VETERANS HEALTH 

ADMINISTRATION

Opportunities Exist for 

Improving Veterans’

Access to Health Care 

Services in the Pacific 

Islands

Report to Congressional Addressees

April 2018

GAO-18-288

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-288, a report to 

congressional addresses

April 2018

VETERANS HEALTH ADMINISTRATION

Opportunities Exist for Improving Veterans’ Access 

to Health Care Services in the Pacific Islands

What GAO Found

For the sample of veterans’ medical records that GAO reviewed, most veterans

received primary and mental health care from the Department of Veterans Affairs 

(VA) Pacific Islands Health Care System (VAPIHCS) within timeliness goals set 

by VA’s Veterans Health Administration (VHA). However, GAO also found that 

some of these veterans experienced delays related to the processing of their 

enrollment applications, contacting them to schedule appointments, and 

completing comprehensive mental health evaluations. These delays were similar 

to some GAO had identified in previous work pertaining to veterans’ access to 

care nationwide.

For the sample of veterans’ medical records that GAO reviewed, VAPIHCS 

referred nearly all specialty care to non-VA providers within VHA’s timeliness 

goal, but the time taken to provide care was variable and sometimes lengthy. 

Specifically, VAPIHCS sent specialty care referrals to

• the Veterans Choice Program (Choice Program)—for veterans that GAO 

reviewed, the number of days to receive care from the Choice Program 

was, on average, 75 days. 

• Department of Defense (DOD) military treatment facilities—for veterans 

that GAO reviewed, the number of days to receive care from the two 

DOD facilities for which VAPIHCS has agreements was, on average, 37

days from one facility and 47 days from the other.

GAO identified weaknesses in VAPIHCS’ management of its referral process for 

sending veterans for specialty care services at one of the two military treatment 

facilities. GAO found VAPIHCS did not always manage referrals to the military 

treatment facility in a timely way and there was inconsistent guidance describing 

the roles and responsibilities of the VAPIHCS staff involved in the process. 

These weaknesses may have contributed to the amount of time it took for 

veterans to receive specialty care services.

GAO also found that VAPIHCS faces challenges recruiting and retaining 

physicians. As of October 2017, 17 of approximately 100 VAPIHCS physician

positions were vacant, as were several other types of health care providers. 

Some of the challenges VAPIHCS faced are unique to the Pacific Islands, such 

as the availability of only one local medical school from which to recruit, along 

with travel burdens and a high cost of living that may discourage physicians from 

relocating there. Other challenges were similar to those GAO has previously 

identified as faced by VA medical centers across the country, such as 

differences in interpretation of hiring and recruiting policies. VAPIHCS officials 

said they use several strategies to help recruit and retain physicians, including 

VHA strategies used by other VA medical centers such as financial incentives 

and an educational debt reduction program. Although they described limits to the 

success of some of these strategies, they have not evaluated their effectiveness. 

Without completing an evaluation of its strategies, VAPIHCS may not be 

optimizing its resources to improve its hiring efforts and may continue to struggle 

with physician shortages.

Why GAO Did This Study

Veterans’ access to timely health care 

at VA medical facilities has been a 

long-standing problem identified by 

GAO and VA’s Office of Inspector 

General. The remote nature of the 

Pacific Islands creates some unique 

challenges for VAPIHCS, which may 

affect its ability to provide the 

approximately 50,000 veterans it 

serves in American Samoa, Guam, 

Hawaii, and the Commonwealth of the 

Northern Mariana Islands with timely 

access to primary, mental health, and 

specialty care.

House Report 114–497 included a 

provision for GAO to review VHA’s 

efforts to provide timely access to 

health care within VAPIHCS. Among 

other things, this report examines: the 

extent to which the VAPIHCS veterans 

received (1) timely primary and mental 

health care, and (2) timely specialty 

care; and (3) any challenges VAPIHCS 

faced in recruiting and retaining 

physicians, and strategies to resolve

them. GAO reviewed relevant policy 

documents and a randomly selected, 

non-generalizable sample of 164 

medical records, and interviewed VHA, 

VAPIHCS, and DOD officials.

What GAO Recommends

GAO makes four recommendations, 

including that VAPIHCS improve 

monitoring of referrals to one DOD 

facility and evaluate the effectiveness 

of physician recruitment and retention 

strategies. VA concurred with three 

recommendations and partially 

concurred with the fourth. GAO 

maintains that monitoring referrals to 

the DOD facility is needed, as 

discussed in the report.

View GAO-18-288. For more information, 

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

draperd@gao.gov.
Page i GAO-18-288 Veterans Health Administration

Letter 1

Background 8

Most Veterans in Our Review Received Primary and Mental 

Health Care from VA Providers within VHA’s Timeliness Goals, 

although Some Faced Delays 13

VAPIHCS Referred Most Specialty Care to Non-VA Providers 

within VHA’s Timeliness Goal, but Time Taken to Provide Care 

Was Variable and Sometimes Lengthy 22

VAPIHCS Has Faced Physician Recruitment and Retention 

Challenges, but Has Not Evaluated the Strategies It Used to 

Help Resolve Them 34

Veterans Face a Number of Challenges Accessing Health Care in 

the Pacific Islands, and VAPIHCS Uses Several Strategies to 

Improve Access 42

Conclusions 50

Recommendations for Executive Action 51

Agency Comments and Our Evaluation 52

Appendix I Department of Veterans Affairs Comments 55

Appendix II GAO Contact and Staff Acknowledgments 59

Related GAO Products 60

Tables

Table 1: Information on the Sample of Medical Records GAO 

Reviewed from the Department of Veterans Affairs (VA) 

Pacific Islands Health Care System (VAPIHCS) 6

Table 2: Number of Veterans Enrolled in and Using Outpatient 

Care from the Department of Veterans Affairs (VA) Pacific 

Islands Health Care System (VAPIHCS) in Fiscal Year 

2017, by Clinic 9

Table 3: Timeliness of Processing Enrollment Applications by the 

VA Pacific Islands Health Care System for a Sample of 

Newly Enrolled Veterans 14

Contents
Page ii GAO-18-288 Veterans Health Administration

Table 4: Timeliness of Contacting and Receiving Initial Primary 

Care Appointments by the VA Pacific Islands Health Care 

System for a Sample of Newly Enrolled Veterans 16

Table 5: Timeliness of Receiving Initial Mental Health Care 

Appointments by the VA Pacific Islands Health Care 

System for a Sample of Veterans 18

Table 6: Timeliness of Completing Comprehensive Mental Health 

Evaluations by the VA Pacific Islands Health Care System 

for a Sample of Veterans 19

Table 7: Timeliness of Receiving Follow-Up Primary Care and 

Mental Health Care Appointments by the VA Pacific 

Islands Health Care System for a Sample of Veterans 21

Table 8: Timeliness of Scheduling Select Specialty Care 

Appointments by TriWest for a Sample of Referrals 

Referred from the VA Pacific Islands Health Care System 

(VAPIHCS) 25

Table 9: Range and Average Number of Days to Receive 

Specialty Care from Choice Program Providers for a 

Sample of Referrals Sent from the VA Pacific Islands 

Health Care System (VAPIHCS) 27

Table 10: Range and Average Number of Days to Receive 

Specialty Care from Military Treatment Facilities for a 

Sample of Referrals from the VA Pacific Islands Health 

Care System 28

Table 11: Type of Care Provided by Travelling Department of 

Veterans Affairs Pacific Islands Health Care System 

(VAPIHCS) Providers and the Frequency of Their Visits, 

by Clinic, as of December 2017 47

Figures

Figure 1: Number and Percent of Referrals the Department of 

Veterans Affairs (VA) Pacific Islands Health Care System 

(VAPIHCS) Sent to Non-VA Care in Fiscal Year 2017 12

Figure 2: Distances and Flight Times Veterans Enrolled in the 

Department of Veterans Affairs Pacific Islands Health 

Care System (VAPIHCS) May Need to Travel to Receive 

Care 44
Page iii GAO-18-288 Veterans Health Administration

Abbreviations

DOD Department of Defense

TAMC Tripler Army Medical Center

NHG U.S. Naval Hospital Guam

OIG Office of Inspector General

VA Department of Veterans Affairs

VAMC Veterans Affairs medical center

VAPIHCS VA Pacific Islands Health Care System

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-18-288 Veterans Health Administration

441 G St. N.W.

Washington, DC 20548

April 12, 2018

Congressional Addressees

The Veterans Health Administration (VHA), within the Department of 

Veterans Affairs (VA), operates one of the nation’s largest health care 

systems. In fiscal year 2016, VHA provided care to about 6.9 million 

veterans and obligated about $65 billion for their care through 170 VA 

medical centers (VAMC) and 1,082 clinics nationwide. The VA Pacific 

Islands Health Care System (VAPIHCS) is part of Veterans Integrated 

Service Network (VISN) 21 and includes 1 of VHA’s 170 VAMCs—the 

Spark M. Matsunaga VAMC, located in Honolulu, Hawaii—and 10 clinics 

located across the Pacific Islands.1 VAPIHCS provides health care 

services to approximately 50,000 veterans that reside in the Pacific 

Islands of Hawaii, American Samoa, Guam, and the Commonwealth of 

the Northern Mariana Islands. While some outpatient specialty care is 

provided at the Spark M. Matsunaga VAMC and the 10 clinics, VAPIHCS 

primarily provides outpatient primary and mental health care services. 

Unlike most VAMCs, the Spark M. Matsunaga VAMC does not include an 

inpatient hospital. For most inpatient and other specialty care, veterans 

are referred to local military treatment facilities through joint venture and 

sharing agreements with the Department of Defense (DOD) or to non-VA 

providers in the community.2 In particular, VAPIHCS partners with Tripler 

Army Medical Center (TAMC) through a joint venture in Hawaii and U.S. 

Naval Hospital Guam (NHG) through a sharing agreement, and also 

 1

VHA’s health care system is divided into 18 health care networks, referred to as VISNs, 

which are responsible for managing and overseeing VAMCs within a defined geographic 

area. There were previously 21 VISNs, but VA consolidated some networks so that there 

were 18 VISNs by fiscal year 2018. VISN 21 was not renamed following the consolidation.

2

VA and DOD must facilitate the mutually beneficial coordination, use, or exchange of use 

of the health care resources of the two departments. 38 U.S.C. 8111(a). VA and DOD 

collaborate through joint venture and sharing agreements to provide health care services

to VA and DOD beneficiaries, reimbursing each other for the services provided. A joint 

venture involves the sharing of multiple health care services and sometimes facilities. A 

sharing agreement ranges in complexity and scope from sharing a single service to 

agreements that govern the sharing of multiple services. 

Military treatment facilities include military hospitals, ambulatory care clinics, and dental 

clinics owned by DOD and staffed by the military services (Army, Navy and Air Force) 

under the command of the respective Surgeons General. 

Letter
Page 2 GAO-18-288 Veterans Health Administration

offers veterans access to non-VA providers in the community through the 

Veterans Choice Program (Choice Program).3

In recent years, we and the VA Office of the Inspector General (OIG) 

have expressed concerns about veterans’ ability to access timely medical 

care and VHA’s oversight of its appointment scheduling practices.4 VHA 

has timeliness goals outlined in policies that measure the amount of time 

it should take to schedule appointments, and for veterans to receive 

health care services. Additionally, we and the VA OIG have expressed 

concerns about whether VHA is able to ensure that it has the appropriate 

clinical workforce to meet the needs of veterans.5 The VA OIG also has 

found that VAPIHCS faces unique challenges in providing patient care 

given the geographic remoteness of the Pacific Islands, and identified 

concerns including about lengthy wait times for primary care.6

House report 114-497, which accompanied the Military Construction, 

Veterans Affairs, and Related Agencies Appropriations Bill, 2017, 

 3

The Choice Program was enacted by the Veterans Access, Choice, and Accountability 

Act of 2014 to address longstanding challenges with veterans’ access to care at VAMCs. 

Under the Choice Program, eligible veterans may receive care from non-VA health care 

providers when they experience long wait times, lengthy travel distances, or other 

challenges accessing VA care. The VA uses two contractors to administer the program. 

TriWest Healthcare Alliance Corp. (TriWest) is the contractor for VISN 21. 

4

See, for example, GAO, VA Health Care: Reliability of Reported Outpatient Medical 

Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-13-130 

(Washington, D.C.: Dec. 21, 2012); VA Mental Health: Clearer Guidance on Access 

Policies and Wait-Time Data Needed, GAO-16-24 (Washington, D.C.: Oct. 28, 2015); and 

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

Care, GAO-16-328 (Washington, D.C.: Mar. 18, 2016). In addition, see, for example, 

Department of Veterans Affairs, Office of Inspector General, Veterans Health 

Administration: Audit of Veteran Wait Time Data, Choice Access, and Consult 

Management in VISN 6; Report No. 16-02618-424 (Washington, D.C.: Mar. 2, 2017), and 

Veterans Health Administration: Review of Veterans’ Access to Mental Health Care, 

Report No. 12-00900-168 (Washington, D.C.: Apr. 23, 2012).

5

See, for example, GAO, Veterans Health Administration: Better Data and Evaluation 

Could Help Improve Physician Staffing, Recruitment, and Retention Strategies, 

GAO-18-124 (Washington, D.C.: Oct. 19, 2017), and OIG Determination of Veterans 

Health Administration’s Occupational Staffing Shortages, Report No. 16-00351-453 (Sept. 

28, 2016). 

6

See U.S. Department of Veterans Affairs Office of Inspector General, Combined 

Assessment Program Review of the VA Pacific Islands Health Care System Honolulu, 

Hawaii, Report No. 15-00626-28 (Nov. 10, 2015) and Healthcare Inspection

Summarization of Select Aspects of the VA Pacific Islands Health Care System Honolulu, 

Hawaii, Report No. 15-04655-347 (Sept. 22, 2016).
Page 3 GAO-18-288 Veterans Health Administration

included a provision for us to review the scheduling, staffing, outreach, 

and access management practices at VAPIHCS. This report examines:

1. the extent to which veterans in the Pacific Islands receive primary and 

mental health care from VA providers within VHA’s timeliness goals;

2. the extent to which veterans in the Pacific Islands are referred to and 

receive specialty care from non-VA providers within VHA’s timeliness 

goals;

3. the challenges, if any, in the recruitment and retention of physicians in 

the Pacific Islands, and the extent to which strategies are used to help 

resolve any such challenges; and

4. the challenges, if any, veterans in the Pacific Islands face in 

accessing care, and the strategies used to improve veterans’ timely 

access to care.

To examine all four objectives, we focused our review on services 

provided to veterans in 3 of the 10 clinics—located on the islands of 

American Samoa, Guam and Maui—because they provided the most 

comparable types of primary and mental health care services across all 

clinics. We interviewed VAPIHCS officials, DOD officials, and a local 

representative of TriWest, the third-party administrator for the Choice 

Program in VISN 21, the program through which most veterans in the 

Pacific Islands receive non-VA care, and we conducted site visits to the 

VA and DOD facilities in Guam and Honolulu in April 2017.7 We 

interviewed VA and DOD officials, and the local TriWest representative 

about policies and guidance for scheduling veterans for outpatient 

primary, mental health, and specialty care; arranging for and providing 

specialty care at a DOD military treatment facility or with a non-VA 

provider in the community; physician recruitment and retention 

challenges; and challenges veterans have with accessing health care 

 7

Veterans may also receive care from non-VA providers in the community through other 

programs, such as the Patient-Centered Community Care Programs or individual 

authorizations to community providers. The VA Budget and Choice Improvement Act, 

which was enacted on July 31, 2015, required VA to develop a plan for consolidating all of 

its community care programs into a new, single program to be known as the “Veterans 

Choice Program.” VHA submitted this plan, which included proposed legislative changes, 

to Congress on Oct. 30, 2015, and according to this plan, the agency expects to 

implement a consolidated community care program in fiscal year 2018. See Department of 

Veterans Affairs, Plan to Consolidate Programs of Department of Veterans Affairs to 

Improve Access to Care, (Washington, D.C.: Oct. 30, 2015).

