of, for example, 

a large influx at a given moment in time. 

Has that been a productive exercise? Has it been helpful to engage in that contracting out? 

Ms. JONES. Absolutely. It has gotten the guys the care that they 

needed in a timely manner. 

Absolutely. It has gotten them good care with local physicians, 

with people who they are probably familiar with anyway in some 

cases. 

I have seen more and more contracting out with radiation services because of our Vietnam vets and the exposure issues and prostate cancer. So we see more and more radiation treatment for prostate cancer contracted out locally, and that has been very productive. Otherwise, our guys have to drive 2.5 hours daily for 5 to 6 

weeks for that treatment to the nearest VA that can provide it. 

That is a long drive. 

Mr. SPACE. Okay. Thank you, Mary. I have no further questions. 

I yield back. 

Mr. MICHAUD. Thank you very much. 

Once again, I would like to thank you both for your enlightening 

testimony, and I look forward to working with you as we move forward on this very important issue of making sure that veterans get 

timely access to healthcare. 

So, once again, thank you both. 

Ms. BROWN-WAITE. Mr. Chairman, if I may ask Ms. Jones just 

one additional question? 

Mr. MICHAUD. Yes. 

Ms. BROWN-WAITE. Because there are so many snowbirds who 

come from your State down to Florida, have any of them compared 

appointment times that they are able to get in, let us say, Southern 

States, not necessarily Florida, when they spend six months in anVerDate Aug 31 2005 02:26 Oct 04, 2008 Jkt 039648 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 E:\HR\OC\39648.XXX 39648

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other State as opposed to when they are in your State? Have any 

of them mentioned that? 

Ms. JONES. I have had several talk to me about that. Quite 

frankly, when they come to Ohio, they are a little upset. They say, 

‘‘We are getting good care. I am calling in,’’ you know, ‘‘and I am 

able to be seen very quickly in the Florida area.’’ They then come 

back to Ohio, and it is hard to transfer from one VISN to another. 

I mean, that is not something that is easy to do to begin with. Then 

to try to get them in is just like trying to get a new patient in 

sometimes. Even though he is very involved in the VA in Florida, 

when he comes back to the State of Ohio, he is being seen as a new 

patient. 

So there is a 2- to 3-month delay. What these guys who are 

regulars at doing this have learned is to try to get your medication 

filled before you leave Florida before you come back to Ohio for the 

summer. Yes, ma’am. 

Mr. MICHAUD. I guess that raised another question for Representative Space. 

Mr. SPACE. Thank you, Mr. Chairman, for indulging me. It will 

be brief. 

Based upon your experience, Mary, do you see, perhaps, a difference in terms of the scheduling times that apply to those who 

have access to rural versus urban areas? In other words, is this a 

problem that afflicts rural America more so than urban America? 

Ms. JONES. Very much so. I have talked to guys who have moved 

into our area, a more rural area, from, say, the Dayton, Cincinnati, 

Cleveland area where there is a hospital. A lot of them are ready 

to move back to their areas just because they cannot get the treatment that they need in our area. 

Mr. SPACE. Thank you. 

I yield back. 

Ms. BROWN-WAITE. Mr. Chairman, I was just handed a question 

from another Member of the Oversight Subcommittee for Mr. 

McCarthy, Kevin McCarthy, the representative from Unum. 

Mr. MCCARTHY. Yes. 

Ms. BROWN-WAITE. His question is, ‘‘How might the system that 

Unum deploys in its intake and management of disability claims 

have any relevance to the VA healthcare system?’’ 

The followup question that he has is, ‘‘Are there any lessons to 

be learned?’’ 

Mr. MCCARTHY. Although we are not directly in the provision of 

care, we are in the business of tracking the responsiveness of our 

company within a care system, and so all of our disability benefits 

specialists use a common system. 

So, for example, in the example that Ms. Jones just was using, 

a patient’s moving—geography—would be tracked within the system, and he would be provided the same availability of information 

in real-time with the same amount of vocational, clinical and rehabilitation support or medical support regardless of where he would 

be located. For example, all of our tracking systems would follow 

the claimant. They would not be separated by jurisdiction, for example. 


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Ms. BROWN-WAITE. So, if I understand you correctly—and this 

question was directed at you. It was not from Mr. McCarthy. That 

is your name. I apologize. 

So what you are saying is that your system would prevent the 

problems that Ms. Jones has brought to light where they go from 

one VISN to another? 

Mr. MCCARTHY. I think, within our system, we have a number 

of quality standards built in. We do quality assurance evaluations 

based on those standards of all of our disability benefits management specialists. We track the constant availability of the information and the transferability of that information, so I would think 

that type of system would be beneficial to any administrative process involving the delivery of care. 

Ms. BROWN-WAITE. Okay. Ms. Jones, let me just tell you that I 

used to hear from veterans who would go back North in the summer. They would have trouble, and they would be considered a new 

patient, but somehow I do not hear those complaints anymore, and 

I am not sure that they are getting their medications, if that is how 

they are solving it, or if in some areas the VA may be better at 

sharing the patient information. I do not know which of those two 

scenarios explains why it is happening. I have not heard in 2 years 

from a snowbird that they have had problems. 

Ms. JONES. I have more recently, yes. 

Ms. BROWN-WAITE. But it is on your end, not on the Florida end? 

Ms. JONES. It is on our end. 

Ms. BROWN-WAITE. Okay. Thank you. 

I really do yield back this time. 

Mr. MICHAUD. No problem. 

Once again, I would like to thank our first two panelists for your 

testimony today. We look forward to working with you. Thank you. 

Mr. MICHAUD. On our second panel is Belinda Finn, who is Assistant Inspector General for Auditing. Belinda is accompanied by 

Larry Reinkemeyer, who also works in the Office of Inspector General. 

So I want to welcome you both here today, and we look forward 

to your testimony, Belinda. 

STATEMENT OF BELINDA J. FINN, ASSISTANT INSPECTOR 

GENERAL FOR AUDITING, OFFICE OF INSPECTOR GENERAL, 

U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED 

BY LARRY REINKEMEYER, DIRECTOR, KANSAS CITY AUDIT 

OPERATIONS DIVISION, OFFICE OF INSPECTOR GENERAL, 

U.S. DEPARTMENT OF VETERANS AFFAIRS 

Ms. FINN. Thank you, Chairman Michaud, Chairman Mitchell 

and Members of the Subcommittee. 

I am pleased to be here today to discuss our findings and conclusions on outpatient waiting times. With me is Mr. Larry Reinkemeyer, Director of our Kansas City Audit Office, who directed the 

work on our two audits. 

The VHA calculates waiting time for each appointment from the 

desired date of care, which is defined as the earliest date that either the patient or the medical provider requests care. The VHA 

has established a performance goal of scheduling appointments 


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within 30 days. Veterans who cannot be scheduled within this 

timeframe should be placed on an electronic waiting list. 

In 2005, we reported that the VHA did not follow established 

procedures when scheduling appointments, resulting in inaccurate 

waiting times and waiting lists. Because schedulers did not follow 

procedures, only 65 percent of the 1,100 appointments we reviewed 

had been scheduled within 30 days. Nationwide, the electronic 

waiting list could have been understated by as many as 10,000 veterans. 

The VHA also lacked a standardized training program for schedulers, and it did not provide sufficient oversight of the process. Almost half of the 15,000 schedulers who talked to us about their 

training and scheduling practices said they had not been formally 

trained on the scheduling system; 81 percent had received no training on the use of the electronic waiting list. At the conclusion of 

our audit, the VHA agreed with our findings and accepted our recommendations. 

In 2007, we conducted a followup audit to determine whether the 

VHA had addressed the findings and recommendations in our report. We concluded again that the data in the scheduling system 

remains inaccurate, in part because the VHA had not implemented 

five of the eight earlier recommendations. We reviewed 700 medical 

care appointments that the VHA had reported as being completed 

within 30 days. We found that only 75 percent of those appointments had actually met the 30-day timeframe. Our review of 300 

consult referrals found that more than 180 veterans were not included on the waiting list, but should have been. The VHA disagreed with our findings and said that patient preference had 

caused the unexplained differences. Although policy requires schedulers to document patient preferences, the VHA felt this was an 

unrealistic expectation. They conceded, however, that the system 

lacked the documentation to support their position. 

We contend that, without this basic annotation, the VHA cannot 

support its assumption that patient preference caused our findings. 

We find it contradictory that the VHA agreed with our 2005 report 

but disagreed with our followup audit. We used the same methodology and found a continuation of the same problems, problems 

that could have been resolved had VHA implemented our recommendations. 

In 2006 and 2007, the VA reported high performance affecting 

appointments within 30 days. They reported this high level of performance even after we had twice reported the scheduling system 

contains inaccurate, incomplete and unreliable data. 

In closing, I would like to say the issues today before us go beyond reported waiting times. Debating whose numbers are more 

correct only overshadows the primary point of both of our audit reports, which is that the information in the VHA’s scheduling system is incomplete. The VA and Congress must have reliable information for budgeting, assessing and managing the demand for 

care. More importantly, they need accurate information to ensure 

that every veteran receives timely medical care. 

Thank you for having us here today, and we would be happy to 

answer any questions. 

[The prepared statement of Ms. Finn appears on p. 35.] 


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Mr. MICHAUD. Thank you very much, Ms. Finn. 

What does the VHA need to do to improve their data reliability? 

Have you communicated that with them? What was their response, 

if they had one? 

Ms. FINN. Yes, sir. We made recommendations in both of our reports that the VHA should provide the oversight of the schedulers, 

should monitor what the schedulers do, and should provide quality 

assurance over the data in the scheduling system. They agreed 

with the recommendation in 2005, but we did not find their actions 

had really resolved the problem, and therefore, we reinstituted the 

recommendation in our later report. They do have procedures to 

monitor the number of veterans who are taking more than 30 days 

to get an appointment. We found procedures in place to monitor 

this, but not procedures to monitor the quality and the accuracy of 

the data in the system. 

Mr. MICHAUD. You had mentioned that they have not implemented five out of the eight recommendations. Did they tell you 

why they have not implemented those five? 

Mr. Reinkemeyer. 

Mr. REINKEMEYER. It would be better for them to explain that, 

but they have taken some actions. From 2005 to 2007, they created 

a pretty detailed directive in 2006–055 as part of the response to 

our first audit that lays out step by step procedures for the schedulers to follow, and it is pretty clear. Those, in fact, are the guides 

that we used when we did this last audit. 

There was one recommendation that dealt with IT that they are 

working, and I think they are close to having that implemented 

now. I know that they want to close a couple of the recommendations but we just have not had a chance to evaluate them yet, and 

we will take a look at their actions for those to see if we agree with 

those or not. However, it would be best to ask them, I think, on 

exactly why some of them have not been implemented. 

Mr. MICHAUD. Great. 

Ms. Brown-Waite. 

Ms. BROWN-WAITE. Thank you. 

Have you all taken the data actually down and reviewed each of 

the VISNs to track the performances that the individual VISNs are 

experiencing? 

Mr. REINKEMEYER. No. You could do that. The VHA has plenty 

of data that will show you by VISN what performance is occurring 

in that VISN. 

In our first audit in 2005, we went to eight different facilities. 

That was the extent of our work. In this last audit, we went to 10 

facilities at 4 different VISNs. We did not really compare who was 

doing better and who was doing worse. We tried to focus on the actual appointments themselves to see how well the data that was 

in the system was supported by the medical records. 

Ms. BROWN-WAITE. I actually asked for information on VISN 8, 

which is the VISN that Florida is in, tracking their performance. 

When I asked for it, I got information that seems to indicate that 

while outpatient wait times are going down in the medical centers, 

the wait times are actually increasing at the CBOC level. 

Is there any way to account for this situation? 


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Mr. REINKEMEYER. Well, typically the CBOCs—I mean, not all 

CBOCs are the same, but a lot of the CBOCs are not going to be 

staffed with the same type of providers, so I do not know exactly 

if it is waiting time for specialists or for primary care, but that 

could be one reason. 

Ms. BROWN-WAITE. I did have them break it down by primary 

care. This was primary care’s average wait time new patients/average wait time established patients. So we did it both for hospitals 

and for CBOCs. Obviously, more and more people are using the 

community-based outpatient clinics. I mean, that is, overall, a good 

thing that they are using the clinics, but I am now starting to also 

hear that there is a wait time. Let me ask you a somewhat related 

question. 

At what point in time does the scheduling request begin? 

On page 2 of the VHA directive 2006–055, number 4, it says, 

‘‘ ‘Desired Date’ is defined as,’’ quote, ‘‘The desired appointment 

date is the earliest date on which the patient or clinician specifies 

the patient needs to be seen. This desired date may be the date the 

request is made by the patient or the date a request is made by 

a clinician. When available, the desired date may be a specific date 

to be seen submitted by the patient or by the requesting provider. 

In some cases, the desired date may need to be modified after an 

initial appropriate clinic visit. For example: a patient may request 

to be seen by a specialist, but a clinician reviewing the request may 

determine that before being seen in specialty care, the patient 

needs to be evaluated in primary care,’’ end of quote. 

Isn’t that kind of a very confusing definition of that point in time 

that the actual appointment was requested? It is almost like you 

read this five or six times, and you say, ‘‘Huh?’’ 

Ms. FINN. Yes. I think the ultimate point of the definition is that 

both the medical provider and the patient can request a date. The 

medical provider, of course, recommends a date of care, and the 

patients also have some latitude as to when they schedule their appointments. We recognize that patients may schedule their appointments a little later or, perhaps, earlier than when the doctor 

absolutely recommends it. 

Ms. BROWN-WAITE. Mr. Chairman, just a quick followup question. I know my time is almost up, and I will yield back. 

Is the problem of how to set that point in time when the request 

is made because of the somewhat convoluted description in the 

VA’s own directive? 

Ms. FINN. The problem is recording the correct desired date of 

care in the scheduling system to make sure that it really reflects 

what the doctor recommends or what the patient has requested. 

That is the date that we measure the waiting times from. 

Ms. BROWN-WAITE. I yield back the balance of my time. 

Mr. MICHAUD. Mr. Space. 

Mr. SPACE. Thank you, Mr. Chairman. 

I think we can all agree that inaccurate waiting time data compromises the VHA’s ability to assess and to manage the demand for 

medical care. That is, in fact, taken directly from your testimony 

today. Your testimony also includes the following sentence, and I 

will read it and then follow it with a question. 


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‘‘VHA managers plan budget priorities, measure organizational 

and individual medical center directors’ performances and determine whether strategic goals are met, in part by reviewing data on 

waiting times and lists.’’ 

The operative part of that sentence was measuring an individual 

medical center director’s performance. Clearly that data is important to assess whether a particular medical center director is performing adequately. My question relates to the bonuses that all of 

us are familiar with that raised some controversy earlier this year. 

If you know—and perhaps you are not prepared to answer this— 

is it possible that bonuses were at least, in part, calculated or 

based upon high-performance standards regarding waiting times 

that were not accurate? 

Ms. FINN. We know that the waiting time is part of the performance standards for directors. It is one of many factors. We really 

do not have a great deal of information today about how that is actually factored into a particular bonus. 

Mr. SPACE. Are you prepared to say today whether there is evidence that waiting time data was intentionally fabricated at any of 

the medical centers that you have surveyed? 

Ms. FINN. We know that some of the practices used by schedulers 

and some that schedulers have told us about would serve to understate a specific wait time. As to whether that was a widespread 

manipulation, I cannot say right now, but we have seen a number 

of cases where we believe that practices serve to understate the 

time. 

Mr. SPACE. I understand that from reading your testimony. The 

word ‘‘practices’’ can encompass a lot of things. Certainly it can include inefficient habits. It can include procedures that are not up 

to par, but it could also include the intentional manipulation of 

data. 

Did your investigation determine that there has been any act, intentional overt act, to misrepresent the data? 

Mr. REINKEMEYER. In this recent audit, which was a followup to 

the previous audit, we did not really explore that question, but in 

2005, if you have seen that report, we did an extensive survey that 

over 15,000 schedulers responded to. One of the questions was, 

have you ever been directed to intentionally manipulate scheduling 

procedures in order to circumvent the system, which would result 

in reduced waiting times? That is not the exact question, but it was 

close. Seven percent said yes. So, in 2005, we did have some evidence that schedulers were directed to schedule in a particular way 

in order to effect the waiting times. 

In 2007, we know that those procedures are still out there. The 

two most common procedures would be taking longer than allowed 

before they are put on an electronic waiting list, and you probably 

saw some of our references to consult referrals from a primary care 

to a specialist where the standard is 7 days. If you do not act on 

that appointment within 7 days, you are supposed to be put on the 

electronic waiting list and the VHA and their directors would take 

that information and use it to determine where to apply resources. 

By holding onto those referrals for more than 7 days and not putting them on the electronic waiting list, that serves to understate 

the waiting list. 


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The second procedure that tended to manipulate would be establishing the starting point for the waiting time. It is the desired date. We have seen both in 2005 and in 2007 that a common 

practice for a scheduler was to find out when the first available appointment was—January 15th—and then use that as the 

desired date of care, which effectively reduces the waiting time to 

zero. 

So those are the two types of scheduling practices that tend to 

manipulate VHA’s data. 

Mr. SPACE. If I may just have time for one more question? 

Mr. MICHAUD. If it is quick. We still have one more panel, and 

we have votes coming shortly. 

Mr. SPACE. I will be very quick. Okay. 

The 7 percent that were directed to intentionally misrepresent 

the data, that falls separate and apart from those two incidences 

which represent practices that you just recited, correct? 

Mr. REINKEMEYER. Yes. 

Mr. SPACE. Has any action been taken to determine who was intentionally directing people to manipulate the data? If so, what repercussions have resulted from it? 

Mr. REINKEMEYER. In 2005, we did not ask who did it, and the 

survey was anonymous. I cannot tell you now, but we have some 

information that would say where they were. If I recall correctly, 

they were spread out. 

Mr. SPACE. Thank you. I will assume that the answer to that is 

no. 

With that, I thank the Chairman for indulging me with additional time. 

Mr. MICHAUD. Thank you very much. 

I would like to ask the third panel to come up. While they are 

coming up, there will be additional questions that we will provide in writing, and hopefully, you will be able to answer them as 

well. 

Mr. KENNEDY. Mr. Chairman. 

Mr. MICHAUD. On the third panel—— 

Mr. KENNEDY. Mr. Chairman. 

Mr. MICHAUD. Yes. 

Mr. KENNEDY. Briefly—— 

Mr. MICHAUD. If you can hold your question until the end, we 

still have one more panel. We have to give this room up at 4:30, 

and we have votes, so—— 

Mr. KENNEDY. We have 120 veterans committing suicide a week. 

Did you break out mental health appointments on your outpatient 

waiting lists? 

Mr. REINKEMEYER. No, sir. 

Mr. KENNEDY. You did not. 

