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Submission For The Record of The Government Accountability Office

Chairman Miller, Ranking Member Michaud, and Members of the Committee:
I am pleased to have the opportunity to comment on overcoming barriers for quality mental health care for veterans—particularly those who are returning from deployment. In 2011, we reported that the number of veterans receiving mental health care had increased each year from fiscal year 2006 to 2010, and veterans who served in Afghanistan and Iraq accounted for an increasing proportion of veterans receiving mental health care during this period.  We also reported on the key barriers that may hinder veterans from accessing mental health care from the Department of Veterans Affairs (VA), which included difficulty scheduling appointments.  More recently, in December 2012, we reported on problems with VA’s oversight of outpatient medical appointment scheduling processes and measurement of outpatient medical appointment wait times.
In fiscal year 2011, there were more than 8 million veterans enrolled in VA’s health system, which is operated by the Veterans Health Administration (VHA). VHA provided nearly 80 million outpatient medical appointments to veterans through its primary and specialty care clinics.  Although access to timely medical appointments is critical to ensuring that veterans obtain needed medical care, long wait times and inadequate scheduling processes at VA medical centers (VAMC) have been long-standing problems that persist today. For example, in 2001, we reported on the timeliness of medical appointments and found that two-thirds of the specialty care clinics visited had wait times longer than 30 days, although some clinics had made progress in reducing wait times, primarily by improving their scheduling processes and making better use of their staff.  Later, in 2007, the VA Office of Inspector General (OIG) reported that VHA facilities did not always follow VHA’s scheduling policies and processes and that the accuracy of VHA’s reported wait times for medical appointments was unreliable.  Most recently, in 2012, the VA OIG reported that VHA was not providing all new veterans with timely access to full mental health evaluations, and had overstated its success in providing veterans with timely new and follow-up appointments for mental health treatment.  Although VHA has reported continued improvements in measuring and achieving timely access to medical appointments, patient complaints and media reports about long wait times have persisted, prompting renewed concerns about excessive medical appointment wait times.
VHA has a scheduling policy intended to help its VAMCs meet its commitment to scheduling medical appointments with no undue waits or delays.  The policy establishes processes and procedures for scheduling medical appointments and ensuring the competency of staff directly or indirectly involved in the scheduling process. It includes several requirements that affect timely appointment scheduling, as well as accurate wait time measurement.  For example, the policy requires schedulers to record appointments in VHA’s Veterans Health Information Systems and Technology Architecture (VistA) medical appointment scheduling system, including the date on which the patient or provider wants the patient to be seen—known as the desired date.
At the time of our review, VHA measured medical appointment wait times as the number of days elapsed from the patient’s or provider’s desired date, as recorded in the VistA scheduling system by VAMCs’ schedulers. According to VHA central office officials, VHA measures wait times based on desired date in order to capture the patient’s experience waiting and to reflect the patient’s or provider’s wishes. In fiscal year 2012, VHA had a goal of completing primary care appointments within 7 days of the desired date, and scheduling specialty care appointments within 14 days of the desired date.  VHA established these goals based on its performance reported in previous years.  To help facilitate accountability for achieving its wait time goals, VHA includes wait time measures—referred to as performance measures—in its Veterans Integrated Service Network (VISN) directors’ and VAMC directors’ performance contracts,  and VA includes measures in its budget submissions and performance reports to Congress and stakeholders.
This statement highlights key findings from our December 2012 report that describes needed improvements in the reliability of VHA’s reported medical appointment wait times, scheduling oversight, and VHA initiatives to improve access to timely medical appointments.  For that report, we reviewed VHA’s scheduling policy and methods for measuring medical appointment wait times and interviewed VHA central office officials responsible for developing them. We did not include mental health appointments in the scope of our work, because this issue was already being reviewed by VA’s Office of Inspector General. We also visited
23 high-volume outpatient clinics at four VAMCs selected for variation in size, complexity, and location; these four VAMCs were located in Dayton, Ohio; Fort Harrison, Montana; Los Angeles, California; and Washington, D.C. At each VAMC we interviewed leadership and other officials about how they manage and improve medical appointment timeliness, their oversight to ensure accuracy of scheduling data and compliance with scheduling policy, and problems staff experience in scheduling timely medical appointments. We examined each VAMC’s and clinic’s implementation of elements of VHA’s scheduling policy and obtained documentation of scheduler training completion. In addition, we interviewed schedulers from 19 of the 23 clinics visited, and also reviewed patient complaints about telephone responsiveness, which is integral to timely medical appointment scheduling. We interviewed the directors and relevant staff of the four VISNs for the sites we visited. We also interviewed VHA central office officials and officials at the VAMCs we visited about selected initiatives to improve veterans’ access to timely medical appointments. We performed this work from February 2012 through December 2012 in accordance with generally accepted government auditing standards.
