[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
TRUE TRANSPARENCY? ASSESSING WAIT TIMES FIVE YEARS AFTER PHOENIX
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HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, JULY 24, 2019
__________
Serial No. 116-27
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
40-856 WASHINGTON : 2021
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
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C O N T E N T S
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Wednesday, July 24, 2019
Page
True Transparency? Assessing Wait Times Five Years After Phoenix. 1
OPENING STATEMENTS
Honorable Mark Takano, Chairman.................................. 1
Honorable David P. Roe, Ranking Member........................... 2
WITNESSES
Dr. Debra Draper, Ph.D., M.S.H.A., Director, Health Care Team,
U.S. Government Accountability Office.......................... 4
Prepared Statement........................................... 43
Dr. Teresa S. Boyd, Assistant Deputy Under Secretary for Health
for Clinical Operations, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 5
Prepared Statement........................................... 57
Accompanied by:
Dr. Susan R. Kirsh, Acting Assistant Deputy Under Secretary
for Health for Access to Care, Veterans Health
Administration
Dr. Clinton "Leo" Greenstone, Deputy Executive Director for
Clinical Integrity, Office of Community Care, Veterans
Health Administration
The Honorable Kenneth W. Kizer, MD, MPH, Chief Healthcare
Transformation Officer & Senior Executive Vice President, Atlas
Research, Inc.................................................. 7
Prepared Statement........................................... 61
TRUE TRANSPARENCY? ASSESSING WAIT TIMES FIVE YEARS AFTER PHOENIX
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Wednesday, July 24, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 210, House Visitors Center, Hon. Mark Takano [Chairman of
the Committee] presiding.
Present:Representatives Takano, Brownley, Lamb, Levin,
Brindisi, Rose, Pappas, Lee, Cunningham, Cisneros, Peterson,
Allred, Underwood, Roe, Radewagen, Bost, Dunn, Bergman, Banks,
Meuser, and Steube.
OPENING STATEMENT OF MARK TAKANO, CHAIRMAN
The Chairman. Good morning. I call this hearing to order.
This year marks the 5-year anniversary of a watershed
moment for VA and for this Committee: the 2014 VA wait time
scandal. Whistleblowers from the Phoenix VA health care system
exposed an elaborate scheme by supervisors and senior leaders
to conceal the amount of time veterans were waiting to receive
health care. Some patients' conditions deteriorated, while
other veterans died after waiting too long for VA appointments.
After months of hearings and independent investigations, we
concluded that serious appointment scheduling improprieties and
delays in veterans' access to care were not limited to Phoenix,
but were occurring at dozens of other VA facilities nationwide.
And this had been going on for years.
To address this, Congress passed the Veterans Choice
Program in August 2014 with the goal of helping veterans'
access more timely health care by sending them to community
providers.
Five years ago today, we held a hearing with VA's then-
Acting Secretary, Sloan Gibson, and leaders from several
veteran's service organizations, to learn how VA planned to
restore the trust of veterans, Congress, and the American
people.
In his statement for that hearing, Mr. Gibson presented a
stark, but honest assessment of VA's challenges. Three of the
main challenges he identified are on this chart behind me:
widespread scheduling improprieties, inadequate IT resources,
and a culture of fear and retaliation.
Honestly, after reviewing our witnesses' written testimony
and several articles that have appeared recently in the
national media, I am alarmed that too much of what Acting
Secretary Gibson observed 5 years ago still rings true today.
This is, frankly, just unacceptable. We simply cannot put
veterans' lives at risk while they wait for care.
Today, it is time to assess VA's progress in earning back
the trust of veterans, Congress, and the American people.
Within the last couple of months, several media outlets
published articles where whistleblowers allege that VA is still
keeping secret waiting lists. This doesn't come as a surprise.
Our Committee staff also have been approached by several
whistleblowers with these allegations, and some have faced
retaliation after raising their concerns with VA. They allege
that VA has mass-canceled pending requests for certain types of
care without sufficient clinical review, and that front-line
employees have been ordered to schedule veteran patients in
imaginary clinics as a means of concealing wait times.
Some of these whistleblowers recently testified before our
Committee. Yet, as we learned from the whistleblower hearing
that wrapped up yesterday, VA's Office of Accountability and
Whistleblower Protection is failing to protect whistleblowers.
We rely on whistleblowers to speak truth to power and hold
VA accountable. OAWP must do its job and immediately end the
toxic culture of retaliation at VA.
Dr. Boyd, you claim in your written statement that, quote,
``no veterans were harmed,'' end quote, as a result of being on
wait lists like those mentioned in the news. You also state
that VA is operating with, quote, ``unprecedented
transparency,'' end quote. Those are two very bold statements.
With the MISSION Act, more and more veterans will be
eligible for community care. However, as you will hear from
some of our witnesses today, VA has never reliably tracked or
reported veterans' wait times for community care, yet there is
evidence that wait times in the community are often longer than
wait times for VA care. VA's own data on wait times for
appointments at VA facilities remain incomplete and unreliable.
The policy goal of the Choice Act and the MISSION Act was
to reduce wait times for veterans and increase access.
Therefore, the lack of accurate information on wait times
at VA hospitals and with community providers should cause us
all to question whether the policy to send more veterans to
community care providers is sound or even if it is working.
Veterans have a right to make informed choices about where
to receive care; however, that choice is dependent on
transparent and accurate information about wait times. This
Committee will not allow our veterans to be harmed by the same
deceptive practices that led to the Phoenix VA scandal.
I look forward to engaging our witnesses and my colleagues
in this conversation, and with that, I will recognize Ranking
Member Dr. Roe for 5 minutes for any opening remarks that he
may have.
OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER
Mr. Roe. Thank you, Mr. Chairman.
A little over 5 years ago, as the Chairman stated, on April
14th, 2014, this Committee held a hearing very similar to this
one on ``Access to Care for Veterans in the Department of
Veterans Affairs.''
During that hearing, then-Chairman Miller disclosed that a
Committee investigation had uncovered a secret list, a waiting
list at the Phoenix VA Medical Center, and that as many as 40
veterans on that list had died waiting for care. That
disclosure embroiled VA in a nationwide access-and-
accountability crisis that is still reverberating across the VA
health care system today.
We would be remiss if we do not take a moment to
acknowledge the many ways in which access to care for veterans
has improved since 2014. VA is seeing more veteran patients
today than ever before.
Last year alone, VA completed more than 1 million more
appointments than it had the year before. In many cases, those
appointments occurred faster within VA than they would have in
the private sector, according to the Journal of the American
Medical Association. We should all be proud of those
achievements, particularly the thousands of VA employees across
the country whose hard work is what led us to that.
However, despite how far VA has come in the last 5 years,
there is no doubt that VA has further still to go. While I was
preparing for this hearing yesterday morning, the VA Inspector
General released an alarming report about delays in care for
veterans seeking mental health appointments at the Albuquerque
VA Medical Center. That report paints a heartbreaking picture
of why we must continue to focus on access to care for our
Nation's veterans, until we are assured that every veteran,
every time, receives the care that they need when they need it.
In a system as large and dynamic and as evolving as VA,
there will never be a perfect way to measure access; it is as
much of an art as it is a science. That is why I am grateful to
have the experts from VA and the Government Accountability
Office, and the private sector, here with us today to discuss
not only how access has improved for veterans over the last 5
years, but also how it can continue to improve for veterans
over the next 5 years.
I am particularly grateful to have Dr. Kenneth Kizer with
us. Dr. Kizer is a veteran of the United States Navy, a
physician with a long and distinguished career as a public
health leader in government, the private sector, and academia.
He also served as Under Secretary for Health in the mid-'90s
during the last critical transformation period for the VA
health care system.
Thank you, Dr. Kizer, for taking time out of your busy
schedule to share your expertise with us this morning. I am
very much looking forward to your testimony and that of your
fellow panelists.
With that, Mr. Chairman, I yield back.
The Chairman. Thank you, Dr. Roe.
With us today are Dr. Debra Draper, Director of the Health
Care Team at the U.S. Government Accountability Office,
otherwise known as the GAO. We have also Dr. Teresa Boyd,
Assistant Deputy Under Secretary for Health for Clinical
Operations, accompanied by Dr. Susan Kirsh and Dr. Clinton
Greenstone.
We also have with us the Honorable Kenneth Kizer, Chief
Healthcare Transformation Officer and Senior Executive Vice
President of Atlas Research, Incorporated.
And with that, I will begin with Dr. Draper for her opening
statement.
STATEMENT OF DEBRA A. DRAPER
Dr. Draper. Chairman Takano, Ranking Member Roe, and
Members of the Committee, thank you for the opportunity to be
here today to discuss VA's medical appointment wait times on
the 5th anniversary of this Committee's hearing following the
Phoenix wait times crisis in 2014. While Phoenix was the
epicenter of the crisis, the identified problems were
widespread, affecting the entire VA health care system.
Access to timely health care is critical for veterans
seeking needed medical care; however, long wait times and
weaknesses in the schedule system have been persistent, and
have hindered veterans' ability to access care. For the past 20
years, we have conducted an extensive body of work on veterans'
access to care. We have reported significant and wide-ranging
weaknesses that contributed to the addition of veterans' health
care to the GAO's high-risk list for the first time in 2015 and
where it remains today.
In 2012, we conducted a comprehensive review of VA's
outpatient medical appointment scheduling policy and processes.
We found that the medical appointment wait times reported by VA
were unreliable, in part because VA did not ensure consistency
in how schedulers recorded dates that provided the basis for
measuring wait times. We found these dates to be subject to
interpretation and prone to scheduler error. We recommended
that VA clarify its definition of these dates. VA concurred and
has taken some actions since 2012 to improve wait time
measurement, such as improved oversight through ongoing audits
of schedulers.
VA provided us new information related to this
recommendation on July 12th. Once we have had the opportunity
to fully review this information, we will be able to determine
what additional actions and information are needed. However, at
this time we continue to be concerned that VA has not
sufficiently addressed the reliability of its wait time data.
For example, in its first internal audit in August 2018, VA
was unable to evaluate the accuracy or reliability of its wait
time data, data posted to its website or used by veterans.
In 2012, we found that the medical appointment wait times
reported by VA were also unreliable because VA did not ensure
the schedulers received the required training. We recommended
that VA ensure consistent implementation of a scheduling policy
and ensure that all schedulers complete the required training.
VA concurred with this recommendation and has taken action
since 2012 to update its scheduling policy and complete
training for schedulers.
We believe that these actions, along with the additional
information VA provided us earlier this month, sufficiently
address this recommendation.
While improvements to the VA's scheduling policy and
processes will help ensure veterans timely access to health
care, it is important to acknowledge that there are also other
factors that may affect access that are not currently reflected
in VA's wait time data. For example, we have found that VA's
wait times do not capture the time it takes the Department to
enroll veterans in VA health care benefits, which we found
could be quite lengthy.
Issues with appointment scheduling have not been limited to
VA's internal delivery of care, but have also existed for its
community care programs. Our prior work on appointment
scheduling in VA's Choice Program found weaknesses resulting in
recommendations to address the lack of timeliness goals and
reliance on incomplete and inaccurate wait time data.
In June 2018, for example, we found that the data VA used
to monitor the timeliness of appointments for the Choice
Program captured only a portion of the total appointment-
scheduling process. Although VA had a wait time goal of 30 days
under this program, the timeliness data did not capture certain
processes such as the time taken to prepare veterans' referrals
and send those to a third party administrator. We found that,
if those processes were accounted for, veterans could wait up
to 70 days to see a provider.
As of July 2019, our recommendations in this area have not
been implemented. VA officials told us that these
recommendations would be addressed by the tools and systems
created for the new Veterans Community Care Program. According
to VA officials, for example, one of the new systems that will
support the management and monitoring of referrals, appointment
scheduling, and authorizations will be fully implemented across
all VA medical facilities in fiscal year 2021.
In closing, we have identified weaknesses in VA's wait time
measurement and scheduling processes over the years, affecting
not only VA's internal delivery of care, but also that provided
through community care providers. We have made a number of
related recommendations. We are pleased that VA has taken
actions to address some of these recommendations, but
additional work is needed.
The implementation of enhanced technology such as a new
scheduling system is crucial and will provide an important
foundation for improvements; however, this is not a panacea for
addressing all of the identified problems. Moving forward, VA
must also continue to ensure that its policies clearly
delineate roles and responsibilities; oversight and
accountability remain front and center; and training is ongoing
and effective.
Mr. Chairman, this concludes my opening remarks. I am happy
to answer any questions.
[The prepared statement of Debra A. Draper appears in the
Appendix]
The Chairman. Thank you, Dr. Draper.
I will now turn to Dr. Teresa Boyd.
STATEMENT OF TERESA S. BOYD
Dr. Boyd. Good morning, Chairman Takano, Ranking Member
Roe, and Members of the Committee. I appreciate the opportunity
to discuss VA's current practices for measuring veterans'
access to health care and to provide a clearer picture
concerning wait times in light of the 5-year anniversary of the
issues in Phoenix.
I am accompanied today by Dr. Susan Kirsh, Acting Assistant
Deputy Under Secretary for Health for Access, and Dr. Clinton
Leo Greenstone, Deputy Executive Director, Clinical
Integration, Office of Community Care.
VHA has undergone a tremendous transformation since 2014,
operating with a renewed focus, unprecedented transparency, and
increased accountability. We recognize that there are still
challenges ahead of us, but it is important to keep in mind
that veterans continue to receive the highest quality care,
often with shorter wait times than in the private sector.
As in the community, most VA patients come to us for
routine or elective care. For established patients, VA's
average wait times for primary care and mental health care
appointments are under 5 days and 7 days for specialty care. To
ensure that veterans with more urgent needs are accommodated
appropriately, as of 2017 the VA began offering same-day
services for mental health and primary care at all VA medical
centers and community-based outpatient clinics across VA.
So what does that mean? Well, it means that when a veteran
contacts us seeking same-day services for primary care and
mental health care, we address the need that day with perhaps
an appointment, if that's appropriate; by refilling a
prescription; answering a question over the phone or by secure
messaging; or even scheduling clinically appropriate follow-up
care.
We have also simplified the consult management process and
resolution of these referrals has made it easier for veterans
to be seen in a timelier manner. When in 2014 it took an
average of 19 days to complete a stacked consult, we are now
completing these referrals in under 48 hours, which is the
industry target.
Listening to our employees and sharing strong practices
across the enterprise, as well as lessons learned from
implementing the Veterans Access, Choice, and Accountability
Act of 2014 were among the reasons we have seen these
improvements, and we expect continued success under the
implementation of the MISSION Act of 2018.
As a learning organization, VA encourage employees who have
ideas or concerns to report them; VA will not tolerate efforts
to retaliate against employees for doing so.
In January, VA Assistant Secretary for Accountability and
Whistleblower Protection, Dr. Tamara Bonzanto, was sworn in,
and for the last several months she and her team have been
working closely with the VA Inspector General to ensure her
office is operating as Congress has intended and with maximum
efficiency.
When it became apparent that VHA needed to improve the
scheduling process, we created the Office of Veterans' Access
to Care, or OVAC, to lead VA's new approach, which has included
updated scheduling software, standardized national processes,
national audits, and scheduler trainings at the local level.
More than 58,000 VHA employees, including medical support
assistants, clinicians, nurses, and health care technicians
have completed this training, which includes technical and
customer service skills, as well as in-depth training on
standard processes and procedures per VHA's scheduling
directive.
Over the last 5 years, we have transformed how we deliver
care, and our success has been realized due to strategic
planning and cooperative implementation efforts across the
enterprise; once again, listening to our staff, our veterans,
and their families.
Recently, OVAC implemented a three-phase initiative to
improve capacity, efficiency, and productivity to help
facilities and our national teams better understand demand and
increased access to care at specific sites. So, overall, this
work has helped us to improve access to high-quality care for
our Nation's veterans, more closely aligning capacity to meet
demand.
We also recognize that quality care comes from having
adequate levels of staff available to provide and coordinate
that care. Today, there are more than 200,000 health care
professionals, including doctors and nurses, who treat veterans
in the VA system.
VHA values what veterans have to say, and we know that,
ultimately, it is our veterans who will determine whether we
are meeting their expectations as health care partners. To
better understand that perspective, VA has moved to the
industry standard for assessing patient satisfaction, the
Consumer Assessment of Health Providers and Systems Survey.
Based on survey results, veterans are telling us we are
moving in the right direction. VA has seen improvement in
patient satisfaction scores across every category related to
veterans getting care when they needed it. More than 77 percent
of those who responded to the survey said they were treated as
a valued customer during their most recent VA encounter, and
three in four veterans say they trust VA with their health
care.
Placing veterans at the center of their care helps ensure
they receive that care when and where they need it, and is
fundamental to all we do. We have made significant progress and
are committed to earning the trust of our veterans and the
American people. We will continue to improve veterans' access
to timely, high-quality care from VA facilities, while also
providing veterans with more choice to receive community care
where and when they want it. Your continued support is
essential to providing this care for veterans and their
families.
Mr. Chairman, this concludes my testimony. My colleagues
and I are prepared to respond to any questions you may have.
[The prepared statement of Teresa S. Boyd appears in the
Appendix]
The Chairman. Thank you, Dr. Boyd.
I now recognize Secretary Kizer for 5 minutes.
STATEMENT OF KENNETH W. KIZER
Dr. Kizer. Good morning, Chairman Takano, Ranking Member
Roe, and Members of the Committee. Thank you for the
opportunity for allowing me to offer some comments about
assessing and tracking wait times and timely access to care,
and also to comment about what timely access to care means or
the evolving nature of what that means today.
You have my written testimony, so I am going to take the 5
minutes I have here just to highlight a few points that were
made there. And I would note also that my comments here are
informed by more than 40 years of experience in a variety of
health care roles, from being a practitioner to managing the
largest health care system in the United States, to being a
researcher and a variety of other perspectives on issues
related to access.
Perhaps the first point I would make is that, while
assuring timely access to care is widely recognized as an
important dimension of high-quality health care and has been a
priority for American health care for many years, consistently
achieving timely access to care continues to be a challenge
throughout American health care. Unfortunately, long wait times
for care are all too common for patients and families
everywhere, although especially for those who are on publicly-
funded insurance such as Medicaid.
I think the problems related to long wait times are known
and I won't go into that. Suffice it to say that when patients
have to wait weeks or months to see a physician, bad things
tend to happen.
There are multiple reasons why we have problems in timely
access to care in this country, much has been written about
this and I won't take the time now to delve into all of those
reasons. I would just note that one of the problems simply is
the lack of national standards about what constitutes timely
access to care in the variety of settings in which patients
receive care.
I would also comment that wait times, while seemingly a
straightforward or simple thing to measure, actually,
technically, turns out to be exceedingly complex and difficult
to capture, all the variables that go into wait times. And I
would also note that even if wait times were accurately
measured, they have many limitations. They are just one
dimension of looking at access and access is a multi-
dimensional issue that includes many factors other than just
wait times.
I was gratified to hear that VA has moved to using HCAHPS
as a patient-reported measure of timeliness of access. I would
note that leading health care systems around the country are
increasingly looking to patient-reported measures of timeliness
of care in addition to looking at wait times, but they find
that patients' perceptions of the timeliness of care is very
revealing as to how well their health system is functioning.
And we can talk more about that later, if there is interest.
I think I would be remiss if I didn't also take the
opportunity here to comment that in considering timeliness of
care and how accessibility to care should be measured, we need
to ask a basic or very fundamental question about what access
to care means in an era of enhanced connectivity through all of
the information and communication technologies that exist today
that, candidly, 10, 15, 20 years ago were simply not available.
In a time when a large proportion of the population
accomplishes many critically important and sensitive
activities, such as their banking through the Internet, we need
to ask ourselves why do we continue to view access to care only
or primarily through the lens of face-to-face visits. And,
indeed, I would posit that measuring access to care simply by
counting face-to-face encounters is increasingly anachronistic
and really does not promote patient-centered care. We know that
70 to 80 percent of patients when queried would like to be able
to take care of their health care needs just like they take
care of their banking and shopping and other needs through
technology-enabled devices, and when those folks are queried,
more than 90 percent of them say that they are satisfied and
happy with their interactions through telehealth and health,
other technology-assisted ways.
And I would just perhaps, recognizing that the clock is
running out, note that while VA is an acknowledged leader in
telehealth and virtual care, I believe that it is has only
scratched the surface of what could be done to enhance access
to care through technology-assisted means. And I offer in my
written comments a number of suggestions for where I think VA
could go and should go to enhance access to care using
technology-enabled means and engaging entities like the
National Academy of Sciences, Engineering, and Medicine, and
the National Quality Forum, to help them address some of the
technical issues attendant to getting there.
With that, let me close, and I am happy to respond to your
questions.
[The prepared statement of Honorable Kenneth W. Kizer
appears in the Appendix]
The Chairman. Thank you, Secretary Kizer. I now recognize
myself for 5 minutes.
