VA Health Care: Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care
Published: 2016-03-18T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Primary care services are often the entry point for veterans needing care, and VHA has faced a growing demand for outpatient primary care services over the past decade. On average, 380,000 veterans were newly enrolled in VHA's health care system each year in the last decade.
GAO was asked to examine VHA's efforts to provide timely access to primary care services. This report examines, among other things, (1) newly enrolled veterans' access to primary care and (2) VHA's related oversight. GAO interviewed officials from six VA medical centers selected to provide variation in factors such as geographic location, clinical services offered, and average primary care wait times; reviewed a randomly selected, non-generalizable sample of medical records for 180 newly enrolled veterans; and interviewed VHA and medical center officials on oversight of access to primary care. GAO evaluated VHA's oversight against relevant federal standards for internal control.
section_title: What GAO Found
paragraphs: GAO found that not all newly enrolled veterans were able to access primary care from the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA), and others experienced wide variation in the amount of time they waited for care. Sixty of the 180 newly enrolled veterans in GAO's review had not been seen by providers at the time of the review; nearly half were unable to access primary care because VA medical center staff did not schedule appointments for these veterans in accordance with VHA policy. The 120 newly enrolled veterans in GAO's review who were seen by providers waited from 22 days to 71 days from their requests that VA contact them to schedule appointments to when they were seen, according to GAO's analysis. These time frames were impacted by limited appointment availability and weaknesses in medical center scheduling practices, which contributed to unnecessary delays.
VHA's oversight of veterans' access to primary care is hindered, in part, by data weaknesses and the lack of a comprehensive scheduling policy. This is inconsistent with federal internal control standards, which call for agencies to have reliable data and effective policies to achieve their objectives. For newly enrolled veterans, VHA calculates primary care appointment wait times starting from the veterans' preferred dates (the dates veterans want to be seen), rather than the dates veterans initially requested VA contact them to schedule appointments. Therefore, these data do not capture the time these veterans wait prior to being contacted by schedulers, making it difficult for officials to identify and remedy scheduling problems that arise prior to making contact with veterans. Further, ongoing scheduling errors, such as incorrectly revising preferred dates when rescheduling appointments, understated the amount of time veterans waited to see providers. Officials attributed these errors to confusion by schedulers, resulting from the lack of an updated standardized scheduling policy. These errors continue to affect the reliability of wait-time data used for oversight, which makes it more difficult to effectively oversee newly enrolled veterans' access to primary care.
section_title: What GAO Recommends
paragraphs: GAO recommends that VHA (1) ensure veterans requesting appointments are contacted in a timely manner to schedule one; (2) monitor the full amount of time newly enrolled veterans wait to receive primary care; and (3) issue an updated scheduling policy. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

section_title: Letter
paragraphs: The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), operates one of the nation’s largest health care  systems. It provided care to about 6.6 million veterans in fiscal year 2014  and spent about $58 billion for their care in that year. Primary care  services are often the entry point to the VHA health care system for  veterans, including an aging veteran population and a growing number of  younger veterans returning from military operations in Afghanistan and  Iraq. Over the past decade, VHA has faced a growing demand for  outpatient primary care services. From fiscal years 2005 through 2014,  the number of annual outpatient primary care medical appointments VHA  provided through its medical facilities increased by 17 percent, from  approximately 10.2 million to 11.9 million. Each year over that period, an  average of 380,000 veterans were newly enrolled in VHA’s health care  system. In fiscal year 2014, VHA provided about 730,000 primary care  appointments for new patients—appointments for those patients who  have not been seen in a primary care clinic in the past 24 months,  including those who are newly enrolled.
Access to timely primary care medical appointments is critical to ensuring  that veterans obtain needed medical care, because primary care is a  gateway to obtaining other VHA health care services, including specialty  care. When veterans need specialty care—such as cardiology or  gastroenterology—they are typically referred to a specialist by their  primary care provider, and each veteran’s primary care team manages  and coordinates the needed care. Veterans may obtain primary care  services at VHA’s medical facilities, which include 167 medical centers  and more than 800 community-based outpatient clinics. Responsibility  for ensuring timely access to primary care rests with 20 regional Veterans  Integrated Service Networks (VISN), which oversee the medical centers,  and with VHA’s central office, which oversees the entire VA health care  system.
In recent years, we and others have expressed concerns about VHA’s  ability to effectively oversee timely access to health care for veterans, and  the failure to provide timely access to care, which, in some cases,  reportedly has resulted in harm to veterans. Our prior work on VHA’s  oversight of primary and specialty care found VHA did not have adequate  data and oversight mechanisms in place to ensure veterans receive  timely care. For example, since 2012, we have issued several reports  recommending that VA improve appointment scheduling, ensure the  reliability of wait-time and other performance data, and improve oversight  to ensure VA medical centers provide veterans with timely access to  outpatient primary and specialty care, as well as mental health care. (See  app. I for the status of those recommendations.) Based on these serious  concerns about VA’s management and oversight of its health care  system, we have concluded that VA health care is a high-risk area and, in  2015, added it to GAO’s High Risk List. To help improve timely access to  health care, Congress passed the Veterans Access, Choice, and  Accountability Act of 2014 (Choice Act), which provided veterans facing  long waits or lengthy travel distances the opportunity to obtain care from  providers (non-VA) in the community.
You asked us to examine VHA’s efforts to provide timely access to  primary care services. This report examines  1.  the extent to which newly enrolled veterans access primary care in a  2.  the extent to which veterans access follow-up primary care in a timely  3.  the extent to which VHA provides oversight of veterans’ access to  4.  recent VHA efforts to help improve veterans’ timely access to primary  care.
