[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
A CONTINUED ASSESSMENT OF DELAYS IN VETERANS' ACCESS TO HEALTH CARE
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, APRIL 19, 2016
__________
Serial No. 114-65
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
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C O N T E N T S
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Tuesday, April 19, 2016
Page
A Continued Assessment Of Delays In Veterans' Access To Health
Care........................................................... 1
OPENING STATEMENTS
Honorable Jeff Miller, Chairman.................................. 1
Prepared Statement........................................... 40
Honorable Corrine Brown, Ranking Member.......................... 3
Prepared Statement........................................... 41
WITNESSES
Honorable David J. Shulkin,, M.D., Under Secretary for Health,
U.S. Department of Veterans Affairs............................ 4
Prepared Statement........................................... 42
Accompanied by:
Thomas Lynch, M.D., Assistant Deputy Under Secretary for
Health for Clinical Operations, U.S. Department of
Veterans Affairs
Mr. Larry Reinkemeyer, Director, Kansas City Office of Audits and
Evaluations, Office of Inspector General, U.S. Department of
Veterans Affairs............................................... 6
Prepared Statement........................................... 44
Accompanied by:
Mr. Gary Abe, Acting Assistant Inspector General for Audits
and Evaluations, Office of Inspector General, U.S.
Department of Veterans Affairs
Ms. Debra Draper, Director, Health Care Team, U.S. Government
Accountability Office.......................................... 8
Prepared Statement........................................... 49
STATEMENTS FOR THE RECORD
The American Legion.............................................. 55
QUESTIONS AND ANSWERS
Submitted by Chairman Jeff Miller................................ 57
From Congresswoman Jackie Walorski............................... 66
Letter From Michael J. Missal to Chairman Jeff Miller............ 69
Additional Questions and Answers................................. 69
A CONTINUED ASSESSMENT OF DELAYS IN VETERANS' ACCESS TO HEALTH CARE
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Tuesday, April 19, 2016
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:30 a.m., in
Room 334, Cannon House Office Building, Hon. Jeff Miller
[Chairman of the Committee] presiding.
Present: Representatives Miller, Lamborn, Bilirakis, Roe,
Benishek, Huelskamp, Coffman, Wenstrup, Walorski, Abraham,
Zeldin, Costello, Bost, Brown, Takano, Brownley, Ruiz,
O'Rourke, Walz, and McNerney.
OPENING STATEMENT OF JEFF MILLER, CHAIRMAN
The Chairman. The hearing will come to order. I would like
to welcome everyone to today's hearing entitled ``A Continued
Assessment of Delays in Veterans' Access to Health Care.'' This
hearing marks two years since this Committee exposed the wait
time scandal that has gripped the Department since 2014.
I am proud of the work that we have done in those two
years, particularly digging into the actions of bureaucrats
whose self-interest was put ahead of the veterans that they
were charged with assisting. The purpose of this hearing is to
examine the efforts that VA has taken to improve access to care
for veterans and to identify where serious issues still exist.
Based on the bipartisan work of this Committee, GAO has
undertaken an audit of new patient primary care wait times at
six facilities across the Veteran Health Administration. GAO's
review found that veterans at those facilities waited between
22 and 71 days, which is significantly more than the 5-day
average that Secretary McDonald has declared to this Committee
earlier this month. Now, this discrepancy can probably be
easily explained.
First, VA only tracks and monitors a portion, a portion, of
a veteran's actual wait time when tracking access data. Instead
of considering a veteran's wait time to be from the date when
the veteran first contacts VA to request an appointment to when
the appointment takes place, VA actually considers a veteran's
wait time to be from the date when the veteran wants an
appointment and the date when the appointment actually occurs.
This is problematic because it doesn't take into account
the following. Doesn't take into account the time it takes the
VA scheduler to contact the veteran to schedule the
appointment; the fact that it is a regular practice for
schedulers to negotiate a desired date with a veteran; or the
fact that outright manipulation of desired dates to zero out
wait times is still one of the most prevalent types of data
manipulation that occurs within the Department today.
In effect, VA continues to ignore the main forms of data
manipulation while it continues to come to Congress, to this
Committee, saying there is no data manipulation. To this point,
you will not find what you do not seek. The obvious result of
VA reporting only a portion of a veteran's actual wait time is
artificially low results.
I still don't understand how a culture could persist in
presenting inaccurate data to this Committee, or more
importantly to the veterans of this country. A true picture of
wait times, or more importantly, the veteran experience the
Secretary speaks about quite frequently, can help us ensure an
adequate allocation of the resources that we are asked to
provide. But when this Committee only hears requests for more
manpower, more space, and more flexibility, it is hard to
reconcile the additional resources with a reported wait time of
only five days.
This discrepancy between reality and VA claims was captured
by GAO in its report where VA data shows that wait times were,
at best, underestimated by two-and-a-half times, and, at worst,
11 times the full wait time that the veteran experienced.
Another tactic that VA uses to make its wait time appear
lower is to combine shorter wait times for the large pool of
established patients with the longer wait times of the smaller
pool of new patients. This dilutes the wait time data, making
new patients waits appear shorter since they have been co-
mingled with data from the other cohort.
For years VA has blamed incorrect appointment scheduling
and long wait times on training issues, largely because it was
warned about those issues as far back as 2005 when the
Inspector General's office published a report highlighting the
improper scheduling practices and poor training process.
Many OIG and GAO reports since that time have found that
the same scheduling problems continue to exist. Yet, in the 11
years since VA continues to blame wait time manipulation on the
very same cause, a control over which a VA has complete
control. Secretary McDonald has repeatedly asked that we allow
him to run VA like a business. But I can assure you that if an
executive running a company used the same excuse to explain
away 11 years of problems in a row with no change to show for
it, that individual would be out of a job. But not at VA.
Despite years of reports of confirming systemic issues, the
Department has successfully fired just four people for wait
time manipulation while letting the bulk of those behind its
nationwide delays in care scandal off with no discipline or
very weak slaps on the wrist. Another issue regarding
accountability is how VA continues to ignore retaliation
against the whistleblowers that we have relied on for some of
the information that our Committee has acted on.
The Committee has asked VA for all adverse actions where an
employee was disciplined for retaliation against a
whistleblower. VA provided our Committee a list showing that as
of March 15th, 2016, only six individuals were disciplined for
whistleblower retaliation. However, looking deeper at the
report, one of the listed employees is Sharon Helman, who the
Committee has already shown was not successfully disciplined
for whistleblower retaliation, was, in fact, successfully
disciplined for failing to report accepting gifts.
Two of the other disciplined employees were listed as
housekeeping aide supervisors who are clearly not high-level
supervisors. That leaves three employees. Two received
reprimands and one received a less than 14-day suspension. To
be clear, according to VA-provided documentation no employee
has been removed for whistleblower retaliation. This is
representative of the fact that, contrary to public statements
by VA senior officials, whistleblower retaliation appears to
most certainly be tolerated within the Department.
So now, two years after what was and is a systemic crisis
in care being brought to light, it is time for VA to stop using
misleading data to tout wait time successes that simply do not
show the real wait time experienced by our veterans.
I want to hear what concrete actions have been taken, what
fundamental changes have been made, and what tangible cultural
shifts are occurring within the Department. Advertising
artificially lowered numbers does nothing to stimulate the
change that is needed to improve veterans' access to care.
And with that, I yield to the Ranking Member, Ms. Brown,
for any opening remarks that she may have.
[The prepared statement of Chairman Miller appears in the
Appendix]
OPENING STATEMENT OF CORRINE BROWN, RANKING MEMBER
Ms. Brown. Thank you, Mr. Chairman, for calling this
hearing today. Following the wait time scandal of Phoenix,
Congress passed, and President Obama signed, the Veterans
Access, Choice and Accountability Act of 2014. In it, we
mandated that there be an Independent Assessment of veterans'
health care.
The Assessment Highlighted many of the things we hear from
our veterans. We hear that VA provides excellent health care,
especially health care related to the special needs of our
veterans. We also hear that in certain areas, VA is at the
forefront of health care in this country. We also hear from our
veterans that VA care is often fragmented, and that it can be
difficult to navigate and arrange non-VA care. We hear of long
wait times and limited access.
Following the assessment in the Surface Transportation in
Veterans Health Care Choice Improvement Act of 2015, we
mandated a report by the VA regarding a plan for how VA could
consolidate all purchased care programs into one New Veterans
Choice Program. We received that report last year and this
Committee is currently working with the VA on the best way to
implement the legislative request.
The VA is on track to see 6,277,360 unique patients, and
9,247,803 unique enrollees. In Fiscal Year 2015, VA completed
56.7 million appointments, nearly 2 million more than Fiscal
Year 2014. That is roughly 226 appointments per day. Let me
repeat that. That's 226,000 appointments per day.
The number of patients that the VA sees would put any other
health care system to shame.
I am pleased the GAO study newly enrolled veterans and
their access to primary care. In my conversations with
veterans, time and time again they say that once you get into
the VA system, the care is the best in the world. Let me repeat
that. Once you get into the system, the care is the best in the
world. It is this initial appointment that is so hard to get. I
am troubled by the GAO finding that nearly half was unable to
access primary care because VA medical center staff did not
schedule appointments for these veterans in a quick timeframe.
The GAO report goes on to say that veterans' access to
primary care is hindered in part by data weaknesses and by the
lack of a comprehensive scheduling policy.
We are at a tipping point right now as to what the VA would
look like and the services it would provide for veterans in the
coming decades. I look forward to hearing from witnesses today
as to what this aspect of the VA would look like in the future.
With that, Mr. Chairman, I yield back the balance of my
time.
[The prepared statement of Corrine Brown appears in the
Appendix]
The Chairman. Thank you very much, Ms. Brown.
As a custom with this Committee, I would ask that all
Members waive their opening statement to allow me the
opportunity to introduce the witnesses at the table today.
From VA, we are going to hear from Dr. David Shulkin, the
Under Secretary for Health in the Department of Veterans
Affairs, and he is accompanied by Dr. Lynch, Assistant Deputy
Under Secretary for Health and Clinical Operations. From the
office of Inspector General we have Mr. Larry Reinkemeyer,
Director of OIG's Kansas City office of Audits and Evaluation,
he is accompanied by Mr. Gary Abe, Acting Assistant Inspector.
Finally, we will hear from Ms. Debra Draper, Director of the
Health Care Team at the Government Accountability Office.
And I would ask if all the witnesses would please stand so
we can swear you in.
[Witnesses sworn.]
The Chairman. Thank you. Please be seated.
Let the record reflect that all witnesses did answer in the
affirmative.
Dr. Shulkin, you are recognized for your opening statement
of five minutes.
STATEMENT OF DAVID SHULKIN
Dr. Shulkin. Good morning, Chairman Miller, Ranking Member
Brown, Members of the Committee. As the Chairman said, I'm
accompanied by my right here by Dr. Thomas Lynch, who is the
Assistant Deputy Under Secretary for Clinical Operations, and
seated behind me, Dr. Poonam Alaigh, who is the Senior Advisor
to the Under Secretary.
I arrived at VA approximately nine months ago, and I
understood when I came here that this access crisis was a
national priority and the status quo simply wasn't acceptable.
It's not my objective today to tell you that we fixed all the
problems or that we don't have issues, rather it's my objective
today to tell you that we are focused on this, this is my
number one priority, that this is VHA's number one priority,
and we're going to stick at this 'til we get this problem
resolved.
The first thing I did when I arrived as the Under Secretary
was to assess all the data on wait times. There were literally
file cabinets full of reports and bookshelves filled with data.
And I have to tell you, I made it through medical school okay,
but I had a really hard time understanding all this data; very,
very confusing.
What I didn't see was the ability to clinically prioritize
which veterans needed care first, and I didn't know how to run
a health care system unless I understood that you needed to see
the patients that were sickest the first.
So that's the first thing we did, we changed it so we could
clinically prioritize the veterans. And that led to two
national stand-downs where we opened up every VA medical center
across the country and saw those veterans who needed the care
that day on the day of the stand-down. And that led to real
significant sustainable improvements.
We had 57,000 urgent consults in what we call Level 1 at
the first stand-down, today it's a 77 percent reduction, there
were 12,000 urgent Level 1 consults. On our second stand-down,
we addressed 81,000 urgent appointments and we got 93 percent
of those gone through and resolved.
This month, we're launching what we call our Declaration of
Independence, which is called the Declaration of Access, which
are nine core principles that are going to fundamentally
redesign the way that we provide access to veterans. They
include some pretty bold moves like same-day access in primary
care, and same-day access in mental health.
Now I will tell you these are aspirational goals to be done
by the end of 2016, but I've never been part of a change effort
that started with low expectations. And I'm confident we can
get these bold goals done because today we have 34 medical
centers in the VA system that are currently doing same-day
access in primary care. So we can do this, we have to spread
these best practices throughout the system.
We also have to make the wait times more understandable.
Mr. Chairman, as you said, it is very, very difficult to
understand. And I will tell you that I am--my academic studies
are in patient safety. I teach my students that there are bad
systems, not bad people. And so I've already said we have to
change our systems, but when we do identify bad people in the
VA, and people who have lost their ways not following out
values, we will hold them accountable.
We have held 29 individuals so far accountable with
disciplinary actions on the VA wait crisis. As the Chairman
said, four of them have been fired. We've trained 32,067
schedulers. We've done 11,500 individual visits auditing these
schedulers. The Joint Commission has been invited and visited
every single one of our medical facilities. We have a new
training program for schedules to launch this spring, beginning
in May. But our measurement system's too complex. And where I
want to move this to is the veteran experience: asking veterans
are they satisfied with access.
And, in fact, in every medical center today, we have a
system called VetLink. When you come in, you go to a kiosk, you
actually are asked whether you're satisfied with the access to
care. Eighty-nine percent of veterans today are satisfied with
the access to care throughout VAs. And I have all of your
individual data by the way.
But we have to do better. We hired 17,000 new employees in
the last fiscal year, that's a net number. A ten percent
increase in productivity through RVVs user over the last two
years. Two point two million square feet we've added of
clinical space. We have a new scheduling system being rolled
out now called VSE, a new veterans application that they can
schedule themselves.
We've allowed direct scheduling in audiology and optometry.
We have group practice managers now over all of our medical
centers. We're sharing best practices and access across the
entire system. And, of course, as you know, we're working much
closer than ever with our community partners to provide care.
Fifty-seven million appointments last year, as the Ranking
Member said, 1.6 million more visits last year than the year
before, 96 percent scheduled within 30 days. We're processing
claims faster than ever before, 25 percent increase in claims
processed last month. We're looking forward to the comments by
the GAO and the IG. I have to tell you, we're not afraid of
criticism, we welcome it, we want this type of transparency.
In conclusion, I just want to tell you, the VA is making
sweeping changes, we are making progress, but there's
significant work that lies ahead. That's what I'm here to do.
But recall, as the Ranking Member said, the VA provides
excellent care everyday, in fact, this year alone four peer-
reviewed studies showing our care is equal or superior to
what's happening in the private sector.
We appreciate the support of all of you on this Committee
and look forward to answering any questions. Thank you, Mr.
Chairman.
[The prepared statement of David Shulkin appears in the
Appendix]
The Chairman. Thank you very much, Dr. Shulkin.
Mr. Reinkemeyer, you are now recognized for five minutes.
STATEMENT OF LARRY REINKEMEYER
Mr. Reinkemeyer. Mr. Chairman and Members of the Committee,
thank you for this opportunity to discuss the recent reports we
have issued that have addressed various obstacles to veterans
receiving timely access to health care. As you mentioned, I am
accompanied by Mr. Gary Abe, the Deputy Assistant Inspector
General Of Audits and Evaluations.
Two years ago, VHA's ability to provide veterans timely
access to care became an even larger national focus. In 2014,
we published two reports detailing the serious conditions that
existed at the Phoenix health care system and provided VA
leadership with recommendations for immediate implementation.
These reports brought much needed accountability over serious
access issues.
Since our August 2014 reports, we have initiated a series
of audits and reviews evaluating the extent to which veterans
receive timely care. We have published several comprehensive
reports detailing veterans' experiences during their initial
application and their enrollment for health care, VHA's
effectiveness in its efforts to improve veterans' access to
psychiatrists, and VHA's consult management.
In addition, a number of more recent reviews are still in
progress, including work which Members of Congress requested at
the Phoenix health care system to evaluate hiring practices of
medical support assistants, or the schedulers, and continued
concerns about timely access to care.
The national attention sparked by our reporting on the
Phoenix health care system resulted in a dramatic increase in
the number of contacts to the OIG hotline and the number of
inquiries and requests sent to us by Members of Congress. A
number of these hotline contacts continue to allege
inappropriate practices by VHA staff that undermine the
integrity and reliability of wait time metrics, as well as
allege that VHA's initiatives to provide veterans care in the
community are not working.
Our audits, reviews, and health care inspections have
reported challenges VA faces in administering all aspects of
purchased care programs, authorizing, scheduling care,
documenting the care in the veterans' VA medical records, and
timely and accurate payments for care.
Two reports we issued in February 2016 highlight some of
the problems we see. In our review of alleged untimely care at
the Colorado Springs community based outpatient clinic, we
substantiated the allegation that some eligible Colorado
Springs veterans did not receive timely care and non-VA care
staff did not add veterans to the Veterans Choice list, or the
VCL, in a timely manner, or in some cases not at all.
Generally, this occurred because scheduling staff used
incorrect dates that made it appear the appointment wait time
was less than 30 days, which resulted in the veteran's
exclusion from the VCL.
In our review of alleged patient scheduling issues at the
VA medical Center in Tampa, we again substantiated that the
facility did not add all eligible veterans to the VCL when
their scheduled appointment was greater than 30 days. But we
also found that staff inappropriately removed veterans from the
VCL, and the facility staff did not cancel veterans' existing
VA appointments when they did receive an appointment in the
community through the Veterans Choice Program, which blocked
other veterans from taking that VA appointment.
My office recently initiated a pilot project to audit one
VISN and its facilities to evaluate three key components of
access: data reliability of wait time metrics, access through
the Veterans Choice Program, and consult management.
Our objective for this pilot is to provide comprehensive
and timely oversight at all facilities within a VISN in order
to provide the facility directors within that VISN a report
detailing their current data and scheduling practices. We hope
that by focusing our resources on this issue, we can audit each
VISN and its facilities every three years as we currently do
with our VBA regional offices.
We feel this work is important and will help provide a
veteran centric view of what actions VISN management is taking
to ensure situations like Phoenix do not occur in the future.
In conclusion, our work has shown that VA faces challenges
in providing adequate access to health care. We have a number
of active projects involving VHA practices and procedures that
ultimately affect veterans' access to the Veterans Choice
Program. We will continue to work with VA to provide the
independent oversight and objective recommendations to help
move these programs and initiatives forward.
Mr. Chairman, this concludes my statement. We would be
happy to answer any questions you or Members of the Committee
may have.
[The prepared statement of Larry Reinkemeyer appears in the
Appendix]
The Chairman. Thank you, Mr. Reinkemeyer.
Ms. Draper, you are recognized for five minutes.
STATEMENT OF DEBRA DRAPER
Ms. Draper. Chairman Miller, Ranking Member Brown, and
Members of the Committee, thank you for the opportunity to be
here today to discuss veterans' access to VA health care. My
testimony today is based on GAO's ongoing body of work in this
area, including most recently a report publically released
yesterday, ``A Newly Enrolled Veteran's Access to Primary
Care.''
