[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
OUTPATIENT WAITING TIMES
=======================================================================
JOINT HEARING
before the
SUBCOMMITTEE ON HEALTH
and the
SUBCOMMITTEE ON OVERSIGHT AND
INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
DECEMBER 12, 2007
__________
Serial No. 110-62
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
Subcommittee on Health
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
______
Subcommittee on Oversight and Investigations
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio GINNY BROWN-WAITE, Florida,
TIMOTHY J. WALZ, Minnesota Ranking
CIRO D. RODRIGUEZ, Texas CLIFF STEARNS, Florida
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.
C O N T E N T S
__________
December 12, 2007
Page
Outpatient Waiting Times......................................... 1
OPENING STATEMENTS
Hon. Michael H. Michaud, Chairman, Subcommittee on Health........ 1
Prepared statement of Chairman Michaud....................... 29
Hon. Harry E. Mitchell, Chairman, Subcommittee on Oversight and
Investigations................................................. 3
Prepared statement of Chairman Mitchell...................... 29
Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee
on Oversight and Investigations................................ 2
Prepared statement of Congresswoman Brown-Waite.............. 30
Hon. Zachary T. Space............................................ 4
WITNESSES
U.S. Department of Veterans Affairs:
Belinda J. Finn, Assistant Inspector General for Auditing,
Office of Inspector General................................ 14
Prepared statement of Ms. Finn........................... 35
Gerald M. Cross, M.D., FAAFP, Principal Deputy Under
Secretary for Health, Veterans Health Administration....... 20
Prepared statement of Dr. Cross.......................... 41
Paul A. Tibbits, M.D., Deputy Chief Information Officer,
Office of Enterprise Development, Office of Information and
Technology................................................. 21
Prepared statement of Dr. Tibbits........................ 42
______
Jones, Mary C., Licking County Veterans' Service Officer, Licking
County Veterans' Service Commission, Newark, OH................ 5
Prepared statement of Ms. Jones.............................. 31
McCarthy, Kevin P., President and Chief Executive Officer, Unum
US, Portland, ME............................................... 7
Prepared statement of Mr. McCarthy........................... 32
SUBMISSIONS FOR THE RECORD
Miller, Hon. Jeff, Ranking Republican Member, Subcommittee on
Health, and a Representative in Congress from the State of
Florida, statement............................................. 44
Stearns, Hon. Cliff, a Representative in Congress from the State
of Florida, statement.......................................... 44
MATERIAL SUBMITTED FOR THE RECORD
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................ 45
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
outpatient clinics, will be retained in the Committee
files.].................................................... 48
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....................... 51
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, M.D., Secretary, U.S. Department of
Veterans Affairs, letter dated February 29, 2008, and VA
responses.................................................. 53
OUTPATIENT WAITING TIMES
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WEDNESDAY, DECEMBER 12, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Subcommittee on Oversight and Investigations,
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.
OPENING STATEMENT OF CHAIRMAN MICHAEL H. MICHAUD
SUBCOMMITTEE ON HEALTH
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 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 followup 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 followup is critical in achieving success. I hope
that we can use this time to work toward 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 Investigation, for
an opening statement.
[The prepared statement of Chairman Michaud appears on p. 29
.]
OPENING STATEMENT OF HON. GINNY BROWN-WAITE, RANKING REPUBLICAN
MEMBER, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
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 prepared statement of Congresswoman Brown-Waite
appears on p. 30.]
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.
OPENING STATEMENT OF CHAIRMAN HARRY E. MITCHELL
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
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 prepared statement of Chairman Mitchell appears on p.
29.]
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.
OPENING STATEMENT OF HON. ZACHARY T. 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
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 1983 to May 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.
STATEMENTS OF MARY C. JONES, LICKING COUNTY VETERANS' SERVICE
OFFICER, LICKING COUNTY VETERANS' SERVICE COMMISSION, NEWARK,
OH; AND KEVIN P. MCCARTHY, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, UNUM US, PORTLAND, ME
STATEMENT OF MARY C. 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 canceled 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 prepared statement of Ms. Jones appears on p. 31.]
Mr. Michaud. Thank you, Ms. Jones.
Mr. McCarthy.
STATEMENT OF KEVIN P. 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 followup 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
decisionmaking 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 followup 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 followup 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 prepared statement of Mr. McCarthy appears on p. 32.]
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 online. 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 online. 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. Twenty-four/seven.
Mr. Michaud. Twenty-four/seven. 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 [continuing]. 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 timeframe.
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 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 6
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 followup 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.
STATEMENT OF BELINDA J. FINN, ASSISTANT INSPECTOR GENERAL FOR
AUDITING, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY LARRY REINKEMEYER, DIRECTOR,
KANSAS CITY AUDIT OPERATIONS DIVISION, OFFICE OF INSPECTOR
GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS
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 timeframe 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 followup 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
timeframe. 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 followup 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 prepared statement of Ms. Finn appears on p. 35.]
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 2006-055 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, ``The desired
appointment date is the earliest date on which the patient or
clinician specifies the patient needs to be seen. This desired
date may be the date the request is made by the patient or the
date a request is made by a clinician. When available, the
desired date may be a specific date to be seen submitted by the
patient or by the requesting provider. In some cases, the
desired date may need to be modified after an initial
appropriate clinic visit. For example: a patient may request to
be seen by a specialist, but a clinician reviewing the request
may determine that before being seen in specialty care, the
patient needs to be evaluated in primary care,'' end of quote.
Isn't that kind of a very confusing definition of that
point in time that the actual appointment was requested? It is
almost like you read this five or six times, and you say,
``Huh?''
Ms. Finn. Yes. I think the ultimate point of the definition
is that both the medical provider and the patient can request a
date. The medical provider, of course, recommends a date of
care, and the patients also have some latitude as to when they
schedule their appointments. We recognize that patients may
schedule their appointments a little later or, perhaps, earlier
than when the doctor absolutely recommends it.
Ms. Brown-Waite. Mr. Chairman, just a quick followup
question. I know my time is almost up, and I will yield back.
Is the problem of how to set that point in time when the
request is made because of the somewhat convoluted description
in the VA's own directive?
Ms. Finn. The problem is recording the correct desired date
of care in the scheduling system to make sure that it really
reflects what the doctor recommends or what the patient has
requested. That is the date that we measure the waiting times
from.
Ms. Brown-Waite. I yield back the balance of my time.
Mr. Michaud. Mr. Space.
Mr. Space. Thank you, Mr. Chairman.
I think we can all agree that inaccurate waiting time data
compromises the VHA's ability to assess and to manage the
demand for medical care. That is, in fact, taken directly from
your testimony today. Your testimony also includes the
following sentence, and I will read it and then follow it with
a question.
``VHA managers plan budget priorities, measure
organizational and individual medical center directors'
performances and determine whether strategic goals are met, in
part by reviewing data on waiting times and lists.''
The operative part of that sentence was measuring an
individual medical center director's performance. Clearly that
data is important to assess whether a particular medical center
director is performing adequately. My question relates to the
bonuses that all of us are familiar with that raised some
controversy earlier this year.
If you know--and perhaps you are not prepared to answer
this--is it possible that bonuses were at least, in part,
calculated or based upon high-performance standards regarding
waiting times that were not accurate?
Ms. Finn. We know that the waiting time is part of the
performance standards for directors. It is one of many factors.
We really do not have a great deal of information today about
how that is actually factored into a particular bonus.
Mr. Space. Are you prepared to say today whether there is
evidence that waiting time data was intentionally fabricated at
any of the medical centers that you have surveyed?
Ms. Finn. We know that some of the practices used by
schedulers and some that schedulers have told us about would
serve to understate a specific wait time. As to whether that
was a widespread manipulation, I cannot say right now, but we
have seen a number of cases where we believe that practices
serve to understate the time.
Mr. Space. I understand that from reading your testimony.
The word ``practices'' can encompass a lot of things. Certainly
it can include inefficient habits. It can include procedures
that are not up to par, but it could also include the
intentional manipulation of data.
Did your investigation determine that there has been any
act, intentional overt act, to misrepresent the data?
Mr. Reinkemeyer. In this recent audit, which was a followup
to the previous audit, we did not really explore that question,
but in 2005, if you have seen that report, we did an extensive
survey that over 15,000 schedulers responded to. One of the
questions was, have you ever been directed to intentionally
manipulate scheduling procedures in order to circumvent the
system, which would result in reduced waiting times? That is
not the exact question, but it was close. Seven percent said
yes. So, in 2005, we did have some evidence that schedulers
were directed to schedule in a particular way in order to
effect the waiting times.
In 2007, we know that those procedures are still out there.
The two most common procedures would be taking longer than
allowed before they are put on an electronic waiting list, and
you probably saw some of our references to consult referrals
from a primary care to a specialist where the standard is 7
days. If you do not act on that appointment within 7 days, you
are supposed to be put on the electronic waiting list and the
VHA and their directors would take that information and use it
to determine where to apply resources. By holding onto those
referrals for more than 7 days and not putting them on the
electronic waiting list, that serves to understate the waiting
list.
The second procedure that tended to manipulate would be
establishing the starting point for the waiting time. It is the
de-
sired date. We have seen both in 2005 and in 2007 that a common
practice for a scheduler was to find out when the first avail-
able appointment was--January 15th--and then use that as the
desired date of care, which effectively reduces the waiting
time to
zero.
So those are the two types of scheduling practices that
tend to manipulate VHA's data.
Mr. Space. If I may just have time for one more question?
Mr. Michaud. If it is quick. We still have one more panel,
and we have votes coming shortly.
Mr. Space. I will be very quick. Okay.
The 7 percent that were directed to intentionally
misrepresent the data, that falls separate and apart from those
two incidences which represent practices that you just recited,
correct?
Mr. Reinkemeyer. Yes.
Mr. Space. Has any action been taken to determine who was
intentionally directing people to manipulate the data? If so,
what repercussions have resulted from it?
Mr. Reinkemeyer. In 2005, we did not ask who did it, and
the survey was anonymous. I cannot tell you now, but we have
some information that would say where they were. If I recall
correctly, they were spread out.
Mr. Space. Thank you. I will assume that the answer to that
is no.
With that, I thank the Chairman for indulging me with
additional time.
Mr. Michaud. Thank you very much.
I would like to ask the third panel to come up. While they
are coming up, there will be additional questions that we will
pro-
vide in writing, and hopefully, you will be able to answer them
as well.
Mr. Kennedy. Mr. Chairman.
Mr. Michaud. On the third panel----
Mr. Kennedy. Mr. Chairman.
Mr. Michaud. Yes.
Mr. Kennedy. Briefly----
Mr. Michaud. If you can hold your question until the end,
we still have one more panel. We have to give this room up at
4:30, and we have votes, so----
Mr. Kennedy. We have 120 veterans committing suicide a
week. Did you break out mental health appointments on your
outpatient waiting lists?
Mr. Reinkemeyer. No, sir.
Mr. Kennedy. You did not.
Was there a correlation between inpatient waiting time and
outpatient waiting time in your audits?
Mr. Reinkemeyer. Again, we only looked at the outpatient
waiting times.
Mr. Michaud. Okay. On the third panel, we have Dr. Gerald
Cross, who is the Principal Deputy Under Secretary for Health;
as well as Dr. Paul Tibbits, who is the Deputy Chief
Information Officer (CIO).
So I want to welcome the last panel. If you could summarize
your testimony, your full testimony will be submitted for the
record. As you know, we do have votes coming shortly, and we
will not be able to continue the hearing because we will have
to give up this room at 4:30. Unfortunately, the full Committee
went over by 45 minutes, so I apologize for that.
So, Dr. Cross, without further ado, would you begin?
STATEMENTS OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WILLIAM F.
FEELEY, MSW, FACHE, DEPUTY UNDER SECRETARY FOR HEALTH FOR
OPERATIONS AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION;
ODETTE LEVESQUE, CLINICAL/QA LIAISON, OFFICE OF THE DEPUTY
UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT,
VETERANS HEALTH ADMINISTRATION; AND KATHY FRISBEE, DEPUTY
DIRECTOR, SUPPORT SERVICE CENTER, VETERANS HEALTH
ADMINISTRATION; AND PAUL A. TIBBITS, M.D., DEPUTY CHIEF
INFORMATION OFFICER, OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE
OF INFORMATION AND TECHNOLOGY,
U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF GERALD M. CROSS, M.D.
Dr. Cross. Thank you. Thank you, Mr. Chairman. And since
time is short, I have a written statement. I will submit that,
and I will abbreviate my oral statement.
Mr. Michaud. Thank you.
Dr. Cross. We are making good progress in meeting the needs
of our veterans in terms of access, and we are committed to
providing all necessary care, including preventive care. I want
to be clear that we are talking about waiting times for
general, routine outpatient appointments. Veteran appointments
with urgent or emergent needs are seen immediately separately.
In a healthcare system as large as VA where we provide over
1 million patient encounters in our clinics each week, we
understand there are opportunities for improvement. With
national implementation of the Advanced Clinical Access
Initiative, we have made significant progress of reducing wait
times.
And you may see some of the graphs that are portrayed on
the stands to our left. In the patient satisfaction survey for
the third quarter year to date fiscal year 2007, 85 percent of
veterans surveyed reported that they received primary care
appointments when they wanted them, and 81 percent reported
that they received their specialty care appointments and that
they were made at a time that was acceptable to them. In fiscal
year 2007, 96 percent of our 40 million appointments were seen
within 30 days of the desired appointment date. This represents
waits for outpatient primary and specialty care appointments.
We continue to improve access for new veterans. The percent
of new primary care patients seen within 30 days of their
desired date has improved from 75 percent in fiscal year 2005,
to 83 percent in fiscal year 2007. And in September 2007, 90
percent of new primary care patients were seen within 30 days
of their desired date. Our statistics are even better for
followup appointments.
Finally, we are focusing on mental health access by setting
new standards that require all new mental health patients to be
seen and their needs for care evaluated within 24 hours, and
that these veterans have a followup evaluation within 14 days.
With the assistance of Congress and the administration, we have
increased, by 3,600, the number of mental health professionals
with our system since 2005.
As you are aware, VA has several concerns about VA's Office
of Inspector General's audit methodology used in the 2007
report. While differences in methodology exist, the overriding
focus of both sets of measurements, and our overriding focus,
is the veteran patient. VA has a driving interest to accurately
monitor and to continually improve access for our veterans.
There are an estimated 40 million appointments each year in the
VA system. There are multiple variables involved in that
measurement, and tracking that does include patient preferences
and differences in the organization of individual facilities
and clinics.
VA has identified ongoing training of our scheduling clerks
as critical for success; however, we are still using antiquated
software for this important task. VA is proactively taking
steps to review this whole scheduling process, including the
way VA measures waiting times.
We will continue to improve our processes, educate
scheduling staff and strive to improve clinic access to further
reduce waiting times, and to this end VA has contracted with an
independent third party to conduct an evaluation of VA
scheduling practices and waiting time metrics. The contractor
is beginning the pilot program phase of its assessment, and we
anticipate receiving the final report in the spring of 2008.
In conclusion, we are taking the following substantive
actions to aggressively address the issues of veteran access
and wait times. We ask the VA's Office of Information and
Technology to develop a new scheduling software package, as
well as developing shorter-term software solutions for our
current scheduling package. We are continually improving our
training programs, and we are contracting with an outside
consulting firm for an independent review of our scheduling
process and metrics.
Thank you, and I will be pleased to accept your questions.
[The prepared statement of Dr. Cross appears on p. 41.]
Mr. Michaud. Thank you very much.
And because of time, Dr. Tibbits, we do have your written
testimony, you wouldn't mind if we go right directly to
questions; there is no objection?
Dr. Tibbits. No. Fine.
[The prepared statement of Dr. Tibbits appears on p. 42.]
Mr. Michaud. I have a couple questions--my first, actually,
Dr. Cross, is you mentioned the methodology, but we heard just
from the previous panel that the methodology was the same in
2005 as it was in 2007, and you didn't object to the
methodology in 2005. So I guess my question is why you haven't
implemented, well, five of the eight recommendations that they
recommended.
Dr. Cross. We are recommending the recommendations that the
IG proposed, and we do track that. I want to point out that one
of the most important things that we are doing is the new
directive to comprehensively approach many of the
recommendations that they made. There was a difference in our
analysis. And on review of the OIG report from 2005 to 2007,
there were significant differences in what we found, and that
was the reason, based on that evaluation, as to our different
response.
Mr. Michaud. I understand that the VHA said that this is a
documentation issue, but I also know that on the first page of
the fiscal 2007 performance report VA provided to Congress just
a couple of weeks ago, VA said it made 96 percent of its
outpatient appointments within 30 days. Do you really feel that
VA should be reporting 96 percent when you only can document 75
percent to the IG? How is VA or Congress to make the right
policy decisions without having reliable numbers to go by?
