VA HEALTH CARE

Actions Needed to 

Improve Access to Primary 

Care for Newly Enrolled 

Veterans

Statement of Debra A. Draper

Director, Health Care

Testimony 

Before the Committee on Veterans’

Affairs, House of Representatives

For Release on Delivery 

Expected at 10:30 a.m. ET

Tuesday, April 19, 2016

GAO-16-562T

United States Government Accountability Office
Letter

Page 1 GAO-16-562T 

Chairman Miller, Ranking Member Brown, and Members of the 

Committee:

I am pleased to be here today as you discuss issues concerning veterans’

access to health care. My remarks today are based on our report that was 

released yesterday, VA Health Care: Actions Needed to Improve Newly 

Enrolled Veterans’ Access to Primary Care. This report is the latest in our 

ongoing body of work examining veterans’ access to timely health care.1

The Department of Veterans Affairs’ (VA) Veterans Health Administration 

(VHA) operates one of the nation’s largest health care systems; it 

provided care to about 6.6 million veterans in fiscal year 2014, including

an aging veteran population and a growing number of younger veterans 

returning from military operations in Afghanistan and Iraq. VHA spent 

about $58 billion for their care in that year. Over the past decade, VHA 

has faced a growing demand for outpatient primary care services. From 

fiscal years 2005 through 2014, the number of annual outpatient primary 

care medical appointments VHA provided through its medical facilities 

increased by 17 percent, from approximately 10.2 million to 11.9 million. 

Each year over that period, an average of 380,000 veterans were newly 

enrolled in VHA’s health care system. In fiscal year 2014, VHA provided 

about 730,000 primary care appointments for new patients—

appointments for those patients who had not been seen in a primary care 

clinic in the past 24 months, including those who were newly enrolled.

Primary care services are often the entry point to the VHA health care 

system for veterans, and access to these services is critical to ensuring 

that veterans obtain needed medical care, including specialty care. When 

veterans need specialty care—such as cardiology or gastroenterology—

they are typically referred to specialists by their primary care providers, 

 1

See VA Health Care: Actions Needed to Improve Newly Enrolled Veterans’ Access to 

Primary Care, GAO-16-328 (Washington, D.C.: Mar. 18, 2016). See also GAO, VA Mental 

Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, GAO-16-24 

(Washington, D.C.: Oct. 28, 2015); VA Health Care: Management and Oversight of 

Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient 

Specialty Care, GAO-14-808 (Washington, D.C.: Sept. 30, 2014); VA Health Care: 

Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling 

Oversight Need Improvement, GAO-13-130 (Washington, D.C.: Dec. 21, 2012); VA 

Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts to 

Increase Access, GAO-12-12 (Washington, D.C.: Oct. 14, 2011); and VA Faces 

Challenges in Providing Substance Use Disorder Services and Is Taking Steps to Improve 

These Services for Veterans, GAO-10-294R (Washington, D.C.: Mar. 10, 2010). 

Letter
Page 2 GAO-16-562T 

and each veteran’s primary care team manages and coordinates the 

needed care.2 Veterans may obtain primary care services at VHA’s 

medical facilities, which include 167 medical centers and more than 800 

community-based outpatient clinics. Responsibility for ensuring timely 

access to primary care rests with 20 regional Veterans Integrated Service 

Networks (VISN), which oversee the medical centers, and with VHA’s 

central office, which oversees the entire VA health care system.

In recent years, we and others have expressed concerns about VHA’s 

ability to effectively provide and oversee timely access to health care for 

veterans, which, in some cases, reportedly has resulted in harm to 

veterans. Our prior work on VHA’s oversight of primary and specialty care 

found VHA did not have adequate data and oversight mechanisms in 

place to ensure veterans receive timely care. For example, since 2012, 

we have issued several reports recommending that VA improve 

appointment scheduling, ensure the reliability of wait-time and other 

performance data, and improve oversight to ensure VA medical centers 

provide veterans with timely access to outpatient primary and specialty 

care, as well as mental health care.3 Based on these serious concerns 

about VA’s management and oversight of its health care system, we have 

concluded that VA health care is a high-risk area and, in 2015, added it to 

our High Risk List.4 To help improve timely access to health care, 

Congress passed the Veterans Access, Choice, and Accountability Act of 

2014 (Choice Act), which provided veterans facing long waits or lengthy 

 2

VHA provides primary care services through patient aligned care teams consisting of a 

primary care provider and support staff, including a nurse care manager, clinical associate 

such as a licensed practical nurse, and administrative clerk.

3

See GAO-16-328, GAO-16-24, GAO-14-808, GAO-13-130, and GAO-10-294R.

4

GAO, High Risk Series: An Update, GAO-15-290, (Washington, D.C.: February 2015). 

