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Outpatient Waiting Times.

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DECEMBER 12, 2007

SERIAL No. 110-62

Printed for the use of the Committee on Veterans' Affairs





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
HENRY E. BROWN, JR., South Carolina

HARRY E. MITCHELL, Arizona, Chairman

TIMOTHY J. WALZ, Minnesota
GINNY BROWN-WAITE, Florida, Ranking
BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



December 12, 2007

Outpatient Waiting Times


Chairman Michael E. Michaud, Subcommittee on Health
    Prepared statement of Chairman Michaud
Chairman Harry E. Mitchell, Subcommittee on Oversight and Investigations
    Prepared statement of Chairman Mitchell
Hon. Ginny Brown-Waite, Ranking Republican Member
    Prepared statement of Congresswoman Brown-Waite
Hon. Zachary T. Space


U.S. Department of Veterans Affairs:
Belinda J. Finn, Assistant Inspector General for Auditing, Office of Inspector General
    Prepared statement of Ms. Finn
Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for Health, Veterans Health Administration
    Prepared statement of Dr. Cross
Paul A. Tibbits, M.D., Deputy Chief Information Officer, Office of Enterprise Development, Office of Information and Technology
    Prepared statement of Dr. Tibbits

 Jones, Mary C., Licking County Veterans' Service Officer, Licking County Veterans’ Service Commission, Newark, OH,
    Prepared statement of Ms. Jones
Unum US, Portland, ME, Kevin P. McCarthy, President and Chief Executive Officer
    Prepared statement of Mr. McCarthy


Miller, Hon. Jeff, Ranking Republican Member, Subcommittee on Health, and a Representative in Congress from the State of Florida, statement
Stearns, Hon. Cliff, a Representative in Congress from the State of Florida, statement


Post Hearing Questions and Responses for the Record:

Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. Gordon Mansfield, Acting Secretary, U.S. Department of Veterans Affairs, letter dated December 13, 2007, attached legislative text for H.R. 92, the "Veterans Timely Access to Health Care Act, and response letter from VA dated July 31, 2008 

Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary, U.S. Department of Veterans Affairs, letter dated January 16, 2008, and response letter dated February 15, 2008.  [The attachment to the letter, a breakdown by VISN and facility of the outpatient and specialty care waiting times for the Department's major medical centers and the community-based outpatients clinics, will retained in the Committee files.]

Hon. Michael H. Michaud, Chairman, and Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, and Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. George J. Opfer, Inspector General, U.S. Department of Veterans Affairs, letter dated February 14, 2008, and response letter dated March 17, 2008

Hon. Michael H. Michaud, Chairman, and Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, and Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. James B. Peake, Secretary, U.S. Department of Veterans Affairs, letter dated February 29, 2008, and VA responses


Wednesday, December 12, 2007
U. S. House of Representatives,
Subcommittee on Health
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittees met, pursuant to notice, at 2:50 p.m., in Room 345, Cannon House Office Building, Hon. Michael H.  Michaud [Chairman of the Subcommittee on Health] presiding.

Present from Subcommittee on Health:  Representative Michaud. 

Present from Subcommittee on Oversight and Investigations:  Representatives Mitchell, Space, and Brown-Waite.

Also present:  Representative Kennedy.


Mr. MICHAUD.  I would like to call to order this joint hearing on the U.S. Department of Veterans Affairs (VA) outpatient waiting times . 

I would ask unanimous consent that my full statement be included in for the record.  Hearing no objection, so ordered. 

The focus of this hearing is waiting times for outpatient appointments in the Veterans Health Administration (VHA).  Outpatient waiting times are one aspect of a much broader focus of the Subcommittee on Health, access to high-quality healthcare.  "Access to healthcare" is defined as the ability to get medical care in a timely manner when needed.  We know that access to healthcare is important for veterans.  It improves treatment outcomes and the quality of life for those who have it. 

Since the beginning of the 110th Congress, the Subcommittee on Health has taken broad action to increase veterans' access to healthcare.  Today I hope that we will learn more about how the VA is doing, in seeing patients in a timely manner for initial and necessary follow-up appointments, and how the VA tracks this information.  I would also like to learn how the VA is managing patient care to provide necessary preventative medicine. 

In a system that handles 40 million outpatient appointments per year, it is clear that efficient and effective policy, training and follow-up is critical in achieving success.  I hope that we can use this time to work towards a solution so that we can all achieve our primary goal, to improve the access to healthcare for all veterans.  I am confident that, by working together, we will be successful.  Timely access to quality healthcare is something that those who have served our country have earned.  We must work together to provide it for them.

I now would like to yield to Ms. Brown-Waite, the Ranking Member of the Subcommittee on Oversight and Investigations, for an opening statement. 

[The statement of Chairman Michaud appears in the Appendix.]


Ms. BROWN-WAITE.  Thank you, Mr. Chairman. 

I want to thank Ranking Member Miller, who I know is on his way, along with the rest of the Members of the Subcommittee on Health for joining us for this important hearing on outpatient waiting times at the Department of Veterans Affairs. 

