VA Health Care: Actions Needed to Improve Access to Primary Care for Newly Enrolled Veterans
Published: 2016-04-19T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: This testimony summarizes the information contained in GAO's March 2016 report, entitled VA Health Care: Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care , GAO-16-328 .
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: Letter
paragraphs: I am pleased to be here today as you discuss issues concerning veterans’  access to health care. My remarks today are based on our report that was  released yesterday, VA Health Care: Actions Needed to Improve Newly  Enrolled Veterans’ Access to Primary Care. This report is the latest in our  ongoing body of work examining veterans’ access to timely health care.
The Department of Veterans Affairs’ (VA) Veterans Health Administration  (VHA) operates one of the nation’s largest health care systems; it  provided care to about 6.6 million veterans in fiscal year 2014, including  an aging veteran population and a growing number of younger veterans  returning from military operations in Afghanistan and Iraq. VHA spent  about $58 billion for their care in that year. Over the past decade, VHA  has faced a growing demand for outpatient primary care services. From  fiscal years 2005 through 2014, the number of annual outpatient primary  care medical appointments VHA provided through its medical facilities  increased by 17 percent, from approximately 10.2 million to 11.9 million.  Each year over that period, an average of 380,000 veterans were newly  enrolled in VHA’s health care system. In fiscal year 2014, VHA provided  about 730,000 primary care appointments for new patients— appointments for those patients who had not been seen in a primary care  clinic in the past 24 months, including those who were newly enrolled.
Primary care services are often the entry point to the VHA health care  system for veterans, and access to these services is critical to ensuring  that veterans obtain needed medical care, including specialty care. When  veterans need specialty care—such as cardiology or gastroenterology— they are typically referred to specialists by their primary care providers,  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 provide and oversee timely access to health care for  veterans, which, in some cases, reportedly has resulted in harm to  veterans. Our prior work on VHA’s oversight of primary and specialty care  found VHA did not have adequate data and oversight mechanisms in  place to ensure veterans receive timely care. For example, since 2012,  we have issued several reports recommending that VA improve  appointment scheduling, ensure the reliability of wait-time and other  performance data, and improve oversight to ensure VA medical centers  provide veterans with timely access to outpatient primary and specialty  care, as well as mental health care. Based on these serious concerns  about VA’s management and oversight of its health care system, we have  concluded that VA health care is a high-risk area and, in 2015, added it to  our High Risk List. 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.
In the context of these serious and longstanding concerns, my testimony  today highlights selected findings from our most recent report on  veterans’ access to primary care. My remarks will therefore focus on the  extent to which  1.  newly enrolled veterans access primary care in a timely manner; and  2.  VHA provides oversight of veterans’ access to primary care.
For our report, we reviewed relevant regulations, guidance, and other key  documents, as well as interviewed staff with responsibility for ensuring  timely access to primary care, including officials from VA, VHA, six VA  medical centers, and the six corresponding VISNs that oversee the  medical centers in our review. We selected the medical centers based  on variation in average wait times for primary care appointments, facility  complexity, and geographic location. From these medical centers, we  selected a sample of 60 newly enrolled veterans (10 randomly selected  from each of the six medical centers), all of whom had requested VA  contact them to schedule medical appointments, but had not been seen  by primary care providers. We also selected a sample of 120 newly  enrolled veterans (20 randomly selected from each of the six medical  centers), all of whom had requested that VA contact them to schedule  medical appointments and were seen by primary care providers. We  examined the medical records for each of these 180 veterans to  determine the history of actions taken to schedule appointments, such as  dates the appointments were scheduled and dates veterans were seen by  primary care providers, if applicable. We also evaluated VHA’s  mechanisms for overseeing veterans’ access to primary care against the  federal internal control standards related to control activities, information,  and monitoring. Additional information on our scope and methodology is  available in our report. The work this testimony is based on was  performed in accordance with generally accepted government auditing  standards.
subsections: section_title: Problems Newly Enrolled Veterans Faced in Accessing Primary Care and Obtaining Timely Access to Care
paragraphs: Our review of medical records for a sample of newly enrolled veterans at  six VA medical centers found several problems in medical centers’  processing of veterans’ requests that VA contact them to schedule  appointments, and thus not all newly enrolled veterans were able to  access primary care. For the 60 newly enrolled veterans in our review  who requested care but had not been seen by primary care providers, we  found that 29 did not receive appointments due to the following problems  in the appointment scheduling process:
Veterans did not appear on VHA’s New Enrollee Appointment  Request (NEAR) list. We found that although 17 newly enrolled  veterans in our review requested that VA contact them to schedule  appointments, medical center officials said that schedulers did not  contact the veterans because they had not appeared on the NEAR  list. 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. 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.