I wish that I was here today to discuss better news, but,
unfortunately, that's not the case. Since 2000, and in
particular over the past five years, we have consistently
reported on VA's failure to ensure veterans' timely access to
health care. In 2012, we found that outpatient medical
appointment wait time data were unreliable, implementation of
the scheduling policy was inconsistent across medical
facilities, telephone access was problematic, and scheduling
resources were not effectively allocated.
In 2014, we found that access to outpatient specialty care
was problematic due to mismanagement of the consult process,
including poor oversight and the lack of clear policies. In
2015, we looked at veterans' access to mental health care and
found that the way VA calculates wait times does not always
reflect the overall time a veteran is waiting for care, the
lack of clear policies precludes effective oversight, and
access data may not be comparable over time or between medical
facilities.
Our most recent work focused on newly enrolled veterans'
access to primary care, which is typically the entry point to
VA's health care system, and critical to ensuring veterans
obtain needed medical care, including specialty care. For this
work, we found many of the same problems as we had previously
reported.
We reviewed a sample of 180 newly enrolled veterans'
medical records across six VA medical centers and found, for
example, for the 60 veterans in our review who requested VA
contact them to schedule appointments, but had not been seen by
primary care providers, 17 were not contacted at all because
these veterans did not appear on the new enrollee appointment
list, which is intended to help track newly enrolled veterans
needing appointments. Medical center officials were not aware
that this problem was occurring and could not tell us why these
veterans did not appear on the list.
Further, for 12 of these 60 newly enrolled veterans,
medical centers did not follow VA policy for making contact to
schedule an appointment, which states that there should be
three documented attempts by phone, and if unsuccessful, a
letter sent. For the 120 veterans who requested care and were
seen by primary care providers, we found the average number of
days between the initial request that they be contacted to
schedule appointments and the dates they were actually seen
ranged from 22 to 71 days. About half were seen in less than 30
days.
However, veterans' experiences varied widely with 12
veterans, for example, waiting more than 90 days. Delays in
care were due to issues such as appointments not being
available when veterans wanted to be seen and medical centers'
failure to follow VA scheduling policy.
In this most recent work, we also continue to see data
weaknesses due to errors such as schedulers incorrectly
changing dates, as well as the lack of a comprehensive
scheduling policy, which has created confusion and contributed
to the errors seen.
In 2015, veterans' health care was added to GAO's high risk
list due to VA's problems providing timely access to care,
among other reasons. This list identifies government operations
that are vulnerable to fraud, waste, abuse and mismanagement,
or need a major organizational transformation.
In designating VA health care as high risk, we identified a
number of concerns, all of which affect veterans' access to
timely health care and includes, for example, ambiguous
policies, and inconsistent processes, inadequate oversight and
accountability, and poor training.
It has now been over a year since the addition of VA Health
Care to the high risk list, and to date, we have seen at best,
little progress by VA in addressing the issues. We are very
concerned about the lack of meaningful progress and our concern
is heightened further because the window of opportunity for
making progress under the current administration is rapidly
closing, if not already closed.
VA health care's access problems are significant,
persistent, and not only a disservice to our Nation's veterans,
but places them at risk for harm. The status quo is not
appropriate, nor should it be accepted.
Mr. Chairman, this concludes my opening remarks, I would be
happy to answer any questions.
[The prepared statement of Debra Draper appears in the
Appendix]
The Chairman. Thank you very much.
Dr. Shulkin, I know that you have been hard at it for nine
months. And a simple question, does it irritate you that even
after your nine months--and we are talking about two years from
the exposure of the wait time problem--that there still is
serious problems in manipulation of wait times?
Dr. Shulkin. I am very, very impatient to get this problem
resolved. I am concerned that we have data out there that is
not necessarily understandable by people. I am concerned when I
hear about mistakes being made. Wherever we do find that there
is manipulation of data, that is unacceptable and we're taking
action.
So we're doing everything that we can, but am I impatient?
Am I upset about it? Absolutely. We are--this is why it's our
number one priority, Mr. Chairman.
The Chairman. Expound on the action that you are taking,
because it appears, you know, that folks have said for almost a
decade that it has been lack of training or improper training.
That is 10 years that this has been going on, or more. Give me
some concrete steps as to what you are doing, and have you
really analyzed what the root cause--
Dr. Shulkin. Yep.
The Chairman [continued]. --of this issue is?
Dr. Shulkin. Well, let me first start. It's an excellent
question, and very fair question. First of all, I want
everybody to be clear, we do not have access or wait times in
our performance measures. In other words, nobody's getting
bonuses, there is no incentive whatsoever to be manipulating
this financially as there was in the past. So, I think, thanks
to your Committee's work, we make sure that that isn't
existing.
So I'm going to go back to the fact that, in general, we
mostly, of our 340,000 employees, have very, very good,
dedicated employees; we have bad systems in place. One of the
things that we've talked to you about is this is our current
scheduling system to the right. It is DOS black screen. To
think that this is how we're having our 32,000 schedulers have
to schedule appointments invites confusion; it invites the
inability to do this accurately.
So we are putting in now, currently being rolled out, the
one to the left, which looks like a Microsoft Outlook calendar.
That's important that we give our people the right tools. We're
also evaluating a commercial system called MASS, which offers
greater capabilities.
Number three, we are insisting that our leadership do
visits to the schedulers personally, and where they find that
people aren't scheduling appropriately, they're pulling their
scheduling keys, and we're doing that on a regular basis.
We are talking about this and trying to do better training.
We are taking disciplinary actions where we find that people
have deviated. So we're just going to have to stick at this. I
don't know any other faster magical way to make this happen,
and I'm frustrated by it.
The Chairman. I think it would surprise many of the Members
to know, or maybe it wouldn't, you know, we just saw an example
of the scheduling software that is being used $127 million
later, and we are just now looking at something that could be
purchased off the shelf.
Quick question. GAO found that almost one-third of the
veterans that it reviewed, 17 out of 60 did not get contacted
for an appointment because they did not appear on the NEAR
list, and one would assume that directors at these facilities
neither knew this was occurring, nor they didn't know why a
veteran would not appear on the NEAR list. And so the question
is why would a hospital director not know?
Dr. Shulkin. Yep. Well, when you read the GAO report, I
think it's pretty clear that we didn't do the best that we
could for veterans. So that's why we appreciate the spirit and
the information 'cause it's going to help us do this better. So
we are sunsetting the NEAR report, we are moving it towards an
automatic system called Welcome My VA where we're contacting,
reaching out to every veteran.
Part of the problem that was in the GAO report they said is
we had the wrong phone numbers for some of these veterans, we
couldn't reach them. When we reached some veterans, they didn't
want appointments, they wanted C&P exams, so we got them there.
Other veterans said, no thank you, I know I originally said I
wanted an appointment, but I no longer want an appointment.
So we have to do a better job, but it wasn't that every
veteran that Ms. Draper just mentioned we failed. We failed too
many, but a lot of them, frankly, those facilities just weren't
able to get in touch with or when they did, they didn't want
the appointments.
The Chairman. Okay. And my time is expired, but I got one
more question that I want to ask you because a lot of folks
have talked about accountability at the table and wanting to
hold people accountable for things that they had done, but, you
know, in the media, there have been examples including an
employee who participated in an armed robbery, a chief of staff
that was improperly prescribing drugs to a VISN director's
wife, a nurse who is being charged with manslaughter in the
death of a veteran patient, they are all still on the payroll.
Similarly, according to the weekly list that VA provides to
the Committee in the wake of the nationwide wait time
manipulation scandal, VA has successfully fired only four
people for wait time manipulation. How is any of this possible,
especially those on the front end who have been--some of them
have been convicted of crimes?
Dr. Shulkin. Yep. Seems hard to believe, Mr. Chairman, so
let me try to step through my understanding, and if I make any
mistakes, I will commit to you that I will get back to you with
that.
You mentioned the VISN director, he is not on our payroll;
he's retired from Federal service. It is my understanding that
the person who--who was found with some of the criminal
allegations, no longer at the VA. The person--one of them
actually is going through a court hearing and we're following
the court's procedures on that.
But, look, somebody who does either violate the law or
violate our principles does not belong at the VA, and we
clearly take that seriously. We go through a very extensive
process of, you know, due process to get them there, sometimes
it takes a long time, but we do not want people that shouldn't
be treating veterans treating veterans, and I take that very
seriously. So if there are some of those cases that you've
talked about that we haven't acted fast enough, we will go back
and take a look at them.
The Chairman. You talked about the VISN director having
retired, it wasn't the VISN director, it was his wife that was
receiving prescription drugs by the chief of staff of that
particular hospital.
And one other thing, something that hit the press a couple
weeks ago and that was the doctor at Tomah that had his medical
license suspended for emergency reasons by the state. I believe
you took action, fired that individual, now a court or a--has
been adjudicated that his license should not have been
suspended on an emergency basis. So you have to, I assume, put
that person back on the payroll--
Dr. Shulkin. No.
The Chairman. Not on the payroll?
Dr. Shulkin. Not the payroll.
The Chairman. Okay.
Dr. Shulkin. No. No, you're correct about the court action,
but that does not change our administrative action.
The Chairman. Okay. Is that person appealing at this point,
your firing of them?
Dr. Shulkin. My understanding is they're looking at their
options in that regard, yes, sir.
The Chairman. Okay. Because my question would be, if that
person is brought back on the payroll and subsequently the
medical board goes through the normal process of suspending
that person's license, how do you get that money back from that
individual that comes back on your payroll?
Dr. Shulkin. Well, you know, I think we have to let people
have their due process, but right now we've made the decision,
an administrative decision, not to have him on the payroll, and
we are not planning on changing that decision unless there's
new information that comes up that we would have to consider.
The Chairman. Okay. Thank you, thank you very much.
Ms. Brown?
Ms. Brown. Thank you, Mr. Chairman. Mr. Secretary, it just
seems like you have been here longer than nine months. This
problem that we are having with the VA goes back more than ten
years. I have been on this Committee for 23 years, and we have
had problems with the VA over a long period of time, and it
would be a misnomer to act like these things just occurred.
I would like to ask, and I am very concerned about, is that
the GAO report have once again, just a couple of days ago, put
VA on the high risk list. Explain that to me, and what we are
doing to take care of this problem? I want to address the
stand-down, what you all have done, and all the positive things
that you have done? I am real concerned.
Dr. Shulkin. Yes. Well, I believe that VA was placed on the
high risk list probably well over a year ago because it was
prior to my confirmation, but the GAO has been very clear about
the reasons they put the VA on the high risk list.
We have inconsistent policies and procedures; we have not
systematized best practices, or the best processes across the
VA the way that a health care system should; and we have 102
outstanding recommendations, or at least that was when we went
on the GAO report, I think we've gotten some of them down, but
there's still many outstanding recommendations.
We work with the GAO now on a regular basis to show them
how we're working to fix that, and in consultation with them.
But look, the GAO was right in this regard. We have policies
and procedures that were conflicting, and we're working to fix
that 'cause you can't have that.
The best practices across the system, that's what health
care system should be doing, it's why it's one of my five
priorities, and we are focused on learning from the best and
putting it throughout the system.
This is going to make VA a better system, and I thank GAO
for that. I'm anxious to get off this list fast. I don't agree
with Mr. Draper's assessment that we're not making progress. I
know we're making progress. It may not be as fast as she wants
us to, or as fast as I want us to, but we're heading in the
right direction and we're addressing the right issues.
Ms. Brown. The stand-downs?
Dr. Shulkin. The stand-down--the stand-downs are part of
it, but the stand-downs aren't a way that you sustain
improvements; they are the declarations of emergencies. When
you have urgent patients that aren't being seen, they are
emergencies, and we have to act like that. But they've led to
sustainable improvements, our nine core principles of how we're
going to redesign accessing the system. So ten years from now,
a year from now, we're not going to be talking about this in
the same way.
Ms. Brown. When you all had the stand-downs, how many
people showed up in the various areas?
Dr. Shulkin. One hundred percent of our medical centers
were open on those Saturdays. No exceptions. People asked for
exceptions; I denied them. So we acted as a system in the
country. Thousands of people--Dr. Lynch, do you have a number
of how many?
Dr. Lynch. I think we had 5,000 employees that were
actually involved in the stand-down. There were 10,000 patients
or so that were actually seeing on the day of the stand-down.
But make no mistake, the stand-down was only a symbol.
Everything was going on prior to that stand-down. So we were
actually evaluating open consults, evaluating pending
appointments, scheduling appointments, and assessing patients
prior to that.
The stand-down was actually a way to really bring together
the five points that are in Dr. Shulkin's priorities. We
focused on access, we engaged our employees, we looked to the
community for help where we needed it, we engaged best
practices from across the networks, and we're working to
basically restore trust with our veterans.
Ms. Brown. I just want to say the next time that you all
schedule a stand-down, it would be good to let the Members of
this Committee know because we would like to attend, I know I
would like to be at my center on a Saturday when this occurs.
Dr. Shulkin. I know at the last stand-down, Congresswoman,
I was in Orlando, Florida, and there were Members of the
Congressional staff there. So we welcome your involvement.
Ms. Brown. My last question. What policies, directives,
have resulted from the stand-downs?
Dr. Shulkin. What we've done as a result of the stand-down,
we sequestered a team of people from the field, not from the
central office, who have told us what needs to be done to
redesign the system so we don't ever get long wait lists again
of veterans who need care urgently.
And that led to this Declaration of Access, the nine core
principles that every VA medical center is now signing their
name to, committing to these principles to fix access in
calendar year 2016 with same-day access in primary care and
mental health, eliminating our recall system, which we've been
using for veterans for a long time, and in making sure that
we're using telehealth and expanded opportunities to improve
access.
Ms. Brown. Thank you. And thank you, Mr. Chairman, I yield
back the balance of my time.
The Chairman. Thank you very much.
I heard something I was unaware of just a second ago. You
testified, I think, at a Subcommittee hearing on Thursday about
the commercial scheduling software MASS that you just talked
about, and I think your testimony was that it is on a strategic
hold at this point. A hundred and fifty-two million dollars is
what it would cost to do that? And the question is, how in the
world could a pilot cost $152 million?
Dr. Shulkin. Yep. So, again, the VSE, the VistA scheduling
enhancement solution that's being rolled out now, total cost of
the project, $6.4 million. MASS, which we do have a contract
for--it's an IDIQ contract so we can implement this--the next
step would be to do a pilot at three sites. It would be a ten-
month pilot where you have to build the interchanges between
VistA and MASS, and the cost of it is $152 million. The total
cost of the national rollout is $600 and something million.
The Chairman. Okay. With that, Mr. Lamborn, you are
recognized.
Mr. Lamborn. Mr. Secretary, you paint a much too rosy
picture. The system is broken. For those of us on the this side
of the dais, we talk to the people, and we listen to the
people, and the people in my district are very frustrated and
angry that we have all of this dysfunction here in Washington,
and more specifically with the bureaucracy that continues to
fail our veterans.
People want real reform, real change, and not just talking
points about how everything is about to be fixed. And I have
even been told to my face, well, the problems were already
fixed at the beginning of the study and what the GAO documented
was--or, the Office of Inspector General documented was after
the beginning of the study and everything is okay. We can't
have a real conversation if you won't even admit that there is
a problem in places like Colorado Springs.
I want to share with you a brief excerpt from a letter I
recently received from a constituent who found it impossible to
navigate the VA system to get health care. His case is
important as an individual, but I think there are thousands
like him. He wrote a respectful letter, but he is simply beyond
being fed up. Here is an excerpt.
``Sir, I speak for myself and thousands of veterans when I
tell you enough is enough.'' He says, ``Stop the tough talk and
for once act on the corruption and deceit going on at the
clinics.'' And he is talking about the CBOC in Colorado
Springs. He ends up with his letter describing a 14-month
runaround with the clinic and says, ``When will it stop?''
So when will it stop, Mr. Secretary? Veterans take way too
much time to get their care, and they are not being able to
really have access to the Veterans Choice Program, which is
especially frustrating because that was implemented by Congress
to try to stem the tide of some of this dysfunction.
So the first question, Mr. Secretary, according to the OIG,
in places like Colorado Springs, VA staff did not add some
veterans to the Choice list or did not add others in a timely
manner. What we see clearly is that besides the VA altering the
times for VA care, like Phoenix and other places all over the
country, it now does the same thing by acting as a gatekeeper
for veterans who should have access to Choice. Why aren't
veterans really being given the opportunity to use the Choice
Program?
Dr. Shulkin. Okay. Congressman, if you think I've painted a
rosy picture, I've failed because I'm telling you right now I
am acknowledging that we still have significant issues, and we
have a lot of work to do. That's why it's my top priority, and
I'm not going to rest until we do get this fixed. It's why I
came here, and I am focused on it, and you and I sound similar
when I'm with my staff because I'm hearing directly from the
veterans just like you. So I'm with you.
What I am saying, and maybe this is where you thought I was
painting a rosy picture, I know we're headed in the right
direction. Where we had 57,000 urgent veterans waiting more
than 30 days for care, today that's 12,000. Our electronic wait
list for our Level 1, our most important clinics, down 32
percent in the past couple months. Our veterans themselves are
telling us on these kiosks--we can't manipulate this data, it's
our veterans--that 89 percent are satisfied with their care.
The Choice Program isn't working for veterans, there's no
question. We've told you that, and we need to make this system
work better, and that's why we have legislation before you to
try to simplify and streamline the care in the community to
make this work better. So we have significant problems. I'm
hearing the same things you are. We're headed in the right
direction, but we are a long way from declaring that we've got
this problem solved.
Mr. Lamborn. Mr. Secretary, your own metrics from February
of this year showed that 29 percent of veterans received
appointments in excess of 30 days, 5 percent of those waited
longer than 120 days, worst of all, over 2,400 veterans are
still waiting on a wait list to receive an appointment, and 708
of those have been waiting longer than 120 days.
These metrics made the clinic in my district the eighth
worst in the United States. So, and I know of at least three
people who have died, and it could have been because of this
waiting problem. It could have been directly a result of these
delays.
So I do not see the VA fixing it. I don't really see them
being held accountable. And I just have to agree with the man
who wrote the letter to my office, enough is enough. Thank you,
Mr. Chairman, I yield back.
The Chairman. Thank you, Mr. Lamborn.
Mr. Takano, you are recognized for five minutes.
Mr. Takano. Thank you, Mr. Chairman. Dr. Shulkin, I am very
concerned that the VHA has been placed on the GAO's high risk
list and that veterans are still struggling to get timely
access to care. The VA has undergone significant change in the
past year, and it will take continued commitment from those in
this room and Members on the Committee to work together to make
sure the VA is functioning the best it can to care for our
veterans. But I want to move on to some other questions I have,
Dr. Shulkin.
In your testimony you mentioned that one of the VA's top
priorities remains legislation to streamline the process for VA
to work with outside providers. Now I am concerned that the
provider agreement legislation this Committee considered throws
out crucial workplace protections in the name of expediency.
I offered an amendment when we marked up the provider
agreement bill to ensure that the Office of Federal Contract
Compliance Programs retained the authority to enforce workplace
nondiscrimination protections. The OFCCP is the only Federal
office that protects LGBT employees from discrimination in the
workplace, and notably protects veterans from being
discriminated against for their veteran status.