As of October 2007, there were 7.9 million veterans enrolled in the VA healthcare system.  Today there are more than 153 VA medical centers and 724 community-based outpatient clinics—we refer to them as "CBOCs"—available to serve the needs of our veterans.  When a veteran or a physician calls to schedule an appointment in one of these clinics, they should be able to receive an appointment that is timely and appropriate to the medical needs of the veteran. 

I am looking forward to hearing from our first panel of witnesses today as well as from the other panel as to how they feel outpatient wait times at the VA has affected them as well as any possible solutions that we can, as a legislative body, come up with to remedy the situation.  I am also interested in hearing from the VA Office of Inspector General (OIG) on their perspective on the wait time issue.  Finally, I expect to hear from the VA as to how they monitor wait times and what steps they are taking to improve the timeliness of services provided to our veterans. 

On January 4, 2007, I introduced H.R. 92, the "Veterans Timely Access to Health Care Act," which would make the standard for a veteran seeking primary care from the Department of Veterans Affairs 30 days from the date the veteran actually contacts the Department.  Unfortunately, the bill is needed because current practices do not meet that goal. 

I monitor data in my area, which is part of Veterans Integrated Service Network (VISN) 8, from the Department of Veterans Affairs to determine the time new patients and existing patients wait to receive an appointment.  While established patients wait less than 15 days for an appointment, the numbers for new patients happen to be much higher. 

What I also found interesting, in looking over the data, is that there appears to be a decrease in the wait times at the major medical facilities; however, at the CBOC level, the community-based outpatient clinic level, wait times actually have increased.  In the third quarter of fiscal year 2007, new patients had to wait an average of 45 to 50 days to receive an appointment at a VA clinic, while new patients waited an average of 22 to 25 days to receive an appointment at the VA medical centers.  This simply is not acceptable. 

I am also curious as to the dramatic decrease in the wait times at the VA medical centers in VISN 8.  I question whether patients are being redirected to the CBOCs to reduce wait times at the medical centers.  If veterans are having problems receiving their care within 30 days, then Congress needs to allow them to look for an alternative. 

My bill is not—and I underline "not"—a scheme to move VA toward privatization.  It simply ensures that veterans receive care in a timely manner. 

The VA can and does provide a high level of care to all of the veterans who are enrolled in the system.  However, if a veteran cannot be seen by a physician in a timely manner, what good does that do?  The Department of Veterans Affairs' Web site states that it is the goal of the VA to, and I quote, "provide excellence in patient care, veterans benefits and consumer satisfaction."  This hearing today is to determine whether the VA is meeting that goal with timely access to care. 

As everyone knows, this issue is tremendously important to every American.  Our veterans did not wait to answer the call of duty.  They answered their Nation's call and took up arms to protect our freedom.  They served, and many returned injured and in need of care. 

I talk with veterans from my district on a daily basis about the issues that they have with the VA, and getting in to see a doctor in a timely fashion is at the top of their list.  I do not believe that veterans' care should be a political issue.  Instead, Members of Congress should work together to improve veterans healthcare so that it becomes the model for good governance and excellence in healthcare. 

Again, I thank you, Mr. Chairman, and I yield back the balance of my time. 

[The statement of Congresswoman Brown-Waite appears in the Appendix.]

Mr. MICHAUD.  Thank you very much.

I now will recognize Mr. Mitchell, who is the Chairman of the Subcommittee on Oversight and Investigations, for an opening statement. 


Mr. MITCHELL.  Thank you, Mr. Chairman. 

You know, the Veterans Health Administration is one of the best healthcare providers in the country, yet our veterans can only take advantage of this healthcare if they get the appointments they need to access it.  Unfortunately, too many of our troops are returning home and are encountering long waiting times. 

When I was back in my district this past weekend, I met with a group of Arizona veterans.  Many of those veterans expressed concerns about the long waiting times they have encountered to get doctors' appointments.  One local veteran, John Tymczyszyn, tried to make an appointment for treatment for a service-related injury he suffered.  John requested his appointment in December 2006, and his appointment was scheduled in late May of 2007, 6 months after his initial request.  John told me that he continued to struggle to make appointments with the VA, and because of that difficulty, he now relies on civilian providers for his healthcare.  This is unacceptable. 

When we tried to look into the problem to see what we could do to address it, we were unable to secure verifiable documentation of waiting times.  According to a recent audit by the Department of Veterans Affairs Inspector General (IG), the waiting times reported by the VHA are both understated and incomplete.  The VA reported to the Department of Veterans Affairs fiscal year 2006 performance and accountability report in November 2006 that 95 percent of veterans seeking specialty medical care were scheduled for appointments within the required 30-day period; however, the IG audit found sufficient evidence to support that only about 75 percent of veterans had been seen within 30 days of the requested appointment time.  Furthermore, the IG audit found that schedulers were not following established procedures for making and recording medical appointments.  This means that we do not even have a clear picture of how many veterans have requested appointments. 

VHA's schedulers were supposed to act on a veteran's request within 7 days.  If this appointment cannot be made within the required 30 days, the scheduler should place the veteran's request on an electronic waiting list.  However, the IG found that a majority of schedulers are not trained to use this system, so they do not use the electronic waiting list.  Perhaps more alarming are reports that schedulers have been instructed to reduce waiting times by not putting patients on the electronic waiting list.  This attempt to reduce cases of long waiting times could lead to gaming of the scheduling process. 