GAO maintains a high-risk program to focus attention on government operations that it 

identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and 

mismanagement or the need for transformation to address economy, efficiency, or 

effectiveness challenges.
Page 3 GAO-16-562T 

travel distances the opportunity to obtain care from providers (non-VA) in 

the community.5

In the context of these serious and longstanding concerns, my testimony 

today highlights selected findings from our most recent report on 

veterans’ access to primary care. My remarks will therefore focus on the 

extent to which

1. newly enrolled veterans access primary care in a timely manner; and

2. VHA provides oversight of veterans’ access to primary care.

For our report, we reviewed relevant regulations, guidance, and other key 

documents, as well as interviewed staff with responsibility for ensuring 

timely access to primary care, including officials from VA, VHA, six VA 

medical centers, and the six corresponding VISNs that oversee the 

medical centers in our review.6 We selected the medical centers based 

on variation in average wait times for primary care appointments, facility 

complexity, and geographic location. From these medical centers, we 

selected a sample of 60 newly enrolled veterans (10 randomly selected 

from each of the six medical centers), all of whom had requested VA 

contact them to schedule medical appointments, but had not been seen 

by primary care providers. We also selected a sample of 120 newly 

enrolled veterans (20 randomly selected from each of the six medical 

centers), all of whom had requested that VA contact them to schedule 

medical appointments and were seen by primary care providers. We 

examined the medical records for each of these 180 veterans to 

determine the history of actions taken to schedule appointments, such as 

dates the appointments were scheduled and dates veterans were seen by 

primary care providers, if applicable. We also evaluated VHA’s 

mechanisms for overseeing veterans’ access to primary care against the 

 5

Pub. L. No. 113-146, 128 Stat. 1754 (2014). Under this authority, VHA created the 

Veterans Choice Program, which was introduced in November 2014. Under the program, 

for example, certain veterans are able to receive care in the community, including primary 

care, if the next available medical appointment with a VA provider is more than 30 days 

from the date a veteran wants to see a provider or if the veteran lives more than 40 miles 

driving distance from the nearest VA facility.

6

These medical centers were: VA Central Western Massachusetts Healthcare System 

(Leeds, Massachusetts); Tennessee Valley Healthcare System (Nashville, Tennessee); 

Fayetteville VA Medical Center (Fayetteville, North Carolina); Ralph H. Johnson VA 

Medical Center (Charleston, South Carolina); VA Eastern Kansas Health Care System 

(Leavenworth, Kansas); and VA San Diego Healthcare System (San Diego, California).
Page 4 GAO-16-562T 

federal internal control standards related to control activities, information, 

and monitoring.7 Additional information on our scope and methodology is 

available in our report. The work this testimony is based on was 

performed in accordance with generally accepted government auditing 

standards.

Our review of medical records for a sample of newly enrolled veterans at 

six VA medical centers found several problems in medical centers’

processing of veterans’ requests that VA contact them to schedule 

appointments, and thus not all newly enrolled veterans were able to 

access primary care. For the 60 newly enrolled veterans in our review 

who requested care but had not been seen by primary care providers, we 

found that 29 did not receive appointments due to the following problems 

in the appointment scheduling process:

• Veterans did not appear on VHA’s New Enrollee Appointment 

Request (NEAR) list. We found that although 17 newly enrolled 

veterans in our review requested that VA contact them to schedule 

appointments, medical center officials said that schedulers did not 

contact the veterans because they had not appeared on the NEAR 

list.8 According to VHA policy, as outlined in its July 2014 interim 

scheduling guidance, VA medical center staff should contact newly 

enrolled veterans to schedule appointments within 7 days from the 

date they were placed on the NEAR list.9 Medical center officials were 

not aware that this problem was occurring, and could not definitively 

tell us why these veterans never appeared on the NEAR list.

 7

See GAO, Standards for Internal Control in the Federal Government

GAO/AIMD-00-21.3.1. (Washington, D.C.: November 1999). Internal control is a process 

effected by an entity’s oversight body, management, and other personnel that provides 

reasonable assurance that the objectives of an entity will be achieved. 

8

Veterans who request on their applications for health benefits that VA contact them to 

schedule appointments are to be placed on the NEAR list. The NEAR list is intended to 

help VA medical centers track newly enrolled veterans needing appointments.

9

Department of Veterans Affairs, “Rescission of VHA Outpatient Scheduling Policy and 

Procedures and Interim Guidance,” (Washington, D.C.: July 7, 2014). This interim 

guidance rescinded and replaced VHA Directive 2010-027 Outpatient Scheduling 

Processes and Procedures (June 9, 2010). 