Your testimony seemed to imply that we can improve provider
agreements without undermining workplace protections. Do you
agree?
Dr. Shulkin. What I agree with is, is that I know that we
desperately need provider agreements to make this program work
better for veterans. It's not working well and we need them
desperately to be able to do that. I certainly don't know if
there's an unintended consequence that you're talking about,
and so I haven't looked at your legislation, but we have no
intent of wanting to impose discrimination or to take away
protections from people in putting in place provider
agreements.
What provider agreements do is, too many small providers,
the doctors and the small practices that are today caring for
veterans, can't deal with the Federal contracting process. It's
way too complex. They simply drop out, especially our nursing
homes and our skilled nursing facilities. So we need provider
agreements to be able to do a easy to do contract with our
providers to care for our veterans. We certainly have no intent
to discriminate against our employees.
Mr. Takano. I realize there is a need to get these
providers on board as quickly as possible, I am concerned that
in the spirit of quickly as possible that on two counts, the
possibility of the LGBT people could be discriminated against,
and our own veterans could be discriminated against, that we
need to make sure we balance--
Dr. Shulkin. Yeah.
Mr. Takano [continued]. --the desire to bring the providers
on, but make sure those provider agreements are not
discriminatory.
Dr. Shulkin. Yeah. Yeah, Congressman, I have to tell you, I
don't understand the linkage between what a provider agreement
does and how it could potentially discriminate, but I will get
back to you and have our legislative people help me understand
that, because that's not our intent.
Mr. Takano. Well, thank you. Part of providing timely
access to care requires having a sufficient workforce.
Leveraging community providers can benefit veterans, but we
must be mindful of the fact there are many areas across the
country that face health workforce shortages in the private
market as well.
And that is why I was supportive of increasing the number
of graduate medical school education residencies in the Choice
Act. Can you keep--give us a brief update on how that rollout
is going?
Dr. Shulkin. Well, I think it is one of the most important
things that you authorized as part of the Choice Act; we need
to train more health care professionals. There are actually
more medical students now than residency spots, and so the VA
expanding these spots is important. You authorized 5,000, to
date we've only--we've only implemented more than about 380 of
those spots.
So we're continuing to work with your academic partners in
your districts to look to expand these. There are a couple
issues, one is the funding, as you know, goes away with the end
of the Choice Program. So when an academic center--'cause we do
this in partnership with academic centers, VA doesn't, with the
exception of Puerto Rico, run its own GME programs.
So we say to our academic partners in California, would you
like to expand your psychiatry program, and they say of course
we would, but the funding's going to be eliminated when Choice
is sunset. Then they say, well, what happens then? So that's
one of the problems we'd like to work with you on.
Mr. Takano. I think there are Members on both sides of the
aisle that are working with you on that--
Dr. Shulkin. Yes, actually.
Mr. Takano [continued]. --as well as the Medicare cap
issue.
Dr. Shulkin. Yes. That's an important issue too, the
Medicare cap issue. But we believe this is part of the
solution: training more health care professionals in areas of
need. I know, for example, in El Paso we're just working,
thanks to the Congressman, to work with tech--with Texas Tech
on the new agreement.
Mr. Takano. Well, I certainly appreciate my colleagues Mr.
O'Rourke and Ms. Titus, and my colleagues on the other side of
the aisle, for working together in a bipartisan way to deal
with this germane issue.
Dr. Shulkin. Yes, thank you.
The Chairman. Dr. Shulkin, there were two pots of money in
the Choice, the 10 billion and then there was 5 billion. So the
5 billion doesn't sunset, the Choice Program sunsets, but the 5
billion is there until the 5 billion goes away.
Dr. Shulkin. Yeah. My understanding is on the GME program,
it has a five-year--it has a five-year length of time that you
can use the funding for. If I have a correct understanding of
that, that would be good news. So I'll look at that.
The Chairman. So it is your testimony today that the part
of the reason you cannot get more slots is because of the
sunset, and that needs to change?
Dr. Shulkin. The reason we're not going faster, and we want
to desperately go faster, is our academic partners need to
agree to do this with us. They're telling us that there are two
things in general that are preventing them from going faster.
One is the Medicare cap issue. The Medicare cap says that if
you go above your number, you can't get additional Medicare
reimbursement, direct and indirect graduate medical education
funding. Many hospitals, every hospital I've worked for, has
been at their cap or above.
The second is the length of time that it takes to start a
program. When you start a program from ground zero to starting
it, it often takes two years or so. If your money's going to
expire before you graduate your first group of residents, the
administrators at those hospitals say I'm not so sure this is a
great deal for us.
So those are the two issues I'm hearing. If I have it
incorrect about the money running out after five years, that
would be good news and I will look into that.
The Chairman. Well, if we are just now talking about
setting up the program, somebody is way behind the curve. The
other thing is, I would tend to believe that the bigger issue
is the Medicare cap issue and the reimbursement rates.
But, Mr. Bilirakis, you are recognized.
Dr. Shulkin. Yeah.
Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it.
Dr. Shulkin, you mentioned in your testimony about direct
scheduling. I want you to elaborate on direct scheduling--
Dr. Shulkin. Yes.
Mr. Bilirakis [continued]. --that is available to certain
veterans for certain specialties, you mentioned ophthalmology
and I believe one more.
Dr. Shulkin. Yes.
Mr. Bilirakis. Elaborate, for the benefit of our veterans
out there, who can direct schedule and why is it only limited
to a couple specialties?
Dr. Shulkin. Right. Right. The way the VA has done this for
a long time is you go through a primary care physician, a
gatekeeper. So you have to be able to get an appointment with a
primary care doctor just to be authorized to get a consult.
I have to tell you, I practice now, I'm a primary care
physician in the VA, my first appointment was just to get a
pair of shoes. I had to actually approve a consult to get a
pair of shoes. It makes no sense. So we've started piloting a
program where veterans can now directly schedule, without going
through a primary care doctor, in audiology and optometry. It
worked terrifically.
We're expanding that now across the system. I think that
was done in Florida. We're expanding that across the system.
Then I want to look at, exactly as you're saying, other
specialties: podiatry, social work, nutrition, you know, all
sorts of things that, frankly, veterans can make the decisions
themselves, they don't need primary care doctors' time to do
it.
Mr. Bilirakis. Very good. Another question has to do with
walk-in clinics. How many walk-in clinics are out there? Where
you mention about access, same-day access--
Dr. Shulkin. Yes.
Mr. Bilirakis [continued]. --is that widespread? Because we
do have a walk-in clinic in our outpatient center in Newport
Ridge, and I think it works very well.
Dr. Shulkin. Yeah.
Mr. Bilirakis. How many walk-in clinics are out there? How
long--what is the average time where a veteran would have to
wait to get the same-day access?
Dr. Shulkin. Yeah. Actually, where I practice in New York
City at the VA, that's where I practice, in the walk-in clinic,
so we're there--if anybody needs to be seen, we see them that
day. Not all of our VA's have walk-in clinics. Of the sample I
looked at, for example, of the six in the GAO report, three had
walk-in clinics, three didn't. But what many--
Mr. Bilirakis. Why don't they?
Dr. Shulkin. Well, because many, 34 actually have same-day
access in their primary care centers. So if you can see your
patients through your primary care center, you don't need walk-
ins, the other ones do need some type of urgent care visits.
We do know that in areas that are challenged, they've
actually begun some pilots with commercial urgent care clinics
as well too. So this is part of our Declaration of Access.
Everybody needs to get to same-day access for primary care by
the end of 2016. Walk-in clinics are certainly a strategy to
get there.
Mr. Bilirakis. So do veterans who need same-day access, do
they all qualify, if they qualify for VA care, to go to a walk-
in clinic?
Dr. Shulkin. We don't have walk-in clinics in every one of
our medical centers, but--
Mr. Bilirakis. Well, the ones that do?
Dr. Shulkin. Yep.
Mr. Bilirakis. That the centers that do?
Dr. Shulkin. The ones that do, I can tell you that if
there's a walk-in clinic and they are eligible for VA care,
they can walk in and be seen that day, yes.
Mr. Bilirakis. Thank you. Next question, again for Dr.
Shulkin. One of the VA's legislative asks is to have
flexibility and budget authority to avoid artificial
restrictions that impeded delivery of care and benefits to
veterans. However, the VA has experienced many issues in which
they attribute to lack of training and education. Not too long
ago, the VA encountered a budget shortfall for the same fiscal
year, as you know. The VA did not submit to Congress a formal
request for emergency funds until months after the VA had
already identified a potential budget shortfall as early as
March of that year.
This was in part due to the fact that the VA employees were
not utilizing the $10 billion appropriated for community care
through the Choice program, and utilizing the traditional non-
VA care account. The VA's only solution was a potential
shutting down of VA medical facilities throughout the country;
that's unacceptable. The question is, should Congress allow
such flexibility, what assurances do veterans and taxpayers
have that employees will be trained this time around properly
so that another budget shortfall, nor threats of medical
facilities being closed, does not happen again? So give me some
assurances, please.
Dr. Shulkin. Yep. Well, Congressman, I think you got it
exactly right, which is what we had was, we had spent all the
money in one checking account so it got down to zero, and we
had lots of money in the other checking account. In order to be
able to give veterans care in the community, we had to come and
ask you for authorization at the last minute.
What we're saying is, we don't ever want to do that again.
That's not acceptable, it's not the right way to run a system,
so we want the flexibility to use care in the community funds
to support veterans who get care in the community.
That means when we train our people in the system how to
use it, we can train them that there's one pot of money and now
focus on doing the right thing for veterans instead of
following rules for seven to eight or nine different pots of
money that, frankly, are too complex, and we've shown doesn't
work for veterans. So that's why we really do need this type of
legislation and we need your support in getting that passed.
Mr. Bilirakis. Thank you very much. I yield back. Thank
you.
The Chairman. Thank you very much.
Dr. Ruiz, you are recognized for five minutes.
Mr. Ruiz. Thank you, Mr. Chairman, for holding this
hearing. The issues that we are discussing are wrong in so many
different levels, and I am going to talk about three. One, are
your goals; two, are your data integrity; and, three, is the
veterans' experience.
So goals are important because it defines your success, it
helps you achieve your objectives. Setting a goal of 30 days is
arbitrary, there is no clinical data to suggest that is the
best practice anywhere in the health care literature. And you
had mentioned a term which earlier in the beginning of your
presentation about trying to match scheduling with the clinical
practice. Right?
So we know that some illnesses are urgent, and emergent,
and we need to really take care of them right away, and some
others could be scheduled maybe more than 30 days, like your
routine colonoscopies that you get once a year. Right?
So I think that you need to start perhaps changing your
premise in getting more towards a clinical approach so that you
can take care of your high priorities first and--not
necessarily rush--take up a spot for your high priorities with
things that can be done in a routine basis.
The second thing is setting up of goals of urgent care
appointments within 30 days, which I recently heard of, is
nonsensical. Then why are they urgent if you are going to wait
30 days? Usually an urgent is what you call your walk-ins or
maybe even within 48 days when you want to match your clinical
practice with your scheduling goals.
The third thing that I am concerned about in terms of your
goals is the use of the word ``same-day access for all primary
care and mental health.'' You are setting yourself up for more
controversy by not clearly defining to the veteran what access
is. Is it going into--picking up the phone and having--speaking
with a scheduler, is that what access means? Is it receiving
the appropriate care, is that what access means?
So the second part is your data integrity. Now, we use
population studies to reduce the chance that errors are done by
chance, so that we can get a statistical significant accounting
of whether this is a true problem and whether this is systemic.
But the only way that we can really rely on those population
studies is if your data is accurate, if your data has
integrity, and the GAO is continuing to find faults in the way
that you collect data and how you are reporting it. So you can
understand why we are still skeptical when you tout the number
that 96 percent of all appointments have been seen within this
arbitrary goal of 30 days.
The other thing is the way you report data. So you are
telling me that by veterans who use VetLink inside the
hospitals are telling you that 89 percent of them rate their
access good, what--you are giving me data with a very high
reporting bias. Of course they are going to rate it good
because they are already on the inside of the hospital. How
about asking those that don't get access, that are not inside
the hospital, to tell us what their access is going to look
like?
So for those of us who know statistics and know
methodologies, you know, we are skeptical when you report some
of these reports to us that may not be as accurate as possible.
And lastly, when we can't rely on the population data, when
we can't rely on the integrity, then we go by case studies. And
case studies, depending on the accuracy, and the write up, and
the details is what oftentimes we are left to look at. So let
me tell you about a case of a wounded warrior who actually
works in my office, who is a hero in my book, who went for his
yearly checkup for the VA.
He is service-connected disabled, manages well, he is
prescribed medication through the VA. After waiting 30 minutes
on hold, 30 minutes on hold, the veteran was notified that
because he had not had an appointment in over a year, he would
have to schedule a new patient appointment, even though he was
not a new patient.
He agreed to the appointment, asked to schedule that
appointment as well. They couldn't fit him in until 134 days
later. Again, arbitrary, right? As a result, this veteran
elected Choice, but they still said you have to come in and do
your new patient appointment before you get to your Choice
appointment.
So, one, what does same-day access mean? And, two, why do
these arbitrary numbers exist in the first place? And, three,
why do they need to have--why do veterans need to have a new
patient appointment after a certain amount of time, even though
they have been getting prescribed medications, you know, as
recent as a month?
Dr. Shulkin. Okay. Thank you. I appreciate your skepticism.
I think most doctors and politicians generally are skeptical of
data and I think that's a good thing.
So let me very briefly tell you. First of all, you said it
absolutely perfectly, the VA needs to clinically prioritize its
appointments. That is exactly what I brought into the system.
We used to have 31 ways of ordering a consult, today we have 2.
It's either urgent or it's not. There is no 30-day rule for
urgent care, I don't know where you got that. That does not
exist. Urgent patients have to be seen now, that's why we did
the stand-downs. I've never had a patient who has a urgent care
need that I wasn't working to get them to be seen right away.
That's our goal; get them seen right away when they have an
urgent care problem. So I completely agree, and you said it
perfectly.
Secondly, same-day access, what does it mean? It means
resolving the veteran's needs that day. If they need a
prescription refill, they don't have to come in, we can do that
on the phone or electronically. If they need to talk about how
to understand how to use their treatments, we can do that over
the phone or from telehealth. But patients who are sick and
need to be seen, should be seen that day, that's what we're
working to get implemented. So I agree with you, we have to set
expectations and explain it in a way quicker than we can do
today.
The last thing about the veteran's experience. Look, the
only thing that matters, are we meeting the needs of veterans?
The VetLink system that you talked about asks them when they're
in the system, you're exactly right. So we have a second survey
called CAHPS, it's what's used by the industry, the private
sector industry too.
That asks whether you've been able to get in to see your
doctors when you needed, both for routine and urgent care. So
we compare ourselves to the private sector using CAHPS,
internally we use the VetLink system because that's a point-of-
care system. So all of your points are absolutely right,
Congressman, and we take them to heart.
Mr. Ruiz. Thank you.
The Chairman. Dr. Roe?
Mr. Roe. Thank you, Mr. Chairman. And, Dr. Shulkin, you
know I have great respect for you and one of the things I don't
think I would have said if I were you is, at one year from now
things will be different. I am not sure they will be. I hope
they will be, but I am not convinced.
Just a couple, three, quick points I would like to have
your answer on. One is if the VA is doing its job, why did we
need a stand-down? What was that need to be done?
Dr. Shulkin. Believe me, stand-downs are not the way you
run a system. Dr. Roe, absolutely right. If we have to continue
to do stand-downs, something's really wrong. The reason why you
do a stand-down is because you've reached an unacceptable
situation. The day I learned, literally the day I learned, we
had 57,000 patients who had urgent consults greater than 30
days, I said there is nothing to do but to declare it an
emergency. That's why two weeks from then we had our first
stand-down, because it's unacceptable. But that can't be the
way that you run the system. You have to put in sustainable
fixes, that's what we're doing now.
Mr. Roe. And I looked at the number of schedulers you've
got, you've got 32,000 schedulers, that is plenty of
schedulers. Because I did the math right quickly in my head,
and they scheduled ten people a day which shouldn't overwork
anybody. That is way past 70 million schedules--I mean,
appointments in a year. So you got that fixed.
If the system works--and I would like to have you guys
define what an appointment is. And what I finally figured out
through all this is, look, if the day I called you, if you are
my doctor and I called, treed, that is the day I want--I am
calling to get the appointment. What I would see happening was
that you would tell the veteran, well, you don't have--we don't
have an appointment the day you want it, but we have got one
six, would that be okay? When the veteran says that is okay,
that is their desired date, according to you guys.
Just look, the numbers are what they are, just go ahead and
say we don't have it until then and if it is a problem, if you
prioritize, as Dr. Ruiz said, the sicker patients, then see
them early. Why is that hard? Why have we made this so
difficult?
Dr. Shulkin. No. So, Dr. Roe, a couple things, 32,067
schedulers seems like a lot. The only issue I would add to that
is it's got a 25 percent turnover rate every year, you know,
GS5s, and so you're constantly circulating people in and out.
Mr. Roe. Food restaurant, sounds like.
Dr. Shulkin. Right. Secondly, seeing the urgent patients
first, that's what health care systems need to do, that's what
doctors do, absolutely. That was missing from the VA. That's
what we're focused on now, I absolutely agree.
I think when you talked about how, you know, we assign
clinically indicated dates, preferred dates, that's what the
Chairman was talking about when he said there's this
negotiation going on, that's where we're confusing people.
So look, we need to do better with that. We can't have it
be an arbitrary way of assigning appointments and that's where
I think we really need to move towards this veteran experience
and seeing if we're meeting the veterans' needs because you
can't manipulate data there, right? That's--you're listening to
your patients, your customers, the data is what it is, and
that's where we need to get to.
Mr. Roe. Yeah. And then if you--if everybody is speaking
from the same--singing from the same song book, then you can
make some changes, but you--when Ms. Draper comes in with
completely different information, we hear from you all, how are
we up here on this dais supposed to make any sense out of it?
And, Ms. Draper, a question to you. What would you be
recommending to the VA after your analysis? Because, clearly,
this is not what the VA is telling us is happening, this
investigation that you did.
Ms. Draper. Yes. In that report, this recent report, we
made three recommendations to VA. One was that we think the
entire period that a veteran waits from the time that they
first request care to when they actually receive care, that
entire wait time should be monitored. There's a lot that can
happen between the period a veteran requests care to when that
preferred date is set.
So we made a recommendation with which VA concurred that
that whole period of time should be monitored. The preferred
date is really an artificial measure for the veteran. They
really don't understand what that means. And so the veteran's
wait time experience is from when they actually request care to
when they actually receive it.
Mr. Roe. Got it.
Ms. Draper. So that's one. The second piece is that VHA has
been without a scheduling policy since 2014. And what they've
done, they implemented a scheduling policy in 2010; it was
rescinded in 2014 after Phoenix.
And the way that they've provided guidance to the field has
been through memos, and that's really not the way to do it;
it's been a really piecemeal effort. The field will tell us
that it's very confusing because they get memos, they don't
know what they're supposed to be doing.
And so you need a really good policy which sets the stage
for also really being able to do effective oversight because if
you don't have a very clear policy or you don't have steps that
you should be looking at in the scheduling process, it's really
hard to evaluate whether people are doing the right things or
not. And we've heard a lot of confusion about that.