The VA has discounted the IG's report because it disagrees with how waiting times were calculated.  This is unacceptable.  I am not willing to walk away from this audit over a disagreement about methodology.  This is a real problem that we must look into. 

When our veterans encounter long waiting times, their conditions go undiagnosed, and serious diseases go untreated.  Furthermore, until we have a clearer picture about waiting times, the VA cannot improve the situation because we cannot identify problem facilities or effectively allocate resources.  We should not allow our servicemembers to encounter long wait times for doctors' appointments. 

I look forward to hearing from our witnesses. 

[The statement of Chairman Mitchell appears in the Appendix.]

Mr. MICHAUD.  Thank you, Mr. Mitchell.

Now I would like to recognize a Member who is a very strong advocate for veterans' issues to introduce one of our first panelists.  Mr. Zack Space. 


Mr. SPACE.  Thank you, Mr. Chairman. 

If I might, very briefly, in advance echo the sentiments of my colleagues from both sides of the aisle.  Clearly we have an obligation as a Nation to live up to the promises made to veterans and to provide them with the best and most efficient care that we can.  Certainly part of what this hearing is about is to ensure that that happens, but part of this hearing is also to determine whether the very numbers that the VA has calculated in terms of the delays are accurate. 

As my Subcommittee Chairman, Mr. Mitchell from Arizona, has pointed out, there is a significant discrepancy between what the VA has reported compared to what the IG has reported.  There is a significant discrepancy.  The questions that I am hoping that will be answered today are as to whether that discrepancy is the result of mere incompetence or is the result of intentional misconduct.  To me, it would seem reprehensible that our veterans would be shortchanged at the expense of bureaucratic bookmaking. 

So, with that in mind, I am delighted to have with us today our first presenter, Mary Jones, from Ohio's 18th Congressional District.  Mary Jones served with the United States Army from May of 1983 to May of 1986.  She served with the 101st Airborne Division at Fort Campbell, Kentucky, and she served with the 2nd Infantry Division at Camp Casey, Korea.  Ms. Jones is a graduate of Kent State University and is currently serving as a Licking County Veterans' Service Officer.  She has been with the office since 1995, and is accredited as a service officer with the American Legion, the Disabled American Veterans, the Veterans of Foreign Wars (VFW), the Governor's Office of Veterans Affairs, and with AMVETS.  In that capacity, she directs an office of four accredited service officers working in a county with nearly 16,000 veterans. 

Ms. Jones is a life member of the Disabled American Veterans chapter number 23, of the AMVETS post number 345, of the American Legion's post number 85, and of the VFW's post number 1060.  She is currently serving as the Second Vice Commander of the Sixth District of the American Legion Department of Ohio, and is serving on the board of directors as the Secretary of the Licking County Veterans' Memorial and Educational Center.  A native of Ohio, she and her husband Donald reside in Newark, which is in Ohio's 18th district.  Ms. Jones, I am very happy to report, is also a member of my Veterans Advisory Board. 

I thank you for being here today, Mary, and welcome. 

Ms. JONES.  Thank you.

Mr. MICHAUD.  The second panelist is Kevin P. McCarthy, who is president and Chief Executive Officer of Unum. 

Since the previous panel cut into about 45 minutes of our time, and since we will have votes, actually, within about 45 minutes, you will find Mr. McCarthy's impressive resume in our packets, and hopefully you will have a chance to look at that as well. 

So, without any further ado, I will recognize Ms. Jones to begin her testimony.  I want to thank both of you for coming here today, and I look forward to hearing your remarks. 

So, Ms. Jones?



Ms. JONES.  Thank you, Mr. Chairman and Members of the Subcommittee.  Thank you for providing me with this opportunity to testify regarding issues of outpatient waiting times. 

I have worked as a County Veterans Service Officer for the past 12 years, and in that capacity I have had an opportunity to enjoy a great relationship with the staff at both the Columbus VA Outpatient Clinic and the Newark Community-Based Outpatient Clinic, and I feel privileged to be able to have this relationship.  I use the VA healthcare system as my primary provider of medical care for my service-connected conditions. 

My concern with outpatient waiting times is our inability to get veterans into an appointment in a timely manner.  Their appointments are scheduled so far out, often 2 to 3 months, that their condition worsens, and they are left angry and frustrated at a system that is supposed to be in place to care for those who have given so much to our great Nation.  As examples of the problems created by these wait times, I offer to you some experiences from our office. 

We see many veterans shortly after their return home.  They have been promised dental care within 90 days from their discharge.  One veteran's first available appointment was scheduled almost 90 days from the date of his request.  When he got to the dental clinic, he was told that his appointment needed to be cancelled and rescheduled.  They did not have any appointments available within that 90-day period, and he was, therefore, not seen. 

Female veterans have unique healthcare concerns and face difficult wait times to see gynecologists, often as long as 6 to 8 months.  Please keep in mind that most of the women who we are working with do not have other viable options for healthcare.  Many are wartime veterans on a nonservice-connected pension and are, therefore, very low income.  They are unable to get Medicaid treatment for preventative or diagnostic medical care.  Pap tests and mammograms are increasingly important as we get older and often are life-saving diagnostic tools, but waiting as long as 6 months for the initial exam, and then often even longer to get the test scheduled ,can lead to greater problems if a cancer exists. 