We did not travel to American Samoa and Maui, but spoke with clinic staff from these 

locations via teleconference while in Honolulu.
Page 4 GAO-18-288 Veterans Health Administration

services in the Pacific Islands. In addition, we discussed access to care 

challenges with community stakeholders, including with members from a 

local advisory council that represents veterans on Guam.8

To examine the extent to which veterans accessed primary and mental 

health care from VA providers, and specialty care services from non-VA 

providers, within VHA’s timeliness goals, we reviewed relevant VHA 

policies for veteran enrollment application processing and appointment 

scheduling within VA facilities, and for facilitation of health care services 

referred outside a VA facility.9 We also examined VAPIHCS’ joint venture 

and sharing agreements with DOD and VA’s Choice Program contract 

with TriWest. In addition, we compared the processes VAPIHCS followed 

to refer veterans to care outside a VA facility to appropriate federal 

internal control standards.10 Additionally, we interviewed officials from 

VHA’s Office of Veteran Access to Care, Office of Mental Health 

Services, and Office of Community Care to obtain information on VHA’s 

scheduling policies. To measure the timeliness of care provided by VA 

and non-VA providers, we reviewed a sample of 164 medical records of 

veterans enrolled at clinics on the islands of American Samoa, Guam, 

and Maui. The results from our review cannot be generalized to all 

veterans within VAPIHCS, or to other VAMCs, but provide insights into 

the extent to which veterans were able to receive timely access to health 

care services. Our sampling methodology for the 164 medical records 

included requesting and obtaining lists of veterans from VHA, unless 

otherwise noted, that satisfied the following criteria:

 8

We invited other veterans groups in Hawaii to participate in our discussions; however, 

these groups declined to participate or did not respond to our efforts to contact them. We 

were unable to identify an active local veterans’ group in American Samoa. 

9

See U.S. Department of Veterans Affairs’ Veterans Health Administration, VHA Directive 

2012-001 Time Requirements for Processing VA Forms 10-10EZ, Application for Health 

Benefits and 10-10EZR, Health Benefits Renewal Form (Jan. 9, 2012); VHA Directive 

1230 Outpatient Scheduling Processes and Procedures (July 15, 2016); VHA Handbook 

1160.01 Uniform Mental Health Services in VA Medical Centers and Clinics (Sept. 11, 

2008, amended Nov. 16, 2015); and VHA Directive 1232(1) Consult Processes and 

Procedures (Aug. 24, 2016, amended Sept. 23, 2016). In this report, when measuring 

VHA’s timeliness goals, “days” refers to calendar days, unless otherwise indicated.

10See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: Sept. 10, 2014). 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.
Page 5 GAO-18-288 Veterans Health Administration

Initial primary care appointments. Those veterans who applied for 

enrollment and were successfully enrolled in VHA health care 

benefits; requested on their enrollment applications that VA contact 

them to schedule medical appointments; and received their first 

primary care appointment from Oct. 1, 2016, through Mar. 31, 2017.

Initial mental health appointments. Those veterans that received 

their first appointment with a mental health care provider from Oct. 1, 

2016, through Mar. 31, 2017.

Follow-up appointments. Those established veterans—veterans 

who were seen by a VA primary or mental health provider within the 

last 2 years—who saw a provider for a follow-up primary or mental 

health care appointment in March 2017.

Specialty care referrals. Those routine outpatient specialty care 

referrals that were created from Oct. 1, 2016, through Mar. 31, 2017, 

that VAPIHCS sent to either (1) DOD military treatment facilities 

working in partnership with VAPIHCS: TAMC and NHG, or (2) 

community providers through the Choice Program. The majority of 

veterans enrolled in VAPIHCS received non-VA care in fiscal year 

2016 through the Choice Program.11 From these lists, we selected a 

random sample that included referrals for orthopedics—a missioncritical physician specialty—as well as the specialty care service most 

frequently referred to TAMC, NHG, and the Choice Program from 

each of the three selected clinics in fiscal year 2016.12 These referrals 

resulted in a face-to-face consultation with a specialty care provider. 

Additionally, we also reviewed a select sample of general surgery 

 11For the purposes of this report, we refer to care, or consults, sent to non-VA providers 

as “referrals.” A consult is an electronic request entered into VA’s electronic health record 

by a VA provider who is seeking an opinion, advice, or expertise regarding evaluation or 

management of a veteran’s condition. A routine consult indicates that the veteran should 

be seen by a date indicated by that veteran’s provider.

Our review examined the scheduling actions of VAPIHCS staff when receiving, 

authorizing, and referring consults to the Choice Program to understand the length of time 

it took for veterans to receive care. We did not evaluate if veterans were eligible for the 

Choice Program, or if VAPIHCS correctly referred veterans to the Choice Program. 

Additionally, depending on their eligibility, some veterans can self-refer to a non-VA 

provider in the Choice Program. Veterans eligible to self-refer contact TriWest directly to 

request care through the Choice Program. This process does not involve VAPIHCS and 

we did not examine the veterans’ self-referral process to the Choice Program.

12VHA obtains data from its VISNs and VAMCs on which occupations are the highest 

priority for recruitment and retention based on known concerns, and uses this data to 

identify, among others, the nationwide top five mission-critical physician occupations. 

Orthopedic surgery was identified as one of these occupations in fiscal year 2016. 
Page 6 GAO-18-288 Veterans Health Administration

referrals sent to NHG that were subsequently canceled by VAPIHCS; 

we reviewed these referrals to further assess reasons for the 

cancelations.

See Table 1 for information on the number of medical records reviewed, 

by type of appointment and health care service, number of records 

sampled, and location of veteran.

Table 1: Information on the Sample of Medical Records GAO Reviewed from the Department of Veterans Affairs (VA) Pacific 

Islands Health Care System (VAPIHCS)

Number of records reviewed

Provider

Appointment 

type 

American 

Samoa clinic

Guam 

clinic

Maui 

clinic Total 

VA Initial primary care 7 8 15 30a

VA Initial mental health care 10 10 10 30

VA Follow-up primary care 5 5 5 15

VA Follow-up mental health care 5 5 5 15

Total records reviewed for primary care and mental health appointments 90

Tripler Army 

Medical Center 

(TAMC)

Orthopedic specialty care 5 5 5 15

TAMC Urology specialty care 5 0 4b 9

TAMC Cardiology specialty care 0 5 0 5

U.S. Naval Hospital 

Guam (NHG)

Orthopedic specialty care 0 5 0 5

NHG General surgery specialty care 0 5 0 5

Total records reviewed for Department of Defense appointment referrals 39

NHG General surgery specialty care 

– cancelled

0 5 0 5

Total records reviewed for cancelled specialty care appointment referrals 5

Choice Program Orthopedic specialty care 5 5 5 15

Choice Program Ophthalmology specialty care 5 5 0 10

Choice Program Dermatology specialty care 0 0 5 5

Total records reviewed for Choice Program appointment referrals 30

Total 164

Source: GAO. | GAO-18-288

a

Our review of initial primary care services included all new primary care patients from the American 

Samoa and Guam clinics, and 15 veterans randomly selected from among the 35 new primary care 

patients from the Maui clinic.

b

There were only 4 veterans from the Maui clinic referred to TAMC during our review time frame who 

satisfied our selection criteria.
Page 7 GAO-18-288 Veterans Health Administration

To identify any challenges in the recruitment and retention of physicians 

in the Pacific Islands, and the extent to which strategies have been used 

to help resolve such challenges, we reviewed key VHA documents 

related to physician recruitment and retention and workforce and 

succession planning; directives related to staffing and pay administration; 

and guidance regarding the composition of primary care and mental 

health providers within clinics. Additionally, we reviewed information on 

the current physician staffing and vacancy levels for each clinic within 

VAPIHCS. We assessed VAPIHCS’ strategies to address challenges it 

faces to recruit and retain physicians within the context of federal 

standards for internal control.13 Finally, we interviewed VHA, VISN, and 

VAPIHCS officials involved in physician recruitment and retention, 

including from VHA’s Office of Workforce Management and Consulting, 

VISN 21’s Office of Human Resources, and VAPIHCS’ Office of Human 

Resources.

To identify any challenges veterans in the Pacific Islands face in 

accessing care, and the strategies used to improve access, we reviewed 

VHA’s handbook and guidance related to its beneficiary travel program. 

This program is intended to improve veterans’ access to timely care by 

reimbursing certain travel costs to medical appointments. Additionally, we 

reviewed VAPIHCS materials used to inform veterans about their access 

options. We also collected and assessed information on the number of 

outreach efforts conducted by VAPIHCS to inform veterans about access 

to care. We also interviewed officials from VAPIHCS and VHA’s Office of 

Rural Health and TriWest to obtain information about any access 

challenges for veterans they have identified and strategies used to 

address them.

We conducted this performance audit from January 2017 to April 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

 13See GAO-14-704G.
Page 8 GAO-18-288 Veterans Health Administration

VAPIHCS provides comprehensive health care to eligible veterans who 

reside in Hawaii and the three U.S. territories in the Pacific— American 

Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. 

According to VAPIHCS officials, the geographic distances between the 

Pacific Islands and the use of multiple sources of health care to provide 

services to veterans in this region create complex care delivery and 

coordination challenges for VAPIHCS.

VAPIHCS generally provides outpatient primary and mental health care 

services to the veterans it serves. These services are provided through its 

ambulatory care clinic, housed at the Spark M. Matsunaga VAMC in 

Honolulu, Hawaii, on the island of Oahu, and 10 clinics located in other 

communities across the Pacific Islands.14 These 10 clinics include

• 7 in the state of Hawaii on the islands of Oahu (1 clinic); Hawaii (2 

clinics); Maui (1 clinic); Lanai (1 clinic); Molokai (1 clinic); and Kauai (1 

clinic);

• 1 in the territory of American Samoa;

• 1 in the territory of Guam; and

• 1 in the Commonwealth of the Northern Mariana Islands on the island 

of Saipan.15

VAPIHCS provides some outpatient specialty care services through the 

ambulatory care clinic and through traveling VAPIHCS specialty care 

 14Seven of the 10 clinics are community-based outpatient clinics, while the remaining 

three are outreach clinics. According to VA, a community-based outpatient clinic is 

completely staffed by VA; typically serves more than 2,500 veterans; and is required to 

provide a minimum, defined set of health care services, including primary and mental 

health care. An outreach clinic, by comparison, typically serves a smaller number of 

veterans and services are provided through partnered arrangements using other 

organizations’ space and services. 

15There are separate contractual agreements for the three outreach clinics in the Pacific 

Islands. In Molokai, VAPIHCS has a contractual agreement with Molokai General Hospital 

to use clinic space 30 hours per week to provide primary and mental health care services. 

In Lanai, VAPIHCS has a contractual agreement with a local health center to use clinic 

space once a month. The health center also provides a health technician to work during 

clinic hours and traveling VA primary and mental health care clinicians provide episodic 

care. In Saipan, care is provided by two contracted primary care providers and a VA 

mental health provider who travels there from Guam on a recurring basis. 

Background

VAPIHCS and Primary and 

Mental Health Care 

Services
Page 9 GAO-18-288 Veterans Health Administration

providers.16 Table 2 shows the number of enrolled veterans and the 

number of veterans that have used outpatient services in fiscal year 2017 

at each VAPIHCS facility.

Table 2: Number of Veterans Enrolled in and Using Outpatient Care from the Department of Veterans Affairs (VA) Pacific 

Islands Health Care System (VAPIHCS) in Fiscal Year 2017, by Clinic

Location

Enrolled 

veteransa Number of outpatient encountersb

State of Hawaii

Spark M. Matsunaga VA Medical Centerc 34,747 289,783

Oahu clinicc —— —-

Hawaii clinic (Hilo) 4,128 18,676

Hawaii clinic (Kona) 2,445 11,824

Maui clinicd 3,517 16,796

Lanai clinicd —- —-

Molokai clinicd —- —-

Kauai clinic 2,170 12,503

Territory of American Samoa

American Samoa clinic 937 7,977

Territory of Guam

Guam clinice 3,269 15,425

 16Specialty care services available include: audiology, allergy, cardiology, dermatology, 

endocrinology, hematology, neurology, pulmonary, nephrology, gastroenterology, 

podiatry, rheumatology, optometry, orthopedics, and urology. In addition, VAPIHCS sends 

select specialty care providers, or traveling providers, to different islands using an 

established schedule. For those veterans who require health care services beyond those 

provided at their local clinics or from these travelling providers, VAPIHCS may provide 

benefits to eligible veterans to travel to other locations to receive care, such as to another 

VA or DOD facility.
Page 10 GAO-18-288 Veterans Health Administration

Location

Enrolled 

veteransa Number of outpatient encountersb

Commonwealth of the Northern Mariana Islands

Saipan clinice —- —-

Total 51,213 372,984

Source: VAPIHCS. | GAO-18-288

a

Enrolled veterans refers to the total number of veterans enrolled in a clinic in fiscal year 2017.

b

Number of outpatient encounters refers to the number of contacts between a patient and a provider 

in fiscal year 2017.

c

The number of veterans enrolled in and using the Spark M. Matsunaga VA Medical Center include 

those enrolled in and using the Oahu clinic. VAPIHCS did not separately report the Oahu clinic 

veterans from those enrolled in and using the Spark M. Matsunaga VA medical center in its data.

d

The number of veterans enrolled in and using the Maui clinic include those located on the islands of 

Lanai and Molokai. VAPIHCS has two outreach clinics on these islands, but, at the time of our review, 

did not separately report the Molokai and Lanai veterans from the Maui veterans in its data.

According to VAPIHCS, as of October 2017, workload data from the Lanai and Molokai clinics are 

now separated from the Maui clinic.

e

The number of veterans enrolled in and using the Guam clinic include those located in Saipan within 

the Commonwealth of the Northern Mariana Islands. VAPIHCS has an outreach clinic on the island of 

Saipan, but, at the time of our review, did not separately report these veterans from the Guam 

veterans in its data. According to VAPIHCS, as of October 2017, workload data from the Saipan clinic 

are now separated from the Guam clinic.

According to VAPIHCS officials, VAPIHCS provides most specialty care 

and inpatient services to veterans at military treatment facilities through 

joint venture and sharing agreements with DOD or through non-VA 

providers in the community.17 In fiscal year 2017, VAPIHCS sent 50,000 

referrals outside of VA, mostly to DOD or through the Choice Program.

Military treatment facilities. Two military treatment facilities located in 

the Pacific Islands provide care for veterans through joint venture and 

sharing agreements with VAPIHCS: TAMC and NHG. According to 

VAPIHCS’ data, VAPIHCS made more than 8,000 referrals to these 

facilities in fiscal year 2017.

VAPIHCS’ joint venture with TAMC: VAPIHCS’ joint venture 

agreement with TAMC—1 of 10 joint venture agreements in place 

between VA and DOD as of December 2017—states that VAPIHCS 

may refer veterans to TAMC providers for specialty care and inpatient 

services and, in return, for VAPIHCS to provide services for DOD 

 17A limited number of inpatient services are also provided by VAPIHCS providers through 

its (1) psychiatric unit embedded within TAMC (20 beds), (2) transitional rehabilitative 

medical care program (60 beds), and (3) Post Traumatic Stress Residential Rehabilitation 

Program (12 beds).

VAPIHCS and Specialty 

Care and Inpatient 

Services
Page 11 GAO-18-288 Veterans Health Administration

beneficiaries, such as psychiatric and post-traumatic stress disorder 

services.

VAPIHCS’ sharing agreement with NHG: VAPIHCS’ sharing 

agreement with NHG—1 of more than 200 active sharing agreements 

in place between VA and DOD as of December 2017—states that 

VAPIHCS may refer patients from the Saipan and Guam clinics to 

NHG for available specialty care, laboratory, emergency care, and 

inpatient services. NHG is located within a mile of the Guam clinic.