So those are some of the things. And VA, again, concurred
with our recommendations. So there's a lot that needs to be
done. I would say the other thing related to training is that I
know that they have said that they trained over 32,000
schedulers--I don't know if they're all schedulers, but people
with scheduling keys which could be other people as well.
But have they evaluated the effectiveness of that training?
One of things that we saw when we went into some facilities, we
saw schedulers, the same scheduler making multiple mistakes. We
didn't see intentional manipulation, but the question to me is
how effective is that training? Where's the oversight? And, you
know, maybe there's some people that lack the capability or the
skills to be able to do this job, and that needs to be
accounted for. So there's just a lot of things that go into
this whole process.
Mr. Roe. Mr. Chairman, I am going to yield back because I
am over time, but there is one other subject that Mr. Takano
brought up that we've discussed in the docs caucus, and maybe
one of my colleagues will bring it up, is the GME
implementation. It may be worth a hearing because what Dr.
Shulkin is saying is correct.
We had the VA come over and talk to the entire docs caucus
and we walked through that, and I have been walking through
that in my local medical center trying to get this done. So I
think it would be worthwhile in doing that, because 300, we
would like to get them out there, get these young doctors in
these training positions. I yield back. Thank you for--
The Chairman. Thank you very much. And we will. Let's go
ahead and take care of that because the issues that you brought
up are really the first time that I have heard that, and I
think it is something that we need to go ahead and address as
quickly as we possibly can. It is an easy fix from a
legislative standpoint.
Mr. O'Rourke, you are recognized.
Mr. O'Rourke. Thank you, Mr. Chairman. Secretary Shulkin,
shortly after I arrived in Congress in 2013, I noticed a gross
discrepancy between what the VA was reporting on wait times in
the district that I represent, El Paso, Texas, and what
veterans themselves were telling me.
In 2014, because we couldn't resolve that based on the data
we were given by the VA and the assurances from one of your
predecessors, Dr. Petzel, we commissioned a third-party
independent survey of El Paso veterans that returned results
with a margin of error under 5 percent, that showed that
instead of waiting eight or nine days for primary or mental
health care, veterans were waiting over 70 days, over 80 days,
for those two respectively.
The conclusion I arrived at, and I still insist upon, is
that the only way to find out how long veterans are waiting for
care is to ask veterans directly. And so we will continue to
survey. We surveyed in 2015; we will survey again this year.
I am glad to hear that you agree with Ms. Draper's
conclusion that the VA must measure from the date that the
veteran first requested help to the day that that appointment
was delivered. And for anyone who hasn't read this GAO report,
this is illustrated graphically on the first page in a way that
anyone can understand.
So I have a question about that. When will we receive those
numbers, and when will that be standardized as the way that VA
measures wait times so that we don't have preferred wait times
with multiple points of potential failure and manipulation, and
we just have you asked for an appointment on this day, you
received it on this day, number one?
And number two, you gave a great presentation in October on
the way forward for VHA that acknowledges that today we have
43,000 authorized, funded, but unhired positions within the VA.
We will never hire all of them. We are going to leverage
capacity in the community. We are going to specialize within
the VA on what the VA should be doing best. That is something
that needs to happen if we are going to resolve the fact that
there is more demand than there is capacity within the VA.
Where are we on that? So those are my two questions, the
standardizing of wait time reporting, and where are we on the
October plan that you announced at the end of last year?
Dr. Shulkin. Well, Congressman, I've already acknowledged
that our systems for measuring wait times are overly complex
and very difficult to understand. Where I believe that we need
to go is to simplify this by looking at the veteran experience,
by asking our veterans, are we meeting the needs of the
veterans in the El Paso community?
That's the way that it's done in the private sector, they
don't have these complex wait times. Remember we went out, we
asked the Institute on Medicine, we've asked so many consulting
companies, I can't even imagine, tell us the right way to do
this, the way the private sector's doing it, and they've come
back and they said there is no standard.
So I think what VA is doing is, we're measuring so much
right now and trying to report everything, we're confusing the
picture. So we have to get better at this, and we have to
simplify it, and we are going to do that. I think what the GAO
report is talking about is the new enrollees and that's where
we've concurred that we will measure the full wait time. But
I'm not anxious to start redefining wait times and getting even
more data and more confusing; I actually want to simplify this.
On the issue of what do we need to do to go forward to work
with care in the community, we need the legislation to
streamline the care in the community, we need the provider
agreement legislation passed because we need to fix this
program for veterans, and we do need to work with the private
sector.
We are committed to that as well as our Federal partners
like DoD, the Indian Health Service, federally qualified health
centers. So we think we did present a plan, we know that you're
looking very hard at that, and we'd appreciate your support.
Mr. O'Rourke. So on both of these issues, I would love to
follow up with you to get written specifics on just when we'll
have wait times reported in the way recommended by GAO. And,
two, I want to know specifically what is on our plate that we
have to finish in order to allow you to implement what I
thought was a very ambitious proposal to make VA work for every
veteran and get to what you describe, which is outstanding
care, and that should be the ultimate focus.
When it comes from my colleagues, when it comes to
measuring wait times, we have introduced a bill the Ask
Veterans Act, which would standardize throughout the country in
each of our districts the ability to get objective third-party
confirmed wait times, the actual wait times. The VA reports for
April of 2016 that veterans are waiting 13 days in my district
for primary care, 10 days for mental health care. When I say
that in my town halls, I almost get laughed out of the room.
When we report back what veterans have told us in the
surveys, they all nod their heads. This confirms the experience
that they have had. So we welcome the support and collaboration
of my colleagues on this, and I thank you for your commitment
for making sure that we report more honest wait times for
veterans in our communities.
Dr. Shulkin. Thank you.
Mr. O'Rourke. With that. I yield back.
The Chairman. Mr. Huelskamp, you are recognized for five
minutes.
Mr. Huelskamp. Thank you, Mr. Chairman. I think the keyword
I have been looking for in my time on here is accountability
from the VA employees and leadership. And I want to drill down
on a couple situations that I think are pretty striking
examples and perhaps, Dr. Shulkin, you can clarify what has
occurred here.
But apparently, what I understand is the VA in Puerto Rico
has refused to fire a medical center employee who was convicted
of crimes related to armed robbery, and apparently in comments
to the media a VA spokesman apparently suggested it was okay
for VA's employees to participate as long as it was on their
free time.
Now, I am sure you don't agree with that. What is the VA
doing to take care of this situation in Puerto Rico?
Dr. Shulkin. Congressman, I am aware of that situation and
I don't--it is my understanding, and, you know, I'm very
careful, I want to give you accurate information. So if I
misspeak on this, I will commit I will get back to you by the
end of the day. But it is my understanding that that person is
not currently working at the VA in San Juan.
Mr. Huelskamp. Is he on paid leave?
Dr. Shulkin. No. That's not my understanding. Again, I
will--I will personally make sure that we confirm that with
you. But, no, that is not my understanding, that they are not
an employee of the VA.
Mr. Huelskamp. Okay. I look forward to that. Second one, VA
apparently, as I understand it, still has not disciplined the
chief of staff at the Cincinnati VA Medical Center who was
found had improperly prescribed controlled substances. What is
the status of that particular employee at the VA?
Dr. Shulkin. That situation, I'm a little bit closer to. If
you will recall, I made a administrative decision to suspend
their clinical privileges of the chief of staff, and she was
actually in a acting chief of staff role, and also to remove
her from that role. She is following her due process, which
means that the medical staff is looking at the clinical
privileges and there's a due process going on, on the
administrative decision I made. So there was both a
administrative and clinical decision. But currently she's
certainly not in that role, and she is not--
Mr. Huelskamp. And I appreciate the follow up on that. So
no access to veterans as it stands today? No access?
Dr. Shulkin. She's not in a clinical role and not in that
leadership role, no.
Mr. Huelskamp. Okay. And what role is she in?
Dr. Shulkin. My understanding is she's doing administrative
reviews, like quality reviews.
Mr. Huelskamp. And has been found improperly prescribed
controlled substances and is still doing quality reviews?
Dr. Shulkin. We had concerns, that's why we took actions.
We invited the Inspector General, that was my first request, to
come in to take a look at this. I know that the DEA has also
come in to take a look at this. We are waiting for their final
reports on this before we can make a additional determination
about that.
Mr. Huelskamp. And thirdly, going back two years, and I am
looking at a statement from Mr. Sloan Gibson, it is in June 5th
of 2014, and here is the statement. ``In Phoenix, we initiated
a process to remove senior leaders.'' And as I understand
today, a number of those senior leaders are either still on
paid leave or have not been removed, or are still working
through the process, in particular, the Chief of Staff Darren
Deering. Is that the case that it has taken two years, and Mr.
Gibson has yet to fulfill that process and in that process to
remove these folks that were covering up secret waiting lists
that harmed up to 20 veterans?
Dr. Shulkin. Yeah. I believe approximately 30 days ago Mr.
Gibson did make a disciplinary decision on all three
individuals. That decision was removal. They are each in their
own process of due--of due process. Dr. Deering is a Title 38
employee, so he has a shorter period of time in which to do
that. The other two are Title 5 employees, which is, we know
we've talked about as part of the Accountability Act, takes a
little bit longer.
Mr. Huelskamp. And I am out of time. So that is what I
understand about that situation. So June 5th of 2014, the
promise is made public, CNN, we are going to take care of this.
As we sit here today, April 19th, still not completed the
process to take care of someone and get them out of harming our
veterans.
You know, Mr. Shulkin, I would ask you to pass on to your
superiors, and I appreciate the work you are doing. We have got
a VA Accountability Act to take care of this, for some reason
the Senate is still sitting on it, they are talking about
spending more money instead of taking care of these folks. This
is absolutely outrageous, whether it is Puerto Rico,
Cincinnati, or Phoenix, still almost two years later and we
can't get rid of the folks that have harmed our veterans.
And just like Mr. O'Rourke, I go in town halls and say we
have got a VA Accountability Act, they are really working for
us, and they all laugh. They have lost all respect within the
veterans community. And so we hear these numbers and I
appreciate it, and I didn't get a time to ask questions because
I have gone over, but I understand, you know, we had 58 cases
referred to the Department of Justice for possible criminal
charges.
That would be my thought from the Committee if we could
find out what the response has been from those Justice
Department to those 58 criminal cases and the disposition of
those. So with that, Mr. Chairman, I appreciate letting me go
over a few seconds. I yield back.
The Chairman. Thank you.
Ms. Brownley, you are recognized.
Ms. Brownley. Thank you, Mr. Chairman. Secretary, Shulkin,
I appreciate your testimony today to say that your intention in
your testimony, both written and your earlier testimony, was
not to paint, you know, an extraordinarily positive picture,
but to say that it paints a picture that we are on track, so I
appreciate that.
I have to say, though, in your testimony, when you ``That
in April 1st, 30"--or ``the wait time for VA overall is
completed 96 percent of the time within 30 days overall,'' and
that is data, I think, from February. When I was reading your
testimony last night, I said to myself, oh, gee, it must be my
district that is causing the four percent that is not there.
So I went back to look at the--I went back to look at the
data, and as of April 1st, almost 30 percent of our veterans
that I represent in the Oxnard CBOC in Ventura County have
primary care appointments pending over 30 days. And, actually,
I asked my staff for the data this morning and I think based on
the data in that one metric, we are the second highest CBOC in
the country with Dover, Tennessee, being the highest at 48 days
for a pending appointment within 30 days.
So we have a problem, and we have had a problem, and I am
extraordinarily excited that the VA Greater Los Angeles health
care system has finally hired a medical center director who is
permanent. We have had interims now for a year and a half to
two years, I have sort of lost count.
But we are working very, very closely with Ann Brown, who
was, I believe, is doing a very good job, and is very aware of
what is going on in Oxnard. And, clearly, we have had trouble
hiring and keeping teams there within the CBOC. I think we have
a contracted out facility that plays a role. The Choice Program
is not really working too terribly much in our district, so
that is not as large a option as that we would like it to be.
So we know these things are happening. I guess, you know,
my question is that if I was not watching this closely, my
question is, is the VA watching this closely and would you
have--nobody brought it to my attention, I just bring it to
your attention. And so my concern is, you know, is the VA
looking specifically at regional problems that is skewing your
data perhaps, to really address these pockets within the
country that aren't doing very well at all?
Dr. Shulkin. Yes, we are tracking this. I think you have it
correct, which is--which is that the--this is very different
depending upon the geography of the country that you're in. So
that we have some VAs that actually don't have backlogs at all,
and others, like in your district, that have significant
backlogs in primary care.
So we are paying attention to that, we're actually focused
on those top 10 to 15 percent. We're sending our veterans
engineering resource center teams out now to work with those
most distressed facilities to help them redesign their systems.
We're focused on recruitment in areas that really are
struggling with recruitment. So we absolutely are focused on
that, but I think that it's a relatively new direction for us
to focus on those areas that have been so--that really are
struggling the way that yours is.
Ms. Brownley. So when did you start working, you know,
with--teamed up with the Oxnard facility to help facilitate
some of the issues?
Dr. Shulkin. Well, I think you identified it correctly in
your district. You need permanent leadership in place and you
need experienced leadership. Ann Brown, which, of course, as
you know came from Jesse Brown in Chicago, is one of those
experienced leaders. We knew Greater Los Angeles was one of our
most challenged facilities, so we brought an experienced leader
there. I think you're seeing that makes a big difference. But
without having permanent experienced leadership in place, it's
very hard to address this in a system as large as we are.
Ms. Brownley. All right, but I can rest assured that the
Washington team is working directly with Ann Brown to help
facilitate this issue in Oxnard?
Dr. Shulkin. I've recently been out there to visit with
Ann--
Ms. Brownley. Okay.
Dr. Shulkin [continued].--and the Secretary, some people
think he lives in Los Angeles, he goes there so often, so--
Ms. Brownley. And I just want to, you know, say publicly
that I believe that Ann is working very, very hard on this and
I appreciate her leadership, and she is now giving my district
office regular updates. But it is an eyesore compared to, you
know, the rest of the country and needs that attention.
So Ms. Draper talked about--or you spoke actually, Mr.
Shulkin, about working directly with the GAO now in a team to
recognize where some of this--some of these improvements have
come from, and I guess I just would ask Ms. Draper, you know,
to ask you your feedback in terms of are those meetings
productive, and are you meeting on a regular basis with
specific agendas?
Ms. Draper. Yeah. So there are five criteria for removal
from the high risk list. One is leadership commitment, one is
capacity, and that's having the necessary resources, people and
otherwise; a third piece is the action plan, fourth is
monitoring, and then the fifth is demonstrated progress.
So what's happened thus far is that VA provided us a draft
action plan in January, and it really addressed one of the five
areas, and we felt that the action plan was not sufficient. So
we met with them, provided them comments, and then we referred
them to an agency we felt has done a really good job making
progress on their high-risk status.
So they have gotten that action plan, and we have committed
to VA that we will begin meeting with them starting the end of
this month and then monthly. I think they are trying to get it
on target to get us an action plan, a reliable or feasible
action plan by August.
And that includes having metrics that we both can agree
that show there's progress made. The first plan did not include
that. So there's a lot of work to be done, and we are going to
work with them to provide feedback. It's a little difficult for
us because we have to straddle the line of independence, but we
can provide them feedback and direct them to other agencies
that we feel have made good progress, improving their high-risk
status.
Ms. Brownley. Thank you. I apologize for going over. I
yield back.
The Chairman. That is all right.
Dr. Abraham, you are recognized.
Mr. Abraham. Thank you, Mr. Chairman. Like Dr. Roe, Dr.
Shulkin, my respect for you personally is great, and I know in
my heart of hearts you want to get this right. My concern is,
like Ranking Member Brown said, this is way before your time,
goes back ten years plus. So, you know, my concern is the
culture of the VA, this may be a bridge too far to actually fix
this problem within the VA system itself. And, you know, it may
be time to look outwardly to a private sector to just do simply
the scheduling.
If 89 percent of the veterans are satisfied with their care
once they get there, we certainly want to enhance your ability
to treat those veterans with the expert care that we know the
VA gives our veterans' population. But we are talking today
mostly about the scheduling issue where either VA has the
inability or they lack resolve to actually get rid of these
poor scheduling employees. And it is certainly in the private
sector they can fire at will, and they are gone, and they
replace them with somebody that does.
And your turnover rate you said 25 percent. You know, that
is hard to keep any quality employee on task, on target, with
that going on. And certainly, with the $152 million and
extrapolate to the $600 million to implement the software
program, you dangle that carrot in front of private enterprise,
they are going to be knocking your door down to do this. And
you know there are businesses that do this for a living, that
is all they do is schedule patients.
So, again, just a thought and maybe a pilot program or
something could be on the agenda, just to compare how the
private sector does. On just the scheduling, I am not talking
about health care for the veteran, but just the scheduling the
veteran to get the appointment, and, you know, compare it
against the VA's track record. So, again, just a thought.
Mr. Reinkemeyer, couple of questions to you. You had said
that you guys are hopefully go to each VISN every three years
and you look at data reliability, the Veterans Choice Program
implementation, and the consult management if I remember the
three tagged right. And I guess the first question on the data
reliability that you guys are getting from the VA, because the
old adage, garbage in garbage out.
If you don't get the data that you need, and if you don't
trust the data that you get, then it is hard to make informed
decisions. So the question is are you satisfied, are you
comfortable to date, with the data that you are receiving from
the VA on this issue of scheduling?
Mr. Reinkemeyer. No. We continue to see the data is
unreliable, which is one of the reasons why we're going to try
to implement this VISN approach. National reviews are great,
where we sample so many facilities throughout the country. But
we think if we can push this down to a more local level and
feed this information to the VISN management, and give them an
opportunity to take control of their VISN and make changes, we
think that's going to be more helpful. But the 96 percent, and
the data that has been discussed today, we don't see it. I
mean, every facility we go to, it's not accurate.
Mr. Abraham. Okay. And my next question to you too, and it
has a quote so I want to make sure I get it right. It says in a
February 25, 2016, letter to the President of the Office of
Special Counsel, said that the VA OIG investigations of
whistleblower disclosures regarding wait times in Hines,
Illinois''--it is Freeport, Louisiana, which is in my state--
``were inadequate.''
OCS found that, ``The OIG investigations found evidence to
support the allegations that employees were using separate
spreadsheets outside of the VA's electronic scheduling and
patient record systems. However, the OIG largely limited its
review to determine whether the separate spreadsheets were
'secret'.'' Please explain why the OIG limited its review?
Mr. Reinkemeyer. So that review was conducted by our
investigative staff, so I was not directly involved with that.
I am aware of the concerns and I know Ms. Halliday, my boss,
has made sure that we try not to interpret the allegations too
strictly. And, you know, I can ask the Office of Investigations
to get back to you on their response.
Mr. Abraham. I guess my follow-up question, were there any
criminal charges that were sent up to the DOJ for prosecution
that you know of?
Mr. Reinkemeyer. So I would say, no, I don't know of them.
I know that there were some and there's been discussions, but
that's outside of our office.
Mr. Abraham. Okay. Thank you, Mr. Chairman, I yield back.
The Chairman. Thanks.
Mr. Zeldin, you are recognized.