I mentioned earlier that I am a service-connected veteran, that I use the VA outpatient clinic myself.  I was having health concerns and tried to schedule an appointment with my physician and was told the earliest appointment I could get was in 6 months.  Because I am a county employee and have medical insurance through my employment, I was able to see a doctor outside of the VA system within 3 weeks and ended up needing major medication changes and a heart catheterization.  I hate to think what would have happened to a veteran without those options. 

We are filing many claims for post traumatic stress disorder (PTSD).  Usually when we file a claim, we have a veteran who has a diagnosis for a condition, but PTSD is different.  Most veterans can get into the VA to see a social worker and can get assigned to group counseling fairly quickly.  Most can see a psychiatrist within 3 to 4 months for an initial exam, but within the 12 to 18 months that a service-connected claim takes to adjudicate, the veteran is still left without a diagnosis for PTSD because the wait times prohibit the doctor from seeing the patient often enough to provide a definitive diagnosis of any mental health issue.  Because no diagnosis exists, the Veterans Benefits Administration must deny the claim for service connection.  Seeing private psychologists and psychiatrists is beyond the financial reach of most veterans. 

My most memorable experience is a World War II veteran who was in receipt of a nonservice-connected pension.  He was diagnosed with prostate cancer through a prostate-specific antigen test done by his primary care.  Treatment was scheduled, but the wait time was several months.  In the meantime, this very gentle man clearly understood that he would not survive due to the fact that his cancer had spread and was continuing to spread during this wait.  The treatment would have only prolonged his life and would not have saved his life, but this would have been an excellent opportunity to send a positive message of support from our government to this World War II vet.  That opportunity was missed.  He died before his appointment with an oncologist. 

This has been an honor for me to have this opportunity to bring examples of the difficulties experienced by the veterans who I serve caused by the long wait times to be seen at clinics.  I did not come to criticize the VA, because the care given by our outpatient clinic is excellent, but at this time that care comes at a price, and that price is patience. 

Thank you, Mr. Chairman.  This concludes my testimony. 

[The statement of Ms. Jones appears in the Appendix.]

Mr. MICHAUD.  Thank you, Ms. Jones. 

Mr. McCarthy?


Mr. MCCARTHY.  Thank you, Mr. Chairman and Members of the Subcommittee.  I would like to thank you for the opportunity to testify before you.  My name is Kevin McCarthy.  I am the President of Unum.  I have submitted written testimony, which has been made available to you, but I will briefly present an overview. 

Unum's involvement was generated by our company's wanting to explore how we could assist with sharing best practices that might be useful in caring for our veterans.  Recently, Representative Michaud visited Unum and viewed firsthand how the combination of our people and technology are integrated together in a way that reduces delays in every aspect of claims processing and case management, including appointment scheduling. 

As a result of this visit and our meetings this summer and fall with House and Senate Congressional staff, with the Department of Veterans Affairs and with the U.S. Department of Defense (DoD) on the sharing of best practices between the private and public sectors, I am here today to discuss how we use these smart systems and our people not only to reduce waiting times in setting up independent medical examinations, but also to discuss how these are aspects of a larger, integrated case management and claim management approach that include everything from regular contact with our insureds so they know what is happening in real-time on their claims to assisting them with vocational rehabilitation.  This integrated approach actually speeds not only wait times on individual specific issues, but on the entire case management process. 

With regard to the specific issue before you of outpatient wait times, we work closely with our insureds, and with their physicians, to make sure that they are receiving appropriate and regular care, and we follow up shortly after scheduled visits.  As a function of our follow-up and prompting system, we track our insureds' medical visits and revisits, and we record new medical information. 

As one of the world's leading employee benefits providers, Unum helps to protect more than 21 million working Americans and their families in the event of illness or injury.  In 2006, we responded to more than 420,000 newly filed claims and replaced $4 billion of lost income to help provide support to our insureds and to their families.  These benefits are paid directly to our insureds. 

Obviously, the management of disability claims differs from health insurance, but when circumstances warrant, we do follow up in person with our customers and with their providers to determine if they have kept medical appointments.  Also, we typically follow up shortly after appointments to determine if their medical status has changed. 

Our ability to pay our customers billions of dollars annually with these high levels of satisfaction is due to our highly trained people supported by the right technologies.  Specifically, we deploy experienced people and technologies with a comprehensive claims management process that applies the most accurate and appropriate resources to each claim and decision making supported by expert systems and resources with an emphasis on consistent quality and regular tracking. 

While a person's disability can be a complex, ongoing and ever-changing life event, our goal is to make the claims process simple and transparent for our customers during what is a trying time in their lives, so we make it easy to submit a claim.  It can be done by Internet, telephone, fax or mail.  At any time after a claim has been submitted, our customers can speak regularly with a skilled specialist.  We handle more than 4.5 million calls a year. 