Was there a correlation between inpatient waiting time and outpatient waiting time in your audits? 

Mr. REINKEMEYER. Again, we only looked at the outpatient waiting times. 

Mr. MICHAUD. Okay. On the third panel, we have Dr. Gerald 

Cross, who is the Principal Deputy Under Secretary for Health; as 

well as Dr. Paul Tibbits, who is the Deputy Chief Information Officer (CIO). 


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So I want to welcome the last panel. If you could summarize your 

testimony, your full testimony will be submitted for the record. As 

you know, we do have votes coming shortly, and we will not be able 

to continue the hearing because we will have to give up this room 

at 4:30. Unfortunately, the full Committee went over by 45 minutes, so I apologize for that. 

So, Dr. Cross, without further ado, would you begin? 

STATEMENTS OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL 

DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY WILLIAM F. FEELEY, MSW, 

FACHE, DEPUTY UNDER SECRETARY FOR HEALTH FOR 

OPERATIONS AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION; ODETTE LEVESQUE, CLINICAL/QA LIAISON, 

OFFICE OF THE DEPUTY UNDER SECRETARY FOR HEALTH 

FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH 

ADMINISTRATION; AND KATHY FRISBEE, DEPUTY DIRECTOR, SUPPORT SERVICE CENTER, VETERANS HEALTH ADMINISTRATION; AND PAUL A. TIBBITS, M.D., DEPUTY CHIEF 

INFORMATION OFFICER, OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND TECHNOLOGY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF GERALD M. CROSS, M.D., FAAFP 

Dr. CROSS. Thank you. Thank you, Mr. Chairman. And since 

time is short, I have a written statement. I will submit that, and 

I will abbreviate my oral statement. 

Mr. MICHAUD. Thank you. 

Dr. CROSS. We are making good progress in meeting the needs 

of our veterans in terms of access, and we are committed to providing all necessary care, including preventive care. I want to be 

clear that we are talking about waiting times for general, routine 

outpatient appointments. Veteran appointments with urgent or 

emergent needs are seen immediately separately. 

In a healthcare system as large as VA where we provide over 1 

million patient encounters in our clinics each week, we understand 

there are opportunities for improvement. With national implementation of the Advanced Clinical Access Initiative, we have made significant progress of reducing wait times. 

And you may see some of the graphs that are portrayed on the 

stands to our left. In the patient satisfaction survey for the third 

quarter year to date fiscal year 2007, 85 percent of veterans surveyed reported that they received primary care appointments when 

they wanted them, and 81 percent reported that they received their 

specialty care appointments and that they were made at a time 

that was acceptable to them. In fiscal year 2007, 96 percent of our 

40 million appointments were seen within 30 days of the desired 

appointment date. This represents waits for outpatient primary 

and specialty care appointments. 

We continue to improve access for new veterans. The percent of 

new primary care patients seen within 30 days of their desired 

date has improved from 75 percent in fiscal year 2005, to 83 percent in fiscal year 2007. And in September 2007, 90 percent of new 


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primary care patients were seen within 30 days of their desired 

date. Our statistics are even better for follow-up appointments. 

Finally, we are focusing on mental health access by setting new 

standards that require all new mental health patients to be seen 

and their needs for care evaluated within 24 hours, and that these 

veterans have a follow-up evaluation within 14 days. With the assistance of Congress and the administration, we have increased, by 

3,600, the number of mental health professionals with our system 

since 2005. 

As you are aware, VA has several concerns about VA’s Office of 

Inspector General’s audit methodology used in the 2007 report. 

While differences in methodology exist, the overriding focus of both 

sets of measurements, and our overriding focus, is the veteran patient. VA has a driving interest to accurately monitor and to continually improve access for our veterans. There are an estimated 40 

million appointments each year in the VA system. There are multiple variables involved in that measurement, and tracking that 

does include patient preferences and differences in the organization 

of individual facilities and clinics. 

VA has identified ongoing training of our scheduling clerks as 

critical for success; however, we are still using antiquated software 

for this important task. VA is proactively taking steps to review 

this whole scheduling process, including the way VA measures 

waiting times. 

We will continue to improve our processes, educate scheduling 

staff and strive to improve clinic access to further reduce waiting 

times, and to this end VA has contracted with an independent 

third party to conduct an evaluation of VA scheduling practices and 

waiting time metrics. The contractor is beginning the pilot program 

phase of its assessment, and we anticipate receiving the final report in the spring of 2008. 

In conclusion, we are taking the following substantive actions to 

aggressively address the issues of veteran access and wait times. 

We ask the VA’s Office of Information and Technology to develop 

a new scheduling software package, as well as developing shorterterm software solutions for our current scheduling package. We are 

continually improving our training programs, and we are contracting with an outside consulting firm for an independent review 

of our scheduling process and metrics. 

Thank you, and I will be pleased to accept your questions. 

[The prepared statement of Dr. Cross appears on p. 41.] 

Mr. MICHAUD. Thank you very much. 

And because of time, Dr. Tibbits, we do have your written testimony, you wouldn’t mind if we go right directly to questions; there 

is no objection? 

Dr. TIBBITS. No. Fine. 

[The prepared statement of Dr. Tibbits appears on p. 42.] 

Mr. MICHAUD. I have a couple questions—my first, actually, Dr. 

Cross, is you mentioned the methodology, but we heard just from 

the previous panel that the methodology was the same in 2005 as 

it was in 2007, and you didn’t object to the methodology in 2005. 

So I guess my question is why you haven’t implemented, well, five 

of the eight recommendations that they recommended. 


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Dr. CROSS. We are recommending the recommendations that the 

IG proposed, and we do track that. I want to point out that one 

of the most important things that we are doing is the new directive 

to comprehensively approach many of the recommendations that 

they made. There was a difference in our analysis. And on review 

of the OIG report from 2005 to 2007, there were significant differences in what we found, and that was the reason, based on that 

evaluation, as to our different response. 

Mr. MICHAUD. I understand that the VHA said that this is a documentation issue, but I also know that on the first page of the fiscal 2007 performance report VA provided to Congress just a couple 

of weeks ago, VA said it made 96 percent of its outpatient appointments within 30 days. Do you really feel that VA should be reporting 96 percent when you only can document 75 percent to the IG? 

How is VA or Congress to make the right policy decisions without 

having reliable numbers to go by? 

Dr. CROSS. Congressman, the report that we did in the prior does 

include an additional explanation related to the IG report. So we 

did acknowledge the IG report and the difference that they found 

as opposed to what we found. And so I don’t want to obscure that. 

We understand that and put that in there. 

Mr. MICHAUD. Ms. Brown-Waite. 

Ms. BROWN-WAITE. Thank you, Mr. Chairman. 

Dr. Tibbits, how long has the VA been trying to launch its VistA 

scheduling program? 

Dr. TIBBITS. The VistA program in the scheduling module dates 

back to the 1970s. It is actually in operation. Over that period of 

time, it has had modifications to it to get the best performance out 

of that kind of architecture and that software approach that we 

could get in the system. 

It has limitations. Those limitations finally, I guess I can say, 

came to a head and were recognized as being not addressable in 

total with that old architecture, VistA, and the environment and 

programming medium that it is in. And the replacement scheduling 

application, helped do that scheduling, in order to replace that 

scheduling module in toto, was launched in May of 2001, to turn 

off the 2001, and to bring us into a more modern software and architecture, and also much more robust functionality, much better 

metrics. 

Ms. BROWN-WAITE. So it wasn’t just a name change in 2001? 

Dr. TIBBITS. Not a name change. It was a complete, and remains 

today—that initiative to help do that scheduling is a complete revision of the programming approach, the architecture, a much more 

robust functionality. 

Ms. BROWN-WAITE. And the cost of this program? 

Dr. TIBBITS. I think I should get back to you with an exact figure 

on that, if you don’t mind. 

Ms. BROWN-WAITE. Has it been $30 million, $50 million? 

Dr. TIBBITS. Well, I would rather get back to you with the number. I don’t know the number today. We have the numbers both for 

the anticipated numbers and the actuals. It will be easy for me to 

get that information for you. 

[The information from the VA follows:] 


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(In Millions) 

FY 2004 

Actual * 

FY 2005 

Actual * 

FY 2006 

Actual 

FY 2007 

Actual 

FY 2008 

Current 

Estimate 

FY 2009 

President’s 

Budget 

Request 

VistA Scheduling 

Replacement 31,216 12,888 10,553 18,419 28,300 29,909 

* FY 2004 and 2005 reports VHA obligations prior to the OI&T centralization. OI&T cannot substantiate 

these obligations since Scheduling Replacement was not a specific budget line item in the VHA budget operating plan. Prior to FY 2004, funds expended for Scheduling project activities were not specifically identified or 

reported. 

Ms. BROWN-WAITE. I understand that the scheduling module has 

been delayed again. Is this accurate? 

Dr. TIBBITS. That is the new package. Yes, it is accurate, and unfortunately some of that has occurred on my watch. I will be the 

first to tell you that we need to strengthen program management 

discipline in the Department. We are attempting to do so, both 

with IT workforce improvement initiatives, training and education, 

real-time coaching and mentoring. We are also bringing in industry 

experts, and the Department of Defense has numerous industry experts attached to them which we are bringing in to do real-time 

coaching and mentoring to help us revise our finance and accounting and program management practices as well. And also IBM, by 

the way, is consulting with us to help us implement the 36 processes that were recommended to us as part of standing up and reorganizing the entire Office of Information and Technology. So we 

are trying our best to strengthen those practices to get this program delivered on schedule to the office site. 

Ms. BROWN-WAITE. So do I understand correctly from your testimony that it won’t be fully implementational until 2011. 

Dr. TIBBITS. Yes, ma’am. The current schedule is January 2011 

to have that new module deployed throughout the VA. The alpha 

site deployment date is this summer, and the beta site would be 

December of 2008. 

Ms. BROWN-WAITE. So 10 years for determining wait times 

scheduling. 

Dr. TIBBITS. Yes ma’am. There are significant issues in the Department. Many of them—— 

Ms. BROWN-WAITE. Sir, issues—I don’t think is what the taxpayers want to hear. That there are issues in the Department. 

Dr. TIBBITS. Yes, ma’am. And the Department is taking, I would 

say, quite a number of steps to try to deal with those issues, not 

the least of which was the IT reorganization itself. We have moved 

6,000 people from their former alignments in the organization to a 

new, we are taking steps to professionalize the workforce, we have 

the most empowered CIO in Federal Government, we have now 

complete alignment of authority and responsibility with respect to 

the CIO, none of which the Department had before, just 1 year ago 

the Department did not have this. So while we are well positioned 

to address those issues, nonetheless addressing those issues is hard 

work, and much work remains to be done. 

Dr. CROSS. May I add, Congresswoman, that we can’t wait until 

2011. We are doing things right now within our side of this equation to make sure that our veterans get the access that they need. 


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That is why we are adding the staff. That is why we are opening 

the new clinics. That is what really matters. 

We are going to deal with the IT issue working in collaboration 

with my colleagues from IT, but in the meantime there is much 

that we can do, and we must do that, and that is particularly 

boots-on-the-ground people helping veterans, getting them their appointments, putting the staff in the clinics, and that is what we are 

doing right now. That includes 3,600 mental health workers. 

Ms. BROWN-WAITE. After all of this period of time, after 12 years 

of implementation, and now it is going to be up to 2011. Will this 

program be able to calculate waiting times, yes or no? 

Dr. TIBBITS. Yes. 

Ms. BROWN-WAITE. And if we are here in 2011, will we be told 

it will be 2015, and the answer will still be yes? 

Dr. TIBBITS. Well, we are certainly taking steps for that not to 

be the case. 

Ms. BROWN-WAITE. I yield back the balance of my time. 

Mr. MICHAUD. Yet earlier today we heard testimony that a lot of 

the issues with calculating patients’ waiting times has to do with 

the schedulers. Specifically what have you done as far as to help 

solve that problem with the schedulers to make sure that we do 

have accurate information? 

Dr. CROSS. Mr. Chairman, what we have done is training, and 

training is very important. I think the Congresswoman read from 

a part of our directive. It is quite complex. And people have to understand that that doesn’t come immediately to them. They have 

to be trained to do that. 

I am going to ask a couple of my colleagues here, Ms. Frisbee or 

Ms. Levesque, to comment on that and talk a little bit about our 

training program. 

Ms. LEVESQUE. We issued a policy on scheduling and subsequent 

to that had union negotiations. And once we were cleared, we provided the training to all the schedulers. And to date, we have 

trained about 40,000 schedulers, which means anybody who has access to the scheduling package. Many physicians like to schedule 

their own patients, so they have had to take the training as well, 

and those who have not taken the training have had their permission to schedule removed from them. 

We are in the process of relooking at our directive. Given that 

it has been out there for a year, there are issues that bubble up 

as any issue would with any directive, and we are in the process 

of revising that directive. And once that is revised, we will revise 

the training for the schedulers, and we will do that on an annual 

basis. They will have to take the training annually. We also asked 

all the networks to certify that their facilities have basically 

trained all of their schedulers, and we received those certifications. 

Mr. MICHAUD. And you heard the previous testimony from Mr. 

McCarthy from Unum in that their timeframe that they deal with 

their patients or clients is 3 to 5 days on average, and that they 

handle over 41⁄2 million calls a year within 20 seconds with very 

limited amount of staff 24/7. Have you looked at what the private 

sector, such as Unum, is doing that might improve on what the VA 

is doing? 


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Dr. CROSS. I mentioned in my opening testimony that one of the 

things we are doing is bringing in an independent reviewer. And 

we have established a contract with a well-known, famous contractor, to look at waiting times and how we measure it. 

I will ask Dr. Tibbits if he wants to add anything to that. I think 

the answer is no. 

Mr. KENNEDY. If I might. 

Mr. MICHAUD. Is there unanimous consent that Mr. Kennedy be 

allowed to ask questions? Any objections? 

Hearing none, Mr. Kennedy. 

Mr. KENNEDY. In our community health centers in Rhode Island, 

we have same-day walk-ins, and they have never thought it could 

be possible where they could go without prescheduled appointments, and they have now done without them. And they have accommodated it, and it is, to everyone’s surprise, not a problem. And 

so I would be happy to hook you up with them and figure out how 

they have managed to do it. But I understand they are doing it in 

the VA in Hartford. They don’t have prescheduled appointments. 

They have it via you walk in, you get taken care of. 

Now, a big problem that I have is we are not even seeing a fraction of the veterans we need to see. The big issue here that we are 

not touching is the numerator and the denominator. VA is only 

touching a fraction of the number of veterans that it should be 

touching. 

Now, the real question is what happens when the VA actually 

goes out and does its job, and that is touch all the veterans that 

are supposed to be brought into the VA? Then what happens to this 

waiting period? That is the real issue. And what happens when it 

has to contract out, and will it contract out for partnership with 

the private sector in order to meet these needs? 

You mentioned the mental health. It is great if you hire a bunch 

of mental health providers, but it is a lot easier if you co-opt the 

existing mental health providers and use them as leveraging resources so you can build a broader system to meet the need. 

But I am interested to hear whether you have heard of this notion of, you know, same-day walk-in services. 

Mr. FEELEY. Dr. Cross, might I comment? I would just want to 

mention it is Bill Feeley, class of 1969 and Providence College responding. 

I wanted to share with you that we have the 724 communitybased outpatient clinics that were mentioned. So we are out there 

with mental health providers in all those clinics. You can have 

same-day walk-in service at any VA hospital in the system, and 

you can get that at the community-based clinics as well. 

Because of the serious nature of the disease entity that we are 

talking about, we have established a new standard of a response 

within 24 hours to a patient who presents. On a call, they can come 

in, but we are going to evaluate them within 24 hours. The standard to see a patient routinely—not in crisis, but routinely—is dropping from 30 to 14 days, which is the way we are going to use these 

mental health warriors that we are hiring out there, and 3,600 of 

those employees. In addition, we already contract for $3 billion 

worth of services in various community-based setups where there 

might be remote challenges. So we are doing it. 


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And I would like to get on the record that people come to us as 

the subject matter experts on access frequently and view us that 

way. We are not perfect. This is a work in progress that will keep 

me busy for many years. I set a goal as a professional mental 

health worker to wipe out mental illness by the time I was 28. I 

am now 60, and I still have work ahead of me. 

Mr. KENNEDY. I would just like to follow up. I was just down in 

south Texas, and there is no real VA down in the McAllen area. 

They send them up to San Antonio. They tell me that, you know, 

it is a 4- or 5-hour drive. That is the only place they can get their 

appointments. It would be a lot easier for them if they were able 

to get it, obviously, down where they live in that area. The population is huge. And rather than—maybe they could get their appointments all, you know, kind of in an accumulated timeframe 

and do better scheduling that way than have them take that 4- 

hour drive. Maybe they could do teleconferencing and other things. 

Have you thought about these things? 

Mr. FEELEY. Let me just share with you, so no one thinks that 

you sent me this question in advance. I did a ribbon-cutting ceremony in Harlingen last Friday at the CBOC there that has been 

expanded from 11,000 square feet to 34,000 square feet, visited the 

clinic 35 minutes away. The mental health service delivery system 

that you are describing is going to be in this new Harlingen expanded clinic. And we are going to be contracting for inpatient care 

whenever needed since it is an unreasonable commute to expect 

someone who is having a mental illness breakdown to ride in a van 

for 300 miles. 

So we are really going to bolster up services in the Laredo, 

McAllen, Harlingen, Corpus Christi area by investing in those 

mental health providers and bringing them down there. But Mexican food did bring me down to the dedication. 

Mr. MICHAUD. I want to thank you, Mr. Kennedy, too, for your 

interest not only in veteran issues, but also in mental health. You 

have been a true leader in Congress. I really appreciate your interest in these issues. 

Ms. Brown-Waite. 

Ms. BROWN-WAITE. Thank you, Mr. Chairman. 

You know, in thinking about the whole scheduling problem that 

VA has had for a very, very long time, have you looked at what 

major hospitals do, New York University, Mayo Clinic, M.D. Anderson, a little clinic maybe in rural Ohio? Scheduling of patients isn’t 

new, it is not rocket science. Why has it taken so long, cost so 

much? And yet, I will tell you, I have been here just 5 years. Before 

I got sworn in, I got sworn at by the VA people in my Congressional district because I asked them for a list of wait times, because what I heard on the campaign trail was nowhere like what 

they initially provided me. And I challenged them. I said, I don’t 

believe these numbers. You better go back. You better look. And I 

gave them names of people who had told me how long they had to 

wait. Well, then they finally ’fessed up. 

I do not believe that they have ever had the audacity to fudge 

those numbers again because they know I will call them on it. They 

know I stand on those numbers. But why are we reinventing the 

scheduling wheel here? 


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Dr. CROSS. Congresswoman, we are a learning organization. And 

I listened to what Congressman Kennedy said and what you said. 