Dr. Cross. Congressman, the report that we did in the prior
does include an additional explanation related to the IG
report. So we did acknowledge the IG report and the difference
that they found as opposed to what we found. And so I don't
want to obscure that. We understand that and put that in there.
Mr. Michaud. Ms. Brown-Waite.
Ms. Brown-Waite. Thank you, Mr. Chairman.
Dr. Tibbits, how long has the VA been trying to launch its
VistA scheduling program?
Dr. Tibbits. The VistA program in the scheduling module
dates back to the 1970s. It is actually in operation. Over that
period of time, it has had modifications to it to get the best
performance out of that kind of architecture and that software
approach that we could get in the system.
It has limitations. Those limitations finally, I guess I
can say, came to a head and were recognized as being not
addressable in total with that old architecture, VistA, and the
environment and programming medium that it is in. And the
replacement scheduling application, helped do that scheduling,
in order to replace that scheduling module in toto, was
launched in May of 2001, to turn off the 2001, and to bring us
into a more modern software and architecture, and also much
more robust functionality, much better metrics.
Ms. Brown-Waite. So it wasn't just a name change in 2001?
Dr. Tibbits. Not a name change. It was a complete, and
remains today--that initiative to help do that scheduling is a
complete revision of the programming approach, the
architecture, a much more robust functionality.
Ms. Brown-Waite. And the cost of this program?
Dr. Tibbits. I think I should get back to you with an exact
figure on that, if you don't mind.
Ms. Brown-Waite. Has it been $30 million, $50 million?
Dr. Tibbits. Well, I would rather get back to you with the
number. I don't know the number today. We have the numbers both
for the anticipated numbers and the actuals. It will be easy
for me to get that information for you.
[The information from the VA follows:]
----------------------------------------------------------------------------------------------------------------
(In Millions)
-----------------------------------------------------------------------------------------------------------------
FY 2009
FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 President's
Actual * Actual * Actual Actual Current Budget
Estimate Request
----------------------------------------------------------------------------------------------------------------
VistA Scheduling Replacement 31,216 12,888 10,5533 18,419 28,300 29,909
----------------------------------------------------------------------------------------------------------------
* FY 2004 and 2005 reports VHA obligations prior to the OI&T centralization. OI&T cannot substantiate these
obligations since Scheduling Replacement was not a specific budget line item in the VHA budget operating plan.
Prior to FY 2004, funds expended for Scheduling project activities were not specifically identified or
reported.
Ms. Brown-Waite. I understand that the scheduling module
has been delayed again. Is this accurate?
Dr. Tibbits. That is the new package. Yes, it is accurate,
and unfortunately some of that has occurred on my watch. I will
be the first to tell you that we need to strengthen program
management discipline in the Department. We are attempting to
do so, both with IT workforce improvement initiatives, training
and education, real-time coaching and mentoring. We are also
bringing in industry experts, and the Department of Defense has
numerous industry experts attached to them which we are
bringing in to do real-time coaching and mentoring to help us
revise our finance and accounting and program management
practices as well. And also IBM, by the way, is consulting with
us to help us implement the 36 processes that were recommended
to us as part of standing up and reorganizing the entire Office
of Information and Technology. So we are trying our best to
strengthen those practices to get this program delivered on
schedule to the office site.
Ms. Brown-Waite. So do I understand correctly from your
testimony that it won't be fully implementational until 2011.
Dr. Tibbits. Yes, ma'am. The current schedule is January
2011 to have that new module deployed throughout the VA. The
alpha site deployment date is this summer, and the beta site
would be December of 2008.
Ms. Brown-Waite. So 10 years for determining wait times
scheduling.
Dr. Tibbits. Yes ma'am. There are significant issues in the
Department. Many of them----
Ms. Brown-Waite. Sir, issues--I don't think is what the
taxpayers want to hear. That there are issues in the
Department.
Dr. Tibbits. Yes, ma'am. And the Department is taking, I
would say, quite a number of steps to try to deal with those
issues, not the least of which was the IT reorganization
itself. We have moved 6,000 people from their former alignments
in the organization to a new, we are taking steps to
professionalize the workforce, we have the most empowered CIO
in Federal Government, we have now complete alignment of
authority and responsibility with respect to the CIO, none of
which the Department had before, just 1 year ago the Department
did not have this. So while we are well positioned to address
those issues, nonetheless addressing those issues is hard work,
and much work remains to be done.
Dr. Cross. May I add, Congresswoman, that we can't wait
until 2011. We are doing things right now within our side of
this equation to make sure that our veterans get the access
that they need. That is why we are adding the staff. That is
why we are opening the new clinics. That is what really
matters.
We are going to deal with the IT issue working in
collaboration with my colleagues from IT, but in the meantime
there is much that we can do, and we must do that, and that is
particularly boots-on-the-ground people helping veterans,
getting them their appointments, putting the staff in the
clinics, and that is what we are doing right now. That includes
3,600 mental health workers.
Ms. Brown-Waite. After all of this period of time, after 12
years of implementation, and now it is going to be up to 2011.
Will this program be able to calculate waiting times, yes or
no?
Dr. Tibbits. Yes.
Ms. Brown-Waite. And if we are here in 2011, will we be
told it will be 2015, and the answer will still be yes?
Dr. Tibbits. Well, we are certainly taking steps for that
not to be the case.
Ms. Brown-Waite. I yield back the balance of my time.
Mr. Michaud. Yet earlier today we heard testimony that a
lot of the issues with calculating patients' waiting times has
to do with the schedulers. Specifically what have you done as
far as to help solve that problem with the schedulers to make
sure that we do have accurate information?
Dr. Cross. Mr. Chairman, what we have done is training, and
training is very important. I think the Congresswoman read from
a part of our directive. It is quite complex. And people have
to understand that that doesn't come immediately to them. They
have to be trained to do that.
I am going to ask a couple of my colleagues here, Ms.
Frisbee or Ms. Levesque, to comment on that and talk a little
bit about our training program.
Ms. Levesque. We issued a policy on scheduling and
subsequent to that had union negotiations. And once we were
cleared, we provided the training to all the schedulers. And to
date, we have trained about 40,000 schedulers, which means
anybody who has access to the scheduling package. Many
physicians like to schedule their own patients, so they have
had to take the training as well, and those who have not taken
the training have had their permission to schedule removed from
them.
We are in the process of relooking at our directive. Given
that it has been out there for a year, there are issues that
bubble up as any issue would with any directive, and we are in
the process of revising that directive. And once that is
revised, we will revise the training for the schedulers, and we
will do that on an annual basis. They will have to take the
training annually. We also asked all the networks to certify
that their facilities have basically trained all of their
schedulers, and we received those certifica-
tions.
Mr. Michaud. And you heard the previous testimony from Mr.
McCarthy from Unum in that their timeframe that they deal with
their patients or clients is 3 to 5 days on average, and that
they handle over 4\1/2\ million calls a year within 20 seconds
with very limited amount of staff 24/7. Have you looked at what
the private sector, such as Unum, is doing that might improve
on what the VA is doing?
Dr. Cross. I mentioned in my opening testimony that one of
the things we are doing is bringing in an independent reviewer.
And we have established a contract with a well-known, famous
contractor, to look at waiting times and how we measure it.
I will ask Dr. Tibbits if he wants to add anything to that.
I think the answer is no.
Mr. Kennedy. If I might.
Mr. Michaud. Is there unanimous consent that Mr. Kennedy be
allowed to ask questions? Any objections?
Hearing none, Mr. Kennedy.
Mr. Kennedy. In our community health centers in Rhode
Island, we have same-day walk-ins, and they have never thought
it could be possible where they could go without prescheduled
appointments, and they have now done without them. And they
have accommodated it, and it is, to everyone's surprise, not a
problem. And so I would be happy to hook you up with them and
figure out how they have managed to do it. But I understand
they are doing it in the VA in Hartford. They don't have
prescheduled appointments. They have it via you walk in, you
get taken care of.
Now, a big problem that I have is we are not even seeing a
fraction of the veterans we need to see. The big issue here
that we are not touching is the numerator and the denominator.
VA is only touching a fraction of the number of veterans that
it should be touching.
Now, the real question is what happens when the VA actually
goes out and does its job, and that is touch all the veterans
that are supposed to be brought into the VA? Then what happens
to this waiting period? That is the real issue. And what
happens when it has to contract out, and will it contract out
for partnership with the private sector in order to meet these
needs?
You mentioned the mental health. It is great if you hire a
bunch of mental health providers, but it is a lot easier if you
co-opt the existing mental health providers and use them as
leveraging resources so you can build a broader system to meet
the need.
But I am interested to hear whether you have heard of this
notion of, you know, same-day walk-in services.
Mr. Feeley. Dr. Cross, might I comment? I would just want
to mention it is Bill Feeley, class of 1969 and Providence
College responding.
I wanted to share with you that we have the 724 community-
based outpatient clinics that were mentioned. So we are out
there with mental health providers in all those clinics. You
can have same-day walk-in service at any VA hospital in the
system, and you can get that at the community-based clinics as
well.
Because of the serious nature of the disease entity that we
are talking about, we have established a new standard of a
response within 24 hours to a patient who presents. On a call,
they can come in, but we are going to evaluate them within 24
hours. The standard to see a patient routinely--not in crisis,
but routinely--is dropping from 30 to 14 days, which is the way
we are going to use these mental health warriors that we are
hiring out there, and 3,600 of those employees. In addition, we
already contract for $3 billion worth of services in various
community-based setups where there might be remote challenges.
So we are doing it.
And I would like to get on the record that people come to
us as the subject matter experts on access frequently and view
us that way. We are not perfect. This is a work in progress
that will keep me busy for many years. I set a goal as a
professional mental health worker to wipe out mental illness by
the time I was 28. I am now 60, and I still have work ahead of
me.
Mr. Kennedy. I would just like to follow up. I was just
down in south Texas, and there is no real VA down in the
McAllen area. They send them up to San Antonio. They tell me
that, you know, it is a 4- or 5-hour drive. That is the only
place they can get their appointments. It would be a lot easier
for them if they were able to get it, obviously, down where
they live in that area. The population is huge. And rather
than--maybe they could get their appointments all, you know,
kind of in an accumulated timeframe and do better scheduling
that way than have them take that 4-hour drive. Maybe they
could do teleconferencing and other things. Have you thought
about these things?
Mr. Feeley. Let me just share with you, so no one thinks
that you sent me this question in advance. I did a ribbon-
cutting ceremony in Harlingen last Friday at the CBOC there
that has been expanded from 11,000 square feet to 34,000 square
feet, visited the clinic 35 minutes away. The mental health
service delivery system that you are describing is going to be
in this new Harlingen expanded clinic. And we are going to be
contracting for inpatient care whenever needed since it is an
unreasonable commute to expect someone who is having a mental
illness breakdown to ride in a van for 300 miles.
So we are really going to bolster up services in the
Laredo, McAllen, Harlingen, Corpus Christi area by investing in
those mental health providers and bringing them down there. But
Mexican food did bring me down to the dedication.
Mr. Michaud. I want to thank you, Mr. Kennedy, too, for
your interest not only in veteran issues, but also in mental
health. You have been a true leader in Congress. I really
appreciate your interest in these issues.
Ms. Brown-Waite.
Ms. Brown-Waite. Thank you, Mr. Chairman.
You know, in thinking about the whole scheduling problem
that VA has had for a very, very long time, have you looked at
what major hospitals do, New York University, Mayo Clinic, M.D.
Anderson, a little clinic maybe in rural Ohio? Scheduling of
patients isn't new, it is not rocket science. Why has it taken
so long, cost so much? And yet, I will tell you, I have been
here just 5 years. Before I got sworn in, I got sworn at by the
VA people in my Congressional district because I asked them for
a list of wait times, because what I heard on the campaign
trail was nowhere like what they initially provided me. And I
challenged them. I said, I don't believe these numbers. You
better go back. You better look. And I gave them names of
people who had told me how long they had to wait. Well, then
they finally 'fessed up.
I do not believe that they have ever had the audacity to
fudge those numbers again because they know I will call them on
it. They know I stand on those numbers. But why are we
reinventing the scheduling wheel here?
Dr. Cross. Congresswoman, we are a learning organization.
And I listened to what Congressman Kennedy said and what you
said. We will learn from anyone, and we often do reach out to
many different organizations, universities that we are
affiliated with and others. If someone has a better package
that will fit within our system to do the vast job that we are
asking it to do, we are quite open to that.
Now I will ask my IT colleague to add to mine. I am not an
expert on IT.
Dr. Tibbits. Well, right. I mean, just from the IT
perspective, I would say exactly the same thing. We are not
wedded to in-house development, we are certainly not wedded to
the legacy system which has inadequate functionality, and we
are happy to look at cost packages. And so far, we have not
identified a cost package. We have, by the way, looked at DoD's
experience with commercial off-the-shelf packages for
scheduling, which was not a happy experience. And we have wound
up with the conclusion we wound up, that the existing system
needs replacement, it needs replacement badly, the current
foundation is not adequate to build on, and we need a new
module.
Ms. Brown-Waite. The current system needs replacement
badly, and so we have been at this now for 10 years?
Dr. Tibbits. We have been at the replacement system since
May of 2001.
Ms. Brown-Waite. That doesn't equate to quickly, even May
of 2001.
As I said, this isn't rocket science. And I appreciate your
offer to reach out to the private sector, but you can take an
off-the-shelf program that perhaps M.D. Anderson uses, and it
can be modified. You can take those modules and you can modify
them.
I don't understand. Tell me the uniqueness of the VA
scheduling system unless it relates to that very convoluted
description that I read earlier today that I don't want to bore
everybody by reading again, because it is like, okay, when is
it official that appointment was requested? Is that what makes
it unique? Please help me to understand.
Dr. Tibbits. Sure. Let me speak to some of that, and then I
am going to defer to my colleagues who understand the
scheduling business far better than I do and the policies. But
from an IT perspective, when one starts modifying a commercial
package, it is a disaster, because what happens is modification
of a commercial package then creates frequently a separate
production line, which then that industry cannot continue to
market commercially, but we wind up being a unique customer for
that commercial package. That winds up being a very expensive
proposition, which has proven to be a failure in many
implementations of commercial packages around the world--around
the country.
Now, what specifically makes VA requirements unique? I am
not the best person to answer that, but we have veterans
categories and many of the things that you all are very
familiar with that the private sector does not have to deal
with.
Ms. Brown-Waite. You are talking about a couple of extra
boxes there on the initial application for an appointment.
Mr. Feeley, one quick question, and I would like this in
writing from the VA. The bill that I referred to that says you
either provide the healthcare service within 30 days or--really
30 days, by the way--or the patient can seek care elsewhere, I
would like an official position by the VA on this, a written
position. I realize you can't do that now. And you also have a
new Secretary coming in. But I would like that within--I think
maybe the next 30 days would be an appropriate response time. I
certainly would appreciate it. And I would, with the permission
of the Chairman, certainly share it with everyone else. And if
you would send it to Mr. Michaud with a copy to me, I would
greatly appreciate that.
[Congresswoman Brown-Waite sent a letter to VA on December
13, 2007, requesting additional views for H.R. 92. The request
letter and VA's responses dated July 31, 2008, appear on p.
45.]
Mr. Feeley. If I could just comment. I think that we need
to meet the standard, and we are working very aggressively to
meet that standard, and my goal is certainly to hope that we
do. So we are continuing to monitor and measure on a biweekly
basis. And I think the bill has elements of reasonableness if
we can't meet the standard. But we will get the written
position of the Secretary.
Ms. Brown-Waite. I appreciate that. Thank you. And I yield
back.
Mr. Michaud. Thank you.
Once again, I would like to thank you, Dr. Cross and Dr.
Tibbits, for your testimony and for the accompanying panelists.
I look forward to working with you as we move forward to deal
with the wait time issue. And we can't emphasize enough that
this is extremely important because there are individuals out
there who serve this great Nation of ours that need the
service. They need it in a timely manner, and unfortunately, as
we heard from the full Committee this morning, if they do not
get that service, unfortunately some do ultimately commit
suicide.
So this is an extremely important issue. I look forward to
working with each and every one of you as we move forward to
improve on what the VA currently does. And once again, thank
you very much, and the hearing is adjourned.
[Whereupon, at 4:30 p.m., the Subcommittees were
adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud
Chairman, Subcommittee on Health
This joint hearing on VA outpatient waiting times will come to
order.
Good afternoon. I would like to thank everyone for coming to
today's hearing.
The focus of this hearing is waiting times for outpatient
appointments in the Veterans Health Administration. 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 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.
In May 2007, the House passed H.R. 612 which extends the period of
eligibility for VA healthcare for veterans of Operations Enduring and
Iraqi Freedom from 2 to 5 years.