While our goal is to make it easy for customers to reach us, we also understand that many need our help.  Thus, we regularly reach out to our insureds and to their healthcare teams.  We view it as critically important to speak with our insureds and their physicians, and we frequently help our patients follow up with their doctors.  We are able to do this because we have invested in an innovative technological process which sorts claims by complexity and severity, and it allows all case and claim management activities to be conducted real-time in one place.  This technology is supported by hundreds of highly trained benefits specialists, physicians, nurses, and vocational rehabilitation specialists.  Our technology allows our people, for example, to make appointments, to schedule exams and follow-up calls, to manage workloads, to review claim documents, and to provide real-time management access and robust quality assurance and continuous improvement.  Each one of the activities the benefits specialist does is scheduled and tracked to ensure that the right resources are applied to the right claims at the right time. 

The claim status is viewable on the Web so our customers can access their claim status.  Privacy safeguards are in place.  For the more complex claims, each customer is called, and we set individual follow-up action plans in place with the insured based on the dynamics of their specific medical condition. 

Our contribution here today is to provide you with insight into our best practices, and we welcome the opportunity to continue to be a resource for public- and private-sector sharing as you continue to evaluate claim processes. 

Thank you very much for the opportunity to testify before your Subcommittees. 

[The statement of Mr. McCarthy appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. McCarthy.

As you mentioned, I have seen your system and your facility in Portland, and I am very impressed with your system.  Patients see specialists very quickly. 

What is the average time that it actually takes them to see a specialist or to see a doctor? 

Mr. MCCARTHY.  Typically we handle all claim inquiries within 3 to 5 days.  The scheduling process, of course, depends on the availability of physicians and their responsiveness to the claimants, but we resolve all short-term disability claims within 3 to 5 days and all long-term disability claims typically within 45 days.

Mr. MICHAUD.  As you mentioned, patients can view their cases on-line.  They can see their care plan, their next appointment, future appointments, et cetera, and you follow up with the patients, as you mentioned, to make sure that they understand what they need and to make sure that they are getting it. 

Can you go into a little more detail on how Information Technology (IT) manages your cases and how that could be implemented within the VA system? 

Mr. MCCARTHY.  Our systems are designed to assist our claimants and the specialists who manage and work with those claimants to make sure that care is delivered in a high-quality and consistent fashion. 

So, for example, in the case of a patient's requiring an independent medical examination, our disability specialist will contact that claimant, will record the conversation, will log the requirement for an independent medical examination.  Simultaneously, that information is available to one of our in-house physicians also on line.  We are able to then work with an outside physician to schedule that appointment.  That information is then logged in the system.  The disability benefits specialist then can see the activity.  He knows when to follow up with the claimant to ensure that the appointment was kept and that care was delivered.  All through the process, this information is available real-time to anyone managing and supporting our claimants.

Mr. MICHAUD.  You also mentioned that you receive 4.5 million calls a year.  How many staff handle those calls?  Is there a waiting list?  Is it an automated list, or can they get a live person? 

Mr. MCCARTHY.  They get a live person.  Every call is answered within 20 seconds.  We have 300 people answering these calls.

Mr. MICHAUD.  Twenty seconds? 

Mr. MCCARTHY.  Twenty seconds.

Mr. MICHAUD.  Three hundred people? 

Mr. MCCARTHY.  Three hundred. 

Mr. MICHAUD.  What is the availability if someone calls in?  Can they call in during the evening, or is it during the daytime? 

Mr. MCCARTHY.  24/7.

Mr. MICHAUD.  24/7.  Thank you. 

Mr. MCCARTHY.  Thank you.

Mr. MICHAUD.  Ms. Brown-Waite?

Ms. BROWN-WAITE.  Thank you very much, Mr. Chairman. 

Ms. Jones, I am very familiar with the great work the veterans service organization officers do, and my hat is off to you. 

You mentioned in your testimony the difficulty in getting veterans appointments for specialty care, including dental, gynecological and oncology services.  Is this a problem with the scheduling of appointments, or is it a specific problem with staffing in these specialties in the Ohio area where you are? 

Ms. JONES.  I have to think it is within the staffing.  There is just not enough staff available.

Ms. BROWN-WAITE.  Okay.  So there are not enough of the specialty care physicians available.  Am I understanding your response correctly? 

Ms. JONES.  Yes, ma'am.

Ms. BROWN-WAITE.  Okay.  How about primary care?  What is the length of time with a veteran getting primary care? 

Ms. JONES.  An initial call is usually 2 to 3 months still.

Ms. BROWN-WAITE.  So it is 2 to 3 months? 

Ms. JONES.  Yes, ma'am.

Ms. BROWN-WAITE.  I mentioned in my opening statement the bill that I have that basically says if veterans cannot get medical care within 30 days, if they cannot get the appointments from the time that they ask for the appointments, that they would be able to seek care in the private sector, because the issue, really, is the timeliness of care. 

Could you give me your view of whether this is a good idea or a bad idea or how you think your veterans would react? 

Ms. JONES.  That is a tough question. 

I have to say that it is encouraging for me to think that we are looking outside of the box.  I know that a lot of the veterans organizations are not pleased with that, so I have to make it clear that I do not speak for them. 