To examine the extent to which newly enrolled veterans access primary  care in a timely manner, we reviewed relevant VHA and VA medical  center documents, such as health care enrollment and appointment  scheduling policies. Additionally, we interviewed officials from VA’s Health  Eligibility Center, VHA central office—VHA’s Health Resource Center,  Office of Primary Care, and Access and Clinical Administration  Program—and six VA medical centers about policies and guidance for  scheduling newly enrolled veterans for outpatient primary care  appointments. These medical centers were: VA Central Western  Massachusetts Healthcare System (Leeds, Massachusetts); Tennessee  Valley Healthcare System (Nashville, Tennessee); Fayetteville VA  Medical Center (Fayetteville, North Carolina); Ralph H. Johnson VA  Medical Center (Charleston, South Carolina); VA Eastern Kansas Health  Care System (Leavenworth, Kansas); and VA San Diego Healthcare  System (San Diego, California).  We selected the six medical centers for  variation in (1) average time new patients were waiting for primary care  based on appointment wait-time data published on VA’s public website,  (2) facility complexity, and (3) geographic location. Although our previous  work, as well as that of the VA Office of Inspector General, has shown  that the VHA wait-time data are unreliable and prone to errors and  interpretation, through interviews with VHA officials knowledgeable about  the wait-time data, we determined that these data were sufficiently  reliable for our use in selecting individual medical centers to include in our  review. We also interviewed officials from each of the VISNs  responsible for oversight of these medical centers. We also obtained the  perspectives of VHA, VISN, and VA medical center officials about issues  such as challenges to veterans’ access to primary care appointments and  potential solutions for improving access.
Further, for each of the six VA medical centers included in our review, we  obtained a list of veterans who, between October 1, 2014, and March 31,  2015, requested on their enrollment applications that VA contact them to  schedule medical appointments. From this list, we selected a sample of  60 veterans, each of whom had not yet been seen by a primary care  provider, 10 randomly selected from each of the six medical centers. We  also selected a sample of 120 veterans who each were seen by a primary  care provider, 20 randomly selected from each medical center included in  our review. We examined the medical records for each of these 180  veterans to determine the history of actions taken to schedule  appointments, such as dates the appointments were scheduled; dates  veterans were seen by primary care providers, if applicable; and whether  initially scheduled appointments were canceled, and if so, whether and  when they were rescheduled. We also obtained information on the dates  each of the six medical centers contacted veterans to schedule  appointments. For those veterans who had been seen by providers, we  calculated the amount of time it took from the dates the veterans  requested on their enrollment applications that VA contact them to  schedule appointments until their appointment dates, and compared  those time frames to the amount of time reflected in the medical centers’  scheduling systems. For those veterans who had not been seen by  providers at the time of our review, we interviewed medical center officials  to identify reasons why they were not seen. We used the results of our  analyses to determine whether the medical centers were contacting  veterans and scheduling appointments according to VHA policies.
To examine the extent to which veterans access follow-up primary care in  a timely manner, we reviewed relevant VHA and VA medical center  documents, and interviewed officials from VHA’s central office, and the  six medical centers in our review regarding the policies and procedures  for scheduling follow-up outpatient appointments. For each of the six  medical centers, we obtained a list of veterans who saw primary care  providers for follow-up appointments in June 2015. From that information,  we selected a sample of 60 veterans, 10 randomly selected from each of  the six medical centers. We examined the medical records of these 60  veterans to determine whether a VHA provider had instructed veterans to  return for follow-up appointments, and if so, the time frames for  scheduling the return visits. We then reviewed the history of actions taken  to schedule each of the follow-up appointments to determine whether the  appointments were scheduled according to both VHA policies and the  providers’ instructions, and if not, the factors that affected timely  scheduling. The results from our work at six medical centers, including  our medical record reviews of 240 veterans—180 newly enrolled and 60  who saw providers for follow-up primary care appointments—cannot be  generalized to all veterans at the medical centers in our review, or to  other medical centers.
To determine the extent to which VHA provides oversight of veterans’  access to primary care, we reviewed documents, including national VHA  and local medical center appointment scheduling policies. Additionally,  we interviewed officials from VHA central office and the six VISNs and  medical centers in our review about their oversight efforts. As part of our  review, we also reviewed the key mechanisms that officials told us they  were using to conduct oversight of veterans’ access to primary care,  including the key measures they were using to monitor the timeliness of  appointments. We evaluated VHA’s mechanisms for overseeing veterans’  access to primary care against the federal internal control standards  related to control activities, information, and monitoring.
To identify recent VHA efforts to improve veterans’ timely access to  primary care, we reviewed provisions of the Choice Act intended to  enhance veterans’ access to care, as well as relevant documents from  VHA and medical centers in our review that outline steps taken to  enhance or improve veterans’ access to primary care appointments. We  also interviewed officials from VHA central office and our selected VISNs  and medical centers to obtain their perspectives on the impact of the  Choice Act on veterans’ access to primary care, as well as other efforts  underway to help ensure veterans’ timely access to primary care.