Also in May, the House passed H.R. 2199 which develops programs
aimed to improve access to care for veterans with Traumatic Brain
Injury.
And in July of this year, the House passed H.R. 2874 which among
other things, provides therapeutic readjustment and rehabilitation
services to veterans, provides improved transportation to rural
veterans, and improves and enhances services to homeless veterans.
I am very proud of our accomplishments so far this year and I feel
that we have come a long way in improving healthcare for veterans. But
we still have more work to do.
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 followup
appointments, and how VA tracks this information.
I would also like to learn how 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
followup is critical in achieving success.
I hope that we can use this time to work toward solutions so that
we can all achieve our primary goal to improve 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.
Prepared Statement of Hon. Harry E. Mitchell
Chairman, Subcommittee on Oversight and Investigations
Yet, our veterans can only take advantage of this healthcare if
they can get the appointments they need to access it. Unfortunately,
too many of our troops are returning home and encountering long waiting
times.
When I was back in the district last weekend, I met with a group of
Arizona veterans. Many of these 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
this appointment in December 2006, and his appointment was scheduled in
late May 2007--6 months after his initial request. John told me that he
continued to struggle to make appointments within the VHA and because
of that difficulty he now relies on civilian providers for his
healthcare.
This is unacceptable.
When we've tried to look into the problem and see what we can do to
address it, we have been unable to secure verifiable documentation of
waiting times.
According to a recent audit by the Department of Veterans' Affairs
Inspector General, the wait times reported by the VHA are both
understated and incomplete.
The VA reported in the Department of Veteran Affairs Fiscal Year
2006 Performance and Accountability Report in November 2006 that 95% 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% of veterans had been seen within 30 days of the
requested appointment date.
Furthermore, the IG audit found that schedulers are ``not following
established procedures for making and recording medical appointments.''
This means that we don't even have a clear picture of how many veterans
have requested appointments.
VHA schedulers are 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 don't use the electronic waiting lists.
But perhaps most 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 wait
times could lead to ``gaming'' of the scheduling process.
The VA has discounted the IG's report because it disagrees with how
wait times were calculated. This is unacceptable.
I'm 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. This is no way to treat
those who have honorably served our country.
Furthermore, until we have a clearer picture about waiting times,
the VA can't improve the situation because we can't identify problem
facilities or effectively allocate resources.
It is time for us to do the right thing for our veterans and stop
hiding behind unsupported claims that these servicemen don't encounter
long waits for doctors' appointments.
I look forward to hearing from our witnesses.
Prepared Statement of Hon. Ginny Brown-Waite, Ranking Republican
Member, Subcommittee on Oversight and Investigations
Mr. Chairman,
I thank you and Ranking Member Miller, along with the rest of the
Members of the Subcommittee on Health for joining us in 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.
And today there are 153 VA medical centers and 724 community-based
outpatient clinics (CBOCs) available to serve the needs of these
veterans.
When a veteran or 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 on how they feel outpatient waiting times at the VA has affected
them, as well as any possible solutions they can offer.
I am also interested in hearing from the VA Office of the Inspector
General on their perspective on the waiting times issue.
Finally, I expect to hear from the VA as to how they monitor
waiting 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 contacts the Department.
Unfortunately, this bill is needed because current practices do not
meet that goal.
I monitor data for 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 are much higher.
What I also found interesting in looking over the data is that
there appeared to be a decrease in the waiting times at the major
medical facilities; however, at the CBOC level, waiting times have
increased.
In the 3rd quarter of FY 2007, new patients had to wait an average
of 45-50 days to receive an appointment at a VA CBOC, while new
patients waited an average of 22-25 days to receive an appointment at
the VA medical centers.
This is simply not acceptable.
I am also curious as to the dramatic decrease in waiting times at
the VA medical centers in VISN 8.
I question whether patients are being redirected to the CBOCs to
reduce waiting times at the medical centers.
If veterans are having problems receiving care within 30 days, then
Congress needs to allow them to look for an alternative.
My bill is NOT a scheme to move the VA toward privatization; it
simply ensures veterans receive care in a timely manor.
VA can and does provide a high level of care to all the veterans
that are enrolled in the system; however, if a veteran cannot be seen
by a physician then what good does that do?
The Department of Veterans Affairs' Web site states that the goal
of the VA is ``to provide excellence in patient care, veterans'
benefits and customer satisfaction.''
This hearing today is to determine whether the VA is meeting that
goal with timely access to care.
As everyone here knows, this issue is tremendously important to
every American.
Our veterans did not wait to answer the call to duty.
They answered their Nation's call, and took up arms to protect our
freedom.
They served and many returned to us injured and in need of care.
I talk with the veterans from my district on a daily basis about
the issues they have with the VA, and getting in to see a doctor in a
timely fashion is at the top of their list.
And the care of our Nation's veterans should not be a political
issue.
Instead, Congress should work together to improve veterans
healthcare so that it becomes the model of good governance.
Thank you again, Mr. Chairman, and I yield back the balance of my
time.
Prepared Statement of Mary C. Jones, Licking County Veterans' Service
Officer, Licking County Veterans' Service Commission, Newark, OH
Mr. Chairman and Members of the Subcommittee:
Thank you for providing me with the opportunity to testify
regarding the important issue of outpatient waiting times.
I have worked as a County Veterans Service Officer for the past 12
years and in that capacity 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 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 for almost 90 days from the date of request. When he got
to the dental clinic he was told that his appointment needed to be
canceled and rescheduled. They did not have any appointments available
within the 90-day period that he was entitled to dental care and
therefore he was not seen.
Female veterans have unique healthcare concerns and face difficult
wait times to be seen by gynecologists--often as long as 6 to 8 months.
Please keep in mind that most of the women that 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 are often 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 and 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 the veteran who had no other options.
We are now 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 VBA must
deny the claim for service connection. Seeing private psychologists and
psychiatrists are beyond the financial reach of most veterans.
My most memorable experience is a WWII veteran who was in receipt
of a nonservice-connected pension. He was diagnosed with prostate
cancer through a PSA test done by his primary care physician. Treatment
was scheduled, but the wait time was several months. In the meantime
this gentle man very 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 only have prolonged his life and
probably not saved his life, but this would have been an excellent
opportunity to send a positive message of support from the government
to this WWII veteran, and that opportunity was missed. He died before
his appointment with an oncologist.
This has been an honor for me to have an opportunity to bring
examples of the difficulties experienced by the veterans that I serve
caused by the long wait times to be seen at the 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.
Mr. Chairman, this concludes my testimony.
Prepared Statement of Kevin P. McCarthy
President and Chief Executive Officer, Unum US, Portland, ME
Mr. Chairman, Members of the Committee, I'd like to thank you for
the opportunity to testify before you. My name is Kevin McCarthy and I
am the President of Unum US. Unum is a subsidiary of Unum Corporation.
Unum's involvement was generated by our CEO (a graduate of Virginia
Military Institute) wanting to explore how the company could assist
with sharing its best practices that might be useful in a new world,
``post-Walter Reed.'' Since that time, Representative Michaud has
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 claim processing/case management. As a result of this
visit and our meetings this summer and fall with House and Senate
Congressional staff, the Veterans Affairs Administration and the
Department of Defense on sharing best practices between the private
sector and the public sector, I am here today to discuss how we use
these smart systems and people not only to reduce waiting times for
setting up independent medical examinations or assisting a claimant's
medical team in developing a treatment plan specific to that
individual, but also how these are aspects of a larger integrated case
management/claim management approach that includes everything from
regular contact with our insureds so they know what is happening
``real-time'' on their claim to assisting them with vocational
rehabilitation. This integrated approach actually speeds up not only
actions like wait times on individual, specific issues, but the entire
claim/case management process. We would be pleased to continue to be a
resource for the sharing of best practices between the public and
private sectors as you continue to evaluate the disability
adjudication/case management processes at the VA.
Corporate Overview
Unum is a company of people serving people. As one of the world's
leading employee benefits providers, Unum helps protect more than 21
million working people and their families in the event of illness or
injury.
We provide more than a benefit check to customers--we provide a
wide range of benefits and services designed to help people during what
is often the most trying time of their lives--loss of income due to
illness or injury.
For 30 years Unum has been an industry leader in providing income
protection and employee benefits. Unum is ranked #1 in long-term
disability income protection, #1 in short-term disability income
protection, #1 in individual income protection, and #1 in group long-
term care insurance. We are also among the market leaders in group life
insurance and supplemental benefits. We provide leave management
administration services, health and productivity services and a work-
life balance program with health risk assessments.
In 2006, we serviced more than 420,000 newly filed claims
(disability products, long-term care, and voluntary benefits) and
replaced $4 billion in lost income to help provide support to our
insureds and their families. These benefits are paid directly to our
insureds. To our knowledge, this is more than any other private income
protection provider in the world.
Our customers expect that their claims will be paid promptly and
accurately. In order to ensure we get it right the first time, we
carefully measure customer satisfaction. In fact, 9 out of 10 are
satisfied with the handling of their claim. In addition, 97% of the
businesses we insure give us high marks.
Our ability to pay our customers billions of dollars annually with
these high levels of satisfaction is due to our highly trained people,
coupled with the right technology.
The substance of my testimony will be focused on how we track,
manage and pay the more than 400,000 claims we receive each year with
high levels of customer satisfaction.
Our people and tracking systems ensure we stay in close touch with
our customers as we take the steps necessary to enable us to pay their
claims. Our physicians and claims payers work closely with the
insureds' medical providers to, for example, schedule medical
examinations, set up calls so our doctors can speak directly with the
insureds' doctors and establish that they are receiving regular care
and treatment.
How do we keep our promises?
By employing:
experienced people and leading technology;
a claims management approach that applies the most
accurate resources to each claim;
best-in-class decisionmaking supported by expert systems
and resources with an emphasis on quality and tracking.
Customer Service and the Disability Management Process
While a person's disability can be a complex, ongoing and ever-
changing life event, our goal is to make the claim payment process
simple and transparent for our customers during this trying time in
their lives.
We make it easy to submit a claim. It can be done by Internet,
telephone, fax or mail.
At any time after the claim has been submitted, our customers can
speak with a skilled person. We handle more than 4.5 million calls a
year. Eighty percent of calls are answered within 20 seconds and 85
percent are managed without holding or transferring. It is a
combination of selecting talent with the right skills, developing
quality training programs, and employing the right technology that
enables us to handle these high volumes with just 300 employees.
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 their healthcare
teams. We view it as critically important to speak with our insureds
and their physicians and we frequently help them 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--
this technology is supported by hundreds of highly trained Benefits
Specialists, physicians, nurses and vocational rehabilitation
consultants. Again, it is this unique combination of people and
technology that enables us to fully understand and respond to our
customers' needs.
The Benefit Specialists help the claimants keep everything on
track--the Benefits Specialists essentially ``case manage'' the claims.
For example, they set up medical exams, help insureds with vocational
rehabilitation, assist our customers in obtaining Social Security once
we have determined that they may be eligible, and ensure that the
relevant medical records have been received by Unum for a full, fair
and thorough evaluation.
Our technology provides a single point of coordination which
enables the team to efficiently:
manage workloads;
make appointments;
review all claim documents;
schedule followup appointments, calls, letters and
medical exams; and
provide real-time management access and quality assurance
review.
This technology involves an imaging system so all the claims are
paperless and can be viewed across multiple locations at the same time.
This allows us to tap into expertise in other locations while also
enabling easy communication between team members, even if they are not
located in the same office. It also allows real-time claim assessment
and processing. Finally, it ensures a consistent claim history, claim
documentation, medical records and correspondence.
The technology also includes an automated scheduling system so
claim management activities--such as calling doctors' offices and
setting up independent medical exams--are done accurately and promptly.
Each one of the activities the Benefit Specialist does is scheduled
and tracked to ensure that the right resources are applied to the right
claims at the right time. In fact, the technology gives us the ability
to determine whether appointments are being kept, calls are being made
and whether there are delays in the claim processing.
The claim status is also viewable on the Web so our customers can
see their claim status ``real-time.'' Privacy protections are in place.
Unum's goal is to make a determination within 3-5 days on 95% of
short duration claims and within 45 days on longer term, more complex
claims.
In regard to the specifics of the management process, when a claim
is received it undergoes an initial claim review. During this phase the
following steps occur:
we verify eligibility;
we evaluate the claimant's functional ability;
we work in partnership with the insured's employer to
assess the physical and cognitive occupational demands;
we partner with the employer to determine any possible
accommodations that could be made so the person can return to work; and
the Benefit Specialist partners with in-house medical,
vocational and management resources as needed.
The more complex claims are sent electronically to Benefits
Specialists and medical professionals who specialize in certain types
of claims--allowing efficient, high quality, customer focused handling.
For these claims, each customer is called and we set up an individual
followup action plan with the insured based on the dynamics of the
specific medical condition. The claims process looks at the whole
person, not just the diagnosis. We provide information and motivation
to the claimant and the employer and work in collaboration to find the
most appropriate resolution to the claim. The claimant's level of
function is assessed, medical records and the treatment plan are
obtained, and activities of daily living are determined. We then work
with the insured on a return to work plan. A specific claim example may
be a behavioral health claim that is based on ICD9 (``International
Coding of Diagnostics 9''--a standardized Medical Diagnosis system
where each diagnosis is assigned a code, i.e. The ``ICD9 code'') code
and is sent to a Benefits Specialist with a specific skill set. That
Benefit Specialist would review the claim on our image-based system.
Based on the specific facts of the file, the Benefit Specialist could:
call the claimant, obtain medical records, schedule an independent
medical examination if necessary, call the claimant's doctor or set up
a meeting between one of our doctors and the claimant's medical team to
establish a treatment plan or gather outstanding information. The
system could be set up to automatically remind our claims payer, nurse
or doctor to call the claimant and see whether the appointment was kept
or the agreed upon treatment plan was being followed. Based on the
specific diagnosis, the system can automatically generate followup
activities to ensure that our team is in regular contact with the
insured and his or her medical team. As the insured's condition
improves or otherwise changes, we can continuously adjust our actions
to make sure that the insured is getting the treatment, care and claim
management that will enable us to assess the individual's condition
``real-time.''
During the assessment and review process, the Benefits Specialist
partners with the insured's medical team as well as with our internal
doctors, nurses and vocational rehabilitation staff to:
assess the duration of the claim;
provide rapid resolution to medical issues; and
assist with helping the claimant return to work.
In addition to medical and vocational professionals, the Benefits
Specialist has access to a wide variety of experts who can help with
Social Security advocacy, wellness and disease management, an employee
assistance program and return-to-work consulting.
Quality Assurance
The investment in the people and technology has given us the
ability to easily measure and carry out all of the actions we schedule
during the claim process.
From a Quality Assurance perspective, it gives us the ability to
roll up the information in many ways. For example, we know whether
appointments are being kept as we stay in close touch with the
claimants and their doctors.
Behind the tracking systems, our robust quality assurance and
continuous improvement programs also help:
maintain a strong, customer-based focus;
manage workloads for each of our claims specialists,
nurses, doctors, and vocational rehabilitation specialists;
facilitate an audit of claim decisions, both real-time
and post-claim;
support an appeal process with feedback; and
allow for management review, involvement and reporting.
In conclusion, we would be more than happy to assist you in any
way. You have an open invitation to visit Unum. We would welcome the
opportunity to continue to share knowledge of our capabilities, systems
and expertise. Thank you for the opportunity to testify before the
Committee.
Prepared Statement of Belinda J. Finn, Assistant Inspector General for
Auditing, Office of Inspector General, U.S. Department of Veterans
Affairs
INTRODUCTION
Mr. Chairmen and Members of the Subcommittees, I am pleased to be
here to address the Office of Inspector General's (OIG) findings
related to the Veterans Health Administration's (VHA) reported waiting
times for outpatient appointments. I am accompanied by Larry
Reinkemeyer, Director of the Kansas City Audit Operations Division, who
directed the teams responsible for the audits we performed. Our audit
coverage on outpatient waiting times and waiting lists consists of two
reports. I will discuss both reports today in order to provide a more
complete assessment of the problems we identified and the current
status of actions by VHA to improve outpatient waiting times.
In July 2005 we issued Audit of the Veterans Health
Administration's Outpatient Scheduling Procedures (Report No. 04-02887)
and concluded that schedulers were not following outpatient scheduling
procedures, resulting in inaccurate waiting times and incomplete
waiting lists. As a followup to the 2005 report, we issued Audit of the
Veterans Health Administration's Outpatient Waiting Times (Report
No. 07-00616-199) in September 2007. We again concluded that schedulers
were not following established procedures for making outpatient
appointments, causing VHA's reported performance on waiting times and
waiting lists to be unreliable for Congressional and VA decisionmaking.