For me, to see the possibility of our being able to use outside physicians might be a good idea.  What I like about that is that maybe outside physicians who are already treating our veterans anyway would then get some kind of training about dealing with veterans issues.  Right now most doctors do not even ask, "Are you a veteran," let alone, "Are you a combat veteran?"  That is critical to their care that they are getting outside of the VA because they cannot get into the VA.

Ms. BROWN-WAITE.  I appreciate your candid response to that.

Ms. JONES.  Thank you.

Ms. BROWN-WAITE.  I think that it is a mixed blessing.  People want to receive the services in the VA because, when they do get the services, overall they are happy.  I see you are shaking your head in agreement.

Ms. JONES.  Yes, ma'am.

Ms. BROWN-WAITE.  If there is a long delay in getting those services, you certainly do not want someone who has an ongoing problem, such as the one that you pointed out with the fellow with the prostate cancer—you do not want that going on without receiving the proper medical care.  I know some veterans groups are adamantly opposed to this.  If our goal here is to provide quality care, then care not rendered in an expeditious manner is not quality care, so we do have to, I think, think outside the box.  If we cannot provide that in the VA, then I think that we need to throw that gauntlet down to the VA and say, if you cannot do it in 30 days, then the veteran would have the option to go elsewhere.  That is why I put the bill in.  It is not that I do not believe in the VA system; I do believe in the VA system, but we also want to make sure that there is a timeliness of that care. 

I have just one other question, and that relates to—you mentioned the difficulty of the veterans that you are trying to assist getting their PTSD claims adjudicated in a timely manner—

Ms. JONES.  Yes, ma'am.

Ms. BROWN-WAITE. —because of the problem in obtaining an appointment with a psychiatrist, which, obviously, then delays the diagnosis needed to adjudicate the claim. 

Do you feel that a joint VA/DoD/Benefits Delivery at Discharge physical may reduce the amount of time that it would take to obtain a diagnosis for PTSD and would allow a claim to be processed more rapidly? 

Ms. JONES.  If the veteran is going to start talking about what the issues are at that time. 

What bothers me is that if they are still involved in DoD, they may not be open to discussing mental health issues. 

Ms. BROWN-WAITE.  Thank you. 

I yield back, Mr. Chairman.

Mr. MICHAUD.  Thank you very much. 

Mr. Space?

Mr. SPACE.  Thank you, Mr. Chairman. 

My first question, really, is for both of the panelists.  The VA has reported that 95 percent of outpatient appointments are scheduled within 30 days of the desired date.  My question is:  Based upon your experience, is that consistent with your own observations and experiences? 

Ms. JONES.  Absolutely not. 

Mr. MCCARTHY.  I would not have any experience, actually, directly with respect to veterans appointments, but in general in the private sector, that would be quite a common occurrence to be within that time frame. 

Mr. SPACE.  Okay.  Well, I want to follow up a little bit on what Congresswoman Brown-Waite referenced. 

By the way, Mary, I want to commend you for the diplomatic fashion in which you responded to her inquiries. 

Given that you have been involved in the system yourself as well as in your extensive experience with helping others navigate the system, is there any means—let us take the example of the gentleman whom you referenced in your testimony who suffered from prostate cancer.  Is there any means by which a veterans service officer can intervene to expedite an outpatient scheduled appointment in the event that there are exigent or compelling circumstances? 

Ms. JONES.  We absolutely call in all the chips that we can when there is a circumstance where we have got someone.  Sometimes the VA can be responsive, but sometimes there simply just is not an available appointment.  I have had experiences similar to what we are talking about where the VA is able to contract services out.  It is what we saw when we had a large number of troops coming into our community from a maintenance company that was coming back from Iraq and was scheduled for dental care.  They contracted out dental care for a period of time, and they did it locally rather than having them all try to fight their way into the VA clinic in Columbus.  So I have seen them do some contracting when we call and say, "Look, we have a large number of people who are needing the same treatment," but that is not across the board, and that is not always available. 

Mr. SPACE.  So those are instances in which you have seen or have observed the active contracting out because of, for example, a large influx at a given moment in time. 

Has that been a productive exercise?  Has it been helpful to engage in that contracting out? 

Ms. JONES.  Absolutely.  It has gotten the guys the care that they needed in a timely manner.  Absolutely.  It has gotten them good care with local physicians, with people who they are probably familiar with anyway in some cases. 

I have seen more and more contracting out with radiation services because of our Vietnam vets and the exposure issues and prostate cancer.  So we see more and more radiation treatment for prostate cancer contracted out locally, and that has been very productive.  Otherwise, our guys have to drive 2.5 hours daily for 5 to 6 weeks for that treatment to the nearest VA that can provide it.  That is a long drive. 

Mr. SPACE.  Okay.  Thank you, Mary.  I have no further questions. 

I yield back. 

Mr. MICHAUD.  Thank you very much. 

Once again, I would like to thank you both for your enlightening testimony, and I look forward to working with you as we move forward on this very important issue of making sure that veterans get timely access to healthcare. 

So, once again, thank you both. 

Ms. BROWN-WAITE.  Mr. Chairman, if I may ask Ms. Jones just one additional question? 

Mr. MICHAUD.  Yes.