We conducted this performance audit from January 2015 to March 2016  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.
subsections: section_title: Background
subsections: section_title: Enrolling for VHA Health Care Benefits
paragraphs: VHA offers eligible veterans a standard medical benefits package,  including primary care. To receive these health care benefits, veterans  must first complete VA’s enrollment application—the 1010 EZ—and  submit it online, in person, by mail, or by fax to a VA medical center or  VA’s Health Eligibility Center. Health Eligibility Center officials query  several VA and Department of Defense databases to verify veterans’  eligibility for benefits and share this information with the applicable  medical centers. If the Health Eligibility Center cannot make a  determination as to veterans’ eligibility, officials notify veterans’ local  medical centers to take further action, such as requesting additional  documentation of military service records. The Health Eligibility Center  sends a letter to each veteran once it has made an eligibility  determination with the decision and a description of benefits.
section_title: Scheduling Appointments for Newly Enrolled Veterans
paragraphs: Veterans requesting on their enrollment applications that VA contact them  to schedule appointments, if eligible, are to be placed on VHA’s New  Enrollee Appointment Request (NEAR) list. (See fig.1 for an illustration of  how newly enrolling veterans request on their enrollment applications that  VA contact them to schedule appointments.) The NEAR list is intended to  help VA medical centers track newly enrolled veterans needing  appointments. It includes information regarding the medical center at  which the veteran wants to be seen, contact information for the veteran,  and whether the veteran is waiting to be contacted to schedule an  appointment. If a veteran submits an application in person, medical center  staff may schedule an appointment for the veteran at that time. Once the  appointment is scheduled, the request is considered “filled” and the  veteran’s name is removed from the NEAR list.
According to VHA policy, as outlined in its July 2014 interim scheduling  guidance, VA medical center staff should contact newly enrolled veterans  to schedule appointments within 7 days from the date they were placed  on the NEAR list. When contacted by the medical center, which may be  by phone or letter, each veteran is scheduled for a 60-minute  appointment based on the veteran’s preferred date—the date the veteran  wants to be seen. Schedulers negotiate appointment dates with veterans  using the preferred date and appointment availability.
In July 2015, VA’s Health Resource Center began implementing a new  program called “Welcome to VA.” Under this program, Health Resource  Center staff located at central call centers are responsible for contacting  each newly enrolled veteran within 5 days of the veteran’s enrollment  date. Call center staff are to contact each veteran who submits an  enrollment application and is determined eligible for health care,  regardless of whether the veteran requests to be contacted on the  application, to determine whether the veteran wants to schedule an  appointment. To make an appointment, Health Resource Center staff are  to provide the veteran with the phone number for his or her preferred VA  medical center and connect the veteran with a local scheduler. Health  Resource Center officials explained that although this program was  running concurrently with the NEAR list process at the time of our review,  the program will eventually replace the NEAR list process. When fully  implemented, which is expected in spring 2016 according to Health  Resource Center officials, medical centers would use a list generated by  the Health Resource Center to contact veterans who request  appointments.
If VA medical center schedulers attempt to schedule appointments for  new patients, including newly enrolled veterans, and no appointments are  available within 90 days from when veterans would like to be seen, VHA  policy requires that veterans be added to the electronic wait list. As  appointments become available, schedulers contact veterans on the  electronic wait list to schedule their appointments, at which time they are  removed from the wait list.
section_title: Scheduling Follow-up Appointments for Veterans
paragraphs: According to VHA policy, providers should document clinically appropriate  return-to-clinic dates in the veterans’ medical records at the end of each  appointment. Follow-up appointments requested by providers within 90  days of seeing a veteran should be scheduled before the veteran leaves  the clinic. Follow-up appointments requested beyond 90 days are to be  entered into the VA medical center’s Recall Reminder System. The recall  system automatically notifies veterans, of the need to schedule a follow- up appointment. When a veteran receives an appointment reminder, he  or she is asked to contact the clinic to make an appointment. Primary  care appointments for established patients are generally scheduled for 30  minutes. Schedulers determine the date of each follow-up appointment  based on the return-to-clinic date the provider documented in the  veteran’s medical record.
section_title: VHA Wait-Time Measurement
paragraphs: VHA’s July 2014 interim scheduling guidance established an appointment  wait-time goal of 30 days for new patients based on the date each  appointment was created (referred to as the create date) and 30 days for  established patients based on each veteran’s preferred date. In October  2014, in response to the Choice Act, VHA eliminated the wait-time  measure based on create date. It instituted a new wait-time goal of  providing appointments for new and established patients not more than  30 days from the date that an appointment is deemed clinically  appropriate by a VA health care provider, or if no such determination has  been made, the veteran’s preferred date.
section_title: Oversight of Primary Care Access
paragraphs: VHA, VISNs, and VA medical centers each have responsibilities for  developing scheduling and wait-time policies for primary care and for  monitoring wait-time measures to ensure medical centers are providing  timely access. The VHA Director of Access and Clinical Administration  and VHA’s Chief Business Office have responsibilities for oversight of  medical centers’ implementation of VHA’s enrollment and scheduling  policies, including measuring and monitoring ongoing performance. Each  VISN is responsible for overseeing the facilities within its designated  region, including the oversight of enrollment, scheduling, and wait lists for  eligible veterans. Finally, medical center directors are responsible for  ensuring local policies are in place for the timely enrollment of veterans  and for the effective operation of their primary care clinics, including  affiliated community-based outpatient clinics and ambulatory care  centers. In addition, the medical center director is responsible for  ensuring that any staff who have access to the appointment scheduling  system have completed the required VHA scheduler training.