We will learn from anyone, and we often do reach out to many different organizations, universities that we are affiliated with and 

others. If someone has a better package that will fit within our system to do the vast job that we are asking it to do, we are quite 

open to that. 

Now I will ask my IT colleague to add to mine. I am not an expert on IT. 

Dr. TIBBITS. Well, right. I mean, just from the IT perspective, I 

would say exactly the same thing. We are not wedded to in-house 

development, we are certainly not wedded to the legacy system 

which has inadequate functionality, and we are happy to look at 

cost packages. And so far, we have not identified a cost package. 

We have, by the way, looked at DoD’s experience with commercial 

off-the-shelf packages for scheduling, which was not a happy experience. And we have wound up with the conclusion we wound up, 

that the existing system needs replacement, it needs replacement 

badly, the current foundation is not adequate to build on, and we 

need a new module. 

Ms. BROWN-WAITE. The current system needs replacement badly, 

and so we have been at this now for 10 years? 

Dr. TIBBITS. We have been at the replacement system since May 

of 2001. 

Ms. BROWN-WAITE. That doesn’t equate to quickly, even May of 

2001. 

As I said, this isn’t rocket science. And I appreciate your offer to 

reach out to the private sector, but you can take an off-the-shelf 

program that perhaps M.D. Anderson uses, and it can be modified. 

You can take those modules and you can modify them. 

I don’t understand. Tell me the uniqueness of the VA scheduling 

system unless it relates to that very convoluted description that I 

read earlier today that I don’t want to bore everybody by reading 

again, because it is like, okay, when is it official that appointment 

was requested? Is that what makes it unique? Please help me to 

understand. 

Dr. TIBBITS. Sure. Let me speak to some of that, and then I am 

going to defer to my colleagues who understand the scheduling 

business far better than I do and the policies. But from an IT perspective, when one starts modifying a commercial package, it is a 

disaster, because what happens is modification of a commercial 

package then creates frequently a separate production line, which 

then that industry cannot continue to market commercially, but we 

wind up being a unique customer for that commercial package. 

That winds up being a very expensive proposition, which has proven to be a failure in many implementations of commercial packages 

around the world—around the country. 

Now, what specifically makes VA requirements unique? I am not 

the best person to answer that, but we have veterans categories 

and many of the things that you all are very familiar with that the 

private sector does not have to deal with. 

Ms. BROWN-WAITE. You are talking about a couple of extra boxes 

there on the initial application for an appointment. 


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Mr. Feeley, one quick question, and I would like this in writing 

from the VA. The bill that I referred to that says you either provide 

the healthcare service within 30 days or—really 30 days, by the 

way—or the patient can seek care elsewhere, I would like an official position by the VA on this, a written position. I realize you 

can’t do that now. And you also have a new Secretary coming in. 

But I would like that within—I think maybe the next 30 days 

would be an appropriate response time. I certainly would appreciate it. And I would, with the permission of the Chairman, 

certainly share it with everyone else. And if you would send it to 

Mr. Michaud with a copy to me, I would greatly appreciate that. 

[Congresswoman Brown-Waite sent a letter to VA on December 

13, 2007, requesting additional views for H.R. 92. The request letter and VA’s responses dated July 31, 2008, appear on p. 45.] 

Mr. FEELEY. If I could just comment. I think that we need to 

meet the standard, and we are working very aggressively to meet 

that standard, and my goal is certainly to hope that we do. So we 

are continuing to monitor and measure on a biweekly basis. And 

I think the bill has elements of reasonableness if we can’t meet the 

standard. But we will get the written position of the Secretary. 

Ms. BROWN-WAITE. I appreciate that. Thank you. And I yield 

back. 

Mr. MICHAUD. Thank you. 

Once again, I would like to thank you, Dr. Cross and Dr. Tibbits, 

for your testimony and for the accompanying panelists. I look forward to working with you as we move forward to deal with the 

wait time issue. And we can’t emphasize enough that this is extremely important because there are individuals out there who 

serve this great Nation of ours that need the service. They need it 

in a timely manner, and unfortunately, as we heard from the full 

Committee this morning, if they do not get that service, unfortunately some do ultimately commit suicide. 

So this is an extremely important issue. I look forward to working with each and every one of you as we move forward to improve 

on what the VA currently does. And once again, thank you very 

much, and the hearing is adjourned. 

[Whereupon, at 4:30 p.m., the Subcommittees were adjourned.] 


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A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud, 

Chairman, Subcommittee on Health 

This Joint Hearing on VA Outpatient Waiting Times will come to order. 

Good afternoon. I would like to thank everyone for coming to today’s hearing. 

The focus of this hearing is waiting times for outpatient appointments in the Veterans Health Administration. Outpatient waiting times are one aspect of a much 

broader focus of the Subcommittee on Health—access to high-quality healthcare. 

Access to healthcare is defined as the ability to get medical care in a timely manner when needed. 

We know that access to healthcare is important for veterans. It improves treatment outcomes and quality of life for those who have it. 

Since the beginning of the 110th Congress, the Subcommittee on Health has 

taken broad action to increase veterans’ access to healthcare. 

In May 2007, the House passed H.R. 612 which extends the period of eligibility 

for VA healthcare for veterans of Operations Enduring and Iraqi Freedom from 2 

to 5 years. 

Also in May, the House passed H.R. 2199 which develops programs aimed to improve access to care for veterans with Traumatic Brain Injury. 

And in July of this year, the House passed H.R. 2874 which among other things, 

provides therapeutic readjustment and rehabilitation services to veterans, provides 

improved transportation to rural veterans, and improves and enhances services to 

homeless veterans. 

I am very proud of our accomplishments so far this year and I feel that we have 

come a long way in improving healthcare for veterans. But we still have more work 

to do. 

Today, I hope that we will learn more about how the VA is doing in seeing patients in a timely manner for initial and necessary follow-up appointments, and how 

VA tracks this information. 

I would also like to learn how VA is managing patient care to provide necessary 

preventative medicine. 

In a system that handles 40 million outpatient appointments per year, it is clear 

that efficient and effective policy, training and follow-up is critical in achieving success. 

I hope that we can use this time to work toward solutions so that we can all 

achieve our primary goal to improve access to healthcare for all veterans. I am confident that by working together, we will be successful. 

Timely access to quality healthcare is something that those who have served our 

country have earned. We must work together to provide it for them. 

f 

Prepared Statement of Hon. Harry E. Mitchell, 

Chairman, Subcommittee on Oversight and Investigations 

Yet, our veterans can only take advantage of this healthcare if they can get the 

appointments they need to access it. Unfortunately, too many of our troops are returning home and encountering long waiting times. 

When I was back in the district last weekend, I met with a group of Arizona veterans. Many of these veterans expressed concerns about the long waiting times they 

have encountered to get doctors appointments. 

One local veteran, John Tymczyszyn, tried to make an appointment for treatment 

for a service-related injury he suffered. John requested this appointment in December 2006, and his appointment was scheduled in late May 2007—six months after 

his initial request. John told me that he continued to struggle to make appointVerDate Aug 31 2005 02:26 Oct 04, 2008 Jkt 039648 PO 00000 Frm 00033 Fmt 6604 Sfmt 6621 E:\HR\OC\39648.XXX 39648

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ments within the VHA and because of that difficulty he now relies on civilian providers for his healthcare. 

This is unacceptable. 

When we’ve tried to look into the problem and see what we can do to address it, 

we have been unable to secure verifiable documentation of waiting times. 

According to a recent audit by the Department of Veterans’ Affairs Inspector General, the wait times reported by the VHA are both understated and incomplete. 

The VA reported in the Department of Veteran Affairs Fiscal Year 2006 Performance and Accountability Report in November 2006 that 95% of veterans seeking 

specialty medical care were scheduled for appointments within the required 30-day 

period. 

However, the IG audit found sufficient evidence to support that only about 75% 

of veterans had been seen within 30 days of the requested appointment date. 

Furthermore, the IG audit found that schedulers are ‘‘not following established 

procedures for making and recording medical appointments.’’ This means that we 

don’t even have a clear picture of how many veterans have requested appointments. 

VHA schedulers are supposed to act on a veteran’s request within seven days. If 

this appointment cannot be made within the required 30 days, the scheduler should 

place the veteran’s request on an electronic waiting list. 

However, the IG found that a majority of schedulers are not trained to use this 

system so they don’t use the electronic waiting lists. 

But perhaps most alarming are reports that schedulers have been instructed to 

reduce waiting times by not putting patients on the electronic waiting list. This attempt to reduce cases of long wait times could lead to ‘‘gaming’’ of the scheduling 

process. 

The VA has discounted the IG’s report because it disagrees with how wait times 

were calculated. This is unacceptable. 

I’m not willing to walk away from this audit over a disagreement about methodology. This is a real problem that we must look into. 

When our veterans encounter long waiting times, their conditions go undiagnosed 

and serious disease go untreated. This is no way to treat those who have honorably 

served our country. 

Furthermore, until we have a clearer picture about waiting times, the VA can’t 

improve the situation because we can’t identify problem facilities or effectively allocate resources. 

It is time for us to do the right thing for our veterans and stop hiding behind 

unsupported claims that these servicemen don’t encounter long waits for doctors’ appointments. 

I look forward to hearing from our witnesses. 

f 

Prepared Statement of Hon. Ginny Brown-Waite, Ranking Republican 

Member, Subcommittee on Oversight and Investigations 

Mr. Chairman, 

I thank you and Ranking Member Miller, along with the rest of the Members of 

the Subcommittee on Health for joining us in this important hearing on outpatient 

waiting times at the Department of Veterans Affairs. 

As of October 2007, there were 7.9 million veterans enrolled in the VA healthcare 

system. 

And today there are 153 VA Medical Centers and 724 Community-Based Outpatient Clinics (CBOCs) available to serve the needs of these veterans. 

When a veteran or physician calls to schedule an appointment in one of these clinics, they should be able to receive an appointment that is timely and appropriate 

to the medical needs of the veteran. 

I am looking forward to hearing from our first panel of witnesses today on how 

they feel outpatient waiting times at the VA has affected them, as well as any possible solutions they can offer. 

I am also interested in hearing from the VA Office of the Inspector General on 

their perspective on the waiting times issue. 

Finally, I expect to hear from the VA as to how they monitor waiting times, and 

what steps they are taking to improve the timeliness of services provided to our veterans. 

On January 4, 2007, I introduced H.R. 92, the Veterans Timely Access to Health 

Care Act, which would make the standard for a veteran seeking primary care from 

the Department of Veterans Affairs 30 days from the date the veteran contacts the 

Department. 


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Unfortunately, this bill is needed because current practices do not meet that goal. 

I monitor data for VISN 8 from the Department of Veterans Affairs to determine 

the time new patients and existing patients wait to receive an appointment. 

While established patients wait less than 15 days for an appointment, the numbers for new patients are much higher. 

What I also found interesting in looking over the data is that there appeared to 

be a decrease in the waiting times at the major medical facilities; however, at the 

CBOC level, waiting times have increased. 

In the 3rd quarter of FY 2007, new patients had to wait an average of 45–50 days 

to receive an appointment at a VA CBOC, while new patients waited an average 

of 22–25 days to receive an appointment at the VA Medical Centers. 

This is simply not acceptable. 

I am also curious as to the dramatic decrease in waiting times at the VA Medical 

Centers in VISN 8. 

I question whether patients are being redirected to the CBOCs to reduce waiting 

times at the medical centers. 

If veterans are having problems receiving care within 30 days, then Congress 

needs to allow them to look for an alternative. 

My bill is NOT a scheme to move the VA toward privatization; it simply ensures 

veterans receive care in a timely manner. 

VA can and does provide a high level of care to all the veterans that are enrolled 

in the system; however, if a veteran cannot be seen by a physician then what good 

does that do? 

The Department of Veterans Affairs’ Web site states that the goal of the VA is 

‘‘to provide excellence in patient care, veterans’ benefits and customer satisfaction.’’ 

This hearing today is to determine whether the VA is meeting that goal with 

timely access to care. 

As everyone here knows, this issue is tremendously important to every American. 

Our veterans did not wait to answer the call to duty. 

They answered their Nation’s call, and took up arms to protect our freedom. 

They served and many returned to us injured and in need of care. 

I talk with the veterans from my district on a daily basis about the issues they 

have with the VA, and getting in to see a doctor in a timely fashion is at the top 

of their list. 

And the care of our Nation’s veterans should not be a political issue. 

Instead, Congress should work together to improve veterans healthcare so that it 

becomes the model of good governance. 

Thank you again, Mr. Chairman, and I yield back the balance of my time. 

f 

Prepared Statement of Mary C. Jones, Licking County Veterans’ Service 

Officer, Licking County Veterans’ Service Commission, Newark, OH 

Mr. Chairman and Members of the Subcommittee: 

Thank you for providing me with the opportunity to testify regarding the important issue of outpatient waiting times. 

I have worked as a County Veterans Service Officer for the past 12 years and in 

that capacity have had an opportunity to enjoy a great relationship with the staff 

at both the Columbus VA Outpatient Clinic and the Newark Community-Based Outpatient Clinic and feel privileged to be able to have this relationship. I use the VA 

Healthcare system as my primary provider of medical care for my service-connected 

conditions. My concern with outpatient waiting times is our inability to get veterans 

into an appointment in a timely manner. Their appointments are scheduled so far 

out (often two to three months) that their condition worsens and they are left angry 

and frustrated at a system that is supposed to be in place to care for those who 

have given so much to our great Nation. 

As examples of the problems created by these wait times I offer to you some experiences from our office. We see many veterans shortly after their return home. They 

have been promised dental care within 90 days from their discharge. One veteran’s 

first available appointment was scheduled for almost 90 days from the date of request. When he got to the dental clinic he was told that his appointment needed 

to be canceled and re-scheduled. They did not have any appointments available 

within the 90-day period that he was entitled to dental care and therefore he was 

not seen. 

Female veterans have unique healthcare concerns and face difficult wait times to 

be seen by gynecologists—often as long as six to eight months. Please keep in mind 

that most of the women that we are working with do not have other viable options 


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for healthcare. Many are war time veterans on a nonservice-connected pension and 

are therefore very low income. They are unable to get Medicaid treatment for preventative or diagnostic medical care. Pap tests and mammograms are increasingly 

important as we get older and are often life-saving diagnostic tools, but waiting as 

long as six months for the initial exam and then often even longer to get the test 

scheduled can lead to greater problems if a cancer exists. 

I mentioned earlier that I am a service-connected veteran and that I use the VA 

outpatient clinic myself. I was having health concerns and tried to schedule an appointment with my physician and was told the earliest appointment I could get was 

in six months. Because I am a county employee and have medical insurance through 

my employment, I was able to see a doctor outside of the VA system within three 

weeks and ended up needing major medication changes and a heart catheterization. 

I hate to think what would have happened to the veteran who had no other options. 

We are now filing many claims for post traumatic stress disorder (PTSD). Usually 

when we file a claim we have a veteran who has a diagnosis for a condition, but 

PTSD is different. Most veterans can get into the VA to see a social worker and 

can get assigned to group counseling fairly quickly. Most can see a psychiatrist 

within three to four months for an initial exam, but within the 12 to 18 months 

that a service-connected claim takes to adjudicate, the veteran is still left without 

a diagnosis for PTSD because the wait times prohibit the doctor from seeing the patient often enough to provide a definitive diagnosis of any mental health issue. Because no diagnosis exists, the VBA must deny the claim for service connection. Seeing private psychologists and psychiatrists are beyond the financial reach of most 

veterans. 

My most memorable experience is a WWII veteran who was in receipt of a nonservice-connected pension. He was diagnosed with prostate cancer through a PSA 

test done by his primary care physician. Treatment was scheduled, but the wait 

time was several months. In the meantime this gentle man very clearly understood 

that he would not survive due to the fact that his cancer had spread and was continuing to spread during this wait. The treatment would only have prolonged his 

life and probably not saved his life, but this would have been an excellent opportunity to send a positive message of support from the government to this WWII veteran, and that opportunity was missed. He died before his appointment with an 

oncologist. 

This has been an honor for me to have an opportunity to bring examples of the 

difficulties experienced by the veterans that I serve caused by the long wait times 

to be seen at the clinics. I did not come to criticize the VA, because the care given 

by our outpatient clinic is excellent, but at this time that care comes at a price and 

that price is patience. 

Mr. Chairman, this concludes my testimony. 

f 

Prepared Statement of Kevin P. McCarthy, 

President and Chief Executive Officer, Unum US, Portland, ME 

Mr. Chairman, Members of the Committee, I’d like to thank you for the opportunity to testify before you. My name is Kevin McCarthy and I am the President 

of Unum US. Unum is a subsidiary of Unum Corporation. 

Unum’s involvement was generated by our CEO (a graduate of Virginia Military 

Institute) wanting to explore how the company could assist with sharing its best 

practices that might be useful in a new world, ‘‘post-Walter Reed.’’ Since that time, 

Representative Michaud has visited Unum and viewed firsthand how the combination of our people and technology are integrated together in a way that reduces 

delays in every aspect of claim processing/case management. As a result of this visit 

and our meetings this summer and fall with House and Senate Congressional staff, 

the Veterans Affairs Administration and the Department of Defense on sharing best 

practices between the private sector and the public sector, I am here today to discuss how we use these smart systems and people not only to reduce waiting times 

for setting up independent medical examinations or assisting a claimant’s medical 

team in developing a treatment plan specific to that individual, but also how these 

are aspects of a larger integrated case management/claim management approach 

that includes everything from regular contact with our insureds so they know what 

is happening ‘‘real time’’ on their claim to assisting them with vocational rehabilitation. This integrated approach actually speeds up not only actions like wait times 

on individual, specific issues, but the entire claim/case management process. We 

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tween the public and private sectors as you continue to evaluate the disability adjudication/case management processes at the VA. 

Corporate Overview 

Unum is a company of people serving people. As one of the world’s leading employee benefits providers, Unum helps protect more than 21 million working people 

and their families in the event of illness or injury. 

We provide more than a benefit check to customers—we provide a wide range of 

benefits and services designed to help people during what is often the most trying 

time of their lives—loss of income due to illness or injury. 

For 30 years Unum has been an industry leader in providing income protection 

and employee benefits. Unum is ranked #1 in long-term disability income protection, 

#1 in short-term disability income protection, #1 in individual income protection, 

and #1 in group long-term care insurance. We are also among the market leaders 

in group life insurance and supplemental benefits. We provide leave management 

administration services, health and productivity services and a work-life balance 

program with health risk assessments. 

In 2006, we serviced more than 420,000 newly filed claims (disability products, 

long-term care, and voluntary benefits) and replaced $4 billion in lost income to help 

provide support to our insureds and their families. These benefits are paid directly 

to our insureds. To our knowledge, this is more than any other private income protection provider in the world. 