Choice Program. VAPIHCS may also refer veterans to a non-VA 

provider in the community when veterans need care that is not offered by 

VAPIHCS, or cannot obtain the needed care in a timely manner. In fiscal 

year 2017, 61 percent of VAPIHCS referrals sent to community providers 

were through the Choice Program. (See fig. 1 for the breakdown of the 

number and percent of referrals sent to care outside of VAPIHCS in fiscal 

year 2017.) Veterans may opt to obtain health care services from a 

network of community providers through the Choice Program if they meet 

certain criteria, including:

1. the next available medical appointment with a VHA clinician is more 

than 30 days from the veteran’s preferred appointment date or the 

date the veteran’s physician determines he or she should be seen;

2. the veteran lives more than 40 miles driving distance from the nearest 

VHA facility with a full-time primary care physician;

3. the veteran needs to travel by air, boat, or ferry to the VHA facility that 

is closest to his or her home;

4. the veteran faces an unusual or excessive burden in travelling to a 

VHA facility based on geographic challenges, environmental factors, 

or a medical condition; 18

5. the veteran’s specific health care needs, including the nature and 

frequency of care needed, warrants participation in the program;

19 or

6. the veteran lives in a state or territory without a full-service VHA 

medical facility.20

 18A determination about whether the veteran meets this criterion is made in conjunction 

with staff at the veteran’s local VHA medical facility. 

19A determination about whether the veteran meets this criterion is made in conjunction 

with staff at the veteran’s local VHA medical facility 

20See U.S. Department of Veterans Affairs, Veterans Health Administration, Veterans 

Choice Program Eligibility Details (Washington, D.C.: Dec. 1, 2015).
Page 12 GAO-18-288 Veterans Health Administration

Figure 1: Number and Percent of Referrals the Department of Veterans Affairs (VA) 

Pacific Islands Health Care System (VAPIHCS) Sent to Non-VA Care in Fiscal Year 

2017

Note: Other non-VA community providers include the Patient-Centered Community Care Program or 

instances where VA individually authorized care for veterans with specific community providers. The 

Veterans Choice Program (Choice Program) was enacted by the Veterans Access, Choice, and 

Accountability Act of 2014 to address longstanding challenges with veterans’ access to care at VA 

medical centers. Under the Choice Program, eligible veterans may receive care from non-VA health 

care providers when they experience long wait times, lengthy travel distances, or other challenges 

accessing VA care. Additionally, the number of referrals sent to each source of non-VA care may not 

reflect the total number of encounters the veteran had with each non-VA provider; a referral may 

result in more than one encounter, such as a visit and diagnostic test. 

As the third-party administrator of the Choice Program for VAPIHCS, 

TriWest is responsible for establishing networks of community providers, 

scheduling appointments with community providers for eligible veterans, 

and paying providers for their services. TriWest has contractual time 

frames in which to accept and schedule the appointment, or return the 

referral to VAPIHCS for further action.
Page 13 GAO-18-288 Veterans Health Administration

Our review of 30 medical records of newly enrolled veterans accessing 

initial primary care services at the American Samoa, Guam, or Maui clinic 

found some delays in processing of health care benefits enrollment 

applications and contacting of veterans to schedule appointments. Once 

contacted, however, most veterans in our sample received initial primary 

care within VHA’s timeliness goal. These enrollment delays may have 

contributed to the time taken for veterans to see primary care providers, 

consistent with findings from our prior work.21

Timeliness of enrollment application processing. For the 30 veterans’ 

medical records we reviewed, we found that VHA staff responsible for 

enrollment processing did not always process veterans’ enrollment 

 21See GAO, VA Health Care: Opportunities Exist for Improving Implementation and 

Oversight of Enrollment Processes for Veterans, GAO-17-709 (Washington, D.C.: Sept. 5, 

2017). In this report we recommended, among other things, that VA develop procedures 

for collecting consistent and reliable data system-wide to track and evaluate timeliness of 

enrollment processes, and institute an oversight mechanism to ensure VAMC and Health 

Eligibility Center staff are appropriately following the procedures. VA agreed with this 

recommendation, and plans to define tracking mechanisms to accurately evaluate the 

timeliness of enrollment processes, among other actions. As of January 2018, this 

recommendation has not yet been implemented. See also GAO-16-328, in which we 

recommended that VA review its processes for identifying and documenting newly 

enrolled veterans requesting appointments, and to revise as appropriate to ensure all 

veterans requesting appointments are contacted in a timely manner. VA agreed with this 

recommendation, and among other things, revised internal reports to enhance oversight of 

its process for identifying and scheduling newly enrolled veterans who requested primary 

care appointments.

Most Veterans in Our 

Review Received 

Primary and Mental 

Health Care from VA 

Providers within 

VHA’s Timeliness 

Goals, although 

Some Faced Delays

Veterans in Our Review 

Faced Some Enrollment 

Delays, but Once 

Contacted, Most Received 

Initial Primary Care from 

VA Providers within VHA’s 

Timeliness Goal
Page 14 GAO-18-288 Veterans Health Administration

applications within the timeliness goal set in VHA policy.22 For 27 of the 

30 veterans in our sample, VHA staff recorded the date the application 

was received, which enabled us to assess the timeliness of enrollment 

processing for these veterans. We found that 22 of these 27 applications 

were processed within VHA’s required 5 business days, with an average 

of 1 day for processing. (See table 3.) Five applications were not 

processed within the 5-day requirement; for four of these veterans, it took 

an average of 10 days to process the enrollment applications. For the fifth 

veteran, it took 627 days for VHA to process the application, and for 

which VAPIHCS staff could not explain the delay.

Table 3: Timeliness of Processing Enrollment Applications by the VA Pacific Islands Health Care System for a Sample of 

Newly Enrolled Veterans

Clinic

Number of 

veterans in 

sample

Number of veterans 

with recorded enrollment 

application dates

Number of enrollment 

applications processed within 

the required 5 business days 

American Samoa 7 6 6 

Guam 8 6 5 

Maui 15 15 11 

Total 30 27 22 

Source: GAO analysis of Department of Veterans Affairs (VA) medical records. | GAO-18-288

Notes: We reviewed a sample of 30 medical records for newly enrolled veterans who requested on 

their enrollment applications that the VA contact them to schedule appointments and had completed 

their appointment from Oct. 1, 2016, through Mar. 31, 2017. This sample included all new primary 

care patients from the American Samoa clinic (7 veterans) and Guam clinic (8 veterans), and 15 

veterans randomly selected from the 35 new primary care patients from the Maui clinic. Our findings 

cannot be generalized to all veterans at the Maui clinic in our review, or to other VA medical centers.

Timeliness of contact for appointment scheduling. For the 30 

veterans’ medical records we reviewed, VAPIHCS staff did not always 

initiate contact with newly enrolled veterans to schedule an appointment 

 22See VHA Directives 2012-001 and 1230. After a veteran submits an enrollment 

application, a determination of eligibility for VA health care needs to be made. VHA’s 

Health Eligibility Center is its central authority for eligibility and enrollment processing 

activities. VHA staff responsible for enrollment processing may work at a particular VAMC 

(in this case, VAPIHCS), or at the Health Eligibility Center. We did not determine whether 

VAPIHCS staff or VHA staff from VHA’s Health Eligibility Center processed the enrollment 

applications for the veterans in our sample.

Enrollment for VA Health Care Benefits

To receive VA health care benefits, a veteran 

may submit an enrollment application by mail, 

telephone, through VA’s website, or by 

applying in person at a VA health care facility. 

Once a veteran submits an application, there 

are three key steps for processing the 

application: (1) intake of application, (2) 

verification of eligibility, and (3) enrollment 

determination. In fiscal year 2016, most 

enrollment applications were processed by VA 

medical center staff. According to Veterans 

Health Administration policy, staff are required 

to process applications within 5 business days 

of receipt.

Source: Department of Veterans Affairs (VA) and GAO. | 

GAO-18-288
Page 15 GAO-18-288 Veterans Health Administration

within 7 days of their eligibility determination as required by VHA policy.23

We found that 15 of the 30 veterans in our review had contact initiated 

within 7 days to schedule an appointment, with an average of 4 days. 

(See table 4.) Fifteen veterans did not have contact initiated within the 7 

day requirement; for 14 of these veterans, it took an average of 20 days 

to initiate contact. For the 15th veteran, it took 183 days to initiate contact. 

According to clinic staff, gaps in communication between clinic and 

VAPIHCS staff responsible for veteran enrollment, as well as staffing 

shortages, may have contributed to delays in contacting newly enrolled 

veterans. Clinic staff reported differences in how they are notified that a 

veteran’s enrollment application has been processed and that 

appointment scheduling should be initiated. In addition, staff from two 

clinics said there were staffing vacancies for primary care appointment 

schedulers in their clinics during the time of our medical record sample 

selection (October 2016 through March 2017), which may have caused 

delays in contacting veterans.

Timeliness of initial primary care services. For the 30 newly enrolled 

veterans’ medical records we reviewed, we found that, once contacted, 

27 veterans received initial primary care services within VHA’s timeliness 

goal of 30 days of their preferred appointment dates (the date a veteran 

requests health care services), with an average wait time of 7 days.24

(See table 4.) Three veterans did not receive initial primary care 

appointments at the Guam clinic within the 30-day requirement, and 

waited an average of 62 days. However, as we have previously reported, 

VHA’s timeliness goal monitors only a portion of the overall time it takes 

newly enrolled veterans to access primary care, and does not account for 

the time it takes to process enrollment applications, to notify clinic staff of 

successful enrollments, or to contact veterans to schedule their 

appointments. In our March 2016 report, we recommended that VA 

monitor the full amount of time newly enrolled veterans wait to be seen by 

primary care providers, starting with the date veterans request they be 

 23See VHA Directive 1230.

24See VHA Directive 1230. Requests are made at the time VA contacts the veteran to 

schedule the appointment (and not the date that the veteran requests to be contacted to 

schedule the appointment).

We did not examine whether VAPIHCS met a goal it set by memorandum in April 2017 to 

schedule newly enrolled veteran appointments within 7 days of the veteran’s preferred 

appointment date because this policy memorandum went into effect after the time frame of 

our medical record review. See Department of Veterans Affairs Pacific Islands Health 

Care Systems, Outpatient Scheduling Processes and Procedures, Facility Policy 

Memorandum 136-17-004 (Honolulu, Hawaii: Apr. 19, 2017). 

New Enrollee Appointments 

Veterans can request on their enrollment 

applications that Department of Veterans 

Affairs (VA) staff contact them to schedule an 

initial outpatient appointment. After a 

veteran’s enrollment application has been 

processed, VA staff are to initiate the 

scheduling of appointment requests within 7 

days. 

Source: Veterans Health Administration. | GAO-18-288.
Page 16 GAO-18-288 Veterans Health Administration

contacted to schedule appointments.25 When accounting for the time to 

process applications and contact veterans, we found 6 of the 30 veterans 

in our review waited more than 90 days to see a provider while 9 waited 

30 days or less. 

Table 4: Timeliness of Contacting and Receiving Initial Primary Care Appointments by the VA Pacific Islands Health Care 

System for a Sample of Newly Enrolled Veterans

Clinic

Number of 

veterans in 

sample

Number of veterans’

contact initiated within 

the required 7 days 

Number of veterans 

receiving care within 

the required 30 days

American Samoa 7 6 7 

Guam 8 2 5 

Maui 15 7 15 

Total 30 15 27 

Source: GAO analysis of Department of Veterans Affairs (VA) medical records. | GAO-18-288

Notes: We reviewed a sample of 30 medical records for newly enrolled veterans who requested on 

their enrollment applications that the VA contact them to schedule appointments and had completed 

their appointment from Oct. 1, 2016, through Mar. 31, 2017. This sample included all new primary 

care patients from the American Samoa clinic (7 veterans) and Guam clinic (8 veterans), and 15 

veterans randomly selected from the 35 new primary care patients from the Maui clinic. Our findings 

cannot be generalized to all veterans at the Maui clinic, or to other VA medical centers.

 25See GAO-16-328.VA agreed with our recommendation to monitor full wait times, and in 

June 2017, reported to us that it had taken actions to address this recommendation, 

including revising an internal report to help identify and document all newly enrolled 

veterans and monitor their appointment request status. However, VA indicated in its 

response that it does not have the data to capture application dates for all newly enrolled 

veterans, and as a result, this report cannot be used to consistently monitor the full 

amount of time these veterans wait to be seen by primary care providers. As of January 

2018, this recommendation had not been implemented. 
Page 17 GAO-18-288 Veterans Health Administration

Our review of a randomly selected sample of 30 medical records for 

veterans who accessed mental health care services for the first time at 

one of the selected three clinics found that most veterans received initial 

mental health care within VHA’s timeliness goal. Although most veterans 

in our sample received timely initial services, our review found that those 

veterans needing comprehensive mental health evaluations often 

experienced delays receiving them.26

Timeliness of initial mental health care services. Our review found 

that 21 of the 30 veterans in our sample who needed mental health care 

received their initial mental health care appointments within VHA’s 

timeliness goal of 30 days of their documented clinically indicated dates 

(the date an appointment is deemed clinically appropriate by the referring 

provider), or in the absence of clinically indicated dates, their preferred 

dates.27 (See table 5.) These 21 veterans were seen by a mental health 

care provider within an average of 7 days of their clinically indicated date 

or preferred date. Nine veterans did not receive initial mental health care 

appointments within VHA’s 30-day timeliness goal, and waited an 

average of 46 days to receive care from a mental health provider.28

 26Throughout this report we will refer to the “comprehensive diagnostic and treatment 

planning evaluation” as the “comprehensive mental health evaluation.”

27See VHA Directive 1230.

28VAPIHCS officials said that they provide same-day services for veterans with emergent 

mental health care needs.

Most Veterans in Our 

Review Received Initial 

Mental Health Care from 

VA Providers within VHA’s

Timeliness Goal, but 

There Were Some Delays 

Completing 

Comprehensive Mental 

Health Evaluations

Mental Health Care Appointments 

Veterans can either request mental health 

care services, or be referred for these 

services, such as by their primary care 

providers. Once care is requested for nonemergent mental health care needs, 

appointments are to be scheduled within 30 

days of the referral’s clinically indicated date, 

or in the absence of a clinically indicated date, 

the veteran’s preferred date for their first 

mental health care appointment. In addition to 

scheduling the initial appointment, veterans 

are to receive a comprehensive mental health 

evaluation within 30 days of that initial 

referral’s clinically indicated date, or in the 

absence of a clinically indicated date, the 

veteran’s preferred date for their first mental 

health care appointment. This comprehensive 

mental health evaluation occurs during a 

mental health appointment, and includes a 

diagnosis and a plan for treatment. While this 

evaluation does not necessarily have to occur 

during the first mental health care 

appointment, it is expected to be completed 

within the timeliness goals as noted.

Source: Veterans Health Administration and GAO. | 

GAO-18-288
Page 18 GAO-18-288 Veterans Health Administration

Table 5: Timeliness of Receiving Initial Mental Health Care Appointments by the VA Pacific Islands Health Care System for a 

Sample of Veterans

Clinic

Number of veterans

in sample

Number of veterans 

receiving care within the required 30 days

American Samoa 10 7

Guam 10a 7

Maui 10b 7

Total 30 21

Source: GAO analysis of Department of Veterans Affairs (VA) medical records. | GAO-18-288

Notes: We reviewed10 randomly selected medical records from each of the three clinics in our review 

for a total sample of 30 veterans who needed mental health services and were seen for their first 

mental health appointments from Oct. 1, 2016, through Mar. 31, 2017. Our findings cannot be 

generalized to all veterans at the clinics in our review, or to other VA medical centers.

a

This sample includes one veteran from Saipan who received telemental health services from the 

provider at the Guam clinic.

b

This sample includes one veteran from Molokai who established mental health services with a 

provider from the Maui clinic.