Mr. Zeldin. Thank you, Mr. Chairman. Dr. Shulkin, April 7th
USA Today story starts with, ``Supervisors instructed employees
to falsify patient wait times at Veterans Affairs medical
facilities in at least seven states.'' Was that accurate?
Dr. Shulkin. I've reviewed 72 IG reports, 11 of them were
found to have intentional manipulation. So that would be
accurate, but it's not representative of the majority of their
findings.
Mr. Zeldin. And of these supervisors, how many of them have
been fired?
Dr. Shulkin. We have for a total of all of those IG
reports, when I add up going across that, we have 29
individuals that have been disciplined. I think Chairman Miller
before had said four have been fired, I'm aware of five who
retired under investigation. So rather than letting the
investigation go forward, they decided to retire from Federal
service.
Mr. Zeldin. When you referenced the number 29 disciplined,
that is from this USA Today story?
Dr. Shulkin. From the 72 IG reports that I've reviewed. I
sort of--I manually counted them up as we went through each of
the accountability actions.
Mr. Zeldin. Have any supervisors who instructed employees
to falsify patient wait times, have any not been disciplined?
Dr. Shulkin. Oh, I suspect that of people investigated,
many--there were many, many more than 29. Probably lots more
that were investigated and the evidence did not suggest that
there was discipline that needed to be imposed.
Mr. Zeldin. Okay. Are you saying that there were
supervisors who instructed employees to falsify patient wait
times who have not been disciplined?
Dr. Shulkin. Of the investigations that we've done that
found intentional manipulation, we then would send in our
office of accountability review to do to these investigations.
Everybody that was found to have a action or found to have a
behavior that required disciplinary action, we have imposed or
they have retired.
Mr. Zeldin. So no one has not been disciplined?
Dr. Shulkin. Oh, I wouldn't say that.
Mr. Zeldin. We are going in circles right now.
Dr. Shulkin. Yep.
Mr. Zeldin. I am asking about the people who of the
supervisors who instructed employees to falsify patient wait
times, have any not been disciplined?
Dr. Shulkin. You know, I don't know the--I don't know what
your denominator is. Anybody that has been accused of a
manipulation, we have investigated. When we have found that
there's evidence that they did do the manipulation, we have
implemented disciplinary action.
Mr. Zeldin. None of those people haven't been disciplined?
Dr. Shulkin. I am not aware of anybody that we found that
was supervising a manipulation that we haven't implemented
disciplinary action. Now sometimes after the action, they've
appealed and those actions have been overturned.
Mr. Zeldin. But no supervisor who you have investigated who
has instructed employees to falsify patient wait times has not
been disciplined?
Dr. Shulkin. You know, Congressman, I feel like--I feel
like I'm being asked some questions about--you have to ask me
individuals, you'd have to say--
Mr. Zeldin. I am asking about anyone.
Dr. Shulkin [continued]. Well, look--
Mr. Zeldin. Has anyone not been disciplined?
Dr. Shulkin. These disciplinary actions have been going on
well before I got here. What I--all the information I have, and
this is not my responsibility to implement these disciplinary
actions, we have an office of accountability review. What I'm
telling you is, is that when I've reviewed these reports, when
I find that other people have taken disciplinary action against
29 individuals, I'm sure there are many more that have been
accused of supervising. So I don't know how to answer your
question.
Mr. Zeldin. Right. Okay. Well, I mean, it is a simple
question. There was a USA Today story that says, ``Supervisors
instructed employees to falsify patient wait times in at least
seven states.'' You are then saying that you investigate it,
and if you have evidence to back that up, then the person is
disciplined. I am asking if through that process has anyone not
been disciplined, and then we start going around in circles.
We are talking about patient wait times while we are here,
we have issues with patient advocates, where I have
constituents who will call a patient advocate, they will not
get someone on the phone, they will leave a message, sometimes,
many times they will not get a call back. Reports about calling
a suicide hotline and getting a voicemail, in some cases not
getting a call back.
A backlog of appeals this Committee is concerned about,
greatly concerning numbers, the Denver VA hospital construction
project. I have a constituent, John Mitchell, in an aid and
attendance case with over 20 years of service, an Army Ranger
in Vietnam with over 16 years in service with special ops. He
suffers from traumatic brain injury that's directly connected
to his service. One was from an accident in a military vehicle,
another one was from a parachute fall.
And because the VA lost his file, he is being denied his
benefits. Twenty-year veteran, Vietnam veteran, special ops,
and he is unable to take care of himself. And we are getting
all these different cases, but the only time that it comes to
light for this Committee is when the Committee brings it up to
the VA. The VA needs to be bringing these issues up to the
Committee beforehand.
When one example after another doesn't come to light until
this Committee brings it to light, or the USA Today does, or
the Inspector General, or GAO, if it is not initiated by the
Department of Veterans Affairs, it looks like a cover-up.
So you say that someone who violates the law, or violates
our principles doesn't belong at the VA, well, I would argue
that that goes straight up to the top of people who are
violating the principles of the VA. And it is greatly
concerning that it is this Committee responsible, and it is the
GAO responsible, it is the Inspector General, it is the media
responsible for bringing this to light, and you don't do that
for us.
I yield back.
The Chairman. Thank you.
Mr. Coffman, you are recognized.
Mr. Coffman. Thank you, Mr. Chairman. Just a question about
the appointment wait times scandal because I think that we are
getting kind of different summaries of it, if you will. And so
wasn't the--you said that it wasn't about cash bonuses, but you
didn't put a date on that, I guess that the policy had changed.
But what was the policy in 2013 when this issue came to light?
Dr. Shulkin. Congressman, I wasn't here then, so. But I
believe that there was wait times as part of people's
performance evaluations. And so, Dr. Lynch, am I correct in
that?
Dr. Lynch. Yes.
Dr. Shulkin. So there was a potential of a financial bonus
if people hit certain criteria.
Mr. Coffman. Sure.
Dr. Shulkin. Today, that doesn't exist. There is nobody.
Mr. Coffman. So you allowed--people were allowed to retire
who are under investigation, who were complicit in manipulating
appointment wait times; is that correct? I think--
Dr. Shulkin. I think I said the investigation didn't to
conclude. Before the investigation was able to conclude, they
retired from Federal service.
Mr. Coffman. So, but this involves fraud and fraud is a
criminal issue. How many criminal referrals occurred of people
who were involved in this scandal?
Dr. Shulkin. My understanding--I don't know whether the
Inspector General can help us with this--was that we did ask, I
think this was actually Senator Blumenthal who asked that the
Department of Justice come in to take a look at this, and they
ended up declining on looking at most of these cases. But I
know that there are referrals that go from the IG to the
criminal division.
Mr. Coffman. Could someone comment on that?
Mr. Reinkemeyer. There are referrals and I know in every
case where we suspect something we will make that referral. I
can tell you, and this is not my area of expertise, but I think
a lot of the money that you're referring to, the bonuses, while
inappropriate, is not necessarily a high dollar amount, and
there's not a lot of traction.
Mr. Coffman. So fraud is okay if it is a low dollar amount,
is that what we are saying here today?
Mr. Reinkemeyer. Not for me, but I'm just saying--
Mr. Coffman. Really?
Mr. Reinkemeyer. --the Department of Justice, I think
there's not a lot of traction if it's a small dollar amount.
Mr. Coffman. That is disappointing, under this
administration, that that would occur. And let me state what is
current law, and that is if somebody commits fraud, but is
awarded a bonus, there is no clawback provision in current law;
is that not correct? Who can answer that?
Dr. Shulkin. I'm not aware of the answer.
Mr. Coffman. There is no provision. And, in fact, there is
legislation before the Congress, and the position of the VA is
neutral on that, which I find is appalling, as a taxpayer and
as a veteran, that when somebody gets a bonus that they clearly
did not earn, should not have been given, that the only
provision in which the VA is allowed to claw it back is if it
is given administratively to the wrong person. But if it is
given to the person that is the subject matter of the bonus,
even if they didn't earn it, there is no provision for
clawback. That law needs to change, and the Secretary needs to
take a position affirmative for that legislation and not simply
sit on the sidelines. This is about cleaning up the VA. And the
Secretary was giving a speech in Denver last weekend--well, I
think it is two weekends ago--
Dr. Shulkin. Yes.
Mr. Coffman [continued]. --that I was at where he said that
the fundamental problem in terms of the appointment wait time
scandal was a lack of training of VA personnel; is that
correct? Was it due to a lack of training?
Dr. Shulkin. I think what the Secretary most likely meant
was that our system was complex and we weren't spending enough
time training. But I don't think he would say that was the only
factor. This was--there were many factors involved in this.
Mr. Coffman. It really had nothing to do with a lack of
training, it had everything to do with people that were fairly
skilled at manipulating the system, because what, in fact, they
did was to make the numbers look smaller to get these cash
awards, is that they pushed veterans out on these secret
waiting lists who did not get health care and, in fact, there
are veterans who died on those secret waiting lists.
And, you know, I don't know how we ever clean up problems
in the VA if we really don't acknowledge their existence, and I
really do not believe that the leadership of the VA has
acknowledged the depth of the problems that exist here, and
that's why they will never be cleaned up under current
leadership. I yield back.
Mr. Benishek. [Presiding.] Mr. Bost, you are recognized.
Mr. Bost. Thank you, Mr. Chairman. Mr. Shulkin, I have to
ask specifically. In the individual VA medical facilities,
administrators and/or directors basically have the ability to
monitor this with their own facilities, correct, so make sure
they are the ones that are in charge of doing that; is that
correct?
Dr. Shulkin. Monitor this wait time?
Mr. Bost. This wait time and all of these.
Dr. Shulkin. Yes.
Mr. Bost. They are the ones who do that?
Dr. Shulkin. Yes, sir.
Mr. Bost. Okay. The concern that I have, and I am going to
express this--and I am going to tell you about a bill that we
are working on that you may be aware of. The problem is I see
right now--St. Louis is one of our facilities--in the last 34
months, every 120 days or 280 days, depending on--or 240 days
by your rule, we keep circulating directors in and out.
I ran business for years, and if--in 120 days I couldn't
get all of my employees' names down, I couldn't--definitely
couldn't figure out where the problems were. And whenever--I
thought this was only in the St. Louis facility, but our
research has found out that there is 40 facilities that are
actually in interim directors that are just kind of cycling
through like this. It is very hard to have oversight if someone
is not there for a long period of time and they understand that
is their job. Is there anything being done right now to try to
cure those problems?
Dr. Shulkin. Yes. First of all, I couldn't agree more. You
can't solve the problems in the VA unless you have the right
leaders in place and they need to be permanent leaders. So
we're on the same page. St. Louis, very unfortunate. We
actually had named a permanent leader who was coming--
Mr. Bost. He was no longer available.
Dr. Shulkin [continued]. Yeah. He was coming from Hawaii,
and because of personal issues he retired from Federal service.
And so now we're back in a national search, and we have some
candidates. So I am very focused on getting a leader in St.
Louis.
But I don't count 40, I count 34. That's 34 too many. So we
have national recruitments out in place. It's one of the
reasons why we've asked again for your support for Title 38
legislation, because we need not only accountability in the VA,
but we also need market rates that will help us attract the
very best who will come to take these jobs. Right now, there
aren't enough people who want to come and take these jobs.
Mr. Bost. Because of salary?
Dr. Shulkin. I think that the bad press that VA has been
getting, our applications are down 78 percent from the date of
the crisis. These are known to be very, very tough jobs and the
salary is not anywhere near where what the market rates are for
these jobs.
Mr. Bost. I am pretty sure that nobody wants to jump on a
ship that is sinking. And that is the problem is--or maybe it
needs to be sealed up and then bailed out in the condition that
it is right now. And I think this is a possible--this just
causes a downward spiral and I think it needs to be cured.
Now I am willing to work with you on that, and I understand
the legislation we are going to be pushing forward gives the
Secretary about 120 days to look over proposals on what it is
that we can do and move forward to try to cure these problems.
With that, Mr. Chairman, I yield back.
Dr. Shulkin. Thank you.
Mr. Benishek. Thank you, Mr. Bost.
I am going to yield myself five minutes to ask a few
questions. Dr. Shulkin, as you know, we have been aware of this
problem with the training and the procedures for these
schedulers since 2005 when the Inspector General first reported
on it, and it has been 11 years since then. And the Inspector
General stated in its August 14 Phoenix report, since July
2005, the Inspector General has published 20 oversight reports
on VA patient wait times and access to care, and that the VA
has been resistant to change.
I guess my question is about the procedure for responding
to and dealing with Office of Inspector General reports. Okay?
This is something that I have been working on for years in my
position here. Is someone actually put in charge of responding
to a specific Inspector General report?
Dr. Shulkin. Yes. I did not do, when I came into office, a
major reorganization of VA leadership because I wanted us
focused on this problem, fixing the wait time crisis, not
internal politics. But the one thing I did do, was, I
established a new deputy undersecretary for organizational
excellence, whose position it is to focus on this. That's Dr.
Carolyn Clancy.
Mr. Benishek. There is one person then--
Dr. Shulkin. Yes.
Mr. Benishek [continued]. --has the responsibility--
Dr. Shulkin. One office, one person.
Mr. Benishek [continued]. --to deal with this?
Dr. Shulkin. Yes.
Mr. Benishek. So then that person will be held responsible
for making sure that the Inspector General reported deficiency
as corrected?
Dr. Shulkin. Well, I will be held responsible and the
Secretary ultimately is held responsible--
Mr. Benishek. Yeah, yeah. But it is difficult because--
Dr. Shulkin. Yes.
Mr. Benishek [continued]. --you know, we have had so many
Inspector General reports where the VA Secretary has agreed
with the report and agreed to change it.
Dr. Shulkin. Yes.
Mr. Benishek. The way things are going. But nothing has
changed in 20, 30 years. You realize that, right? I mean, the
Inspector General report--
Dr. Shulkin. I do realize this.
Mr. Benishek. For example, I will give you a good example,
identified the fact there is no central hiring process for
physicians at the VA. That was reported, I think, 8 times over
30 years. That problem still exists.
Dr. Shulkin. Yeah.
Mr. Benishek. So no one seems to have fixed that problem.
So I want to have us where one person is responsible for
responding to the Inspector General reports. Let me ask of Mr.
Reinkemeyer, has there ever been an accountable employee
assigned to fix a problem in your history with the Inspector
General?
Mr. Reinkemeyer. So there's always someone assigned, but
quite honestly, and I was involved with the first 2005 report,
and we reported it. And until 2014, there was really no
priority placed to it. We reported it in '05, we reported it in
2007. The right words were said, changes were made, but when we
came back two years later, we found that nothing had been put
in place.
Mr. Benishek. Right. Well, that is my experience as well.
They say we are going to fix it, but then nobody is actually
responsible, a name of an individual whose job it is, to
actually make it happen, never seems to get fixed, you know.
You think that legislation mandating that the VA assign a
specific accountable employee to fix a problem would be an
effective strategy?
Mr. Reinkemeyer. I think Dr. Shulkin was right that
ultimately he's responsible and the Secretary. We make our
recommendations generally to the Under Secretary for Health
assigning responsiblity. I wouldn't think legislation would be
necessary, but that's certainly something you can explore.
Mr. Benishek. I know, but that is what I mean by saying
that, you know, there was this problem for 30 years with the IG
telling the VA they need to have a central plan for hiring
physicians. They said that to the VA six times over 30 years.
The VA's agreed with them six times over 30 years. And, yet,
nobody was ever assigned to fix that problem, and it still
occurs today that there is no real central plan for hiring
physicians within the VA.
So, I mean, you see what I am talking about, Dr. Shulkin?
Dr. Shulkin. Yeah.
Mr. Benishek. That, you know, this is something that is a
procedural, the way things are done. I mean, it is given to
some Committee, it is given to some department, but then there
is nobody actually who is in charge other than you. And then
you say, well, you know, we are all working on it.
Dr. Shulkin. But, Dr. Benishek, what I'm saying is, that is
the organizational change I made. I have a brand new deputy
undersecretary whose job it is to do that, and they've put
together the Office of Medical Inspector, all of the compliance
officers, the regulatory officers, the ethics people.
Mr. Benishek. What is his name?
Dr. Shulkin. Well, Dr. Carolyn Clancy. You know Dr. Clancy.
Mr. Benishek. Okay. Okay.
Dr. Shulkin. Yep.
Mr. Benishek. So then how many Inspector General reports
has he looked at so far in that position?
Dr. Shulkin. They've been keeping us pretty busy this year.
We've looked at at least 72 on the wait times alone, and you've
probably sent over a bunch of others on top of that. So I would
say--
Mr. Benishek. Well, I would like to see--
Dr. Shulkin [continued]. --probably over 100.
Mr. Benishek. I would like to see the Inspector General
reports that he has looked at and what exactly he has done to
respond to those Inspector General reports.
Dr. Shulkin. Absolutely.
Mr. Benishek. All right. Thank you. I am out of time. And I
think everybody has asked their questions. So we are just about
ready for the closing.
Ms. Brown has a closing statement she would like to talk
about.
Ms. Brown. Yes. I want to ask Ms. Draper a question.
You mentioned the scheduler and that perhaps they are not
getting an adequate training. We all know that a scheduler is
an entry-level job. Do you think that the VA needs to do more
to upgrade, because once a person is trained in that position,
if they see another opening, they want to move up?
Ms. Draper. Yeah. Let me just back up a little bit because
I think training is an issue, but I think it's much more
complicated than that. I think there's oversight issues, the
VistA scheduling system is really prone to user error. There's
a lot of things that factor into the errors that we've seen.
As far as the schedulers, it is an entry-level position,
it's usually generally GS4, 5, 6. In previous work that we've
done, we heard from facilities that it's a very high turnover
position, I think it's the number one or two clinical position
within VHA that turns over each year. And so there's not really
a good career path for those individuals.
And what we've heard is when someone demonstrates a high
level of capability, they're often scooped up and moved
someplace else. I think at one point a couple of years ago,
they had instituted in some places a GS6, so there was a career
path. My understanding is that that doesn't exist any longer.
It's a lot of pressure and responsibility on these
individuals, so, it is important that they have the support,
and the training and the oversight.
Because, as I said in my opening remarks, if someone
continues to make the same errors, where is the oversight for
that, and what happens when that continues to happen? Because
that is what we've seen. So it raises the question about
oversight. And, you know, quite frankly, whether some of these
people are really able to do the jobs that they're put in.
Ms. Brown. Thank you. Mr. Secretary, last thing. I have
gone to the medical schools in the Orlando area with the
Secretary, but I didn't know that there was some problems with
it. I know we need additional slots. I am hoping that you all
will get back with us, and if there is something that we, on
our side, need to do, I know we want to do it because we need
those additional physicians. And, of course, if they train and
have those residents, they will probably stay in the area.
Dr. Shulkin. Yes. Yes. We would--we'd welcome further
discussion on that.
Ms. Brown. And in closing, I am hoping that the veterans
that is listening to what we are doing today understand that we
are seeing over 2 million additional veterans in 2015 than
2014, over 226 appointments per day.
So if veterans need to come to the system, don't be dumbed
down by what you hear in here, go and get assistance. Go to
your Member's office. Go to the VA.
And with that, you know, we all need to soldier up and make
sure that the veterans are being taken care of. Thank you, and
I yield back the balance of my time.
Mr. Benishek. Thanks to the entire panel for being here.
You are now excused.
Today we have had a chance to hear about the many ongoing
problems related to Veterans Access. Oh, I guess we are going
to have the Chairman give a closing statement or something.