OIG IDENTIFIES DATA INTEGRITY PROBLEMS IMPACTING THE RELIABILITY OF
VHA'S WAITING TIMES INFORMATION
In FY 2005, at the request of the Secretary of Veterans Affairs, we
audited VHA's compliance with outpatient scheduling procedures to
determine the accuracy of the reported veterans' waiting times and
facility waiting lists. Our objectives were to determine whether
schedulers followed established procedures when selecting the type of
appointment and entering the desired appointment date into the Veterans
Health Information Systems and Technology Architecture (VistA) and to
evaluate the effectiveness of the procedures used at VHA medical
facilities to ensure all veterans either had appointments or were
identified on electronic waiting lists.
Our 2005 audit work analyzed a statistical sample of 1,104
appointments from a universe of 38,786 appointments at 8 medical
centers. We reviewed scheduling data and medical records to determine
when the appointments were scheduled, how the schedulers created the
appointments, and whether the schedulers used the correct desired dates
when creating the appointments. We also reviewed each appointment to
determine whether the veteran qualified for the electronic waiting list
and if service-connected veterans received appointments within 30 days.
In addition, we gathered information from 15,750 (53 percent) of the
29,818 schedulers nationwide on their training, experience, adequacy of
supervision, and scheduling practices through a national survey. We
also interviewed 247 schedulers at the 8 medical facilities visited
during the audit.
VHA calculates outpatient waiting time for each appointment from
the desired date of care recorded in the VistA scheduling software to
the actual appointment date. The desired date of care is defined as the
earliest date that the patient or clinician specifies the patient needs
to be seen. In addition, VHA policy establishes a goal of scheduling
appointments within 30 days of the desired appointment but not more
than 4 months beyond the desired appointment date. When a specific
appointment date is not requested, VHA policy requires the scheduler to
use the next available appointment. VHA policy requires that all
appointment requests, including consult referrals to a specialist, must
be acted on by the medical facility within 7 days. Acting on the
request involves either scheduling the requested care or placing the
patient on the electronic waiting list. The electronic waiting list is
a standard tool that VHA implemented in December 2002 to capture and
track information about veterans waiting for clinic appointments in VHA
medical facilities.
Our 2005 results showed that outpatient scheduling procedures
needed to be improved to ensure accurate and reliable reporting of
veterans' waiting times and facility waiting lists. Because schedulers
did not follow established procedures, medical facility directors were
unaware that 18 percent of the service-connected veterans in our sample
waited more than 30 days for their appointment. We projected that over
2,000 service-connected veterans waited longer than 30 days from their
desired date to see a physician at these 8 medical facilities.
Nationwide, as many as 24,463 service-connected veterans could have
been similarly impacted. Inaccurate waiting time data and waiting lists
can compromise VHA's ability to assess and manage demand for medical
care. VHA managers plan budget priorities, measure organizational and
individual medical center directors' performance, and determine whether
strategic goals are met, in part, by reviewing data on waiting times
and lists.
We found that schedulers created appointments using the wrong
appointment type for 380 (34 percent) of the 1,104 appointments and the
wrong desired date for 457 (41 percent) of the 1,104 appointments in
our sample. When scheduling an outpatient appointment, schedulers are
asked if the appointment should be considered as ``next available.'' If
the scheduler answers yes to this question, then the system enters that
date as the desired date of care by default. If the scheduler answers
no to the question, then the scheduler must input a desired date of
care. In 2005, VHA strived to schedule at least 90 percent of all next
available appointments for veterans within 30 days. Our results showed,
however, that 65 percent of the next available appointments were
scheduled within 30 days--well below the VHA goal of 90 percent and the
medical facilities directors' reported accomplishment of 81 percent.
VHA medical facilities did not have effective procedures to ensure
all veterans were identified on the electronic waiting lists. In fact,
our testing showed that 5 medical facilities understated their waiting
list by 856 veterans. Nationwide, the electronic waiting lists could be
understated by as many as 10,301 veterans. We also identified clinics
with substantial backlogs of consult referrals where veterans did not
have appointments within 7 business days, and those veterans were not
included on the electronic waiting lists. Further, 17 percent of the
247 schedulers interviewed told us they maintained informal waiting
lists of veterans who needed appointments.
VHA did not have a standardized training program for schedulers so
schedulers were receiving most of their training as on-the-job
training. This led to inconsistencies implementing the scheduling
procedures and directly contributed to the errors we identified. Forty-
five percent of schedulers responding to our survey reported that they
had received no formal training on the use of the VistA scheduling
module, and 81 percent responded that they had received no training on
the use of the electronic waiting list. Further, 2,246 (68 percent) of
the 3,298 schedulers who identified themselves as trainers in our
nationwide survey, did not know how to correctly create an appointment
for a veteran who wanted an appointment as soon as possible but who did
not need urgent or emergency care. Seven percent of schedulers said
that managers or supervisors directed or encouraged them to schedule
appointments contrary to established procedures. Sixteen percent of the
schedulers reported that they maintained informal waiting lists.
We recommended that the Under Secretary for Health take the
following actions to improve outpatient scheduling procedures and the
data integrity of waiting time information:
Ensure that medical facility managers require schedulers
to create appointments following established procedures.
Monitor the schedulers' use of correct procedures when
creating appointments.
Monitor consult referrals to ensure that all veterans
with referrals either have scheduled appointments within 7 business
days or are included on electronic waiting lists.
Establish an automated link from the Computerized Patient
Record System consult package to the Vista scheduling module.
Ensure medical facilities prohibit the use of informal
waiting lists.
Develop a standard training package for medical
facilities to train schedulers on electronic waiting list and VistA
scheduling modules.
Ensure all schedulers view the video training titled
``Vista Scheduling Software: Making a Difference.''
Require all schedulers to receive annual training on the
electronic waiting list and VistA scheduling module.
The Under Secretary for Health agreed with the findings and
recommendations to make the needed improvements in outpatient
scheduling. According to the Under Secretary, VHA was vigorously
addressing problems with waiting times and scheduling delays, and they
had taken steps to accurately quantify the numbers of patients on
waiting lists, lengths of waits, and the reasons for the scheduling
delays. The Under Secretary also stated that VHA's Advanced Clinic
Access (ACA) initiative, in conjunction with other planned and ongoing
improvements, was expected to result in needed scheduling enhancements
that are consistently applied to all VHA medical facilities. While we
did not evaluate the implementation of the ACA initiative, our 2005
results showed that the schedulers' use of incorrect procedures
distorted the reported measurement of veterans' waiting times and
facility waiting lists, regardless of whether the clinic had
implemented ACA.
In response to our 2005 report, VHA issued new policy, Directive
2006-055, on October 11, 2006, for implementing processes and
procedures for the scheduling of outpatient appointments and for
ensuring the competency of staff involved in any or all components of
the scheduling process. VHA's directive also addressed the VA medical
facilities' responsibilities relating to recall, reminder systems, and
other forms of patient-driven scheduling, noting that facilities must
ensure that the patient entitled to priority access is given an
appointment in 30 days and all others within 120 days. The facility
retains principal responsibility for providing the patient an
appointment to be seen within the appropriate timeframes. VHA policy
further extends the facility's responsibility to call and/or send a
reminder letter and to make available a scheduled appointment for the
patient to be seen within 30 days of the originally specified desired
date for patients entitled to priority access or 120 days for all
others.
OIG FOLLOWUP REVIEW SHOWS VHA'S OUTPATIENT WAITING TIMES INFORMATION
STILL HAS DATA INTEGRITY PROBLEMS
In November 2006, we received a Congressional request to follow up
on the patient waiting times issue to determine if VHA had improved
their practices and procedures related to outpatient scheduling. The
objectives of our review, completed in 2007, were essentially the same
as our 2005 review, except that we also assessed whether the 2005 audit
report recommendations were fully implemented.
During our followup review, we determined whether established
scheduling procedures were followed, outpatient waiting times reported
by VHA were accurate, and electronic waiting lists were complete. We
visited 10 medical facilities, testing 700 appointments. A key point of
our methodology was that we reviewed appointments that VHA had reported
as being completed in 30 days. We also tested 300 consult referrals to
assess the accuracy of the consult tracking report because medical
facility personnel said that clinic personnel did not always update the
report after action was taken. VHA includes and relies upon this same
information in its performance and accountability reporting measure. At
the time of our review, these 10 facilities listed over 70,000 consult
referrals that were over 7 days old on the consult tracking reports.
The review showed that many of the data integrity weaknesses
reported in 2005 were still impacting the reliability of patient
waiting times and that schedulers were not following established
procedures for making or recording medical appointments. We concluded
that the accuracy of VHA's reported waiting times could not be relied
on and the electronic waiting lists at the 10 medical facilities were
not complete.
In reviewing each appointment, we researched the medical records to
find out when the referring medical provider had recommended that the
patient receive an appointment and compared the recommended date of
care to the actual appointment. We found unexplained differences
between the desired dates as shown in the scheduling system and used by
VHA to calculate and report waiting times, as compared to the desired
dates recommended by the medical provider and indicated in the
patients' related medical records. In a few appointments, schedulers
had annotated the appointment records to indicate when a patient
requested a specific date and we used that date to calculate the
waiting time. Our review also found instances where medical providers
had suggested a range of time, such as 4 to 6 months, instead of a
specific date for care. In those cases, we followed the guidance in
VHA's scheduling directives and used the earliest point of the time
range as the desired date of care.
Our review of 700 appointments provided us with reasonable
assurance to conclude that schedulers were not recording either
accurate, complete, or in some cases any information to support the
desired date of care used to compute the reported waiting time.
Overall, we found evidence to support that only 524 (75 percent) of the
700 appointments that VHA reported as having completed within 30 days
actually were. The 700 appointments that had occurred within 30 days
included 78 percent of the primary care appointments and 73 percent of
specialty care appointments. As a result, VHA's reported waiting times
are not based on accurate and complete information. For example, on
December 20, 2005, a veteran who was 50 percent service-connected was
seen in an Eye Clinic. The provider wrote in the progress note that the
veteran should return to the clinic in 6 weeks (January 31, 2006). On
September 6, the scheduler created an appointment for the veteran on
October 17. The scheduler entered a desired date of October 2, which
resulted in a reported waiting time of 15 days. However, based on the
provider's desired date of January 31, the veteran actually waited 259
days for his appointment. The scheduling records did not contain any
explanation for the delay. Medical facility personnel told us the
reason this appointment took so long to schedule was because it ``fell
through the cracks.''
In order to validate our results at each medical facility, we
provided our case review findings to the local medical facility
personnel responsible for scheduling. In response, our findings were
validated as being accurate and supportable. Concern over our
methodology did not become an issue until the draft report was
presented to VHA senior management. VHA nonconcurred with this finding
and told us that even though schedulers did not document it, the
unexplained differences between the date recommended by the medical
provider and the date shown in the scheduling system can be attributed
to patient preferences for a specific appointment date. VHA directives
require schedulers to annotate appointment records to indicate patient
requests for specific appointment dates. VHA personnel told us that
schedulers often do not document patient preferences due to high
workload; and that this documentation only serves to support audit
requirements. We contend that this basic annotation is critical to the
integrity of reported waiting times information. To accept an
assumption that every patient requested a desired date different than
the documented desired date shown in the medical records would be
irresponsible and contrary to VHA's own directives. We would agree that
some of the date differences we identified in appointment information
could possibly be due to patient preferences that were not documented
by schedulers. However, in the absence of specific information, neither
we nor VHA can be sure whether patient preference or the scheduler's
use of inappropriate scheduling procedures contributed to the 25
percent error rate we found.
VHA'S ELECTRONIC WAITING LISTS CONTINUE TO BE INCOMPLETE
VHA's policy prohibits schedulers from making appointments for
veterans that exceed the 30- or 120-day requirement and the policy
requires that those veterans be placed on the electronic waiting list
immediately. Our review identified 64 veterans (9 percent of the total
appointments reviewed) who should have been on the 30-day electronic
waiting list and were not.
Additionally, VHA's consult tracking report identified over 70,000
veterans with consult referrals over 7 days old that--in accordance
with VHA policy--should have been on the waiting list of the 10
facilities we reviewed. Our review of 300 consult referrals found that
183 (61 percent) of the associated veterans should have been on the
waiting list and more than half of those had been waiting more than 30
days. The remaining referrals had already been acted on, but facility
personnel had not updated the records to reflect the true status (for
example, completed or discontinued). The lack of action on consults may
lead to situations such as the following one highlighted in our 2007
report:
On April 18, 2006, a veteran who was 80 percent service-
connected, including service-connected for hearing impairment,
was referred to the Audiology Clinic. Because this was a
consult referral, the veteran should have received the next
available appointment. On September 20 (155 days after the
referral), the scheduler created an appointment for the veteran
for October 20 and entered the desired date of September 20,
which resulted in a reported waiting time of 30 days. However,
based on the provider's desired date of April 18, the veteran
actually waited 185 days for his appointment. The scheduling
records did not contain any explanation for the delay. Medical
facility personnel agreed with our recalculated waiting time.
At the time of our review, the 10 facilities had reported only
2,600 veterans on the waiting list. In 2007, we found that schedulers
at some facilities interpreted guidance from their managers to reduce
waiting times as instructions never to put patients on the electronic
waiting list. This seems to have resulted in some ``gaming'' of the
scheduling process. Medical center directors told us their guidance was
intended to ensure patients received their appointments timely and did
not need to be on the electronic waiting lists.
Low priority for training schedulers continues to affect the
accuracy of waiting times and completeness of waiting lists. Schedulers
and managers told us that, although training is readily available, they
were short of staff and did not have time to take the training. In
2007, 47 percent of the schedulers we interviewed reported they had no
training on consults within the last year, and 53 percent had no
training on the electronic waiting list within the last year.
PRIOR OIG RECOMMENDATIONS REMAIN OPEN
Outpatient waiting times continue to be inaccurate and waiting
lists continue to be incomplete because management has not yet
effectively implemented our recommendations. Almost 3 years later, five
of the eight recommendations remain open, which included one
recommendation that was reopened based on the findings in our 2007
report. Specifically, actions taken by VHA with respect to one of the
previously closed recommendations proved ineffective in monitoring
schedulers' use of correct procedures when making appointments.
We believe that the most important recommendations from our two
reports concern the need for VHA management to monitor how schedulers
perform and routinely test the accuracy of reported waiting times and
completeness of electronic waiting lists. In our opinion, these are
critical quality assurance steps that are necessary to ensure that the
VistA system contains complete and accurate information on waiting
times.
In addition to monitoring the accuracy of information, management
needs to take corrective action when testing shows questionable
differences between the desired dates of care shown in medical records
and those documented in the VistA scheduling package. To date, VHA has
not implemented an effective process to routinely test the accuracy of
reported waiting times and the completeness of electronic waiting
lists.
The findings in our 2005 and 2007 reports demonstrate that the data
recorded in VistA and used to calculate veteran outpatient waiting
times is not reliable. It is our position that until VHA establishes
procedures to ensure that schedulers comply with policy and document
the correct desired dates of care, whether recommended by medical
providers or requested by veterans, that calculations of waiting times
using VHA's current system will remain inaccurate.
2007 FOLLOWUP REVIEW LEADS TO FIVE OIG RECOMMENDATIONS
Based upon our followup work, we recommended that the Under
Secretary implement the following recommendations:
Establish procedures to routinely test the accuracy of
reported waiting times and completeness of electronic waiting lists,
and take corrective action when testing shows questionable differences
between the desired dates of care shown in medical records and
documented in the VistA scheduling package.
Ensure schedulers comply with the policy to create
appointments within 7 days or revert back to calculating the waiting
times of new patients based on the desired date of care.
Amend VHA Directive 2006-055 to clarify specialty clinic
procedures and requirements for receiving and processing pending and
active consults to ensure they are acted on in a timely manner and, if
not, are placed on the electronic waiting lists.
Ensure all schedulers receive required annual training.
Identify and assess the alternatives to the current
process of scheduling appointments and recording and reporting waiting
times, and develop a plan to implement changes to the current process.
VHA RESPONSE TO LATEST OIG REPORT AND OIG REBUTTAL
The Under Secretary for Health agreed that our report correctly
identifies areas VHA needs to address to improve outpatient waiting
times accuracy. The Under Secretary acknowledged that our report
highlights many of the roadblocks VHA faces making improvements in wait
times. However, VHA took exception to the findings on the wait times
because of their perceived limitations of our review methodology.
The Under Secretary stated that one of the most valid measurements
VHA has relating to access efficiency is generated directly from a
patient satisfaction survey of the veterans seeking healthcare services
and noted that 85 percent of the veterans who completed the survey
reported that they had access to primary care appointments when they
needed them, and 81 percent of these same veterans also reported
satisfaction with timely access to specialty care.