Our customers expect that their claims will be paid promptly and accurately. In 

order to ensure we get it right the first time, we carefully measure customer satisfaction. In fact, 9 out of 10 are satisfied with the handling of their claim. In addition, 97% of the businesses we insure give us high marks. 

Our ability to pay our customers billions of dollars annually with these high levels 

of satisfaction is due to our highly trained people, coupled with the right technology. 

The substance of my testimony will be focused on how we track, manage and pay 

the more than 400,000 claims we receive each year with high levels of customer satisfaction. 

Our people and tracking systems ensure we stay in close touch with our customers as we take the steps necessary to enable us to pay their claims. Our physicians and claims payers work closely with the insureds’ medical providers to, for example, schedule medical examinations, set up calls so our doctors can speak directly 

with the insureds’ doctors and establish that they are receiving regular care and 

treatment. 

How do we keep our promises? 

By employing: 

• experienced people and leading technology; 

• a claims management approach that applies the most accurate resources to 

each claim; 

• best-in-class decision making supported by expert systems and resources with 

an emphasis on quality and tracking. 

Customer Service and the Disability Management Process 

While a person’s disability can be a complex, ongoing and ever-changing life event, 

our goal is to make the claim payment process simple and transparent for our customers during this trying time in their lives. 

We make it easy to submit a claim. It can be done by Internet, telephone, fax or 

mail. 

At any time after the claim has been submitted, our customers can speak with 

a skilled person. We handle more than 4.5 million calls a year. Eighty percent of 

calls are answered within 20 seconds and 85 percent are managed without holding 

or transferring. It is a combination of selecting talent with the right skills, developing quality training programs, and employing the right technology that enables 

us to handle these high volumes with just 300 employees. 

While our goal is to make it easy for customers to reach us, we also understand 

that many need our help. 

Thus, we regularly reach out to our insureds and their healthcare teams. We view 

it as critically important to speak with our insureds and their physicians and we 

frequently help them follow up with their doctors. 

We are able to do this because we have invested in an innovative technological 

process which sorts claims by complexity and severity—this technology is supported 

by hundreds of highly trained Benefits Specialists, physicians, nurses and vocational 

rehabilitation consultants. Again, it is this unique combination of people and technology that enables us to fully understand and respond to our customers’ needs. 


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The Benefit Specialists help the claimants keep everything on track—the Benefits 

Specialists essentially ‘‘case manage’’ the claims. For example, they set up medical 

exams, help insureds with vocational rehabilitation, assist our customers in obtaining Social Security once we have determined that they may be eligible, and ensure 

that the relevant medical records have been received by Unum for a full, fair and 

thorough evaluation. 

Our technology provides a single point of coordination which enables the team to 

efficiently: 

• manage workloads; • make appointments; • review all claim documents; • schedule follow-up appointments, calls, letters and medical exams; and • provide real-time management access and quality assurance review. 

This technology involves an imaging system so all the claims are paperless and 

can be viewed across multiple locations at the same time. This allows us to tap into 

expertise in other locations while also enabling easy communication between team 

members, even if they are not located in the same office. It also allows real-time 

claim assessment and processing. Finally, it ensures a consistent claim history, 

claim documentation, medical records and correspondence. 

The technology also includes an automated scheduling system so claim management activities—such as calling doctors’ offices and setting up independent medical 

exams—are done accurately and promptly. 

Each one of the activities the Benefit Specialist does is scheduled and tracked to 

ensure that the right resources are applied to the right claims at the right time. 

In fact, the technology gives us the ability to determine whether appointments are 

being kept, calls are being made and whether there are delays in the claim processing. 

The claim status is also viewable on the web so our customers can see their claim 

status ‘‘real-time.’’ Privacy protections are in place. 

Unum’s goal is to make a determination within 3–5 days on 95% of short duration 

claims and within 45 days on longer term, more complex claims. 

In regard to the specifics of the management process, when a claim is received 

it undergoes an initial claim review. During this phase the following steps occur: 

• we verify eligibility; • we evaluate the claimant’s functional ability; • we work in partnership with the insured’s employer to assess the physical and 

cognitive occupational demands; • we partner with the employer to determine any possible accommodations that 

could be made so the person can return to work; and • the Benefit Specialist partners with in-house medical, vocational and management resources as needed. 

The more complex claims are sent electronically to Benefits Specialists and medical professionals who specialize in certain types of claims—allowing efficient, high 

quality, customer focused handling. For these claims, each customer is called and 

we set up an individual follow-up action plan with the insured based on the dynamics of the specific medical condition. The claims process looks at the whole person, 

not just the diagnosis. We provide information and motivation to the claimant and 

the employer and work in collaboration to find the most appropriate resolution to 

the claim. The claimant’s level of function is assessed, medical records and the 

treatment plan are obtained, and activities of daily living are determined. We then 

work with the insured on a return to work plan. A specific claim example may be 

a behavioral health claim that is based on ICD9 (‘‘International Coding of 

Diagnostics 9’’—a standardized Medical Diagnosis system where each diagnosis is 

assigned a code, i.e. The ‘‘ICD9 code’’) code and is sent to a Benefits Specialist with 

a specific skill set. That Benefit Specialist would review the claim on our imagebased system. Based on the specific facts of the file, the Benefit Specialist could: 

call the claimant, obtain medical records, schedule an independent medical examination if necessary, call the claimant’s doctor or set up a meeting between one of 

our doctors and the claimant’s medical team to establish a treatment plan or gather 

outstanding information. The system could be set up to automatically remind our 

claims payer, nurse or doctor to call the claimant and see whether the appointment 

was kept or the agreed upon treatment plan was being followed. Based on the specific diagnosis, the system can automatically generate follow-up activities to ensure 

that our team is in regular contact with the insured and his or her medical team. 

As the insured’s condition improves or otherwise changes, we can continuously adjust our actions to make sure that the insured is getting the treatment, care and 


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claim management that will enable us to assess the individual’s condition ‘‘realtime.’’ 

During the assessment and review process, the Benefits Specialist partners with 

the insured’s medical team as well as with our internal doctors, nurses and vocational rehabilitation staff to: 

• assess the duration of the claim; 

• provide rapid resolution to medical issues; and 

• assist with helping the claimant return to work. 

In addition to medical and vocational professionals, the Benefits Specialist has access to a wide variety of experts who can help with Social Security advocacy, 

wellness and disease management, an employee assistance program and return-towork consulting. 

Quality Assurance 

The investment in the people and technology has given us the ability to easily 

measure and carry out all of the actions we schedule during the claim process. 

From a Quality Assurance perspective, it gives us the ability to roll up the information in many ways. For example, we know whether appointments are being kept 

as we stay in close touch with the claimants and their doctors. 

Behind the tracking systems, our robust quality assurance and continuous improvement programs also help: 

• maintain a strong, customer-based focus; 

• manage workloads for each of our claims specialists, nurses, doctors, and vocational rehabilitation specialists; 

• facilitate an audit of claim decisions, both real-time and post-claim; 

• support an appeal process with feedback; and 

• allow for management review, involvement and reporting. 

In conclusion, we would be more than happy to assist you in any way. You have 

an open invitation to visit Unum. We would welcome the opportunity to continue 

to share knowledge of our capabilities, systems and expertise. Thank you for the opportunity to testify before the Committee. 

f 

Prepared Statement of Belinda J. Finn, Assistant Inspector General for 

Auditing, Office of Inspector General, U.S. Department of Veterans Affairs 

INTRODUCTION 

Mr. Chairmen and Members of the Subcommittees, I am pleased to be here to address the Office of Inspector General’s (OIG) findings related to the Veterans Health 

Administration’s (VHA) reported waiting times for outpatient appointments. I am 

accompanied by Larry Reinkemeyer, Director of the Kansas City Audit Operations 

Division, who directed the teams responsible for the audits we performed. Our audit 

coverage on outpatient waiting times and waiting lists consists of two reports. I will 

discuss both reports today in order to provide a more complete assessment of the 

problems we identified and the current status of actions by VHA to improve outpatient waiting times. 

In July 2005 we issued Audit of the Veterans Health Administration’s Outpatient 

Scheduling Procedures (Report No. 04–02887) and concluded that schedulers were 

not following outpatient scheduling procedures, resulting in inaccurate waiting 

times and incomplete waiting lists. As a followup to the 2005 report, we issued 

Audit of the Veterans Health Administration’s Outpatient Waiting Times (Report 

No. 07–00616–199) in September 2007. We again concluded that schedulers were 

not following established procedures for making outpatient appointments, causing 

VHA’s reported performance on waiting times and waiting lists to be unreliable for 

Congressional and VA decisionmaking. 

OIG IDENTIFIES DATA INTEGRITY PROBLEMS IMPACTING THE RELIABILITY OF VHA’S WAITING TIMES INFORMATION 

In FY 2005, at the request of the Secretary of Veterans Affairs, we audited VHA’s 

compliance with outpatient scheduling procedures to determine the accuracy of the 

reported veterans’ waiting times and facility waiting lists. Our objectives were to determine whether schedulers followed established procedures when selecting the type 

of appointment and entering the desired appointment date into the Veterans Health 

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tiveness of the procedures used at VHA medical facilities to ensure all veterans either had appointments or were identified on electronic waiting lists. 

Our 2005 audit work analyzed a statistical sample of 1,104 appointments from a 

universe of 38,786 appointments at 8 medical centers. We reviewed scheduling data 

and medical records to determine when the appointments were scheduled, how the 

schedulers created the appointments, and whether the schedulers used the correct 

desired dates when creating the appointments. We also reviewed each appointment 

to determine whether the veteran qualified for the electronic waiting list and if 

service-connected veterans received appointments within 30 days. In addition, we 

gathered information from 15,750 (53 percent) of the 29,818 schedulers nationwide 

on their training, experience, adequacy of supervision, and scheduling practices 

through a national survey. We also interviewed 247 schedulers at the 8 medical facilities visited during the audit. 

VHA calculates outpatient waiting time for each appointment from the desired 

date of care recorded in the VistA scheduling software to the actual appointment 

date. The desired date of care is defined as the earliest date that the patient or clinician specifies the patient needs to be seen. In addition, VHA policy establishes a 

goal of scheduling appointments within 30 days of the desired appointment but not 

more than 4 months beyond the desired appointment date. When a specific appointment date is not requested, VHA policy requires the scheduler to use the next available appointment. VHA policy requires that all appointment requests, including consult referrals to a specialist, must be acted on by the medical facility within 7 days. 

Acting on the request involves either scheduling the requested care or placing the 

patient on the electronic waiting list. The electronic waiting list is a standard tool 

that VHA implemented in December 2002 to capture and track information about 

veterans waiting for clinic appointments in VHA medical facilities. 

Our 2005 results showed that outpatient scheduling procedures needed to be improved to ensure accurate and reliable reporting of veterans’ waiting times and facility waiting lists. Because schedulers did not follow established procedures, medical 

facility directors were unaware that 18 percent of the service-connected veterans in 

our sample waited more than 30 days for their appointment. We projected that over 

2,000 service-connected veterans waited longer than 30 days from their desired date 

to see a physician at these 8 medical facilities. Nationwide, as many as 24,463 service-connected veterans could have been similarly impacted. Inaccurate waiting time 

data and waiting lists can compromise VHA’s ability to assess and manage demand 

for medical care. VHA managers plan budget priorities, measure organizational and 

individual medical center directors’ performance, and determine whether strategic 

goals are met, in part, by reviewing data on waiting times and lists. 

We found that schedulers created appointments using the wrong appointment 

type for 380 (34 percent) of the 1,104 appointments and the wrong desired date for 

457 (41 percent) of the 1,104 appointments in our sample. When scheduling an outpatient appointment, schedulers are asked if the appointment should be considered 

as ‘‘next available.’’ If the scheduler answers yes to this question, then the system 

enters that date as the desired date of care by default. If the scheduler answers 

no to the question, then the scheduler must input a desired date of care. In 2005, 

VHA strived to schedule at least 90 percent of all next available appointments for 

veterans within 30 days. Our results showed, however, that 65 percent of the next 

available appointments were scheduled within 30 days—well below the VHA goal 

of 90 percent and the medical facilities directors’ reported accomplishment of 81 percent. 

VHA medical facilities did not have effective procedures to ensure all veterans 

were identified on the electronic waiting lists. In fact, our testing showed that 5 

medical facilities understated their waiting list by 856 veterans. Nationwide, the 

electronic waiting lists could be understated by as many as 10,301 veterans. We also 

identified clinics with substantial backlogs of consult referrals where veterans did 

not have appointments within 7 business days, and those veterans were not included on the electronic waiting lists. Further, 17 percent of the 247 schedulers 

interviewed told us they maintained informal waiting lists of veterans who needed 

appointments. 

VHA did not have a standardized training program for schedulers so schedulers 

were receiving most of their training as on-the-job training. This led to inconsistencies implementing the scheduling procedures and directly contributed to the errors we identified. Forty-five percent of schedulers responding to our survey reported that they had received no formal training on the use of the VistA scheduling 

module, and 81 percent responded that they had received no training on the use 

of the electronic waiting list. Further, 2,246 (68 percent) of the 3,298 schedulers who 

identified themselves as trainers in our nationwide survey, did not know how to correctly create an appointment for a veteran who wanted an appointment as soon as 


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possible but who did not need urgent or emergency care. Seven percent of schedulers said that managers or supervisors directed or encouraged them to schedule appointments contrary to established procedures. Sixteen percent of the schedulers reported that they maintained informal waiting lists. 

We recommended that the Under Secretary for Health take the following actions 

to improve outpatient scheduling procedures and the data integrity of waiting time 

information: 

• Ensure that medical facility managers require schedulers to create appointments following established procedures. 

• Monitor the schedulers’ use of correct procedures when creating appointments. 

• Monitor consult referrals to ensure that all veterans with referrals either have 

scheduled appointments within 7 business days or are included on electronic 

waiting lists. 

• Establish an automated link from the Computerized Patient Record System consult package to the Vista scheduling module. 

• Ensure medical facilities prohibit the use of informal waiting lists. 

• Develop a standard training package for medical facilities to train schedulers 

on electronic waiting list and VistA scheduling modules. 

• Ensure all schedulers view the video training titled ‘‘Vista Scheduling Software: 

Making a Difference.’’ 

• Require all schedulers to receive annual training on the electronic waiting list 

and VistA scheduling module. 

The Under Secretary for Health agreed with the findings and recommendations 

to make the needed improvements in outpatient scheduling. According to the Under 

Secretary, VHA was vigorously addressing problems with waiting times and scheduling delays, and they had taken steps to accurately quantify the numbers of patients on waiting lists, lengths of waits, and the reasons for the scheduling delays. 

The Under Secretary also stated that VHA’s Advanced Clinic Access (ACA) initiative, in conjunction with other planned and ongoing improvements, was expected to 

result in needed scheduling enhancements that are consistently applied to all VHA 

medical facilities. While we did not evaluate the implementation of the ACA initiative, our 2005 results showed that the schedulers’ use of incorrect procedures distorted the reported measurement of veterans’ waiting times and facility waiting 

lists, regardless of whether the clinic had implemented ACA. 

In response to our 2005 report, VHA issued new policy, Directive 2006–055, on 

October 11, 2006, for implementing processes and procedures for the scheduling of 

outpatient appointments and for ensuring the competency of staff involved in any 

or all components of the scheduling process. VHA’s directive also addressed the VA 

medical facilities’ responsibilities relating to recall, reminder systems, and other 

forms of patient-driven scheduling, noting that facilities must ensure that the patient entitled to priority access is given an appointment in 30 days and all others 

within 120 days. The facility retains principal responsibility for providing the patient an appointment to be seen within the appropriate timeframes. VHA policy further extends the facility’s responsibility to call and/or send a reminder letter and 

to make available a scheduled appointment for the patient to be seen within 30 days 

of the originally specified desired date for patients entitled to priority access or 120 

days for all others. 

OIG FOLLOWUP REVIEW SHOWS VHA’S OUTPATIENT WAITING TIMES 

INFORMATION STILL HAS DATA INTEGRITY PROBLEMS 

In November 2006, we received a Congressional request to follow up on the patient waiting times issue to determine if VHA had improved their practices and procedures related to outpatient scheduling. The objectives of our review, completed in 

2007, were essentially the same as our 2005 review, except that we also assessed 

whether the 2005 audit report recommendations were fully implemented. 

During our followup review, we determined whether established scheduling procedures were followed, outpatient waiting times reported by VHA were accurate, and 

electronic waiting lists were complete. We visited 10 medical facilities, testing 700 

appointments. A key point of our methodology was that we reviewed appointments 

that VHA had reported as being completed in 30 days. We also tested 300 consult 

referrals to assess the accuracy of the consult tracking report because medical facility personnel said that clinic personnel did not always update the report after action 

was taken. VHA includes and relies upon this same information in its performance 

and accountability reporting measure. At the time of our review, these 10 facilities 

listed over 70,000 consult referrals that were over 7 days old on the consult tracking 

reports. 


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The review showed that many of the data integrity weaknesses reported in 2005 

were still impacting the reliability of patient waiting times and that schedulers were 

not following established procedures for making or recording medical appointments. 

We concluded that the accuracy of VHA’s reported waiting times could not be relied 

on and the electronic waiting lists at the 10 medical facilities were not complete. 

In reviewing each appointment, we researched the medical records to find out 

when the referring medical provider had recommended that the patient receive an 

appointment and compared the recommended date of care to the actual appointment. We found unexplained differences between the desired dates as shown in the 

scheduling system and used by VHA to calculate and report waiting times, as compared to the desired dates recommended by the medical provider and indicated in 

the patients’ related medical records. In a few appointments, schedulers had annotated the appointment records to indicate when a patient requested a specific date 

and we used that date to calculate the waiting time. Our review also found instances where medical providers had suggested a range of time, such as 4 to 6 

months, instead of a specific date for care. In those cases, we followed the guidance 

in VHA’s scheduling directives and used the earliest point of the time range as the 

desired date of care. 

Our review of 700 appointments provided us with reasonable assurance to conclude that schedulers were not recording either accurate, complete, or in some cases 

any information to support the desired date of care used to compute the reported 

waiting time. Overall, we found evidence to support that only 524 (75 percent) of 

the 700 appointments that VHA reported as having completed within 30 days actually were. The 700 appointments that had occurred within 30 days included 78 percent of the primary care appointments and 73 percent of specialty care appointments. As a result, VHA’s reported waiting times are not based on accurate and 

complete information. For example, on December 20, 2005, a veteran who was 50 

percent service-connected was seen in an Eye Clinic. The provider wrote in the 

progress note that the veteran should return to the clinic in 6 weeks (January 31, 

2006). On September 6, the scheduler created an appointment for the veteran on 

October 17. The scheduler entered a desired date of October 2, which resulted in 

a reported waiting time of 15 days. However, based on the provider’s desired date 

of January 31, the veteran actually waited 259 days for his appointment. The scheduling records did not contain any explanation for the delay. Medical facility personnel told us the reason this appointment took so long to schedule was because 

it ‘‘fell through the cracks.’’ 