The Chairman. [Presiding.] No. No closing statement. I just
confirmed with the Caribbean health care system that the
individual that we were discussing is still on the payroll.
Dr. Shulkin. Thank you for correcting that.
The Chairman. So, again, the question is, why in the world
would somebody who has been convicted of armed robbery still be
working at the Department of Veterans Affairs?
Dr. Shulkin. Okay. Well, hard for me--hard for me to answer
that right now. So I think we know owe you an answer.
The Chairman. Please. Thank you.
Mr. Benishek. Thank you, Mr. Chairman.
We have had a chance to hear about many of the ongoing
problems related to veterans access to health care that
continue to occur today over two years since the wait time
scandal.
As we have discussed, the VA has not taken the aggressive
steps needed to improve access to care for veterans. Until the
VA stops using the excuse of poor training to explain away
systemic wait time manipulation, begins holding itself
accountable, nothing will change. Dr. Shulkin, it seems to me
that the I CARE, and MyVA Access Declaration are just words.
These ideas speak to an intent, but to this Committee and to
veterans, results are what counts. Slogans and rhetoric
designed to deflect blame are not good substitute for action-
oriented results.
Until VA addresses the issues we have discussed today,
beginning with accountability, our veterans will have to hope
the VA gets itself squared away. But as we know, hope is not a
plan.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks, and to
include extraneous material. And without objection, so ordered.
I would also would like to once again thank all of the
witnesses and the audience members for joining us today. And
with that, the hearing is adjourned.
[Whereupon, at 12:35 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Chairman Jeff Miller
I would like to welcome everyone to today's hearing titled, ``A
Continued Assessment of Delays in Veterans' Access to Health Care.''
This hearing marks two years since this Committee exposed the wait
times scandal that gripped the department in 2014. I am proud of the
work we have done in those two years, particularly digging into the
actions of corrupt bureaucrats who put self-interest ahead of the
veterans they are charged with assisting.
The purpose of this hearing is to examine the efforts VA has taken
to improve access to care for veterans and to identify where serious
issues persist. Based on this Committee's investigation, GAO undertook
an audit of new patient primary care wait times at six facilities
across VHA. GAO's review found that veterans at those facilities waited
between 22 to 71 days, which is significantly more than the five-day
average Secretary McDonald declared earlier this month. This
discrepancy can be easily explained.
First, VA only tracks and monitors a portion of a veteran's actual
wait time when tracking access data. Instead of considering a veteran's
wait time to be from the date when the veteran first contacts VA to
request an appointment to when the appointment takes place, VA
considers a veteran's wait time to be from the date when the veteran
wants the appointment to occur to the date when the appointment
actually occurs.
This is problematic because it does not take into account: the time
it takes a VA scheduler to contact the veteran to schedule the
appointment; the fact that it is a regular practice for schedulers to
``negotiate'' a desired date with a veteran; or the fact that outright
manipulation of desired dates to zero-out wait times is one of the most
prevalent types of data manipulation occurring in VHA. In effect, VA
continues to ignore the main forms of data manipulation, while it
continues to come to congress saying it no longer occurs. To this
point, you will not find what you do not seek.
The obvious result of VA reporting only a portion of veterans'
actual wait times is artificially low results. I still do not
understand a culture that persists in presenting inaccurate data. A
true picture of wait times, or more importantly the veteran experience,
can help us ensure an adequate allocation of resources. But, when this
Committee only hears requests for more manpower, more space, and more
flexibility, it is hard to reconcile the additional resources with a
reported ``wait time'' of only five days. This discrepancy between
reality and VA's claims was captured by GAO in its report where VA data
shows that wait times were at best understated by 2+ times and at worst
11 times the full wait times experience of veterans reviewed in the
audit.
Another tactic VA uses to make its wait times appear lower is to
combine the shorter wait times for the large pool of established
patients with the longer wait times of the smaller pool of new
patients. This dilutes the wait times data making new patients' waits
appear shorter since they have been comingled with data from the other
cohort.
For years, VA has blamed incorrect appointment scheduling and long
wait times on training issues, largely because it was warned about
those issues as far back as 2005, when the OIG published a report
highlighting improper scheduling practices and poor training. Many OIG
and GAO reports since then have found the same scheduling problems.
Yet, in the 11 years since, VA continues to blame wait time
manipulation on the same cause, a cause over which VA has complete
control.
Secretary McDonald has repeatedly asked that we allow him to run VA
like a business. But, I can assure you that if an executive running a
company used the same excuse to explain away problems 11 years in a
row, with no change to show for it, that individual would be out of a
job. But, not at VA. Despite years of reports confirming systemic
issues, the department has successfully fired just four people for wait
time manipulation while letting the bulk of those behind its nationwide
delays-in-care scandal off with no discipline or weak slaps on the
wrist.
Another issue regarding accountability is how VA continues to
ignore retaliation against whistleblowers who report wrongdoing. The
Committee asked VA for all adverse actions where an employee was
disciplined for ``retaliation against a whistleblower''. VA provided
the Committee a list showing that as of March 15, 2016, only six
individuals were disciplined for whistleblower retaliation.
However, upon further review, one of the listed employees is Sharon
Helman, who the committee has shown was not successfully disciplined
for whistleblower retaliation and was in fact successfully disciplined
for failing to report accepted gifts. Two of the other disciplined
employees listed were ``Houskeeping Aid Supervisors'', who are clearly
not high-level supervisors. That leaves three employees: two received
reprimands and one received a less-than-fourteen-day suspension. To be
clear, according to VA provided documentation, no employee has been
removed for whistleblower retaliation. This is representative of the
fact that, contrary to public statements by VA officials, whistleblower
retaliation appears to most certainly be tolerated by the department.
So now, two years after what was and is a systemic crisis in care
being brought to light, it is time for VA to stop using misleading data
to tout wait times successes that simply do not show the real wait time
experience of veterans. I want to hear what concrete actions have been
taken, what fundamental changes have been made, and what tangible,
cultural shifts are occurring. Advertising artificially lowered numbers
does nothing to stimulate the change needed to improve veterans' access
to care.
Prepared Statement of Corrine Brown, Ranking Member
Thank you, Mr. Chairman, for calling this hearing today.
Following the wait time scandal in Phoenix, Congress passed, and
President Obama signed, the Veterans Access, Choice, and Accountability
Act of 2014. In it, we mandated that there be an Independent Assessment
of veterans' health care.
The Assessment highlighted many of the things we hear from our
veterans. We hear that VA provides excellent health care, especially
health care related to the special needs of our veterans. We also hear
that in certain areas, VA is at the forefront of health care in this
country. We also hear from our veterans that VA care is often
fragmented, and that it can be difficult to navigate and arrange non-VA
care. We hear of long wait times and limited access.
Following the assessment, in the Surface Transportation and
Veterans Health Care Choice Improvement Act of 2015, we mandated a
report by the VA regarding a plan for how VA could consolidate all
purchased care programs into one New Veterans Choice Program. We
received that report late last year and this committee is currently
working with the VA on the best way to implement the legislative
requests.
The VA is on track to see 6,277,360 unique patients, and 9,247,803
unique enrollees. In FY2015, VA completed 56.7 million appointments,
nearly 2 million more than FY2014. That is roughly 226,000 appointments
per day.
The number of patients the VA sees would put any other health care
system to shame.
I am pleased the GAO studied newly enrolled veterans and their
access to primary care. In my conversations with veterans, time and
again they say that once you get into the VA system the care is the
best in the world. It is this initial appointment that is so hard to
get. I am troubled by the GAO findings that ``nearly half were unable
to access primary care because VA medical center staff did not schedule
appointments for these veterans'' in a quick timeframe.
The GAO report goes onto say that ``veterans' access to primary
care is hindered, in part, by data weaknesses and the lack of a
comprehensive scheduling policy.'' Just last week in a Subcommittee
hearing, Under Secretary Shulkin and Assistant Secretary Council
testified that they were working together through the MyVA initiative
to modernize VistA and work on a scheduling system that is focused
purely on scheduling. I support the VA in working to fix the scheduling
and be able to get data we can trust.
We are at a tipping point right now as to what the VA will look
like and the services it will provide for veterans in the coming
decades. I look forward to hearing from our witnesses today on what
this aspect of the VA will look like in the future.
Thank you, Mr. Chairman, and I yield back the balance of my time.
Prepared Statement of David Shulkin, M.D.
Good morning, Mr. Chairman, Ranking Member Brown, and Members of
the Committee. Thank you for the opportunity to discuss the efforts
that VHA has taken to improve access to care for Veterans. I am
accompanied today by Dr. Thomas Lynch, Assistant Deputy Under Secretary
for Health for Clinical Operations and Dr. Poonam Alaigh, Senior
Medical Advisor.
The year 2014 was one of the most significant times in VA's
history. To say that we had a crisis on our hands would be an
understatement. After losing the trust of the Nation, and most
importantly, Veterans, we had to look at every basic principle of
operating a health care system. Without the appropriate data, we were
unable to truly understand how much space, staff, and other resources
were really needed.
When I first entered this office approximately 9 months ago, I
began to realize that the access issues had been slowly building up for
many years and that correcting those issues had to be addressed
systematically, rather than piecemeal. We needed to re-design and re-
launch our approach to access in order to provide the care for Veterans
that they have earned and deserved.
As a whole, VA is working to rebuild trust with Veterans and the
American people, improve service delivery, and set the course for long-
term VA excellence and reform, while delivering better access to care.
This initiative is called MyVA. All of us in the VA health care system
are focused on the MyVA initiative.
To ensure that VHA remains aligned with MyVA, I developed five
priorities that are the focus of VHA. My first priority is to fix the
access issues and continue to work on reducing the wait time for
Veterans who need our services. In order to do this, we need to get the
right leaders in place at VHA who understand that it is their job to
take care of Veterans. We also need to change the way that we measure
wait times and put in place a new system for how we see Veterans that
focuses on the clinical urgency.
Immediate Steps - Addressing Urgent Care Needs
VA's ability to improve access to care and improve the Veterans'
experience is tied directly to how we meet the urgent health needs of
our Veterans. We must identify who needs the help the most and commit
to treating those Veterans who have clinically urgent needs as soon as
possible. As long as there is even a single Veteran with an urgent care
need that we are not meeting in a timely fashion, we will not be
satisfied. That is why VHA hosted two National Access Stand Down events
- one on November 14, 2015, and a second on February 27, 2016 - at all
VA Medical Centers. The immediate goal of the first event was to
connect with Veterans that have urgent health care needs; address their
needs; and reduce the number of Veterans waiting greater than 30 days
for urgent care. This initiative ensured coordinated efforts to
increase access to health care by:
Maximizing the opportunities for ``same day''
appointments as much as possible;
Getting timely and convenient care, referrals and
information from any VA medical center, not just the Veteran's
preferred VA care facility; and
Ensuring Veterans see their provider within 30 days of
their preferred date or date of clinical need.
The February 27, 2016 event resulted in VA reviewing the records of
more than 80,000 Veterans to get those waiting for urgent care off wait
lists. Approximately 93 percent of Veterans waiting for urgent care
were contacted. Since not every type of clinic appointment has the same
urgency, or the same medical risk to the patient in the event of delay,
we focused on addressing the highest priority needs first. Both of
these events proved to be a success, and the goal is to keep the
momentum going. We also know that it will take much more to fix access
issues and achieve the goal of providing Veterans same day access for
primary care.
Declaration of Access
The focused Access Stand Down events in November 2015, and February
2016, have addressed Veterans with urgent needs and significantly
reduced the number of Veterans waiting for care. Moving forward, we
developed the ``MyVA Access Declaration,'' a set of foundational
principles for every VHA employee to improve and ensure access to care.
The MyVA Access Declaration is our pledge to improve access to care for
Veterans by committing to a list of access improvements. This list of
principles will be distributed to VHA staff and VHA leadership and
staff will hold themselves responsible for meeting these commitments
over the course of the next year.
We aspire to provide access to care based on the following core
principles:
Provide timely care including same-day access in Primary
Care, as needed;
Respond to routine clinical inquiries within 2 business
days;
Offer follow-up appointments upon the Veteran leaving the
clinic;
Involve Veterans in the process of making or canceling
appointments;
Not cancel clinic appointments without appropriate
Veteran notification and rescheduling;
Integrate community providers as needed to enhance
access;
Offer Veterans extended clinic hours, and/or virtual care
options, such as Tele-Health, when appropriate; and
Transparently report to the public and manage access to
care data for Veterans.
The MyVA Access' goal for 2016 is when a Veteran calls or visits
primary care at a VHA Medical Center, their clinical needs will be
addressed that day. It is important for Veterans to be in control of
their health care. We are changing our old systems that have been in
place for decades at VA to a system that works for Veterans and is
focused on contemporary practices in access. This initiative and the
Declaration represent VA's pledge to improve access to care for all
Veterans seeking VA health services. MyVA Access will ensure
coordination of initiatives and their rapid deployment to meet the
access needs of Veterans at VA medical centers.
Moving toward long-term transformation, VHA has already implemented
a number of actions to address access, quality and patient satisfaction
within the larger transformation of MyVA. Within the 12 Breakthrough
Priorities laid out by Secretary McDonald, 2 focus squarely on health
care outcomes, specifically improving access to care and improving
community care. Since the introduction of the MyVA initiative, VA has
made significant progress in improving access to health care:
Nationally, VA completed more than 57.36 million
appointments from March 1, 2015, through February 29, 2016. This
represents an increase of 1.6 million more appointments than were
completed during the same time period in 2014 through 2015.
VHA and Choice contractors created over 3 million
authorizations for Veterans to receive care in the private sector from
February 1, 2015, through January 31, 2016. This represents a 12
percent increase in authorizations when compared to the same period in
2014 through 2015.
From fiscal year (FY) 2014 to FY2015, Community Care
appointments increased approximately 20 percent from 17.7 million in
FY2014 to 21.3 million in FY2015.
VA completed 96.46 percent of appointments in February
2016, within 30 days of clinically indicated or Veteran's preferred
date.
VA continues to expand and improve the VCL, which has
answered nearly 2 million calls since its launch in 2007. Nearly
490,000 calls, or a quarter of these 2 million calls, were answered
during the last fiscal year. VCL responders dispatched emergency
responders to callers in crisis over 11,000 times last year - over
53,000 times since 2007.
VHA has increased net onboard staff by over 17,000
employees since the beginning of FY15 through February 29, 2016. This
includes over 6,000 nurses (RN, LPN & NA), 1,550 physicians, 112
psychiatrists, and 450 psychologists.
Women Veterans Call Center (WVCC), created to contact
women Veterans to inform them about eligible services. As of February
2016, WVCC received 30,399 incoming calls and made 522,038 outbound
calls, successfully reaching 278,238 women Veterans.
In FY2015, VA activated 2.2 million square feet of space
for clinical, mental health, long-term care, and associated support
facilities to care for Veterans.
VA increased its total clinical work (direct patient
care) by 10 percent over the last 2 years as measured by private sector
standards (relative value units). This increase translates to roughly
20 million additional provider hours of care for our Veterans.
VHA offers an extensive community provider network of
over 257,000 providers through the Patient-Centered Community Care/
Choice Programs and more are joining each month.
VA Telehealth services are critical to expanding access
to VA care in more than 45 clinical areas.
In FY2015, 12 percent of all Veterans enrolled for VA
care received Telehealth based care. This includes 2.14 million
telehealth visits, touching 677,000 Veterans.
Veteran Experience - Veteran Satisfaction
The ability to describe wait times does not exist anywhere outside
of the VA, so there is no standard on how to report wait times. We have
gone to such lengths to make sure that we document every aspect of wait
time data that we have developed a system that is too complex and has
proven too confusing to Veterans, our employees, and Congress. Although
the data may be accurate, they do not reflect the actual Veteran
experience. Therefore, we have decided to use a singular measure -
asking Veterans, our customers - whether they were satisfied with being
able to get care when they need it. VHA currently utilizes sign-in
kiosks at VA facilities all across the country to assess patient
satisfaction, of those Veterans who obtained appointments, with their
ability to get their appointment when they wanted it. Eighty-nine
percent of Veterans were completely satisfied or satisfied with their
ability to get care when they wanted it.
As the Under Secretary, I want to ensure that we can say there are
no Veterans who need care now who are not receiving it. We are not
fully there yet, but that is the direction to which we are moving.
Legislative Priorities
VA is grateful for your continuing support of Veterans and
appreciates your efforts to pass legislation enabling VA to provide
Veterans with the high-quality care they have earned and deserve. As
the Department focuses on ways to help provide access to health care
across the country, we have identified a number of necessary
legislative items that require action by Congress in order to best
serve Veterans.
Flexible budget authority would allow VA to avoid artificial
restrictions that impede our delivery of care and benefits to Veterans.
Currently, there are over 70 line items in VA's budget that dedicate
funds to a specific purpose without adequate flexibility to provide the
best service to Veterans. These include limitations within the same
general areas, such as health care funds that cannot be spent on health
care needs and funding that can be used for only one type of Care in
the Community program, but not others. These restrictions limit the
ability of VA to deliver Veterans with care and benefits based on
demand, rather than specific funding lines.
VA also requests your support for legislation that would allow VA
to contract with providers on an individual basis in the community
outside of Federal Acquisition Regulations, and includes explicit
protections for procurement integrity, provider qualifications, price
reasonableness and employment protections. Such legislation will ensure
that VA is able to provide local care to Veterans in a timely and
responsible manner. VA would support language that addresses concerns
related to employment nondiscrimination and equal employment
protections. We would have strong concerns with any legislative
language, such as that currently being considered by this committee,
that rolls back employment protections. VA further requests your
support for our efforts to recruit and retain the very best clinical
professionals. These include, for example, flexibility for the Federal
work period requirement, which is not consistent with private sector
medicine, and special pay authority to help VA recruit and retain the
best talent possible to lead our hospitals and health care networks.
Conclusion
VA is committed to providing timely access to Veterans as
determined by their clinical needs. VA Medical Centers will be making
sweeping changes over the next several months to realize the goal of
same-day access for our Veteran population. We realize the significant
work that remains ahead. The good news is that moving forward, along
with Congress, we have an opportunity to reshape the future and make
long-lasting valuable changes. We also look forward to the Commission
on Care recommendations to inform or planning and execution. We
appreciate Congress' support and look forward to responding to any
questions you may have.
Prepared Statement of Larry Reinkemeyer
Mr. Chairman and Members of the Committee, thank you for the
opportunity to discuss the Office of Inspector General's (OIG) recent
work concerning veterans' access to health care. The OIG has issued
many reports that have addressed various impediments to patient access
to health care. Most recently, our audit work has centered on VA's
purchased care programs and the challenges VA has faced in
administering them. I am accompanied by Mr. Gary Abe, Deputy Assistant
Inspector General for Audits and Evaluations.
BACKGROUND
For more than a decade, the OIG has conducted oversight of the
Veterans Health Administration's (VHA) performance in providing
veterans timely access to care. Our reports have brought attention to
problems relating to wait times, scheduling practices, consult
management, data integrity, clinician staffing shortages, and the lack
of physician and nurse staffing standards. We have repeatedly reported
that VHA managers need to improve efforts for collecting, trending, and
analyzing clinical data.