We see no valid basis for comparison between the results of the
patient satisfaction survey and the results of our audit. Further,
there is no basis for comparing overall patient satisfaction and VA's
compliance with specific policy requirements, or the accuracy of
waiting time information reported by VHA. We also noted that waiting
time information reported by VHA was obtained by the same data system
that the OIG used to conduct the audit, not from the patient
satisfaction survey. To support any level of comparison, the patient
satisfaction survey would have to ask veterans whether they were seen
in the 30-day requirement.
In addition, the patient satisfaction results do not support the
results VHA reported to Congress in November 2006. VHA reported that 96
percent of all veterans seeking primary care and 95 percent seeking
specialty care were seen within the 30-day standard. Only 85 percent of
the veterans who responded to the survey reported satisfaction with
access to primary care and only 81 percent were satisfied with timely
access to specialty care. These percentages are closer to the results
in our audit, which were 78 percent and 73 percent, respectively. Our
results are accurate, well-documented, and based on all available VA
information.
We also disagree with the Under Secretary's statement that during
our review we did not consider a patient's preference for a specific
date other than what the medical provider requested. We accepted
schedulers' comments on specific date requests as evidence of patient
preference, but we cannot accept a blanket statement that all
differences are due to patient preference. Although the Under Secretary
stated that it is unrealistic to expect schedulers to document patient
requests due to workload demands, we noted that scheduling directives
contain numerous requirements for documentation of patient requests and
actions.
While we recognize that ensuring scheduling information nationwide
has its challenges, both the 2005 and 2007 OIG reviews showed that
schedulers were not following VHA's policies and procedures to record
the correct desired date of care. Further, the findings in our reports
do support the fact that data recorded in VistA and used to calculate
veteran outpatient waiting times is not reliable. Until VHA establishes
procedures to ensure that schedulers comply with policy and document
the correct desired dates of care, whether recommended by medical
providers or requested by veterans, calculations of waiting times from
the current system will remain inaccurate.
Our followup review results showed that VHA has not taken timely
action to implement five of the eight recommendations in our 2005
report, and the Under Secretary for Health, by his own admission said
the system information is inaccurate in that it does not always
document patient preference for a specific date. We find it contrary
for VHA to state their agreement with the findings and recommendations
in our 2005 report and then to disagree with our followup report that
found a continuation of the same problems--problems that could have
been resolved had VHA implemented the recommendations in our 2005
report. In fact, VHA's response to our 2007 report concedes the failure
of scheduling clerks to adequately document patient preferences in
appointment dates. Both reports demonstrated and supported the fact
that the system is not accurate and therefore should not be relied on
as an accurate source for reporting waiting times to Congress.
PERFORMANCE AND ACCOUNTABILITY REPORTING
VA's FY 2006 Performance and Accountability Report prominently
reported that 96 percent of primary care outpatient appointments and 95
percent of specialty care outpatient appointments were scheduled within
30 days. We cannot compare this performance measure to the results of
our latest audit because we selected appointments from a different
timeframe. In FY 2007, VA reported that 97.2 percent of primary care
appointments and 95 percent of specialty care appointments were
scheduled within 30 days. We took great exception to VA's reporting of
this performance measure because our audit clearly showed significant
issues with the integrity of data being used to formulate these
performance measures. Although VA has continued to report these
measures, they added a footnote acknowledging our reports.
CLOSING
Long-term fixes and changes to the scheduling system may take years
to implement; however, in the meantime VHA needs to address the data
integrity issues associated with its scheduling system and ensure
accuracy in its current system. In addition, VHA needs to ensure
scheduling procedures are followed and implemented consistent with its
own policies. It is problematic when VHA continues to report waiting
time information to Congress that was knowingly derived from a system
that contains inaccurate and incomplete data. Debating the differences
between our reported error rate and VHA's reported waiting times would
only serve to overshadow the primary point of both audit reports, which
is that the data in VHA's scheduling system is inaccurate. Our concern
is that VA and Congress not only have accurate and reliable information
for budgeting, assessing, and managing the demand for care but, more
importantly, for ensuring no veteran falls through the cracks and fails
to receive timely medical care.
Mr. Chairmen, that concludes my remarks and thank you once again
for the opportunity to discuss this important issue. Mr. Reinkemeyer
and I would be pleased to answer any questions.
Prepared Statement of Gerald M. Cross, M.D., FAAFP
Principal Deputy Under Secretary for Health
Veterans Health Administration, U.S. Department of Veterans Affairs
Good afternoon, Chairman Michaud and Chairman Mitchell and Members
of the Subcommittees. Thank you for inviting me here today to discuss
the issue of outpatient waiting times. Accompanying me today are Mr.
William Feeley, Deputy Under Secretary for Health for Operations and
Management; Ms. Kathy Frisbee, Deputy Director of the VHA Support
Service Center; and Ms. Odette Levesque, Clinical/QA Liaison for the
Office of the Deputy Under Secretary for Health for Operations and
Management.
I am pleased to have this opportunity to share with you the current
actions the Department of Veterans Affairs (VA) is taking to guarantee
that our veteran patients have access to timely medical care at our VA
facilities. We are making good progress in meeting the needs of our
veterans and we are committed to providing all necessary care,
including preventive care, in a timely manner. I just want to be clear
that we are talking about waiting times for general routine outpatient
appointments; veteran patients with urgent or emergent needs are seen
immediately. In a healthcare system as large as VA, where we provide
over 1 million patient encounters in our clinics each week, we
understand there would be opportunities for improvement. VA is actively
seeking solutions to further reduce wait times as we are committed to
ensuring the care we provide our veterans is timely as well as high
quality.
VA has identified timely access to outpatient care as a top
priority. With national implementation of the Advanced Clinical Access
initiative, we have made significant progress in reducing waiting
times, but challenges continue. In the patient satisfaction survey for
the third quarter year to date for FY 2007, which is administered by
the National Research Corporation (NRC), 85 percent of veterans
surveyed reported they received primary care appointments when they
wanted them, and 81 percent reported that their specialty care
appointments were made at a time that was acceptable to them.
In FY 2007, 96 percent of our 40 million appointments were seen
within 30 days of the desired appointment date. This percentage
represents waits for outpatient primary and specialty care
appointments. It does not, however, reflect waits for outpatient or
inpatient procedures such as colonoscopies or joint replacements. VHA
is also building upon existing measures by actively moving forward with
enhancements to the current scheduling package. For example, an
enhancement to the current surgery case scheduler is expected to be
released nationally during the middle of this fiscal year and will
better enable us to manage and measure wait times for outpatient and
inpatient procedures.
We are improving access for new veterans as well as improving
waiting times for mental health services and medical procedures. The
percent of new primary care patients who were seen within 30 days of
their desired date has improved from 75 percent in FY 2005 to 83
percent in FY 2007--and the percent of new primary care patients seen
within 30 days of their desired date for the month of September 2007,
was 90 percent. Our statistics are even better for patients seen for
followup appointments. Finally, we are focusing on mental health access
by setting a new standard this fiscal year that requires all new mental
health patients be seen and their needs for care evaluated within 24
hours and that these veterans have a followup evaluation within 14
days. With the assistance of Congress, we have increased by 3,600, the
number of mental health professionals within our system since 2005.
This includes physicians, psychologists and social workers.
The conclusions made by VA's Office of the Inspector General (OIG)
in the recent September 10, 2007 report on outpatient waiting times
differs from the 85 percent patient satisfaction score with respect to
access and VA's metric on the 96 percent of appointments seen within 30
days of the desired date. VA has several concerns about the OIG's audit
methodology that was used in this particular audit. VA takes OIG
reports seriously. Nonconcurrences are infrequent with the last major
nonconcurrence occurring in the early 1990's. For this report on wait
times, specifically, the methodology used by OIG and VHA to calculate
waiting times do not match. VA's waiting times data reflects a ``real-
time'' approach to measure patient access using an old scheduling
system not designed for this purpose. While differences in methodology
exist, the overriding focus for both sets of measurements is the
veteran patient. VA has a driving interest to accurately monitor and
continually improve access for our veterans.
VA has worked diligently to develop an objective, reliable process
to measure waiting times. I am not aware of any other large system in
the public or private sector that has attempted to duplicate the
efforts of VA to measure the waiting times for each appointment. There
are an estimated 40 million appointments each year in the VA system.
There are multiple variables involved in this measurement tracking,
which includes patient preferences and differences in the organization
of individual facility services and clinics, including scheduling
practices. VA has identified that ongoing training of our scheduling
clerks is critical for success. For this reason, we require our
scheduling clerks to be trained using our scheduling education modules
and to pass a competency exam for certification. We also began
requiring annual refresher training.
VA is proactively taking steps to review the total scheduling
process, including the way VA measures waiting times. We will continue
to improve our processes, educate scheduling staff, and strive to
improve clinic access to further reduce waiting times. To this end, VA
has contracted with an independent third party to conduct an evaluation
of VA's scheduling practices and waiting time metrics. The contractor
is beginning the pilot program phase of its assessment, and VA
anticipates receiving the final report in Spring of 2008.
In conclusion, we are taking the following substantive actions to
aggressively address the issues of veteran access and wait times--we
are developing a new scheduling software package as well as developing
shorter term software solutions for our current scheduling package; we
are continually improving our training programs, and we are contracting
with an outside consulting firm for an independent review of our
scheduling process and metrics.
Thank you, again, for having me here today. I would be pleased to
answer any questions you or any of the Members of the Committee may
have.
Prepared Statement of Paul A. Tibbits, M.D.
Deputy Chief Information Officer, Office of Enterprise Development
Office of Information and Technology, U.S. Department of Veterans
Affairs
Good afternoon, Chairman Michaud, Chairman Mitchell, Ranking Member
Brown-Waite, Ranking Member Miller and Members of the Subcommittees,
thank you for the opportunity to report on the progress made by the
Department of Veterans Affairs (VA) on providing the information
technology needed to ensure that veterans are afforded timely access to
healthcare. We are committed to serving veterans and meeting the wait
time policies of the VA.
VHA has been using a scheduling system that was designed in the
1970's and
is out-of-date, negatively impacting patient scheduling and patient
access. The HealtheVet Scheduling Project (Replacement Scheduling
Application) was initiated in May 2001 to address this deficiency. The
RSA software offers a number of advantages over the current scheduling
system and I will highlight just a few:
Improved support and flexibility for site management of
resources (people, rooms, equipment).
Greater efficiency in scheduling appointments.
Improved continuity of care for referral management and
veterans who travel to other VA medical centers.
RSA waiting time metrics will be similar in construct to the
metrics now used by VHA but will have a higher degree of specificity
because they will be provider based rather than clinic based.
As you know the RSA project has experienced significant delays from
the original plan to release the software in mid-2005. These delays
have resulted from both vendor and VA related issues. My office is
actively addressing the causes of these delays by taking the following
actions:
Bringing in industry experts to strengthen program
management discipline;
Establishing standard IT processes for system
development, based on industry best practices, with mentoring for the
VA staff by industry experts;
IT staff professional development focused on
implementation of the high priority industry best practices needed to
assure software delivery on schedule and at cost.
Re-organizing the IT development organization to better
focus on high priority software projects and to identify and develop
common services once for use in all projects.
However, much work remains to be done.
The current schedule for RSA is to release the alpha version to
Muskogee VAMC in early summer 2008. This release will support basic
functionality followed by a test release with full functionality at the
Dallas VAMC in December 2008. I anticipate that RSA will be installed
at all VAMC's by January 2011.
Recognizing the difficulty that these delays impose upon VHA, the
VA Office of Information and Technology is making limited enhancements
to the current scheduling system as well as formalizing the process for
converting locally developed ``Class III'' software adapted to become
national ``Class I'' software. Class III software is developed locally
to meet a business need and historically sites have shared this
software to some extent. This sharing has produced variations in the
base VistA system which if we allow to continue will impede our ability
to convert to a national HealtheVet architecture, while providing less
than uniform IT support for scheduling across VA medical centers. In
the interest of leveraging the ingenuity and innovation that resides
locally we have created a path for converting Class III software to
national Class I software so that the Class III software will be
standardized before it is shared across VA facilities, and it will be
implemented in all VA facilities. As of October 2007, the VHA
Informatics and Data Management Committee prioritized the first three
Class III products for national release: Shift Hand-Off Tool,
Medication Reconciliation, and Surgery Case Manager. The Shift Hand-Off
Tool is projected for release in January 2008. This will provide, when
the veteran's primary care physician is not available, a synopsis of
the hospital care, pertinent medical history, alerts and special
instructions relative to a patient's care during a particular shift.
Medication Reconciliation is projected for release in January 2008.
This will provide a complete and accurate medication list that would be
given to every patient upon discharge from the VA facility or upon
departure from every clinic visit. Last, Surgery Case Manager is
projected for release in May 2008. This will track and report the
length of time veterans must wait for surgical procedures. Tracing this
will give VA the ability to improve efficiency and improve access to
inpatient surgical care by allowing facilities to identify delays and
access issues.
To assure that we are addressing all the high priority
requirements, VA has commissioned an independent study which will be
completed in Spring 2008. This study will look at patient scheduling,
scheduling staff, business rules, patient preferences, data accuracy,
and a review of the redesigned scheduling software, as well as
comparisons to health industry practices.
Thank you for the opportunity to appear before you and provide you
the status of our ongoing efforts. My colleagues and I are happy to
answer any questions you or other Members of the Subcommittee might
have.
Statement of Hon. Jeff Miller
Ranking Republican Member, Subcommittee on Health
Thank you, Chairman Mitchell and Chairman Michaud.
Timely access to healthcare services is a critical aspect of
providing high quality care to our Nation's veterans.
Since 2004, the VA has continued to report substantial improvements
in meeting the performance standard VA itself established to schedule
appointments within 30 days of a patient's requested date of an
appointment.
However, while we have been receiving reports showing that VA was
meeting its goal in about 96% of the cases, I am extremely disturbed by
a recent audit of VA's outpatient waiting times by the VA Office of
Inspector General (IG).
The IG found that previous problems with outpatient scheduling
procedures uncovered in their 2005 audit still exist and the accuracy
of the data recorded to calculate outpatient waiting times is not
reliable.
The IG report states: ``While waiting time inaccuracies and
omissions from electronic waiting lists can be caused by a lack of
training and data entry errors, we also found that schedulers at some
facilities were interpreting the guidance from their managers to reduce
waiting times as instruction to never put patients on the electronic
waiting list. This seems to have resulted in some ``gaming'' of the
scheduling process.''
I take great interest in monitoring how long veterans must wait for
care and it is unacceptable for the VA to provide incomplete and
erroneous waiting time data.
I expect as an outcome of our hearing today that VA immediately
employ corrective actions to record and report waiting times
accurately. It is my top priority to ensure that veterans are able to
access the care they need from VA.
Further, as a cosponsor of my colleague, Ginny Brown-Waite's
legislation, H.R. 92, the Veterans Timely Access to Health Care Act, I
believe if VA cannot meet its own established access standard for any
veteran, that patient should be given the choice to receive care in a
non-VA facility.
Thank you, Mr. Chairman. I look forward to the testimony and I
yield back the balance of my time.
Statement of Hon. Cliff Stearns
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman, for holding this important hearing.
If there is one issue that we hear about more often than any other,
it is the issue of access to healthcare for our veterans. From my
veterans, I am pleased to hear that veterans are happy with the quality
of care they receive at our medical centers and hospitals, however
often the wait time for appointments, in particular specialty
appointments, can be incredibly long--months after they request to be
seen. This is unacceptable. The Veterans Health Administration (VHA)
reports to Congress on the number of patients seen within 30 days of
requesting an appointment, and there is also an electronic waiting list
at the VA to ensure that no veteran falls through the cracks. However,
these systems are not being used correctly.
In 2007, Inspector General (IG) auditors assessed whether VA
schedulers followed procedures correctly when selecting appointments
and veterans' desired dates of care. The auditors also looked at how
medical facilities ensured that all veterans seeking care either had
appointments or were identified on electronic waiting lists. The IG
determined that scheduling procedures were not followed and that
electronic waiting lists were not complete. Often schedulers did not
enter the correct desired dates of care. In 2007, the error rate of
schedulers' entries was 72%! The IG also found that the VA's
performance measures were overstated. VHA reported that 96% of all
veterans seeking primary medical care and 95% seeking specialty care
were seen within 30 days of their desired date. IG's analysis showed
instead that 78% of veterans seeking primary care and 73% of veterans
seeking specialty care were seen within 30 days.
I understand that we will hear today more about the issue of
whether the statistics are correct or not, and the issues involved in
getting these numbers right. The issue of VA outpatient waiting times
comes down to whether or not the desired date of care recorded in the
scheduling system is the correct date to use. However, the main issue,
the key problem that we are here to deal with today, is how are we
going to work together to ensure our veterans are receiving timely
access to healthcare? I look forward to hearing the testimony from our
witnesses regarding their plans.