Dr. Boyd, I will begin with you. Where can veterans go to
find out about the wait times to see a community provider?
Dr. Boyd. So currently the VA does not have a roll-up or
even a provider's specific information about a specific
community care provided.
The Chairman. Okay, so the VA doesn't currently provide
that, so there's no way for a veteran right now to be able to
assess how long it will take to see a community provider.
When a veteran makes an appointment, is that veteran given
information about the wait time to see a VA provider versus a
community provider, so they can make an informed decision about
which is better?
Dr. Boyd. So that is a great question and as I--and I was
remiss in not mentioning this, but all three of us, the
physicians here from VA, practicing physicians within the VA at
some time--
The Chairman. I only have so much time. I'm sorry, Doctor,
I don't mean to be rude. But--
Dr. Boyd. So I will answer that for you, I will answer that
for you.
The Chairman [continued]. --it would seem to me that since
you can't find out any times for a wait time for a community
provider that a comparison tool is also not possible; is that
correct?
Dr. Boyd. What I will answer is this. In my conversation
with my patient, which is very sacred, I do mention what our
eligibility wait times are within the VA and by the MISSION
Act. And I do discuss with my patient, you need to be seen
within X, Y, and Z time. So it is the patient preference to go
out to the community, knowing when that needs to be done, or
stay within the VA.
The Chairman. But, nevertheless, there is not really a tool
or information available to say this is how long it will take
for the VA, this is how long it will take to go to the
community, you don't have that capability right now?
Dr. Boyd. We have that within what we call our Decision
Support Tool that was rolled out on June 6th that all of our
providers use when they meet with their patient and they
discuss their options for care.
The Chairman. We have--so that--but that is not available
generally to the veteran outside on a website someplace, right?
Dr. Boyd. That is correct.
The Chairman. And we haven't seen this tool independently
tested for the accuracy of these comparative wait times?
Dr. Boyd. Well, I could pass off to Dr. Greenstone, who
is--
The Chairman. So, wait, does--
Dr. Boyd.--effectively the developer of that.
The Chairman [continued]. --does the tool actually show
wait times?
Dr. Boyd. The DST does.
Dr. Greenstone. So, Mr. Chairman, the tool actually shows
average wait times within the VA and we are now beginning to
collect data that we intend to put into the tool to show
comparative data in the community.
The Chairman. So an average over how long, an average over
30 days?
Dr. Greenstone. Yes, it is a rolling 30-day average that we
actually show.
The Chairman. So, at the point of consultation, there is no
real-time comparison, you know, within that day or the week for
that veteran to know the real-time wait time at the facility,
at the VA, or in the community?
Dr. Greenstone. That is correct. So that is determined at
the time that a scheduler is working with a veteran.
The Chairman. So real-time wait times are not available.
The average is available in a limited sense.
Dr. Greenstone. That is correct.
The Chairman. VA uses the Consumer Assessment Health Care
Providers and Systems Survey, mentioned earlier, to collect
data on whether a veteran received care when they need it and
it is the health care industry standard. Why isn't this
information made easier for veterans to find and why isn't VA
publishing this same data from its community providers, so
veterans know if they can expect to receive care in the
community when they need it? Dr. Boyd.
Dr. Boyd. So, currently, our veterans are able to look
online. We have Access to Care website that our veterans can go
online and look for their specific medical center or their CBOC
as well.
The Chairman. I understand that, but I specifically asked
you about the Consumer Assessment Health Care Providers and
Systems Survey data. My understanding is that VA does not
publish this for community care providers.
Dr. Boyd. That is correct.
The Chairman. Yeah. So and why aren't we publishing that
data?
Dr. Boyd. That is--I could pass it off to Dr. Greenstone,
who is more informed about that particular part.
The Chairman. Dr. Greenstone, go ahead.
Dr. Greenstone. Sure. So we do not have the specific HCAHPS
data on the community providers. We have data on the veterans'
experiences when those veterans go and see providers in the
community, and we ask them the question about how satisfied
were they with their community care experience with a provider
they--
The Chairman. But I have heard testimony here that these
consumer reports are actually a pretty good way to figure out
how timely the service is.
Dr. Kizer, did you want to comment on this?
Dr. Kizer. Well, a couple things I would say is, one, the
private providers, community providers are not routinely
required to report wait time data the same way that the VA is,
and in the instances where some of that information is
available, it certainly has not been subjected to the scrutiny
for its accuracy and validity as has the VA data.
The information on HCAHPS, while that could be gleaned from
various sources and made available, that does tend to lag
behind. Whether it is available in realtime or close to
realtime may be more difficult to achieve, but some of that
information is reported to the CMS and other bodies and one
could basically mine those data sources to get some of that
information.
The Chairman. Well, thank you, Dr. Kizer.
Dr. Roe, you are recognized for 5 minutes.
Mr. Roe. Thank you, Mr. Chairman.
Dr. Boyd, I guess one of the questions I have is that why
does it take 3 months to enroll somebody in the VA health care
system?
Dr. Boyd. So I am not aware of a standard time for
enrollment. We have multiple entryways for veterans to be
enrolled; they can walk into a medical center, to the
eligibility center, and sign up.
Mr. Roe. Well, it says--I mean, I read the script today and
the data in here and it said that--let me ask another question.
And I read something in your testimony that I have a hard
time believing--and I hope it is true, but I just have a hard
time believing it is true, is if you call up, you can get an
appointment that day for mental health or for primary care at
any CBOC and at any VA medical center, 172 of them in the
country.
Let me just ask you this question: if a patient calls up
and says I am having real problems coping and I am concerned
about my safety, what does the scheduler tell this person and
what do they do? Do they get in that day? And, if that is true,
then what is going on in Albuquerque?
Dr. Boyd. Okay. So that is a great question, it is about
same-day services. So in that particular case, when that
veteran calls in to that clinic, the scheduler is not clinical.
That would be handed off to a clinical person who would assess
the needs with the veterans, is this something that can be
taken care of on the phone, with another health care provider
through telehealth, a video-connect session, or is it of an
urgent need and the veteran needs to go more of an urgent care
center or to an ER.
So, we assess the needs, and it is at very VA medical
center and at every CBOC.
Mr. Roe. Well, my bet is that I will call before the end of
the day that refutes that, that would be my bet.
Dr. Boyd. And, Dr. Roe, if I may add? Twenty percent of our
completed appointments every single day--and we look at this
every morning at 7:45--so 20 percent of our completed
appointments every day are same-day appointments. So it is
those same-day service requests that actually go on to making
an appointment.
Mr. Roe. Oh, I think it is a noble goal, I mean, I
absolutely do, it is just hard for me to believe it can be
carried out.
Now, the VA is seeing over a million more patients in '18
or '17, which is remarkable--or appointments, I should say--how
does that occur? Is it new hires or are they not seeing a
doctor, maybe they are seeing a nurse practitioner or a PA or
something? How has that occurred? And then I have got a follow-
up question.
Dr. Boyd. So I will be brief then; so, in a myriad of ways.
We look at efficiencies of the actual clinics and to make sure
that our grids are open, that is how we schedule patients, to
making sure that we are effectively supporting a provider,
whether it be a nurse practitioner, PA, or a physician. And so
we have found efficiencies, we have found some extra time in
there for bookable hours, if you will. So that is part of it.
The other part is, you know, what we heard about
telehealth, we have different modalities with which to actually
see patients, if you will, to complete those appointments as
well.
So in some areas we have increased staff, because there was
an increased demand and high-growth areas, and also using the
actual team around say our primary care team or our mental
health team, not always having to be just the provider.
Mr. Roe. I guess the thing that I have looked at--and, Dr.
Kizer, I would like to have--you are absolutely right, I don't
know that we ever measured wait times; I know I didn't in our
practice. And if one of the measurements is somebody calls in
to get a refill, boy, I did really well with that, if you look
at those--that is the standard that you are using, because I
didn't even look at that as a contact with somebody that day.
And typically, how a private--and I'm sure it does at the VA
too works--you know, at the end of the day I would have 15 to
30 phone calls that I would make to patients and contact them.
Talk about telehealth, I used to telephone. We didn't have
Internet then, but I did that, and I guarantee Dr. Kizer has
done the same thing.
Going forward--and I want to commend the VA for it has
absolutely improved since 2014, there is no question about
that. It has been a Herculean effort to do right by our
Nation's veterans, there is no question about that. And I have
got, Dr. Draper, just a couple of very quick questions. My time
is about expired, but if you had today to improve the accuracy
and consistency of this, what would you have the VA do today?
Dr. Draper. Well, I think they need not to consider this as
a one-off like training. This needs to be consistent. I mean,
one of the issues is that the schedulers are among the top ten
highest turnover positions in the VA. So, you know, there is
constant turnover, there is, you know, really educating those
schedulers and making sure that they are consistently
implementing the scheduling policy, that is one big thing.
Oversight and accountability, you know, we continue to find
pockets of that where that is not so effective, and that really
needs--as I said in my oral comments, that needs to be front
and center and just on the mind, you know, pervasive on
everything that they do.
And I think that the--you know, the new scheduling system
that is expected to roll out in the next couple of years, that
will be very helpful, but that will not solve all the problems.
You still have to, you know, as I said, have training,
oversight and accountability, and other things that, you know,
together.
Mr. Roe. Just one last comment. The two most important
people in my office was the first person to answer the phone
when the patient called in to make that appointment and the
person that greeted them when they came in, because if they had
a bad experience there, it was going to be hard to get a good
clinical experience.
So I would encourage you to do exactly that, is train those
folks that are doing the scheduling and meeting people. They
are the front line, they are the face of the VA.
I yield back.
The Chairman. Thank you, Dr. Roe.
I now recognize Mr. Allred for 5 minutes.
Mr. Allred. Well, thank you, Mr. Chairman and Ranking
Member Roe for holding today's hearing. I want to thank our
witnesses for being here.
Wait times for veterans in North Texas are too long. Every
day, 40 to 80 veterans are in temporary care awaiting a bed at
a VA facility, and that is why I led a bipartisan letter with
my colleagues in North Texas to ask the VA to work with us in
facilitating the acquisition of a donated hospital in Garland
to help us meet the growing demand. This hospital is an easy
solution to growing access problems and will help North Texas
address the gaps in our capacity to provide for a growing
number of veterans.
So I will ask you, Dr. Boyd, to take that back to your
colleagues in the VHA and the VA. Secretary Wilke has appeared
before us in this Committee and has said that he is interested
in doing it, the Dallas VA wants to do it, the City of Garland
wants to do it, and I am a little bit frustrated at the amount
of time that this is taking for us to move forward. It is
something that we critically need to meet our capacity and it
is I think the smart thing for the VA, for our veterans, and
will save us a lot of money as well.
Dr. Boyd. So, if I could just briefly comment. In many
meetings recently there is an urgency with this discussion, so
I just want you to know it is front and center. It is being
discussed at all levels of VA and VHA. As you can only imagine,
it is a very complex--it sounds easy, but it is a complex
discussion, but no doubt we want to do the right thing for
veteran care. So, just so you know, we are working it.
Mr. Allred. Good. I am glad to see that it is getting
discussed. It is a matter of urgency, I think, and I am glad
that you all are recognizing that.
Texas is proud to be home to the most women veterans of any
state, and yet wait times for women's health care services can
be longer than wait times for other services, and I want to ask
if you have a specific plan to address wait times for our women
veterans.
Dr. Boyd. So, roughly, in working with our National Program
for Women Veterans, Dr. Patty Hayes, we are absolutely
accelerating the footprint with which, if you will, the
capacity for women-specific providers in all of our areas.
And the other thing, just so you know--and I am a Texan, by
the way--the other thing is that when we recruit providers now,
it is not a perhaps do you want to do women's health, it is
going to be something that is part of the recruitment package.
So I think that is another thing that we will do, but
absolutely we are very well aware of that.
Mr. Allred. Well, that is good to hear, because I think
that we are going to have to continue to change and grow our
VHA services to deal with our new community of veterans and
especially here in Texas with us having the most women
veterans, it is a big issue for us.
I want to also talk about community care, and I want to
talk about how we are going to monitor this. I think you
addressed it briefly, you could go into a little more what the
plans are, where we are in the implementation of that, and how
we in Congress can help you oversee how the community care
system is being enacted.
Dr. Boyd. So I will hand that off to Dr. Greenstone, who
can speak very eloquently about that.
Dr. Greenstone. Yes, certainly. Thank you very much.
So, as you know, we have undergone a great deal of
transformation overall in our programs, that is with new
technology, new legislation under MISSION, we have new
contracts that have been awarded and are now coming on line,
and a significant amount of change in our business processes
for overseeing community care. That means we have the ability
to now, which we never had before, using new technology in
identifying the time that it takes for us from when a colleague
or a provider, like Dr. Kirsh or myself or Dr. Boyd, places a
consult, a request for care, the time that care actually takes
place in the community and every important step along the way.
And that way we will have an opportunity to measure what
matters, that means measuring that veterans are getting
appropriate, timely, high-quality care, and when they are not,
we have an idea now of where the problems are taking place. How
can you really drill down and make the appropriate changes to
actually improve upon the work that all of our staff are
working on to improve getting veterans timely care. So that is
going to be one of the ways we have the opportunity to oversee
that data now.
Mr. Allred. Well, I hope you understand that this Committee
wants to work with you on it. We want this to be a success. I
don't want it to also take away from our initial mission at the
VHA, providing and improving the care we are providing there,
as I said, to address our diversifying community of veterans.
So I hope that you will stay in touch with us. I hope that
we have a productive conversation around this, because I have
heard from some of our VSOs a lot of concerns about how this is
going to be implemented. And so it is certainly going to be a
focus for us here in the Committee and I look forward to
staying in touch with you on it.
And, with that, I yield back.
Dr. Greenstone. Absolutely. Thank you.
The Chairman. Thank you, Mr. Allred.
Mr. Bost, you are recognized for 5 minutes.
Mr. Bost. Thank you, Mr. Chairman.
This is for Dr. Draper and Dr. Kizer both. The Journal of
American Medical Association released a study in January, and
they found the VA generally outperformed the private sector
with respect to wait times. Are you both familiar with that
study--
Dr. Draper. Yes, I am.
Mr. Bost [continued]. --and do you agree with the findings?
Dr. Draper. Well, this is what I would say. It is really a
piece of the story, because it looked at 15 major metropolitan
market areas and we know across VA's 172 medical centers there
is great variation. And a lot of the access issues are more
prominent for rural markets or rural--less urban markets. So I
think it is important to really understand the implications or
what happens in those markets as well, because, as I said,
there is a great deal of variability, as we all know, across
medical centers. So I think it is a piece of the story.
I think it also has implications for community care,
because the wait times are really--if they are worse in the
private sector, then, you know, that suggests that VA is more
able to provide care within its own facilities. But I would say
the variability piece and particularly looking at rural markets
is really important to consider.
Dr. Kizer. Yes, sir. I am familiar with the paper, although
it has been a while since I looked at it. I think it was a
sound study, good results. If I recall correctly, in the paper
it did discuss some of the limitations that it has and some of
which have been alluded to already.
But I would also take this occasion or opportunity to
comment on something that Dr. Roe made, as well as the person
before you, and that one of the predictable and foreseeable
problems that VA is going to have in assessing community wait
times is the fact that there is no standard way of assessing
wait times in the private sector. There are no national
standards, there is no widely-accepted or single way of doing
this. So, even though they may procure lots of information,
there is no certainty that there is going to be apples-to-
apples type comparisons, and so there is going to be difficulty
comparing the information that is made available from community
providers.
Mr. Bost. Thank you.
And, Dr. Boyd, you know, during the period of 2014,
following the scandal of Phoenix, have veterans' satisfaction
ratings increased or decreased with the VA or do you think the
wait times are--is wait times a factor in that?
Dr. Boyd. With regards to the tremendous increase in the
satisfaction scores with our veterans, I think the wait times
have a piece of that, but really going back to what Dr. Kizer
was really--it is meeting their needs. So whatever that means,
and that is--you know, it is an individual. It may be
different. And it could be, as Dr. Roe said, it could be
because they had a great experience, too, an appropriate
experience.
But no doubt our satisfaction scores are going up, and I do
think that that is a piece of it. It absolutely is.
Mr. Bost. Well, let me just say that as Members of the
Committee, all of us are wanting the VA as a whole to succeed
and to do their job to the best of its ability.
That being said, each one of us have our own districts and
see the particular VAs in our districts and we use the
scientific studies that we have, which is how many complaints
come and say how bad is our local VA in comparison to how many
say, hey, they are doing a great job.
And so as we do that, as we move forward, I hope that we
find some kind of system which we can truly make that judgment
call. I am the state legislator in the State of Illinois, and
this is a scientific--we have a deer season. And the deer
season and the amount of permits is released based on the
amount of people who call in and say, there are too many deer
in comparison that there is not enough. And that is how they
issue the amount of permits.
I am afraid that when we move forward with our veterans,
that that is not the real--really the best way. What the best
way would be is truly find a way to track the numbers. And
right now I am concerned that we are not able to track those
numbers. And I hope we can get through that.
So with that, Mr. Chairman, I yield back.
The Chairman. I now recognize Mr. Brindisi for 5 minutes.
Mr. Brindisi. Thank you, Mr. Chairman.
Dr. Boyd, I recently had a meeting of my veterans' advisory
council back in my district and one of the issues that was
raised by several of the veterans who attended the meeting was
about the committee providers under the Mission Act, being able
to search them on the VA's website.
But in an area like mine, which is very rural, and where
high speed internet is spotty at best, and cell phone service
is almost non-existent in certain areas, if you don't have
access to a website or can't pull up the VA's website on your
phone, how does a veteran go about searching what community
providers are available under the Mission Act?
Dr. Boyd. So just a couple of things for that.
First of all, before we rolled out, you know, the June 6th
Mission Act, we ensured that every VA medical center had the
capability from the incoming phone lines to press 6 for more
mission information. That is the one thing. But what you are
asking is something that has a different twist to it as well.
Veterans need to engage with their facility, with their VA
clinic, their provider in order to get into that system. There
is no direct reaching out to the committee providers. And that
discussion then will be had at the VA center.
And if Dr. Greenstone has anything to add on that because
he truly is in that area.
Dr. Greenstone. Thank you.
It is a very important question, reaching out to our rural
veterans who may not have access. And so clearly, you know,
like Dr. Roe mentioned, the telephone is going to be one way
that you can certainly get information. And if you contact
someone, we can actually go to our directory and find out where
that veteran lives and what kind of providers are in their sort
of neighborhood, if you will, or close to them.
But then as Dr. Boyd mentioned, in order to access those
providers in the community, it has to be initiated by a request
for care from a provider within the VA. So that would be one
thing.
And then at that time, anytime you are working directly
with a provider and a veteran, that provider has access to see
the providers in the community, the average wait times in the
VA, and eventually we plan on being able to demonstrate the
average wait times in the community for a comparison to take
place at that point in time.
Mr. Brindisi. Okay. So and another question I wanted to ask
was about the same day services initiative. I wanted you to
just expand a little bit on that initiative. Does that always
mean a face to face appointment? Are there other areas where
you can get help, telehealth? What does that exactly mean?
Dr. Boyd. You are absolutely right. And I will let Dr.
Kirsh answer that. It is from her office. But you are
absolutely right, and that is a super question.
Dr. Kirsh. Thank you for that question.
And I wanted to provide some further detail in that this
has been a pretty robust effort over the last couple of years
to ensure that primary care, mental health, substance use
disorder, that we have the ability for a veteran to contact us
and for us to take an action, essentially.
While as we heard previously, 20 percent of the time it may
result in a face to face appointment, we know, as has been
pointed out previously, that this can be addressed through
fulfilling a medication or assessing the patient and
determining that that patient needs to be seen for some knee
pain in 2 weeks as the appropriate follow up.
So it really is about addressing the need of the veteran
that day, ensuring that there is not something urgent that is
happening, and then ensuring that that happens in the way the
veteran wants that, whether it is in a text message follow up
or if it is in a phone call follow up. That is our goal is to
be veteran-centric.
Mr. Brindisi. And just to follow up on that a little bit,
in the written testimony GAO said that ongoing staffing and
space shortages have created challenges for implementing and
sustaining same-day services.
What are you doing to help those facilities with that
challenge?
Dr. Kirsh. So overall since 2013 we have increased staff
very significantly by approximately 50,000 staff. And 63 of
that percentage, 63 percent has been an increase in schedulers
specifically.
Our office was engaged with GAO and I think the report is
not yet final, but the recommendation was really only around
measuring what we do. As you heard previously, having a
telephone follow up or a secure messaging follow up is not as
easy to measure and to roll that and understand how we are
doing in that area.
And to that end, I have been engaged with the National
Quality Forum to help assist us in understanding the best way
to measure a same-day service.
Mr. Brindisi. Thank you.
I see I am out of time, so thank you for your responses.
The Chairman. Thank you, Mr. Brindisi.
Dr. Dunn, you are recognized for 5 minutes.