Timeliness of comprehensive mental health evaluations. Although 21 

of 30 veterans in our sample received initial mental health care 

appointments in a timely manner, our review found that most veterans 

needing comprehensive mental health evaluations experienced delays 

receiving them. Of the 30 veterans in our sample, 25 were identified as 

needing a comprehensive mental health evaluation, and only 9 received 

that evaluation within VHA’s timeliness goal of 30 days of their clinically 

indicated date, or in the absence of a clinically indicated date, the 

veteran’s preferred date.29 (See table 6.) These 9 veterans received their 

evaluations within an average of 8 days. For the 16 veterans that did not 

receive a comprehensive mental health evaluation within the 30-day 

requirement, it took between 35 and 217 days (an average of 82 days) for 

15 veterans to receive an evaluation from the initial referral’s clinically 

 29See VHA Handbook 1160.01. According to our discussions with VAPIHCS staff, not all 

veterans seeking mental health care services require the completion of such an 

evaluation. VHA also requires all new patients requesting or being referred for mental 

health services to receive an initial evaluation within 24 hours to identify those who need 

urgent or immediate access to mental health care. Because the initial 24-hour evaluation 

can be conducted in settings outside of VHA (for example, through a referring licensed 

independent provider), and not always documented in the veteran’s medical record, we 

were unable to evaluate the timeliness of these initial evaluations for our sample of 

veterans.
Page 19 GAO-18-288 Veterans Health Administration

indicated date or veteran’s preferred appointment date. The remaining 

veteran had not completed an evaluation as of February 2018.30

Table 6: Timeliness of Completing Comprehensive Mental Health Evaluations by the VA Pacific Islands Health Care System 

for a Sample of Veterans

Clinic Number of 

veterans in 

sample

Number of veterans 

needing a comprehensive 

mental health evaluation

Number of comprehensive 

mental health evaluations completed 

within the required 30 days 

American Samoa 10 8 2

Guam 10a 10 6

Maui 10b 7 1

Total 30 25 9

Source: GAO analysis of Department of Veteran Affairs (VA) medical records. | GAO-18-288

Notes: We reviewed10 randomly selected medical records from each of the three clinics for a total 

sample of 30 veterans who were seen for their first mental health appointments from Oct. 1, 2016, 

through Mar. 31, 2017. Our findings cannot be generalized to all veterans at the clinics in our review, 

or to other VA medical centers. Staff from VA’s Veterans Health Administration’s Office of Mental 

Health told us that a VA provider has discretion to determine if a veteran in its care needs a 

comprehensive mental health evaluation. Of the 30 veterans, 25 veterans were determined to need 

comprehensive mental health evaluations by their providers.

a

This sample includes one veteran from Saipan who received telemental health services from the 

provider at the Guam clinic.

b

This sample includes one veteran from Molokai who established mental health services with a 

provider from the Maui clinic.

The process by which veterans received comprehensive mental health 

evaluations varied by clinic, and this sometimes resulted in the 

evaluations being completed outside of VHA’s timeliness goal:

• American Samoa clinic staff stated that they provide veterans with a 

hard-copy comprehensive mental health evaluation at the veteran’s 

first appointment. The veteran is instructed to complete the form at 

home, and return to the clinic at a later date to discuss with a 

provider.31 Staff stated that allowing veterans to fill out the form on 

their own saves time at the clinic, and allows veterans to be more 

thorough in their answers. A staff member stated that the 

 30 The veteran who had not yet completed an evaluation was last seen by a Maui clinic 

provider in February 2017, at which time it was recommended that the veteran return for 

mental health services the following month. However, the veteran has not yet returned to 

the mental health clinic.

31An official from VHA’s Office of Mental Health Services stated that it is an acceptable 

practice to provide veterans with hardcopies of the comprehensive mental health 

evaluation to complete at home. 
Page 20 GAO-18-288 Veterans Health Administration

comprehensive mental health evaluation is just one piece of the 

diagnostic interview and that, presumably, the provider obtains 

sufficient information from the veteran to develop a treatment plan and 

initiate services for the veteran while waiting for the veteran to 

complete the form.

• Guam clinic staff said that they generally complete the comprehensive 

mental health evaluation during the veteran’s first mental health care 

appointment, but do sometimes need to schedule a second 

appointment to complete the entire evaluation. Staff stated that the 

first priority is to treat and address what is clinically indicated, so they 

are sometimes delayed in completing all form requirements until a 

later time.

• Maui clinic staff stated that they typically schedule the first 

appointment with a veteran, and if it becomes clear that the veteran 

needs to continue receiving mental health services, they will schedule 

a comprehensive mental health evaluation at a future appointment.

Our review of a randomly selected sample of medical records for 30 

veterans in the Pacific Islands (15 veterans needing primary care and 15 

veterans needing mental health care) who received follow-up 

appointments found that most of these veterans received care within 

VHA’s timeliness goal. Specifically, we found that of the 30 veterans, 25 

veterans received follow-up care within 30 days of the clinically indicated 

date determined by each veteran’s provider, in accordance with VHA 

policy.32 (See table 7.) This included 10 veterans needing follow-up 

primary care (who received care an average of 6 days within the 

veteran’s clinically indicated date), and all 15 veterans needing follow-up

mental health care (who received care an average of 3 days within the 

veteran’s clinically indicated date). The 5 veterans needing follow-up 

primary care that were not seen within the required 30 days were seen 

between 109 and 584 days (an average of 299 days) from their clinically 

indicated dates. Explanations for the length of time it took for these 5 

veterans to receive care varied; for example, Guam clinic staff told us that 

one veteran’s follow-up care was delayed due to clinical and scheduling 

staffing shortages.

 32See VHA Directive 1230.

Most Veterans in Our 

Review Received FollowUp Primary and Mental 

Health Care from VA 

Providers within VHA’s 

Timeliness Goal

Follow-Up Appointments 

After a veteran is seen for an appointment at 

a Department of Veterans Affairs (VA) facility, 

the provider is to document in the veteran’s 

medical record a clinically appropriate specific 

return date or interval (such as 2, 3, or 6 

months), when the provider determines the 

veteran should return for care. This is also 

known as the clinically indicated date. The 

follow-up appointment should then be 

scheduled within 30 days of the clinically 

indicated date. 

Source: Veterans Health Administration. | GAO-18-288
Page 21 GAO-18-288 Veterans Health Administration

Table 7: Timeliness of Receiving Follow-Up Primary Care and Mental Health Care Appointments by the VA Pacific Islands 

Health Care System for a Sample of Veterans

Clinic Type of Care

Number of veterans 

in sample 

Number of veterans receiving care 

within the required 30 days 

American Samoa Primary 5 3

Mental Health 5 5

Guam Primary 5 2

Mental Health 5 5

Maui Primary 5 5

Mental Health 5 5

Total 30 25

Source: GAO analysis of Department of Veterans Affairs (VA) medical records. | GAO-18-288

Notes: We reviewed 10 randomly selected medical records from each of the three clinics in our 

review (5 for primary care, 5 for mental health care) for a total sample of 30 veterans who had 

documented clinically indicated dates in their medical records and were seen by providers for followup appointments in March 2017. Our findings cannot be generalized to all veterans at the clinics in 

our review, or to other VA medical centers.
Page 22 GAO-18-288 Veterans Health Administration

We found that VAPIHCS referred 67 of 69 randomly selected specialty 

care referrals in our sample to non-VA providers in the Choice Program or 

through DOD within 7 days, in accordance with the timeliness goal set in 

VHA policy.33 Specifically, VAPIHCS met this goal for 28 of 30 specialty 

care referrals sent to Choice Program providers, and all 39 specialty care 

referrals sent to DOD providers at two military treatment facilities.34

VAPIHCS staff took an average of 2 days to review and send referrals to 

VAPIHCS staff responsible for Choice Program referrals, and an average 

of 1 day to review and send specialty care referrals to TAMC and NHG. 

VAPIHCS staff responsible for Choice Program referrals also are 

responsible for uploading the referrals into TriWest’s portal, the Choice 

 33According to VHA Directive 1232(1), the receiving service has 7 days from when it 

receives a referral from a VA provider to review the referral and determine the appropriate 

source of non-VA care in which to send the referral. According to an official from VHA’s 

Office of Community Care, VAPIHCS staff act as the receiving service in implementing 

VA’s referral policy. We therefore evaluated VAPIHCS staff in meeting the 7-day 

timeliness goal. The referral processing requirements found in VHA Directive 1232(1) 

applied to the time frame of our medical record review. In June 2017, however, VHA 

released a memo updating their requirements, and now require referrals to be reviewed 

and authorized to the appropriate source of non-VA care within 2 business days of receipt.

34We did not assess if VAPIHCS staff met the timeliness requirement for seeing if 

veterans want to utilize, or opt-in, to the Choice Program for the veterans in our sample. 

VAPIHCS Referred 

Most Specialty Care 

to Non-VA Providers 

within VHA’s 

Timeliness Goal, but 

Time Taken to 

Provide Care Was 

Variable and 

Sometimes Lengthy

VAPIHCS Met VHA’s 

Timeliness Goal for Almost 

All Specialty Care 

Referrals in Our Sample 

Sent to Choice Program 

and DOD Providers
Page 23 GAO-18-288 Veterans Health Administration

Programs’ third-party administrator within VAPIHCS.35 Although VHA 

policy applies to referrals sent to in-house providers, a VHA official told us 

that VHA expects VAMCs to manage non-VA referrals as they would 

those referred in-house.36 A VAPIHCS official confirmed that it holds staff 

to the 7-day requirement found in VHA policy.

We found that once specialty care referrals in our review were sent to the 

Choice Program or one of the two DOD military treatment facilities—

TAMC and NHG—the amount of time it took veterans to receive care 

from these non-VA providers varied, and sometimes was lengthy.

Time taken to receive care from a Choice Program provider. Once 

VAPIHCS staff reviews and uploads each referral into TriWest’s portal, 

TriWest is required to meet VA’s timeliness requirements for the Choice 

Program, which specify the amount of time TriWest has to (1) contact the 

veteran, (2) schedule the appointment, (3) and provide veterans with 

care.

• We found that for all 30 referrals in our sample, TriWest first 

attempted to contact the veteran within the 4 business days 

required once TriWest received and accepted the referral from 

VAPIHCS. However, we also found that TriWest did not follow the 

requirements for mailing letters for 3 of the referrals when it was 

unable to reach the veterans by phone. If TriWest is unable to reach a 

veteran after calling a minimum of three times over 4 business days, a 

letter is to be mailed to the veteran on the 7th business day after 

receiving the referral notifying them that they have 10 business days 

from the date of the letter to contact TriWest to schedule an 

 35After reviewing Choice Program referrals, VHA does not have timeliness requirements 

for VAMCs to upload a referral into TriWest’s portal. See GAO, Veteran’s Health Care: 

Preliminary Observations on Veterans’ Access to Choice Program Care, GAO-17-397T 

(Washington, D.C.: March, 7, 2017). Our review found that once the referrals were 

reviewed within VHA’s 7 day timeliness goal, it took an average of 6 additional days to 

upload each referral into TriWest’s portal. A VAPIHCS official stated that the length of time 

to upload referrals into the portal may reflect the time it takes staff to process the high 

volume of referrals. This official estimated that VAPIHCS staff process approximately 300 

referrals per day, and it takes approximately 5 to 7 minutes to upload each referral into 

TriWest’s portal. 

36VHA’s Office of Community Care official stated that they are working with their DOD 

counterparts to develop a national policy, similar to VHA Directive 1232(1), to oversee and 

manage referrals that are sent from a VA facility to a military treatment facility. The 

process is currently being piloted at two sharing locations.

Time Taken for Veterans in 

Our Review to Receive 

Specialty Care from 

Choice Program and DOD 

Providers Was Variable 

and Sometimes Lengthy
Page 24 GAO-18-288 Veterans Health Administration

appointment. For these 3 referrals, TriWest mailed a letter, but did not 

do so until one day later than the required 7th business day after 

receiving and accepting the referral.37

• We found that after reaching the veteran, TriWest staff scheduled 

appointments for 17 of the 25 referrals within the 5 business 

days required for scheduling an appointment after the veteran 

opts in to the Choice Program.38 (See table 8.) We found varying 

reasons that may have delayed the scheduling of an appointment. For 

example, some records showed that TriWest staff did not begin to call 

a provider until 4 or more days after they reached the veteran and 

confirmed they wanted to utilize, or opt in to, the Choice Program to 

receive care. In addition, some providers required time to review the 

veteran’s medical record before scheduling the appointment with 

TriWest.

 37According to TriWest officials, letters are mailed from their headquarters in Phoenix, 

Arizona, which may lead to long mail delivery times for letters that are mailed to the Pacific 

Islands. For example, according to VAPIHCS officials, there are only 2 flights a week that 

deliver mail to American Samoa from Hawaii. 

38Although our total sample was 30 referrals, 4 veterans scheduled their appointments 

directly with the provider, in which cases TriWest confirmed the appointment date with the 

provider, and one veteran’s date was not documented, leaving a sample size of 25 

veterans for which TriWest scheduled the veteran’s appointment.

The appointment scheduling requirements found in TriWest’s contract applied to the time 

frame of our medical record review. In June 2017, however, VHA temporarily relaxed this 

requirement and now allows TriWest 15 days to schedule a veteran’s appointment after 

opting-in the veteran.
Page 25 GAO-18-288 Veterans Health Administration

Table 8: Timeliness of Scheduling Select Specialty Care Appointments by TriWest for a Sample of Referrals Referred from the 

VA Pacific Islands Health Care System (VAPIHCS)

Clinic 

Number of 

referrals in 

sample

Number of referrals 

in sample in which TriWest 

scheduled the appointmenta

Number of appointments 

scheduled within 5 

business days 

American Samoa 10 7 5 

Guam 10 10 5 

Maui 10 8 7 

Total 30 25 17 

Source: GAO analysis of Department of Veterans Affairs (VA) and TriWest medical records. | GAO-18-288

Notes: We reviewed a sample of 30 randomly selected veterans’ specialty care referrals sent to the 

Choice Program that were created from Oct. 1, 2016, and Mar. 31, 2017. Our findings cannot be 

generalized to all referrals from the clinics in our review, or to other VA medical centers. TriWest, the 

third-party administrator for the Choice Program within VAPIHCS, has 5 business days to schedule a 

veteran’s appointment after reaching the veteran and confirming that the veteran wants to be 

scheduled for an appointment with a Choice Program provider.

a

During our review, we found that four veterans scheduled their appointments directly with the 

provider after VAPIHCS determined these veterans were time-eligible under the Choice Program, but 

without TriWest involvement. One veteran’s date of appointment scheduling was not documented. 

Therefore, we were unable to determine if the appointments for these five veterans were scheduled 

within 5 business days of TriWest reaching the veteran.

• We found that 20 of the 30 veterans referred to Choice Program 

providers received care within VHA’s 30-day timeliness goal that 

VA used to evaluate TriWest’s performance under its contract. 

TriWest has an overall timeliness goal from VHA to provide veterans 

care through Choice Program providers, although the way this was 

calculated changed during our review due to changes in their practice 
Page 26 GAO-18-288 Veterans Health Administration

and modifications to the contract.39 The 20 veterans that received 

care within the timeliness goal did so within an average of 14 days. 

The 10 veterans that did not receive care within the 30-day timeliness 

goal waited between 31 and 126 days (an average of 62 days). 

Veteran preferences and specific provider tendencies sometimes led 

to delays in scheduling, causing care to be completed outside VHA’s 

timeliness goal. For example, our review of TriWest records found that 

two veterans in Guam noted that they preferred to stay on island for 

their ophthalmology referrals, rather than flying to Honolulu, and the 

non-VA Guam orthopedist sometimes took a week or more to review 

a veteran’s file before scheduling the appointment with TriWest.

The 30-day timeliness goal that VA used to evaluate TriWest’s 

performance captured a portion of the overall amount of time that it took 

for these veterans to receive care. We found that the number of days 

from the referral’s creation to the date that veterans received care from 

Choice Program providers varied by clinic, and ranged from 19 to 239 

days, with the average being 75 days. (See table 9.) This range and 

average includes circumstances outside of TriWest’s control; for example,

• four veterans in our sample chose to reschedule their appointments 

for a later date. One veteran from American Samoa was originally 

scheduled for an appointment within 40 days of the referral’s creation 

date; however, the veteran chose to reschedule the appointment and, 

in doing so, it took a total of 166 days for the veteran to be seen.

 39For those referrals that were uploaded to TriWest’s portal between Oct. 1, 2016, and 

Mar. 22, 2017, regardless of whether clinically indicated dates passed, TriWest had a 30-

day appointment completion time frame, from the clinically indicated date to the date the 

appointment was completed (the patient was seen by a provider), however VA was not 

implementing this contractual provision for purposes of evaluating TriWest’s performance. 