Thank you.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
December 13, 2007
The Honorable Gordon Mansfield
Acting Secretary
Department of Veterans Affairs
820 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Mansfield,
On December 12, 2007, the Subcommittee on Health and the
Subcommittee on Oversight and Investigations held a joint hearing on
Outpatient Waiting Times at the Department of Veterans Affairs.
During this hearing, I discussed legislation I introduced to help
reduce outpatient waiting times at VA Medical Centers and Community-
Based Outpatient Clinics, H.R. 92. At the end of the hearing, I asked
Dr. Cross to provide within 30 days the official administration views
on this legislation, which he agreed to do.
In order to assist you, I am enclosing a copy of H.R. 92 for your
review. Please provide in writing the official administration views on
this legislation by Jan-
uary 11, 2008. I would also greatly appreciate you sharing your
response with Chairman Filner, Ranking Member Buyer, Chairman Michaud
and Ranking Member Miller of the Subcommittee on Health, and Chairman
Mitchell, who I have the honor of serving with on the Subcommittee on
Oversight and Investigations.
I look forward to receiving your response shortly.
Sincerely,
Ginny Brown-Waite
Ranking Republican Member
Enclosure (H.R. 92)
__________
110th CONGRESS
1st Session
H.R. 92
To amend title 38, United States Code, to establish standards of
access to care for veterans seeking healthcare from the Department of
Veterans Affairs, and for other purposes.
----------------------------------------
IN THE HOUSE OF REPRESENTATIVES
January 4, 2007
Ms. Ginny Brown-Waite of Florida introduced the following bill;
which was referred to the Committee on Veterans' Affairs
----------------------------------------
A BILL
To amend title 38, United States Code, to establish standards of
access to care for veterans seeking healthcare from the Department of
Veterans Affairs, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. Short title.
This Act may be cited as the ``Veterans Timely Access to Health Care
Act''.
SEC. 2. Standards for access to care.
(a) Required Standards for Access to Care.--Section 1703 of title 38,
United States Code, is amended by adding at the end the following new
subsection:
``(e)(1) For a veteran seeking primary care from the Department,
the standard for access to care, determined from the date on which the
veteran contacts the Department seeking an appointment until the date
on which a visit with a primary-care provider is completed, is 30 days.
``(2)(A) The Secretary shall prescribe an appropriate standard for
access to care applicable to waiting times at Department healthcare
facilities, determined from the time at which a veteran's visit is
scheduled until the time at which the veteran is seen by the provider
with whom the visit is scheduled.
``(B) The Secretary shall periodically review the performance of
Department healthcare facilities compared to the standard prescribed
under subparagraph (A). The Secretary shall submit to the Committees on
Veterans' Affairs of the Senate and House of Representatives an annual
report providing an assessment of the Department's performance in
meeting that standard.
``(3) Effective on the first day of the first fiscal year
beginning after the date of the enactment of this section, but subject
to paragraph (4), in a case in which the Secretary is unable to meet
the standard for access to care applicable under paragraph (1) or (2),
the Secretary shall, or with respect to a veteran described in section
1705(a)(8) of this title may, use the authority of subsection (a) to
furnish healthcare and services for that veteran in a non-Department
facility. In any such case--
``(A) payments by the Secretary may not exceed the
reimbursement rate for similar outpatient services paid by the
Secretary of Health and Human Services under part B of the Medicare
Program (as defined in section 1781(d)(4)(A) of this title); and
``(B) the non-Department facility may not bill the veteran for
any difference between the facility's billed charges and the amount
paid by the Secretary under subparagraph (A).
``(4) Paragraph (3) shall not apply to a veteran enrolled or
seeking care at a Department facility within a Department geographic
service area that has a compliance rate, determined over the first
quarter of the first calendar-year beginning after the date of the
enactment of this Act, for the standards for access to care under
paragraphs (1) and (2) of 90 percent or more. The Secretary shall make
the determination of the compliance rate for each Department geographic
service area for purposes of the preceding sentence not later than July
1 of the first calendar-year beginning after the date of the enactment
of this Act.
``(5)(A) The Secretary shall submit to the Committees on Veterans'
Affairs of the Senate and House of Representatives for each calendar-
year quarter, not later than 60 days after the end of the quarter, a
comprehensive report on the experience of the Department during the
quarter covered by the report with respect to waiting times for
veterans seeking appointments with a Department healthcare provider.
``(B) Each report under subparagraph (A) shall include the total
number of veterans waiting, shown for each geographic service area by
the following categories:
``(i) Those waiting under 30 days for scheduled appointments.
``(ii) Those waiting over 30 days but less than 60 days.
``(iii) Those waiting over 60 days but less than 4 months.
``(iv) Those waiting over 4 months but who cannot be scheduled
within 6 months.
``(v) Those waiting over 6 months but who cannot be scheduled
within 9 months of seeking care.
``(vi) Those who cannot be scheduled within one year of
seeking care.
``(vii) Any remaining veterans who cannot be scheduled, with
the reasons therefore.
``(C) For each category set forth in subparagraph (B), the report
shall distinguish between--
``(i) waiting times for primary care and specialty care; and
``(ii) waiting times for veterans who are newly enrolled
versus those who were enrolled before October 1, 2001.
``(D) Each such report shall also set forth the number of veterans
who have enrolled in the Department's healthcare system but have not
since such enrollment sought care at a Department healthcare facility.
``(E) The final report under this paragraph shall be for the
quarter ending on December 31, 2010.''.
(b) Effective Date.--Subsection (e) of section 1703 of title 38, United
States Code, as added by subsection (a), shall take effect on the first
day of the first month beginning more than six months after the date of
the enactment of this Act. The first report under paragraph (5) of that
subsection shall be submitted for the quarter ending on December 31 of
the first calendar year beginning after the date of the enactment of
this Act.
__________
U.S. Department of Veterans Affairs
Washington, DC.
July 31, 2008
The Honorable Ginny Brown-Waite
Ranking Republican Member
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Congresswoman Brown-Waite:
On December 12, 2007, we appeared before the Subcommittee on Health
and the Subcommittee on Oversight and Investigations, to testify on
waiting times at VA medical facilities. At the hearing and again by
letter dated December 13, 2007, you requested the Department's views on
H.R. 92. Please find enclosed a copy of the Department's testimony sent
to the House Committee on Veterans' Affairs, Subcommittee on Health,
for the legislative hearing held on April 26, 2007. H.R. 92 is the
first bill discussed in our written statement.
We would also like to take this opportunity to expand upon two
technical issues. First, as we stated in our original testimony, VA has
no significant objection to
H.R. 92 with respect to setting a 30-day standard for the scheduling of
patients. We would, however, like to request that the bill language be
clarified under section (2)(a), regarding the starting date from which
the 30-day standard would be computed. The current language would begin
this computation on the date that the ``veteran contacts the
Department.'' There are many patients who contact the Department to
schedule appointments that are needed more than 30 days in the future.
The more appropriate start point would be the desired date specified by
the veteran. This could be reflected by changing the relevant language
to read: ``For a veteran seeking primary care from the Department, the
standard for access to care, determined from the desired appointment
date specified by the veteran seeking an appointment until the date on
which a visit with a primary-care provider is completed, is 30 days.''
In addition, VA is almost always able to provide access to primary care
within 30 days of the desired date at its Medical Centers, but may have
more difficulty meeting the access standard at some of the smaller
Community-Based Outpatient Clinics. VA's policy is to offer care to a
veteran within the specified 30-day access standard at a location that
is proximal to the veteran, but it should be understood that this may
or may not be at the specific location requested by the veteran.
Second, there is no requirement in the bill that contractors, even
if they are Medicare providers, agree to accept the Medicare rate from
VA. Regarding the provision to restrict VA to pay the Medicare rate, VA
is developing regulations that would support the requirement that
providers accept a Medicare rate payment. However, these regulations
will allow VA flexibility in those circumstances where services cannot
be obtained based upon use of Medicare reimbursement rates. VA wishes
to avoid a situation where the Medicare reimbursement rate requirement
would limit the services that the VA could provide to veterans if the
services cannot be purchased in the community at this rate.
We estimate the cost of H.R. 92 to be as follows: For veterans
enrolled in priority groups 1-7, we estimate the cost of meeting the
bill's 30-day standard to be $205,850,000 for FY 2009 and for veterans
currently enrolled in Priority Group 8, we estimate that cost to be
$61,123,000 for FY 2009, which is part of the FY 2009 President's
Budget. With respect to the 20-minute standard we discussed in
our testimony, we estimate the costs to be $1,278,850,000 for FY 2009,
and $14,817,870,000 over a 10-year period. This requirement was not
envisioned in the FY 2009 President's Budget request and would involve
significant new resource demands in future years that could create the
need for offsets in other medical requirements.
The Office of Management and Budget advises that there is no
objection to the submission of this report from the standpoint of the
Administration's program.
Sincerely yours,
James B. Peake, M.D.
Secretary
Enclosure
[The enclosed testimony of Dr. Gerald M. Cross, M.D., FAAFP, Acting
Principal Deputy Under Secretary for Health, Veterans Health
Administration, U.S. Department of Veterans Affairs, which was
enclosed, has been previously printed in Committee on Veterans'
Affairs, Subcommittee on Health ``Legislative Hearing on
H.R. 92, H.R. 315, H.R. 339, H.R. 463, H.R. 538, H.R. 542, H.R. 1426,
H.R. 1470, H.R. 1471, H.R. 1527, 1944 and Discussion Draft Rural Health
Care Bill,'' April 26, 2007, Serial No. 110-17, and will not be
reprinted. You can download a copy of
Dr. Cross' testimony from the Committee's Website at http://
www.house.gov/sites/ comms/veterans_dem/hearings/schedule110/apr07/04-
26-07/print_versions/4-26-07 cross.htm.]
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
January 16, 2008
The Honorable James B. Peake, M.D.
Secretary
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake,
As part of my Subcommittee's oversight over patient waiting times
at the Department of Veterans Affairs, I am writing to request
information relating to outpatient waiting times at VA medical
facilities.
I am requesting 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 outpatient clinics. I am also
interested in the percentage of waiting times which fall within the 30-
day timeframe for outpatient appointments, and whether documentation
exists as to why those that fell outside the 30-day timeframe took
longer to obtain an appointment.
I would like a response to this request no later than February 15,
2008. Thank you for your kind consideration.
Sincerely,
Ginny Brown-Waite
Ranking Republican Member
__________
U.S. Department of Veterans Affairs
Washington, DC.
February 15, 2008
The Honorable Ginny Brown-Waite
Ranking Republican Member
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Congresswoman Brown-Waite:
In response to your request, the Department of Veterans Affairs
(VA) is providing information on outpatient wait times at VA medical
centers. I, too, share your concerns regarding our veterans receiving
timely medical appointments and quality healthcare.
The Veterans Health Administration's (VHA) 30-day timeliness
standard does not apply to the wait time for a veteran to ``obtain an
appointment'' (i.e. the act of scheduling an appointment with the
clerk), but rather to the wait time between the desired date for the
appointment to occur and the actual date the scheduled appointment is
completed. Attached is a breakdown for primary and specialty care
waiting times from VA operated clinics using VA's scheduling software
during the month of December 2007 (fiscal year 2008). This is the most
recent data available on completed appointments.
Nationally, during the month of December 2007, 97.6 percent of all
scheduled appointments were completed within 30 days or less of the
desired date for that appointment as specified by the provider or
patient.
VHA frequently collects documentation of the reasons these times
exceed 30 days. Examples of why some patients wait greater than 30 days
from the desired appointment date are as follows:
Patient Preference. Schedulers are instructed to talk to
the patient during the scheduling process to ensure that the date and
time of the appointment offered is acceptable to the patient. In many
instances, staff found these patients were scheduled more than 30 days
from desired date because patients had specifically requested an
appointment beyond the specified 30 days. So while they appear as
waiting on the Access List, in fact they are scheduled to be seen at
times and on dates of their own choosing.
Cancelations and No-Shows. Staff reported that many
veterans waiting more than 30 days according to the Access List had
failed to appear for their scheduled appointment or had canceled a
previously scheduled appointment. VHA monitors Missed Opportunities
monthly and provides data to the facilities. Cancelations and No-Shows
make up the Missed Opportunities Report. For example, during the month
of December 2007, the missed opportunities rate nationally for
Cardiology was 13.7 percent and Mental Health was 18.3 percent (see
enclosures).
Scheduler Errors. In some instances, staff found patients
waiting more than 30 days from the desired appointment date due to
errors made by schedulers. Those errors were typically errors in entry
of the ``desired date'' and were subsequently corrected.
Capacity Constraints. In other instances, staff
determined patients were waiting beyond 30 days from the desired
appointment date due to capacity constraints that would not allow them
to offer appointments sooner. In those instances, facilities may have
purchased non-VA care, or added VHA resources through recruitment to
fill vacancies, added additional space, opened additional clinics, or
expanded clinic hours.
Thank you for your interest and support of the efforts of our
dedicated VHA staff to provide timely and quality care to our Nation's
veterans.
Sincerely yours,
James B. Peake, M.D.
Secretary
Enclosures
[The attachment, ``a breakdown for primary and specialty care waiting
times from VA operated clinics using VA's scheduling software during
the month of December 2007 (fiscal year 2008),'' will be retained in
the Committee files.]
[GRAPHIC] [TIFF OMITTED] 39648A.001
[GRAPHIC] [TIFF OMITTED] 39648A.002
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
February 14, 2008
Honorable George J. Opfer
Inspector General
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Opfer:
On Wednesday, December 12, 2007, the Subcommittee on Health and the
Subcommittee on Oversight and Investigations of the House Committee on
Veterans' Affairs held a joint hearing on outpatient waiting times.
During the hearing, the Subcommittees heard testimony from Ms.
Belinda Finn, the Assistant Inspector General for Auditing. She was
accompanied by Mr. Larry Reinkemeyer, Director of the Kansas City Audit
Operations Division. As a followup to that hearing, the Subcommittee is
requesting that the following questions be answered for the record:
1. VHA states in their response to your 2007 report that it is
unrealistic to expect schedulers to maintain such a high level of
documentation. What level of documentation is minimally required to
provide auditable analysis?
2. Overshadowed by the discussion on accurate waiting times is the
high number of veterans waiting for specialty consults. How significant
is this issue, and what are industry acceptable standards?
3. Should VHA have VAMC directors certify waiting times' lists and
would this certification improve the waiting times numbers?
We request you provide responses to the Subcommittee no later than
close of business, Wednesday, March 12, 2008.
Sincerely,
MICHAEL H. MICHAUD
JEFF MILLER
Chairman
Ranking Republican Member
Subcommittee on Health
Subcommittee on Health
HARRY E. MITCHELL
GINNY BROWN-WAITE
Chairman
Ranking Republican Member
Subcommittee on Oversight and
Subcommittee on Oversight
and
Investigations
Investigations
__________
U.S. Department of Veterans Affairs
Washington, DC.
March 17, 2008
The Honorable Michael H. Michaud
Chairman, Subcommittee on Health
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515
Dear Reps. Michaud, Miller, Mitchell, and Brown-Waite:
Enclosed are the responses to the questions from the December 12,
2007, joint hearing before your Subcommittee and the Subcommittee on
Oversight and Investigations on outpatient waiting times. A similar
letter is being sent to Congressman Jeff Miller, Ranking Republican
Member, Congressman Harry Mitchell, Chairman, Subcommittee on Oversight
and Investigations, and Congresswoman Ginny Brown-Waite, Ranking
Republican Member, Subcommittee on Oversight and Investigations.
Thank you for your interest in the Department of Veterans Affairs.
Sincerely,
GEORGE J. OPFER
Inspector General
Enclosure
__________
Responses from the Office of Inspector General
to Post Hearing Questions on Outpatient Waiting Times
1. VHA states in their response to your 2007 report that it is
unrealistic to expect schedulers to maintain such high level of
documentation. What level of documentation is minimally required to
provide auditable analysis?
In our 2007 report, the Under Secretary concedes that the failure
of scheduling clerks to adequately document patient preferences in
appointment dates contributed to the OIG findings and states that it is
unrealistic to expect schedulers to maintain such a high level of
documentation. While the OIG recognizes the workload associated with
millions of appointments made every year, documenting changes in
veteran desired dates is required by VHA's policy. The Under Secretary
also comments that this documentation is solely to support audit
requirements and does little, if anything, to support the actual
scheduling of the appointment. Contrary to this position, the OIG
maintains that full compliance with established scheduling procedures
is critical to ensuring patients are seen in a timely manner.
Compliance is also critical to ensure data integrity. In the absence of
specific information, neither we nor VHA can be sure whether the
desired date differences were due to patient preference or the
scheduler's use of inappropriate scheduling procedures. To accept VHA's
assumption that our reported error rate in waiting times is somehow
flawed because we failed to consider that the veterans may be canceling
and changing their
appointments for which there is no supporting documentation would be irr
esponsible.
