[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

                              ----------                              


                      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.

                                 
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