section_title: Not All Newly Enrolled Veterans in Our Review Were Able to Access Primary Care; Others Experienced Wide Variation in the Amount of Time They Waited for Care
subsections: section_title: Newly Enrolled Veterans Did Not Always Receive Primary Care Appointments Due to Weaknesses in VHA’s Appointment Scheduling Process and Other Factors
paragraphs: Our review of medical records for a sample of veterans at six VA medical  centers found several problems in medical centers processing veterans’  requests that VA contact them to schedule appointments, and thus not all  newly enrolled veterans were able to access primary care. For the 60  veterans in our review who had requested care, but had not been seen by  primary care providers, we found that 29 did not receive appointments  due to the following problems in the appointment scheduling process:
Veterans did not appear on NEAR list. We found that although 17  of the 60 veterans in our review requested that VA contact them to  schedule appointments, medical center officials said that schedulers  did not contact the veterans because they had not appeared on the  NEAR list. Medical center officials were not aware that this problem  was occurring, and could not definitively tell us why these veterans  never appeared on the NEAR list. For 6 of these veterans, VA medical  center officials told us that when they reviewed the medical records at  our request, they found that these veterans’ requests were likely filled,  in error, by a compensation and pension exam. In these cases,  officials had no record that these veterans had appeared on the  NEAR list that schedulers used to contact veterans. Officials at one  medical center explained that they encourage providers to discuss  how to make an appointment with veterans at the end of the  compensation and pension exam. For the remaining 11 veterans,  after reviewing their medical records, officials were unable to  determine why the veterans never appeared on the NEAR list.
VA medical center staff did not follow VHA scheduling policy. We  found that VA medical centers did not follow VHA policies for  contacting newly enrolled veterans for 12 of the 60 veterans in our  review. VHA policy states that medical centers should document three  attempts to contact each newly enrolled veteran by phone, and if  unsuccessful, send the veteran a letter. However, for 5 of the 12  veterans, our review of their medical records revealed no attempts to  contact them, and medical center officials could not tell us whether the  veterans had been contacted to schedule appointments. Medical  centers attempted to contact the other 7 veterans at least once, but  did not follow the process to contact them as outlined in VHA policy.
For 24 of the 60 veterans who did not have a primary care appointment,  VA medical center officials stated that scheduling staff were either unable  to contact them to schedule an appointment or upon contact, the veterans  declined care. Officials stated that they were unable to contact 6 veterans  either due to incorrect or incomplete contact information in veterans’  enrollment applications, or to veterans not responding to medical centers’  attempts to contact them. In addition, VA medical center officials stated  that 18 veterans declined care when contacted by a scheduler. These  officials said that in some cases veterans were seeking a VA identification  card, for example, and did not want to be seen by a provider at the time.
The remaining 7 of the 60 veterans had appointments scheduled but had  not been seen by primary care providers at the time of our review. Four of  those veterans had initial appointments they needed to reschedule, which  had not yet been rescheduled at the time of our review. The remaining  three veterans scheduled their appointments after VHA provided us with a  list of veterans who had requested care.
section_title: Veterans Experienced Wide Variation in the Amount of Time They Waited for Primary Care Due to Limited Appointment Availability and Weaknesses in Scheduling Practices
paragraphs: Based on our review of medical records for a sample of veterans across  the six VA medical centers in our review, we found the average number of  days between newly enrolled veterans’ initial requests that VA contact  them to schedule appointments and the dates the veterans were seen by  primary care providers at each medical center ranged from 22 days to 71  days. (See table 1.) Slightly more than half of the 120 veterans in our  sample were able to see a provider in less than 30 days; however,  veterans’ experiences varied widely, even within the same medical  center, and 12 of the 120 veterans in our review waited more than 90  days to see a provider.
We found that two factors generally impacted veterans’ experiences  regarding the number of days it took to be seen by primary care  providers. First, appointments were not always available when veterans  wanted to be seen, which contributed to delays in receiving care. For  example, one veteran was contacted within 7 days of being placed on the  NEAR list, but no appointment was available until 73 days after the  veteran’s preferred appointment date. This veteran was placed on the  electronic wait list per VHA policy, and a total of 94 days elapsed before  the veteran was seen by a provider. In another example, a veteran  wanted to be seen as soon as possible, but no appointment was available  for 63 days. Officials at each of the six medical centers in our review told  us that they have difficulty keeping up with the demand for primary care  appointments for new patients because of shortages in the number of  providers, or lack of space due to rapid growth in the demand for these  services. Officials at two of the medical centers told us that because of  these capacity limitations, they were placing veterans who requested  primary care services on an electronic wait list at the time our review.
Second, we found weaknesses in VA medical center scheduling practices  may have impacted the amount of time it took for veterans to see primary  care providers and contributed to unnecessary delays. Staff at the  medical centers in our review did not always contact veterans to schedule  an appointment according to VHA policy, which states that attempts to  contact newly enrolled veterans to schedule appointments must be made  within 7 days of their being added to the NEAR list. Among the 120  veterans included in our review, 37 veterans (31 percent) were not  contacted according to VHA policy within 7 days to schedule an  appointment, and compliance varied across medical centers. (See   table 2.)
We found some medical center processes for contacting newly enrolled  veterans to schedule appointments were inconsistent with VHA policy and  may have contributed to delays in scheduling newly enrolled veterans:
VA officials at one medical center told us that they send letters to  newly enrolled veterans who apply online, which inform the veterans  that it is their responsibility to come into the medical center to  complete enrollment and schedule appointments. According to VISN  officials with oversight of this VA medical center, this practice is not  consistent with VHA scheduling policies, and veterans should not be  asked to come to medical centers to schedule their appointments. In  one case, a veteran enrolled online and requested VA contact him to  schedule an appointment, but according to medical center officials,  the veteran was not called to schedule an appointment, although a  letter was later sent. As a result, officials said he did not receive an  appointment until he contacted the medical center to again ask for  one 47 days later.