Ms. BROWN-WAITE.  Because there are so many snowbirds who come from your State down to Florida, have any of them compared appointment times that they are able to get in, let us say, Southern States, not necessarily Florida, when they spend six months in another State as opposed to when they are in your State?  Have any of them mentioned that? 

Ms. JONES.  I have had several talk to me about that.  Quite frankly, when they come to Ohio, they are a little upset.  They say, "We are getting good care.  I am calling in," you know, "and I am able to be seen very quickly in the Florida area."  They then come back to Ohio, and it is hard to transfer from one VISN to another.  I mean, that is not something that is easy to do to begin with.  Then to try to get them in is just like trying to get a new patient in sometimes.  Even though he is very involved in the VA in Florida, when he comes back to the State of Ohio, he is being seen as a new patient. 

So there is a 2- to 3-month delay.  What these guys who are regulars at doing this have learned is to try to get your medication filled before you leave Florida before you come back to Ohio for the summer.  Yes, ma'am.

Mr. MICHAUD.  I guess that raised another question for Representative Space.

Mr. SPACE.  Thank you, Mr. Chairman, for indulging me.  It will be brief. 

Based upon your experience, Mary, do you see, perhaps, a difference in terms of the scheduling times that apply to those who have access to rural versus urban areas?  In other words, is this a problem that afflicts rural America more so than urban America? 

Ms. JONES.  Very much so.  I have talked to guys who have moved into our area, a more rural area, from, say, the Dayton, Cincinnati, Cleveland area where there is a hospital.  A lot of them are ready to move back to their areas just because they cannot get the treatment that they need in our area.

Mr. SPACE.  Thank you. 

I yield back.

Ms. BROWN-WAITE.  Mr. Chairman, I was just handed a question from another Member of the Oversight Subcommittee for Mr. McCarthy, Kevin McCarthy, the representative from Unum.

Mr. MCCARTHY.  Yes. 

Ms. BROWN-WAITE.  His question is, "How might the system that Unum deploys in its intake and management of disability claims have any relevance to the VA healthcare system?" 

The follow-up question that he has is, "Are there any lessons to be learned?"

Mr. MCCARTHY.  Although we are not directly in the provision of care, we are in the business of tracking the responsiveness of our company within a care system, and so all of our disability benefits specialists use a common system. 

So, for example, in the example that Ms. Jones just was using, a patient's moving—geography—would be tracked within the system, and he would be provided the same availability of information in real-time with the same amount of vocational, clinical and rehabilitation support or medical support regardless of where he would be located.  For example, all of our tracking systems would follow the claimant.  They would not be separated by jurisdiction, for example. 

Ms. BROWN-WAITE.  So, if I understand you correctly—and this question was directed at you.  It was not from Mr. McCarthy.  That is your name.  I apologize. 

So what you are saying is that your system would prevent the problems that Ms. Jones has brought to light where they go from one VISN to another? 

Mr. MCCARTHY.  I think, within our system, we have a number of quality standards built in.  We do quality assurance evaluations based on those standards of all of our disability benefits management specialists.  We track the constant availability of the information and the transferability of that information, so I would think that type of system would be beneficial to any administrative process involving the delivery of care.

Ms. BROWN-WAITE.  Okay.  Ms. Jones, let me just tell you that I used to hear from veterans who would go back North in the summer.  They would have trouble, and they would be considered a new patient, but somehow I do not hear those complaints anymore, and I am not sure that they are getting their medications, if that is how they are solving it, or if in some areas the VA may be better at sharing the patient information.  I do not know which of those two scenarios explains why it is happening.  I have not heard in 2 years from a snowbird that they have had problems.

Ms. JONES.  I have more recently, yes.

Ms. BROWN-WAITE.  But it is on your end, not on the Florida end? 

Ms. JONES.  It is on our end.

Ms. BROWN-WAITE.  Okay.  Thank you. 

I really do yield back this time. 

Mr. MICHAUD.  No problem. 

Once again, I would like to thank our first two panelists for your testimony today.  We look forward to working with you.  Thank you.

Mr. MICHAUD.  On our second panel is Belinda Finn, who is Assistant Inspector General for Auditing.  Belinda is accompanied by Larry Reinkemeyer, who also works in the Office of Inspector General. 

So I want to welcome you both here today, and we look forward to your testimony, Belinda.


Ms. FINN.  Thank you, Chairman Michaud, Chairman Mitchell and Members of the Subcommittee.

I am pleased to be here today to discuss our findings and conclusions on outpatient waiting times.  With me is Mr. Larry Reinkemeyer, Director of our Kansas City Audit Office, who directed the work on our two audits. 

The VHA calculates waiting time for each appointment from the desired date of care, which is defined as the earliest date that either the patient or the medical provider requests care.  The VHA has established a performance goal of scheduling appointments within 30 days.  Veterans who cannot be scheduled within this time frame should be placed on an electronic waiting list. 

In 2005, we reported that the VHA did not follow established procedures when scheduling appointments, resulting in inaccurate waiting times and waiting lists.  Because schedulers did not follow procedures, only 65 percent of the 1,100 appointments we reviewed had been scheduled within 30 days.  Nationwide, the electronic waiting list could have been understated by as many as 10,000 veterans. 