In order to validate our results at each medical facility, we provided our case review findings to the local medical facility personnel responsible for scheduling. In 

response, our findings were validated as being accurate and supportable. Concern 

over our methodology did not become an issue until the draft report was presented 

to VHA senior management. VHA nonconcurred with this finding and told us that 

even though schedulers did not document it, the unexplained differences between 

the date recommended by the medical provider and the date shown in the scheduling system can be attributed to patient preferences for a specific appointment 

date. VHA directives require schedulers to annotate appointment records to indicate 

patient requests for specific appointment dates. VHA personnel told us that schedulers often do not document patient preferences due to high workload; and that this 

documentation only serves to support audit requirements. We contend that this 

basic annotation is critical to the integrity of reported waiting times information. 

To accept an assumption that every patient requested a desired date different than 

the documented desired date shown in the medical records would be irresponsible 

and contrary to VHA’s own directives. We would agree that some of the date differences we identified in appointment information could possibly be due to patient 

preferences that were not documented by schedulers. However, in the absence of 

specific information, neither we nor VHA can be sure whether patient preference or 

the scheduler’s use of inappropriate scheduling procedures contributed to the 25 percent error rate we found. 

VHA’S ELECTRONIC WAITING LISTS CONTINUE TO BE INCOMPLETE 

VHA’s policy prohibits schedulers from making appointments for veterans that exceed the 30- or 120-day requirement and the policy requires that those veterans be 

placed on the electronic waiting list immediately. Our review identified 64 veterans 

(9 percent of the total appointments reviewed) who should have been on the 30-day 

electronic waiting list and were not. 

Additionally, VHA’s consult tracking report identified over 70,000 veterans with 

consult referrals over 7 days old that—in accordance with VHA policy—should have 

been on the waiting list of the 10 facilities we reviewed. Our review of 300 consult 

referrals found that 183 (61 percent) of the associated veterans should have been 


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on the waiting list and more than half of those had been waiting more than 30 days. 

The remaining referrals had already been acted on, but facility personnel had not 

updated the records to reflect the true status (for example, completed or discontinued). The lack of action on consults may lead to situations such as the following 

one highlighted in our 2007 report: 

• On April 18, 2006, a veteran who was 80 percent service-connected, including 

service-connected for hearing impairment, was referred to the Audiology Clinic. 

Because this was a consult referral, the veteran should have received the next 

available appointment. On September 20 (155 days after the referral), the 

scheduler created an appointment for the veteran for October 20 and entered 

the desired date of September 20, which resulted in a reported waiting time of 

30 days. However, based on the provider’s desired date of April 18, the veteran 

actually waited 185 days for his appointment. The scheduling records did not 

contain any explanation for the delay. Medical facility personnel agreed with 

our recalculated waiting time. 

At the time of our review, the 10 facilities had reported only 2,600 veterans on 

the waiting list. In 2007, we found that schedulers at some facilities interpreted 

guidance from their managers to reduce waiting times as instructions never to put 

patients on the electronic waiting list. This seems to have resulted in some ‘‘gaming’’ 

of the scheduling process. Medical center directors told us their guidance was intended to ensure patients received their appointments timely and did not need to 

be on the electronic waiting lists. 

Low priority for training schedulers continues to affect the accuracy of waiting 

times and completeness of waiting lists. Schedulers and managers told us that, although training is readily available, they were short of staff and did not have time 

to take the training. In 2007, 47 percent of the schedulers we interviewed reported 

they had no training on consults within the last year, and 53 percent had no training on the electronic waiting list within the last year. 

PRIOR OIG RECOMMENDATIONS REMAIN OPEN 

Outpatient waiting times continue to be inaccurate and waiting lists continue to 

be incomplete because management has not yet effectively implemented our recommendations. Almost 3 years later, five of the eight recommendations remain 

open, which included one recommendation that was reopened based on the findings 

in our 2007 report. Specifically, actions taken by VHA with respect to one of the 

previously closed recommendations proved ineffective in monitoring schedulers’ use 

of correct procedures when making appointments. 

We believe that the most important recommendations from our two reports concern the need for VHA management to monitor how schedulers perform and routinely test the accuracy of reported waiting times and completeness of electronic 

waiting lists. In our opinion, these are critical quality assurance steps that are necessary to ensure that the VistA system contains complete and accurate information 

on waiting times. 

In addition to monitoring the accuracy of information, management needs to take 

corrective action when testing shows questionable differences between the desired 

dates of care shown in medical records and those documented in the VistA scheduling package. To date, VHA has not implemented an effective process to routinely 

test the accuracy of reported waiting times and the completeness of electronic waiting lists. 

The findings in our 2005 and 2007 reports demonstrate that the data recorded 

in VistA and used to calculate veteran outpatient waiting times is not reliable. It 

is our position that until VHA establishes procedures to ensure that schedulers comply with policy and document the correct desired dates of care, whether recommended by medical providers or requested by veterans, that calculations of waiting 

times using VHA’s current system will remain inaccurate. 

2007 FOLLOW-UP REVIEW LEADS TO FIVE OIG RECOMMENDATIONS 

Based upon our follow-up work, we recommended that the Under Secretary implement the following recommendations: 

• Establish procedures to routinely test the accuracy of reported waiting times 

and completeness of electronic waiting lists, and take corrective action when 

testing shows questionable differences between the desired dates of care shown 

in medical records and documented in the VistA scheduling package. 

• Ensure schedulers comply with the policy to create appointments within 7 days 

or revert back to calculating the waiting times of new patients based on the desired date of care. 


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• Amend VHA Directive 2006–055 to clarify specialty clinic procedures and requirements for receiving and processing pending and active consults to ensure 

they are acted on in a timely manner and, if not, are placed on the electronic 

waiting lists. 

• Ensure all schedulers receive required annual training. 

• Identify and assess the alternatives to the current process of scheduling appointments and recording and reporting waiting times, and develop a plan to 

implement changes to the current process. 

VHA RESPONSE TO LATEST OIG REPORT AND OIG REBUTTAL 

The Under Secretary for Health agreed that our report correctly identifies areas 

VHA needs to address to improve outpatient waiting times accuracy. The Under 

Secretary acknowledged that our report highlights many of the roadblocks VHA 

faces making improvements in wait times. However, VHA took exception to the findings on the wait times because of their perceived limitations of our review methodology. 

The Under Secretary stated that one of the most valid measurements VHA has 

relating to access efficiency is generated directly from a patient satisfaction survey 

of the veterans seeking healthcare services and noted that 85 percent of the veterans who completed the survey reported that they had access to primary care 

appointments when they needed them, and 81 percent of these same veterans also 

reported satisfaction with timely access to specialty care. 

We see no valid basis for comparison between the results of the patient satisfaction survey and the results of our audit. Further, there is no basis for comparing 

overall patient satisfaction and VA’s compliance with specific policy requirements, 

or the accuracy of waiting time information reported by VHA. We also noted that 

waiting time information reported by VHA was obtained by the same data system 

that the OIG used to conduct the audit, not from the patient satisfaction survey. 

To support any level of comparison, the patient satisfaction survey would have to 

ask veterans whether they were seen in the 30-day requirement. 

In addition, the patient satisfaction results do not support the results VHA reported to Congress in November 2006. VHA reported that 96 percent of all veterans 

seeking primary care and 95 percent seeking specialty care were seen within the 

30-day standard. Only 85 percent of the veterans who responded to the survey reported satisfaction with access to primary care and only 81 percent were satisfied 

with timely access to specialty care. These percentages are closer to the results in 

our audit, which were 78 percent and 73 percent, respectively. Our results are accurate, well-documented, and based on all available VA information. 

We also disagree with the Under Secretary’s statement that during our review we 

did not consider a patient’s preference for a specific date other than what the medical provider requested. We accepted schedulers’ comments on specific date requests 

as evidence of patient preference, but we cannot accept a blanket statement that 

all differences are due to patient preference. Although the Under Secretary stated 

that it is unrealistic to expect schedulers to document patient requests due to workload demands, we noted that scheduling directives contain numerous requirements 

for documentation of patient requests and actions. 

While we recognize that ensuring scheduling information nationwide has its 

challenges, both the 2005 and 2007 OIG reviews showed that schedulers were not 

following VHA’s policies and procedures to record the correct desired date of care. 

Further, the findings in our reports do support the fact that data recorded in VistA 

and used to calculate veteran outpatient waiting times is not reliable. Until VHA 

establishes procedures to ensure that schedulers comply with policy and document 

the correct desired dates of care, whether recommended by medical providers or requested by veterans, calculations of waiting times from the current system will remain inaccurate. 

Our follow-up review results showed that VHA has not taken timely action to implement five of the eight recommendations in our 2005 report, and the Under Secretary for Health, by his own admission said the system information is inaccurate 

in that it does not always document patient preference for a specific date. We find 

it contrary for VHA to state their agreement with the findings and recommendations in our 2005 report and then to disagree with our follow-up report that found 

a continuation of the same problems—problems that could have been resolved had 

VHA implemented the recommendations in our 2005 report. In fact, VHA’s response 

to our 2007 report concedes the failure of scheduling clerks to adequately document 

patient preferences in appointment dates. Both reports demonstrated and supported 

the fact that the system is not accurate and therefore should not be relied on as 

an accurate source for reporting waiting times to Congress. 


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PERFORMANCE AND ACCOUNTABILITY REPORTING 

VA’s FY 2006 Performance and Accountability Report prominently reported that 

96 percent of primary care outpatient appointments and 95 percent of specialty care 

outpatient appointments were scheduled within 30 days. We cannot compare this 

performance measure to the results of our latest audit because we selected appointments from a different timeframe. In FY 2007, VA reported that 97.2 percent of primary care appointments and 95 percent of specialty care appointments were scheduled within 30 days. We took great exception to VA’s reporting of this performance 

measure because our audit clearly showed significant issues with the integrity of 

data being used to formulate these performance measures. Although VA has continued to report these measures, they added a footnote acknowledging our reports. 

CLOSING 

Long-term fixes and changes to the scheduling system may take years to implement; however, in the meantime VHA needs to address the data integrity issues associated with its scheduling system and ensure accuracy in its current system. In 

addition, VHA needs to ensure scheduling procedures are followed and implemented 

consistent with its own policies. It is problematic when VHA continues to report 

waiting time information to Congress that was knowingly derived from a system 

that contains inaccurate and incomplete data. Debating the differences between our 

reported error rate and VHA’s reported waiting times would only serve to overshadow the primary point of both audit reports, which is that the data in VHA’s 

scheduling system is inaccurate. Our concern is that VA and Congress not only have 

accurate and reliable information for budgeting, assessing, and managing the demand for care but, more importantly, for ensuring no veteran falls through the 

cracks and fails to receive timely medical care. 

Mr. Chairmen, that concludes my remarks and thank you once again for the opportunity to discuss this important issue. Mr. Reinkemeyer and I would be pleased 

to answer any questions. 

f 

Prepared Statement of Gerald M. Cross, M.D., FAAFP, 

Principal Deputy Under Secretary for Health, 

Veterans Health Administration, U.S. Department of Veterans Affairs 

Good afternoon Chairman Michaud and Chairman Mitchell and Members of the 

Subcommittees. Thank you for inviting me here today to discuss the issue of outpatient waiting times. Accompanying me today are Mr. William Feeley, Deputy 

Under Secretary for Health for Operations and Management; Ms. Kathy Frisbee, 

Deputy Director of the VHA Support Service Center; and Ms. Odette Levesque, 

Clinical/QA Liaison for the Office of the Deputy Under Secretary for Health for Operations and Management. 

I am pleased to have this opportunity to share with you the current actions the 

Department of Veterans Affairs (VA) is taking to guarantee that our veteran patients have access to timely medical care at our VA facilities. We are making good 

progress in meeting the needs of our veterans and we are committed to providing 

all necessary care, including preventive care, in a timely manner. I just want to be 

clear that we are talking about waiting times for general routine outpatient appointments; veteran patients with urgent or emergent needs are seen immediately. In a 

healthcare system as large as VA, where we provide over one million patient encounters in our clinics each week, we understand there would be opportunities for 

improvement. VA is actively seeking solutions to further reduce wait times as we 

are committed to ensuring the care we provide our veterans is timely as well as 

high quality. 

VA has identified timely access to outpatient care as a top priority. With national 

implementation of the Advanced Clinical Access initiative, we have made significant 

progress in reducing waiting times, but challenges continue. In the patient satisfaction survey for the third quarter year to date for FY 2007, which is administered 

by the National Research Corporation (NRC), 85 percent of veterans surveyed reported they received primary care appointments when they wanted them, and 81 

percent reported that their specialty care appointments were made at a time that 

was acceptable to them. 

In FY 2007, 96 percent of our 40 million appointments were seen within 30 days 

of the desired appointment date. This percentage represents waits for outpatient 

primary and specialty care appointments. It does not, however, reflect waits for outpatient or inpatient procedures such as colonoscopies or joint replacements. VHA is 

also building upon existing measures by actively moving forward with enhanceVerDate Aug 31 2005 02:26 Oct 04, 2008 Jkt 039648 PO 00000 Frm 00045 Fmt 6604 Sfmt 6621 E:\HR\OC\39648.XXX 39648

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ments to the current scheduling package. For example, an enhancement to the current surgery case scheduler is expected to be released nationally during the middle 

of this fiscal year and will better enable us to manage and measure wait times for 

outpatient and inpatient procedures. 

We are improving access for new veterans as well as improving waiting times for 

mental health services and medical procedures. The percent of new primary care patients who were seen within 30 days of their desired date has improved from 75 percent in FY 2005 to 83 percent in FY 2007—and the percent of new primary care 

patients seen within 30 days of their desired date for the month of September 2007, 

was 90 percent. Our statistics are even better for patients seen for follow-up appointments. Finally, we are focusing on mental health access by setting a new 

standard this fiscal year that requires all new mental health patients be seen and 

their needs for care evaluated within 24 hours and that these veterans have a follow-up evaluation within 14 days. With the assistance of Congress, we have increased by 3,600, the number of mental health professionals within our system since 

2005. This includes physicians, psychologists and social workers. 

The conclusions made by VA’s Office of the Inspector General (OIG) in the recent 

September 10, 2007 report on outpatient waiting times differs from the 85 percent 

patient satisfaction score with respect to access and VA’s metric on the 96 percent 

of appointments seen within 30 days of the desired date. VA has several concerns 

about the OIG’s audit methodology that was used in this particular audit. VA takes 

OIG reports seriously. Non-concurrences are infrequent with the last major nonconcurrence occurring in the early 1990’s. For this report on wait times, specifically, 

the methodology used by OIG and VHA to calculate waiting times do not match. 

VA’s waiting times data reflects a ‘‘real time’’ approach to measure patient access 

using an old scheduling system not designed for this purpose. While differences in 

methodology exist, the overriding focus for both sets of measurements is the veteran 

patient. VA has a driving interest to accurately monitor and continually improve access for our veterans. 

VA has worked diligently to develop an objective, reliable process to measure 

waiting times. I am not aware of any other large system in the public or private 

sector that has attempted to duplicate the efforts of VA to measure the waiting 

times for each appointment. There are an estimated 40 million appointments each 

year in the VA system. There are multiple variables involved in this measurement 

tracking, which includes patient preferences and differences in the organization of 

individual facility services and clinics, including scheduling practices. VA has identified that ongoing training of our scheduling clerks is critical for success. For this 

reason, we require our scheduling clerks to be trained using our scheduling education modules and to pass a competency exam for certification. We also began requiring annual refresher training. 

VA is proactively taking steps to review the total scheduling process, including 

the way VA measures waiting times. We will continue to improve our processes, 

educate scheduling staff, and strive to improve clinic access to further reduce waiting times. To this end, VA has contracted with an independent third party to conduct an evaluation of VA’s scheduling practices and waiting time metrics. The contractor is beginning the pilot program phase of its assessment, and VA anticipates 

receiving the final report in Spring of 2008. 

In conclusion, we are taking the following substantive actions to aggressively address the issues of veteran access and wait times—we are developing a new scheduling software package as well as developing shorter term software solutions for our 

current scheduling package; we are continually improving our training programs, 

and we are contracting with an outside consulting firm for an independent review 

of our scheduling process and metrics. 

Thank you, again, for having me here today. I would be pleased to answer any 

questions you or any of the Members of the Committee may have. 

f 

Prepared Statement of Paul A. Tibbits, M.D., 

Deputy Chief Information Officer, Office of Enterprise Development, 

Office of Information and Technology, U.S. Department of Veterans Affairs 

Good afternoon Chairman Michaud, Chairman Mitchell, Ranking Member BrownWaite, Ranking Member Miller and Members of the Subcommittees, thank you for 

the opportunity to report on the progress made by the Department of Veterans Affairs (VA) on providing the information technology needed to ensure that veterans 

are afforded timely access to health care. We are committed to serving veterans and 

meeting the wait time policies of the VA. 


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VHA has been using a scheduling system that was designed in the 1970’s and 

is out-of-date, negatively impacting patient scheduling and patient access. The 

HealtheVet Scheduling Project (Replacement Scheduling Application) was initiated 

in May 2001 to address this deficiency. The RSA software offers a number of advantages over the current scheduling system and I will highlight just a few: 

• Improved support and flexibility for site management of resources (people, 

rooms, equipment). • Greater efficiency in scheduling appointments. • Improved continuity of care for referral management and veterans who travel 

to other VA medical centers. 

RSA waiting time metrics will be similar in construct to the metrics now used by 

VHA but will have a higher degree of specificity because they will be provider based 

rather than clinic based. 

As you know the RSA project has experienced significant delays from the original 

plan to release the software in mid-2005. These delays have resulted from both vendor and VA related issues. My office is actively addressing the causes of these 

delays by taking the following actions: 

• Bringing in industry experts to strengthen program management discipline; • Establishing standard IT processes for system development, based on industry 

best practices, with mentoring for the VA staff by industry experts; • IT staff professional development focused on implementation of the high priority 

industry best practices needed to assure software delivery on schedule and at 

cost. • Re-organizing the IT development organization to better focus on high priority 

software projects and to identify and develop common services once for use in 

all projects. 

However, much work remains to be done. 

The current schedule for RSA is to release the alpha version to Muskogee VAMC 

in early summer 2008. This release will support basic functionality followed by a 

test release with full functionality at the Dallas VAMC in December 2008. I anticipate that RSA will be installed at all VAMC’s by January 2011. 