At another medical center, we found that the medical center’s process  for contacting newly enrolled veterans involves initial calls to explain  their VHA health care benefits. After the initial call, each veteran’s  name is sent to a scheduler to contact the veteran to schedule an  appointment. Although officials indicated that initial outreach to the  veterans in our review often occurred within 7 days of their addition to  the NEAR list, these veterans were not always contacted again to  schedule appointments within 7 days, in accordance with VHA’s  scheduling policy.
Finally, officials at a third medical center told us they added every new  enrollee to the electronic wait list even when there were appointments  available within 90 days of the veteran’s request. The VA medical  center then used the electronic wait list rather than the NEAR list to  identify veterans who needed to be contacted to schedule an  appointment. For example, a veteran requested VA contact him to  schedule an appointment, and was added to the electronic wait list.  Rather than contacting the veteran within 7 days of being added to the  NEAR list, in accordance with VHA policy, officials contacted the  veteran 19 days later to schedule an appointment. Officials told us  that they changed their process during our review and are now using  the NEAR list to identify newly enrolled veterans who need  appointments.
section_title: Most Veterans in Our Review Accessed Follow-Up Primary Care within the Time Frames Outlined in VHA Policy
paragraphs: Our review found that of 60 veterans who received follow-up primary  care, most received care within 30 days of the return-to-clinic date  determined by each veteran’s provider, in accordance with VHA’s policy.  Our review found that for 51 veterans return-to-clinic dates were  applicable and documented in their medical records and 38 of these  veterans were seen by providers within 30 days of their return-to-clinic  dates. However, the percentage of veterans seen within 30 days of their  return-to-clinic dates varied across medical centers in our review. (See  table 3.)
We found several reasons why the 13 veterans (out of the 51 for whom  return-to-clinic dates were applicable) were not seen for follow-up  appointments within 30 days of their return-to-clinic dates:  Improperly managed recall reminder process. For 6 of the 13  veterans, VA medical center staff did not properly manage their “recall  reminder” process, which notifies veterans that they need to schedule  a follow-up appointment, as outlined in VHA policy. Our review of the  veterans’ medical records and discussions with medical center  officials found that medical center staff did not place 5 veterans on the  recall list to receive appointment scheduling reminders as outlined in  VHA policy, and thus the veterans were not contacted to schedule  their appointments in a timely manner. For the other veteran, one  recall notice was sent, and schedulers did not attempt to make  contact again, according to medical center officials.
Lack of available appointments or veterans preferred later  appointment dates. Four of the 13 veterans were seen more than 30  days beyond the return-to-clinic dates due to the lack of available  appointments or based on their preferred dates.
Cancellations and no-shows. For the remaining 3 of the 13  veterans, medical records indicated that appointments were initially  scheduled within 30 days of the return-to-clinic dates; however, 2  veterans did not show up for their appointments and the other  veteran’s appointment was canceled by the primary care clinic. These  veterans were ultimately seen beyond the 30-day time frame.
section_title: VHA’s Oversight of Veterans’ Access to Primary Care Is Hindered in Part by Data Weaknesses
subsections: section_title: VHA Monitors Only a Portion of the Time It Takes Newly Enrolled Veterans to Access Primary Care
paragraphs: A key component of VHA’s oversight of veterans’ access to primary care,  particularly for newly enrolled veterans, relies on monitoring appointment  wait times. However, VHA monitors only a portion of the overall time it  takes newly enrolled veterans to access primary care.
VHA officials said they regularly review data related to access, including  data on wait times for primary care. VHA has developed reports to track  these data for each VISN and VA medical center. VHA officials indicated  that they look for trends in average wait times across medical centers,  and also track the percentage of veterans seen within 30 days of their  preferred dates or return-to-clinic dates. Officials from all six VISNs and  medical centers in our review said they use these reports, and other  locally developed reports, to monitor wait times for each of their sites of  care to identify any trends. VISN and VA medical center officials said if  they find wait times are increasing, they work to identify solutions, which  the medical center is then tasked with implementing. For example,  officials from two VISNs and medical centers told us that in response to  increasing wait times for primary care, actions have been taken to  improve patient access, including opening new sites of care and hiring  additional providers.
We found, however, that VHA monitors only a portion of the overall time it  takes newly enrolled veterans to access primary care, which is  inconsistent with federal internal control standards. According to the  internal controls for information and communications, information should  be recorded and communicated to management and others within the  entity who need it to carry out their responsibilities. However, VHA  monitors access using veterans’ preferred appointment dates, which are  not determined until schedulers make contact with veterans, as the basis  for measuring how long it takes veterans to be seen, rather than the dates  newly enrolled veterans requested on their enrollment applications that  VA contact them to schedule appointments. (See fig. 2.) Therefore, VHA  does not account for the time it takes to process enrollment applications,  or the time it takes VA medical centers to contact veterans to schedule  their appointments. Consequently, data used for monitoring and oversight  do not capture veterans’ overall experiences, including the time newly  enrolled veterans wait prior to being contacted by a scheduler, which  makes it difficult for officials to effectively identify and remedy scheduling  problems that arise prior to making contact with veterans.
Our review of medical records for 120 newly enrolled veterans found that,  on average, the total amount of time it took to be seen by primary care  providers was much longer when measured from the dates veterans  initially requested VA contact them to schedule appointments than it was  when using appointment wait times calculated using veterans’ preferred  dates as the starting point. (See table 4.)