Mr. Dunn. Thank you very much, Mr. Chairman.
Dr. Kizer, I read your resume, very impressive. You have a
great depth of experience. I, too, am a physician. I appreciate
your insightful comments on your opening statement there.
So just doctor to doctor here, what do you think is the
value of wait time measures as we are performing them in the VA
given the inherent technical problems in doing those measures,
and are we guilty of an overly microscopic focus on a set of
macroscopic problems?
Dr. Kizer. Let me try to answer you in a couple of ways. I
think wait times are an important metric to assess and to
track. I think they, what many private or leading private
health systems find is that they are more useful for quality
improvement purposes. There are targets to try to achieve. That
from an accountability or compliance point of view, just the
technical issues make it very difficult.
So while they are an important metric to track, they are
but one metric. As I said before, it is a uni-dimensional way
of looking at a multi-dimensional issue. Access is much more
complicated than just wait times, and as Dr. Roe--
Mr. Dunn. I appreciate you saying that, and I wanted you to
underscore that because I think it is important that we don't
get too far chasing down wait times.
But on the same subject, are you aware of any wait time
measure that is immune to faulty interpretation or scheduling
errors?
Dr. Kizer. No, I am not.
Mr. Dunn. Yeah. I am not either. Dr. Draper, are you?
Dr. Draper. Well, one thing that has greater accuracy is
the create day. So that has, that is the time stamp that the
system creates, and it doesn't allow manipulation of days like
some of the other days.
Mr. Dunn. Good. I think there is a lot of things we could
look at in the VA besides just wait times.
Dr. Boyd, your testimony notes that the Choice Act, now the
Mission Act, is a large factor behind many improvements. And
the Department has made far access, recognizing that the
implementation of the Mission Act really just started a few
weeks ago. What impact do you think it has had on access so far
and what impact do you think it will have going forward?
Dr. Boyd. So in several areas. And you are right. We just
started. But it seems like we have been living it now, you
know, in preparation.
The access portion is that when we look at community care,
our new community care network, as a senior leader when I am
looking at the world of capacity of where my veteran patients
can go is a combination of my internal systems and my
integrated outside network. So that is huge, and it gives
veterans choices. There are--no one, no 2 veterans are the same
with regards to where they live and so forth.
The part of the mission that I wanted to thank the group
for is that we have certain authorities now that will improve
our ability to not only recruit, but to retain our employees.
So that to me, those 2 big things just stand right out.
Mr. Dunn. So, also, Dr. Boyd, on this note, the VA now
provides many more appointments than it did back in '14. What
do you attribute that capacity do, and what role do you think
the community care plays in that?
Dr. Boyd. So currently we--year to date we have had 1.75
million more completed appointments. That is amazing.
Mr. Dunn. Year on year.
Dr. Boyd. That is internal.
Mr. Dunn. Is that year to year comparison?
Dr. Boyd. Yes, sir.
Mr. Dunn. Okay.
Dr. Boyd. Yes, sir. So we are already 1.75 million ahead.
And a couple of things as I had mentioned earlier. One is our
attention to detail with regards to efficiencies. I, too, came
from the private sector and we didn't have a lot of fluff. You
know, people needed to have a good working environment, to have
the good support so everyone could practice up to the top of
their licensure.
So we have paid really close attention to that through Dr.
Kirsh's office with regards to efficiencies and productivity.
That is a big piece of it.
But, also, I also want to believe that it is the regaining
the trust of our veterans as well.
Mr. Dunn. Well, that's good. And, specifically, sort of
following the end of that question was the community care. What
does it do for that, increasing your ability to give
appointments?
Dr. Boyd. Okay. So having the options for our veterans in
the community, especially for services that may be in some
areas, they just don't have.
Mr. Dunn. Yeah. In rural areas like mine.
Dr. Boyd. Rural areas. Yeah. Exactly.
Mr. Dunn. Yeah.
Dr. Boyd. Or there is not enough volume to support that
service internally. We have a partner now in the community that
we can coordinate that care and that is that continued mode of
care that we promise our veteran patients.
Mr. Dunn. I appreciate that. So in my remaining 20 seconds,
Dr. Draper, what do you think is our single biggest opportunity
to improve access to care and what do you think the biggest
barrier to improving access to care is?
Dr. Draper. One of the biggest barriers I think is to have
the sufficiency of providers to see patients. I mean, that has
been an ongoing issue with VA, their recruitment and retention.
Mr. Dunn. But we sort of solved that with the community
care, right?
Dr. Draper. Well, it depends on the community, I think.
Some communities probably--
Mr. Dunn. Fair enough.
Dr. Draper. You know, I think it--
Mr. Dunn. And the opportunity?
Dr. Draper. Opportunity for the biggest improvement?
Mr. Dunn. Yeah. What's the biggest barrier? Well, I guess
barrier and opportunity. I'll take that as an answer to both
questions. Thank you very much, Dr. Draper.
Mr. Chairman, I yield back.
The Chairman. Thank you, Dr. Dunn.
Ms. Underwood, you are recognized for 5 minutes.
Ms. Underwood. Thank you, Mr. Chairman, and thank you to
all the witnesses for joining us today.
I recently surveyed veterans in my district outside of
Chicago and learned that the vast majority of respondents are
satisfied overall with the care that the VA provides, including
the wait times to see a physician at a local facility like the
Level Healthcare Center.
Despite these local success stories, nationwide wait times
remain a serious concern. Veterans prefer VA for many reasons,
and we owe it to them to provide convenient, patient-centered
access to quality care.
Dr. Patricia Hayes, VA's chief consultant for women's
health services said in February that a ``small, but persistent
disparities' exist for women veterans accessing care at the VA.
Overall, she said ``women veterans are still waiting longer for
appointments than males.''
And so I know my colleague, Congressman Allred touched on
this, but women are a growing proportion of the veteran
population. And Dr. Boyd, I believe it was Dr. Boyd, you said
that--or maybe--okay. Yes. That the VA is ``accelerating the
footprint in all areas for women veterans.''
I was wondering if you might be a little bit more specific
about the timeline to closing the gap on wait times.
Dr. Boyd. I wish it was, you know, said and done yesterday.
But the reality is that with the enhanced recruitment
capabilities, the authorities that we have within Mission, that
will get us a little further.
But as Dr. Hayes I am sure has probably testified before,
we continue to accelerate the many residencies and to stay on
top of women's health needs and their special concerns.
Ms. Underwood. Right.
Dr. Boyd. And so we are not losing focus on that. And we
are actually integrating that even into our mental health world
as well to make it an actual crosswalk, to make it part of the
fabric as well.
So we do have work to do. And I wish I had an exacting
timeline, but as you know, Dr. Hayes, she will not let us, you
know, at all lose urgency on this one. And, in fact, we just
recently set up another governing board, if you will, that is
primarily focused on women veterans and some--to keep that
fresh and also to keep the opportunities in line and on our
mind with leadership as well.
Ms. Underwood. Sure. I appreciate those steps. Are there
any kind of internal goals or metrics that you all are working
towards?
Dr. Boyd. I would have to get back to you on that
specifically and speak with her office on that.
Ms. Underwood. Okay. Please do.
Dr. Boyd. I would sure be glad to.
Ms. Underwood. Connecting veterans to timely care at the VA
is especially important, as you said, regarding mental health
and addressing the veteran suicide crisis.
Some of our veterans will not self-report their suicidal
ideations which could limit the benefits of same day care.
Right. They have to proactively say that they need to come in
because they are having these kinds of thoughts.
So, Dr. Boyd, does the VA collect data on average wait
times for veterans specifically seeking mental health care
treatments?
Dr. Boyd. Yes, we do.
Ms. Underwood. Okay. Mental health care is one of the
several critical risk factors in addressing the suicide crisis.
According to the CDC, access to effective clinical care for
mental, physical and substance abuse disorders can help protect
people from suicidal thoughts and behaviors.
Dr. Boyd, does the VA collect data on wait times for
veterans waiting to be seen for pain management, substance
abuse disorders or other chronic medical conditions?
Dr. Boyd. Yes, we do.
Ms. Underwood. Oh, that's good.
Okay. My last set of questions is in both the GAO and the
VA testimonies, the need for consistent and comprehensive
training of VA staff was highlighted. I commend the steps that
you have taken to increase scheduling training completion rates
and would like your perspective on how that was achieved.
Dr. Boyd, how do you track the completion rates for staff
who require scheduling training?
Dr. Boyd. I will ask that Dr. Kirsh answer that for you.
She has the specifics for that.
Ms. Underwood. Thank you.
Dr. Boyd. You are welcome.
Dr. Kirsh. Thank you for that question.
Our office oversees scheduling policy, standardizing
processes, trainings and audits. And the trainings have been
very robustly engaged with our 58,000 staff out there who do
schedule.
Ms. Underwood. So how do you track the rates?
Dr. Kirsh. We have our talent management system through the
employee education system. It is trackable across all sites.
You have to log in as a VA employee and complete trainings.
But more important or in addition to that is really when
anything, a nuance is brought up or there are bi-communication
calls every week--
Ms. Underwood. Yeah.
Dr. Kirsh [continued]. --with the scheduling community.
Ms. Underwood. Can I ask one other follow up question? Is
there an incentive to complete the training?
Dr. Kirsh. It is an expectation as a component of your job
that you complete the training, if that is in your job
description as a role.
Ms. Underwood. So it is in like your PDP?
Dr. Kirsh. Yes, it is.
Ms. Underwood. I see. Okay. Thank you so much.
The Chairman. Thank you, Ms. Underwood.
General Bergman, you are recognized for 5 minutes.
Mr. Bergman. Thank you, Mr. Chairman.
Thanks to all of you for being here. This is complex to say
the least. You know, putting my airline pilot hat on from
decades, you know, at one point we were graded on how much we
supported our passengers to make sure they didn't miss their
flights. The next time you turn around we are being graded on
our on-time performance.
And as an airline captain, I had the challenge to decide
what do we do. The gate agents wanted to close the door even
though there were passengers running between flights because
they were going to get a ding on their record because of the
fact that they didn't shut that door on time.
My plan was and is always the passenger first. I said I
will take the hit. If someone wants to call me as to why the
flight left three minutes late, they can deal with me and don't
worry. I will take you off the hook.
So as we look at what we are trying to do here, which is
not only identify wait times, but to accommodate our veterans
who need care, it is going to be, again, a complex challenge to
make sure that nobody gets hung out to dry for the wrong
reasons. So it is the accountability and the structure all the
way up and down the line.
But having said that, Michigan's first district, my home,
is a combination of small towns, rural, and remote. So when--
and you noticed that I didn't say urban or suburban. That
doesn't fit. So when you think about wait times and what it
means with the combination of services that we would have in
our district with one small VA hospital in Iron Mountain, but
the accommodation of the CBOC or a community care, it is kind
of a microcosm of all other, not that big organized system that
is within Uber distance. In fact, we don't have really much
Uber in our district at all.
Are we in some cases--and by the way, anybody can answer
this? Are we in some cases comparing apples and oranges when we
try to talk about wait times at a VA hospital, wait times at a
CBOC, wait times in community care? I mean, are we just--we
have separate silos here and are we trying to compare, again,
apples and oranges? Anybody want to take a shot at that one?
Dr. Boyd. I will start off. So when we go into the access
to care website, you know, where our veterans can go on and
look, if you go on and click onto Michigan, it will be bring up
the VA medical Center and then all the clinics. And they will
have posted a 30-day average, and it is an average, of the wait
times, if you will. And so it is specific geographically and to
that particular area.
So I am not sure if that answers your question.
Mr. Bergman. Well, it does kind of in a way. Its kind of
basically means that the comparisons, if you don't have big VA
hospitals and you don't have your--you may fall outside of the
80 percent norm of that bell curve. Okay. I mean, that is--I
mean, we are trying to make here an 80 percent solution. If we
can get 8 out of 10 right. Think about even Ted Williams only
hit 400. You know, if we could hit 800, we would be doing very
well.
I would like to go down a different road here for a second.
Can VA solve the problem that we are trying to deal with her,
the wait times, can they solve it from within? In other words,
does VA have that capability or, said a different way, is there
a model, Dr. Kizer, that already exists somewhere outside of
the VA that we can modify, again, to the 80 percent level to
make it work? We are open to anything that will work to make
sure the veterans are realistic about what the wait times are
where they live and for the condition they have, and we also
want the VA and the CBOCs and the community providers to be
realistic about what they can provide and not--you know, I
would rather have them under promise and over produce.
Dr. Kizer. Yes, sir. A few things.
One, there is no model. No one has solved this problem.
There is no single model out there that the VA could just
modify and adapt. There are glimpses of what are what we might
call promising practices and I am encouraged to hear that VA
has implemented and is pursuing a number of those, such as
same-day service and what they have done in that regard.
Certainly, expanding telehealth and other technology assisted
options which may be particularly useful in rural and
underserved areas.
But I also want to go back to your first point underscoring
the complexity of this issue and the need that exists for
standards that are setting specific, whether that is primary
care or specialty care, a hospital, a clinic. All of the
different settings really have--we should be thinking about
different standards for those settings of care.
And there may be opportunities for the VA to engage with
entities like the National Quality Forum or with the National
Academy of Sciences to help solve or at least address some of
the technical issues that may provide better answers for where
we need to go in that regard.
Mr. Bergman. Thank you. And I appreciate your answer.
Mr. Chairman, I yield back.
The Chairman. Thank you, General Bergman.
Mr. Pappas, you are recognized for 5 minutes.
Mr. Pappas. Well, thank you, Mr. Chairman. Thank you to the
Ranking Member, and to our panel. I appreciate your testimony
here today.
I want to take a step back. We are marking 5 years since
Phoenix. We are here having these discussions, talking about
some steps that have been taken forward because of
whistleblowers.
And I noted, Dr. Boyd, in your testimony you said, ``due to
the recent media reports of a whistleblower indicating issues
with the electronic wait lists, we conducted a top to bottom
review.'' And I think that is great.
But let's unpack that a bit. You say, ``due to recent media
reports.'' And I am wondering why it took media reports and not
a disclosure from a whistleblower with valuable information to
spur that review.
Dr. Boyd. So at the facility level where this may have
occurred, there is always--that is just the practice. That is
the ongoing practice is to always look at harm, unintended harm
if you will.
And it should not take a media, a piece of paper, you know,
a story in the media to call our attention. We should be very
responsive to when, as I mentioned, when employees or any
staff--I don't care where they work or hat their role is--
comes forward and says, something doesn't look right.
So this is an ongoing practice at facilities to look at
things that rise to the top. So it should not take a media
story.
Mr. Pappas. Well, I appreciate that.
Dr. Boyd. Sure.
Mr. Pappas. And we are working. As the oversight and
investigation subcommittee we have done a couple of panels on
whistleblower issues. We want to ensure that they are heard,
that we improve processes to protect their rights and prevent
retaliation which we have seen.
We recently heard from a few whistleblowers in our June
25th session who raised some serious concerns that have a
connection to the wait time issue that we are talking about
today. The whistleblowers told us that they saw 12,000 canceled
radiology orders in Iowa City, ``imaginary opioid clinics in
Baltimore set up to hide wait lists,'' and 400,000 plus
consults opened over 90 days across 5 districts.
I am wondering what steps the VA is taking to identify and
curtail any sort of practice of hiding and masking the problem
that exists with wait times.
Dr. Boyd. So it is multi-fold. One thing that is, I think,
at the core is changing the culture. When I go around to sites,
one of the first things that I do is meet with various staff,
usually at town hall, frontline staff. I don't want leadership
there, don't want supervisors there, to get a feel for is there
a good culture there, is there a culture of, I will raise my
hand and stop the line.
So I think it really, it goes to us as senior leaders to
walk the talk and to make sure that our facility leadership
does that as well because without that we could have every
possible process in place, but no one is going to feel
comfortable raising their hand because no process is perfect.
We want people to put holes in it. So it is all about changing
that culture.
Mr. Pappas. Well, thank you. You know, reading some of the
terms that have been used with scheduling, I can understand why
there has been some confusion. We are talking about terms like
patient-indicated date, desired date, preferred date,
clinically indicated date. Is there a difference between these
terms or are they interchangeable?
Dr. Boyd. I will have Dr. Kirsh answer that one. Thank you.
Dr. Kirsh. Thank you for your question.
And you bring up an important point that is that names have
changed over time. The patient indicated date was a decision
made a few years ago really with an emphasis and focus on that
it is about the patient preference in the equation.
As a doctor, when I make a follow up appointment for a
patient, and that is what patient indicated date is used for,
it is a clinical timeline when the patient should be seen and
then when the patient as well can--is agreeable to the
appointment within a certain amount of time. That is what the
patient indicated date is. It has evolved after the clinically
indicated date and preferred date. It is now the replacement
for follow up appointments.
Mr. Pappas. Okay.
Dr. Kirsh. I hope that answers your question.
Mr. Pappas. Yeah. And I think that the GAOs indicated some
improvement here at logging these terms. 18 percent improvement
in manually entering dates, but also there still exists an
error rate that is of some substance that has an impact.
So I am wondering in terms of the GAOs perspective on this,
how are we doing and are they on track to be in compliance?
Dr. Kirsh. Well, since our implementing our recommendation,
the VA has taken a number of actions. One is bi-annual audits
of schedulers. And the most recent, in 2018 they audited about
667,000 appointments and they found an 8 percent error rate. So
that effected about 53,000 appointments.
So there is improvement. There is more work to be done,
definitely, and I think that as we talked about in our written
statement, you know, a lot of the scheduling, the terms are
pretty, they are pretty much the same. They are just different
names. The patient indicated day is basically, it is a, you
know, the schedule, we used a clinically indicated date if a
provider provides one. And if not, in the absence of that they
will use the veterans preferred date, which is essentially the
same as the desired date.
So not much difference--
Mr. Pappas. Thank you.
Dr. Kirsh [continued]. --between the terms.
Mr. Pappas. Thank you, Mr. Chair.
The Chairman. Mr. Banks, you are recognized for 5 minutes.
Mr. Banks. Thank you, Mr. Chairman.
Well, I am encouraged by the Jamma study published earlier
this year that found VA has significantly shorter wait times
for primary care than private doctors. I remain concerned about
VA's ability to provide urgent mental health services to our
veterans in crisis.
Dr. Boyd, in your testimony you discuss how VA began
offering same-day appointments for mental health at every VA
medical center in CBOC in 2017. According to VA, when veterans
request a same-day appointment, they are assessed for the level
of urgency and either provided a form of consultation or a
future appointment.
I have a constituent veteran who had quite a different
experience last year and I would like to take a moment to
quickly summarize his story for you.
This veteran was having a mental health episode and was
found walking down the highway by police. The veteran was
turned over to his mother who picked him up and was instructed
by a county VSO to immediately drive him to our local VA
medical center for a mental health assessment.
The VSO called ahead, but was informed that the local VA
medical center didn't have room or a doctor that could see the
veteran at the time. The VA medical center recommended that
they go to the next closest VA facility which was over an hour
away.
Upon arrival, this VA medical center also refused to see
him due to ``lack of space.'' 2 police officers were in the
waiting room and saw that something was wrong with the veteran
and told the hospital staff that the veteran must be admitted,
and yet they refused. The officers then went on and got a court
order from a judge to mandate that the veteran be admitted.
Dr. Boyd, this situation may very well be an outlier or an
anomaly. And for all intents and purposes I really hope that it
is. But can you explain what VHA is doing to ensure that
veterans in crisis are not being turned away and that these
mental health assessments are available and consistent across
all VA medical centers?
Dr. Boyd. First of all, I want to make a comment. If, in
fact, we have not looked at that particular case, I would
appreciate that, if your staff could get that to us.
Mr. Banks. Indeed.
Dr. Boyd. If it happens one time, that is one time too
many. Okay.
With regards to the process, we do have oversight of how
patients are triaged and by what discipline. And when I mean
that, I mean by social work, a licensed social worker, or a
psychologist or a psychiatrist. So our central office or our
national program office meets regularly with the field, and
when I say the field, I mean their regional leads who know
exactly what is going on in facilities.
So do I know for certain that there is not another one out
there like that, I do not. That would be--it would be perfect
if we did. But we make every intent to ensure that the urgency
is assessed first. And so I have a lot of concern with what--
with the story that you just relayed to me. It doesn't fit with
what we expect and what we see when I go out.
Mr. Banks. Yeah. Very well.
Dr. Draper, I understand that GAO has studied the
availability of same-day services within VA and we can expect
the findings and recommendations of the reports to be released
soon.
That being said, can you shed any light on how frequently
situations like what my constituent experienced occur and, if
so, do you have any recommendations for us on how VA can better
prevent situations like this from happening in the future?
Dr. Draper. Well, according to the information based on our
work, the same-day services are available to anyone who comes
into the VA and presents. You know, I think there is some
expectations on veterans because it was really intended for
those with more urgent needs or more immediate needs. But we
have heard from the facilities that we visited that basically
any veteran can show up and request same-day services.