At a minimum, we expect schedulers to maintain the documentation
prescribed by VHA Directive 2006-055. This requires that for every
patient who requests a specific appointment date that is different than
the date specified by the provider in the medical records, the
scheduler should annotate why the date was used in the ``Other Info''
section in the Veterans Health Information Systems and Technology
Architecture (VistA) scheduling package. For example, ``patient
requested appointment for 3/2/08.'' The ``Other Info'' section is
included with a series of questions and prompts that each scheduler
answers when creating most appointments. During our review, we
generally found no information in the ``Other Info'' section.
2. Overshadowed by the discussion on accurate waiting times is the
high number of veterans waiting for specialty consults. How significant
is this issue, and what are industry acceptable standards?
We believe this issue is significant for several reasons. The high
number of veterans waiting for specialty consults means that veterans
with serious medical conditions could be experiencing significant
delays in receiving treatment from medical specialists. We also believe
that a sizable number of veterans may be affected. In our 2005 review,
we reported that electronic waiting lists could be understated by as
many as 10,301 veterans nationwide. At the 10 facilities we reviewed in
2007, VHA's consult tracking report identified over 70,000 veterans
with consult referrals over 7 days old that--in accordance with VHA
policy--should have been on the waiting list of the 10 facilities we
reviewed. At the time of our review, the 10 facilities had reported
only 2,600 veterans on the waiting list. We believe that this problem
could potentially be much larger since the VHA medical system consists
of 153 medical centers.
While having a large number of veterans on waiting lists is an
indication that VA may not be capable or funded to handle its patient
workload within prescribed timeframes, we believe there is an even more
significant issue--the large numbers of veterans waiting for specialty
consults who are intentionally or inappropriately not placed on waiting
lists who fall through the cracks and do not receive needed critical
care.
We were unable to identify a firm industry standard on acceptable
waiting time for specialty care, although we noted an international
study on access to care that
measured the percentage of patients who waited 4 weeks or longer for spe
cialty care.
3. Should VHA have VAMC directors certify waiting times' lists and
would this certification improve the waiting times numbers?
Requiring VAMC Directors to certify waiting times and waiting lists
would help establish accountability. However, the most important action
VHA needs to take is to establish procedures to routinely test the
accuracy of reported waiting times and completeness of electronic
waiting lists, and take corrective action when testing shows
questionable differences between the desired dates of care shown in
medical records and documented in the VistA scheduling package.
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
February 29, 2008
The Honorable James B. Peake
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
On Wednesday, December 12, 2007, the Subcommittee on Health and the
Subcommittee on Oversight and Investigations of the House Committee on
Veterans' Affairs held a joint hearing on outpatient waiting times.
During the hearing, the Subcommittees heard testimony from Dr.
Gerald M. Cross, Principal Deputy Under Secretary for Health; and Dr.
Paul Tibbits, Deputy Chief Information Officer, Office of Information
and Technology; Mr. William F. Feeley, Deputy Under Secretary for
Health for Operations and Management; Ms. Odette Levesque, Clinical/QA
Liaison; and Ms. Kathy Frisbee, Deputy Director of the Veterans Service
Support Center. As a followup to that hearing, the Subcommittee is
requesting that the following questions be answered for the record:
1. What specific actions will VHA implement to improve the
accuracy and completeness of the scheduling information? Please provide
an implementation schedule with milestones and exit criteria.
2. Are there any issues that would affect your ability to ensure
improvements are made in a timely manner?
3. In 2005, the OIG made specific recommendations--with which VA
agreed--to ensure and then monitor schedulers' use of correct
procedures when creating appointments. In its 2007 report, the OIG once
again reported concerns with the reliability of VA's waiting time data.
If required documentation, without which it is not possible to tell
whether an appointment was made within 30 days, did not exist, is not
the proper conclusion for auditing purposes that the appointment was
not made in 30 days? Suppose that VA claims 95 percent of appointments
are made within 30 days, but documentation required by VA policy does
not exist to support 20 percent of those appointments. Does VA believe
that it would be justified in claiming the 95 percent number in those
circumstances?
4. How do you determine if training is effective if you have no
process in place to test and monitor schedulers' compliance with
scheduling procedures?
5. Other than monitoring appointments with waiting times of more
than 30 days, what specific actions do you take to test the reliability
of the waiting times performance that you include in your annual
Performance and Accountability Report?
6. How will you ensure the accuracy of the current scheduling
system until a new system comes online?
7. If you propose eliminating your current measurement of waiting
times and rely entirely on patient satisfaction surveys, how would you
ensure the survey provides you sufficient, meaningful information
necessary to place resources in the most appropriate places to
positively impact timely patient care?
8. How are directors for each facility held accountable for
veterans' waiting times in their facilities? What measurement did you
hold them to in 2007, and are those same standards in place for 2008?
9. Would it be in the veterans' best interests if you knew
exactly how many veterans were waiting for an appointment and then how
long veterans were waiting for appointments? How do you know where to
apply resources if facilities do not capture accurate waiting time
performance data?
10. The OIG found that there were a number of veterans that should
have been on the electronic waiting list but were not. In 2007, in a
review of 10 facilities, it appears that a significant number of
veterans were waiting an extended period of time for action on their
request for a consult with a specialist. Electronic waiting lists were
created as a mechanism to ensure visibility over all veterans without
appointments. Why are your facilities not using them appropriately?
11. Do you think having VHA bring back the policy of having VAMC
directors certifying the waiting time's list would improve the accuracy
of the waiting times numbers?
12. Why was the certifying procedure the medical facility
directors had to comply with eliminated?
13. Do you think there is a conflict of interest between the VA's
goal of minimizing veteran-patients waiting times and the temptations
for directors to game the numbers to make this specific performance
measure look good for their annual reviews?
14. Since the disbandment of the Medical Administration Service,
supervisory oversight controls of the scheduling clerks may have been
compromised. In addition, their career development needs might not be
properly addressed. How is VA addressing career needs of the scheduling
clerks with a national workgroup? Can you give us an update of what
this workgroup is planning to accomplish?
15. Can you please tell us how VHA defines ``waiting times?'' And
is your definition standardized across every VISN?
16. Please provide documentation of waiting times in the Central
Ohio region. Specifically, the Subcommittees are interested in what is
happening with primary and specialty care around the Newark area. Do
veterans in Licking County have access to more than the Newark
Community-Based Outpatient Clinic? What are the procedures for
arranging treatment at and transportation to the Chalmers P. Wylie
Independent Outpatient Clinic in Columbus, Ohio?
17. What is the status of the feasibility study conducted by the
VA for southeastern Ohio? When is it expected to be completed and
released?
18. The OIG report documents a number of instances where wait time
statistics were artificially improved. It is the understanding of the
Subcommittees that the average wait time is one of the indicators that
helps determine bonuses for administrators. Is there a correlation
between incorrectly improved wait time statistics and the bonus amount
specific administrators received for FY2007?
19. Has there been any evidence (anecdotal or otherwise) to
indicate that schedulers were encouraged to falsify records
specifically for the purpose of increasing bonuses?
20. When determining Medical Center Director bonus amounts, is
there a specific formula equating wait times to a bonus dollar amount?
We request you provide responses to the Subcommittee no later than
close of business on April 4, 2008.
Sincerely,
MICHAEL H. MICHAUD
JEFF MILLER
Chairman
Ranking Republican Member
Subcommittee on Health
Subcommittee on Health
HARRY E. MITCHELL
GINNY BROWN-WAITE
Chairman
Ranking Republican Member
Subcommittee on Oversight and
Subcommittee on Oversight
and
Investigations
Investigations
__________
Responses to Questions from 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, M.D., Secretary,
U.S. Department of Veterans Affairs
Outpatient Waiting Times
Question 1: What specific actions will VHA implement to improve the
accuracy and completeness of the scheduling information? Please provide
an implementation schedule with milestones and exit criteria.
Response: The Veterans Health Administration (VHA) has implemented
several specific actions to improve the accuracy and completeness of
the scheduling information. VHA has revised the scheduling directive
for schedulers. Schedulers will find the scheduling directive to be
more user friendly and simpler to follow. The revised scheduling
directive will be released within the next 60 days.
VHA has also identified and addressed several software deficiencies
that contributed to scheduling errors. For example, information entered
into VistA to explain changes to desired date is being obscured or
erased by existing software. To resolve this deficiency, VHA is working
with the Office of Information and Technology (OIT) to correct this
information loss.
Additional improvements implemented by VHA include new software
that now enables schedulers to link an appointment to a specific
consult request. VHA released a first version of its report on wait
times from the actual consult request date to the dates of appointment
in February 2008. Refinements are being made to the report format and
will be made available nationally on VHA's Web site.
In July 2008, OIT will release a software patch that creates a new
field within the consult request software where requesting providers
will be required to specify the desired date for the service requested.
VHA has submitted a request for an additional software modification
which would display the provider's desired date on the scheduler's
screen as an appointment is scheduled, link that to the scheduled
appointment and then transmit the information to the Veterans Service
Support Center (VSSC) wait time database. This information would be
used to measure the wait time from that desired date until the date of
the scheduled appointment.
Finally, a scheduling process workgroup has been proposed to be
jointly chartered by OIT and the Systems Redesign Office. This group
will be charged with standardizing scripts, processes and tasks for the
major types of scheduling issues. The Department of Veterans Affairs
(VA) would use the products of the workgroup to make improvements in
the existing software, training, and tools.
Question 2: Are there any issues that would affect your ability to
ensure improvements are made in a timely manner?
Response: Yes, there are some issues which could affect our ability
to ensure improvements are made in a timely manner. Revisions to the
Scheduling Directive must be negotiated with the union. The negotiation
process could take up to several months to complete.
VHA lacks national data tracking and direct measurement systems
specific to consultation requests. While information is now being
captured on request dates of consults and it is linked to scheduled
appointments, there is no provision for automatically reporting of
information contained in the computerized patient record system (CPRS).
This information includes the types and dates of consult requests, and
dates of clinical or administrative closure. This deficiency cannot be
corrected until new software routines are developed to automatically
transmit information, and new resources (including equipment and
staffing) are available to manage and analyze the large volume of data
that would be involved. VHA is working with OIT to resolve this issue.
Question 3(a): In 2005, the OIG made specific recommendations--with
which VA agreed--to ensure and then monitor schedulers' use of correct
procedures when creating appointments. In its 2007 report, the OIG once
again reported concerns with the reliability of VA's waiting time data.
If required documentation, without which it is not possible to tell
whether an appointment was made within 30 days, did not exist, is the
proper conclusion for auditing purposes that the appointment was not
made in 30 days?
Response: No, that would not be the correct conclusion. The data
exist, but not necessarily in the proper form or format. To resolve
this problem, scheduler's use of correct procedures when creating
appointments is being monitored using a comprehensive audit tool, which
is supplemented with feedback and regular training. The unions are
reviewing these procedures currently.
Question 3(b): Suppose that VA claims 95% of appointments are made
within 30 days, but documentation required by VA policy does not exist
to support 20% of those appointments. Does VA believe that it would be
justified in claiming the 95 percent number in those circumstances?
Response: Yes, VA believes that it would be justified in making the
claim of 95 percent of appointments made within 30 days. The Office of
Inspector General (OIG) does not consider a desired date real unless
documentation of the date exists in the record. The documentation
exists, but not necessarily in the form or format accepted by the OIG.
VA is developing software that will resolve this problem.
Question 4: How do you determine if training is effective if you
have no process in place to test and monitor schedulers' compliance
with scheduling procedures?
Response: VA uses several ways to determine if training is
effective. For example, supervisors provide training to schedulers,
when needed, and monitor schedulers' compliance and performance, and
this is part of the scheduler's annual performance appraisal. VHA is
standardizing the way supervisors monitor scheduler's compliance and is
providing tools to assist in monitoring schedulers' performance. OIT is
converting software which will be used by facilities to randomly pull
appointments created by each scheduler for review by supervisors.
VHA is negotiating with union representatives on instructions
supervisors will follow to review appointments to ensure desired date
was correctly entered. Followup will be required in instances in which
a scheduler fails to correctly schedule a specified percentage of the
appointments reviewed. Facility directors are required to monitor
supervisors' reviews of scheduler performance.
Question 5: Other than monitoring appointments with waiting times
more than 30 days, what specific actions do you take to test the
reliability of the waiting times performance that you include in your
annual Performance and Accountability Report?
Response: To test the reliability of the waiting times performance,
VHA, on a regular basis, sends wait time data to the facilities to
review for accuracy. During the review process, outliers are identified
and explanations are provided relative to the reasons for the outlier
status. This is a process of sorting out the differences in outlier
numbers associated with real wait time problems versus scheduler
errors, either in entry of desired date, or in selection of an
appointment date. Patients with extended wait times are called and
provided earlier appointments as appropriate consistent with their
preferences and clinical necessity.
VHA also test reliability of the waiting times performance by
asking patients on its Survey of healthcare experience of patients
(SHEP) to respond whether they received an appointment when they wanted
to be seen. Steady improvement has been noted in patient satisfaction
on this issue. VHA tracks patient complaints received and has noted
improvements in numbers of complaints received in spite of increased
numbers of veterans being scheduled.
In fiscal year (FY) 2004, VHA distributed nationally an electronic
tool for use by facilities in continuous auditing of the accuracy of
appointments scheduled more than 30 days from desired date. VHA
Directive 2006-055 published October 2006 required continuous auditing
by supervisors of performance of employees in scheduling using locally
developed or veterans integrated service network (VISN) approved tools.
VHA is now finalizing actions to distribute new tools nationally to
optimize this auditing process.
Question 6: How will you ensure the accuracy of the current
scheduling system until a new system comes online?
Response: Among the actions VA has taken to ensure the accuracy of
its current scheduling system are developing and implementing a revised
directive on scheduling for schedulers to follow; modifying our
existing scheduling software package; developing a standardized method
to monitor scheduler accuracy; and negotiating with unions on enhanced
training and supervision for schedulers.
It is important to note, however, that even once the new
replacement scheduling application comes online there will still be
some scheduling errors. The office responsible for the application is
actively working on a transition plan which would ensure those errors
are kept to a minimum.
Question 7: If you propose eliminating your current measurement of
waiting times and rely entirely on patient satisfaction surveys, how
would you ensure the survey provides you sufficient, meaningful
information necessary to place resources in the most appropriate places
to positively impact timely patient care?
Response: VA is not proposing to eliminate current measurement of
waiting times completely. We would not eliminate measurement of waiting
times in clinics entirely but would use these metrics as internal
measures. We would retain some method of monitoring the clinic backlog
such as a measure of ``future open capacity'' and/or ``third next
available,'' which are capacity measures. These are the most common
methods used in non-VA healthcare.
SHEP data capture meaningful patient information. Currently, we
provide SHEP data on a quarterly basis. VHA is considering various
means of obtaining more comprehensive data, in addition to SHEP data,
such as asking patients or random sample of patients some key question
immediately upon seeing their provider. The cost involved is yet to be
determined.
Question 8(a): How are directors for each facility held accountable
for veterans' waiting times in their facilities?
Response: VHA continues to place increased focus and accountability
for improving performance relative to wait times through national
teleconference calls, meetings, and sending data to the facilities on a
regular basis. Directors remain accountable for health system
indicators which include new patient wait times, missed opportunities
and wait times to see a provider. These contribute to the overall
director's performance evaluation.
Question 8(b): What measurement did you hold them to in 2007, and
are those same standards in place in 2008?
Response: During FY 2007, 60 percent of the directors' overall
score was dependent on results of 22 performance measures. As a result,
during FY 2007, 2.7 percent of a director's performance depended on
veteran's waiting times. Measures included outpatient wait times for
new and established patients, missed opportunity rates and wait times
to see a provider.
During FY 2008, 60 percent of the directors' overall score is
dependent on results of 15 mission critical measures. As a result,
during FY 2008, 4 percent of a director's performance depends on
veteran's waiting times. The measure for FY 2008 is a percent of
appointments completed within 30 days for Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) veterans.
Question 9(a): Would it be in the veterans' best interests if you
knew exactly how many veterans were waiting for an appointment and then
how long veterans were waiting for appointments?
Response: Some measure of patient wait time is needed. During FY
2007, VHA refined its approach to measurement of all patients waiting
for outpatient appointments. The consult-scheduling software linkage
was distributed and implemented to enhance tracking wait times for
consult processing. Reporting strategies are now being refined. A new
access list was developed to provide a snapshot in time of all patients
waiting beyond their desired date for a scheduled appointment or on the
electronic wait list. A new pending report was created to enable
facilities to drill down to view all pending appointments. In addition,
for FY 2008, the VHA consult completion monitor has been refined to
measure numbers of consults clinically completed with results within 30
days of request and within 60 days of request. VHA will continue to
measure wait times for new and established patient appointments and
missed opportunity rates.