Recognizing the difficulty that these delays impose upon VHA, the VA Office of 

Information and Technology is making limited enhancements to the current scheduling system as well as formalize the process for converting locally developed ‘‘Class 

III’’ software adapted to become national ‘‘Class I’’ software. Class III software is 

developed locally to meet a business need and historically sites have shared this 

software to some extent. This sharing has produced variations in the base VistA system which if we allow to continue will impede our ability to convert to a national 

HealtheVet architecture, while providing less than uniform IT support for scheduling across VA medical centers. In the interest of leveraging the ingenuity and innovation that resides locally we have created a path for converting Class III software to national Class I software so that the Class III software will be standardized 

before it is shared across VA facilities, and it will be implemented in all VA facilities. As of October 2007, the VHA Informatics and Data Management Committee 

prioritized the first three Class III products for national release: Shift Hand-off Tool, 

Medication Reconciliation, and Surgery Case Manager. The Shift Hand-off Tool is 

projected for release in January 2008. This will provide, when the veteran’s primary 

care physician is not available, a synopsis of the hospital care, pertinent medical 

history, alerts and special instructions relative to a patient’s care during a particular shift. Medication Reconciliation is projected for release in January 2008. This 

will provide a complete and accurate medication list that would be given to every 

patient upon discharge from the VA facility or upon departure from every clinic 

visit. Last, Surgery Case Manager is projected for release in May 2008. This will 

track and report the length of time veterans must wait for surgical procedures. 

Tracing this will give VA the ability to improve efficiency and improve access to inpatient surgical care by allowing facilities to identify delays and access issues. 

To assure that we are addressing all the high priority requirements, VA has commissioned an independent study which will be completed in Spring 2008. This study 

will look at patient scheduling, scheduling staff, business rules, patient preferences, 

data accuracy, and a review of the redesigned scheduling software, as well as comparisons to health industry practices. 

Thank you for the opportunity to appear before you and provide you the status 

of our ongoing efforts. My colleagues and I are happy to answer any questions you 

or other Members of the Subcommittee might have. 

f 


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Statement of Hon. Jeff Miller, 

Ranking Republican Member, Subcommittee on Health 

Thank you Chairman Mitchell and Chairman Michaud. 

Timely access to healthcare services is a critical aspect of providing high quality 

care to our Nation’s veterans. 

Since 2004, the VA has continued to report substantial improvements in meeting 

the performance standard VA itself established to schedule appointments within 30 

days of a patient’s requested date of an appointment. 

However, while we have been receiving reports showing that VA was meeting its 

goal in about 96% of the cases, I am extremely disturbed by a recent audit of VA’s 

outpatient waiting times by the VA Office of Inspector General (IG). 

The IG found that previous problems with outpatient scheduling procedures 

uncovered in their 2005 audit still exist and the accuracy of the data recorded to 

calculate outpatient waiting times is not reliable. 

The IG report states: ‘‘While waiting time inaccuracies and omissions from electronic waiting lists can be caused by a lack of training and data entry errors, we 

also found that schedulers at some facilities were interpreting the guidance from 

their managers to reduce waiting times as instruction to never put patients on the 

electronic waiting list. This seems to have resulted in some ‘‘gaming’’ of the scheduling process.’’ 

I take great interest in monitoring how long veterans must wait for care and it 

is unacceptable for the VA to provide incomplete and erroneous waiting time data. 

I expect as an outcome of our hearing today that VA immediately employ corrective actions to record and report waiting times accurately. It is my top priority to 

ensure that veterans are able to access the care they need from VA. 

Further, as a cosponsor of my colleague, Ginny Brown-Waite’s legislation, H.R. 92, 

the Veterans Timely Access to Health Care Act, I believe if VA cannot meet its own 

established access standard for any veteran, that patient should be given the choice 

to receive care in a non-VA facility. 

Thank you, Mr. Chairman. I look forward to the testimony and I yield back the 

balance of my time. 

f 

Statement of Hon. Cliff Stearns, 

a Representative in Congress from the State of Florida 

Thank you Mr. Chairman for holding this important hearing. 

If there is one issue that we hear about more often than any other, it is the issue 

of access to healthcare for our veterans. From my veterans, I am pleased to hear 

that veterans are happy with the quality of care they receive at our medical centers 

and hospitals, however often the wait time for appointments, in particular specialty 

appointments, can be incredibly long—months after they request to be seen. This 

is unacceptable. The Veterans Health Administration (VHA) reports to Congress on 

the number of patients seen within 30 days of requesting an appointment, and there 

is also an electronic waiting list at the VA to ensure that no veteran falls through 

the cracks. However, these systems are not being used correctly. 

In 2007, Inspector General (IG) auditors assessed whether VA schedulers followed 

procedures correctly when selecting appointments and veterans’ desired dates of 

care. The auditors also looked at how medical facilities ensured that all veterans 

seeking care either had appointments or were identified on electronic waiting lists. 

The IG determined that scheduling procedures were not followed and that electronic 

waiting lists were not complete. Often schedulers did not enter the correct desired 

dates of care. In 2007, the error rate of schedulers’ entries was 72%! The IG also 

found that the VA’s performance measures were overstated. VHA reported that 96% 

of all veterans seeking primary medical care and 95% seeking specialty care were 

seen within 30 days of their desired date. IG’s analysis showed instead that 78% 

of veterans seeking primary care and 73% of the specialty care were seen within 

30 days. 

I understand that we will hear today more about the issue of whether the statistics are correct or not, and the issues involved in getting these numbers right. The 

issue of VA outpatient waiting times comes down to whether or not the desired date 

of care recorded in the scheduling system is the correct date to use. However, the 

main issue, the key problem that we are here to deal with today, is how are we 

going to work together to ensure our veterans are receiving timely access to healthcare? I look forward to hearing the testimony from our witnesses regarding their 

plans. 

Thank you. 


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POST–HEARING QUESTIONS AND RESPONSES FOR THE RECORD 

Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

December 13, 2007 

The Honorable Gordon Mansfield 

Acting Secretary 

Department of Veterans Affairs 

820 Vermont Avenue, NW 

Washington, DC 20420 

Dear Mr. Mansfield, 

On December 12, 2007, the Subcommittee on Health and the Subcommittee on 

Oversight and Investigations held a joint hearing on Outpatient Waiting Times at 

the Department of Veterans Affairs. 

During this hearing, I discussed legislation I introduced to help reduce outpatient 

waiting times at VA Medical Centers and Community-Based Outpatient Clinics, 

H.R. 92. At the end of the hearing, I asked Dr. Cross to provide within 30 days the 

official administration views on this legislation, which he agreed to do. 

In order to assist you, I am enclosing a copy of H.R. 92 for your review. Please 

provide in writing the official administration views on this legislation by January 11, 2008. I would also greatly appreciate you sharing your response with 

Chairman Filner, Ranking Member Buyer, Chairman Michaud and Ranking Member Miller of the Subcommittee on Health, and Chairman Mitchell, who I have the 

honor of serving with on the Subcommittee on Oversight and Investigations. 

I look forward to receiving your response shortly. 

Sincerely, 

Ginny Brown-Waite 

Ranking Republican Member 

Enclosure (H.R. 92) 

110th CONGRESS 

1st Session 

H.R. 92 

To amend title 38, United States Code, to establish standards of access to care 

for veterans seeking healthcare from the Department of Veterans Affairs, and 

for other purposes. 

———————————————————— 

IN THE HOUSE OF REPRESENTATIVES 

January 4, 2007 

Ms. Ginny Brown-Waite of Florida introduced the following bill; which was referred to the Committee on Veterans’ Affairs 

———————————————————— 

A BILL 

To amend title 38, United States Code, to establish standards of access to care 

for veterans seeking healthcare from the Department of Veterans Affairs, and 

for other purposes. 

Be it enacted by the Senate and House of Representatives of the United States of 

America in Congress assembled, 

SECTION 1. Short title. 

This Act may be cited as the ‘‘Veterans Timely Access to Health Care Act’’. 


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SEC. 2. Standards for access to care. 

(a) Required Standards for Access to Care.—Section 1703 of title 38, United States 

Code, is amended by adding at the end the following new subsection: 

‘‘(e)(1) For a veteran seeking primary care from the Department, the standard 

for access to care, determined from the date on which the veteran contacts the 

Department seeking an appointment until the date on which a visit with a 

primary-care provider is completed, is 30 days. 

‘‘(2)(A) The Secretary shall prescribe an appropriate standard for access to care 

applicable to waiting times at Department healthcare facilities, determined 

from the time at which a veteran’s visit is scheduled until the time at which 

the veteran is seen by the provider with whom the visit is scheduled. 

‘‘(B) The Secretary shall periodically review the performance of Department 

healthcare facilities compared to the standard prescribed under subparagraph 

(A). The Secretary shall submit to the Committees on Veterans’ Affairs of the 

Senate and House of Representatives an annual report providing an assessment 

of the Department’s performance in meeting that standard. 

‘‘(3) Effective on the first day of the first fiscal year beginning after the date 

of the enactment of this section, but subject to paragraph (4), in a case in which 

the Secretary is unable to meet the standard for access to care applicable under 

paragraph (1) or (2), the Secretary shall, or with respect to a veteran described 

in section 1705(a)(8) of this title may, use the authority of subsection (a) to furnish healthcare and services for that veteran in a non-Department facility. In 

any such case— 

‘‘(A) payments by the Secretary may not exceed the reimbursement rate for 

similar outpatient services paid by the Secretary of Health and Human 

Services under part B of the Medicare Program (as defined in section 

1781(d)(4)(A) of this title); and 

‘‘(B) the non-Department facility may not bill the veteran for any difference 

between the facility’s billed charges and the amount paid by the Secretary 

under subparagraph (A). 

‘‘(4) Paragraph (3) shall not apply to a veteran enrolled or seeking care at a Department facility within a Department geographic service area that has a compliance rate, determined over the first quarter of the first calendar-year beginning after the date of the enactment of this Act, for the standards for access 

to care under paragraphs (1) and (2) of 90 percent or more. The Secretary shall 

make the determination of the compliance rate for each Department geographic 

service area for purposes of the preceding sentence not later than July 1 of the 

first calendar-year beginning after the date of the enactment of this Act. 

‘‘(5)(A) The Secretary shall submit to the Committees on Veterans’ Affairs of the 

Senate and House of Representatives for each calendar-year quarter, not later 

than 60 days after the end of the quarter, a comprehensive report on the experience of the Department during the quarter covered by the report with respect 

to waiting times for veterans seeking appointments with a Department healthcare provider. 

‘‘(B) Each report under subparagraph (A) shall include the total number of 

veterans waiting, shown for each geographic service area by the following 

categories: 

‘‘(i) Those waiting under 30 days for scheduled appointments. 

‘‘(ii) Those waiting over 30 days but less than 60 days. 

‘‘(iii) Those waiting over 60 days but less than 4 months. 

‘‘(iv) Those waiting over 4 months but who cannot be scheduled within 6 

months. 

‘‘(v) Those waiting over 6 months but who cannot be scheduled within 9 

months of seeking care. 

‘‘(vi) Those who cannot be scheduled within one year of seeking care. 


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‘‘(vii) Any remaining veterans who cannot be scheduled, with the reasons 

therefore. 

‘‘(C) For each category set forth in subparagraph (B), the report shall distinguish between— 

‘‘(i) waiting times for primary care and specialty care; and 

‘‘(ii) waiting times for veterans who are newly enrolled versus those who 

were enrolled before October 1, 2001. 

‘‘(D) Each such report shall also set forth the number of veterans who have enrolled in the Department’s healthcare system but have not since such enrollment sought care at a Department healthcare facility. 

‘‘(E) The final report under this paragraph shall be for the quarter ending on 

December 31, 2010.’’. 

(b) Effective Date.—Subsection (e) of section 1703 of title 38, United States Code, 

as added by subsection (a), shall take effect on the first day of the first month beginning more than six months after the date of the enactment of this Act. The first 

report under paragraph (5) of that subsection shall be submitted for the quarter 

ending on December 31 of the first calendar year beginning after the date of the 

enactment of this Act. 

U.S. Department of Veterans Affairs 

Washington, DC. 

July 31, 2008 

The Honorable Ginny Brown-Waite 

Ranking Republican Member 

Subcommittee on Oversight and Investigations 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Washington, DC 20515 

Dear Congresswoman Brown-Waite: 

On December 12, 2007, we appeared before the Subcommittee on Health and the 

Subcommittee on Oversight and Investigations, to testify on waiting times at VA 

medical facilities. At the hearing and again by letter dated December 13, 2007, you 

requested the Department’s views on H.R. 92. Please find enclosed a copy of the Department’s testimony sent to the House Committee on Veterans’ Affairs, Subcommittee on Health, for the legislative hearing held on April 26, 2007. H.R. 92 is 

the first bill discussed in our written statement. 

We would also like to take this opportunity to expand upon two technical issues. 

First, as we stated in our original testimony, VA has no significant objection to 

H.R. 92 with respect to setting a 30-day standard for the scheduling of patients. We 

would, however, like to request that the bill language be clarified under section 

(2)(a), regarding the starting date from which the 30-day standard would be computed. The current language would begin this computation on the date that the ‘‘veteran contacts the Department.’’ There are many patients who contact the Department to schedule appointments that are needed more than 30 days in the future. 

The more appropriate start point would be the desired date specified by the veteran. 

This could be reflected by changing the relevant language to read: ‘‘For a veteran 

seeking primary care from the Department, the standard for access to care, determined from the desired appointment date specified by the veteran seeking an appointment until the date on which a visit with a primary-care provider is completed, 

is 30 days.’’ In addition, VA is almost always able to provide access to primary care 

within 30 days of the desired date at its Medical Centers, but may have more difficulty meeting the access standard at some of the smaller Community-Based Outpatient Clinics. VA’s policy is to offer care to a veteran within the specified 30-day 

access standard at a location that is proximal to the veteran, but it should be understood that this may or may not be at the specific location requested by the veteran. 

Second, there is no requirement in the bill that contractors, even if they are Medicare providers, agree to accept the Medicare rate from VA. Regarding the provision 

to restrict VA to pay the Medicare rate, VA is developing regulations that would 

support the requirement that providers accept a Medicare rate payment. However, 


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these regulations will allow VA flexibility in those circumstances where services 

cannot be obtained based upon use of Medicare reimbursement rates. VA wishes to 

avoid a situation where the Medicare reimbursement rate requirement would limit 

the services that the VA could provide to veterans if the services cannot be purchased in the community at this rate. 

We estimate the cost of H.R. 92 to be as follows: For veterans enrolled in priority 

groups 1–7, we estimate the cost of meeting the bill’s 30-day standard to be 

$205,850,000 for FY 2009 and for veterans currently enrolled in Priority Group 8, 

we estimate that cost to be $61,123,000 for FY 2009, which is part of the FY 2009 

President’s Budget. With respect to the 20-minute standard we discussed in 

our testimony, we estimate the costs to be $1,278,850,000 for FY 2009, and 

$14,817,870,000 over a 10-year period. This requirement was not envisioned in the 

FY 2009 President’s Budget request and would involve significant new resource demands in future years that could create the need for offsets in other medical requirements. 

The Office of Management and Budget advises that there is no objection to the 

submission of this report from the standpoint of the Administration’s program. 

Sincerely yours, 

James B. Peake, M.D. 

Secretary 

Enclosure 

[The enclosed testimony of Dr. Gerald M. Cross, M.D., FAAFP, Acting Principal 

Deputy Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs, which was enclosed, has been previously printed in Committee on Veterans’ Affairs, Subcommittee on Health ‘‘Legislative Hearing on 

H.R. 92, H.R. 315, H.R. 339, H.R. 463, H.R. 538, H.R. 542, H.R. 1426, H.R. 1470, 

H.R. 1471, H.R. 1527, 1944 and Discussion Draft Rural Health Care Bill,’’ April 26, 

2007, Serial No. 110–17, and will not be reprinted. You can download a copy of 

Dr. Cross’ testimony from the Committee’s Website at http://www.house.gov/sites/ 

comms/veteransldem/hearings/schedule110/apr07/04–26–07/printlversions/4–26–07 

cross.htm.] 

f 

Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

January 16, 2008 

The Honorable James B. Peake, M.D. 

Secretary 

Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Secretary Peake, 

As part of my Subcommittee’s oversight over patient waiting times at the Department of Veterans Affairs, I am writing to request information relating to outpatient 

waiting times at VA medical facilities. 

I am requesting a breakdown by VISN and facility of the outpatient and specialty 

care waiting times for the Department’s major medical centers and the communitybased outpatient clinics. I am also interested in the percentage of waiting times 

which fall within the 30-day timeframe for outpatient appointments, and whether 

documentation exists as to why those that fell outside the 30-day timeframe took 

longer to obtain an appointment. 

I would like a response to this request no later than February 15, 2008. Thank 

you for your kind consideration. 

Sincerely, 

Ginny Brown-Waite 

Ranking Republican Member 


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U.S. Department of Veterans Affairs 

Washington, DC. 

February 15, 2008 

The Honorable Ginny Brown-Waite 

Ranking Republican Member 

Subcommittee on Oversight and Investigations 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Washington, DC 20515 

Dear Congresswoman Brown-Waite: 

In response to your request, the Department of Veterans Affairs (VA) is providing 

information on outpatient wait times at VA medical centers. I, too, share your concerns regarding our veterans receiving timely medical appointments and quality 

healthcare. 

The Veterans Health Administration’s (VHA) 30-day timeliness standard does not 

apply to the wait time for a veteran to ‘‘obtain an appointment’’ (i.e. the act of 

scheduling an appointment with the clerk), but rather to the wait time between the 

desired date for the appointment to occur and the actual date the scheduled appointment is completed. Attached is a breakdown for primary and specialty care 

waiting times from VA operated clinics using VA’s scheduling software during the 

month of December 2007 (fiscal year 2008). This is the most recent data available 

on completed appointments. 

Nationally, during the month of December 2007, 97.6 percent of all scheduled appointments were completed within 30 days or less of the desired date for that appointment as specified by the provider or patient. 

VHA frequently collects documentation of the reasons these times exceed 30 days. 

Examples of why some patients wait greater than 30 days from the desired appointment date are as follows: 

• Patient Preference. Schedulers are instructed to talk to the patient during the 

scheduling process to ensure that the date and time of the appointment offered 

is acceptable to the patient. In many instances, staff found these patients were 

scheduled more than 30 days from desired date because patients had specifically requested an appointment beyond the specified 30 days. So while they appear as waiting on the Access List, in fact they are scheduled to be seen at 

times and on dates of their own choosing. • Cancelations and No-Shows. Staff reported that many veterans waiting more 

than 30 days according to the Access List had failed to appear for their scheduled appointment or had canceled a previously scheduled appointment. VHA 

monitors Missed Opportunities monthly and provides data to the facilities. 

Cancelations and No-Shows make up the Missed Opportunities Report. For example, during the month of December 2007, the missed opportunities rate nationally for Cardiology was 13.7 percent and Mental Health was 18.3 percent 

(see enclosures). • Scheduler Errors. In some instances, staff found patients waiting more than 30 

days from the desired appointment date due to errors made by schedulers. 