VA medical center staff did not follow VHA scheduling policy. We  found that VA medical centers did not follow VHA policies for  contacting newly enrolled veterans for 12 veterans in our review. VHA  policy states that medical centers should document three attempts to  contact each newly enrolled veteran by phone, and if unsuccessful,  send the veteran a letter. However, for 5 of 12 newly enrolled  veterans, our review of their medical records revealed no attempts to  contact them, and medical center officials could not tell us whether the  veterans had ever been contacted to schedule appointments. Medical  center staff attempted to contact the other 7 veterans at least once  each, but failed to reach out to them with the frequency required by  VHA policy.
For the remaining 31 of 60 newly enrolled veterans included in our review  who did not have a primary care appointment:
24 were unable to be contacted to schedule appointments or upon  contact, declined care, according to VA medical center officials. These  officials said that in some cases they were unable to contact veterans  due to incorrect or incomplete contact information in veterans’  enrollment applications; in other cases, they said veterans were  seeking a VA identification card, for example, and did not want to be  seen by a provider at the time they were contacted.
7 had appointments scheduled but had not been seen by primary care  providers at the time of our review. Four of those veterans had initial  appointments that needed to be rescheduled, which had not yet been  done at the time of our review. Appointments for the remaining 3  veterans were scheduled after VHA provided us with a list of veterans  who had requested care.
For the 120 newly enrolled veterans across the six VA medical centers in  our review who requested care and were seen by primary care providers,  we found the average number of days between newly enrolled veterans’  initial requests that VA contact them to schedule appointments and the  dates the veterans were seen by primary care providers ranged from 22  days to 71 days. Slightly more than half of the 120 veterans in our sample  were seen by providers in less than 30 days; however, veterans’  experiences varied widely, even within the same medical center, and 12  of the 120 veterans in our review waited more than 90 days to be seen by  a provider.
We found that two factors generally impacted newly enrolled veterans’  experiences regarding the number of days it took to be seen by primary  care providers:  1.  Appointments were not always available when veterans wanted  to be seen, which contributed to delays in receiving care. For  example, one veteran was contacted within 7 days of being placed on  the NEAR list, but no appointment was available until 73 days after  the veteran’s preferred appointment date, and a total of 94 days  elapsed before the veteran was seen by a provider. In another  example, a veteran wanted to be seen as soon as possible, but no  appointment was available for 63 days. Officials at each of the six  medical centers in our review told us that they have difficulty keeping  up with the demand for primary care appointments for new patients  because of shortages in the number of providers, or lack of space due  to rapid growth in the demand for these services.  2.  Weaknesses in VA medical center scheduling practices may  have impacted the amount of time it took for veterans to see  primary care providers and contributed to unnecessary delays.  Staff at the medical centers in our review did not always contact  veterans to schedule appointments in accordance with VHA policy,  which states that attempts to contact newly enrolled veterans to  schedule appointments must be made within 7 days of their addition  to the NEAR list. Among the 120 veterans included in our review that  were seen by primary care providers, 37 (31 percent) were not  contacted within 7 days to schedule an appointment; compliance  varied across medical centers.
As a result of these findings, we recommended that VHA review its  processes for identifying and documenting newly enrolled veterans  requesting appointments and revise as appropriate, to ensure that all  veterans requesting appointments are contacted in a timely manner to  schedule them. VHA concurred with this recommendation, and indicated  that by December 31, 2016, it plans to review and revise the process from  enrollment to scheduling to ensure that newly enrolled veterans  requesting appointments are contacted in a timely manner. VHA also  indicated that it will implement internal controls to ensure its medical  centers are appropriately implementing the process.
section_title: VHA’s Oversight of Veterans’ Access to Primary Care Is Hindered in Part by Data Weaknesses
paragraphs: VHA’s oversight of veterans’ access to primary care is hindered, in part,  by data weaknesses and the lack of a comprehensive scheduling policy,  both of which are inconsistent with federal internal control standards.  These standards call for agencies to have reliable data and effective  policies to achieve their objectives, and for information to be recorded and  communicated to the entity’s management and others who need it to  carry out their responsibilities.