So it seems out of character for what you are talking
about, but, I mean, I can't explicitly talk about that
particular case because I am not familiar with it.
But one of the things I do want to clarify that I know that
there has been information about that 20 percent of all
appointments are same-day services. There is a lot of noise in
that information, in that data. So, for example, it could
include like a veteran--a provider will call in sick and his
appointments are canceled, his or her appointments are canceled
for the day and then they get rescheduled with another
provider. That looks like a same-day services when, in fact,
the veterans may have been waiting quite some time to see the
provider.
So that is one instance. So that number is not as clean
as--you know, it is not necessarily that 20 percent of all
appointments are truly same-day services.
It is also, I think, that there is some confusion about
what same-day services are. It is not just a face to face with
a provider, but it could be a nurse providing education. It
could be medication refills. It could be scheduling a future
appointment.
None of those other than the provider, face to face with
the provider, none of those types of activities are captured.
So we don't really know how much, what those different
activities are and how frequent they happen. We did visit one
VA medical center who had a pretty sophisticated group of staff
who were able to set up a system, so they were able to track
it. But that was just one facility that we saw that was able to
provide information about the different types of same-day
services.
Mr. Banks. Thank you. My time has expired.
The Chairman. Thank you, Mr. Banks.
Mr. Cisneros, you are recognized for 5 minutes.
Mr. Cisneros. Thank you, Mr. Chairman.
Dr. Boyd, you know, like Mr. Pappas said, we have had
several hearings, you know, regarding the whistleblowers and
those coming forward and how they have been treated after they
come forward. And some of those whistleblowers were talking
about the secret wait list that are being held at--you know,
that has happened. And I guess Phoenix is our big example of
what has happened there.
In your opinion, what can be done to increase transparency
culture, and you talked about the culture a little bit, and
policy in the VA so that its recurrence of secret VA wait lists
doesn't keep resurfacing?
Dr. Boyd. Well, first of all, I want to be really clear. We
are not 5 years ago. There is no secret wait lists. What we
have are tools that are getting, are somewhat obsolete in their
tracking capabilities that can be misinterpreted. And really,
so they don't fit the mold of what we had said back 5 years ago
that truly were the wait list. And we don't need to go back and
re-litigate and re-talk about all of that.
But what can we do moving forward? I think we are on a
really good path moving forward. And I know it is the soft
stuff, but we are on a journey of high reliability. And you may
have already heard about this, where we are really focusing on
a just culture, and for 0 harm, and for raising your hand,
stopping the line. Those who are the surgeons in the room or
have been in the OR, that is extremely important, or even on
the aircraft. Right. Stop the line. Something is not right.
So it is a matter of doing that, of developing that through
all of our 18 regions, our facilities and in central office
where we all live. It is a matter of providing that environment
for folks to raise their hand and for us to say, it is okay.
Mr. Cisneros. You know, I get that, and I keep hearing
that, right, how we need to adjust the culture at the VA.
Dr. Boyd. We do.
Mr. Cisneros. And there is a lot of work. You know, people
are going to talk to the individuals, those that are working at
the VA. You said it yourself. You are having town halls with
those individuals.
But what are we doing to talk to the supervisors at the
facilities? They are the ones that are conducting the culture.
They are the ones that are overseeing it all. How are we
changing their mindset and what is being done there?
Dr. Boyd. And that is an extremely good point since I did
come from the field within the VA after private sector.
We have not traditionally done a great job of setting our
supervisors and mid-managers up for success. And you are
absolutely right. There is a gap in there. And so part of this
education or this journey that we are on is to give our
supervisors, many of them new, and our mid-managers the tools
and the skillsets with which to be a successful supervisor, to
be a servant leader.
It is a rigorous program that we are embarking on and you
really touched on what I am seeing in the field more and more.
There is that mid-management gap. You are right.
Mr. Cisneros. Now the other thing you mentioned, too, was
that your tracking methods are behind. How are we going to
update these? What needs to be done? How can we in congress
help you bring your systems up to date, so we don't have these,
you know, archaic systems that are like 15, 20 years old and we
are still trying to track things that way? How do we modernize?
Dr. Boyd. So I am going to let Dr. Greenstone talk about it
because we are transitioning, as we went from Choice where you
are purchasing care and had a much different process. And so we
were using a tracking tool, a software. I will let him talk
about where we are going.
Dr. Greenstone. You know, one of the things, you know, that
you raised is so important about, you know, secret wait lists
and not having wait lists and having old, archaic systems. So
we are moving to new technology that allows us to actually put
people, when we are using administrative lists, be able to have
triggers automatically.
Helping schedulers have triggers so when--in my realm of
community care when we are buying care in the community for
veterans and coordinating that care, we have new commercial off
the shelf Cots products that we have configured to work with
our old systems so as not to lose integrity, but to have those
new systems help our schedulers, for example, more effectively
and efficiently get veterans care in the community and have
little reminders that come up and the like, and drive those
schedulers to follow policy. They can't go outside of their
realm.
And so eliminating things like the electronic wait list, so
it is not even available is things that we have done in the
Chairman's district recently to make sure that no one gets put
erroneously on a list because we eliminate the list altogether.
You can't even use it. And the technology allows us now moving
forward to do those kinds of things to have more guidance and
more support, and give the people the tools they need to be
successful.
Mr. Cisneros. I want to thank you all for your testimony
today. My time is expired. Thank you.
The Chairman. Thank you, Mr. Cisneros.
Mr. Roy, you are recognized for 5 minutes.
Mr. Roy. I thank the Chairman. Thank you all very much for
your time and thanks for being here today.
One quick question maybe for you, Dr. Boyd, and then maybe
you, Mr. Kizer, as well. And I realize that we have had a
number of hearings on this topic and will likely have more with
respect to electronic health records.
But a question because it is something that I have raised
to me all the time at Audie Murphy and San Antonio as well as
in Kerrville, Texas is the extent to which the trouble with
accessing records is interfering with, well, I will say Choice,
now Mission, and the ability to go get the care that veterans
are seeking and because there is some difficulty in dealing
with records. How much is that impacting wait times? I mean, we
talk about wait times statistically. But in practice for a
veteran, right, who is going in and saying, well, I want to get
care, and he can't get care because they are going to seek care
and then they are having to get kicked to the VA and they are
kind of in an infinite do loop. What can you say about that as
its impact on wait times?
Dr. Boyd. So I will let Dr. Greenstone comment on that, but
that is an extremely critical observation.
Dr. Greenstone. Yeah. Really important. So one of the thing
that we were able to create in terms of new information
technology is, it was taking our staff about 20 minutes on
average to compile all the medical records that might be
appropriate for a provider in the community to have access to
in order to appropriately care for a veteran.
We created a new tool we called, you know, the referral
document tool which allows the staff with several clicks to
grab that information and put it all together in one document.
And it actually saved 15 minutes of their time on average to be
able to do that.
And then how do you get it to them. So we have a new
referral and authorization system that is essentially a portal.
So the providers in the community, web-based, can log in and
they can actually see the entire medical record of a veteran
for the duration of the episode of care. So that is called our
community viewer.
So we have created ways in which we can facilitate getting
the providers in the community a medical information. We also
need to get those records back. And so that inter-operability
is something that we are working on diligently, and one of them
is using the health information exchange. So if a provider in
the community actually uses these new electronic records, they
have the opportunity to create a computer readable and human
readable document that the VA can actually pull and see
readily, right, without having to worry about faxes and mail
and all these other things.
So they can use our portal. They can use the health
information exchange, the information back to us, and vice
versa. So we are really trying to enhance this issue because it
is a very important issue for us.
Mr. Roy. So you all would agree that has been a part of
delays and wait times in the past?
Dr. Greenstone. I would say it would contribute. So if I am
a scheduler in the VA, I can see the exact schedule. So my
scheduler can see my next available appointment. When I am
scheduling in the community, it may take longer because I may
need to call 3 different cardiologists in the community. So it
takes me longer to make that one appointment for a veteran in
the community. So I can get fewer amount of schedules done in a
day. So that does attribute somewhat to that process.
Mr. Roy. I appreciate that. Let me move on really quickly
because of limited time.
Dr. Boyd, in your prepared statement you noted that
veterans often face shorter wait times in VA than in the
private sector. Are there any regions of the country and/or
clinical specialties where VA is particularly challenged with
respect to wait times compared to the private sector? And
forgive me if you already answered that question.
Dr. Boyd. Oh, that is okay. I would have to roll that up
all for you. But, absolutely, there would be pockets--well, we
already heard from a few of the Committee Members. There are
areas where we just don't have that expertise in-house and
there is a very limited amount within the community as well.
So we do have a fix for that. We have a solution and that
is going to be telemedicine is all through our clinical
resource hubs. But you are right. But I don't have that off the
top of my head, a long list.
Mr. Roy. Okay. That would be great if we could get that in
response to the hearing.
Dr. Draper, a quick question for you. In your testimony you
reference, you know, findings and some of the recommendations
that go back, you know, a number of years, you know, going back
to 2012 and so forth.
Obviously, the VA health system has changed quite a bit
over this last 6, 7 years since that point. Are those findings
and recommendations relevant today and how would you comment on
that?
Dr. Draper. Yes. Absolutely. They still remain relevant. So
our recommendations from our 2012 work was to really improve
the reliability of the wait time measurement and ensure
consistent implementation of the scheduling policy and
scheduler training. So those were 2. Those were 2 that we have
subsequently identified as priority recommendations.
And then a third recommendation was something that Dr. Roe
had eluded to about telephone access. We have found telephone
access to be problematic and, you know, VA had a set of best
practices that they never implemented. So that remains an open
recommendation.
And then the fourth one is to really identify the
scheduling resources needed and allocate them appropriately
based on need.
So all those recommendations still remain open. And I will
say we are going to close one of the priority recommendations,
but it took 7 years to close. And so we are still moving
forward with, you know, we still have 3 that are open that are
open for at least 7 years.
Mr. Roy. Thank you, ma'am.
Thank you, Chairman.
The Chairman. Thank you, Mr. Roy.
Ms. Brownley, you are recognized for 5 minutes.
Ms. Brownley. Thank you, Mr. Chairman.
Dr. Boyd, you stated in your written testimony anyway that
the VA in a RAND study it concluded that the VA performed
similarly or even better than non-VA systems. And so I went
back to find that report. And so first I want to say, I want to
applaud the VA because I think that data point is consistent
with what I hear from veterans all the time is once I am in the
VA and getting my health care, I am very satisfied.
But this report had nothing to do with wait times. And I
just want to make that clear.
A few months ago I had a town hall in my district and the
greater Los Angeles people came into my local town hall and
they read statistics on wait times for veterans in my district.
And the whole room erupted in laughter. And I think the reason
they erupted in laughter is because the definition of wait time
from a veteran's perspective is polar opposite to how the VA
defines wait time and how they measure it.
A veteran or any average citizen would think wait time
means from the time I called to ask for an appointment to when
I receive the appointment. That would be what--their parameters
of wait time. But yet in the VA system, in a typical situation
the veteran will call and ask for an appointment. 6 or 7 days
later the VA gets back to them and says, yes, you know, we want
to see you, what is your preferred date. They give the
preferred date and then the preferred date can't be met.
So, you know, let's say on day 8 they said my preferred
date is on the 13th. They can't meet the 13th, but the next
available appointment is on the 18th. But the way the VA
calculates that wait time is from day 13, the day that they
wanted the appointment and the day that they got it. So they
say that's a 5 day wait time as opposed to all of the preceding
days which were, you know, 10, 11, 12 days before they were
actually able to state their preferred time.
So I think this is--you know, that's why my veterans
erupted in laughter because they were coming from a completely
different perspective.
So I just want to ask a very simple question. And I hope I
can get a very simple answer. Why is it that the VA makes this
so complicated and not just measure it from the time the
veteran calls to the time he or she gets her appointment?
Dr. Boyd. That is a good question. And Dr. Kirsh is here
from that office. I would be more than happy for her to take a
stab at that one.
`Dr. Kirsh. Thank you for that question.
I want to make sure that I am understanding whether it is a
new patient or a follow up patient.
Ms. Brownley. Okay. I understand a follow up patient can be
a little bit different. Okay. And so in this case probably it
is more relevant to a new patient. But I don't want anybody who
is listening to this meeting think that there is a huge
difference between one and the other.
But go ahead.
Dr. Kirsh. I appreciate that.
So for a new patient calling in to get an appointment, that
patient then, the scheduler accommodates that patient if they
are on the phone and they are ready to make that appointment.
The time that the scheduler goes into the system--
Ms. Brownley. No. No. No. I know how the system works.
Dr. Kirsh. Okay.
Ms. Brownley. And I am just asking why is it that you don't
measure from the time, whether it is a new patient or an
existing patient, why don't you measure wait times from the
time the veteran asks for an appointment and the time he or she
receives an appointment? That is the only answer I want. Why is
that you don't measure it that way?
Dr. Kirsh. If the veteran calls and the appointment is made
that day and until the completed time, that is the same
measurement. I think there are some factors in there about
requests in a follow up appointment where it is requested and
the time to reach to the veteran, call them, get back to them,
determine when they want to be seen. There can be some
variability in that component.
Ms. Brownley. Okay. Well, my time is up. And I just don't
feel like I have gotten an answer. But I personally think going
to Dr. Kizer's point and his comment saying that we lack
national standards with regards to wait times, I would love to
have a longer conversation with you about what that should look
like. But I just don't understand why it is not simple.
Everybody keeps saying, it is hard to answer your question
because it is so complicated. But I feel like the VA has made
it so complicated when it is really very simple, from the time
they call to the time they receive their appointment.
I know I am over time. I yield back, Mr. Chair.
The Chairman. Thank you, Ms. Brownley.
Ms. Radewagen, you are recognized for 5 minutes.
Ms. Radewagen. Thank you, Chairman Takano, and Ranking
Member Dr. Roe for holding this hearing. And I want to thank
the panel for being here today.
First off, I just simply want to associate myself with the
concerns that were just raised by Ms. Brownley because in my
home district of American Samoa I go through this with our
veterans all the time. And I am very accessible to our
veterans. As a matter of fact, many of them think nothing of
calling me at 3:00 in the morning to tell me about their wait
time definition that was misinterpreted or whatever.
But at any rate I do hope that sometime in the future VA is
able to find a way to simplify a very simple problem rather
than doing it with a complicated kind of a definition.
Anyway, so, Dr. Kizer, I understand that as the co-chair of
the National Quality Task Force you recently participated in a
conversation with some of the country's top health experts
about access to care in 2019 and how our increasing reliance on
technology is changing how access is defined and measured.
What were the key conclusions of that conversation and how
do they apply to our conversation today regarding access to
care for veterans within the VA health care system?
Dr. Kizer. Thank you for that question.
I think if I were to distill down what was a perhaps
several hour conversation to a couple of points it was this.
One is that all of the utilization measures that are used to
measure wait times have problems and are technically difficult.
And as a result many health systems are increasingly moving to
patient-reported outcomes and what the patient perceptions are
as to whether they got in in a timely manner and how they were
handled.
And that while these health systems are not abandoning
using wait times, they are using then in perhaps a different
way, but putting increasing reliance on what the patients feel
about the timeliness of the accessibility of care.
The second point was the need to increasingly use
technology enabled means to facilitate access of care, whether
it is telehealth or Mhealth or secure e-mail or a variety of
other tools that are now available that simply weren't
available not that long ago. And that, you know, for example,
Kaiser Permanente, a system that sees more than 100,000 million
outpatient encounters a year, are now accomplishing more than
half of those encounters through various telehealth means.
Los Angeles County, as another example, has gone to using
e-consults to support its community based clinics and has
dramatically reduced wait times for specialty consultations by
using, again, technology enabled means.
So I think if I, again, were to distill down a several hour
conversations, it would be to those 2 points about using
patient reported measures and using telehealth and other
technology means to facilitate access to care.
Ms. Radewagen. Thank you.
Dr. Kizer. Which has particular relevance to your district.
Ms. Radewagen. Yes. And going back to this definition of
wait times, my veterans and I are extremely honored that
Secretary Wilke and I will be flying down in a few days to
American Samoa. I am sure he is going to get it in the neck
about the definition of wait times.
Dr. Boyd, please respond to allegations made by a VA
employee, Jeremy Whiteman, in a June 3rd Washington Post
article regarding the electronic waiting list. Are you familiar
with that?
Dr. Boyd. Yes, I am. Peripherally, that is an ongoing,
active investigation at this time, very complex, and if there
were any other specifics, it is not a closed case yet.
Ms. Radewagen. Thank you, Mr. Chairman. I yield back the
balance of my time.
The Chairman. Thank you, Ms. Radewagen.
Ms. Lee, you are recognized for 5 minutes.
Ms. Lee. Thank you, Mr. Chairman, and thank all of you for
the service you provide to our veterans and, Dr. Kizer, for
your leadership, Dr. Boyd as well, and GAO, of course, for your
shining the light on this issue.
Dr. Kizer, while you were at the VA you no doubt saw
challenges that the organization experienced with technology
modernization. And as of now the VA has many modernization
projects in process, including this transition to the
electronic health record from the Vista program.
And it is our understanding that this transition will
entail implementing Cerner's scheduling software which will
replace the current antiquated scheduling system.
But this is going to happen nationwide at first despite the
fact that the Cerner rollout is going to be a step by step
rollout over a 10 year period. And based on your past
experience, Dr. Kizer, what is your view of this transition and
what do you think the impact it will have on wait times and
quality of delivery?
Dr. Kizer. Thank you for the question. And I would
certainly give the colleagues, my friends here from the VA, the
opportunity to respond after I try to address your comments.
I think there are 2 aspects of what you are asking. One has
to do with the scheduling, the new scheduling system, the
underlying scheduling system that is being implemented
concomitant with the implementation of the overall new Cerner
electronic health record.
I am encouraged by what I have seen so far with the
scheduling system. I was particularly encouraged by the fact
that the VA reached out to the National Academy of Medicine to
hold a workshop on what should be the key operating
characteristics and functionalities of that scheduling system.
That workshop was held a couple of months ago. The report is, I
got the draft actually of the report this week and it should be
released soon. And I think it will provide a lot of useful
guidance to the VA as they implement this new scheduling
system.
As far as the rollout of the overall electronic health
record, again, based on what I know and what I have heard from
colleagues, and I do keep some presence in the IT sector, I
have to confess that I have rather serious concerns about the
implementation of the entire rollout and whether either the VA
or the vendor is ready to accomplish all that needs to be done
in the timeframes that have been laid out.
Ms. Lee. Thank you. I would love to chat with you more
about those concerns as well.
Would anyone from the VA like to comment?
Dr. Kirsh. I would like to address the Cerner stand-alone
scheduling.
As you know that was a request last fall from the congress
about VHA's plan, VA's plan in accelerating the scheduling
component of our electronic health record. And we since had
purchased Cerner, spoke to the vendor about the capability and
our collaborating with the Office of Electronic Health Record,
VA OI&T and Cerner, about accelerating that program.
We believe that there will be benefits gained in
efficiencies there and plan to begin that next June.
Ms. Lee. Okay. Thank you.
I just wanted to talk to Dr. Boyd, or it might be Dr.
Greenstone, on your written testimony you cite the use of an
online scheduling app. Are you referring to Myhealthyvet app?
Is that what is being referred to?
Dr. Greenstone. So I can speak to that. Sure. Thank you.
So there is VA online scheduling. We call it VAOS, and that
allows veterans to actually go in and if they are established
within a VA medical center to request appointments and actually
go in and make their own appointments in the grids of their
primary care providers and even mental health.
We have created a similar capability for community care. So
using Mission Act eligibility criteria, we allow veterans to go
into the VA online scheduling. It shows their ability to use
this for community care if the system knows that that veteran
has eligibility: They live in the state or territory with no
full service VA; they were a grandfathered in under Mission.
Ms. Lee. So is that done through this app? I am--
Dr. Greenstone. Yes.
Ms. Lee. Yes. So it is--
Dr. Greenstone. Through the app.
Ms. Lee [continued]. --done through--
Dr. Greenstone. So you can access it through Myhealthyvet.
Ms. Lee. Okay. And I just want to, do you have any idea
about the utilization rate of this app by veterans and what are
the demographics of the veterans using it?
Dr. Greenstone. Dr. Kirsh may have that for internally. I
don't have those data, but we can get those for you as we have
just rolled it out for community care. But for internal VA, Dr.
Kirsh may have some information.
Dr. Boyd. No. I agree with that. If we could get that
information back to you because--
Ms. Lee. Yeah. That would be great.
Dr. Boyd [continued]. --it is very telling for us as well.
Ms. Lee. Good. And I would love if you could also, any
information you have about the satisfaction and the
effectiveness of the use of that app would be helpful.
Dr. Boyd. Certainly.
Ms. Lee. Thank you.
I yield the remainder of my time.
The Chairman. Thank you, Ms. Lee.
Mr. Meuser, you are recognized for 5 minutes.