Instead, VA measured the 30 day goal beginning with the date TriWest scheduled the 

appointment to the date the veteran received care. For those referrals that were uploaded 

between Mar. 23, 2017, and Mar. 31, 2017 (the end of our sample date range) after 

clinically indicated dates had passed, VA evaluated the 30-day appointment completion 

time frame beginning with the date TriWest created the authorization to when the 

appointment was completed. For both time frames, if the referral was uploaded to 

TriWest’s portal before the clinically indicated date had passed, VA evaluated the 

timeliness of Choice Program appointment completion on the basis of whether the 

veteran’s appointment occurred within 30 days of the clinically indicated date.

For the four veterans that scheduled their appointments directly with the provider, we used 

the date that TriWest confirmed with the provider that the veteran had scheduled an 

appointment as the date TriWest scheduled the appointment. For the one veteran whose 

date was not documented, the clinically indicated date had not passed by the time the 

referral was uploaded into TriWest’s portal, so the 30-day appointment completion time 

frame remained the veteran’s clinically indicated date to the appointment completion.
Page 27 GAO-18-288 Veterans Health Administration

• three other veterans experienced delays in care after VAPIHCS 

initially sent their referrals to TAMC or NHG and later redirected the 

referrals to the Choice Program. VAPIHCS referred one veteran from 

Guam for specialty care at NHG. However, when VAPIHCS 

discovered that NHG could not provide care to the veteran, the 

veteran’s referral was redirected to the Choice Program 88 days after 

the referral creation date. This veteran encountered additional delays 

because of the time it took the Choice Program provider to review

medical records before scheduling the appointment. As a result, it 

took a total of 180 days for the veteran to be seen. 

Table 9: Range and Average Number of Days to Receive Specialty Care from Choice Program Providers for a Sample of 

Referrals Sent from the VA Pacific Islands Health Care System (VAPIHCS)

Clinic

Number of 

referrals in sample

Range 

of days

Average number 

of days

American Samoa 10 26 to 166 73

Guam 10 33 to 239 105

Maui 10 19 to 185 48

Total 30 19 to 239 75

Source: GAO analysis of Department of Veterans Affairs (VA) and TriWest medical records. | GAO-18-288

Notes: We calculated the range and average number of days for a veteran to receive care through 

the Choice Program, beginning with the date the referral was created, to the date the veteran 

received care. We reviewed a sample of 30 randomly selected veterans’ specialty care referrals sent 

to the Choice Program created from Oct. 1, 2016, and Mar. 31, 2017. Our findings cannot be 

generalized to all referrals at the clinics in our review, or to other VA medical centers. The range of 

days and average number of days between referral creation and the veteran being seen by a provider 

may reflect certain circumstances outside of TriWest’s control (the third party administrator for the 

Choice Program for VAPIHCS), such as the amount of time VAPIHCS may take to redirect referrals 

to the Choice Program; Choice Program providers may take to review medical records before 

scheduling appointments; and it may take to accommodate veteran preferences for appointment 

dates and providers.

Time taken to receive care from a DOD provider. After referring a 

veteran to a DOD provider, VHA does not have any timeliness goals or 

requirements in place related to the scheduling of appointments, or when 

the veteran should receive care. Our review found wide ranges in the time 

it took for the 39 veterans in our sample to receive care at TAMC and 

NHG. (See table 10.)

• TAMC: It took up to 95 days for 29 veterans from the American 

Samoa, Guam, and Maui clinics referred to TAMC to receive specialty 

care, with an average of 37 days from the creation of the referral to 

receiving care. These time frames include some veterans that 

rescheduled their appointments for later dates. For example, one 

veteran from Maui did not show up to the originally scheduled 

appointment (which was scheduled for approximately a month after 
Page 28 GAO-18-288 Veterans Health Administration

the referral creation date), and the appointment was rescheduled for 

two months later.

• NHG: It took up to 107 days for 10 veterans from the Guam clinic 

referred to NHG to receive specialty care, with an average of 47 days 

from the creation of the referral to receiving care.

Table 10: Range and Average Number of Days to Receive Specialty Care from Military Treatment Facilities for a Sample of 

Referrals from the VA Pacific Islands Health Care System

Clinic

Number of referrals 

in sample

Range 

of daysa Average number of daysb

Tripler Army Medical Center (TAMC)

American Samoa 10 1 to 50 31

Guam 10 20 to 91 46

Maui 9 0 to 95 32

Total 29 0 to 95 37

U.S. Naval Hospital Guam (NHG)

Guam 10 0 to 107 47

Source: GAO analysis of Department of Veterans Affairs (VA) medical records. | GAO-18-288

Notes: We reviewed a sample of 39 randomly selected veterans’ specialty care referrals sent to 

TAMC and NHG that were created from Oct. 1, 2016, and Mar. 31, 2017. Our findings cannot be 

generalized to all referrals from the clinics in our review, or to other VA medical centers.

a

The range of days is the total time elapsed from the referral’s creation date to the date the veteran is 

seen by a provider at the military treatment facility. The range may include veterans who may have 

rescheduled their appointments, or extended their appointment preferred dates, which may result in 

the appearance of longer wait times.

b

The average number of days is the average of the total time elapsed from the referral’s creation date 

to the date the veteran is seen by a provider at the military treatment facility. The average may 

include veterans who may have rescheduled their appointments, or extended their appointment 

preferred dates, which may result in the appearance of longer wait times.
Page 29 GAO-18-288 Veterans Health Administration

When reviewing VAPIHCS’ referrals to NHG, we found weaknesses with 

the VAPIHCS’ referral process, including (1) incorrectly canceling 

referrals, (2) inconsistent guidance describing roles and responsibilities, 

and (3) untimely referral management.40 These weaknesses may have 

contributed to the amount of time it took for veterans to receive care, or 

resulted in the veteran not receiving care.

Some referrals sent to NHG were incorrectly canceled by VAPIHCS 

staff. Specifically, in addition to the 10 completed referrals we reviewed, 

we also examined 5 referrals sent to NHG that were subsequently 

canceled by VAPIHCS staff responsible for referral management, but with 

no indication of appointments ever being scheduled. The reason for 

cancelations recorded in the veterans’ medical records was that the 

referrals had been open for more than 90 days; however, this practice is 

not in alignment with VHA policy. According to VHA policy confirmed by a 

VHA official, canceling a referral is an action taken by the receiving 

service to alert the sending provider that additional information is needed, 

or to correct an obvious error in the referral; a referral should not be 

canceled due to the length of time the referral has been open without care 

being provided.41 VHA policy also states that canceled referrals older than 

90 days are not to be resubmitted by the sending provider; instead, the 

sending provider must reassess the patient’s needs, as the clinical 

circumstances may have changed, and create a new referral, as 

necessary.42 Based on our review, it is unclear why VAPIHCS staff 

 40We also reviewed VAPIHCS’ referral process to TAMC, and found that TAMC was 

scheduling appointments for veterans from the Commonwealth of the Northern Mariana 

Islands, Guam, and American Samoa without their input. This practice, also known as 

“blind scheduling,” is inconsistent with VHA policy. At the time of our review, TAMC staff 

responsible for appointment scheduling were not required to obtain these veterans’ 

scheduling preferences prior to creating the appointment per an agreement with 

VAPIHCS. Only after the appointment was scheduled, and the veteran notified of the 

appointment date, did the veteran have the choice to accept the appointment, or request 

the appointment be rescheduled. According to a TAMC memorandum, this scheduling 

practice was identified as inefficient, and contributed to appointment no-shows and 

veteran frustration. This practice was discontinued, and as of December 2017, TAMC staff 

now make three attempts to contact all veterans over the course of 3 days. If the veteran 

cannot be reached, the referral is returned to VAPIHCS for further action.

41See Directive 1232(1). In this case, the receiving service could include VAPIHCS staff 

that reviews the referral to determine what type of non-VA care to send the referral to, or 

the receiving service could be the non-VA provider—in this case, NHG.

42See Directive 1232(1) and VHA Consult Standard Operating Procedure (February 15, 

2017). 

Weaknesses in VAPIHCS’ 

Referral Process May 

Have Contributed to the 

Time Taken to Provide 

Care at One DOD Military 

Treatment Facility

Military Treatment Facility Referral 

Process

After the Department of Veterans Affairs (VA) 

Pacific Islands Health Care System 

(VAPIHCS) staff review a referral and decide 

care should be rendered at a military 

treatment facility, there are two different 

processes for sending the referral to Tripler 

Army Medical Center (TAMC) or Naval 

Hospital Guam (NHG). If it is determined that 

a veteran needs care at TAMC, VAPIHCS 

staff review and send the referral to TAMC’s 

VA Referral Center. There, TAMC staff enters 

the referral information into DOD’s electronic 

medical record system and completes the 

appointment scheduling process. If it is 

determined that a veteran needs care at NHG, 

VAPIHCS staff review and send the referral to 

designated staff on Guam who have access to 

enter the referral directly into NHG’s electronic 

medical record. After the designated staff on 

Guam enter the referral into the system, NHG 

staff are then responsible for scheduling the 

veteran’s appointment.

Source: GAO analysis of VAPIHCS documentation. | 

GAO-18-288.
Page 30 GAO-18-288 Veterans Health Administration

responsible for referral management were not following VHA policy for 

canceling referrals, whether it was because they did not understand the 

policy or for other reasons. Federal internal control standards require 

management to review processes in a timely manner to ensure that 

control activities are appropriately designed and implemented.43 Because 

our review found that in some cases VAPIHCS staff were not following 

VHA’s referral policy, it is important for VAPIHCS to determine why staff 

are not adhering to the policy and take needed steps to ensure 

compliance. Ultimately, in our review of the veterans’ medical records, we 

did not find documentation that these veterans received the 

recommended care included in the canceled referrals. Additionally, we did 

not find evidence that four of the five referrals had been updated and 

resubmitted, or that any new referrals had been submitted in their place, 

which may have delayed needed care; or that the five affected veterans 

were contacted by VAPIHCS to understand why appointments had not 

been scheduled.44

Inconsistent guidance exists describing the roles and 

responsibilities of VAPIHCS staff involved in the NHG referral 

process. We identified different VAPIHCS guidance that provided 

inconsistent descriptions of the referral process with NHG. For example, a 

VAPIHCS flowchart depicting the referral process states that, after 

review, the referral is to be sent to a VAPIHCS staff member embedded 

within NHG to enter the referral information into NHG’s electronic medical 

record. However, language in the referral itself states that, after review, 

the referral is sent to Guam clinic staff to enter into NHG’s record.45

Federal internal control standards call for management to assign 

responsibility and delegate authority to achieve an agency’s objectives.46

 43See GAO-14-704G.

44A VAPIHCS official stated prior to canceling a referral, staff does attempt to contact the 

veteran. However, our review did not find any such contact attempts documented in the 

medical records. 

45The VAPIHCS staff member embedded within NHG was originally hired in November 

2014 under a joint program between VA and DOD to oversee inpatient discharge planning 

and coordination of follow-up care for Guam veterans accessing NHG for services. 

Depending on the type of specialty care that is needed, the embedded VAPIHCS staff 

member may forward the veteran’s contact information to the relevant NHG specialty care 

clinic’s scheduling staff to contact the veteran instead to schedule the appointment. A 

VAPIHCS staff member told us that some NHG specialty clinics prefer to contact the 

veterans directly, while others prefer to be contacted by the veteran.

46See GAO-14-704G.
Page 31 GAO-18-288 Veterans Health Administration

A VAPIHCS official stated that the embedded member within NHG 

entering in referrals in NHG’s electronic medical record was an interim fix 

and that there are plans in place for those responsibilities to be 

transferred to NHG staff. Specifically, VAPIHCS and NHG officials 

reported that NHG plans to hire two staff members to manage the referral 

process, but as of December 2017, these 2 staff members had not yet 

been hired due to budgetary constraints. Whether or not NHG hires 

additional staff, it is important for VAPIHCS to clarify and document the 

roles and responsibilities of their staff for sending, managing, and 

monitoring referrals to NHG. Without such clarification, there is the risk for 

confusion about responsibilities for entering referrals into NHG’s 

electronic medical record, which could potentially create delays in 

appointment scheduling and veterans’ receiving care.

VAPIHCS did not always manage referrals to NHG in a timely way.

Our review found instances throughout the NHG referral process where 

lack of timely referral management by VAPIHCS staff may have 

contributed to delays in veterans receiving care. VHA policy states that 

the referral process should include appropriate staff to manage referral 

notification, disposition, scheduling and completion; and designate staff to 

run referral reports, which must be reviewed at least weekly to resolve 

issues.47 In addition, federal internal control standards state than an 

organization should establish and operate monitoring activities to 

determine appropriate corrective actions on a timely basis.48

One factor that contributed to the lack of timely referral management was 

that VAPIHCS does not effectively monitor the referrals sent to NHG.

• First, VAPIHCS staff did not always monitor the availability of services 

at NHG with the frequency necessary to ensure the timeliness of 

referral management. NHG is to provide VAPIHCS with a list of 

available outpatient services no less than quarterly so VAPIHCS can 

determine if a referral for a specific service can be made to NHG; we 

confirmed that NHG provided these lists quarterly during our review 

time frame. However, VAPIHCS staff did not monitor whether services 

remained available after sending referrals to NHG in a timely manner. 

For example, one veteran in our review was originally referred to NHG 

in late November 2016, but it was not until VAPIHCS staff followed up 

 47See VHA Consult Standard Operating Procedure.

48See GAO-14-704G. 
Page 32 GAO-18-288 Veterans Health Administration

on the referral in early February 2017 that they were informed that 

NHG could not accommodate the veteran at that time and that they 

instead should refer the veteran to a non-VA provider. This may have 

contributed to delay in care for the veteran by more than 2 months.

• Second, VAPIHCS staff did not ensure that referrals were entered into 

NHG’s electronic medical record system in a timely manner to begin 

the appointment scheduling process; under the process agreed to by 

VAPIHCS and NHG, it is the responsibility of designated VAPIHCS 

staff to enter referrals into the NHG electronic medical record system. 

For example, VAPIHCS staff referred one veteran for care to NHG in 

November 2016. However, it was not until December 2016—one 

month later—that VAPIHCS staff checked on the status of the referral. 

Finding no evidence of actions taken to schedule an appointment, 

staff added a reminder for the embedded VAPIHCS staff member at 

NHG to enter the referral into NHG’s electronic medical record, to 

restart the appointment scheduling process.

• Third, VAPIHCS staff did not always manage referrals to ensure the 

timely disposition and scheduling of appointments. Among the five 

canceled referrals that we reviewed, we found VAPIHCS staff noticed 

appointments had not been scheduled only when they reviewed the 

referrals months later. For example, of the five referrals VAPIHCS 

sent to NHG,

• one referral, sent in mid-November 2016, was canceled in early 

February 2017 after VAPIHCS staff found no evidence that an 

appointment had or would be scheduled.

• another referral was sent in late November 2016. After VAPIHCS 

staff reviewed the referral and found no evidence that an 

appointment had or would be scheduled, they noted that the 

referral was 101 days old and canceled it in late January 2017.

• VAPIHCS staff referred another veteran to NHG in mid-March 

2017. After VAPIHCS staff reviewed the referral and found no 

evidence that an appointment had or would be scheduled, they 

noted that the referral was almost 4 months old and canceled it in 

June 2017.

VAPIHCS’ lack of timely referral management was also due to poor 

communication between VAPIHCS staff and NHG. Federal internal 

control standards state that an organization should communicate with 

external bodies to receive the necessary quality information required to 
Page 33 GAO-18-288 Veterans Health Administration

achieve the entity’s objectives.49 A VAPIHCS official stated that VAPIHCS 

staff do not have the same level of communication with NHG as they do 

with TAMC, which has its own staff to schedule veteran appointments and 

communicate that information back to VAPIHCS on a weekly basis, 

including if they cannot schedule a veteran. Instead, the official stated 

that VAPIHCS staff have to independently monitor the status of referrals 

to NHG, or ask the embedded VAPIHCS staff member at NHG to 

complete referral research for them. In addition, our review of the referral 

notes for these veterans found no evidence of communication between 

VAPIHCS staff and NHG staff regarding NHG’s efforts to schedule 

appointments for veterans before VAPIHCS staff canceled them. 

Furthermore, we also found no evidence of communication regarding 

outreach by NHG staff to VAPIHCS staff to discuss any scheduling 

difficulties, such as being unable to contact a veteran.