The amount of time elapsed between when veterans initially requested  VA contact them to schedule appointments and when they are seen by  providers may be due to veterans’ decisions such as not wanting to  schedule appointments immediately, or cancelling and rescheduling initial  appointments. However, we found the amount of time between initial  requests and when they received care also varied due to factors  unaffected by veterans’ decisions, including VA medical centers not  contacting veterans in a timely manner, medical centers being unaware of  veterans’ requests, and difficulties in processing veterans’ requests that  they be contacted to schedule appointments. For example:
One veteran applied for VHA health care benefits in December 2014,  which included a request to be contacted for an initial appointment.  The VA medical center contacted the veteran to schedule a primary  care appointment 43 days later. When making the appointment, the  medical center recorded the veteran’s preferred date as March 1,  2015, and the veteran saw a provider on March 3, 2015. Although the  medical center’s data showed the veteran waited 2 days to see a  provider, the total amount of time that elapsed from the veteran’s  request until the veteran was seen was actually 76 days.
For another veteran, the medical record indicated that a request to  schedule an appointment was made in October 2014. According to  VA medical center officials, the veteran had a compensation and  pension exam, and as a result, this veteran was not on the list of  those who needed to be contacted to schedule a primary care  appointment. Officials told us that the veteran contacted the medical  center in January 2015 to schedule an appointment, with a preferred  date in January 2015. The veteran had his appointment in February  2015. While the medical center’s data show the veteran waited 13  days to be seen, the total amount of time that elapsed from the  veteran’s initial request to schedule an appointment until the veteran  was seen was 113 days.
According to VHA officials responsible for monitoring wait times, there are  no VHA policies requiring that they measure and monitor the total amount  of time that newly enrolled veterans experience while waiting to be seen  by a primary care provider. Instead, VHA’s policy is to use data that  measure the timeliness of appointments based on veterans’ preferred  dates. Although there is no policy requiring that they measure the total  time veterans wait to be seen, officials from one VISN told us that they  measure this period of time, as it may provide valuable insights into newly  enrolled veterans’ experiences in trying to obtain care from VHA. During  our discussions with these VISN officials, they expressed concern that  monitoring veterans’ wait times using the preferred date is too limited,  because it does not capture the full wait times veterans experience.
Since February 2015, officials from this VISN have instructed each of the  medical centers they oversee to audit a sample of 30 primary care,  specialty care, and mental health appointments for new patients,  including newly enrolled veterans, for a total of 90 appointments each  month. As part of this audit, medical center officials record the dates  veterans initially requested VA contact them to schedule appointments,  the dates appointments were created, and the dates veterans were seen  by providers. VISN officials use the information to prepare a monthly  summary report which tracks a variety of information, including the  percentage of appointments for which the veterans’ overall wait was more  than 30 days. According to data from the October 2015 audit, 24 percent  of veterans waited more than 30 days from their initial request until they  were seen by a provider. Officials indicated that by analyzing trends on  these and other data, they will be able to identify whether factors such as  enrollment issues or problems contacting newly enrolled veterans are  impacting overall wait times. Officials indicated that it is time-consuming  to perform these audits, and it would be helpful if VHA had a centralized  system which would enable them to electronically compile the data.
During our review we also found that under the Health Resource Center’s  Welcome to VA program, officials are developing a centralized electronic  system to track various dates related to newly enrolled veterans, including  the date each veteran applied for VHA health care. Once applications for  benefits are approved, staff in the Health Resource Center call centers  contact each newly enrolled veteran, and ask if that veteran wants to  begin receiving health care at VHA. For veterans that indicated on their  applications that they wanted to be contacted to schedule an  appointment, their requests are confirmed through these calls, and the  dates of the requests on the applications are recorded in the Health  Resource Center system, as well as the dates the veterans were  contacted. For veterans who did not indicate they wanted to be contacted  on their applications, but tell Health Resource Center staff during the calls  that they want care, the dates of contact are documented as their initial  requests for care. Officials indicated that it is important to begin tracking  from the onset of veterans’ requests, because that is when they told VA  they needed care. Officials indicated that since July 2015, they have been  piloting this Welcome to VA data collection and tracking effort with one  VISN, and hope to expand this effort across the VHA system during 2016.  They further indicated that they have been coordinating with the VHA  office responsible for monitoring access, and hoped their data could be  integrated into VHA’s routine monitoring of veterans’ wait times.
section_title: Scheduling Errors Continue to Affect the Reliability of Wait-Time Data, Including for Primary Care
paragraphs: Ongoing problems continue to affect the reliability of wait-time data,  including for primary care, used by VHA, VISN, and VA medical center  officials for monitoring and oversight. Our previous work in 2012, as well  as that of VA and the VA OIG in 2014, has shown that VHA wait-time  data are unreliable and prone to errors and interpretation. Among other  things, we found in December 2012 that medical centers were not  implementing VHA’s scheduling policies in a consistent manner, which  led to unreliable wait-time data. Although VHA has taken steps since then  to improve the reliability of its wait time data, including ensuring that  scheduling staff complete required training, we found VHA schedulers  were continuing to make errors in recording veterans’ preferred dates;  and thus, data reliability problems continue to hinder effective oversight.
During our review of appointment scheduling for 120 newly enrolled  veterans, we found that schedulers in three of the six VA medical centers  included in our review had made errors in recording veterans’ preferred  dates when making appointments. Specifically, we found 15  appointments for which schedulers had incorrectly revised the preferred  dates. In these cases, we recalculated the appointment wait time based  on what should have been the correct preferred dates, according to VHA  policy, and found the wait-time data contained in the scheduling system  were understated. (See table 5.)