Mr. Meuser. Thank you, Mr. Chairman. Thank you all very
much for being here. It is appreciated. Certainly, we are very
encouraged by your work, what the Mission Act, I believe, has
also helped improve. There is always more to do and certainly
our shared goals are to take care of our country's veterans to
the best of our abilities with the highest level of quality
health care.
The number of VAs, Mr. Kizer, I will direct these questions
to you, please. About 170 VA hospitals and 1,063 outpatient
sites, are they all monitored for wait times?
Dr. Kizer. I think it might be best that someone from the
VA respond to that question.
Mr. Meuser. Oh, all right. Would somebody like to respond
to that, please?
Dr. Kirsh. Absolutely. The accesstocare.va.gov website,
veteran or family member can go in and look at wait times in
primary care, mental health and 10 other specialties for a new
patient appointment.
Mr. Meuser. Okay. Dr. Kirsh, I will continue then my
questioning with you.
And is the rating system, is it the 4 star or 5 stars, how
do you set a rating system?
Dr. Kirsh. So the rating system applies to in-patient
hospital care and this access to care website is around
receiving outpatient new appointments.
Mr. Meuser. Is there a percentage of the VA hospitals,
let's say, that are rated the best? Is there 5 percent that are
in the top echelon for wait times?
Dr. Kirsh. We can identify which sites because all sites do
have wait times in primary care, mental health and if they
offer specialty services. We have wait times for every facility
available and we can provide that information for you and your
staff.
Mr. Meuser. Okay. I would actually like to see that. And do
you believe that the Mission Act has helped?
Dr. Kirsh. Absolutely. I think one of the biggest drivers
in my role in leading the internal access office has been to
think about increasing our capacity, efficiency and
productivity really over the last year in preparation. We want
to be able to offer veterans an opportunity to stay in the VA
if that is their preference or then provide an integrated,
expanded network.
Dr. Greenstone. And, Congressman, the other value to the
Mission Act is the provision for urgent care. We have had over
14,000 veterans that we think have actually received urgent
care under the Mission act. So that is another way that we have
expanded the capacity for veterans to be seen when they think
they actually need care.
Mr. Meuser. All right. Great.
And I do know the Mission Act, the Lebanon VA, which is in
my district, Pennsylvania's 9th, does a fantastic job and they
are improving all the time. And they also get a tremendous
amount of feedback from their veterans. I don't know if that is
a customary practice in other Vas, Dr. Boyd?
Dr. Boyd. Yes. With the Veterans Experience Office we have
an amazing tool now where it is called Vsignals. I mean, we can
call it most anything. But we get realtime feedback, comments,
congratulations, positive things, but we also concern from
veteran's realtime, whether they are an in-patient or they are
maybe that housekeeping didn't come in at a certain time, or
they have concerns about medications, most anything.
And we are--and we rapidly--well, the Veterans Experience
Office rapidly gets those down to your site, down to your
medical center and your folks there, your leadership there tend
to that and address that. So they close that loop. We don't
have to wait months for something to kind of fester. So we do
realtime owning that moment.
Mr. Meuser. Okay. Great.
Are there certain model VAs? I mean, there must be that
when it comes to wait times or maybe it is many of the pieces
of the overall operation that 1 VA or 10 VAs do better and you
identify the reasons why, people, process, technology, whatever
it might be and obviously do our very best to model the other
VAs after them? Either one would be fine. Thank you.
Dr. Boyd. So we do have. We call those best practices. I
tend to call them good practices. And we want to socialize
those rapidly, vertically and horizontally throughout our
enterprise. And the way to do that is as we are going forward
with our VHA modernization plan, which I would be glad to talk
about that at some other time, where we are linking together
like programs, like services, clinical services, and the
facility all the way on up to the national offices so we can
help spread those practices. We don't have to wait for 2 years
for a policy to come out, but share those things.
So we do encourage that.
Mr. Meuser. Well, thank you all for your service. And,
Chairman, I yield back.
The Chairman. Thank you, Mr. Meuser.
Mr. Levin, you are recognized for 5 minutes.
Mr. Levin. Thank you, Mr. Chairman. I want to thank you for
holding this important hearing, and thank you to our witnesses
for the work that you do to serve our veterans. I particularly
want to thank the folks at the VA back home in my community in
La Jolla and in Oceanside for the excellent work that they are
doing. There is always room for improvement, and with that in
mind I wanted to ask a few questions.
Our veterans deserve clear information when making
decisions about where to seek care, and Congress needs more
reliable measures to understand veterans' access to care in our
districts and districts across the country.
Dr. Kizer, can you speak to best practices for patient
access measures across the U.S. health care system and how
commonly are wait times used as opposed to the CAPS survey or
other measurements?
Dr. Kizer. As I indicated previously, there currently are
no industry wide or sector wide standards that are used to
assess wait times which makes it difficult for an entity like
the VA health care system to compare itself to community
providers because in the community a variety of different
methods may be used and certainly they don't receive the same
degree of oversight or scrutiny as to the rigor with which
their data has been collected or how valid are the methods they
are using.
So there is some difficulty there. And in my written
testimony one of the suggestions that I offered is that the VA
might want to work with the National Quality Forum to try to
establish some national standards about what would be
appropriate access standards or time limit standards for the
different settings of care, whether that be primary care or
specialty care of different flavors as well as hospital care
and post-acute care, et cetera.
Mr. Levin. Thank you. And I appreciated that suggestion. I
am sure we will follow up.
Dr. Boyd, you also noted in your testimony that VA uses the
CAP survey to assess patient satisfaction for primary care and
for mental health care.
Has VA explored the possibility of expanding this survey to
other aspects of specialty care and, if so, can you walk me
through the cost benefit analysis?
Dr. Boyd. I will let Dr. Kirsh answer that. But we have
some great answers for that.
Mr. Levin. Okay.
Dr. Kirsh. So mental health and other specialty clinics
have been added in the last few years, so we can get
information and we do feed that information back through our
group practice manager program. As a result of VACAA 303
legislation, we have a practice manager much like private
sector who is in charge of and really the point person for
access of every single medical center. There are 238 practice
managers that report to leadership there.
So they really are overseeing and governing and looking at
things like the Vsignals and the CAHPS information. I can get
you some specifics and follow up for you and your staff around
specialty care, cardiology, mental health, et cetera, and what
are some of the questions asked and those responses nationally
or locally.
Mr. Levin. Thank you. I would appreciate that.
I wanted to go back to this question about how dates are
determined. As the GAO, Inspector General and even VA's own
internal audits have found, patient indicated dates are often
entered incorrectly resulting in inaccurate wait time data.
Dr. Boyd, I would like to ask you a few follow ups on this
to kind of understand better how these dates are determined.
You described the patient indicated data as the appointment
date agreed upon by the patient and provider. So what happens
when the patient and provider disagree?
Dr. Boyd. It goes with the patient's preferred date then.
Mr. Levin. Okay. How--go ahead.
Dr. Boyd. Because it is all about veteran preference. It
really is.
Mr. Levin. That is what I was going to ask next. So how
does the veteran's personal preference such as a work or
vacation schedule factor into the determination?
Dr. Boyd. It does. And if I could just elude, being from
Texas, although I practiced up in Maine up in the VA as well,
and it was not uncommon for me to try to be able to convince a
veteran that, oh, you really do need to be seen in 45 days. Oh,
no. That was salmon running time up in the river, so couldn't
do it then.
So I use that because it was a reality to me that that was
the important, that was important to that veteran. So we would
push out the appointment and went to Option B. So we do go with
veteran preference.
Mr. Levin. Okay. Thanks for that clarification.
Dr. Kizer or Dr. Draper, are there any other factors that
you think VA should clarify?
Dr. Kizer. Well, again, in my written comments I suggested
that the VA work with the National Academy of Sciences to try
to define what access means in this era that we live in now of
increased connectivity through advanced communications and
information management technology.
What access meant 10 years ago, certainly 15 years ago, is
different than what it means today. And the fact that we can
accomplish so many of our day to day important and sensitive
activities through technology enabled means has not carried
over into health care. And there is much that we need to do to
move health care as a sector into the same status, say, that
banking and some other sectors have moved to as far as using
the internet as a vehicle to enhance communication to services
or a connection with services.
Mr. Levin. Thank you. And I am out of time, but I want to
thank the Chairman again for his attention to this important
matter. And thank you all again for your testimony.
The Chairman. Thank you, Mr. Levin.
Dr. Roe, you are recognized for any closing remarks you
might have.
Mr. Roe. Well, thank you very much, Mr. Chairman. It has
been good, and I am going to close by remembering a
conversation I had over four decades ago when I started my
medical practice. And this was an old country doctor. He sat
down and he said, son, he said, I am going to tell you how to
be a successful doctor. And I said, how is that, and he said, I
am going to give you the three A's of practicing medicine. A
Number 1 is availability. A Number 2 is affability, and A
Number 3 is ability. And he said you get those 3 rights, if
they don't like you or if they can't get in and they don't know
how good you are, if they don't like you, they are not going to
come back.
So that is a challenge that we all have. It is very simple,
but it still works today. And like I said at the very
beginning, you can do all these measurements if you want to,
but when somebody calls in and they have a bad experience
calling in to make an appointment, when the person that comes
in to greet them, when they come into the VA or into my office
makes them mad I spend the first 10 or 15 minutes trying to get
everybody calmed down so I can actually find out why are you
here today.
So I think you can take those things in training and do
that, whether it is in the private or the public sector.
And, secondly, Dr. Kizer made several great points. And we
do have huge challenges in rural America where I live in
practicing medicine. We know there are going to be huge
shortages in the practice, and that is one of the things this
Committee did when we wrote the VA Mission Act.
And it struck me when I was out in Greg Walden's district
in Oregon a little less than 2 years ago when he said, my
congressional district has more square miles than the State of
Tennessee does. And it does by several thousand more square
miles, just one congressional district. So we had to put
together a replacement of choice with something that worked in
urban America and also tried to work in rural America, which is
why you have to partner with the private sector.
And one of the reasons for that in we know that the
estimates are there will be as many as 100 to 120,000 fewer
physicians or lack of physicians in 2030 than there are today.
And if we start training these doctors today, if you are a
freshman in college today, you are not going to be ready to go
live until the early 2030s to get your training done. So it was
a huge problem.
We also added in the Mission Act residency and how to pay
for it. We know that medical debt is a huge--or debt, student
loan debt, I mean, is a huge problem. So we put that in there.
A lot of things. So if you can't get your appointment at
the VA in a timely fashion, can you get it out in the community
where you live? If you live 5 hours from the VA and the doctor
is sick that day, you don't want to drive 5 hours down there
and find out you don't have an appointment and then turn around
and drive 5 hours back. So those are the things that we tried
to remedy making this right in the Mission Act.
I think that the VA--as a matter of fact I can
unequivocally say that between when I came on this Committee in
2009 and now, the VA is doing a much better job. I really
believe that. I think you are more attentive. And I believe
that the solution to the problems is local leadership. If I am
a local VA hospital administrator, assistant administrator, and
I don't have the doctors, the personnel to take care of the
patients that are going to be coming to my facility, I am going
to be recruiting those people.
Number 2, if I can't get them, I am going to go out in the
community and recruit the community providers. I am going to go
out and say to them, to the cardiologists, hey, we are short
here, can you help us out.
And then what I am going to do because of the tools we gave
you in the Mission Act, I am going to pay you promptly so you
will continue to see VA patients.
So I think it is a lot of things. But it has to be done not
at the 30,000 foot level where we are right here today. It has
got to be done at the local level, at the local CBOC. When I
was out in--and one of the visits I made, as a Chairman we do
in many of these, I realized that the incentives were different
for a VA provider than they were for me in private practice. If
I hired someone, I got an extra night or two off call a week, a
month. So that was a little more sleep that I got. I was highly
motivated to recruit a new obstetrician, believe me. And our
overhead didn't go up much. We could keep our overhead down.
So those motivations are different. But the primary goal
for all of us is to provide the best quality of care that you
can possibly provide for that patient and a veteran. And to me,
I am agnostic about it. If it is in the VA system, I am
perfectly happy with that. If it is out in the community, I am
perfectly happy with that. It is--I want the best care for the
veteran.
I thank all of you all certainly for taking your time and
being here today, and, Mr. Chairman, thank you for having this
hearing. I really appreciate it.
The Chairman. Thank you, Dr. Roe.
Well, let me just say that we know that the VA, echoing Ms.
Brownley's remarks about the RAND study, we know that the VA
offers excellent care as compared to private sector care. And
so, you know, I am not quite as agnostic. I believe the VA
offers great care. The problem was access.
The VA wait list scandal posed serious, serious doubts
about access to care and that scandal brought to light
accessibility and manipulation of wait lists across the
country. In response to that, we had put in place a piece of
legislation, the Choice Act, that was intended to address these
wait list scandals and accessibility.
As Dr. Roe mentioned, we included medical residencies. We
included money to hire people at competitive salaries. But
persistent, what seems to be persistent is, frankly, a lack of
transparency for the veteran in terms of being able to assess
what are the wait times in realtime at VA facilities. And there
is no ability currently to really assess wait times at private
sector community care facilities. And looming over all of this
is what Dr. Kizer had mentioned is a lack of any national
standards or a common understanding of what wait times mean in
the context of today's medicine.
So I believe we have an opportunity for the VA to play a
leadership role in terms of helping to set those standards. If
the VA can get that right, make it simple for veterans to
understand, I believe we will do not only veterans a great
service, but we will do the American people a great service by
setting these standards that the private sector, I think, will
have to adopt, as community care provider networks will have to
also be just as transparent as VA health care.
I remain concerned that we pay attention to building and
maintaining the internal capacity of the VA to deliver the care
that independent studies have said is excellent care. And we
need to pay attention to efforts to increase accessibility to
that internal care, and to rely on our community partners to
supplement what the VA cannot do internally.
With that, I thank all the witnesses for their testimony
today. I thank you for your hard work. All Members will have 5
legislative days to revise and extend their remarks, and
include extraneous material.
Again, thank you for appearing for us today. And this
hearing is now adjourned.
[Whereupon, at 11:39 a.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Debra A. Draper
Why GAO Did This Study
The majority of veterans utilizing VA health care services receive
care in VA- operated medical facilities, including 172 VA medical
centers and more than 1,000 outpatient facilities. For nearly 20 years,
GAO has reported on the challenges VA medical facilities have faced
providing health care services in a timely manner. When veterans face
wait times at VA medical facilities, they may be able to receive
services from VA's community care programs, which VA estimates will be
19 percent of its $86.5 billion in health care obligations in fiscal
year 2020.
This testimony focuses on GAO's large body of work on veterans'
access to care and the status of VA's efforts to address GAO's
recommendations, including those from GAO's June 2018 report on VA's
community care programs and from GAO's December 2012 report on VA's
scheduling of timely medical appointments that VA has provided
information on through July 2019. It also includes preliminary
observations on related ongoing work.
What GAO Recommends
GAO has made a number of recommendations to VA to address timely
scheduling and reliable wait-time data for outpatient appointments and
through community care. VA generally agreed with GAO's recommendations.
As of July 2019, VA has taken actions to fully implement one
recommendation discussed in this statement. GAO continues to believe
that all of the recommendations are warranted.
What GAO Found
GAO has issued several reports recommending that the Department of
Veterans Affairs (VA) take action to help ensure its facilities provide
veterans with timely access to medical care. VA has taken a number of
steps to address GAO's recommendations to improve wait-time measurement
and its appointment scheduling policy. However, additional actions are
needed to fully address most of GAO's recommendations.
GAO found in 2012 that outpatient appointment wait times
reported by VA were unreliable because VA did not ensure consistency in
schedulers' definitions of the dates by which wait times were measured.
GAO recommended that VA clarify these definitions. VA concurred and has
taken a number of actions in response, including improved oversight
through scheduling audits. However, VA's first internal audit in August
2018 was unable to evaluate the accuracy and reliability of its wait-
time data due to the lack of business rules for calculating them,
indicating that additional efforts are needed to address this issue.
GAO also found in 2012 that not all facilities GAO
visited used the electronic wait list to track new patients that needed
medical appointments, as required by VA's scheduling policy. This put
patients at risk for being lost for appointment scheduling. GAO
recommended VA ensure consistent implementation of its policy, and that
all schedulers complete required training. VA concurred, and with the
information VA provided in July 2019 GAO considers VA's actions,
including updating its scheduling policy and completing scheduler
training, sufficient to fully address the recommendation.
While improvements to VA's scheduling policy and
processes will help ensure veterans receive timely access to care,
there are other factors that may also affect access that are not
currently reflected in VA's wait- time data. For example, GAO found
instances in which the time it took the agency to initially enroll
veterans in VA health care benefits was more than 3 months.
GAO has also made recommendations to improve appointment scheduling
and ensure timely access to care from non-VA providers in VA's
community care programs that remain unimplemented. GAO found in June
2018 that the data VA used to monitor the timeliness of the Veterans
Choice Program's appointments captured only a portion of the total
appointment scheduling process. Although VA had a wait-time goal of 30
days, VA's timeliness data did not capture certain processes, such as
the time taken to prepare veterans' referrals and send them to a third-
party administrator. GAO found that if these were accounted for,
veterans could potentially wait up to 70 calendar days to see a
community care provider. VA officials stated that most recommendations
will be addressed with new program tools it plans to implement. For
example, VA is implementing a system for referral management and
appointment scheduling expected to be available in all VA medical
facilities by fiscal year 2021. While technology may be an important
tool, VA will also need clear and consistent policies and processes,
adequate oversight, and effective training to help avoid past
challenges.
Chairman Takano, Ranking Member Roe, and Members of the Committee:
I am pleased to be here today to discuss our work on appointment
wait times for veterans seeking care provided by the Department of
Veterans Affairs (VA) and for those veterans referred to non-VA
providers through VA's community care programs. Access to timely
medical appointments is critical to ensuring that veterans obtain
needed medical care. In particular, access to timely primary care
appointments is essential as a gateway to obtaining other health care
services such as specialty care.
The majority of veterans utilizing health care services delivered
by the VA's Veterans Health Administration (VHA) receive care in VA-
operated medical facilities, including 172 VA medical centers and more
than 1,000 outpatient facilities. For nearly 20 years, we have reported
on the challenges VA medical facilities have faced providing health
care services in a timely manner.\1\ Since 2000, we have issued several
reports recommending that VA improve appointment scheduling, ensure the
reliability of wait-time and other performance data, and improve
oversight. Implementing these recommendations would help ensure VA
medical facilities provide veterans with timely access to outpatient
primary and specialty care, as well as mental health care. Due to these
and other concerns about VA's management and oversight of its health
care system, we concluded that VA health care is a high-risk area and
added it to our High Risk List in 2015, with updates in 2017 and
2019.\2\
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\1\ See, for example, GAO, VA Health Care: More National Action
Needed to Reduce Waiting Times, but Some Clinics Have Made Progress,
GAO-01-953 (Washington, D.C.: Aug. 31, 2001); and 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).
\2\ GAO, High-Risk Series: Substantial Efforts Needed to Achieve
Greater Progress on High-Risk Areas, GAO-19-157SP (Washington, D.C.:
Mar. 6, 2019); High-Risk Series: Progress on Many High-Risk Areas,
While Substantial Efforts Needed on Others, GAO-17-317 (Washington,
D.C.: Feb. 15, 2017); and High-Risk Series: An Update, GAO-15-290
(Washington, D.C.: Feb. 11, 2015). GAO maintains a high-risk program to
focus attention on government operations that it identifies as high
risk due to their greater vulnerabilities to fraud, waste, abuse, and
mismanagement or the need for transformation to address economy,
efficiency, or effectiveness challenges.
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Serious and long-standing problems with veterans' access to care
were also highlighted in a series of congressional hearings in the
spring and summer of 2014, after several well-publicized events raised
additional concerns about wait times for appointments at VA medical
facilities.\3\ Legislation subsequently enacted in 2014 and 2018
established new community care programs, where veterans have the option
to receive hospital care and medical services from a non-VA provider if
certain conditions are met.\4\ VA estimates that community care
programs will be 19 percent of its $86.5 billion in health care
obligations in fiscal year 2020. The length of VA outpatient
appointment wait times is one of the eligibility criteria for several
community care programs, and in fiscal years 2015 and 2016 about half a
million veterans were referred to one of these programs under the wait-
time eligibility criteria.
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\3\ In some cases, delays in care or VA's failure to provide care
reportedly have resulted in harm to veterans.
\4\ Pub. L. No. 113-146, 128 Stat. 1754 (2014); Pub. L. No. 115-
182, tit. I, 132 Stat. 1393 (2018).
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You asked GAO to testify today on appointment wait times at VA
medical facilities and through community care programs, including the
wait-time information the agency makes available to veterans and the
reliability of these data. My remarks focus on
1.our work on VA outpatient appointment scheduling and the status
of VA's efforts to address our recommendations;
2.our work on community care program appointment scheduling and the
status of VA's efforts to address our recommendations; and
3.our ongoing work on one of VA's efforts to improve access to
care.