Problems Newly 

Enrolled Veterans 

Faced in Accessing

Primary Care and 

Obtaining Timely 

Access to Care
Page 5 GAO-16-562T 

• VA medical center staff did not follow VHA scheduling policy. We 

found that VA medical centers did not follow VHA policies for 

contacting newly enrolled veterans for 12 veterans in our review. VHA 

policy states that medical centers should document three attempts to 

contact each newly enrolled veteran by phone, and if unsuccessful, 

send the veteran a letter. However, for 5 of 12 newly enrolled 

veterans, our review of their medical records revealed no attempts to 

contact them, and medical center officials could not tell us whether the 

veterans had ever been contacted to schedule appointments. Medical 

center staff attempted to contact the other 7 veterans at least once

each, but failed to reach out to them with the frequency required by 

VHA policy.

For the remaining 31 of 60 newly enrolled veterans included in our review

who did not have a primary care appointment:

• 24 were unable to be contacted to schedule appointments or upon 

contact, declined care, according to VA medical center officials. These 

officials said that in some cases they were unable to contact veterans 

due to incorrect or incomplete contact information in veterans’

enrollment applications; in other cases, they said veterans were 

seeking a VA identification card, for example, and did not want to be 

seen by a provider at the time they were contacted.

• 7 had appointments scheduled but had not been seen by primary care 

providers at the time of our review. Four of those veterans had initial 

appointments that needed to be rescheduled, which had not yet been 

done at the time of our review. Appointments for the remaining 3 

veterans were scheduled after VHA provided us with a list of veterans 

who had requested care.

For the 120 newly enrolled veterans across the six VA medical centers in 

our review who requested care and were seen by primary care providers, 

we found the average number of days between newly enrolled veterans’

initial requests that VA contact them to schedule appointments and the 

dates the veterans were seen by primary care providers ranged from 22 

days to 71 days. Slightly more than half of the 120 veterans in our sample 

were seen by providers in less than 30 days; however, veterans’

experiences varied widely, even within the same medical center, and 12 

of the 120 veterans in our review waited more than 90 days to be seen by 

a provider.
Page 6 GAO-16-562T 

We found that two factors generally impacted newly enrolled veterans’

experiences regarding the number of days it took to be seen by primary 

care providers:

1. Appointments were not always available when veterans wanted 

to be seen, which contributed to delays in receiving care. For 

example, one veteran was contacted within 7 days of being placed on 

the NEAR list, but no appointment was available until 73 days after 

the veteran’s preferred appointment date, and a total of 94 days 

elapsed before the veteran was seen by a provider. In another 

example, a veteran wanted to be seen as soon as possible, but no 

appointment was available for 63 days. Officials at each of the six 

medical centers in our review told us that they have difficulty keeping 

up with the demand for primary care appointments for new patients 

because of shortages in the number of providers, or lack of space due 

to rapid growth in the demand for these services.

2. Weaknesses in VA medical center scheduling practices may 

have impacted the amount of time it took for veterans to see 

primary care providers and contributed to unnecessary delays. 

Staff at the medical centers in our review did not always contact 

veterans to schedule appointments in accordance with VHA policy, 

which states that attempts to contact newly enrolled veterans to 

schedule appointments must be made within 7 days of their addition 

to the NEAR list. Among the 120 veterans included in our review that 

were seen by primary care providers, 37 (31 percent) were not 

contacted within 7 days to schedule an appointment; compliance 

varied across medical centers.

As a result of these findings, we recommended that VHA review its 

processes for identifying and documenting newly enrolled veterans 

requesting appointments and revise as appropriate, to ensure that all 

veterans requesting appointments are contacted in a timely manner to 

schedule them. VHA concurred with this recommendation, and indicated 

that by December 31, 2016, it plans to review and revise the process from 

enrollment to scheduling to ensure that newly enrolled veterans 

requesting appointments are contacted in a timely manner. VHA also 

indicated that it will implement internal controls to ensure its medical 

centers are appropriately implementing the process.
Page 7 GAO-16-562T 

VHA’s oversight of veterans’ access to primary care is hindered, in part, 

by data weaknesses and the lack of a comprehensive scheduling policy, 

both of which are inconsistent with federal internal control standards.10

These standards call for agencies to have reliable data and effective 

policies to achieve their objectives, and for information to be recorded and 

communicated to the entity’s management and others who need it to 

carry out their responsibilities.

A key component of VHA’s oversight of veterans’ access to primary care, 

particularly for newly enrolled veterans, relies on monitoring appointment 

wait times. However, VHA monitors only a portion of the overall time it 

takes newly enrolled veterans to access primary care.11 For newly 

enrolled veterans, VHA calculates primary care appointment wait times 

starting from veterans’ preferred dates, rather than the dates veterans 

initially requested that VA contact them to schedule appointments. (A 

preferred date is the date that is established when a scheduler contacts 

the veteran to determine when he or she wants to be seen.) Therefore, 

these data do not capture the time veterans wait prior to being contacted 

by schedulers, making it difficult for officials to identify and remedy 

scheduling problems that may arise prior to making contact with veterans. 