In brief, we found that (1) VHA’s reported outpatient medical appointment wait times are unreliable, (2) there was inconsistent implementation of certain elements of VHA’s scheduling policy that could result in increased wait times or delays in scheduling timely medical appointments, and
(3) VHA is implementing or piloting a number of initiatives to improve veterans’ access to medical appointments. Specifically, VHA’s reported outpatient medical appointment wait times are unreliable because of problems with correctly recording the appointment desired date—the date on which the patient or provider would like the appointment to be scheduled—in the VistA scheduling system. Since, at the time of our review, VHA measured medical appointment wait times as the number of days elapsed from the desired date, the reliability of reported wait time performance is dependent on the consistency with which VAMC schedulers record the desired date in the VistA scheduling system. However, aspects of VHA’s scheduling policy and related training documents on how to determine and record the desired date are unclear and do not ensure replicable and reliable recording of the desired date by the large number of staff across VHA who can schedule medical appointments, which at the time of our review was estimated to be more than 50,000. During our site visits, we found that at least one scheduler at each VAMC did not record the desired date correctly, which, in certain cases, would have resulted in a reported wait time that was shorter than the patient actually experienced for that appointment. Moreover, staff at some clinics told us they change medical appointment desired dates to show clinic wait times within VHA’s performance goals. Although VHA officials acknowledged limitations of measuring wait times based on desired date, and told us that they use additional information, such as patient satisfaction survey results, to monitor veterans’ access to medical appointments, reliable measurement of how long veterans wait for appointments is essential for identifying and mitigating problems that contribute to wait times.
At the VAMCs we visited, we also found inconsistent implementation of VHA’s scheduling policy, which can result in increased wait times or delays in scheduling timely medical appointments. For example, four clinics across three VAMCs did not use the electronic wait list to track new patients that needed medical appointments as required by VHA’s scheduling policy, putting these clinics at risk for losing track of these patients. Furthermore, VAMCs’ oversight of compliance with VHA’s scheduling policy was inconsistent across the facilities we visited. Specifically, certain VAMCs did not ensure the completion of scheduler training by all staff required to complete it even though officials stressed the importance of the training for ensuring correct implementation of VHA’s scheduling policy. VAMCs also described other problems that impede the timely scheduling of medical appointments, including VA’s outdated and inefficient VistA scheduling system, gaps in scheduler staffing, and issues with telephone access. The current VistA scheduling system is more than 25 years old, and VAMC officials reported that using the system is cumbersome and can lead to errors.  In addition, shortages or turnover of scheduling staff, identified as a problem by all of the VAMCs we visited, can result in appointment scheduling delays and incorrect scheduling practices. Officials at all VAMCs we visited also reported that high call volumes and a lack of staff dedicated to answering the telephones impede the scheduling of timely medical appointments. Although we did not specifically review mental health clinic wait times, some of the problems we identified were pervasive, and may also affect clinics other than those we visited.
VHA is implementing or piloting a number of initiatives to improve veterans’ access to medical appointments that focus on more patient-centered care; using technology to provide care, through means such as telehealth and secure messaging between patients and their health care providers; and using care outside of VHA to reduce travel and wait times for veterans who are unable to receive certain types of outpatient care in a timely way through local VHA facilities. For example, VHA is piloting a new initiative to provide health care services through contracts with community providers that aims to reduce travel and wait times for veterans who are unable to receive certain types of care from VHA in a timely way. Although VHA collects information on wait times for medical appointments provided through this initiative, these wait times may not accurately reflect how long patients are waiting for appointments because they are counted from the time the contracted provider receives an authorization from VA, rather than from the time the patient or provider first requests an appointment from VHA.
In conclusion, VHA officials have expressed an ongoing commitment to providing veterans with timely access to medical appointments and have reported continued improvements in achieving this goal. However, unreliable wait time measurement has resulted in a discrepancy between the positive wait time performance VA has reported and veterans’ actual experiences. More consistent adherence to VHA’s scheduling policy and oversight of the scheduling process, allocation of staff resources to match clinics’ scheduling demands, and resolution of problems with telephone access would potentially reduce medical appointment wait times. VHA’s ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care to veterans, who may have medical conditions that worsen if access is delayed.
To ensure reliable measurement of how long veterans are waiting for appointments and improve timely medical appointment scheduling, we recommended that the Secretary of VA direct the Under Secretary for Health to take actions to (1) improve the reliability of its medical appointment wait time measures, (2) ensure VAMCs consistently implement VHA’s scheduling policy, (3) require VAMCs to routinely assess scheduling needs for purposes of allocation of staffing resources, and (4) ensure that VAMCs provide oversight of telephone access and implement best practices to improve telephone access for clinical care. VA concurred with our recommendations and identified actions planned or underway to address them.