A key component of VHA’s oversight of veterans’ access to primary care,  particularly for newly enrolled veterans, relies on monitoring appointment  wait times. However, VHA monitors only a portion of the overall time it  takes newly enrolled veterans to access primary care. For newly  enrolled veterans, VHA calculates primary care appointment wait times  starting from veterans’ preferred dates, rather than the dates veterans  initially requested that VA contact them to schedule appointments. (A  preferred date is the date that is established when a scheduler contacts  the veteran to determine when he or she wants to be seen.) Therefore,  these data do not capture the time veterans wait prior to being contacted  by schedulers, making it difficult for officials to identify and remedy  scheduling problems that may arise prior to making contact with veterans.  (See fig. 1.)
Our review of medical records for 120 newly enrolled veterans found that,  on average, the total amount of time it took to be seen by primary care  providers was much longer when measured from the dates veterans  initially requested VA contact them to schedule appointments than it was  when using appointment wait times calculated using veterans’ preferred  dates as the starting point. For example, we found one veteran applied for  VHA health care benefits in December 2014, which included a request to  be contacted for an initial appointment. The VA medical center contacted  the veteran to schedule a primary care appointment 43 days later. When  making the appointment, the medical center recorded the veteran’s  preferred date as March 1, 2015, and the veteran saw a provider on  March 3, 2015. Although the medical center’s data showed the veteran  waited 2 days to see a provider, the total amount of time that elapsed  from the veteran’s request until the veteran was seen was actually 76  days.
Further, ongoing scheduling errors, such as incorrectly revising preferred  dates when rescheduling appointments, understated the amount of time  veterans waited to see providers. For example, 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. For example, in some cases primary care clinics cancelled  appointments, and when those appointments were re-scheduled,  schedulers did not always maintain the original preferred dates in the  system, but updated them to reflect new preferred dates recorded when  the appointments were rescheduled. We found 15 appointments for which  schedulers had incorrectly revised the preferred dates. In these cases, we  recalculated the appointment wait time based on what should have been  the correct preferred dates, according to VHA policy, and found the wait- time data contained in the scheduling system were understated. Officials  attributed these errors to confusion by schedulers resulting from the lack  of an updated standardized scheduling directive, which VHA rescinded  and replaced with an interim directive in July 2014. As in our previous  work, we continue to find scheduling errors that affect the reliability of  wait-time data used for oversight, which make it difficult to effectively  oversee newly enrolled veterans’ access to primary care.
As a result of these findings, we recommended that VHA monitor the full  amount of time newly enrolled veterans wait to receive primary care, and  issue an updated scheduling directive. VHA concurred with both of these  recommendations, and indicated that by December 31, 2016, it plans to  begin monitoring the full amount of time newly enrolled veterans wait to  be seen by primary care providers. It also indicated that it plans to submit  a revised scheduling directive for VHA-wide internal review by May 1,  2016.
This most recent work on veterans’ access to primary care expands  further the litany of VA health care deficiencies and weaknesses that we  have identified over the years, particularly since 2010. As of April 1, 2016,  there were about 90 GAO recommendations regarding veterans’ health  care awaiting action by VHA. These include more than a dozen  recommendations to address weaknesses in the provision and oversight  of veterans’ access to timely primary and specialty care, including mental  health care. Until VHA can make meaningful progress in addressing  these and other recommendations, which underscore a system in need of  major transformation, the quality and safety of health care for our nation’s  veterans is at risk.
Chairman Miller, Ranking Member Brown, and Members of the  Committee, this concludes my prepared statement. I would be pleased to  answer any questions that you may have at this time.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you or your staff members have any questions concerning this  testimony, please contact Debra A. Draper at (202) 512-7114 or  draper@gao.gov. Contact points for our Offices of Congressional  Relations and Public Affairs may be found on the last page of this  statement. Other individuals who made key contributions are Janina  Austin, Assistant Director; Jennie F. Apter; Emily Binek; David  Lichtenfeld; Vikki L. Porter; Brienne Tierney; and Emily Wilson.
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