Because VAPIHCS relies on NHG to provide inpatient and specialty care 

services for veterans from Guam and the Commonwealth of the Northern 

Mariana Islands, it is essential that referrals sent to NHG are managed in 

a timely manner, including verifying the availability of services and 

ensuring referrals are entered into NHG’s electronic medical record 

system, as well as communicating with NHG about the status of veterans’ 

appointments. Without a more robust referral management process, 

VAPIHCS is unable to ensure that veterans receive needed care in a 

timely manner, if they receive care at all.

 49See GAO-14-704G. 
Page 34 GAO-18-288 Veterans Health Administration

We found that VAPIHCS has faced physician recruitment and retention 

challenges that are both unique to the Pacific Islands, such as the limited 

number of local physicians from which to recruit, and challenges that are 

common across VHA, such as the amount of time it takes to hire a new 

physician. Having an adequate physician workforce is key to ensuring 

veterans’ timely access to health care. Overall, there were at least 17 

physician vacancies out of approximately 100 positions across VAPIHCS 

as of October 2017, as well as several more vacancies for other types of 

health care providers, some of which have been unfilled for some time.50

For example, Guam clinic staff told us that at one point between October 

2016 and March 2017, the period of our medical record review, the clinic 

had 1.8 primary care physician full-time equivalents even though it was 

authorized for 4.51 VAPIHCS officials told us they are constantly trying to 

recruit physicians for their facilities.

Recruitment and Retention Challenges Unique to VAPIHCS. Through 

our review of relevant literature and interviews with VAPIHCS officials, we 

learned that physician recruitment is challenging for VAPIHCS in the 

following ways, particularly because of its geographic remoteness:

 50These vacancies included nurses, psychologists, and social workers. 

51As of December 2017, VAPIHCS officials told us they had filled two of the vacant 

primary care physician slots in Guam. One physician started working at the clinic in 

November 2017, while the second candidate is expected to start in January 2018.

VAPIHCS Has Faced 

Physician 

Recruitment and 

Retention 

Challenges, but Has 

Not Evaluated the 

Strategies It Used to 

Help Resolve Them

VAPIHCS Has Faced 

Physician Recruitment and 

Retention Challenges, 

Including Those Unique to 

the Pacific Islands, and 

Others Common across 

VHA
Page 35 GAO-18-288 Veterans Health Administration

• There is one local medical school and limited local providers 

from which VAPIHCS recruits. The University of Hawaii’s John A. 

Burns School of Medicine is the only local medical school across 

Hawaii, Guam, and American Samoa from which VAPIHCS recruits 

physicians.52

• The islands of American Samoa, Guam, and Hawaii all include 

counties, facilities, or populations designated as Health 

Professional Shortage Areas, which indicate health care provider 

shortages in primary, dental, or mental health care.53 These 

designations indicate a limited number of local physicians for 

VAPIHCS to target in the event of a vacancy. A 2015 University of 

Hawaii study further highlighted these shortages. It found that the 

Hawaiian Islands had a deficit of more than 600 physicians, with a 

projected shortage of between 800 and 1,500 physicians by 2020.54

This requires VAPIHCS to focus its recruitment efforts on medical 

schools and physicians located on the mainland United States.

• Travel options for VAPIHCS staff and their families are limited. 

Finding physicians that are willing to relocate to such remote locations 

is difficult, according to VAPIHCS officials. In prior work, we found that 

other VAMCs experienced challenges recruiting physicians who were 

reluctant to practice in rural or geographically remote areas.55 This 

challenge is likely more pronounced for VAPIHCS, given the location 

of its clinics. Both American Samoa and Guam are thousands of miles 

from the mainland United States and travel to and from these islands 

requires significant time and money. For example, American Samoa 

only has two direct commercial flights a week (on Mondays and 

Fridays) and Guam has only a daily direct commercial flight to 

 52Other schools across the islands offer training programs from which VAPIHCS can 

recruit other types of health care providers, including nurses and licensed clinical social 

workers.

53Health Professional Shortage Areas are designated by the Health Resources & Services 

Administration within the U.S. Department of Health and Human Services as having 

shortages of primary care, dental care, or mental health providers. Designations may be 

specific to geography (a county or service area), population (e.g., low income or Medicaid 

eligible) or type of facility (e.g., federally qualified health centers, or state or federal 

prisons). 

54Kelley Withy, University of Hawaii, Report to the 2016 Legislature: Annual Report on 

Findings from the Hawaii Physician Workforce Assessment Project (December 2015). 

55See GAO, Veterans Health Administration: Better Data and Evaluation Could Help 

Improve Physician Staffing, Recruitment, and Retention Strategies, GAO-18-124 

(Washington, D.C.: Oct. 19, 2017).
Page 36 GAO-18-288 Veterans Health Administration

Honolulu. While the Hawaiian Islands are more accessible to the 

mainland, they are still geographically isolated relative to the rest of 

the United States, and face some of the same travel challenges as 

American Samoa and Guam.

• Residents face a high cost of living, limited community 

resources, and trade-offs associated with island living. While 

other regions of the country face similar challenges, they may be 

more pronounced living on an island where alternatives are limited. 

The cost of living in Hawaii is higher than the nationwide average, and 

VAPIHCS officials told us that the real estate market in Hawaii is 

extremely expensive. These officials also said that physician 

candidates have raised concerns about the quality of the public school 

system in some areas of the islands, which could add a potential 

expense of sending their children to private schools and thus deter 

them from accepting employment. Other concerns include, for 

example, the lack of a veterinarian on American Samoa. According to 

an official, VAPIHCS lost a candidate who had agreed to relocate to 

the island until learning of the lack of veterinary services.

• Technical issues due to locations. One physician in American 

Samoa told us that it can take almost 1.5 hours to access the webbased program VHA offers for voice-activated dictation of medical 

notes, and thus, instead, he often uses services offline, although 

doing so means he has to enter his notes into VA’s medical record at 

a later time. Guam clinic staff, including physicians, also face unique 

challenges due to working across the International Date Line from the 

Spark M. Matsunaga VAMC. Specifically, the Guam clinic information 

technology system operates off of a server located in Honolulu that is 

20 hours, or almost a day, behind Guam. Veterans being treated in 

Guam are essentially being treated in the “future” according to VA’s 

server in Honolulu, as the date of a health care appointment in Guam 

is always one day ahead of the server in Honolulu. For example, if a 

Guam physician sees a patient on Monday at 3:00 pm, it is 7:00 pm 

on Sunday in Honolulu. As a result, physicians must wait until the next 

day to retroactively complete clinical notes. Officials also said that 

physicians are frustrated working in a system that may require 

multiple days to complete clinical notes, and that this issue has 

impacted physician recruitment and retention. Guam clinic staff also 

said that, due to the time change, they only have about 16 business 

hours per week that the clinic is open that overlap with business hours 

of VAPIHCS officials working in Honolulu, which limits the amount of 
Page 37 GAO-18-288 Veterans Health Administration

time physicians at the Guam clinic can consult with other VAPIHCS 

physicians or administrators in Honolulu.56

Recruitment and Retention Challenges across VHA. VAPIHCS has 

encountered some of the same physician recruitment and retention 

challenges that we have previously found are common across VHA, 

although some of these challenges may be compounded by the Pacific 

Islands’ geographic remoteness. For example:

• Differences in interpretation of recruiting and hiring policies may 

have contributed to lengthy recruiting times. In prior work, we 

found that differences in VAMC officials’ understanding of some of 

VHA’s recruitment and hiring policies contributed to lengthy 

recruitment and hiring processes.57 We also heard differences in 

policy interpretations during our discussions with VAPIHCS officials 

for this review. For example, some officials mentioned that a physician 

vacancy must be posted to USAJobs; however, VHA’s hiring 

authorities allow facilities to hire physicians for positions without 

regard to civil service requirements, such as requiring public notice of 

the vacancy.58 Some VAPIHCS officials also mentioned having to wait 

to post a position until after the predecessor had vacated it, while 

another official correctly noted that the recruitment process to replace 

a departing physician can begin before the position is vacated. Failure 

to understand VHA’s hiring authorities and use an expeditious hiring 

process most suitable for a particular vacancy may contribute to the 

length of the recruitment process.

• Lack of interoperable electronic medical record systems between 

VA and DOD. We have reported for more than a decade that VA and 

DOD lack interoperable electronic medical record systems that permit 

the efficient electronic exchange of patient health information.59 VA 

and DOD partly addressed the lack of interoperability by utilizing a 

web-based Joint Legacy Viewer to facilitate information-sharing for VA 

 56VAPIHCS officials told us there is a clinical administrator in Honolulu on call 24 hours a 

day for staff from the Guam clinic to speak with if necessary. 

57See GAO-18-124. We made five recommendations to VHA to improve information and 

processes surrounding physician recruitment and retention efforts, and to evaluate the 

effectiveness of its various recruitment and retention strategies. VHA concurred with four 

of our five recommendations and provided information on its plans to address them. 

5838 U.S.C. § 7403(a)(1).

59See GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: February 

2015). 
Page 38 GAO-18-288 Veterans Health Administration

and DOD patients, including those at VAPIHCS, NHG, and TAMC.60

The Joint Legacy Viewer provides VAPIHCS physicians with access 

to clinical notes on a veteran being treated at a military treatment 

facility. However, VAPIHCS and DOD officials told us that there are 

challenges using the Joint Legacy Viewer, including the absence of 

robust information found in electronic medical records, the need for 

physicians to toggle between multiple applications to obtain a patient’s 

full history, slow networks, and reduced worker productivity as a result 

of operating several different systems simultaneously. Retention of 

physicians may be difficult in an environment where the administrative 

burdens associated with information technology may take time away 

from providing patient care.

VAPIHCS and VHA officials told us they have recruited and retained 

physicians to the Pacific Islands by promoting attributes of its location and 

by using VHA strategies, similar to other VAMCs nationwide. Locally, 

officials told us they have advertised the Pacific Islands’ weather and 

scenery during their recruitment efforts. Officials also said they promoted 

VAPIHCS’ unique relationship with DOD through its joint venture with 

TAMC in Honolulu as an incentive for moving to Hawaii. For example, 

some VAPIHCS physicians working in Honolulu have the opportunity to 

work alongside DOD physicians at TAMC—including the ability to consult

face-to-face regarding care for a veteran referred to TAMC and provide 

care to DOD beneficiaries in certain settings.61

VAPIHCS also used many of the VHA strategies used at VAMCs 

nationwide to help with its physician recruitment and retention efforts. 

VAPIHCS officials discussed the use of the following VHA strategies, and 

noted limitations associated with some of them.

• Financial incentives. VAPIHCS officials reported that they 

sometimes used recruitment and retention bonuses and relocation 

 60The Joint Legacy Viewer is a web-based, clinical application that provides an integrated, 

read-only display of health data from DOD, VA, and private sector partners in a common 

data viewer. 

61VAPIHCS physicians provide care to DOD beneficiaries through VAPIHCS’ psychiatric 

unit embedded in TAMC and Post-Traumatic Stress Disorder Residential Recovery 

Program, as well as from a select number of VAPIHCS physicians who are embedded in 

TAMC.

VAPIHCS Has Used, but 

Not Evaluated, VHA 

Strategies to Support 

Physician Recruitment and 

Retention

Primary responsibility for physician 

recruitment and retention rests with each 

Veterans Affairs medical center (VAMC)

While each Veterans Integrated Service

Network has a Human Resources office 

responsible for overseeing the VAMC-level 

Human Resources offices within its network, 

individual VAMCs are responsible for 

managing their employee recruitment and 

retention programs. The Veterans Health 

Administration supports VAMCs in recruiting 

and retaining providers by providing systemwide strategies for their use.

Source: GAO. | GAO-18-288
Page 39 GAO-18-288 Veterans Health Administration

allowances for physicians.62 For example, in fiscal year 2017, 

VAPIHCS paid $217,257 in recruitment incentives to three specialty 

care providers (for an average of $72,419 per physician). VAPIHCS 

did not offer any other financial incentives that year.

• Education Debt Reduction Program. Through the Education Debt 

Reduction Program, VHA reimburses qualifying education loan debt 

for employees, including physicians, in hard-to-recruit positions.63 In 

fiscal year 2017, three primary care physicians in VAPIHCS had 

applications approved for this program. Each recipient was awarded, 

on average, $17,000. VAPIHCS officials said the program was 

generally considered a “great recruiting tool,” but that its success was 

inconsistent given uncertainties regarding the amount of funding that 

would be available to the facility in a given year. Funds for the 

Education Debt Reduction Program, which are centrally managed by 

VHA’s Healthcare Retention and Recruitment Office, are based on the 

availability of funds and demand each year. In instances where 

centralized funding is not available, VAPIHCS and other VAMCs are 

authorized to use local funds to support program offers, but VAPIHCS 

officials said they have not used any local funds to support the 

program in the last 5 years.

• National Recruitment Program. VHA’s National Healthcare 

Recruitment Service, a division of VHA’s Workforce Management and 

Consulting Office, operates the National Recruitment Program, which 

provides direct physician recruitment services to VAMCs for hard-torecruit positions by using private-sector recruiting techniques, 

including representing VHA at medical conferences and screening 

resumes. As part of VISN 21, VAPIHCS may also use the services of 

the network’s one dedicated recruiter responsible for serving the nine 

 62VHA may provide additional pay for prospective or current VHA employees, including 

physicians in hard-to-recruit or hard-to-retain positions. Generally, recruitment and 

relocation incentives may be up to 25 percent of annual base pay multiplied by the 

number of years in the employee’s service agreement. Generally, retention incentives may 

be up to 25 percent of annual base pay and are renewed annually.

63Certain health care professionals, including physicians, in hard to recruit positions may 

be eligible to receive up to $120,000 over a total of five years through the Education Debt 

Reduction Program, of which not more than $24,000 may be received each year. 

However, VA may waive these limitations for a participant the VA determines serves in a 

position where there is a shortage by reason of the location or requirements of the 

position. The funds received through this program are used to repay loans acquired while 

pursuing the degree that led to qualification for the position in VA. See generally 38 U.S.C. 

Chapter 76.
Page 40 GAO-18-288 Veterans Health Administration

facilities in the VISN.64 In the almost 6 years since this recruiter has 

worked for VISN 21, he reported recruiting seven physicians and one 

social worker for VAPIHCS, and is in the process of recruiting a 

nephrologist.65 The recruiter observed that with recent leadership 

changes, VAPIHCS officials have been more engaged with his office 

and the recruiting assistance he can provide. VAPIHCS officials 

shared these sentiments, echoing their interest in increasing utilization 

of the VISN recruiter.

• Rural Health Training and Education Initiative. According to VHA 

officials, VAPIHCS is one of five facilities to participate in VHA’s Office 

of Rural Health’s Rural Health Training and Education Initiative to 

enhance its physician recruitment efforts. This program works with 

academic affiliates to help place physicians in rural areas and 

enhance VAMCs’ recruitment efforts and educate trainees about 

working within a VA rural health environment. According to VAPIHCS 

officials, 3 out of 16 physicians from this program who are eligible to 

be hired have taken positions at its clinics, including positions in 

Guam and Molokai.

• Enhanced Physician Recruiting and Onboarding Model. In 2015, 

VHA issued its Enhanced Physician Recruiting and Onboarding Model 

to standardize interpretation of its recruitment policy, strengthen 

overall physician recruitment at VAMCs, and shorten hiring 

processing time.66 VAMCs were not required to implement the model, 

and in our prior work, we found that implementation has been limited 

due to, for example, the lack of resources to implement the 

recommendation for a dedicated VAMC-based physician recruiter.67

 64According to officials, this program had 19 physician recruiters assigned to the different 

VISNs overseeing VHA’s 170 VAMCs as of May 2017. 

65Specifically, the VISN recruiter recruited one psychiatrist for American Samoa; two 

primary care physicians, a dermatologist, a social worker, and an endocrinologist for 

Honolulu; a psychiatrist for Hilo; and a primary care physician for Guam. 

66See Department of Veterans Affairs, Field Guide for the VA’s Enhanced Physician 

Recruitment and Onboarding Model. The model contained 30 best practices to improve 

physician recruitment and streamline hiring, including suggestions that VAMCs conduct 

some recruitment activities concurrently; use the flexibilities allowed under Title 38 of the 

United States Code; and employ a dedicated physician recruiter to work in tandem with 

VHA’s national recruiters.