The VHA also lacked a standardized training program for schedulers, and it did not provide sufficient oversight of the process.  Almost half of the 15,000 schedulers who talked to us about their training and scheduling practices said they had not been formally trained on the scheduling system; 81 percent had received no training on the use of the electronic waiting list.  At the conclusion of our audit, the VHA agreed with our findings and accepted our recommendations. 

In 2007, we conducted a follow-up audit to determine whether the VHA had addressed the findings and recommendations in our report.  We concluded again that the data in the scheduling system remains inaccurate, in part because the VHA had not implemented five of the eight earlier recommendations.  We reviewed 700 medical care appointments that the VHA had reported as being completed within 30 days.  We found that only 75 percent of those appointments had actually met the 30-day time frame.  Our review of 300 consult referrals, found that more than 180 veterans were not included on the waiting list, but should have been.  The VHA disagreed with our findings and said that patient preference had caused the unexplained differences.  Although policy requires schedulers to document patient preferences, the VHA felt this was an unrealistic expectation.  They conceded, however, that the system lacked the documentation to support their position. 

We contend that, without this basic annotation, the VHA cannot support its assumption that patient preference caused our findings.  We find it contradictory that the VHA agreed with our 2005 report but disagreed with our follow-up audit.  We used the same methodology and found a continuation of the same problems, problems that could have been resolved had VHA implemented our recommendations. 

In 2006 and 2007, the VA reported high performance affecting appointments within 30 days.  They reported this high level of performance even after we had twice reported the scheduling system contains inaccurate, incomplete and unreliable data. 

In closing, I would like to say the issues today before us go beyond reported waiting times.  Debating whose numbers are more correct only overshadows the primary point of both of our audit reports, which is that the information in the VHA's scheduling system is incomplete.  The VA and Congress must have reliable information for budgeting, assessing and managing the demand for care.  More importantly, they need accurate information to ensure that every veteran receives timely medical care. 

Thank you for having us here today, and we would be happy to answer any questions. 

[The statement of Ms. Finn appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Ms. Finn.

What does the VHA need to do to improve their data reliability?  Have you communicated that with them?  What was their response, if they had one? 

Ms. FINN.  Yes, sir.  We made recommendations in both of our reports that the VHA should provide the oversight of the schedulers, should monitor what the schedulers do, and should provide quality assurance over the data in the scheduling system.  They agreed with the recommendation in 2005, but we did not find their actions had really resolved the problem, and therefore, we reinstituted the recommendation in our later report.  They do have procedures to monitor the number of veterans who are taking more than 30 days to get an appointment.  We found procedures in place to monitor this, but not procedures to monitor the quality and the accuracy of the data in the system. 

Mr. MICHAUD.  You had mentioned that they have not implemented five out of the eight recommendations.  Did they tell you why they have not implemented those five? 

Mr. Reinkemeyer?

Mr. REINKEMEYER.  It would be better for them to explain that, but they have taken some actions.  From 2005 to 2007, they created a pretty detailed directive in 2006-55 as part of the response to our first audit that lays out step by step procedures for the schedulers to follow, and it is pretty clear.  Those, in fact, are the guides that we used when we did this last audit. 

There was one recommendation that dealt with IT that they are working, and I think they are close to having that implemented now.  I know that they want to close a couple of the recommendations but we just have not had a chance to evaluate them yet, and we will take a look at their actions for those to see if we agree with those or not.  However, it would be best to ask them, I think, on exactly why some of them have not been implemented. 

Mr. MICHAUD.  Great. 

Ms. Brown-Waite?

Ms. BROWN-WAITE.  Thank you. 

Have you all taken the data actually down and reviewed each of the VISNs to track the performances that the individual VISNs are experiencing? 

Mr. REINKEMEYER.  No.  You could do that.  The VHA has plenty of data that will show you by VISN what performance is occurring in that VISN. 

In our first audit in 2005, we went to eight different facilities.  That was the extent of our work.  In this last audit, we went to 10 facilities at 4 different VISNs.  We did not really compare who was doing better and who was doing worse.  We tried to focus on the actual appointments themselves to see how well the data that was in the system was supported by the medical records. 

Ms. BROWN-WAITE.  I actually asked for information on VISN 8, which is the VISN that Florida is in, tracking their performance.  When I asked for it, I got information that seems to indicate that while outpatient wait times are going down in the medical centers, the wait times are actually increasing at the CBOC level. 

Is there any way to account for this situation? 

Mr. REINKEMEYER.  Well, typically the CBOCs—I mean, not all CBOCs are the same, but a lot of the CBOCs are not going to be staffed with the same type of providers, so I do not know exactly if it is waiting time for specialists or for primary care, but that could be one reason. 

Ms. BROWN-WAITE.  I did have them break it down by primary care.  This was primary care's average wait time new patients/average wait time established patients.  So we did it both for hospitals and for CBOCs.  Obviously, more and more people are using the community-based outpatient clinics.  I mean, that is, overall, a good thing that they are using the clinics, but I am now starting to also hear that there is a wait time.  Let me ask you a somewhat related question. 

At what point in time does the scheduling request begin? 

On page 2 of the VHA directive 2006-055, number 4, it says, "'Desired Date" is defined as.  Quote, "