My remarks today are based on our extensive body of work on
veterans' access to care, including our December 2012 report on VA's
scheduling of timely outpatient medical appointments and our June 2018
report on VA's community care programs, as well as department
information through July 2019 in response to recommendations that we
have made.\5\ For a list of our previous work in this area, see the
Related GAO Products page at the end of this report. Those reports
provide further details on our scope and methodology. This testimony
also includes preliminary observations from our current review
assessing VA's efforts to offer veterans access to routine care without
an appointment (known as VA's same-day services initiative). That
review is based on our review of VA's policies, guidance, and
requirements related to same-day services, and interviews with various
officials, including from relevant VA offices and six VA medical
centers and affiliated outpatient clinics.
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\5\ See GAO-13-130; and GAO, Veterans Choice Program: Improvements
Needed to Address Access-Related Challenges as VA Plans Consolidation
of Its Community Care Programs, GAO-18-281 (Washington, D.C.: June 4,
2018).
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We conducted all of the work on which this statement is based 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.
Background
Scheduling Outpatient Appointments in VA Medical Facilities
Enrollment is generally the first step veterans take to obtain
health care services, within VA or through community care. VA's Health
Eligibility Center manages the process of accepting applications,
verifying eligibility, and determining enrollment, in collaboration
with VA medical centers. VA requires veterans' enrollment applications
be processed within 5 business days of receipt, including pending
applications that require additional information from the applicant to
process.\6\
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\6\ If veterans request that VA contact them to schedule an initial
appointment on their application, they are placed on the New Enrollee
Appointment Request list, and VA medical center staff are required to
initiate the scheduling process 7 calendar days after the veteran is
fully enrolled.
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Once enrolled, veterans can access VA health services by scheduling
an appointment. VA's scheduling policy establishes the procedures for
scheduling medical appointments, as well as sets the requirements for
staff directly or indirectly involved in the scheduling process (e.g.,
training). A scheduler at the VA medical facility is responsible for
making appointments for new and established patients (i.e., patients
who have visited the same VA medical center in the previous 24 months),
which are then recorded in VA's electronic scheduling system. VA
scheduling policy requires patients who have requested an appointment
and have not had one scheduled within 90 days to be placed on VA's
electronic wait list. VA determines wait times at each facility based
on outpatient appointment information from its scheduling system.
If veterans request that VA contact them to schedule an initial
appointment on their application, they are placed on the New Enrollee
Appointment Request list, and VA medical center staff are required to
initiate the scheduling process 7 calendar days after the veteran is
fully enrolled.
VA's Public Websites with Appointment Wait-Time Information
VA is required to publish information on appointment wait times at
each VA medical facility for primary care, specialty care, and hospital
care and medical services, which it does through two public websites.
In November 2014, VA began posting monthly wait times for scheduling
appointments at all VA medical facilities. One public website provides
links to spreadsheets containing data for each VA medical facility,
such as the average wait times for primary, specialty, and mental
health care appointments and the number of patients on the electronic
wait list.\7\ In April 2017, VA created a second public ``Access and
Quality in VA Healthcare'' website to post both patient access data and
information on VA medical facilities' performance on various quality
metrics. This website aims to help veterans find wait times at a
specific facility.\8\ This information would allow veterans and their
family members to use the wait-time data on this website to determine
the best option for obtaining timely care.\9\
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\7\ See https://www.va.gov/health/access-audit.asp.
\8\ See https://www.accesstopwt.va.gov/. According to VA's website,
average wait times are based on appointments completed at VA medical
facilities during the previous month. The Veterans Access, Choice, and
Accountability Act of 2014 required VA to publish the wait times for
scheduling an appointment and quality and outcome measures in the
Federal Register and on a publicly accessible website.
\9\ According to officials, VA does not currently have the
necessary data to publicly report wait times for non-VA providers in
its community care programs. Officials stated that VA has future plans
to measure and report aggregated data for the time elapsed from a
veteran's request for care to the time of a community care appointment.
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VA's Community Care Programs
In order to receive needed care in a timely manner, veterans may
need to obtain care outside of VA medical facilities through one of
VA's community care programs. VA has purchased health care services
from community providers through various community care programs since
1945. Veterans may be eligible for community care when they are faced
with long wait times or travel long distances for appointments at VA
medical facilities, or when a VA facility is unable to provide certain
specialty care services.
Since 2014, Congress has taken steps to expand the availability of
community care for veterans. The Veterans Access, Choice, and
Accountability Act of 2014 provided up to $10 billion in funding for
veterans to obtain health care services from community providers.\10\
The law established a temporary program-called the Veterans Choice
Program (Choice Program)-to offer veterans the option to receive
hospital care and medical services from a community provider when a VA
medical facility could not provide an appointment within 30 days, or
when veterans resided more than 40 miles from the nearest VA facility
or faced other travel burdens. VA contracted with two third-party
administrators (TPA) to establish networks of community providers,
schedule veteran appointments with those providers, and pay those
providers for services rendered through the Choice Program.
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\10\ Pub. L. No. 113-146, Sec. Sec. 101, 802, 128 Stat. 1754,
1755-1765, 1802-1803 (2014). Additional funding for the Choice Program
was provided on three separate occasions. Legislation enacted in August
and December of 2017 provided an additional $4.2 billion for the
Veterans Choice Fund. VA Choice and Quality Employment Act of 2017,
Pub. L. No. 115-46, Sec. 101, 131 Stat. 958, 959 (2017) (providing an
additional $2.1 billion for the Veterans Choice Fund); An Act to amend
the Homeland Security Act of 2002 to require the Secretary of Homeland
Security to issue Department of Homeland Security-wide guidance and
develop training programs as part of the Department of Homeland
Security Blue Campaign, and for other purposes, Pub. L. No. 115-96.
Div. D, Sec. 4001, 131 Stat. 2044, 2052-53 (2017) (providing an
additional $2.1 billion for the Veterans Choice Fund). In addition, the
VA MISSION Act provided an additional $5.2 billion for the Veterans
Choice Fund and authorized VA, beginning March 1, 2019, to use
remaining amounts in the Fund for the Community Care Program, along
with any other available amounts in other appropriation accounts for
such purposes. Pub. L. No. 115-182, Sec. Sec. 142, 510, 132 Stat.
1393, ** (2018).
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In June 2018, the VA MISSION Act of 2018 was enacted to further
address some of the challenges faced by VA in ensuring timely access to
care.\11\ The Act required VA to implement within 1 year a permanent
community care program-the Veterans Community Care Program (VCCP). The
act identified criteria that all veterans enrolled in the VA health
care system would be able to qualify for care through the VCCP; for
example, if VA does not offer the care or service needed by the veteran
or VA cannot provide the veteran with care and services that comply
with its designated access standards. The access standards include
appointment wait times for a specific VA medical facility; for example,
veterans may be eligible for care through the VCCP if VA cannot provide
care within 20 days for primary and mental health care, and 28 days
from the date of request for specialty care, unless veterans agree to a
later date in consultation with their VA health care provider.
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\11\ Pub. L.No. 115-182, tit. I, 132 Stat. 1393 (2018).
VA Has Taken Actions to Address Deficiencies in Appointment Scheduling
and Timeliness Identified in Prior Work, but Additional Actions Are
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Needed
VA Has Taken Steps to Address Our Recommendation to Improve Wait-Time
Measurement and Has Implemented Our Recommendation to Improve
Implementation of Scheduling Policy
VA has taken a number of actions to address our recommendations
regarding deficiencies we found in wait-time measurement and
implementation of its scheduling policy. For wait-time measurement,
these actions included changes to the wait-time measurement
definitions, provision and documentation of scheduler training, and
improved oversight through audits, all of which have been in a state of
flux for the past 6 years. On July 12, 2019, VA provided us additional
updates on efforts to implement our related recommendations. This new
information fully addresses one of our recommendations.
VA Wait-Time Measurement
In December 2012, we found that outpatient medical appointment wait
times reported by VA were unreliable, and, therefore, VA was unable to
identify areas that needed improvement or mitigate problems for
veterans attempting to access care.\12\ VA typically has measured wait
times as the time elapsed between the `start date'-a defined date that
indicates the beginning of the measurement-and the `end date', which is
the date of the appointment. At the time of our 2012 report, VA
measured wait times as the number of days elapsed from the start date
identified as the desired date-the date on which the patient or health
care provider wants the patient to be seen-to the date of the
appointment.\13\ We found that the reliability of the reported wait-
time measures was dependent on the consistency with which schedulers
recorded the desired date in the scheduling system, as required by VA's
scheduling policy. However, VA's scheduling policy and training
documents for recording the desired date were unclear and did not
ensure consistency. We observed that not all schedulers at VA medical
centers that we visited recorded the desired date correctly. Therefore,
we recommended that VA either clarify its scheduling policy to better
define the desired date, or identify clearer wait- time measures that
are not subject to interpretation and prone to scheduler error. VA
concurred with the recommendation, which we have identified as among
those recommendations that warrant priority attention.\14\
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\12\ See GAO-13-130.
\13\ The desired date was defined in VHA Directive 2010-027, VHA
Outpatient Scheduling Processes and Procedures (June 9, 2010). VA
rescinded this policy by memorandum, effective July 31, 2014, and
replaced it with interim guidance.
\14\ We send letters each year to the heads of key departments and
agencies, including VA, that give the overall status of the
department's or agency's implementation of our recommendations and
identify open recommendations that should be a priority for
implementation. In March 2019, we sent the Secretary of VA this year's
letter, which identified 30 recommendations as being a priority for
implementation. See GAO, Priority Open Recommendations: Department of
Veterans Affairs, GAO-19-358SP (Washington, D.C.: Mar. 28, 2019).
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Actions VA has taken or is taking to address this recommendation
include:
changes to the start date and definitions for wait-time
measurement,
provision and documentation of scheduler training, and
improved oversight through scheduler audits.
In addition, we are currently assessing new information VA provided
in July 2019, which will include obtaining additional evidence and
clarification from VA to see whether it has fully addressed our
concerns.
VA's Actions to Change Start Dates for Wait-Time Measurement
While the terminology for the start dates of the wait-time
measurement has changed several times over the past 6 years, we believe
that the current definitions of the start dates are substantively the
same as those we reviewed-and found to be deficient-in our 2012 report.
VA subsequently introduced new terms with similar definitions-from
``desired date'' to ``preferred date''-without fundamentally addressing
the deficiency. See table 1 for the changes to and definitions of the
start dates for measuring outpatient appointment wait times and wait-
time goals since June 2010.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
(a) VHA Directive 2010-027 was the scheduling directive in effect
during our 2012 audit of wait times and scheduling processes.
(b) VA introduced but did not define ``create date'' in its July 7,
2014, memo; it is specified elsewhere as the date the appointment is
created in the scheduling system.
As table 1 shows, for new patients and established patients seeking
appointments without a return-to-clinic date specified by their
provider, VA changed the terminology of the start date to preferred
date in its July 2016 scheduling policy from what it had established in
its June 2010 policy. However, the definition of preferred date is
substantively the same as the definition of desired date in the
previous scheduling policy, the latter of which we found to be subject
to interpretation and prone to scheduler error in our 2012 report.\15\
We continue to believe that the preferred date is also subject to
interpretation and prone to scheduler error, which poses concerns for
the reliability of wait times measured using the patient's preferred
date.
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\15\ VHA Directive 1230(1) and VHA Directive 2010-027. See also
GAO-13-130.
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In its updated July 2016 scheduling policy, VA also changed the
terminology of the start date to the ``clinically indicated date'' for
established patients whose provider has documented a clinically
appropriate return-to-clinic date in the patient's electronic health
record. The clinically indicated date is substantively the same as the
definition of desired date for established patients in the previous
scheduling directive.
While VA has not clarified the definitions of start dates, VA has
taken actions intended to improve the accurate recording of the
clinically indicated date in three ways:
1.VA requires clinical leadership (such as the Associate Chief of
Staff) at each VA medical facility to ensure that providers enter the
clinically indicated date in the electronic health record for future
appointments;
2.VA standardized the entry of the clinically indicated date in the
electronic health record to improve the accuracy of the date, which was
implemented across all VA medical facilities as of July 2018; and
3.VA created a technology enhancement to enable the automatic
transfer of the clinically indicated date from the electronic health
record to the scheduling system. As a result, the scheduler no longer
has to retrieve the date from veterans' electronic health records and
manually enter it into the scheduling system. VA reported that this
enhancement was implemented at all but three VA medical facilities as
of January 2019.
In July 2019, VA reported to us that the error rate for the patient
indicated date (either the clinically indicated date, or in the absence
of that date, the patient's preferred date) was 8 percent of about
667,000 appointments audited in the most recent biannual audit cycle,
ending March 31, 2019. VA cites an almost 18 percent improvement in
reducing the number of errors caused by manual entry of the clinically
indicated date due to the use of the technology enhancements.
VA's Actions to Provide and Document Scheduler Training
Although VA updated its scheduling policy in 2016, we believe the
instructions, which form the basis for wait-time measurement, are still
subject to interpretation and prone to scheduler error, making training
and oversight vital to the consistent and accurate implementation of
the policy. VA reported that 97 percent of all staff who scheduled an
appointment within 30 days completed the required scheduling training
as of July 2, 2019. VA stated that the department will closely monitor
compliance with scheduler training completion for the remaining staff.
Given the high turnover among schedulers, it is important that VA
remain vigilant about scheduler training, ensuring all who need it
receive it.
VA's Actions to Improve Oversight through Scheduler Audits
VA has taken a number of actions to improve oversight of the
scheduling process through biannual scheduling audits at VA medical
centers and second level audits, as well as completion of the first
system-wide internal audit of scheduling and wait-time data.
Biannual scheduler audits. VA's July 2016 scheduling policy
required biannual audits of the timeliness and appropriateness of
schedulers' actions and accuracy of entry of the clinically indicated
date and preferred date, the start dates of wait-time measurement as
identified by the revised scheduling policy. In June 2017, VA deployed
a standardized scheduling audit process for staff at VA medical centers
to use. As part of our recommendation follow-up in July 2019, VA
reported 100 percent completion of the required biannual scheduling
audits in fiscal year 2018. As noted above, VA reported to us that the
error rate for the patient indicated date (either the clinically
indicated date, or in the absence of that date, the patient's preferred
date) was 8 percent of about 667,000 appointments audited. While VA
asserts that errors in the clinically indicated date have decreased, an
error rate of 8 percent still yields errors in more than 53,000
appointments audited. Given these errors, we remain concerned about the
reliability of wait times measured using preferred date (one part of
the patient indicated date), and have requested additional information
from VA about these errors.
Second level scheduler audits. In November 2018, VA
implemented a second-level scheduling audit (Audit the Auditors
program), which is overseen by the VA integrated service networks
tasked with oversight of VA medical facilities within their regions.
Each medical center within a network region is paired with another
medical center and they audit each other's scheduling audit. Throughout
the cycle, medical centers share their findings with each other and the
network. The goal is to standardize scheduling audit practices across
the network and to ensure reliability of the scheduler audit results.
According to VA, the first cycle was completed April 30, 2019, by all
VA medical centers.
First internal system-wide audit of wait-time data and
scheduling. In its first internal audit completed in August 2018, VA
was unable to evaluate the accuracy and reliability of scheduling and
the wait-time data. Specifically, VA was unable to determine the
accuracy and reliability of the scheduling and wait-time data,
databases, and data flow from the electronic health record and
scheduling system to the VA Access and Quality website because they
were not able to obtain the rules for calculating wait times.\16\ Given
our continued concerns about VA's ability to ensure the reliability of
the wait-time data, we plan to obtain additional information from VA
about its methodology and assessment of evidence underlying the audit
findings.
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\16\ From November 2017 through August 2018, VHA's Office of
Internal Audit conducted its first performance audit, which assessed
the accuracy and reliability of the wait times published on the VA
Access and Quality website. VHA issued the audit report in February
2019, which is an internal report and not publicly available. The
methodology included an evaluation of compliance against requirements
in VHA Directive 1230 related to the accuracy and reliability of
veteran wait times.
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Scheduling Policy
In December 2012, we also found inconsistent implementation of VA's
scheduling policy that impeded VA medical centers' scheduling of timely
medical appointments. Specifically, we found that not all of the
clinics across the medical centers we visited used the electronic wait
list to track new patients that needed medical appointments as required
by VA's scheduling policy, putting these patients at risk of being lost
for appointment scheduling.\17\ Furthermore, VA medical centers'
oversight of compliance with VA's scheduling policy, such as ensuring
the completion of required scheduler training, was inconsistent across
facilities. Scheduler training was particularly important given the
high volume of staff with access to the scheduling system-as of July 2,
2019, VA reported there were approximately 33,000 staff that had
scheduled an appointment within the last 30 days. We also found that VA
medical centers identified the outdated and inefficient scheduling
system as one of the problems that can impede the timely scheduling of
appointments and may impact their compliance with VA's scheduling
policy.\18\ We recommended VA ensure that VA medical centers
consistently and accurately implement VA's scheduling policy, including
use of the electronic wait list, as well as ensuring that all staff
with access to the scheduling system completes the required
training.\19\ VA concurred with this recommendation, which we also have
identified as among those recommendations that warrant priority
attention.
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\17\ VHA Directive 2010-027, in effect during our 2012 audit,
defined the electronic wait list as the official VA wait list that is
used to list patients waiting to be scheduled, or waiting for
assignment to a provider's panel. In general, the electronic wait list
is used to keep track of patients with whom the clinic does not have an
established relationship (e.g., the patient has not been seen before in
the clinic).
\18\ See GAO-13-130.
\19\ We also made two recommendations regarding the allocation of
staffing resources to respond to demand for appointment scheduling and
the oversight of telephone access and implementation of telephone
systems best practices. Both of these recommendations remain
unimplemented as of July 2019.
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VA's actions to improve implementation of the scheduling policy,
including updated information VA provided in July 2019, fully addresses
this recommendation. VA issued an updated scheduling policy in July
2016 that provided clarification on scheduling roles and
responsibilities for implementing the policy and business rules for
scheduling appointments, such as using the electronic wait list, and
required biannual scheduler audits. VA also ensured almost all
schedulers received training on the updated scheduling policy and
improved oversight through audits, as previously described.
In addition, VA plans to rapidly deploy a single nationwide
scheduling system that is intended to simplify the operating
environment for schedulers and may mitigate challenges identified in
our 2012 report. The new scheduling system will be a resource-based
system where each provider's schedule is visible on one screen, instead
of requiring the need to toggle through multiple screens as it
currently exists. VA plans to roll out the new scheduling system
starting in 2020, which is expected to be implemented in coordination
with the planned modernization of the electronic health records system
across VA facilities. According to VA, the scheduling system will be
available for use in advance of the completion of the electronic health
record implementation at some sites.\20\
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\20\ VA does not have an end date for the completion of the
scheduling system or electronic health record deployment.
VA Has Taken Steps to Address Our Recommendations to Strengthen
Enrollment Processes and Management of Initial Requests for Care
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That Affect Veterans' Timely Appointments
In addition to the recommendations we made to improve VA's wait-
time data and implementation of its scheduling policy, we have also
made recommendations to address other factors that affect the
timeliness by which veterans obtain appointments. These recommendations
have targeted VA's enrollment processes and its management of veterans'
initial requests for care. While VA has taken some steps to address
these recommendations, they have not yet been fully addressed. For
example, we have found that VA's wait-time measures do not yet capture
the time it takes the agency to enroll veterans in VA health care
benefits, or manage a veterans' initial request for care.\21\
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\21\ Veterans can request VA contact them to schedule an initial
appointment on their enrollment application, and if eligible, they are
placed on VA's New Enrollee Appointment Request list. According to VA's
scheduling policy, scheduling appointments for veterans on the New
Enrollee Appointment Request list must start within 7 days of a veteran
being determined eligible for VA health care benefits.
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Enrollment Process
In September 2017, we found that VA did not provide its medical
centers, who historically receive 90 percent of enrollment
applications, with clear guidance on how to resolve pending
applications, which led to delays in veteran's enrollment.\22\ For
example, we found instances in which pending applications remained
unresolved for more than 3 months. We concluded these delays in
resolving pending applications, along with previously documented delays
due to errors in enrollment determinations, may result in veterans
facing delays when obtaining health care services or incorrectly denied
benefits.
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\22\ 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).
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We made several recommendations to address these deficiencies, two
of which we determined to be priority recommendations for VA to clearly
define roles and responsibilities for (1) resolving pending
applications and (2) overseeing the enrollment process. VA has made
progress in addressing these priority recommendations by beginning to
update, but not yet finalizing, its policies, procedures, and guidance
on enrollment processing. In 2017, VA's Health Eligibility Center began
conducting secondary reviews of enrollment determinations. However, in
fiscal year 2018, Health Eligibility Center staff found that 18 percent
of rejected enrollment determinations and 8 percent of ineligible
enrollment determinations that underwent secondary reviews were
incorrect.\23\ These recommendations remain unimplemented as of July
2019.