67See GAO-18-124. As of May 2017, 155 of VHA’s 170 VAMCs did not have dedicated 

physician recruiters. According to VHA officials in that report, no additional funding was 

provided for implementing recommendations from the Enhanced Physician Recruitment 

and Onboarding Model and VAMC officials told us that VAMCs could not afford to hire 

dedicated physician recruiters.
Page 41 GAO-18-288 Veterans Health Administration

VAPIHCS officials we spoke with said they were unaware of the 

Enhanced Physician Recruitment and Onboarding Model, but 

reported that they use 20 of the 30 best practices listed under the 

model, when asked about those practices. These best practices 

include, for example, leveraging increased pay rates when recruiting 

physicians, engaging with the VISN recruiter for hard-to-fill vacancies, 

and identifying interview questions and an interview panel before 

recruitment begins. VAPIHCS officials reported that they do not use 

other best practices such as utilizing VA’s human resources program

for tracking recruitment actions and having a dedicated physician 

recruiter because they already have an alternate practice in place or a 

practice does not match their needs, among other reasons. However, 

officials told us they plan to examine whether there are opportunities 

to leverage any of these remaining best practices.

As noted, in a prior report we recommended that VHA should conduct a 

comprehensive, system-wide evaluation of the physician recruitment and 

retention strategies used by VAMCs to determine their overall 

effectiveness, identify and implement improvements, ensure coordination 

across VHA offices, and establish an ongoing monitoring process.68

However, because VAMCs are primarily responsible for managing their 

own employee recruitment and retention programs and given the unique 

and ongoing challenges VAPIHCS has experienced with recruiting and 

retaining physicians, it is also important for VAPIHCS to similarly evaluate 

whether the strategies it uses are effective. An evaluation conducted by 

VHA on system-wide recruitment and retention strategies would not 

preclude the need for VAPIHCS to evaluate the strategies it uses; rather, 

it would further help identify those specific strategies that are most 

effective for recruiting and retaining physicians in the Pacific Islands.

Federal standards for internal control related to monitoring calls for 

agencies to perform monitoring activities, including completing 

evaluations to monitor the design and effectiveness of the operations at a 

specific time. Agencies are to then evaluate the results of these activities 

and take corrective actions as needed.69 Ensuring veterans have timely 

access to health care services is one of VA’s objectives, which is 

dependent upon having an adequate number of physicians to provide the 

 68See GAO-18-124. VHA concurred with this recommendation and reported in September 

2017 that VHA’s Office of Workforce Management and Consulting was in the process of 

completing the evaluation, with a target completion date of September 2018.

69See GAO-14-704G.
Page 42 GAO-18-288 Veterans Health Administration

care. VAPIHCS officials told us that as of December 2017 they have not 

conducted any type of evaluation of their current strategies for facilitating 

physician recruitment and retention due to recent changes in leadership 

positions. Without evaluating the strategies currently used to determine 

their effectiveness, or determining if additional strategies offered by VHA 

might be appropriate, VAPIHCS risks missing the opportunity to target its 

efforts to those strategies that have the greatest potential to ameliorate 

long-standing staffing shortages.

According to VAPIHCS officials, veterans face challenges accessing 

health care services on the Pacific Islands due to the lack of certain 

specialty care providers on many of the islands, the significant travel that 

is required to obtain these services, and limitations associated with 

telehealth services.

Lack of certain specialty care providers. VAPIHCS officials told us that 

several Pacific Islands lack certain specialty care services entirely or 

significantly enough that there may be only one or a few of a certain 

provider type available to serve all residents, including veterans. Overall, 

VAPIHCS officials noted that the availability of different types of 

physicians across the islands is constantly in flux, but said that notable 

shortages are in gastroenterology, audiology, podiatry, rheumatology, 

dermatology, and neurology. For example, according to VAPIHCS 

officials,

• there is only one dermatologist on Guam practicing at NHG, and there 

is only one gastroenterologist in the community providing certain 

services;

• Kauai has a shortage of oncologists;

Veterans Face a 

Number of 

Challenges Accessing 

Health Care in the 

Pacific Islands, and 

VAPIHCS Uses 

Several Strategies to 

Improve Access

Lack of Certain Specialties 

on the Pacific Islands and

Significant Travel Are 

among Challenges 

Veterans Face Accessing 

Heath Care
Page 43 GAO-18-288 Veterans Health Administration

• Maui has a shortage of cardiologists; and

• American Samoa has a shortage of almost all types of specialty care 

providers because it only has one hospital—the Lyndon B. Johnson 

Tropical Medical Center—to provide medical care to its approximate 

55,000 residents. VAPIHCS officials said the hospital is lacking many 

specialty services. According to VA, it does not authorize non-VA care 

there because the hospital receives funding from other federal 

agencies to provide medical services. Additionally, the hospital is not 

accredited for safety and quality.70 TriWest officials reiterated that 

there are virtually no specialty providers available on American 

Samoa for them to contract with; as of July 2017, there was only one 

Choice Program provider contracted on the island. As a result, 

essentially all eligible veterans must travel to Hawaii for specialty care 

services.

Significant travel required of veterans. Because many of the islands 

lack certain specialty providers, VAPIHCS officials said that veterans 

often must fly elsewhere to obtain care. While travelling such distances 

helps improve veterans’ access to health care services, it also creates 

challenges. For example, such travel requires time away from their 

homes and families, which may be particularly difficult for veterans in poor 

health. The time and distance required for travel can also be quite 

significant—for example, veterans from American Samoa, Guam, and the 

Commonwealth of the Northern Mariana Islands must travel thousands of 

miles by plane to receive services in Honolulu.71 A Guam veterans group 

said that veterans were frustrated with having to fly 8 hours to Hawaii for 

health care services. In instances where the necessary services are 

beyond those available in Honolulu, veterans must fly to the mainland 

United States for care—a flight from Honolulu to California adds about 5 

hours. The flight times are even longer for veterans travelling from 

American Samoa, the Commonwealth of the Northern Mariana Islands, 

and Guam. Figure 2 illustrates the locations of veterans enrolled in 

 70VA requires that facilities through which veterans are provided services receive 

accreditation from The Joint Commission, an independent, not-for-profit organization that 

has accredited and certified nearly 21,000 health care organizations and programs in the 

United States. Organizations accredited by it have systems and processes in place to 

provide safe and quality-oriented health care. In July 2017, a congressional oversight 

hearing was held on assessing the current conditions and challenges at the Lyndon B. 

Johnson Tropical Medical Center. Accessed January 5, 2018. 

https://naturalresources.house.gov/calendar/eventsingle.aspx?EventID=402562. 

71Veterans residing in other Hawaiian Islands may have to fly to Honolulu on the island of 

Oahu for health care services, typically a flight of less than an hour. 
Page 44 GAO-18-288 Veterans Health Administration

VAPIHCS and the distances and flight times they may need to travel to 

receive care.

Figure 2: Distances and Flight Times Veterans Enrolled in the Department of Veterans Affairs Pacific Islands Health Care 

System (VAPIHCS) May Need to Travel to Receive Care

Note: The flight paths illustrated here represent segments of or total trips some veterans may travel to 

receive health care services. For example, a veteran on Saipan may need to fly to Honolulu, Hawaii, 

for care, which would require a flight to Guam, then a second flight to Honolulu. A veteran in 

American Samoa, meanwhile, needing care on the mainland United States would need to fly first to 

Honolulu, then on to the West Coast of the United States. Additionally, veterans residing in other 

Hawaiian Islands may have to fly to Honolulu for health care services, typically a flight of less than an 

hour.
Page 45 GAO-18-288 Veterans Health Administration

According to VAPIHCS data, most VAPIHCS veterans travelling for health 

care services over the years have received care in Honolulu, although 

some have had to travel to the mainland United States for subspecialty 

care or highly specialized care such as organ transplants. Eligible 

veterans are provided reimbursement for travel-related expenses under 

VHA’s Beneficiary Travel Program.72 In fiscal year 2017, VAPIHCS 

provided beneficiary travel funds to 348 veterans from American Samoa 

and 92 veterans from Guam to travel to Honolulu for care, for a total of 

678 trips.73 During this same year, 15 veterans traveled to the mainland 

United States for care.74 VAPIHCS reported that, overall, 830 VAPIHCS 

veterans used beneficiary travel benefits to travel to Honolulu or the 

mainland United States for care that year. This represents approximately 

2 percent of the total number of veterans (51,213) who received some 

type of care through VAPIHCS in fiscal year 2017. Veterans are 

responsible for paying for travel if they are ineligible for travel benefits and 

travel is required to receive care. The significant costs associated with 

travel among the Pacific islands—flights, lodging, meals—could be cost 

prohibitive for these veterans and, as a result, they may be unable to 

access VA or non-VA health care services off island.

Limitations with telehealth services. Veterans face challenges 

accessing health care services due to limitations with telehealth services. 

For example, VAPIHCS officials told us there are limitations with the 

availability of internet services on the islands of Guam and American 

Samoa. This could lead to disruptions—or even cancellations—of 

veterans’ telehealth appointments. For example, VAPIHCS officials 

shared that damaged cables in the Pacific Ocean due to natural disasters 

and equipment failure on the part of internet service providers on the 

islands have led to disrupted and cancelled appointments for veterans. In 

 72VHA’s Beneficiary Travel Program is designed to encourage eligible veterans to seek 

needed medical care by reimbursing them for certain travel expenses, such as mileage, 

meals, and lodging, associated with medical appointments for services not obtainable 

locally. Veterans must meet certain eligibility criteria to qualify for these benefits; some 

examples are veterans are eligible for travel reimbursement for any condition if they have 

30 percent or more service-connected disability ratings; are receiving care related to their 

service-connected disability regardless of percent of disability; or have an annual income 

below an annual set rate.

73These numbers do not include the number of caregivers who accompanied the veterans 

on their trips. Additionally, the number of trips exceeds the number of veterans travelling 

because a veteran may have had to travel more than once that year.

74These numbers do not include those veterans who paid their own travel expenses. 
Page 46 GAO-18-288 Veterans Health Administration

March 2018, VAPIHCS reported that it had increased bandwidth and 

purchased new equipment to help support its telehealth efforts. 

Additionally, the extent to which a veteran can receive telehealth in his or 

her home versus the local clinic may depend upon the licensure of the 

provider delivering care. If a veteran is receiving telehealth services while 

he or she is physically located in a clinic, under federal law, the provider 

is not required to be licensed in the state in which the facility is 

located.75 When the patient is receiving telehealth services at home, 

however, a state may require that the provider be licensed in the state in 

which the patient is located. An official said that this is currently 

hampering VAPIHCS’ telehealth expansion efforts into the home.76

VAPIHCS has utilized a system of travelling VAPIHCS providers and is 

working to improve its use of telehealth services to better ensure 

veterans’ timely access to care, among other strategies, according to 

VAPIHCS officials.

Use of travelling providers. VAPIHCS officials reported that travelling 

providers enable VAPIHCS to better ensure access for veterans who are 

not eligible for beneficiary travel, and reduce the travel burden on 

veterans who are. Furthermore, they noted that it can be more cost 

effective for VAPIHCS to send a travelling provider to an island on a set 

schedule than it is to fly veterans to Honolulu for care. These providers 

also help expand access by providing specialty care that is in short supply 

or missing entirely in some communities. For example, a VAPIHCS 

optometrist travels to American Samoa for one week each month, 

according to officials, because there is no board-certified optometrist on 

the island. In addition, the travelling providers offer veterans the 

opportunity to receive specialty care from a VA provider.

Officials said they adjust the travelling providers’ schedules to reflect 

changes in service availability in the local communities. Table 11 

 75Providers practicing in a VA facility must be licensed to practice medicine in a state, but 

do not need to be licensed to practice in the state in which the VA facility is located. See 

38 U.S.C. § 7402(b). 

76On Oct. 2, 2017, VA proposed to amend its medical regulations by standardizing the 

delivery of care by VA health care providers through telehealth. The proposed rule would 

allow VA providers to treat patient in any state via telehealth, regardless of where the 

provider is licensed to practice. See Authority of Health Care Providers to Practice 

Telehealth, 82 Fed. Reg. 45756 (proposed Oct. 2, 2017)(to be codified at 38 C.F.R. pt. 

17).

VAPIHCS Uses Several 

Strategies to Improve 

Veterans Access to Health 

Care, including the Use of

Travelling Providers and 

Increased Use of 

Telehealth
Page 47 GAO-18-288 Veterans Health Administration

illustrates the types of VAPIHCS travelling providers and the frequency 

with which they visit different clinics, as of December 2017.

Table 11: Type of Care Provided by Travelling Department of Veterans Affairs Pacific Islands Health Care System (VAPIHCS)

Providers and the Frequency of Their Visits, by Clinic, as of December 2017

Specialty

VAPIHCS Clinic

Hawaii 

(Hilo)

Hawaii

(Kona) Maui Kauai

American

Samoa Guam Saipan

Orthopedic 2 days / 

month

2 days / 

month

2 days / 

month

2 days / 

month

1 week / 

month

Podiatry 1.5 weeks / 

every 2 months

Optometry/ blind 

rehabilitation 

outpatient specialist 

/ visual impairment 

services team

1 week / 

month

Neurology 3 days / 

month

1 day / 

month

2 days / 

month

1 day / 

month

1 week / 

every 3 

months

Nephrology 1 day every 

other month

1 day every 

other month

Gastroenterology/

gastrointestinal 

endoscopy

3 days / 

month 

2 days / 

month

Cardiology 1 day / 

month

1 day / 

month

1 day / 

month

2 days / 

month

Interventional 

pain

1 day / 

month

1 day / 

month 

1 day / 

month

Rheumatology 2 days / 

month

1 day every 

other month

1 day / 

month 

2 days / 

month

Endocrinology 2 days / 

month 

1 day / 

month 

2 days / 

month

1 day / 

month 

3 days every 

2 months

Source: VAPIHCS | GAO-18-288.

Increased use of telehealth services. Even though internet service on 

the Pacific Islands is not always reliable as previously noted, VAPIHCS 

has been increasing its use of telehealth services to improve veterans’ 

access to health care services. In fiscal year 2017, VAPIHCS reported 

that 3,046 VAPIHCS veterans utilized clinic-based telehealth services 
Page 48 GAO-18-288 Veterans Health Administration

compared to 1,299 veterans in fiscal year 2011, an increase of more than 

134 percent.77

VAPIHCS launched two new telehealth hubs in June 2017:78

• According to VA officials, VAPIHCS was 1 of 8 VAMCs selected to 

establish a hub, or center for delivery of teleprimary care from the 

VAMC to distant clinics within its system. According to VAPIHCS 

officials, the teleprimary care hub in the Spark M. Matsunaga VAMC is 

currently providing services to veterans at the Guam clinic and is 

exploring opportunities to provide teleurgent care in partnership with 

VAPIHCS’ call center. Officials further noted this would allow 

telehealth staff to provide veterans with “almost instant access” to 

health care services and, if successful, help improve veterans’ timely 

access to care by increasing the number of appointments at the 

clinics that could be dedicated to more complex concerns. VAPIHCS 

officials also said that the teleprimary care hub would also be used for 

long-term coverage for clinics with provider vacancies.

• Similarly, VAPIHCS was one of 11 VAMCs selected to establish a 

telemental health hub. According to VAPIHCS officials, this hub is 

currently serving veterans at the Oahu, Guam, and Molokai clinics 

and one of the Hawaii clinics (Hilo), with plans to expand services to 

the Kauai clinic in the future.

Overall, officials said that feedback from veterans using these hubs has 

been “overwhelmingly positive,” as veterans appreciate receiving care 

from VAPIHCS providers, the privacy afforded by telehealth, and not 

 77These numbers only account for clinic-based telehealth encounters—that is, telehealth 

encounters that occurred while a veteran was in a clinic. There are other types of 

telehealth services available to veterans, including some that are offered to veterans when 

they are in their homes. As a result, the total number of telehealth users is likely higher. 

For example, according to VAPIHCS, in fiscal year 2016 approximately 9 percent of all 

VAPIHCS’ veterans utilized some form of telehealth services, representing more than 

5,000 telehealth encounters across 35 specialties. 