Two years ago, VHA's inability to provide veterans timely access to
care became the subject of national focus following allegations at the
Phoenix VA Health Care System (PVAHCS) in Phoenix, Arizona, that
included gross mismanagement of VA resources, misconduct by VA senior
hospital leadership, systemic patient safety issues, and patient
deaths. On May 28, 2014, we published a preliminary report
substantiating serious conditions at the PVAHCS. \1\ We provided VA
leadership with recommendations for immediate implementation to ensure
all veterans receive appropriate care. Our August 26, 2014, final
report reflected the full results of our review, including case reviews
of 45 patients who experienced unacceptable and troubling lapses in
follow-up, coordination, quality, and continuity of care. \2\ We made
24 recommendations to correct conditions identified at PVAHCS. To date,
VHA has implemented 20 of the 24 recommendations. \3\ Recommendations
addressing potential disciplinary actions, consult reviews, use of the
electronic waiting list, and efforts to improve procedures used by
schedulers to make appointments will remain open until VHA completes
the actions necessary to implement the recommendations.
---------------------------------------------------------------------------
\1\ Interim Report - Review of Patient Wait Times, Scheduling
Practices, and Alleged Patient Deaths at the Phoenix Health Care System
(May 28, 2014).
\2\ Review of Alleged Patient Deaths, Patient Wait Times, and
Scheduling Practices at the Phoenix VA Health Care System (August 26,
2014).
\3\ Recommendations 9, 13, 19, and 21 remain open as of April 14,
2016.
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As we have previously indicated, the surfacing of allegations
related to wait times and delays in care at PVAHCS was a watershed
event for VA and the OIG. Since April 2014, the national attention
sparked by reporting on PVAHCS led to an increased public awareness of
the OIG and resulted in a dramatic increase in the number of contacts
to the OIG Hotline and the number of inquiries and requests sent to us
by Members of Congress. A number of these Hotline contacts continue to
allege inappropriate practices by VHA staff that undermine the
integrity and reliability of wait time metrics as well as allege that
VHA's initiatives to provide veterans community care are not working.
Since the publication of our August 2014 report on PVAHCS, we have
initiated a series of audits and reviews evaluating the extent to which
veterans are able to receive timely care. Although we have completed
audits and reviews and published comprehensive reports, a number of
more recent reviews are still in progress. One example is an audit we
are conducting at the request of Congresswoman Kyrsten Sinema to review
the PVAHCS Human Resources Department to determine how effectively they
manage their Medical Support Assistant workforce to facilitate veteran
access to outpatient care. The results of our completed work are
consistent-VA continues to face challenges in providing timely access
to care and the management of consult appointments at various points of
service.
HEALTH CARE ENROLLMENT
Veterans are experiencing delays even at the initial application
and enrollment for health care. Most veterans must apply and be
determined eligible in order to be enrolled for VA health care.
Eligibility for enrollment is determined by evaluating evidence of
qualifying military service and financial income status, if necessary.
The Health Eligibility Center (HEC), a component of VHA's Chief
Business Office (CBO), is VA's central authority for eligibility and
enrollment processing activities as well as the business owner for the
Enrollment System (ES), the authoritative system for veterans' health
enrollment and eligibility information. Although ES serves as VHA's
official electronic system of record for veteran health care enrollment
information, it also contains the names of all VA patients as well as
applicants whose military service was not confirmed.
In our September 2015 report, Review of Alleged Mismanagement at
the Health Eligibility Center, we substantiated the existence of about
867,000 pending records residing with the HEC that had not reached a
final determination as of September 30, 2014. Pending records included
entries for over 307,000 individuals reported as deceased by the Social
Security Administration. However, due to limitations in the HEC's ES
data, we could not reliably determine how many of the pending records
existed because of applications for health care. We also determined
that employees incorrectly marked unprocessed applications as completed
and possibly deleted 10,000 or more transactions from the HEC's
Workload Reporting and Productivity (WRAP) tool over the past 5 years.
WRAP was vulnerable because the HEC did not ensure that adequate
business processes and security controls were in place, manage WRAP
user permissions, and maintain audit trails to identify reviews and
approvals of any deleted transactions. The HEC identified over 11,000
unprocessed health care applications and about 28,000 other
transactions in January 2013. This backlog developed because the HEC
did not adequately monitor and manage its workload and lacked controls
to ensure entry of WRAP workload into ES. The Under Secretary for
Health (USH) and the Assistant Secretary for the Office of Information
and Technology concurred with our findings and recommendations. VA
implemented Recommendations 2, 7, 9, and 13, and we will continue to
follow up until the remaining nine recommendations are implemented.
MENTAL HEALTH CARE
VHA's efforts to increase access to mental health care for veterans
face many challenges. These include overcoming stigmas that veterans
may associate with seeking care for mental health and fears that
associated medical records documenting their care may have an
adversarial impact on their lives and employment. Additionally, VHA
struggles to attain and retain a sufficient mental health workforce
capacity, establish a competency-based practice, and have adequate
systems to support improving care nationwide. In the face of these
challenges, we continue to focus our efforts on ensuring veterans
receive timely access to mental health care. The OIG's Office of
Healthcare Inspections has issued a number of reports detailing their
reviews of alleged delays in mental health care. \4\
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\4\ See Healthcare Inspection - Mental Health-Related Deficiencies
and Inadequate Leadership Responsiveness Central Alabama VA Health Care
System, Montgomery, Alabama (July 29, 2015) and Healthcare Inspection -
Mismanagement of Mental Health Consults and Other Access to Care
Concerns, VA Maine Healthcare System, Augusta, Maine (June 17, 2015).
---------------------------------------------------------------------------
In August 2015, the OIG Office of Audits and Evaluations issued a
national review of veterans' access to psychiatrists. \5\ We found VHA
had not been fully effective in its use of hiring opportunities or its
use of existing personnel to improve veterans' access to psychiatrists.
From fiscal year (FY) 2012 through FY2014, VHA increased outpatient
psychiatrist full-time equivalents (FTEs) by almost 15 percent.
However, during that time the number of veteran outpatient encounters
with psychiatrists increased by about 10 percent, and the number of
individual veterans who received outpatient care from a psychiatrist
increased about 9 percent. This means that while VHA significantly
increased the number of psychiatrists providing outpatient clinical
care since FY2012, it did not show a corresponding increase in veterans
receiving care from psychiatrists. In fact, some individual facilities
did not increase encounters from FY2012 through FY2014 even with their
additional psychiatrist FTEs. This occurred because VHA did not have an
effective method for establishing psychiatrist staffing needs.
Throughout recent hiring initiatives, VHA did not stress a specific
need for psychiatrists; instead, facilities determined their own
staffing needs. VHA did not ensure facilities used consistent and
effective clinic management practices.
---------------------------------------------------------------------------
\5\ Audit of VHA's Efforts To Improve Veterans' Access to
Outpatient Psychiatrists (August 25, 2015)
---------------------------------------------------------------------------
This resulted in 94 of 140 health care facilities that needed
additional psychiatrist FTEs to meet demand as of December 2014. We
found VHA facilities could have better used about 25 percent of
psychiatrist FTE clinical time to see veterans in FY2014, which equated
to nearly $113.5 million in psychiatrists' pay. Over the next 5 years,
this would equate to over $567 million if clinic management is not
strengthened now. The USH agreed to ensure facilities incorporate the
Office of Mental Health Operations staffing model to determine the
appropriate number of psychiatrists needed and attain appropriate
staffing levels or identify alternative options. The USH also agreed to
develop clinic management business rules, reassess the appropriateness
of VHA's productivity target for psychiatrists, and develop a mechanism
to monitor the variance in which psychiatrists code encounters. Since
publication, VA implemented Recommendation 4, which was to develop a
mechanism to monitor the variance in which psychiatrists' code
encounters and determine appropriate coding guidance and training to
ensure consistency.
CONSULT MANAGEMENT
In our August 31, 2015 report, Review of Alleged Mishandling of
Ophthalmology Consults at the Oklahoma City, OK, VA Medical Center, we
substantiated that ophthalmology and teleretinal imaging staff, and
referring providers, acted inappropriately on discontinued consults. We
found:
Ophthalmology staff discontinued about 31 percent more
consults than the national average in FY2014, and about 42 percent more
in FY2015 (reported as of March 10, 2015).
Teleretinal imaging staff also discontinued about 9
percent and 10 percent more consults, respectively, than the national
average during these same periods.
Ophthalmology staff discontinued consults without
adequate justification and often because they could not provide eye
exams to the patients within 30 days.
Ophthalmology staff and referring providers did not take
the necessary steps to refer the patients to non-VA care staff to
obtain their medical care outside of the VA.
Referring providers did not ensure that discontinued
teleretinal imaging consults received the appropriate ophthalmology
clinic follow-up.
As a result of our inquiries, VA Medical Center (VAMC) leadership
reviewed ophthalmology consults discontinued from January 1, 2014,
through March 3, 2015, and identified issues with 439 of 1,937
consults. However, ophthalmology leadership did not provide sufficient
oversight for processing consults and the VAMC did not have well
defined guidance to ensure staff took appropriate actions when
processing consults. We recommended the Oklahoma City VAMC Interim
Director take appropriate action on patients affected by ophthalmology
and teleretinal imaging consults, as well as formalize guidance and
train staff on processing consults. Actions by the VAMC to implement
Recommendation 2, which was to initiate a review of discontinued
teleretinal imaging consults and take action to provide eye care when
necessary, remain in progress at this time.
PURCHASED CARE
VA's purchased care programs include the Veterans Choice Program
(VCP), Patient Centered Community Care (PC3), Fee Basis Care, and other
non-VA care programs. VA's purchased care programs are critical to VA
in carrying out its mission of providing medical care, including
outpatient services, inpatient care, mental health, dental services,
and nursing home care to veterans. Our audits, reviews, and health care
inspections have reported the challenges VA faces in administering
these programs, such as authorizing, scheduling care, ensuring
contractors provide medical information to VA in support of the
services provided, ensuring VA inputs the medical information from
contractors into the veteran's VA medical record, and timely and
accurate payment for care purchased outside the VA health care system.
Patient-Centered Community Care Network
The PC3 program is a VHA nationwide program that provides eligible
veterans access to care through contracts for certain medical services.
VA medical facilities use the PC3 program after they have exhausted
other options for purchased care and when local VA medical facilities
cannot readily provide the needed care to eligible veterans due to lack
of available specialists, long wait times, geographic inaccessibility,
or other factors.
In our July 2015 report, Review of Alleged Delays in Care Caused by
Patient-Centered Community Care (PC3) Issues, we examined VHA's use of
PC3 contracted care to determine if it was causing patient care delays.
We found that pervasive dissatisfaction with both PC3 contracts has
caused all nine of the VA medical facilities we reviewed to stop using
the PC3 program as intended. We projected Health Net and TriWest
returned, or should have returned, almost 43,500 of 106,000
authorizations (41 percent) because of limited network providers and
blind scheduling. We determined that delays in care occurred because of
the limited availability of PC3 providers to deliver care.
VHA also lacked controls to ensure VA medical facilities submit
timely authorizations, and Health Net and TriWest schedule appointments
and return authorizations in a timely manner. VHA needed to improve PC3
contractor compliance with timely notification of missed appointments,
providing required medical documentation, and monitoring returned and
completed authorizations. The then Interim Under Secretary for Health
agreed with our recommendations to ensure PC3 contractors submit timely
authorizations, evaluate the PC3 contractors' network, revise contract
terms to eliminate blind scheduling, and implement controls to make
sure PC3 contractors comply with contract requirements. VA has
implemented Recommendations 4, which was to revise contract terms to
eliminate the option of scheduling appointments before communicating
with the veteran.
In our September 2015 report, Review of Patient-Centered Community
Care (PC3) Provider Network Adequacy, we reported that inadequate PC3
provider networks contributed significantly to VA medical facilities'
limited use of PC3. VHA spent 0.14 percent, or $3.8 million of its $2.8
billion FY2014 non-VA care budget on PC3. During the first 6 months of
FY2015, VHA's PC3 purchases increased but still constituted less than 5
percent of its non-VA care expenditures. VHA staff attributed the
limited use of PC3 to inadequate provider networks that lacked
sufficient numbers and mixes of health care providers in the geographic
locations where veterans needed them. VA medical facility staff
considered the PC3 networks inadequate because:
The PC3 network lacked needed specialty care providers,
such as urologists and cardiologists.
Returned PC3 authorizations had to be re-authorized
through non-VA care and increased veterans' wait times for care.
Non-VA care provided veterans more timely care than PC3.
For these staff, inadequate PC3 provider networks were a major
disincentive to using PC3 because it increased veterans' waiting times,
staffs' administrative workload, and delayed the delivery of care.
Further, VHA had not ensured the development of adequate PC3 provider
networks because it lacked an effective governance structure to oversee
the CBO's planning and implementation of PC3, the CBO lacked an
effective implementation strategy for the roll-out of PC3, and neither
VHA nor Health Net and TriWest maintained adequate data to measure and
monitor network adequacy. The Under Secretary for Health agreed with
our recommendations to strengthen controls over the monitoring of PC3
network adequacy and ensure adequate implementation and monitoring
plans are developed for future complex health care initiatives. VA has
implemented Recommendation 3, which was to develop action plans to
improve provider networks that are unable to provide health care
services at the specific geographic locations identified.
Veterans Choice Program
As a result of Public Law 113-146, the Veterans Access, Choice, and
Accountability Act of 2014 (VACAA) VA created the Veterans Choice
Program (VCP) in November 2014. Following enactment of VACAA, VA turned
to Health Net and TriWest, the administrators of the PC3 program, who
had provider networks in place Nation-wide. The VCP allows staff to
identify veterans to include on the Veterans Choice List, a list that
includes veterans with appointments beyond 30 days from the clinically
indicated or preferred appointment dates and veterans who live more
than 40 miles from a VA facility. Under this program, VA facilities
began providing non-VA care to eligible veterans enrolled in VA health
care as of August 1, 2014, and to recently discharged combat veterans
who are within 5 years of their post-combat separation date. With a key
VCP eligibility criterion being a veteran's inability to receive care
within 30 days, VHA's schedulers and supervisors must ensure they
follow VHA scheduling guidance when calculating wait times.
In our February 2016 report, Review of Alleged Untimely Care at the
Community Based Outpatient Clinic, Colorado Springs, CO, we
substantiated the allegation that eligible Colorado Springs veterans
did not receive timely care in six reviewed services. These services
were Audiology, Mental Health, Neurology, Optometry, Orthopedic, and
Primary Care. We found that for 229 of the 288 veterans with
appointments over 30 days, Non-VA Care Coordination staff did not add
173 veterans to the Veterans Choice List in a timely manner and they
did not add 56 veterans to the list at all. In addition, scheduling
staff did not take timely action on 94 consults and primary care
appointment requests. We reviewed 150 referrals for specialty care
consults and 300 primary care appointments. Of the 450 consults and
appointments, 288 veterans encountered wait times in excess of 30 days.
For 59 of the 288 veterans, scheduling staff used incorrect dates that
made it appear the appointment wait time was less than 30 days.
As a result, VA staff did not fully use VCP funds to afford
Colorado Springs veterans the opportunity to receive timely care. The
Eastern Colorado Health Care System Acting Director agreed with our
recommendations. Based on actions already implemented, we closed the
recommendation to ensure that scheduling staff use the clinically
indicated or preferred appointment dates when scheduling primary care
patient appointments.
In another February 2016 report, Review of Alleged Patient
Scheduling Issues at VA Medical Center, Tampa, Florida, we
substantiated that when veterans received appointments in the community
through the VCP, the facility did not cancel their existing VA
appointments. For example, we found that for 12 veterans, staff did not
cancel the veterans' corresponding VA appointments because Non-VA Care
Coordination staff did not receive prompt notification from the
contractor when a veteran scheduled a VCP appointment and no longer
needed the VA appointment. We also substantiated that the facility did
not add all eligible veterans to the Veterans Choice List when their
scheduled appointment was greater than 30 days from their preferred
date, and that staff inappropriately removed veterans from the Veterans
Choice List.
This occurred because Tampa VAMC schedulers thought they were
appropriately removing the veteran from the Electronic Wait List, when
they were actually removing the veteran from the Veterans Choice List.
The Director agreed with our recommendations to ensure the facility
receives prompt notification of scheduled VCP appointments, determine
if the contractor complies with the notification requirements, ensure
appropriate staffs receive scheduling audit results and verify
correction of errors, and ensure staff receive training regarding
management of the Veterans Choice List. Based on actions already
implemented, we closed four of the five recommendations, and will
follow up to ensure the facility receives prompt notification of
scheduled VCP appointments.
NEW OIG OVERSIGHT INITIATIVE
The OIG's Office of Audits and Evaluations recently initiated a
pilot project to audit one Veterans Integrated Service Network (VISN)
and its facilities to evaluate three key components of access-data
reliability of wait time metrics, implementation of VCP, and consult
management. Our objective for this pilot is to provide comprehensive
and timely oversight at all facilities within a VISN in order to
provide facility directors a report detailing their current data and
scheduling practices. We hope that by focusing OIG resources on this
issue we can audit each VISN and its facilities every 3 years, as we
currently do with the Veterans Benefits Administration's regional
offices. We feel this work is important and will help provide a
veteran-centric view of what actions VISN management is taking to
ensure situations like Phoenix do not occur in the future.
CONCLUSION
OIG work has shown that VA faces challenges in providing adequate
access to health care. Risks to the timeliness, cost-effectiveness,
quality, and safety of veterans' health care raised serious concerns
about VA's management and oversight of its health care system and
resulted in U.S. Government Accountability Office concluding VA health
care was a high-risk area in 2015. A recent announcement by VA to once
again change their plans on acquiring a new scheduling package aptly
characterizes their inability to provide consistent and meaningful
tools and guidance to the VA workforce tasked with ensuring veterans
receive timely access to care. A major challenge is in administering
its purchased care programs, in part because VHA schedulers and their
supervisors do not follow established VHA scheduling guidance. We have
a number of active projects involving VHA procedures that ultimately
affect veterans' access through the VCP. We will continue to work with
VA to provide the independent oversight and objective recommendations
to help move these programs and initiatives forward on these issues.
Mr. Chairman, this concludes my statement. We would be happy to
answer any questions you or members of the Committee may have.
Prepared Statement of Debra A Draper
Chairman Miller, Ranking Member Brown, and Members of the
Committee:
I am pleased to be here today as you discuss issues concerning
veterans' access to health care. My remarks today are based on our
report that was released yesterday, VA Health Care: Actions Needed to
Improve Newly Enrolled Veterans' Access to Primary Care. This report is
the latest in our ongoing body of work examining veterans' access to
timely health care. \1\
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\1\ See VA Health Care: Actions Needed to Improve Newly Enrolled
Veterans' Access to Primary Care, GAO 16 328 (Washington, D.C.: Mar.
18, 2016). See also GAO, VA Mental Health: Clearer Guidance on Access
Policies and Wait-Time Data Needed, GAO 16 24 (Washington, D.C.: Oct.