(See fig. 1.)

 10See GAO/AIMD-00-21.3.1. 

11We recently reported that VA similarly focuses on only a portion of the overall time 

veterans wait to see mental health providers. See GAO-16-24. 

VHA’s Oversight of 

Veterans’ Access to 

Primary Care Is 

Hindered in Part by 

Data Weaknesses
Page 8 GAO-16-562T 

Figure 1: Illustration of How the Overall Time It Takes a Veteran to See a Provider 

May Differ from the Wait Time Calculated by the Veterans Health Administration 

(VHA) 

Our review of medical records for 120 newly enrolled veterans found that, 

on average, the total amount of time it took to be seen by primary care 

providers was much longer when measured from the dates veterans 

initially requested VA contact them to schedule appointments than it was 

when using appointment wait times calculated using veterans’ preferred 

dates as the starting point. For example, we found one veteran applied for 

VHA health care benefits in December 2014, which included a request to 

be contacted for an initial appointment. The VA medical center contacted 

the veteran to schedule a primary care appointment 43 days later. When 

making the appointment, the medical center recorded the veteran’s 

preferred date as March 1, 2015, and the veteran saw a provider on 

March 3, 2015. Although the medical center’s data showed the veteran 

waited 2 days to see a provider, the total amount of time that elapsed 

from the veteran’s request until the veteran was seen was actually 76 

days.

Further, ongoing scheduling errors, such as incorrectly revising preferred 

dates when rescheduling appointments, understated the amount of time 

veterans waited to see providers.12 For example, during our review of 

appointment scheduling for 120 newly enrolled veterans, we found that 

 12VHA policy states that when a clinic cancels a veteran’s appointment, the preferred date 

recorded in the initial appointment should be maintained in the system and not revised 

when the appointment is rescheduled. 
Page 9 GAO-16-562T 

schedulers in three of the six VA medical centers included in our review 

had made errors in recording veterans’ preferred dates when making 

appointments. For example, in some cases primary care clinics cancelled 

appointments, and when those appointments were re-scheduled, 

schedulers did not always maintain the original preferred dates in the 

system, but updated them to reflect new preferred dates recorded when 

the appointments were rescheduled. We found 15 appointments for which 

schedulers had incorrectly revised the preferred dates. In these cases, we 

recalculated the appointment wait time based on what should have been 

the correct preferred dates, according to VHA policy, and found the waittime data contained in the scheduling system were understated. Officials 

attributed these errors to confusion by schedulers resulting from the lack 

of an updated standardized scheduling directive, which VHA rescinded 

and replaced with an interim directive in July 2014.13 As in our previous 

work, we continue to find scheduling errors that affect the reliability of 

wait-time data used for oversight, which make it difficult to effectively 

oversee newly enrolled veterans’ access to primary care.

As a result of these findings, we recommended that VHA monitor the full 

amount of time newly enrolled veterans wait to receive primary care, and 

issue an updated scheduling directive. VHA concurred with both of these 

recommendations, and indicated that by December 31, 2016, it plans to 

begin monitoring the full amount of time newly enrolled veterans wait to 

be seen by primary care providers. It also indicated that it plans to submit 

a revised scheduling directive for VHA-wide internal review by May 1, 

2016.

This most recent work on veterans’ access to primary care expands 

further the litany of VA health care deficiencies and weaknesses that we 

have identified over the years, particularly since 2010. As of April 1, 2016, 

there were about 90 GAO recommendations regarding veterans’ health 

care awaiting action by VHA. These include more than a dozen 

recommendations to address weaknesses in the provision and oversight 

of veterans’ access to timely primary and specialty care, including mental 

health care. Until VHA can make meaningful progress in addressing 

 13Department of Veterans Affairs, Rescission of VHA Outpatient Scheduling Policy and 

Procedures and Interim Guidance, (Washington, D.C.: July 7, 2014). This interim 

guidance rescinded and replaced VHA Directive 2010-027, Outpatient Scheduling 

Processes and Procedures (June 9, 2010). Subsequent to this interim directive VHA 

issued numerous individual memos to clarify and update its scheduling policies.
Page 10 GAO-16-562T 

these and other recommendations, which underscore a system in need of 

major transformation, the quality and safety of health care for our nation’s 

veterans is at risk.

Chairman Miller, Ranking Member Brown, and Members of the 

Committee, this concludes my prepared statement. I would be pleased to 

answer any questions that you may have at this time.

If you or your staff members have any questions concerning this 

testimony, please contact Debra A. Draper at (202) 512-7114 or 

draper@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this 

statement. Other individuals who made key contributions are Janina 

Austin, Assistant Director; Jennie F. Apter; Emily Binek; David 

Lichtenfeld; Vikki L. Porter; Brienne Tierney; and Emily Wilson.

GAO Contact and 

Staff 

Acknowledgments

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