78According to VAPIHCS officials, the services available through the teleprimary care hub 

include team-based care consistent with VA’s patient aligned care team model. This 

includes comprehensive primary care, shared medical appointments, telephone clinics, 

and other alternative visits. Services available through the telemental health hub, 

meanwhile, include evidence based therapies for conditions such as post-traumatic stress 

disorder, insomnia, and depression; psychopharmacology, support for substance use 

disorders and chronic disease management; and team-based care consistent with VA’s 

Behavioral Health Interdisciplinary Program. 
Page 49 GAO-18-288 Veterans Health Administration

having to travel for their services. The number of telehealth users in 

VAPIHCS is likely to continue increasing as a result of these new hubs.

While feedback has been positive, VAPIHCS officials said they have 

experienced some challenges with the launch of these hubs, including the 

time and date difference between Guam and Honolulu where the staff for 

both hubs are located. Staff from the hubs had to adjust their schedules 

to support Guam’s hours given that only 16 business hours per week 

overlap between the two islands. Having sufficient space in the clinics for 

telehealth services is another challenge. To address this, one official said 

they are encouraging veterans to hold video visits with their providers 

from their homes if clinical exams are not required during their 

appointments.

Improvements to clinical space. Because sufficient examination and 

treatment space is lacking in many of its clinics, VAPIHCS is in the 

process of building new or expanding existing clinics to increase the 

number and type of services available to veterans. According to a

VAPIHCS official, as of August 2017, VAPIHCS has plans to replace six 

of its existing clinics and open one new clinic. These new clinics are 

expected to be open by fiscal year 2020. For example, the American 

Samoa clinic will be expanded to include additional space for mental 

health consultations and group meeting spaces, while the Guam clinic will 

be expanded to include additional primary and mental health care clinic 

space. This may help address a concern of the Guam veterans group we 

spoke with in Guam, who said the clinic was too small and did not offer 

sufficient patient privacy. According to VAPIHCS officials, VAPIHCS’ new 

clinic, expected to open in 2020, is to be located on the island of Oahu 

and will be a multi-specialty outpatient clinic offering many different 

services, including primary care, mental health, telemedicine, women’s 

care, dental care, a pain clinic, physical and occupational therapy, 

prosthetic, laboratory and pathology, pharmacy, and imaging services.

Improvements to the beneficiary travel process. VAPIHCS is in the 

process of updating its process for arranging beneficiary travel, which 

ultimately could improve veterans’ access to care. Under the old process, 

officials told us that much of the responsibility for coordinating veterans’ 

travel fell on nursing and administrative staff, creating stress and reducing 

the amount of time nurses could spend on providing patient care. As a 

result, VAPIHCS decided to centralize its beneficiary travel process in the 

Office of Beneficiary Travel in Honolulu. The goal, according to VAPIHCS 

officials, is to remove the clinic staff from the process—thereby increasing 

the amount of time dedicated to their clinical duties—and instead 
Page 50 GAO-18-288 Veterans Health Administration

encourage veterans to work directly with the staff in Honolulu to arrange 

their travel. As of September 2017, VAPIHCS was still in the process of 

implementing this new process. VAPIHCS also created a task force to 

improve the process for arranging travel for American Samoa veterans 

needing care off-island. As a result of their efforts, VAPIHCS officials 

reported in December 2017 that they had managed to reduce the time 

clinic staff in American Samoa dedicated each day to addressing travel 

issues from an average of 408 minutes to 64 minutes.

Communicating with veterans about VA and Non-VA services. 

VAPIHCS uses a variety of mechanisms to communicate with veterans 

about access to VA and non-VA health care services. Veterans are 

introduced to these services through New Veteran Orientations that are 

offered at some of the clinics. VAPIHCS also gives newly enrolled 

veterans handbooks that are specific to the clinics where they enrolled.79

VAPIHCS also communicates with veterans through town hall meetings, 

health forums, its Facebook page, television and radio shows, and 

community events. For example, staff from the American Samoa clinic 

told us that they partner with a local television station to host a 30-minute 

monthly segment to educate veterans about available VA services. 

VAPIHCS officials reported they had planned to conduct approximately 

170 outreach events, spanning 9 islands and targeting about 6,000 

veterans, for fiscal year 2017. VAPIHCS officials told us that they try to 

provide culturally appropriate communications with veterans of the 

different Pacific Islands. For example, they said they are planning to 

translate materials into Samoan for veterans from American Samoa. They 

also recognize that many veterans prefer face-to-face interactions with 

VA officials rather than receiving information electronically; for example, 

the Hawaiian tradition known as “talk story” focuses on informal 

conversations and sharing information with friends in the community.

VAPIHCS has generally provided primary and mental health care within 

VHA’s timeliness goals for most veterans reviewed, but there are 

weaknesses in the referral process for specialty care services. Because 

most specialty care services are provided to veterans outside of VA 

through DOD providers or through non-VA providers in the community, it 

 79As of September 2017, VAPIHCS had updated its patient handbooks for the American 

Samoa, Guam, Oahu, Kona, Molokai, and Saipan clinics. According to officials, VAPIHCS 

was still in the process of updating its patient handbooks for the Maui, Hilo, and Kauai 

clinics.

Conclusions
Page 51 GAO-18-288 Veterans Health Administration

is crucial that VAPIHCS improve its management of these referrals to 

ensure adherence to VHA policy. Without improvements to adherence to 

VHA policy in the referral process, inconsistent guidance on roles and 

responsibilities, and lack of timeliness of referral management, these 

weaknesses are likely to persist, and may add to the amount of time it 

takes for some veterans to receive care, or may result in some veterans 

not receiving care at all.

In addition, maintaining an adequate clinical workforce to meet the health 

care needs of veterans is necessary to ensuring veterans’ timely access 

to care. Doing so is particularly important for VAPIHCS given the unique 

challenges it faces in recruiting and retaining physicians in the 

geographically remote Pacific Islands. It is therefore critical that VAPIHCS 

identify and use the most effective recruitment and retention strategies 

offered by VHA. However, VAPIHCS has not evaluated the strategies that 

it has used to determine if they are the most optimal or if other available 

strategies would be more effective. Without completing such an 

evaluation, VAPIHCS does not know if it is optimizing its resources to 

improve its hiring efforts and ameliorate long-standing physician 

shortages.

We are making the following four recommendations to VA:

1. The Secretary of VA should ensure that VAPIHCS review its referral 

process for referrals to DOD providers, including referral cancellation, 

to determine why VHA policy is not being adhered to and make 

changes as needed. (Recommendation 1)

2. The Secretary of VA should ensure that VAPIHCS clarify guidance to 

clearly define and document roles and responsibilities for VAPIHCS 

staff involved in the referral process with NHG. (Recommendation 2)

3. The Secretary of VA should ensure that VAPIHCS improves the 

monitoring of referrals and communication with NHG to ensure the 

timely management of referrals to NHG, including verifying the 

availability of services for veterans; ensuring referrals are entered into 

NHG’s electronic medical record system; and obtaining information 

about the status of scheduling appointments for veterans. 

(Recommendation 3)

4. The Secretary of VA should ensure that VAPIHCS evaluates the 

effectiveness of strategies it currently uses to promote physician 

recruitment and retention, including how the strategies could be 

improved. The plan should also include an assessment of whether 

Recommendations for 

Executive Action
Page 52 GAO-18-288 Veterans Health Administration

additional strategies currently offered by VHA would be beneficial. 

(Recommendation 4)

We provided a draft of this report to VA and DOD for review and 

comment. VA provided written comments, which are reproduced in 

appendix I. In addition, both VA and DOD provided technical comments, 

which we have incorporated as appropriate. 

In its written comments, VA concurred with three of our four 

recommendations and provided information on its plans to address them. 

VA partly concurred with our recommendation for VAPIHCS to improve 

the monitoring of referrals and communication with NHG to ensure the 

timely management of referrals to NHG. For this recommendation, VA 

agreed that it should improve its monitoring of referrals by verifying the 

availability of services at NHG for veterans and obtaining the status of 

their appointments to be scheduled, and noted that VAPIHCS is 

developing a standard operating procedure that includes, among other 

things, monitoring referrals weekly to resolve issues. 

However, VA did not agree with ensuring referrals are entered into NHG’s 

electronic medical record system as part of its monitoring efforts and 

stated that it does not have the authority to do so. During our review, we 

found that designated VAPIHCS staff on Guam have access to, and are 

responsible for entering referrals directly into, NHG’s electronic medical 

record. Only after VAPIHCS staff enter referrals directly into NHG’s 

electronic medical record did NHG staff assume responsibility for 

scheduling veterans’ appointments. We confirmed this practice through 

interviews with VAPIHCS and DOD staff and through our review of a 

sample of referrals sent to NHG, which showed that VAPIHCS staff had 

entered the referrals. Furthermore, the sharing agreement between 

VAPIHCS and NHG documented the arrangement for VAPIHCS staff to 

be granted access to NHG’s electronic medical record. As long as 

VAPIHCS staff continue to be responsible for entering referrals into 

NHG’s electronic medical record system, we believe that it is also their 

responsibility to monitor the status of these referrals, including ensuring 

that referrals are entered correctly and timely. Because VAPIHCS relies 

on NHG to provide inpatient and specialty care services for veterans from 

Guam and the Commonwealth of the Northern Mariana Islands, it is 

important for VAPIHCS to monitor the entire referral management 

process to ensure that veterans receive needed care in a timely manner.

Agency Comments 

and Our Evaluation
Page 53 GAO-18-288 Veterans Health Administration

We are sending copies of this report to the appropriate congressional 

committees and the Secretaries of Veterans Affairs and Defense. In 

addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov.

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or at DraperD@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix II.

Debra A. Draper

Director, Health Care
Page 54 GAO-18-288 Veterans Health Administration

List of Congressional Addresses

The Honorable John Boozman

Chairman

The Honorable Brian Schatz

Ranking Member

Subcommittee on Military Construction,

Veterans’ Affairs, and Related Agencies

Committee on Appropriations

United States Senate

The Honorable Charlie Dent

Chairman

The Honorable Debbie Wasserman Schultz

Ranking Member

Subcommittee on Military Construction, 

Veterans’ Affairs, and Related Agencies

Committee on Appropriations

House of Representatives

The Honorable Madeleine Z. Bordallo

House of Representatives

The Honorable Amata Radewagen

House of Representatives
Appendix I: Department of Veterans Affairs 

Comments

Page 55 GAO-18-288 Veterans Health Administration

Appendix I: Department of Veterans Affairs 

Comments
Appendix I: Department of Veterans Affairs 

Comments

Page 56 GAO-18-288 Veterans Health Administration
Appendix I: Department of Veterans Affairs 

Comments

Page 57 GAO-18-288 Veterans Health Administration
Appendix I: Department of Veterans Affairs 

Comments

Page 58 GAO-18-288 Veterans Health Administration
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 59 GAO-18-288 Veterans Health Administration

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Ann Tynan, Assistant Director,

Kaitlin Coffey (Analyst in Charge), Kate Tussey, Jennie Apter, and Jackie 

Hamilton made key contributions to this report. Also contributing were 

Emily Binek, Muriel Brown, Natalie Hagy, Alexis MacDonald, and Brienne 

Tierney. 

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 60 GAO-18-288 Veterans Health Administration

Veterans Health Administration: Better Data and Evaluation Could Help 

Improve Physician Staffing, Recruitment, and Retention Strategies,

GAO-18-124. Washington, D.C.: October 19, 2017.

VA Health Care: Opportunities Exist for Improving Implementation and 

Oversight of Enrollment Processes for Veterans, GAO-17-709. 

Washington, D.C.: September 5, 2017.

VA Health Care: Improvements Needed in Data and Monitoring of Clinical 

Productivity and Efficiency, GAO-17-480. Washington, D.C.: May 24, 

2017.

Veterans Health Care: Preliminary Observations on Veterans’ Access to 

Choice Program Care, GAO-17-397T. Washington, D.C.: March 7, 2017.

Veterans Health Administration: Management Attention Is Needed to 

Address Systemic, Long-standing Human Capital Challenges,

GAO-17-30. Washington, D.C., December 23, 2016.

Veterans Health Care: Improvements Needed in Operationalizing

Strategic Goals and Objectives, GAO-17-50. Washington, D.C.: October 

21, 2016.

Veterans Health Administration: Personnel Data Show Losses Increased 

for Clinical Occupations from Fiscal Year 2011 through 2015, Driven by 

Voluntary Resignations and Retirements, GAO-16-666R. Washington, 

D.C.: July 29, 2016.

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

Access to Primary Care, GAO-16-328. Washington, D.C.: March 18, 

2016.

VA Mental Health: Clearer Guidance on Access Policies and Wait-Time 

Data Needed, GAO-16-24. Washington, D.C.: October 28, 2015.

VA Primary Care: Improved Oversight Needed to Better Ensure Timely 

Access and Efficient Delivery of Care. GAO-16-83. Washington, D.C.: 

October 8, 2015.

VA Health Care: Oversight Improvements Needed for Nurse Recruitment 

and Retention Initiatives, GAO-15-794. Washington, D.C.: September 30, 

2015.

Related GAO Products
Related GAO Products

Page 61 GAO-18-288 Veterans Health Administration

VA Health Care: Actions Needed to Ensure Adequate and Qualified 

Nurse Staffing, GAO-15-61. Washington, D.C.: October 16, 2014.

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.: September 30, 2014.

VA Health Care: Reliability of Reported Outpatient Medical Appointment 

Wait Times and Scheduling Oversight Need Improvement, GAO-13-130. 

Washington, D.C.: December 21, 2012.

VA and DOD Health Care: Department-Level Actions Needed to Assess 

Collaboration Performance, Address Barriers, and Identify Opportunities,

GAO-12-992. Washington, D.C.: September 28, 2012.

Veterans’ Health Care: Service Delivery for Veterans on Guam and the 

Commonwealth of the Northern Mariana Islands, GAO/HEHS-99-14. 

Washington, D.C.: November 4, 1998.

Veterans’ Benefits: Availability of Benefits in American Samoa, 

GAO/HRD-93-16. Washington, D.C.: November 18, 1992.

(101322)
The Government Accountability Office, the audit, evaluation, and investigative 

arm of Congress, exists to support Congress in meeting its constitutional 

responsibilities and to help improve the performance and accountability of the 

federal government for the American people. GAO examines the use of public 

funds; evaluates federal programs and policies; and provides analyses, 

recommendations, and other assistance to help Congress make informed 

oversight, policy, and funding decisions. GAO’s commitment to good government 

is reflected in its core values of accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no cost is 

through GAO’s website (https://www.gao.gov). Each weekday afternoon, GAO 

posts on its website newly released reports, testimony, and correspondence. To 

have GAO e-mail you a list of newly posted products, go to https://www.gao.gov

and select “E-mail Updates.”

The price of each GAO publication reflects GAO’s actual cost of production and 

distribution and depends on the number of pages in the publication and whether 

the publication is printed in color or black and white. Pricing and ordering 

information is posted on GAO’s website, https://www.gao.gov/ordering.htm. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 

TDD (202) 512-2537.

Orders may be paid for using American Express, Discover Card, MasterCard, 

Visa, check, or money order. Call for additional information.

Connect with GAO on Facebook, Flickr, Twitter, and YouTube.

Subscribe to our RSS Feeds or E-mail Updates. Listen to our Podcasts.

Visit GAO on the web at https://www.gao.gov.

Contact:

Website: https://www.gao.gov/fraudnet/fraudnet.htm

Automated answering system: (800) 424-5454 or (202) 512-7470

Orice Williams Brown, Managing Director, WilliamsO@gao.gov, (202) 512-4400, 

U.S. Government Accountability Office, 441 G Street NW, Room 7125, 

Washington, DC 20548

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548

James-Christian Blockwood, Managing Director, spel@gao.gov, (202) 512-4707

U.S. Government Accountability Office, 441 G Street NW, Room 7814, 

Washington, DC 20548

GAO’s Mission

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Phone

Connect with GAO

To Report Fraud, 

Waste, and Abuse in 

Federal Programs

Congressional 

Relations

Public Affairs

Strategic Planning and 

External Liaison

Please Print on Recycled Paper.