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\23\ We also recommended that VA develop procedures for
consistently collecting reliable enrollment processing data. Although
VA is working on data systems enhancements and plans to regularly test
the reliability of its data, it has not completed those system
enhancements or begun to regularly audit its enrollment processing data
for reliability. VA did implement our recommendation of clarifying the
5-day timeliness standard for processing enrollment applications.
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Initial Requests for Care
Once enrolled, we have found that VA's management of veterans'
initial request for care have led to delays; and although VA has
clarified timeliness requirements, it has yet to fully capture the wait
veterans experience in scheduling initial appointments. In a number of
reports from 2015 to 2018, we found instances in which newly enrolled
veterans were not contacted to schedule initial primary care
appointments, and did not complete initial primary care appointments
and mental health evaluations according to VA timeliness
requirements.\24\ These delays may be understated in VA data, because
VA's wait-time measures do not take into account the time it takes VA
medical center staff to contact the veteran to determine a preferred
date (the starting point for wait-time measurement) from the veteran's
initial request or referral. We found that the total amount of time it
took for veterans to be seen by providers was often much longer when
measured from the dates veterans initially requested to be contacted to
schedule an appointment or were referred for an appointment by another
provider than when using the veterans' preferred dates as the starting
point. See figure 1 for an example of how the two wait-time
calculations differ for an initial primary care appointment.\25\
---------------------------------------------------------------------------
\24\ GAO, VA Mental Health: Clearer Guidance on Access Policies and
Wait-Time Data Needed, GAO-16-24 (Washington, D.C.: Oct. 28, 2015); VA
Health Care: Actions Needed to Improve Newly Enrolled Veterans' Access
to Primary Care, GAO-16-328 (Washington, D.C.: Mar. 18, 2016); and
Veterans Health Administration: Opportunities Exist for Improving
Veterans' Access to Health Care Services in the Pacific Islands, GAO-
18-288 (Washington, D.C.: Apr. 12, 2018).
\25\ We found that although some of the delays may have been
attributed to VA medical center staff not being able to contact
veterans after repeated attempts, or veterans' preferences to delay
treatment, in some cases the delays were caused because VA medical
center officials did not initiate contact according to VA requirements,
did not complete the required number of contact attempts, or did not
have appointments available due to provider and space shortages.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
We made several recommendations to VA, including a priority
recommendation to monitor the full amount of time newly enrolled
veterans wait to be seen by a provider.\26\ VA has taken several steps
to address the priority recommendation, including revising an internal
report to help identify and document newly enrolled veterans and
monitor their appointment request status. The report is intended to
help VA and its medical centers oversee the enrollment and appointment
process by tracking the total time from application to appointment.
However, VA is still in the process of enhancing its electronic
enrollment system to capture the application date for all newly
enrolled veterans. Until the enhancements are implemented, VA may not
consistently capture the start date for newly enrolled veterans, which,
in turn, affects the reliability of its wait-time data. The priority
recommendation remains unimplemented as of July 2019.
---------------------------------------------------------------------------
\26\ We also made recommendations that VA review and revise its
process for identifying and documenting newly enrolled veterans
requesting appointments, clarify timeliness requirements for scheduling
mental health evaluations, and clarify definitions, such as how a new
patient is defined, used to calculate wait times. VA concurred with and
implemented all of these recommendations.
VA Has Not Implemented Recommendations to Address Wait Times and Other
---------------------------------------------------------------------------
Choice Program Issues That Could Affect VCCP Implementation
VA has not implemented several of our recommendations related to
the Choice Program that could impact veterans' timely access to care
under the VCCP. These recommendations address (1) establishing
achievable community care wait-time goals and a scheduling process
consistent with those goals, (2) collecting accurate and complete data
to systematically monitor veteran community care wait times, and (3)
other factors that could adversely affect veterans' access to community
care. VA has begun taking steps to address these recommendations as it
implements the VCCP.
VA Still Needs to Establish Achievable Wait-Time Goals and a Scheduling
Process Consistent with Those Goals to Ensure Veterans' Timely
Access to Care under the VCCP
Our review of the Choice Program in June 2018 found that despite
having a wait-time goal, VA developed a scheduling process for the
Choice Program that was not consistent with achieving that goal. The
Veterans Access, Choice, and Accountability Act of 2014 required VA to
ensure the provision of care to eligible veterans within 30 days of the
clinically indicated date or, if none existed, within 30 days of the
veteran's preferred date. However, we found that those veterans who
were referred to the Choice Program for routine care because services
were not available at VA in a timely manner could potentially wait up
to 70 calendar days for care. Under VA's scheduling processes, this
potential wait time included VA medical centers having at least 18
calendar days to prepare veterans' Choice Program referrals to TPAs and
another 52 calendar days for appointments to occur as scheduled by
TPAs.
Based on this finding, we recommended that VA establish an
achievable wait-time goal for the VCCP that will permit VA to monitor
whether veterans are receiving community care within time frames that
are comparable to the amount of time they would otherwise wait to
receive care at VA medical facilities.\27\ We also recommended that VA
should design an appointment scheduling process for the VCCP that sets
forth time frames within which (1) veterans' referrals must be
processed, (2) veterans' appointments must be scheduled, and (3)
veterans' appointments must occur that are consistent with the wait-
time goal VA has established for the program. VA agreed with both
recommendations, which remain unimplemented, and officials stated that
they are in the process of finalizing metrics to capture wait-time
performance and designing an appointment scheduling process. Without
specifying wait- time goals that are achievable, and without designing
appointment scheduling processes that are consistent with those goals,
VA lacks assurance that veterans are receiving care from community
providers in a timely manner.
---------------------------------------------------------------------------
\27\ The report in which we made these recommendations refers to
the VCCP as the ``consolidated community care program VA plans to
implement'' because at the time of the report, the name of the program
had not yet been announced. See GAO-18-281.
---------------------------------------------------------------------------
VA's Monitoring of Care
under VCCP Could Still Be Compromised by Incomplete and Inaccurate Data
In June 2018, we reported that VA could not systematically monitor
wait times for veterans accessing care under the Choice Program due to
incomplete and inaccurate data. Without complete and accurate data, VA
was not able to determine whether the Choice Program was achieving its
goals of (1) alleviating the wait times veterans experienced when
seeking care at VA medical facilities, and (2) easing geographic
burdens veterans may have faced when accessing care at VA medical
facilities.\28\ We made three recommendations to address VA's
incomplete and inaccurate data related to the Choice Program, and VA is
taking steps to implement two of those recommendations.
---------------------------------------------------------------------------
\28\ GAO selected 6 of 170 VA medical centers (selected for
variation in geographic location and the TPAs that served them) and
manually reviewed a random, non-generalizable sample of 196 Choice
Program authorizations. The authorizations were created for veterans
who were referred to the program between January and April of 2016, the
most recent period for which data were available when we began our
review. The sample of authorizations included 55 for routine care, 53
for urgent care, and 88 that the TPAs returned without scheduling
appointments. The sample of authorizations we reviewed included only
authorizations for which VA's data indicated there were delays when the
TPAs attempted to schedule appointments after the veterans had opted in
to the program; however, our analysis of these authorizations indicates
that delays occurred at other phases of the referral and appointment
scheduling process as well. See GAO-18-281.
---------------------------------------------------------------------------
Incomplete Data
We found that the data VA used to monitor the timeliness of Choice
Program appointments captured only a portion of the total appointment
scheduling process. Though VA had a 30-day wait-time goal to provide
veterans with care under the Choice Program, VA's timeliness data did
not capture (1) the time VA medical centers took to prepare veterans'
referrals and send them to the TPAs, and (2) the time spent by TPAs in
accepting the referrals and opting veterans into the Choice Program.
For example, we found that it took VA medical center staff an average
of 24 calendar days after the veteran's need for care was identified to
contact the veteran, compile relevant clinical information, and send
the veteran's referral to the TPAs. For those same authorizations, it
took the TPAs an average of 14 calendar days to accept referrals and
reach veterans to opt them into the Choice Program.\29\
---------------------------------------------------------------------------
\29\ Similarly in April 2018, we found that while 20 of 30 veterans
accessing specialty care under the Choice Program in the Pacific
Islands received care within VA's 30 day wait- time goal, the actual
wait time from when the referral was created to when the veteran
received care ranged from 19 to 239 days, with the average being 75
days. Our non- generalizable sample included 30 routine Choice Program
authorizations that were created from October 2016 through March 2017
by three selected VA medical facilities. See GAO-18-288.
---------------------------------------------------------------------------
In 2016, VA also conducted its own manual review of appointment
scheduling times and found that wait times could be longer than the 30
days (see fig. 2). Specifically, out of a sample of about 5,000 Choice
Program authorizations, VA analyzed (1) the timeliness with which VA
medical centers sent referrals to the TPAs, and (2) veterans' overall
wait times for Choice Program care. VA's analysis identified average
review times when veterans were referred to the Choice Program to be
greater- than-30-day wait time for an appointment at a VA medical
facility. For example, for overall wait times (i.e., the time veterans'
need for care was identified until they attended initial Choice Program
appointments), wait times ranged from 34 to 91 days across the 18 VA
integrated service networks. The national average was 51 days.\30\
---------------------------------------------------------------------------
\30\ GAO obtained the results of VA's non-generalizable analysis of
wait times for a nationwide sample of about 5,000 Choice Program
authorizations that were created for selected services between July and
September of 2016. Authorizations were for four types of Choice Program
care-mammography, gastroenterology, cardiology, and neurology. VA
calculated the average wait times across these four types of care for
each of the 18 VA integrated service networks.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Note: GAO excluded from its analysis the amount of time the TPA
took to schedule the appointment and the overall wait time because its
sample selection methodology differed from VA's in a way that would
have skewed these two averages but not the averages from the other
segments of the process.
In September 2017, VA began implementing an interim solution to
monitor overall wait times, but this solution relied on VA medical
center staff consistently and accurately entering data on referrals, a
process that is prone to error. In June 2018, we recommended that VA
establish a mechanism to monitor the overall wait times under the VCCP.
VA agreed with this recommendation, and stated that it is developing a
monitoring mechanism that will be incorporated into a new system that
will be fully implemented across all VA medical facilities by fiscal
year 2021.
Inaccurate Data
We also reported that the clinically indicated dates included on
referrals that VA medical centers sent to the TPAs, which are used to
measure the timeliness of care, may not have been accurate, further
limiting VA's monitoring of veterans' access to care. Our review of 196
Choice Program authorizations found that clinically indicated dates
were sometimes changed by VA medical center staff before they were sent
to the TPAs, which could mask veterans' true wait times. We found that
VA medical center staff entered later clinically indicated dates on
referrals for about 23 percent of the 196 authorizations reviewed. We
made two recommendations to improve the accuracy of the Choice Program
data. For example, we recommended that VA establish a mechanism under
the VCCP that prevents clinically indicated dates from being modified.
VA agreed with our recommendation, and stated that a new system will
interface with VA's existing referral package to allow a VA clinician
to enter in a clinically indicated date while restricting schedulers
from making alterations to it.\31\
---------------------------------------------------------------------------
\31\ VA did not agree with one of our recommendations related to
urgent care referrals. However, we maintain that our recommendation is
still warranted.
VA Has Not Addressed Other Factors That Could Adversely Affect
---------------------------------------------------------------------------
Veterans' Access to Care under the VCCP
In June 2018, we also reported that numerous factors adversely
affected veterans' timely access to care through the Choice Program and
could affect access under the VCCP.\32\ These factors included the
following: (1) administrative burden caused by complexities of VA's
referral and appointment scheduling processes; (2) poor communication
between VA and its medical facilities; and (3) inadequacies in the
networks of community providers established by the TPAs, including an
insufficient number, mix, or geographic distribution of community
providers.
---------------------------------------------------------------------------
\32\ See GAO-18-281.
---------------------------------------------------------------------------
VA has taken steps to help address these factors; however, none
have been fully addressed. For example, to help address administrative
burden and improve the process of coordinating veterans' Choice Program
care, VA established a secure e-mail system and a mechanism for TPAs
and community providers to remotely access veterans' VA electronic
health records. However, these mechanisms only facilitate a one-way
transfer of necessary information. They do not provide a means by which
VA medical facilities or veterans can view the TPAs' step-by-step
progress in scheduling appointments or electronically receive medical
documentation associated with Choice Program appointments. We made five
recommendations to VA to address the factors that adversely affected
veterans' access to Choice Program care. VA agreed or agreed in
principle with all five recommendations and has taken some steps in
response to these recommendations. However, our recommendations remain
unimplemented.
As It Implements the VCCP, VA Has Taken Some Steps to Address Community
Care Wait- Time Data and Monitoring Issues
On June 6, 2019, VA began implementing the VCCP, which created a
consolidated community care program. Under the VCCP, VA began
determining veteran eligibility based on designated access standards,
such as wait-time goals of 20 days for primary and mental health care
and 28 days for specialty care and other criteria identified in the
MISSION Act.\33\ According to VA officials, the implementation of the
VCCP also included the use of the new Decision Support Tool-a system
that combines eligibility and other information to help veterans, with
assistance from VA staff, decide whether to seek care in the community.
VA officials previously identified the Decision Support Tool along with
another new system-known as the Health Share Referral Management
system-as key efforts in addressing many of our recommendations related
to VA's community care wait-time data and monitoring issues. VA expects
the Health Share Referral Management system, which will manage
community care referrals and authorizations as well as facilitate the
exchange of health information between VA and community providers, to
be fully implemented across all VA medical facilities in fiscal year
2021. We began work in May 2019 to review VA's implementation of the
VCCP, including how it will address issues such as appointment
scheduling.
---------------------------------------------------------------------------
\33\ 84 Fed. Reg. 26278-01 (June 6, 2019).
Preliminary Observations on VA's Provision of Same- Day Services-
---------------------------------------------------------------------------
Another Access Initiative
In addition to the actions described above, VA has taken other
steps to improve veterans' access to care by, for example, offering
veterans access to routine care without an appointment. We have ongoing
work related to same-day services provided in VA primary care and
mental health clinics. In order to improve access, VA implemented the
same-day service initiative in 2016, and by 2018 offered same-day
services in over 1000 facilities.\34\ As part of the initiative, VA
medical facility staff are directed to address veterans' primary care
and mental health needs that day through a variety of methods,
including face-to-face visits, telehealth, prescription refills, or by
scheduling a follow-up appointment. Our ongoing work indicates that the
six VA medical facilities we visited were generally providing same-day
services prior to the initiative; however, according to VA officials,
ongoing staffing and space shortages created challenges implementing
the initiative. Our ongoing work also indicates that VA does not have
performance goals and measures to determine same-day services' impact
on veterans' access to care. We plan to issue our report on VA's same-
day services initiative in August 2019.
---------------------------------------------------------------------------
\34\ In January 2018, VA announced that same-day services in
primary care and mental health had been achieved not only in all VA
medical centers, but also in all of VA's community-based outpatient
clinics.
---------------------------------------------------------------------------
In closing, we have identified various weaknesses in VA's wait-time
measurement and scheduling processes over the years. These weaknesses
have affected not only VA's internal delivery of outpatient care, but
also that provided through community providers. As we have highlighted
here, we have made a number of recommendations to address these
weaknesses. VA has taken actions to address our recommendations, but
additional work is needed for some. The implementation of enhanced
technology, such as a new scheduling system, is crucial and will
provide an important foundation for improvements. However, this is not
a panacea for addressing all of the identified problems. Moving
forward, VA must also continuously ensure that it has clear and
consistent policies and processes, adequate oversight, and effective
training.
Chairman Takano, Ranking Member Roe, and Members of the Committee,
this completes my prepared statement. I would be pleased to respond to
any questions that you may have at this time.
GAO Contact and Staff Acknowledgments
If you or your staff have any questions about this testimony,
please contact Debra A. Draper, Director, Health Care at (202) 512-7114
or [email protected]. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
statement. GAO staff who made key contributions to this testimony were
Sharon Silas (Acting Director), Ann Tynan (Assistant Director), Cathy
Hamann, Aaron Holling, Akbar Husain, Kate Tussey, and E. Jane Whipple.
Also contributing were Jacquelyn Hamilton and Vikki Porter.
Related GAO Reports
Veterans Health Care: VA Needs to Address Challenges as It
Implements the Veterans Community Care Program, GAO-19-507T
(Washington, D.C.: April 10, 2019).
Priority Open Recommendations: Department of Veterans Affairs, GAO-
19-358SP (Washington, D.C.: March 28, 2019).
High-Risk Series: Substantial Efforts Needed to Achieve Greater
Progress on High-Risk Areas, GAO-19-157SP (Washington, D.C.: March 6,
2019).
Veterans Health Administration: Opportunities Exist for Improving
Veterans' Access to Health Care Services in the Pacific Islands, GAO-
18-288 (Washington, D.C.: April 12, 2018).
Veterans Choice Program: Improvements Needed to Address Access-
Related Challenges as VA Plans Consolidation of Its Community Care
Programs, GAO-18-281 (Washington, D.C.: June 4, 2018).
VA Health Care: Opportunities Exist for Improving Implementation
and Oversight of Enrollment Processes for Veterans, GAO-17-709
(Washington, D.C.: September 5, 2017).
High-Risk Series: Progress on Many High-Risk Areas, While
Substantial Efforts Needed on Others, GAO-17-317 (Washington, D.C.:
February 15, 2017).
Veterans' Health Care: Preliminary Observations on Veterans' Access
to Choice Program Care, GAO-17-397T (Washington, D.C.: March 7, 2017).
VA Health Care: Actions Needed to Improve Newly Enrolled Veterans'
Access to Primary Care, GAO-16-328 (Washington, D.C.: March 18, 2016).
High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11,
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 Mental Health: Clearer Guidance on Access Policies and Wait-Time
Data Needed, GAO-16-24 (Washington, D.C.: October 28, 2015).
VA Health Care: Further Action Needed to Address Weaknesses in
Management and Oversight of Non-VA Medical Care, GAO-14-696T
(Washington, D.C.: June 18, 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: Actions Needed to Improve Administration and
Oversight of VA's Millennium Act Emergency Care Benefit, GAO-14-175
(Washington, D.C.: March 6, 2014).
VA Health Care: Management and Oversight of Fee Basis Care Need
Improvement, GAO-13-441 (Washington, D.C.: May 31, 2013).
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 Mental Health: Number of Veterans Receiving Care, Barriers
Faced, and Efforts to Increase Access, GAO-12-12 (Washington, D.C.:
October 14, 2011).
Information Technology: Management Improvements Are Essential to
VA's Second Effort to Replace Its Outpatient Scheduling System, GAO-10-
579 (Washington, D.C.: May 27, 2010).
VA Health Care: More National Action Needed to Reduce Waiting
Times, but Some Clinics Have Made Progress, GAO-01-953 (Washington,
D.C.: August 31, 2001).
Veterans' Health Care: VA Needs Better Data on Extent and Causes of
Waiting Times, GAO/HEHS-00-90 (Washington, D.C.: May 31, 2000).
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Prepared Statement of Teresa Boyd, DO
Good morning, Chairman Takano, Ranking Member Roe, and Members of
the Committee. I appreciate the opportunity to discuss VA's current
practices for measuring Veterans' access to health care and to provide
a clearer picture concerning wait times in light of the 5-year
anniversary of the issues in Phoenix. I am accompanied today by Dr.
Susan Kirsh, Acting Assistant Deputy Under Secretary for Health (ADUSH)
for Access, and Dr. Clinton L. Greenstone, Deputy Executive Director,
Clinical Integration, Office of Community Care.
Introduction
VHA has undergone tremendous transformation since 2014, operating
with a renewed focus, unprecedented transparency, and increased
accountability. We recognize there are still challenges ahead of us,
but it is important to keep in mind that Veterans continue to receive
the highest quality care, often with shorter wait times than in the
private sector. VHA will continue to identify opportunities to share
strong practices, standardize processes, educate staff, and provide
oversight to ensure these efforts are being effective. Providing
Veterans the care they need, when and where they need it, is central to
all we do. Even with implementation of the new Veterans Community Care
Program through the VA MISSION Act of 2018, Veterans are choosing to
stay within VA to receive their care.
Care When It Is Needed
VHA is providing care to more patients than ever. We completed over
1 million more appointments in 2018 than the previous year while wait
times continue to decline across VA. In fact, the Journal of the
American Medical Association found in a study released in January 2019,
that by 2017 VA had significantly shorter wait times for primary care,
cardiology, and dermatology than the wait times seen for private
doctors. VA had longer wait times for orthopedic care; however, these
wait times improved from 2014 and are still improving.
VA offers Veterans same-day services for mental health and primary
care when clinically indicated at all VA medical centers (VAMC) and
community-based outpatient clinics (CBOC) across VA - an effort
completed by 2017. Same-day primary care and mental health services are
offered when a Veteran contacts us. Accordingly, we will either address
the need that day or schedule appropriate follow up care, depending on
the urgency. We may address the health care needed by providing a face-
to-face visit, returning a phone call, arranging a telehealth or video-
care visit, responding by secure email, or scheduling a future
appointment.