Those errors were typically errors in entry of the ‘‘desired date’’ and were subsequently corrected. • Capacity Constraints. In other instances, staff determined patients were waiting beyond 30 days from the desired appointment date due to capacity constraints that would not allow them to offer appointments sooner. In those instances, facilities may have purchased non-VA care, or added VHA resources 

through recruitment to fill vacancies, added additional space, opened additional 

clinics, or expanded clinic hours. 

Thank you for your interest and support of the efforts of our dedicated VHA staff 

to provide timely and quality care to our Nation’s veterans. 

Sincerely yours, 

James B. Peake, M.D. 

Secretary 

Enclosures 

[The attachment, ‘‘a breakdown for primary and specialty care waiting 

times from VA operated clinics using VA’s scheduling software during the 

month of December 2007 (fiscal year 2008),’’ will be retained in the Committee files.] 


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Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

February 14, 2008 

Honorable George J. Opfer 

Inspector General 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Mr. Opfer: 

On Wednesday, December 12, 2007, the Subcommittee on Health and the Subcommittee on Oversight and Investigations of the House Committee on Veterans’ Affairs held a joint hearing on outpatient waiting times. 

During the hearing, the Subcommittees heard testimony from Ms. Belinda Finn, 

the Assistant Inspector General for Auditing. She was accompanied by Mr. Larry 

Reinkemeyer, Director of the Kansas City Audit Operations Division. As a followup to that hearing, the Subcommittee is requesting that the following questions be 

answered for the record: 

1. VHA states in their response to your 2007 report that it is unrealistic to expect 

schedulers to maintain such a high level of documentation. What level of documentation is minimally required to provide auditable analysis? 

2. Overshadowed by the discussion on accurate waiting times is the high number 

of veterans waiting for specialty consults. How significant is this issue, and 

what are industry acceptable standards? 

3. Should VHA have VAMC directors certify waiting times’ lists and would this 

certification improve the waiting times numbers? 

We request you provide responses to the Subcommittee no later than close of business, Wednesday, March 12, 2008. 

Sincerely, 

MICHAEL H. MICHAUD JEFF MILLER 

Chairman Ranking Republican Member 

Subcommittee on Health Subcommittee on Health 

HARRY E. MITCHELL GINNY BROWN-WAITE 

Chairman Ranking Republican Member 

Subcommittee on Oversight and Subcommittee on Oversight and 

Investigations Investigations 

U.S. Department of Veterans Affairs 

Washington, DC. 

March 17, 2008 

The Honorable Michael H. Michaud 

Chairman, Subcommittee on Health 

Committee on Veterans’ Affairs 

United States House of Representatives 

Washington, DC 20515 

Dear Mr. Chairman: 

Enclosed are the responses to the questions from the December 12, 2007, joint 

hearing before your Subcommittee and the Subcommittee on Oversight and Investigations on outpatient waiting times. A similar letter is being sent to Congressman 

Jeff Miller, Ranking Republican Member, Congressman Harry Mitchell, Chairman, 

Subcommittee on Oversight and Investigations, and Congresswoman Ginny BrownWaite, Ranking Republican Member, Subcommittee on Oversight and Investigations. 

Thank you for your interest in the Department of Veterans Affairs. 

Sincerely, 

GEORGE J. OPFER 

Inspector General 

Enclosure 


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Responses from the Office of Inspector General 

to Post Hearing Questions on Outpatient Waiting Times 

1. VHA states in their response to your 2007 report that it is unrealistic to 

expect schedulers to maintain such high level of documentation. What 

level of documentation is minimally required to provide auditable analysis? 

In our 2007 report, the Under Secretary concedes that the failure of scheduling 

clerks to adequately document patient preferences in appointment dates contributed 

to the OIG findings and states that it is unrealistic to expect schedulers to maintain 

such a high level of documentation. While the OIG recognizes the workload associated with millions of appointments made every year, documenting changes in veteran desired dates is required by VHA’s policy. The Under Secretary also comments 

that this documentation is solely to support audit requirements and does little, if 

anything, to support the actual scheduling of the appointment. Contrary to this position, the OIG maintains that full compliance with established scheduling procedures is critical to ensuring patients are seen in a timely manner. Compliance is 

also critical to ensure data integrity. In the absence of specific information, neither 

we nor VHA can be sure whether the desired date differences were due to patient 

preference or the scheduler’s use of inappropriate scheduling procedures. To accept 

VHA’s assumption that our reported error rate in waiting times is somehow flawed 

because we failed to consider that the veterans may be cancelling and changing 

their appointments for which there is no supporting documentation would be irresponsible. 

At a minimum, we expect schedulers to maintain the documentation prescribed 

by VHA Directive 2006–055. This requires that for every patient who requests a 

specific appointment date that is different than the date specified by the provider 

in the medical records, the scheduler should annotate why the date was used in the 

‘‘Other Info’’ section in the Veterans Health Information Systems and Technology 

Architecture (VistA) scheduling package. For example, ‘‘patient requested appointment for 3/2/08.’’ The ‘‘Other Info’’ section is included with a series of questions and 

prompts that each scheduler answers when creating most appointments. During our 

review, we generally found no information in the ‘‘Other Info’’ section. 

2. Overshadowed by the discussion on accurate waiting times is the high 

number of veterans waiting for specialty consults. How significant is 

this issue, and what are industry acceptable standards? 

We believe this issue is significant for several reasons. The high number of veterans waiting for specialty consults means that veterans with serious medical conditions could be experiencing significant delays in receiving treatment from medical 

specialists. We also believe that a sizable number of veterans may be affected. In 

our 2005 review, we reported that electronic waiting lists could be understated by 

as many as 10,301 veterans nationwide. At the 10 facilities we reviewed in 2007, 

VHA’s consult tracking report identified over 70,000 veterans with consult referrals 

over 7 days old that—in accordance with VHA policy—should have been on the 

waiting list of the 10 facilities we reviewed. At the time of our review, the 10 facilities had reported only 2,600 veterans on the waiting list. We believe that this problem could potentially be much larger since the VHA medical system consists of 153 

medical centers. 

While having a large number of veterans on waiting lists is an indication that VA 

may not be capable or funded to handle its patient workload within prescribed timeframes, we believe there is an even more significant issue—the large numbers of 

veterans waiting for specialty consults who are intentionally or inappropriately not 

placed on waiting lists who fall through the cracks and do not receive needed critical 

care. 

We were unable to identify a firm industry standard on acceptable waiting time 

for specialty care, although we noted an international study on access to care that 

measured the percentage of patients who waited 4 weeks or longer for specialty care. 

3. Should VHA have VAMC directors certify waiting times’ lists and would 

this certification improve the waiting times numbers? 

Requiring VAMC Directors to certify waiting times and waiting lists would help 

establish accountability. However, the most important action VHA needs to take is 

to establish procedures to routinely test the accuracy of reported waiting times and 

completeness of electronic waiting lists, and take corrective action when testing 

shows questionable differences between the desired dates of care shown in medical 

records and documented in the VistA scheduling package. 

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Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

February 29, 2008 

The Honorable James B. Peake 

Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Secretary Peake: 

On Wednesday, December 12, 2007, the Subcommittee on Health and the Subcommittee on Oversight and Investigations of the House Committee on Veterans’ Affairs held a joint hearing on outpatient waiting times. 

During the hearing, the Subcommittees heard testimony from Dr. Gerald M. 

Cross, Principal Deputy Under Secretary for Health; and Dr. Paul Tibbits, Deputy 

Chief Information Officer, Office of Information and Technology; Mr. William F. 

Feeley, Deputy Under Secretary for Health for Operations and Management; Ms. 

Odette Levesque, Clinical/QA Liaison; and Ms. Kathy Frisbee, Deputy Director of 

the Veterans Service Support Center. As a follow-up to that hearing, the Subcommittee is requesting that the following questions be answered for the record: 

1. What specific actions will VHA implement to improve the accuracy and completeness of the scheduling information? Please provide an implementation 

schedule with milestones and exit criteria. 

2. Are there any issues that would affect your ability to ensure improvements 

are made in a timely manner? 

3. In 2005, the OIG made specific recommendations—with which VA agreed— 

to ensure and then monitor schedulers’ use of correct procedures when creating appointments. In its 2007 report, the OIG once again reported concerns 

with the reliability of VA’s waiting time data. If required documentation, 

without which it is not possible to tell whether an appointment was made 

within 30 days, did not exist, is not the proper conclusion for auditing purposes that the appointment was not made in 30 days? Suppose that VA claims 

95 percent of appointments are made within 30 days, but documentation required by VA policy does not exist to support 20 percent of those appointments. Does VA believe that it would be justified in claiming the 95 percent 

number in those circumstances? 

4. How do you determine if training is effective if you have no process in place 

to test and monitor schedulers’ compliance with scheduling procedures? 

5. Other than monitoring appointments with waiting times of more than 30 

days, what specific actions do you take to test the reliability of the waiting 

times performance that you include in your annual Performance and Accountability Report? 

6. How will you ensure the accuracy of the current scheduling system until a 

new system comes online? 

7. If you propose eliminating your current measurement of waiting times and 

rely entirely on patient satisfaction surveys, how would you ensure the survey 

provides you sufficient, meaningful information necessary to place resources 

in the most appropriate places to positively impact timely patient care? 

8. How are directors for each facility held accountable for veterans’ waiting 

times in their facilities? What measurement did you hold them to in 2007, 

and are those same standards in place for 2008? 

9. Would it be in the veterans’ best interests if you knew exactly how many veterans were waiting for an appointment and then how long veterans were 

waiting for appointments? How do you know where to apply resources if facilities do not capture accurate waiting time performance data? 

10. The OIG found that there were a number of veterans that should have been 

on the electronic waiting list but were not. In 2007, in a review of 10 facilities, 

it appears that a significant number of veterans were waiting an extended period of time for action on their request for a consult with a specialist. Electronic waiting lists were created as a mechanism to ensure visibility over all 

veterans without appointments. Why are your facilities not using them appropriately? 


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11. Do you think having VHA bring back the policy of having VAMC directors 

certifying the waiting times list would improve the accuracy of the waiting 

times numbers? 

12. Why was the certifying procedure the medical facility directors had to comply 

with eliminated? 

13. Do you think there is a conflict of interest between the VA’s goal of minimizing veteran-patients waiting times and the temptations for directors to 

game the numbers to make this specific performance measure look good for 

their annual reviews? 

14. Since the disbandment of the Medical Administration Service, supervisory 

oversight controls of the scheduling clerks may have been compromised. In 

addition, their career development needs might not be properly addressed. 

How is VA addressing career needs of the scheduling clerks with a national 

work group? Can you give us an update of what this work group is planning 

to accomplish? 

15. Can you please tell us how VHA defines ‘‘waiting times?’’ And is your definition standardized across every VISN? 

16. Please provide documentation of waiting times in the Central Ohio region. 

Specifically, the Subcommittees are interested in what is happening with primary and specialty care around the Newark area. Do veterans in Licking 

County have access to more than the Newark Community-Based Outpatient 

Clinic? What are the procedures for arranging treatment at and transportation to the Chalmers P. Wylie Independent Outpatient Clinic in Columbus, 

Ohio? 

17. What is the status of the feasibility study conducted by the VA for southeastern Ohio? When is it expected to be completed and released? 

18. The OIG report documents a number of instances where wait time statistics 

were artificially improved. It is the understanding of the Subcommittees that 

the average wait time is one of the indicators that helps determine bonuses 

for administrators. Is there a correlation between incorrectly improved wait 

time statistics and the bonus amount specific administrators received for 

FY2007? 

19. Has there been any evidence (anecdotal or otherwise) to indicate that schedulers were encouraged to falsify records specifically for the purpose of increasing bonuses? 

20. When determining Medical Center Director bonus amounts, is there a specific 

formula equating wait times to a bonus dollar amount? 

We request you provide responses to the Subcommittee no later than close of business on April 4, 2008. 

Sincerely, 

MICHAEL H. MICHAUD JEFF MILLER 

Chairman Ranking Republican Member 

Subcommittee on Health Subcommittee on Health 

HARRY E. MITCHELL GINNY BROWN-WAITE 

Chairman Ranking Republican Member 

Subcommittee on Oversight and Subcommittee on Oversight and 

Investigations Investigations 

Responses to Questions from Hon. Michael H. Michaud, Chairman, and 

Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, 

and Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, 

Ranking Republican Member, Subcommittee on Oversight and 

Investigations, Committee on Veterans’ Affairs, to 

Hon. James B. Peake, M.D., Secretary, 

U.S. Department of Veterans Affairs 

Outpatient Waiting Times 

Question 1: What specific actions will VHA implement to improve the accuracy 

and completeness of the scheduling information? Please provide an implementation 

schedule with milestones and exit criteria. 

Response: The Veterans Health Administration (VHA) has implemented several 

specific actions to improve the accuracy and completeness of the scheduling information. VHA has revised the scheduling directive for schedulers. Schedulers will find 


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the scheduling directive to be more user friendly and simpler to follow. The revised 

scheduling directive will be released within the next 60 days. 

VHA has also identified and addressed several software deficiencies that contributed to scheduling errors. For example, information entered into VistA to explain 

changes to desired date is being obscured or erased by existing software. To resolve 

this deficiency, VHA is working with the Office of Information and Technology (OIT) 

to correct this information loss. 

Additional improvements implemented by VHA include new software that now enables schedulers to link an appointment to a specific consult request. VHA released 

a first version of its report on wait times from the actual consult request date to 

the dates of appointment in February 2008. Refinements are being made to the report format and will be made available nationally on VHA’s Web site. 

In July 2008, OIT will release a software patch that creates a new field within 

the consult request software where requesting providers will be required to specify 

the desired date for the service requested. VHA has submitted a request for an additional software modification which would display the provider’s desired date on the 

scheduler’s screen as an appointment is scheduled, link that to the scheduled appointment and then transmit the information to the Veterans Service Support Center (VSSC) wait time database. This information would be used to measure the wait 

time from that desired date until the date of the scheduled appointment. 

Finally, a scheduling process workgroup has been proposed to be jointly chartered 

by OIT and the Systems Redesign Office. This group will be charged with standardizing scripts, processes and tasks for the major types of scheduling issues. The Department of Veterans Affairs (VA) would use the products of the workgroup to make 

improvements in the existing software, training, and tools. 

Question 2: Are there any issues that would affect your ability to ensure improvements are made in a timely manner? 

Response: Yes, there are some issues which could affect our ability to ensure improvements are made in a timely manner. Revisions to the Scheduling Directive 

must be negotiated with the union. The negotiation process could take up to several 

months to complete. 

VHA lacks national data tracking and direct measurement systems specific to consultation requests. While information is now being captured on request dates of 

consults and it is linked to scheduled appointments, there is no provision for automatically reporting of information contained in the computerized patient record system (CPRS). This information includes the types and dates of consult requests, and 

dates of clinical or administrative closure. This deficiency cannot be corrected until 

new software routines are developed to automatically transmit information, and new 

resources (including equipment and staffing) are available to manage and analyze 

the large volume of data that would be involved. VHA is working with OIT to resolve this issue. 

Question 3(a): In 2005, the OIG made specific recommendations—with which VA 

agreed—to ensure and then monitor schedulers’ use of correct procedures when creating appointments. In its 2007 report, the OIG once again reported concerns with 

the reliability of VA’s waiting time data. If required documentation, without which 

it is not possible to tell whether an appointment was made within 30 days, did not 

exist, is the proper conclusion for auditing purposes that the appointment was not 

made in 30 days? 

Response: No, that would not be the correct conclusion. The data exist, but not 

necessarily in the proper form or format. To resolve this problem, scheduler’s use 

of correct procedures when creating appointments is being monitored using a comprehensive audit tool, which is supplemented with feedback and regular training. 

The unions are reviewing these procedures currently. 

Question 3(b): Suppose that VA claims 95% of appointments are made within 

30 days, but documentation required by VA policy does not exist to support 20% of 

those appointments. Does VA believe that it would be justified in claiming the 95 

percent number in those circumstances? 

Response: Yes, VA believes that it would be justified in making the claim of 95 

percent of appointments made within 30 days. The Office of Inspector General (OIG) 

does not consider a desired date real unless documentation of the date exists in the 

record. The documentation exists, but not necessarily in the form or format accepted 

by the OIG. VA is developing software that will resolve this problem. 


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Question 4: How do you determine if training is effective if you have no process 

in place to test and monitor schedulers’ compliance with scheduling procedures? 

Response: VA uses several ways to determine if training is effective. For example, supervisors provide training to schedulers, when needed, and monitor schedulers’ compliance and performance, and this is part of the scheduler’s annual performance appraisal. VHA is standardizing the way supervisors monitor scheduler’s 

compliance and is providing tools to assist in monitoring schedulers’ performance. 

OIT is converting software which will be used by facilities to randomly pull appointments created by each scheduler for review by supervisors. 

VHA is negotiating with union representatives on instructions supervisors will follow to review appointments to ensure desired date was correctly entered. Followup will be required in instances in which a scheduler fails to correctly schedule a 

specified percentage of the appointments reviewed. Facility directors are required to 

monitor supervisors’ reviews of scheduler performance. 

Question 5: Other than monitoring appointments with waiting times more than 

30 days, what specific actions do you take to test the reliability of the waiting times 

performance that you include in your annual Performance and Accountability Report? 

Response: To test the reliability of the waiting times performance, VHA, on a 

regular basis, sends wait time data to the facilities to review for accuracy. During 

the review process, outliers are identified and explanations are provided relative to 

the reasons for the outlier status. This is a process of sorting out the differences 

in outlier numbers associated with real wait time problems versus scheduler errors, 

either in entry of desired date, or in selection of an appointment date. Patients with 

extended wait times are called and provided earlier appointments as appropriate 

consistent with their preferences and clinical necessity. 

VHA also test reliability of the waiting times performance by asking patients on 

its Survey of healthcare experience of patients (SHEP) to respond whether they received an appointment when they wanted to be seen. Steady improvement has been 

noted in patient satisfaction on this issue. VHA tracks patient complaints received 

and has noted improvements in numbers of complaints received in spite of increased 

numbers of veterans being scheduled. 

In fiscal year (FY) 2004, VHA distributed nationally an electronic tool for use by 

facilities in continuous auditing of the accuracy of appointments scheduled more 

than 30 days from desired date. VHA Directive 2006–055 published October 2006 

required continuous auditing by supervisors of performance of employees in scheduling using locally developed or veterans integrated service network (VISN) approved tools. VHA is now finalizing actions to distribute new tools nationally to optimize this auditing process. 

Question 6: How will you ensure the accuracy of the current scheduling system 

until a new system comes on line? 

Response: Among the actions VA has taken to ensure the accuracy of its current 

scheduling system are developing and implementing a revised directive on scheduling for schedulers to follow; modifying our existing scheduling software package; 

developing a standardized method to monitor scheduler accuracy; and negotiating 

with unions on enhanced training and supervision for schedulers. 