We found that schedulers incorrectly revised patients’ preferred dates to  later dates, inconsistent with VHA policy, under two scheduling scenarios:  1.  Medical center primary care clinics cancelled appointments, and when  those appointments were re-scheduled, schedulers did not always  maintain the original preferred dates in the system, but updated them  to reflect new preferred dates recorded when the appointments were  rescheduled. This is not consistent with VHA policy, which indicates  that if a clinic cancels an appointment, the original preferred date  should be maintained in the system.  2.  Preferred dates initially recorded when placing veterans on the  electronic wait list were incorrectly revised to later dates when  appointments became available and were scheduled. This included  revising preferred dates to the same dates of the scheduled  appointments. This is also inconsistent with VHA policy, which  indicates that the veterans’ preferred dates recorded at the time of  entry on the electronic wait list should not be changed. We confirmed  our understanding of this policy with officials from one of the VISNs,  and discussed these cases with VA medical center officials, who  indicated that they would need to provide additional training to  schedulers to ensure compliance with VHA’s scheduling policies.
We also found in our review of medical records, that of 120 veterans who  saw providers, 65 veterans, or 54 percent, had appointments with a zero- day wait time recorded in the scheduling system. VHA officials indicated  that appointments with wait times of zero days are a potential indicator of  scheduling errors. Based on our review of medical records for these  veterans, 13 of the appointments with zero-day wait times were those that  were incorrect due to schedulers revising preferred dates.
In addition, officials from five of the six VA medical centers in our review  told us they continue to find through their scheduling audits that  schedulers are incorrectly recording preferred dates. Officials from each  of the six medical centers explained that they periodically audit scheduled  appointments to help ensure schedulers are complying with scheduling  policies. Officials from these medical centers indicated a key focus of the  audits is to assess whether schedulers are correctly recording the  preferred date when making appointments, and that wait times are being  calculated correctly. For example, officials from one medical center said  they audited nearly 1,200 appointments between January and June 2015,  and identified 205 appointments for which schedulers incorrectly recorded  the veteran’s preferred date. Officials indicated that based on these  results, scheduling supervisors provided training with those schedulers  who made the errors.
Since July 2014, VHA has issued a revised interim scheduling directive  and numerous individual memos to clarify and update the scheduling  policy, but has not yet published a comprehensive policy that incorporates  all of these changes. Officials from four of the six VISNs in our review  indicated that the way VHA has communicated revised scheduling  policies and updates to medical centers has been ineffective and may be  contributing to continued scheduling errors. They indicated that high  turnover among schedulers and the lack of an updated standardized  scheduling policy make it more difficult to train schedulers and to direct  these staff to current policy, which increases the likelihood of errors.  Federal internal control standards call for management to clearly  document, through management directives or administrative policies,  significant events or activities—which in this instance would include  ensuring that scheduling policies are readily available and easily  understood—and that management should use and communicate, both  internally and externally, quality information to achieve its objectives.  VHA officials acknowledged that they are aware of frustration among  medical center staff, and that they have been working over the past 18  months to develop an updated and comprehensive scheduling policy.  Officials indicated that their current target is to issue a revised policy  some time in 2016.
To help VA medical centers and VISNs identify scheduling problems, in  January 2015, VHA implemented its scheduling trigger tool, which is  designed to provide medical center and VISN officials with an early  warning that scheduling problems may be occurring. According to VHA  officials, the tool uses statistical analysis software to review appointment  data from all medical centers in order to detect potential erroneous  scheduling practices, including those that deviate from VHA policies.  For example, it assesses whether medical center schedulers are  accurately documenting patients’ preferred dates and whether they are  using the electronic wait list correctly for new patients. The tool assesses  each medical center’s scheduling performance and automatically alerts  medical center and VISN leadership if a medical center is performing in  the bottom 20 percent. According to VHA officials, use of the tool has  prompted many requests for assistance, and they have provided  additional scheduler training.
section_title: VHA and Medical Centers Have Implemented Efforts Aimed at Improving Veterans’ Timely Access to Primary Care VHA Has Implemented System-Wide Efforts Designed to Offer Veterans More Timely Access to Primary Care
paragraphs: VHA has implemented two system-wide efforts designed to offer veterans  more timely access to primary care: the Veterans Choice Program,  created through the Choice Act; and an initiative to increase primary-care  hours.
subsections: section_title: VA Medical Centers Have Implemented Local Efforts to Improve Veterans’ Access to Timely Primary Care
paragraphs: In addition to the VHA-wide initiatives aimed at improving access, officials  from the VA medical centers in our review also reported implementing  several local efforts to improve veterans’ timely access to primary care  appointments. (See table 6.)
Specifically, officials from all six medical centers reported reconfiguring or  expanding clinic space. For example, officials at two medical centers  stated that they are reconfiguring their primary care clinic’s space to  accommodate additional providers and other staff without having to lease  additional space. Officials from another medical center told us they were  expanding clinic space by opening several additional community-based  outpatient clinics by entering into emergency lease agreements in  addition to beginning the construction of new clinic space.
Further, officials from five medical centers in our review reported hiring  additional providers or creating additional positions. For example, officials  at one medical center stated that since 2013 they have hired 20 new full- time providers and 18.5 full-time equivalent nurses. Additionally, they  have also created a new position—a “gap” provider who is a doctor, nurse  practitioner, or nurse—that allows flexibility to cover short-term leave such  as sick or annual leave or longer-term leave such as the gap between  one provider leaving and a new provider coming on board. In practice, the  medical center shifts gap providers from one location to another as  needed, enabling the medical center to minimize backlogs that may arise  due to staffing shortages and unanticipated provider absences. Currently,  this medical center has seven gap providers in primary care. Similarly,  two other medical centers reported using flexible providers who work  across several clinic locations to improve access to primary care for  veterans.