VA has improved the average time to complete a stat consult, which
is a critically time-sensitive referral to specialist that should be
completed in less than 48 hours, from 19.3 days in 2014 to just 1.4
days in 2019, a 90 percent decrease. Simplifying the consult management
process and timely resolution of these referrals has made it easier for
Veterans to be seen in a timelier manner. A large factor in these
improvements was VA's response to the Veterans Access, Choice, and
Accountability Act of 2014 and we expect this to continue under the
implementation of the MISSION Act of 2018.
Quality Care
In 2018, the RAND Corporation released a study, Comparing Quality
of Care in Veterans Affairs and Non-Veterans Affairs Settings, that
said VA hospitals on average performed the same or significantly better
on 21 of 26 measures than private sector hospitals, including inpatient
safety and mortality. VA hospitals performed better than commercial and
Medicaid Health Maintenance Organizations on 28 of 30 measures. An
increased emphasis on patient-centered care is a large contributor to
these improvements. Our Veterans Experience Office is constantly
assessing our performance throughout VA and giving us the feedback we
need to identify and resolve problems.
VHA values what Veterans have to say and have made it an Agency
priority. We have been using the industry standard Consumer Assessment
of Health Providers and Systems (CAHPS) survey to assess patient
satisfaction for primary care and mental health. Through this data, our
Veterans have voiced their appreciation with patient satisfaction
scores improving in every category related to getting care when they
needed it. We also recognize that quality care comes from having
adequate levels of staff available to provide the care. Today, there
are more than 200,000 health care professionals, including doctors and
nurses, who treat Veterans in the VA system. VA has hired more than
14,000 new employees in support of health care since October 2016.
Electronic Wait List
The number of Veterans waiting for clinical care appointments to be
made is commonly referred to as the Electronic Wait List (EWL). It is
important to note that the EWL is the name of the software used to
create reports. Reports include those that track Veterans waiting to
schedule an appointment for clinical care, as well as administrative
requests. The most common administrative requests are Veterans who are
already receiving care and prefer another provider within the same
health care facility area such as from a primary care provider at the
main facility instead of one at a VA Community Based Outpatient Clinic
(CBOC). There is no other health care system that VA is aware of that
tracks transfer requests at a regional or system-wide level, it is
tracked locally.
EWL was developed in 2002 by the VHA Office of Informatics and
Technology in response to a rapid increase in demand for clinical
services. After 2014, VA made the decision to track these
administrative requests using EWL software. These administrative
requests are not included as part of wait list numbers because these
are requests from Veterans who are already receiving care. Due to
recent media reports of a whistleblower indicating issues with EWL, we
conducted a top to bottom review, and while no Veterans were harmed
while on the administrative EWL, this review has allowed us to
streamline processes and eliminate confusion for VA staff and Veterans.
We are developing plans to phase out use of EWL altogether by
offering Veterans the choice of care in the community or to be
scheduled for an appointment that could be more than 90 days (patients
waiting this long do not have an urgent clinical need, i.e., waiting
more than 90 days for an optometry appointment to get new prescription
eyeglasses) in the future. Because we respect and value our patients'
preferences, VHA is both implementing new scheduling software that can
track these requests and identifying new tools to track transfer
requests until the new scheduling tools are in place.
Culture of Accountability and Transparency
Since 2014, VHA established an organizational structure, assigned
responsibilities, and delegated authority to ensure multi-level
oversight of access objectives. VHA's Office of Veterans Access to Care
(OVAC) is the primary responsible program office that provides national
oversight and direction for improving access to care. OVAC is headed by
a Senior Executive Service-level Assistant Deputy Under Secretary for
Health.
VA's Access to Care website (https://www.accesstocare.va.gov/) was
created in 2017 to transparently provide helpful information on topics
including wait times, patient satisfaction, and quality. Measuring the
time a new patient waits for an appointment from the date the
appointment request was initiated is a more objective way of measuring
patient wait times. For the majority of our appointments, those with
established patients, measuring from the date the patient says he or
she wants to be seen is a better indicator for patient experience. This
information assists Veterans with decisions about where they can
receive their care in a timely manner. This is a widely used website
with millions of hits.
Additionally, VHA created the Health Improvement Center to track
and trend performance in terms of quality, access, safety, and Veteran
experience across multiple indicators and to identify medical
facilities with unfavorable data trends or those not meeting goals and
targets. In response to data trends, VHA contacts sites of concern or
those not meeting targets and mobilizes a team of experts as needed to
provide collaborative on-site consultation and follow-up to ensure
progress is made and to support ongoing process improvement.
Scheduling and Training
Since 2014, when reports indicated that VHA needed improvement in
scheduling processes and scheduler training, OVAC took the lead to
modernize VA's approach to scheduling appointments and consults. These
efforts have resulted in standardized national processes, national
audits, and standardized scheduler trainings. More than 58,000 VHA
employees, including Medical Support Assistants (MSA), clinicians,
nurses, and health care technicians have completed this training, which
includes technical and customer service skills, as well as in-depth
training on standard processes and procedures per VHA's scheduling
directive. Overall, this has improved access to high-quality care for
our Nation's Veterans.
Continuing to Improve
We continue to look at ways to improve how we deliver care,
utilizing a team-based approach. Recently, OVAC began implementing a
three-phased initiative named Improving Capacity, Efficiency, and
Productivity (ICEP) to help facilities, working through Veterans
Integrated Service Network (VISN) teams, administrative and clinical
staff, along with Group Practice Managers (GPM), to meet the access
standards established by VA pursuant to the VA MISSION Act of 2018. As
a result, more than 98.5 percent of VA sites have wait times under 20
days for new patients who want a mental health care appointment. This
compares favorably to wait times in the private sector.
More than 60 percent of VA sites currently meet the 20-day
threshold for new patient wait times in primary care, with the average
primary care wait time in 2018 for new patients down to 21.2 days and
moving closer to VA's access standards. VA continues working
strategically to help each facility improve in key areas through the
ICEP initiative.
In 2016, VHA began offering Veterans the ability to directly
schedule appointments in audiology and optometry without a consult from
their primary care provider. The following year, VHA expanded direct
scheduling to include podiatry, nutrition, prosthetics, oncology,
screening mammography, amputee clinic, and wheelchair clinic. Using the
Veterans Appointment Online Scheduling application, patients can make
and cancel appointments via a smartphone, tablet, or computer. This
application has improved customer satisfaction, increased data
reliability, and reduced scheduling errors by putting Veterans at the
center of their own care. Using this application, Veterans can also
request a call from VA to help with scheduling primary care and mental
health appointments.
VHA enhanced the VistA Scheduling software to automate the entry of
the correct date, which is the agreed upon appointment date between the
provider and the patients, directly into VistA Scheduling, eliminating
the opportunity for human error in the process. Additionally, in
association with the Veterans, Access, Choice, and Accountability Act
of 2014, all VAMCs have at least one GPM. GPMs, who are a critical
field position supporting Veteran access and every facility, coordinate
with OVAC and their local team to implement best practices to improve
scheduling processes and increase efficiencies to reduce wait times.
OVAC often works with sites, through GPMs, to help them improve access
to care.
Putting Technology to Work
Today's VA is using technology to create opportunities for better
access to care, better care overall, and more convenience for our
Veterans. For example, in 2018, VHA launched a new software named
VEText that enabled us to send more than 98 million text message
appointment reminders to more than 6.2 million Veterans. This resulted
in significant improvements in no-show rates, decreasing from 13.7
percent to 11.7 percent, creating the opportunity for about 1 million
new appointments for Veterans who needed to be seen. In 2019, VHA began
offering earlier appointment times for Veterans when slots become
available through the VEText software, resulting in over 3,800
rescheduled appointments to date because of this technology.
VA has invested in telehealth, providing Veterans the option of
virtual visits using a smartphone, tablet, or laptop, resulting in more
than 1 million video telehealth visits in Fiscal Year 2018, a 19
percent increase in video telehealth visits over the prior fiscal year.
Networks are creating virtual care hubs for primary care and mental
health coverage. The hubs are established in more than half of the
country and will be nationwide in 2020.
Better Integrated Care - The VA MISSION Act of 2018
The VA MISSION Act of 2018 strengthens VA's health care system by
improving both aspects of care-delivery - internal and community care -
and by empowering Veterans to find the balance in the system that is
appropriate for them. We believe VA's new Veterans Community Care
Program is already working better for Veterans, their families, and
providers.
More Veterans are now eligible for community care, allowing them to
choose care in their community if that is their preference. Scheduling
appointments is easier, and care-coordination between VA and community
providers will be better. With implementation of the VA MISSION Act of
2018, Veterans have more ways to access world-class care through VA
than ever before, and the data show that Veterans are choosing VA
health care in record numbers. Veterans continue to tell us they trust
us with their health care. VHA is completing more medical appointments
than ever before, even as the total population of Veterans is
shrinking.
Conclusion
Veterans' care is our mission. We are committed to building the
trust of Veterans and will continue to improve Veterans' access to
timely, high-quality care from VA facilities, while providing Veterans
with more choice to receive community care where and when they want it.
Your continued support is essential to providing this care for Veterans
and their families. Mr. Chairman, this concludes my testimony. My
colleagues and I are prepared to respond to any questions you may have.
Prepared Statement of Kenneth W. Kizer, MD, MPH
Good morning, Chairman Takano, Ranking Member Roe, and Members of
the Committee. Thank you for the opportunity to appear before you today
to comment about assessing and tracking wait times and timely access to
care and the evolving nature of what access to care means in a world
that is increasingly connected by advanced communications and
information technology. Thank you also for asking me to offer some
thoughts about steps that the Department of Veterans Affairs (VA) might
take to improve the transparency and availability of its wait time data
to assist veterans make informed choices about where to receive care.
My comments to you today are informed by my prior experience in
multiple different professional capacities in which assessing access to
care was an important part of my duties. Among others, these roles have
included serving as:
A physician in military, private practice and academic
health care settings;
California's top health official where my
responsibilities included managing the nation's largest Medicaid
program (Medi-Cal), as well as numerous public health programs serving
disadvantaged populations;
VA's Under Secretary for Health for five years in the
late 1990s, where I oversaw an internationally acclaimed transformation
of VA health care, which included materially improving access to care
and decreasing wait times;
Founding President and CEO of the National Quality Forum,
a public- private partnership organization which endorses performance
measures that are widely used today by health plans and insurers,
health systems and individual health care providers throughout the
nation;
Chief Medical Officer for the California Department of
Managed Health Care, where my duties included assessing health plan
network adequacy to ensure time////ly access to care;
Director of the Institute for Population Health
Improvement at the University of California, Davis, where, among other
things, I oversaw programs and research studies aimed at improving
access to care; and
A health care consultant to various private and publicly
funded health systems seeking to improve access to care, including the
Los Angeles County Department of Health Services which manages the
second largest publicly funded metropolitan health system in the
nation.
BACKGROUND AND CONTEXT
Assuring timely access to care is widely recognized as an important
dimension of high-quality health care and has been a priority
throughout American health care for many years. However, consistently
achieving timely access to care continues to be a challenge for most
health plans, health care providers, patients and families throughout
the U.S., as it is in other countries. Wait times for health care vary
greatly across the nation, ranging from same day service to waits of
many months, depending on the health care provider, the type of service
sought, and individual patient factors such as type of health insurance
and place of residence.
Except for certain well-defined emergent situations in which time
to treatment is definitively linked to care outcomes there are no
industrywide standards for timely access to care. Situations in which
widely accepted timeliness of care standards exist include time between
onset of symptoms and administration of thrombolytic medication in
cases myocardial infarction (heart attack) or stroke, the time to
surgical treatment in cases of severe trauma, and the time to
administration of systemic antibiotics in cases of sepsis. In contrast
to these emergency care situations, however, many different sets of
timeliness standards are variously used by health plans and health care
providers when assessing timeliness of care for primary, specialty,
hospital or post-acute care. As a result, numerous different methods
are used to assess wait times and access to care, making it difficult
to understand and compare the timeliness of care across health systems
and among individual providers. Further compounding this, information
about wait times for private health care providers are not routinely
made publicly available.
A good review of the many different methods used for measuring and
tracking the timeliness of care is provided in the Institute of
Medicine's 2015 report on patient scheduling and access.\1\ Of note,
this study was commissioned by the VA.
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\1\ Institute of Medicine. Transforming Health Care Scheduling and
Access: Getting to Now. Washington, DC. National Academies Press. 2015.
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The problems related to long wait times (e.g., poorer health
outcomes; patient inconvenience, frustration and dissatisfaction; and
increased utilization and costs due to delayed care, among other
things) are well known. As Drs. Jaewon Ryu and Thomas Lee succinctly
summarized this in an article in the New England Journal of Medicine in
2017 when they said, ``When patients wait weeks or months for
physician's appointments, bad things happen.''\2\ Clearly, the goal of
all health plans and health systems should be to ensure the timely
delivery of care for each patient every time in every setting.
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\2\ Ryu J, Lee TH. The Waiting game - Why Providers May Fail to
reduce Wait Times. N Engl J Med 2017; 376 (24):2309-2311.
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In 2001, in its landmark report Crossing the Quality Chasm,\3\ the
Institute of Medicine identified six defining properties of high-
quality health care - that it be safe, effective, patient-centered,
efficient, equitable, and timely. Given all that we know about the
adverse consequences of untimely or delayed care, it is ironic that of
the defining attributes of high-quality health care, timeliness of care
is the least-well studied and least-well tracked as a health care
performance metric. Forums such as today's hearing are important in
focusing greater attention on better understanding and assuring the
timeliness of care.
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\3\ Institute of Medicine. Crossing the Quality Chasm. Washington,
DC. National Academies Press. 2001.
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There are multiple reasons for the widespread problems in timely
access to care in this country, and much has been written on this
subject. Delving into these reasons is beyond the scope of this
statement. Suffice it to say that among the patient-related reasons for
delayed care, lack of health insurance or the type of a one's health
insurance (e.g., Medicaid) continue to be the most common reasons for
lack of timely access to care.
From a health system perspective, however, problems in timely
access to care are primarily the result of the extreme complexity of
American health care and the generally non-systematic approach to the
design, implementation and assessment of patient scheduling protocols
and scheduling systems and the absence of national performance
standards for timeliness of care. The lack of reliable performance
standards that can be used to assess and improve health care scheduling
is due in significant part to the technical difficulties in reliably
capturing all the data variables that go into accurately measuring wait
times and the resultant paucity of good data on which to provide care
setting-specific guidance on reasonable timeliness for care.
Measuring wait times seems on one level like it should be very
straightforward, if not simple; however, in practice it turns out to be
extremely complicated. For example, it is very difficult for scheduling
systems to capture all the variables that go into patient preference
and how one's preference for when he or she would like to be seen may
change quickly and repeatedly due to real life circumstances. Likewise,
it is very difficult for scheduling systems to capture clinical issues
related to the appropriate urgency of being seen by a clinician. The
same presenting complaint or reason for seeking care in different
people with different histories and circumstances may translate into
very different timeliness of care needs.
Notwithstanding what is said above, and despite the many technical
challenges, health systems are developing systems-based approaches to
improving access, and there are emerging best practices for scheduling
and for improving timely access to care. A number of these approaches
are highlighted in the previously referenced 2015 report from the IOM.
I am hopeful that additional research and validation of some of these
promising practices will soon provide the foundation for consensus
standards for timely access to care.
Especially important to note in this regard are patient-reported
measures of the timeliness of the care. Increasingly, health systems
are finding that among the most useful ways to assess whether they are
providing timely care is to ask patients to rate their ability to get
the appointment they wanted or to report back on how satisfied they
were with the length of time it took to schedule an appointment and
whether the person scheduling the appointment seemed to care about them
as a person and making sure they were seen as quickly as possible.
While not as quantitative as wait time measures, patient-reported
qualitative measures are very revealing as to how well a health system
works.
Given the inherent difficulties is accurately measuring wait times,
many health systems are increasingly relying upon patient reported
measures for accountability purposes. They are not abandoning measuring
wait times but are using wait times data more for quality improvement
purposes. That is, they use wait time targets more for quality
improvement than accountability.
I think what is clear from the evidence available today is that to
measure and track timeliness of care we need to rely on multiple
methods of assessment using a balanced mix of quantitative (e.g., wait
times) and qualitative (e.g., patient-reported satisfaction) measures
and that more attention needs to be focused on specifying setting-
specific timeliness of care performance standards.
THE NEED TO REFRAME OR REDEFINE WHAT ACCESS TO CARE MEANS
In considering the timeliness of care and how accessibility should
be measured today, we need to ask a basic question about what access to
care means in an era of enhanced connectivity through information and
communication technologies. In a time when a large proportion of the
population accomplishes many critically important activities (e.g.,
banking) via the internet, why do we continue to view access to health
care only or primarily through a lens of in-person face-to-face visits.
Measuring access to care by only counting face-to-face encounters
between the patient and caregiver is anachronistic and does not promote
patient-centered care.
Indeed, a variety of public opinion surveys indicate that 70 to 80
percent of respondents would welcome the opportunity to accomplish
their health care needs through technology-assisted means such as
telehealth.
Increasingly, health systems are finding that a large proportion,
if not the majority, of patient-caregiver interactions can be
accomplished through technology- assisted methods such as telehealth or
secure e-mail. For example, Kaiser Permanente reports that more than
half of its more than100 million annual outpatient encounters are now
completed through various types of telehealth communications. In the
same vein, the Los Angeles County Department of Health Services has
dramatically reduced wait times for specialty care through
implementation of an e-consult program.
The VA is widely acknowledged as a leader in telehealth and virtual
care, but I believe it has only scratched the surface of what could be
done to enhance access to care through technology-assisted methods. The
VA was the first health system in the country to hire a chief
telehealth officer when it did so in 1999, and it has made commendable
progress in telehealth in the intervening 20 years. However, VA has not
fully capitalized on its potential to enhance access to care by
combining technology- assisted care with more traditional face-to-face.
This remains an unfulfilled opportunity.
A PRESCRIPTION FOR ENHANCED VA ACCESS TO CARE
Mr. Chairman let me close these comments by responding to your
request that I offer some thoughts about what VA could do to improve
the transparency and availability of wait time data to assist veterans
make informed choices about where to receive care. I would preface my
suggestions by first noting that I believe the VA health care system
has an unparalleled opportunity to become the nation's leader in
assuring timely access to care. I believe the VA has the potential to
define the future of what timely access to care could and should be.
With the right leadership and technical assistance, I believe the
VA could quickly become the nation's gold standard for timely access to
care for several reasons. These reasons include the VA being the
nation's only truly national health care system, having health care
facilities and other care delivery assets in every state - indeed in
essentially every major metropolitan area of the country; because it is
a federal system that is not encumbered by state practitioner licensure
laws, among other things; and because it uses a global method of
allocating resources (i.e., payment) and functions as both an insurer
and provider so the distinction between cost and lost revenue to
providers is much less important than in the private sector. Further,
the VA has extensive research and training capabilities that could be
applied to evaluating and implementing new methods of access to care.
I believe there are several things that the VA could do to
facilitate the transparency and availability of data while making sure
that veterans have access to care whenever and wherever they need it.
Toward that end, let me note six things here.
One, the VA should set a goal of becoming the nation's leader in
assuring timely access to care through a coordinated combination of
virtual and in-person care utilizing technology-assisted encounters,
face-to-face visits, in-home and group visits, mobile delivery assets,
and expanded use of non-physician caregivers, among other means.
Two, the VA should engage the National Academies of Sciences,
Engineering and Medicine to help it define what 21st century access to
care means and to delineate the key operating characteristics and
functionalities required to operationalize the definition.
Three, the VA should enlist the help of the National Quality Forum
in identifying and endorsing performance measures to monitor and track
access to care in ways that are transparent, reliable and
understandable.
Four, the VA should take immediate and aggressive steps to increase
access to care through virtual means such as tele-health and M-health.
A systemwide initiative should be launched commensurate with
implementation of the Mission Act that would increase the number of
encounters by virtual means by an order of magnitude within two years.
I suggest that an initial high priority target for such an initiative
would be virtual or telehealth urgent care visits.
Five, while the above efforts are in progress, the VA should
increase the use of veteran-satisfaction measures of access to care,
being informed in this regard by its work with the National Quality
Forum. In doing this, VA should use this information, along with the
wait times data, within the construct of a health care learning system
that uses continuous quality improvement methods to feed information
back to the system that leads to continuous improvement.
Six, the VA should call upon its Health Services Research &
Development Service to evaluate the most effective strategies and
methods to ensure timely access to care that meet the diverse needs of
veterans in the many varied communities and settings where veterans
live.
Thank you, Mr. Chairman and members of the Committee for the
opportunity to appear before you today. That concludes my comments, and
I would be pleased to respond to your questions.