It is important to note, however, that even once the new replacement scheduling 

application comes online there will still be some scheduling errors. The office responsible for the application is actively working on a transition plan which would 

ensure those errors are kept to a minimum. 

Question 7: If you propose eliminating your current measurement of waiting 

times and rely entirely on patient satisfaction surveys, how would you ensure the 

survey provides you sufficient, meaningful information necessary to place resources 

in the most appropriate places to positively impact timely patient care? 

Response: VA is not proposing to eliminate current measurement of waiting 

times completely. We would not eliminate measurement of waiting times in clinics 

entirely but would use these metrics as internal measures. We would retain some 

method of monitoring the clinic backlog such as a measure of ‘‘future open capacity’’ 

and/or ‘‘third next available,’’ which are capacity measures. These are the most common methods used in non-VA healthcare. 

SHEP data capture meaningful patient information. Currently, we provide SHEP 

data on a quarterly basis. VHA is considering various means of obtaining more comprehensive data, in addition to SHEP data, such as asking patients or random samVerDate Aug 31 2005 02:26 Oct 04, 2008 Jkt 039648 PO 00000 Frm 00060 Fmt 6621 Sfmt 6621 E:\HR\OC\39648.XXX 39648

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ple of patients some key question immediately upon seeing their provider. The cost 

involved is yet to be determined. 

Question 8(a): How are directors for each facility held accountable for veterans’ 

waiting times in their facilities? 

Response: VHA continues to place increased focus and accountability for improving performance relative to wait times through national teleconference calls, 

meetings, and sending data to the facilities on a regular basis. Directors remain accountable for health system indicators which include new patient wait times, missed 

opportunities and wait times to see a provider. These contribute to the overall director’s performance evaluation. 

Question 8(b): What measurement did you hold them to in 2007, and are those 

same standards in place in 2008? 

Response: During FY 2007, 60 percent of the directors’ overall score was dependent on results of 22 performance measures. As a result, during FY 2007, 2.7 percent 

of a director’s performance depended on veteran’s waiting times. Measures included 

outpatient wait times for new and established patients, missed opportunity rates 

and wait times to see a provider. 

During FY 2008, 60 percent of the directors’ overall score is dependent on results 

of 15 mission critical measures. As a result, during FY 2008, 4 percent of a director’s 

performance depends on veteran’s waiting times. The measure for FY 2008 is a percent of appointments completed within 30 days for Operation Enduring Freedom/ 

Operation Iraqi Freedom (OEF/OIF) veterans. 

Question 9(a): Would it be in the veterans’ best interests if you knew exactly 

how many veterans were waiting for an appointment and then how long veterans 

were waiting for appointments? 

Response: Some measure of patient wait time is needed. During FY 2007, VHA 

refined its approach to measurement of all patients waiting for outpatient appointments. The consult-scheduling software linkage was distributed and implemented to 

enhance tracking wait times for consult processing. Reporting strategies are now 

being refined. A new access list was developed to provide a snapshot in time of all 

patients waiting beyond their desired date for a scheduled appointment or on the 

electronic wait list. A new pending report was created to enable facilities to drill 

down to view all pending appointments. In addition, for FY 2008, the VHA consult 

completion monitor has been refined to measure numbers of consults clinically completed with results within 30 days of request and within 60 days of request. VHA 

will continue to measure wait times for new and established patient appointments 

and missed opportunity rates. 

Question 9(b): How do you know where to apply resources if facilities do not capture accurate waiting time performance data? 

Response: VHA acknowledges that there is a level of imprecision in the data; 

however, experience has shown that it is adequate for resource decision making purposes. In order to make resource decisions, information beyond single waiting time 

measurements are needed. Clinics need to consider information such as the changes 

in patient demand, changes in clinic supply, changes in no-show rates, the quality 

of consults sent to specialty care, continuity scores, re-visit rates, and panel size or 

case load. In general, if waiting times are stable, the problem is more likely a backlog problem than a resource problem. 

Question 10: The OIG found that there were a number of veterans that should 

have been on the electronic waiting list but were not. In 2007, in a review of 10 

facilities, it appears that a significant number of veterans were waiting an extended 

period of time for action on their request for a consult with a specialist. Electronic 

waiting lists were created as a mechanism to ensure visibility over all veterans 

without appointments. Why are your facilities not using them appropriately? 

Response: The CPRS consultation software is used not only to request specialty 

consultation but also to order tests and procedures that are not specialty consultation. On reviewing the lists of consults the OIG asserted should have been placed 

on the electronic wait list, VHA determined that OIG had erred in large measure 

by reviewing a few consults and then projecting numbers that should have been on 

the electronic wait list based on existing, pending, and active consults at the facilities without actually reviewing those lists of pending and active consults. 


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On closer review, VHA found many if not most of these unscheduled active and 

pending consults not listed on the electronic wait list were procedures, and not medical consultations. Examples: consult requests for fee basis and other types of nonVA care, consult requests for electrocardiograms (EKG) performed on patients in 

pre-procedural beds, consult requests for medical and surgical procedures scheduled 

to be done in an operating or procedure room. VHA is working to distinguish the 

‘‘formal consults’’ (requests to qualified healthcare providers for management and 

treatment of problems requiring clinical input, direction in treatment, or review of 

the record) from the use of the consultation software for other purposes. 

Experience has shown that electronic wait lists, in the fashion previously implemented was overly prescriptive and effectively resulted in low priority veterans 

being served sooner than high priority veterans. The new access directive will correct this problem and make the use of the electronic wait list easier for facilities. 

As indicated above, VHA has created an access list which provides a snapshot of 

patients waiting past their desired date for a scheduled appointment or on the electronic wait list. This provides the universe of patients waiting 30 days past their 

desired date and is a more precise metric. 

Question 11: Do you think having VHA bring back the policy of VAMC Directors 

certifying the waiting time’s list would improve the accuracy of the waiting times 

numbers? 

Response: The policy of certification was updated, but not eliminated by VHA. 

Prior to publication of VHA Directive 2006–028 in May 2006, VHA required each 

facility and network director to certify full compliance with the requirements of 

VHA Directive 2002–059 and VHA Directive 2003–068 that provided business rules 

for scheduling. When published, VHA Directive 2006–028 and VHA Directive 2006– 

055 (Oct. 2006) provided new, updated business rules for scheduling. In May 2007, 

every facility and network director was required to certify compliance with VHA Directive 2006–055. 

We believe that we have focused facility and network leadership on access issues 

through numerous teleconferences and meetings and will continue to highlight during the coming year. In addition to the mission critical wait time measures, the directors remain accountable for health system indicators which include new patient 

wait times, missed opportunities and wait times to see a provider and contribute 

to the overall director’s performance evaluation. 

Question 12: Why was the certifying procedure the medical facility directors had 

to comply with eliminated? 

Response: The certifying procedure was not eliminated. The last certifications of 

compliance with requirements of VHA Directive 2006–055 were collected in May 

2007, less than 9 months ago. However, we do believe that there are more effective 

ways of focusing attention on access than having leadership certify compliance with 

numerous elements identified in a directive. We will continue to focus attention on 

access in the coming year. 

Question 13: Do you think there is a conflict of interest between the VA’s goal 

of minimizing veteran-patients waiting times and the temptations for directors to 

game the numbers to make this specific performance measure look good for their 

annual reviews? 

Response: No, VA does not think there is a conflict of interest. We believe that 

having a variety of performance measures and patient satisfaction data will ensure 

the integrity of the process. During the past several years, we have had teams visit 

facilities to do consultative reviews, numerous communities of practice that discuss 

access issues faced locally, shared best practices; regional collaborative meetings, 

and paired sites who are struggling with those who have demonstrated success. 

Wide spread discussion, learning, and focus contributes to a ‘‘learning organization’’ 

atmosphere rather than gaming. 

Question 14(a): Since the disbandment of the Medical Administration Service, 

supervisory oversight controls of the scheduling clerks may have been compromised. 

In addition, their career development needs might not be properly addressed. How 

is VA addressing career needs of the scheduling clerks with a national work group? 

Response: Turnover of scheduling clerks is a problem that may be more related 

to grade and pay issues than service organization. During FY 2007, a small work 

group was tasked with creating a viable career ladder for schedulers, to enable proVerDate Aug 31 2005 02:26 Oct 04, 2008 Jkt 039648 PO 00000 Frm 00062 Fmt 6621 Sfmt 6621 E:\HR\OC\39648.XXX 39648

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gression from nationally standardized GS 3 to GS 7 positions, while still responsible 

for scheduling. 

Question 14(b): Can you give us an update of what this work group is planning 

to accomplish? 

Response: VHA has initiated action to standardize the monitoring of scheduler 

compliance and has provided tools to facilitate supervisory actions in monitoring the 

performance of schedulers. The work of this group continues. 

Question 15: Can you please tell us how VHA defined ‘‘waiting times?’’ And is 

your definition standardized across every VISN? 

Response: Wait times are measured for two different groups of patients. ‘‘New 

patients’’ are those patients not seen within the facility within a clinic group within 

the last 24 months. For these new patients, wait times are defined as the days from 

the date an appointment is created until the date the appointment is completed. 

Time the patient spent waiting on the electronic wait list prior to the scheduling 

of the appointment and time added by clinic cancelation of the original appointment 

created are included in the total wait time reported. 

All other patients are designated as ‘‘established patients.’’ Wait times for established patients are defined as the days from the ‘‘desired date’’ entered by the scheduler until the date the appointment is completed. Time the patient spent waiting 

on the electronic wait list prior to the scheduling of the appointment and time added 

by clinic cancelation of the original appointment created are included in the total 

wait time reported. 

Question 16: Please provide documentation of waiting times in the Central Ohio 

region. Specifically, the Subcommittees are interested in what is happening with 

primary and specialty care around the Newark area. Do veterans in Licking County 

have access to more than the Newark Community-Based Outpatient Clinic? 

What are the procedures for arranging treatment at and transportation to the 

Chalmers P. Wylie Independent Outpatient Clinic in Columbus, Ohio? 

Response: Veterans in Licking County have access to the Columbus Independent 

Outpatient Clinic which is 35 miles west of Newark and the Zanesville Community 

Outpatient Clinic which is 33 miles east of Newark. Patients may opt to come to 

the Columbus Clinic on their own or they may be referred by primary care providers 

for specialty services that are offered in Columbus. If patients do not have means 

of transportation, this can be arranged through the Disabled American Veterans 

(DAV). DAV, a veterans service organization, transport patients from different counties around Central Ohio to the Columbus clinic. 

The chart below contains the most recent wait times for all clinics in Newark. A 

psychiatrist goes to Newark 2 days a week. A social worker was recently hired and 

should be able to screen and see new patients more timely until tele-mental health 

can be implemented or additional providers hired. 

Clinic 

Wait in Days 

(Established Patient) 

Wait in Days 

(New Patient) 

Newark/P Care/Physican 1 12 20 

Newark/P Care/Provider 3 26 26 

Newark/Nemali 42 49 

Newark/Social Work 5 5 

Newark/PTSD 16 16 

Newark/Renal 19 19 

Newark/Podiatry 1 1 

Newark/Nutrition 12 12 

The following wait time data are provided. Major enhancements to primary and 

specialty care services took place at the Newark Community-Based Outpatient Clinic (CBOC) in Central Ohio between July 2007 and January 2008. During January 

2008, a total of 671 patients were seen in 14 different clinics at the Newark CBOC. 


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By contrast, during January 2007, 10 patients were seen under the two mental 

health clinics at the Newark CBOC. During July 2007 a total of 22 unique patients 

were served by this CBOC in mental health. Primary care and other specialty care 

services were not available at the Newark CBOC. 

Patient Type 

DSS 

Clinic Stop 

Performance Measure Clinic Group 

July, 2007 

Total 

Patient Appts. 

New 502 Mental Health—Ind 3 

Estab 502 Mental Health—Ind 8 

Estab 566 Mh Risk Fac Red Edu Grp 11 

Patient Type 

DSS 

Clinic Stop 

Performance Measure Clinic Group 

January, 2008 

Total 

Patient Appts. 

Estab 102 Admit/Screening 6 

New 124 Nutr/Diet—Grp 1 

Estab 171 Hbpc Nursing (Rn/Lp) 33 

New 172 Hbpc Physic Extnd (Np,cns,pa) 3 

Estab 172 Hbpc Physic Extnd (Np,cns,pa) 7 

Estab 173 Hbpc—Social Work 4 

Estab 175 Hbpc—Dietician 2 

Estab 301 General Int Med 83 

New 323 Primary Care/Med 17 

Estab 323 Primary Care/Med 265 

New 408 Optometry 35 

Estab 408 Optometry 90 

New 411 Podiatry 4 

Estab 411 Podiatry 6 

New 502 Mental Health—Ind 2 

Estab 502 Mental Health—Ind 76 

Estab 540 Ptsd Clinical Team Pts Ind 10 

Estab 561 Pct Ptsd—Grp 20 

New 566 Mh Risk Fac Red Edu Grp 1 

Estab 566 Mh Risk Fac Red Edu Grp 6 

Question 17: What is the status of the feasibility study conducted by the VA for 

southeastern Ohio? When is it expected to be completed and released? 

Response: The healthcare needs of veterans residing in Southeastern Ohio was 

discussed at a Joint House and Senate Veterans’ Affairs Committee field hearing 

that was held in Ohio on May 29, 2007. VHA committed to evaluating the healthcare needs of veterans residing in southeastern Ohio in response to the assertion 

that there needs to be a VA medical center (VAMC) in this region. 

VHA conducted an analysis, which demonstrated a projected decline in veteran 

population and enrollment by 2025. In addition, the projected bed demand of 29 inpatient medicine beds by 2025 is of concern. Small hospitals (30 beds or less), 

whether VA or non-VA, face significant challenges in providing a full range of services and in maintaining high-quality healthcare across multiple subspecialties. The 

market share (ratio of the number of veterans enrolled in the system to the total 

veteran population) of just those counties that fall within District 18 is 35 percent, 

which is higher than both VISN 10 and national levels. The higher than average 

market share in District 18 indicates that veterans in the area do not perceive a 


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significant access barrier to obtaining care, that is indicative of areas with low market share rates. 

While VHA is not meeting access standards for acute hospital care (see table 

below) in one of the three Ohio markets (i.e., the Central market) there is sufficient 

capacity in other VISN 10 and nearby facilities to meet inpatient needs. As a result 

of this analysis, VA has concluded that there is an insufficient veteran population 

combined with declining demand to support a VA-owned and operated hospital. 

Type of Care Travel Time Standard 

Guideline 

for Percent 

Enrollees 

Living Within 

Travel Time 

VISN 10 FY06 

Market Performance 

Western Central Eastern 

Primary Care 30 Min.—Urban 

30 Min.—Rural 

60 Min.—Highly Rural 

70% 81% 72% 89% 

Acute Care 60 Min.—Urban 

90 Min.—Rural 

120 Min.—Highly Rural 

65% 94% 36% 63% 

Tertiary Care 240 Min.—Urban 

240 Min.—Rural 

Community Standard— 

Highly Rural 

65% 65% 100% 100% 

Question 18: The OIG report documents a number of instances where wait time 

statistics were artificially improved. It is the understanding of the Subcommittees 

that the average wait time is one of the indicators that helps determine bonuses 

for administrators. Is there a correlation between incorrectly improved wait time 

statistics and the bonus amount specific administrators received for FY2007? 

Response: No, VA does not believe that there is a direct correlation between incorrectly improved wait time statistics and the bonus amount specific administrators received for FY 2007. Because waiting times is but one indicator among many 

that facility directors are evaluated on to determine a bonus, a correlation between 

incorrectly improved wait time statistics and a bonus is difficult to characterize. 

Similarly, instances in the IG report cited as wait time errors may be based on different characterization of the data. 

VHA has identified errors associated with projections and surveys conducted by 

the OIG. For example, the OIG reviewed only completed appointments, so documentation that had been created by schedulers would have been obscured by the 

software glitch VHA has identified that truncates text entries under ‘‘other info’’ 

once an appointment is completed (and erased for appointments rescheduled after 

a cancelation). 

The OIG’s methodology was to review a sample of cases to determine the percent 

with what would appear to be incorrect desired appointment dates based on differences between provider instructions and scheduler entered desired dates, and an 

absence of documentation to explain the use of these desired dates. OIG then 

projects this rate of differences between the desired dates entered by providers, and 

the desired dates entered by schedulers (and used by VHA to calculate waiting 

times) on the entire population of scheduled appointments. Example: In reviewing 

desired dates entered for 750 established patient appointments in VISN 3, OIG 

identified differences between the desired dates specified by providers versus those 

entered by schedulers in 394 of these appointments (53 percent). When they applied 

this discrepancy rate to all established patient appointments, they concluded 98,454 

established patient appointments would be subject to the same discrepancy. 

The OIG measures new patient wait times differently than VHA. VHA measures 

new patient wait times from the date an appointment is created until the date of 

the appointment. Relative to appointments created in response to consults or new 

patient requests, because there is a lag time between these requests and creation 

of an appointment (VHA has allowed a 7 day lag time). OIG states VHA understates 

wait times in its reports. On the other hand, we believe it is equally possible that 

actual waiting times for new patients are overstated because when schedulers contact a patient to create an appointment, the patient is offered the opportunity to 

say when they want to be seen—their desired date. Their desired date may be a 

future date. Because VHA does not measure new patient wait time from desired 

date, but rather from appointment creation date, each time the patient expresses 


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a preference for a future appointment date, wait times are understated. It appears 

the new patient is waiting longer when using the creation date to measure new patient wait time, rather than the desired date specified by a patient when that date 

is some time in the future. 

Question 19: Has there been any evidence (anecdotal or otherwise) to indicate 

that schedulers were encouraged to falsify records specifically for the purpose of increasing bonuses? 

Response: We have no evidence to substantiate this claim. In its 2005 Report of 

Audit of Scheduling, the OIG reported that 10 percent of the schedulers who responded to its survey said that their leadership had pressured them to keep wait 

lists short, causing them to circumvent established procedures for scheduling. In its 

2007 Report of Audit of Scheduling at 10 facilities, there was no mention of findings 

that schedulers were pressured by leadership to keep wait lists short by circumventing established procedures for scheduling. In its 2008 Report of Audit of Scheduling at 5 facilities within VISN 3, the OIG reported it found no evidence of leaders 

or managers threatening staff in a manner that encouraged a willful manipulation 

of scheduling procedures. 

Question 20: When determining Medical Center Director bonus amounts, is there 

a specific formula equating wait times to a bonus dollar amount? 

Response: There is no specific formula. Medical Center Directors are evaluated 

on the entire executive career field performance contract as well as additional measures/monitors identified by their respective network director. 

Æ 


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