Finally, officials from three of the medical centers included in our review  reported developing technological solutions to improve access to timely  primary care appointments. These solutions included increasing the use  of telehealth and secure messaging to improve the convenience and  availability of primary care appointments. For example, officials from  one of the medical centers in our review said providers are using secure  messaging to communicate with patients and reduce the need for in- person encounters, which they said helps free up appointments for other  patients.
section_title: Conclusions
paragraphs: Providing our nation’s veterans with timely access to primary care is a  critical responsibility of VHA. As primary care services are often the entry  point to the VA health care system for newly enrolled veterans, the ability  to access primary care and establish a relationship with a VHA provider  can be instrumental in the ongoing management of a veteran’s overall  health care needs. Although VHA has processes for identifying those  veterans who have requested VA contact them to schedule appointments,  our review of a sample of newly enrolled veterans revealed that VA  medical centers did not always provide that care until several months  after veterans initially indicated interest in obtaining it, if at all. In several  cases, newly enrolled veterans were never contacted to schedule  appointments, due to medical center staff failing to comply with VHA  policies for scheduling such appointments or medical center staff being  unaware of veterans’ requests. In the absence of consistent adherence  by medical center staff to VHA scheduling processes and policies,  veterans may continue to experience delays in accessing care.
To help oversee veterans’ access to primary care, officials at VHA’s  central office, medical centers, and VISNs rely on measuring, monitoring,  and evaluating the amount of time it takes veterans to be seen by a  provider. The data currently being used to evaluate newly enrolled  veterans’ access to primary care, however, are limited because they do  not account for the entire amount of time between veterans’ initial  requests to be contacted for appointments and being seen by primary  care providers. This is because the method VHA uses to measure the  appointment wait times for newly enrolled veterans does not begin at the  point at which veterans initially request that VA contact them to schedule  appointments when applying for VHA health care, but rather begins when  VA medical center staff contact veterans and record the veterans’  preferred dates. Consequently, data used for monitoring and oversight do  not capture the time newly enrolled veterans wait prior to being contacted  by a scheduler, making it difficult for officials to effectively identify and  remedy scheduling problems that arise prior to making contact with  veterans. Recognizing limitations in monitoring and oversight of access  data based on veterans’ preferred dates, some system-wide and local  efforts are being developed and implemented to broaden data collection  and oversight of newly enrolled veterans’ access to primary care; such  efforts could have applicability across the entire VHA system.
Ongoing scheduling problems continue to affect the reliability of wait-time  data, including for primary care. Our previous work has shown that VHA  wait-time data are unreliable due, in part, to medical centers not  implementing VHA’s scheduling policies consistently. VHA central office  officials have responded to scheduling problems throughout the VHA  system by issuing several individual memorandums to clarify scheduling  policies. However, VHA’s piecemeal approach in implementing these  policies may not be fully effective in providing schedulers with the  comprehensive guidance they need to consistently adhere to scheduling  policies or providing the reliable data officials need for monitoring access  to primary care. Our review of medical records for a sample of veterans  found that scheduling errors continue, diminishing the reliability of data  officials use for monitoring the timeliness of appointments by understating  the amount of time veterans actually wait to see providers. Officials at  several of the VA medical centers also continue to uncover scheduling  errors through audits, and VISN officials attribute the errors, in part, to the  lack of an updated comprehensive scheduling policy. While VHA central  office officials are working on finalizing an updated scheduling policy, they  currently have no definitive issuance date. Until a comprehensive  scheduling policy is finalized, disseminated, and consistently followed by  schedulers, the likelihood for scheduling errors will persist.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Veterans Affairs direct the Under  Secretary for Health to take the following three actions:  (1)  Review VHA’s processes for identifying and documenting newly  enrolled veterans requesting appointments, revise as appropriate to  ensure that all veterans requesting appointments are contacted in a  timely manner to schedule them, and institute an oversight  mechanism to ensure VA medical centers are appropriately  implementing the processes.  (2)  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 contacted to schedule appointments. This could be  accomplished, for example, by building on the data collection efforts  currently being implemented under the “Welcome to VA” program.  (3)  Finalize and disseminate a comprehensive national scheduling  directive, which consolidates memoranda and guidance disseminated  since July 2014 on changes to scheduling processes and procedures,  and provide VA medical center staff appropriate training and support  to fully and correctly implement the directive.
section_title: Agency Comments
paragraphs: We provided VA with a draft of this report for its review and comment. VA  provided written comments, which are reprinted in appendix II. In its  written comments, VA concurred with all three of the report’s  recommendations, and identified actions it is taking to implement them.
As arranged with your office, unless you publicly disclose the contents  earlier, we plan no further distribution of this report until 24 days after the  date of this report. At that time, we will send copies of this report to the  appropriate congressional committees, the Secretary of Veterans Affairs,  and other interested parties. In addition, the report will be available at no  charge on the GAO Web site at http://www.gao.gov.
If you or your staff 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 III.
section_title: Appendix I: Prior GAO Recommendations Related to Oversight of Veterans’ Access to Primary and Specialty Care
paragraphs: Our prior work has found weaknesses in the Department of Veterans  Affairs’ (VA) Veterans Health Administration’s (VHA) ability to effectively  oversee timely access to health care for veterans. Specifically, we found  that VHA did not have adequate data and oversight mechanisms in place  to ensure veterans receive timely primary and specialty care, including  mental health care. Since 2012, we have issued several reports and  made recommendations to help ensure VHA has effective policies and  reliable data to carry out its oversight. See table 7 for our previous  recommendations and the status of their implementation.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Jennie F. Apter; Emily Binek; David Lichtenfeld; Vikki L. Porter; Brienne  Tierney; Ann Tynan; and Emily Wilson made key contributions to this  report.