Question 9(b): How do you know where to apply resources if
facilities do not capture accurate waiting time performance data?
Response: VHA acknowledges that there is a level of imprecision in
the data; however, experience has shown that it is adequate for
resource decisionmaking purposes. In order to make resource decisions,
information beyond single waiting time measurements are needed. Clinics
need to consider information such as the changes in patient demand,
changes in clinic supply, changes in no-show rates, the quality of
consults sent to specialty care, continuity scores, re-visit rates, and
panel size or caseload. In general, if waiting times are stable, the
problem is more likely a backlog problem than a resource problem.
Question 10: The OIG found that there were a number of veterans
that should have been on the electronic waiting list but were not. In
2007, in a review of 10 facilities, it appears that a significant
number of veterans were waiting an extended period of time for action
on their request for a consult with a specialist. Electronic waiting
lists were created as a mechanism to ensure visibility over all
veterans without appointments. Why are your facilities not using them
appropriately?
Response: The CPRS consultation software is used not only to
request specialty consultation but also to order tests and procedures
that are not specialty consultation. On reviewing the lists of consults
the OIG asserted should have been placed on the electronic wait list,
VHA determined that OIG had erred in large measure by reviewing a few
consults and then projecting numbers that should have been on the
electronic wait list based on existing, pending, and active consults at
the facilities without actually reviewing those lists of pending and
active consults.
On closer review, VHA found many if not most of these unscheduled
active and pending consults not listed on the electronic wait list were
procedures, and not medical consultations. Examples: consult requests
for fee basis and other types of non-VA care, consult requests for
electrocardiograms (EKG) performed on patients in pre-procedural beds,
consult requests for medical and surgical procedures scheduled to be
done in an operating or procedure room. VHA is working to distinguish
the ``formal consults'' (requests to qualified healthcare providers for
management and treatment of problems requiring clinical input,
direction in treatment, or review of the record) from the use of the
consultation software for other purposes.
Experience has shown that electronic wait lists, in the fashion
previously implemented was overly prescriptive and effectively resulted
in low priority veterans being served sooner than high priority
veterans. The new access directive will correct this problem and make
the use of the electronic wait list easier for facilities. As indicated
above, VHA has created an access list which provides a snapshot of
patients waiting past their desired date for a scheduled appointment or
on the electronic wait list. This provides the universe of patients
waiting 30 days past their desired date and is a more precise metric.
Question 11: Do you think having VHA bring back the policy of VAMC
Directors certifying the waiting time's list would improve the accuracy
of the waiting times numbers?
Response: The policy of certification was updated, but not
eliminated by VHA. Prior to publication of VHA Directive 2006-028 in
May 2006, VHA required each facility and network director to certify
full compliance with the requirements of VHA Directive 2002-059 and VHA
Directive 2003-068 that provided business rules for scheduling. When
published, VHA Directive 2006-028 and VHA Directive 2006-055 (Oct.
2006) provided new, updated business rules for scheduling. In May 2007,
every facility and network director was required to certify compliance
with VHA Directive 2006-055.
We believe that we have focused facility and network leadership on
access issues through numerous teleconferences and meetings and will
continue to highlight during the coming year. In addition to the
mission critical wait time measures, the directors remain accountable
for health system indicators which include new patient wait times,
missed opportunities and wait times to see a provider and contribute to
the overall director's performance evaluation.
Question 12: Why was the certifying procedure the medical facility
directors had to comply with eliminated?
Response: The certifying procedure was not eliminated. The last
certifications of compliance with requirements of VHA Directive 2006-
055 were collected in May 2007, less than 9 months ago. However, we do
believe that there are more effective ways of focusing attention on
access than having leadership certify compliance with numerous elements
identified in a directive. We will continue to focus attention on
access in the coming year.
Question 13: Do you think there is a conflict of interest between
the VA's goal of minimizing veteran-patients waiting times and the
temptations for directors to game the numbers to make this specific
performance measure look good for their annual reviews?
Response: No, VA does not think there is a conflict of interest. We
believe that having a variety of performance measures and patient
satisfaction data will ensure the integrity of the process. During the
past several years, we have had teams visit facilities to do
consultative reviews, numerous communities of practice that discuss
access issues faced locally, shared best practices; regional
collaborative meetings, and paired sites who are struggling with those
who have demonstrated success. Wide spread discussion, learning, and
focus contributes to a ``learning organization'' atmosphere rather than
gaming.
Question 14(a): Since the disbandment of the Medical Administration
Service, supervisory oversight controls of the scheduling clerks may
have been compromised. In addition, their career development needs
might not be properly addressed. How is VA addressing career needs of
the scheduling clerks with a national workgroup?
Response: Turnover of scheduling clerks is a problem that may be
more related to grade and pay issues than service organization. During
FY 2007, a small workgroup was tasked with creating a viable career
ladder for schedulers, to enable progression from nationally
standardized GS 3 to GS 7 positions, while still responsible for
scheduling.
Question 14(b): Can you give us an update of what this workgroup is
planning to accomplish?
Response: VHA has initiated action to standardize the monitoring of
scheduler compliance and has provided tools to facilitate supervisory
actions in monitoring the performance of schedulers. The work of this
group continues.
Question 15: Can you please tell us how VHA defined ``waiting
times?'' And is your definition standardized across every VISN?
Response: Wait times are measured for two different groups of
patients. ``New patients'' are those patients not seen within the
facility within a clinic group within the last 24 months. For these new
patients, wait times are defined as the days from the date an
appointment is created until the date the appointment is completed.
Time the patient spent waiting on the electronic wait list prior to the
scheduling of the appointment and time added by clinic cancelation of
the original appointment created are included in the total wait time
reported.
All other patients are designated as ``established patients.'' Wait
times for established patients are defined as the days from the
``desired date'' entered by the scheduler until the date the
appointment is completed. Time the patient spent waiting on the
electronic wait list prior to the scheduling of the appointment and
time added by clinic cancelation of the original appointment created
are included in the total wait time reported.
Question 16: Please provide documentation of waiting times in the
Central Ohio region. Specifically, the Subcommittees are interested in
what is happening with primary and specialty care around the Newark
area. Do veterans in Licking County have access to more than the Newark
Community-Based Outpatient Clinic?
What are the procedures for arranging treatment at and transportation
to the Chalmers P. Wylie Independent Outpatient Clinic in Columbus,
Ohio?
Response: Veterans in Licking County have access to the Columbus
Independent Outpatient Clinic which is 35 miles west of Newark and the
Zanesville Community Outpatient Clinic which is 33 miles east of
Newark. Patients may opt to come to the Columbus Clinic on their own or
they may be referred by primary care providers for specialty services
that are offered in Columbus. If patients do not have means of
transportation, this can be arranged through the Disabled American
Veterans (DAV). DAV, a veterans service organization, transport
patients from different counties around Central Ohio to the Columbus
clinic.
The chart below contains the most recent wait times for all clinics
in Newark. A psychiatrist goes to Newark 2 days a week. A social worker
was recently hired and should be able to screen and see new patients
more timely until tele-mental health can be implemented or additional
providers hired.
----------------------------------------------------------------------------------------------------------------
Wait in Days Wait in Days (New
Clinic (Established Patient) Patient)
----------------------------------------------------------------------------------------------------------------
Newark/P Care/Physican 1 12 20
----------------------------------------------------------------------------------------------------------------
Newark/P Care/Provider 3 26 26
----------------------------------------------------------------------------------------------------------------
Newark/Nemali 42 49
----------------------------------------------------------------------------------------------------------------
Newark/Social Work 5 5
----------------------------------------------------------------------------------------------------------------
Newark/PTSD 16 16
----------------------------------------------------------------------------------------------------------------
Newark/Renal 19 19
----------------------------------------------------------------------------------------------------------------
Newark/Podiatry 1 1
----------------------------------------------------------------------------------------------------------------
Newark/Nutrition 12 12
----------------------------------------------------------------------------------------------------------------
The following wait time data are provided. Major enhancements to
primary and specialty care services took place at the Newark Community-
Based Outpatient Clinic (CBOC) in Central Ohio between July 2007 and
January 2008. During January 2008, a total of 671 patients were seen in
14 different clinics at the Newark CBOC. By contrast, during January
2007, 10 patients were seen under the two mental health clinics at the
Newark CBOC. During July 2007 a total of 22 unique patients were served
by this CBOC in mental health. Primary care and other specialty care
services were not available at the Newark CBOC.
----------------------------------------------------------------------------------------------------------------
DSS Clinic Stop Performance Measure Clinic Group July Total Patient
Patient Type 2007 Appts.
----------------------------------------------------------------------------------------------------------------
New 502 Mental Health--Ind 3
----------------------------------------------------------------------------------------------------------------
Estab 502 Mental Health--Ind 8
----------------------------------------------------------------------------------------------------------------
Estab 566 Mh Risk Fac Red Edu Grp 11
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
DSS Clinic Stop Performance Measure Clinic Group January Total Patient
Patient Type 2008 Appts.
----------------------------------------------------------------------------------------------------------------
Estab 102 Admit/Screening 6
----------------------------------------------------------------------------------------------------------------
New 124 Nutr/Diet--Grp 1
----------------------------------------------------------------------------------------------------------------
Estab 171 Hbpc Nursing (Rn/Lp) 33
----------------------------------------------------------------------------------------------------------------
New 172 Hbpc Physic Extnd (Np,cns,pa) 3
----------------------------------------------------------------------------------------------------------------
Estab 172 Hbpc Physic Extnd (Np,cns,pa) 7
----------------------------------------------------------------------------------------------------------------
Estab 173 Hbpc--Social Work 4
----------------------------------------------------------------------------------------------------------------
Estab 175 Hbpc--Dietician 2
----------------------------------------------------------------------------------------------------------------
Estab 301 General Int Med 83
----------------------------------------------------------------------------------------------------------------
New 323 Primary Care/Med 17
----------------------------------------------------------------------------------------------------------------
Estab 323 Primary Care/Med 265
----------------------------------------------------------------------------------------------------------------
New 408 Optometry 35
----------------------------------------------------------------------------------------------------------------
Estab 408 Optometry 90
----------------------------------------------------------------------------------------------------------------
New 411 Podiatry 4
----------------------------------------------------------------------------------------------------------------
Estab 411 Podiatry 6
----------------------------------------------------------------------------------------------------------------
New 502 Mental Health--Ind 2
----------------------------------------------------------------------------------------------------------------
Estab 502 Mental Health--Ind 76
----------------------------------------------------------------------------------------------------------------
Estab 540 Ptsd Clinical Team Pts Ind 10
----------------------------------------------------------------------------------------------------------------
Estab 561 Pct Ptsd--Grp 20
----------------------------------------------------------------------------------------------------------------
New 566 Mh Risk Fac Red Edu Grp 1
----------------------------------------------------------------------------------------------------------------
Estab 566 Mh Risk Fac Red Edu Grp 6
----------------------------------------------------------------------------------------------------------------
Question 17: What is the status of the feasibility study conducted
by the VA for southeastern Ohio? When is it expected to be completed
and released?
Response: The healthcare needs of veterans residing in southeastern
Ohio was discussed at a Joint House and Senate Veterans' Affairs
Committee field hearing that was held in Ohio on May 29, 2007. VHA
committed to evaluating the healthcare needs of veterans residing in
southeastern Ohio in response to the assertion that there needs to be a
VA medical center (VAMC) in this region.
VHA conducted an analysis, which demonstrated a projected decline
in veteran population and enrollment by 2025. In addition, the
projected bed demand of 29 inpatient medicine beds by 2025 is of
concern. Small hospitals (30 beds or less), whether VA or non-VA, face
significant challenges in providing a full range of services and in
maintaining high-quality healthcare across multiple subspecialties. The
market share (ratio of the number of veterans enrolled in the system to
the total veteran population) of just those counties that fall within
District 18 is 35 percent, which is higher than both VISN 10 and
national levels. The higher than average market share in District 18
indicates that veterans in the area do not perceive a significant
access barrier to obtaining care, that is indicative of areas with low
market share rates.
While VHA is not meeting access standards for acute hospital care
(see table below) in one of the three Ohio markets (i.e., the Central
market) there is sufficient capacity in other VISN 10 and nearby
facilities to meet inpatient needs. As a result of this analysis, VA
has concluded that there is an insufficient veteran population combined
with declining demand to support a VA-owned and operated hospital.
----------------------------------------------------------------------------------------------------------------
Guideline for VISN 10 FY06 Market Performance
Percent ----------------------------------
Type of Care Travel Time Standard Enrollees Living
Within Travel Western Central Eastern
Time
----------------------------------------------------------------------------------------------------------------
Primary Care 30 Min.--Urban 70% 81% 72% 89%
30 Min.--Rural
60 Min.--Highly Rural
----------------------------------------------------------------------------------------------------------------
Acute Care 60 Min.--Urban 65% 94% 36% 63%
90 Min.--Rural
120 Min.--Highly Rural
----------------------------------------------------------------------------------------------------------------
Tertiary Care 240 Min.--Urban 65% 65% 100% 100%
240 Min.--Rural
Community Standard--
Highly Rural
----------------------------------------------------------------------------------------------------------------
Question 18: The OIG report documents a number of instances where
wait time statistics were artificially improved. It is the
understanding of the Subcommittees that the average wait time is one of
the indicators that helps determine bonuses for administrators. Is
there a correlation between incorrectly improved wait time statistics
and the bonus amount specific administrators received for FY2007?
Response: No, VA does not believe that there is a direct
correlation between incorrectly improved wait time statistics and the
bonus amount specific administrators received for FY 2007. Because
waiting times is but one indicator among many that facility directors
are evaluated on to determine a bonus, a correlation between
incorrectly improved wait time statistics and a bonus is difficult to
characterize. Similarly, instances in the IG report cited as wait time
errors may be based on different characterization of the data.
VHA has identified errors associated with projections and surveys
conducted by the OIG. For example, the OIG reviewed only completed
appointments, so documentation that had been created by schedulers
would have been obscured by the software glitch VHA has identified that
truncates text entries under ``other info'' once an appointment is
completed (and erased for appointments rescheduled after a
cancelation).
The OIG's methodology was to review a sample of cases to determine
the percent with what would appear to be incorrect desired appointment
dates based on differences between provider instructions and scheduler
entered desired dates, and an absence of documentation to explain the
use of these desired dates. OIG then projects this rate of differences
between the desired dates entered by providers, and the desired dates
entered by schedulers (and used by VHA to calculate waiting times) on
the entire population of scheduled appointments. Example: In reviewing
desired dates entered for 750 established patient appointments in VISN
3, OIG identified differences between the desired dates specified by
providers versus those entered by schedulers in 394 of these
appointments (53 percent). When they applied this discrepancy rate to
all established patient appointments, they concluded 98,454 established
patient appointments would be subject to the same discrepancy.
The OIG measures new patient wait times differently than VHA. VHA
measures new patient wait times from the date an appointment is created
until the date of the appointment. Relative to appointments created in
response to consults or new patient requests, because there is a lag
time between these requests and creation of an appointment (VHA has
allowed a 7 day lag time). OIG states VHA understates wait times in its
reports. On the other hand, we believe it is equally possible that
actual waiting times for new patients are overstated because when
schedulers contact a patient to create an appointment, the patient is
offered the opportunity to say when they want to be seen--their desired
date. Their desired date may be a future date. Because VHA does not
measure new patient wait time from desired date, but rather from
appointment creation date, each time the patient expresses a preference
for a future appointment date, wait times are understated. It appears
the new patient is waiting longer when using the creation date to
measure new patient wait time, rather than the desired date specified
by a patient when that date is some time in the future.
Question 19: Has there been any evidence (anecdotal or otherwise)
to indicate that schedulers were encouraged to falsify records
specifically for the purpose of increasing bonuses?
Response: We have no evidence to substantiate this claim. In its
2005 Report of Audit of Scheduling, the OIG reported that 10 percent of
the schedulers who responded to its survey said that their leadership
had pressured them to keep wait lists short, causing them to circumvent
established procedures for scheduling. In its 2007 Report of Audit of
Scheduling at 10 facilities, there was no mention of findings that
schedulers were pressured by leadership to keep wait lists short by
circumventing established procedures for scheduling. In its 2008 Report
of Audit of Scheduling at 5 facilities within VISN 3, the OIG reported
it found no evidence of leaders or managers threatening staff in a
manner that encouraged a willful manipulation of scheduling procedures.
Question 20: When determining medical center director bonus
amounts, is there a specific formula equating wait times to a bonus
dollar amount?
Response: There is no specific formula. Medical center directors
are evaluated on the entire executive career field performance contract
as well as additional measures/monitors identified by their respective
network director.