28, 2015); VA Health Care: Management and Oversight of Consult Process
Need Improvement to Help Ensure Veterans Receive Timely Outpatient
Specialty Care, GAO 14 808 (Washington, D.C.: Sept. 30, 2014); VA
Health Care: Reliability of Reported Outpatient Medical Appointment
Wait Times and Scheduling Oversight Need Improvement, GAO 13 130
(Washington, D.C.: Dec. 21, 2012); VA Mental Health: Number of Veterans
Receiving Care, Barriers Faced, and Efforts to Increase Access, GAO 12
12 (Washington, D.C.: Oct. 14, 2011); and VA Faces Challenges in
Providing Substance Use Disorder Services and Is Taking Steps to
Improve These Services for Veterans, GAO 10 294R (Washington, D.C.:
Mar. 10, 2010).
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The Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA) operates one of the Nation's largest health care
systems; it provided care to about 6.6 million veterans in fiscal year
2014, including an aging veteran population and a growing number of
younger veterans returning from military operations in Afghanistan and
Iraq. VHA spent about $58 billion for their care in that year. Over the
past decade, VHA has faced a growing demand for outpatient primary care
services. From fiscal years 2005 through 2014, the number of annual
outpatient primary care medical appointments VHA provided through its
medical facilities increased by 17 percent, from approximately 10.2
million to 11.9 million. Each year over that period, an average of
380,000 veterans were newly enrolled in VHA's health care system. In
fiscal year 2014, VHA provided about 730,000 primary care appointments
for new patients-appointments for those patients who had not been seen
in a primary care clinic in the past 24 months, including those who
were newly enrolled.
Primary care services are often the entry point to the VHA health
care system for veterans, and access to these services is critical to
ensuring that veterans obtain needed medical care, including specialty
care. When veterans need specialty care-such as cardiology or
gastroenterology-they are typically referred to specialists by their
primary care providers, and each veteran's primary care team manages
and coordinates the needed care. \2\ Veterans may obtain primary care
services at VHA's medical facilities, which include 167 medical centers
and more than 800 community-based outpatient clinics. Responsibility
for ensuring timely access to primary care rests with 20 regional
Veterans Integrated Service Networks (VISN), which oversee the medical
centers, and with VHA's central office, which oversees the entire VA
health care system.
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\2\ VHA provides primary care services through patient aligned
care teams consisting of a primary care provider and support staff,
including a nurse care manager, clinical associate such as a licensed
practical nurse, and administrative clerk.
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In recent years, we and others have expressed concerns about VHA's
ability to effectively provide and oversee timely access to health care
for veterans, which, in some cases, reportedly has resulted in harm to
veterans. Our prior work on VHA's oversight of primary and specialty
care found VHA did not have adequate data and oversight mechanisms in
place to ensure veterans receive timely care. For example, since 2012,
we have issued several reports recommending that VA improve appointment
scheduling, ensure the reliability of wait-time and other performance
data, and improve oversight to ensure VA medical centers provide
veterans with timely access to outpatient primary and specialty care,
as well as mental health care. \3\ Based on these serious concerns
about VA's management and oversight of its health care system, we have
concluded that VA health care is a high-risk area and, in 2015, added
it to our High Risk List. \4\ To help improve timely access to health
care, Congress passed the Veterans Access, Choice, and Accountability
Act of 2014 (Choice Act), which provided veterans facing long waits or
lengthy travel distances the opportunity to obtain care from providers
(non-VA) in the community. \5\
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\3\ See GAO 16 328, GAO 16 24, GAO 14 808, GAO 13 130, and GAO 10
294R.
\4\ GAO, High Risk Series: An Update, GAO 15 290, (Washington,
D.C.: February 2015). GAO maintains a high-risk program to focus
attention on government operations that it identifies as high risk due
to their greater vulnerabilities to fraud, waste, abuse, and
mismanagement or the need for transformation to address economy,
efficiency, or effectiveness challenges.
\5\ Pub. L. No. 113-146, 128 Stat. 1754 (2014). Under this
authority, VHA created the Veterans Choice Program, which was
introduced in November 2014. Under the program, for example, certain
veterans are able to receive care in the community, including primary
care, if the next available medical appointment with a VA provider is
more than 30 days from the date a veteran wants to see a provider or if
the veteran lives more than 40 miles driving distance from the nearest
VA facility.
---------------------------------------------------------------------------
In the context of these serious and longstanding concerns, my
testimony today highlights selected findings from our most recent
report on veterans' access to primary care. My remarks will therefore
focus on the extent to which
1.newly enrolled veterans access primary care in a timely manner;
and
2.VHA provides oversight of veterans' access to primary care.
For our report, we reviewed relevant regulations, guidance, and
other key documents, as well as interviewed staff with responsibility
for ensuring timely access to primary care, including officials from
VA, VHA, six VA medical centers, and the six corresponding VISNs that
oversee the medical centers in our review. \6\ We selected the medical
centers based on variation in average wait times for primary care
appointments, facility complexity, and geographic location. From these
medical centers, we selected a sample of 60 newly enrolled veterans (10
randomly selected from each of the six medical centers), all of whom
had requested VA contact them to schedule medical appointments, but had
not been seen by primary care providers. We also selected a sample of
120 newly enrolled veterans (20 randomly selected from each of the six
medical centers), all of whom had requested that VA contact them to
schedule medical appointments and were seen by primary care providers.
We examined the medical records for each of these 180 veterans to
determine the history of actions taken to schedule appointments, such
as dates the appointments were scheduled and dates veterans were seen
by primary care providers, if applicable. We also evaluated VHA's
mechanisms for overseeing veterans' access to primary care against the
Federal internal control standards related to control activities,
information, and monitoring. \7\ Additional information on our scope
and methodology is available in our report. The work this testimony is
based on was performed in accordance with generally accepted government
auditing standards.
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\6\ These medical centers were: VA Central Western Massachusetts
Healthcare System (Leeds, Massachusetts); Tennessee Valley Healthcare
System (Nashville, Tennessee); Fayetteville VA Medical Center
(Fayetteville, North Carolina); Ralph H. Johnson VA Medical Center
(Charleston, South Carolina); VA Eastern Kansas Health Care System
(Leavenworth, Kansas); and VA San Diego Healthcare System (San Diego,
California).
\7\ See GAO, Standards for Internal Control in the Federal
Government GAO/AIMD 00 21.3.1. (Washington, D.C.: November 1999).
Internal control is a process effected by an entity's oversight body,
management, and other personnel that provides reasonable assurance that
the objectives of an entity will be achieved.
Problems Newly Enrolled Veterans Faced in Accessing Primary Care and
---------------------------------------------------------------------------
Obtaining Timely Access to Care
Our review of medical records for a sample of newly enrolled
veterans at six VA medical centers found several problems in medical
centers' processing of veterans' requests that VA contact them to
schedule appointments, and thus not all newly enrolled veterans were
able to access primary care. For the 60 newly enrolled veterans in our
review who requested care but had not been seen by primary care
providers, we found that 29 did not receive appointments due to the
following problems in the appointment scheduling process:
Veterans did not appear on VHA's New Enrollee Appointment
Request (NEAR) list. We found that although 17 newly enrolled veterans
in our review requested that VA contact them to schedule appointments,
medical center officials said that schedulers did not contact the
veterans because they had not appeared on the NEAR list. \8\ According
to VHA policy, as outlined in its July 2014 interim scheduling
guidance, VA medical center staff should contact newly enrolled
veterans to schedule appointments within 7 days from the date they were
placed on the NEAR list. \9\ Medical center officials were not aware
that this problem was occurring, and could not definitively tell us why
these veterans never appeared on the NEAR list.
---------------------------------------------------------------------------
\8\ Veterans who request on their applications for health benefits
that VA contact them to schedule appointments are to be placed on the
NEAR list. The NEAR list is intended to help VA medical centers track
newly enrolled veterans needing appointments.
\9\ Department of Veterans Affairs, ``Rescission of VHA Outpatient
Scheduling Policy and Procedures and Interim Guidance,'' (Washington,
D.C.: July 7, 2014). This interim guidance rescinded and replaced VHA
Directive 2010-027 Outpatient Scheduling Processes and Procedures (June
9, 2010).
VA medical center staff did not follow VHA scheduling
policy. We found that VA medical centers did not follow VHA policies
for contacting newly enrolled veterans for 12 veterans in our review.
VHA policy states that medical centers should document three attempts
to contact each newly enrolled veteran by phone, and if unsuccessful,
send the veteran a letter. However, for 5 of 12 newly enrolled
veterans, our review of their medical records revealed no attempts to
contact them, and medical center officials could not tell us whether
the veterans had ever been contacted to schedule appointments. Medical
center staff attempted to contact the other 7 veterans at least once
each, but failed to reach out to them with the frequency required by
---------------------------------------------------------------------------
VHA policy.
For the remaining 31 of 60 newly enrolled veterans included in our
review who did not have a primary care appointment:
24 were unable to be contacted to schedule appointments
or upon contact, declined care, according to VA medical center
officials. These officials said that in some cases they were unable to
contact veterans due to incorrect or incomplete contact information in
veterans' enrollment applications; in other cases, they said veterans
were seeking a VA identification card, for example, and did not want to
be seen by a provider at the time they were contacted.
7 had appointments scheduled but had not been seen by
primary care providers at the time of our review. Four of those
veterans had initial appointments that needed to be rescheduled, which
had not yet been done at the time of our review. Appointments for the
remaining 3 veterans were scheduled after VHA provided us with a list
of veterans who had requested care.
For the 120 newly enrolled veterans across the six VA medical
centers in our review who requested care and were seen by primary care
providers, we found the average number of days between newly enrolled
veterans' initial requests that VA contact them to schedule
appointments and the dates the veterans were seen by primary care
providers ranged from 22 days to 71 days. Slightly more than half of
the 120 veterans in our sample were seen by providers in less than 30
days; however, veterans' experiences varied widely, even within the
same medical center, and 12 of the 120 veterans in our review waited
more than 90 days to be seen by a provider.
We found that two factors generally impacted newly enrolled
veterans' experiences regarding the number of days it took to be seen
by primary care providers:
1. Appointments were not always available when veterans wanted to
be seen, which contributed to delays in receiving care. For example,
one veteran was contacted within 7 days of being placed on the NEAR
list, but no appointment was available until 73 days after the
veteran's preferred appointment date, and a total of 94 days elapsed
before the veteran was seen by a provider. In another example, a
veteran wanted to be seen as soon as possible, but no appointment was
available for 63 days. Officials at each of the six medical centers in
our review told us that they have difficulty keeping up with the demand
for primary care appointments for new patients because of shortages in
the number of providers, or lack of space due to rapid growth in the
demand for these services.
2. Weaknesses in VA medical center scheduling practices may have
impacted the amount of time it took for veterans to see primary care
providers and contributed to unnecessary delays. Staff at the medical
centers in our review did not always contact veterans to schedule
appointments in accordance with VHA policy, which states that attempts
to contact newly enrolled veterans to schedule appointments must be
made within 7 days of their addition to the NEAR list. Among the 120
veterans included in our review that were seen by primary care
providers, 37 (31 percent) were not contacted within 7 days to schedule
an appointment; compliance varied across medical centers.
As a result of these findings, we recommended that VHA review its
processes for identifying and documenting newly enrolled veterans
requesting appointments and revise as appropriate, to ensure that all
veterans requesting appointments are contacted in a timely manner to
schedule them. VHA concurred with this recommendation, and indicated
that by December 31, 2016, it plans to review and revise the process
from enrollment to scheduling to ensure that newly enrolled veterans
requesting appointments are contacted in a timely manner. VHA also
indicated that it will implement internal controls to ensure its
medical centers are appropriately implementing the process.
VHA's Oversight of Veterans' Access to Primary Care Is Hindered in Part
by Data Weaknesses
VHA's oversight of veterans' access to primary care is hindered, in
part, by data weaknesses and the lack of a comprehensive scheduling
policy, both of which are inconsistent with Federal internal control
standards. \10\ These standards call for agencies to have reliable data
and effective policies to achieve their objectives, and for information
to be recorded and communicated to the entity's management and others
who need it to carry out their responsibilities.
---------------------------------------------------------------------------
\10\ See GAO/AIMD 00 21.3.1.
---------------------------------------------------------------------------
A key component of VHA's oversight of veterans' access to primary
care, particularly for newly enrolled veterans, relies on monitoring
appointment wait times. However, VHA monitors only a portion of the
overall time it takes newly enrolled veterans to access primary care.
\11\ For newly enrolled veterans, VHA calculates primary care
appointment wait times starting from veterans' preferred dates, rather
than the dates veterans initially requested that VA contact them to
schedule appointments. (A preferred date is the date that is
established when a scheduler contacts the veteran to determine when he
or she wants to be seen.) Therefore, these data do not capture the time
veterans wait prior to being contacted by schedulers, making it
difficult for officials to identify and remedy scheduling problems that
may arise prior to making contact with veterans. (See fig. 1.)
---------------------------------------------------------------------------
\11\ We recently reported that VA similarly focuses on only a
portion of the overall time veterans wait to see mental health
providers. See GAO 16 24.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Our review of medical records for 120 newly enrolled veterans found
that, on average, the total amount of time it took to be seen by
primary care providers was much longer when measured from the dates
veterans initially requested VA contact them to schedule appointments
than it was when using appointment wait times calculated using
veterans' preferred dates as the starting point. For example, we found
one veteran applied for VHA health care benefits in December 2014,
which included a request to be contacted for an initial appointment.
The VA medical center contacted the veteran to schedule a primary care
appointment 43 days later. When making the appointment, the medical
center recorded the veteran's preferred date as March 1, 2015, and the
veteran saw a provider on March 3, 2015. Although the medical center's
data showed the veteran waited 2 days to see a provider, the total
amount of time that elapsed from the veteran's request until the
veteran was seen was actually 76 days.
Further, ongoing scheduling errors, such as incorrectly revising
preferred dates when rescheduling appointments, understated the amount
of time veterans waited to see providers. \12\ For example, during our
review of appointment scheduling for 120 newly enrolled veterans, we
found that schedulers in three of the six VA medical centers included
in our review had made errors in recording veterans' preferred dates
when making appointments. For example, in some cases primary care
clinics cancelled appointments, and when those appointments were re-
scheduled, schedulers did not always maintain the original preferred
dates in the system, but updated them to reflect new preferred dates
recorded when the appointments were rescheduled. We found 15
appointments for which schedulers had incorrectly revised the preferred
dates. In these cases, we recalculated the appointment wait time based
on what should have been the correct preferred dates, according to VHA
policy, and found the wait-time data contained in the scheduling system
were understated. Officials attributed these errors to confusion by
schedulers resulting from the lack of an updated standardized
scheduling directive, which VHA rescinded and replaced with an interim
directive in July 2014. \13\ As in our previous work, we continue to
find scheduling errors that affect the reliability of wait-time data
used for oversight, which make it difficult to effectively oversee
newly enrolled veterans' access to primary care.
---------------------------------------------------------------------------
\12\ VHA policy states that when a clinic cancels a veteran's
appointment, the preferred date recorded in the initial appointment
should be maintained in the system and not revised when the appointment
is rescheduled.
\13\ Department of Veterans Affairs, Rescission of VHA Outpatient
Scheduling Policy and Procedures and Interim Guidance, (Washington,
D.C.: July 7, 2014). This interim guidance rescinded and replaced VHA
Directive 2010-027, Outpatient Scheduling Processes and Procedures
(June 9, 2010). Subsequent to this interim directive VHA issued
numerous individual memos to clarify and update its scheduling
policies.
---------------------------------------------------------------------------
As a result of these findings, we recommended that VHA monitor the
full amount of time newly enrolled veterans wait to receive primary
care, and issue an updated scheduling directive. VHA concurred with
both of these recommendations, and indicated that by December 31, 2016,
it plans to begin monitoring the full amount of time newly enrolled
veterans wait to be seen by primary care providers. It also indicated
that it plans to submit a revised scheduling directive for VHA-wide
internal review by May 1, 2016.
This most recent work on veterans' access to primary care expands
further the litany of VA health care deficiencies and weaknesses that
we have identified over the years, particularly since 2010. As of April
1, 2016, there were about 90 GAO recommendations regarding veterans'
health care awaiting action by VHA. These include more than a dozen
recommendations to address weaknesses in the provision and oversight of
veterans' access to timely primary and specialty care, including mental
health care. Until VHA can make meaningful progress in addressing these
and other recommendations, which underscore a system in need of major
transformation, the quality and safety of health care for our Nation's
veterans is at risk.
Chairman Miller, Ranking Member Brown, and Members of the
Committee, this concludes my prepared statement. I would be pleased to
answer any questions that you may have at this time.
GAO Contact and Staff Acknowledgments
If you or your staff members have any questions concerning this
testimony, please contact Debra A. Draper at (202) 512-7114 or
[email protected]. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
statement. Other individuals who made key contributions are Janina
Austin, Assistant Director; Jennie F. Apter; Emily Binek; David
Lichtenfeld; Vikki L. Porter; Brienne Tierney; and Emily Wilson.
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Statements For The Record
THE AMERICAN LEGION
The American Legion has been actively tracking the amount of time
it takes for veterans to access the health care they have earned for
over a decade. In 2002, The American Legion launched the ``I Am Not a
Number'' campaign to identify and document the delays veterans were
facing in obtaining medical care from the Department of Veterans
Affairs (VA). This project grew into to the ``System Worth Saving''
(SWS) Task Force of The American Legion. The SWS team has been
crisscrossing the country annually with boots on the ground to evaluate
the Veterans Health Administration (VHA) in the field ever since. The
American Legion has not been shy about raising concerns, such as in the
testimony of Mr. Roscoe Butler in March of 2013, fully a year before
the Phoenix wait time scandal would break, where Mr. Butler raised
concerns about inaccurate self-reporting from the VA as well as the
large number of empty medical staff positions that needed to be filled
if VA was to have any hope of maintaining manageable wait times for
care. \1\
---------------------------------------------------------------------------
\1\ Witness testimony of Roscoe Butler, The American Legion - HVAC
Subcommittee on Oversight and Investigation, "Waiting for Care:
Examining Patient Wait Times at VA" - March 14, 2013
---------------------------------------------------------------------------
When the scandal broke in Phoenix, The American Legion not only led
the chorus demanding accountability, but also continued to put
resources toward solving the problems and helping veterans receive
care, by establishing Veterans Crisis Command Centers (VCCCs) and
conducting town hall meetings to facilitate communication between
veterans and the VA and help veterans access with the care they needed.
Today, we know from validated reports that there was systemic
falsification of wait times at VA medical facilities. \2\
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\2\ "VA Bosses in 7 States Falsified Vets' Wait Times for Care" -
USA Today, Donovan Slack April 7, 2016
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The American Legion and the American people were rightfully
concerned. The obvious concerns and the conclusions that can be drawn
from this may not be easily solved by some of the pat solutions being
thrown around. Some of these concerns are shared by the larger health
care industry of America as a whole and while these problems may not be
easily solvable - transparency must be a staple of VA, and the ability
to report accurately will be critical toward finding solutions for
veterans.
Chairman Miller, Ranking Member Brown, and Members of the
Committee:
On behalf of National Commander Dale Barnett and the over two
million members of The American Legion, we welcome this opportunity to
comment on improving the access to the health care system of the
Department of Veterans Affairs (VA).
While veterans wait for care in the VA system, many find that the
private sector is just as rife with delays and wait times that rival or
exceed those at VA. Newspaper reports note ``emerging evidence that
lengthy waits to get a doctor's appointment have become the norm in
many parts of American medicine, particularly for general doctors but
also for specialists'' \3\. A report from the National Academy of
Sciences noted ``tremendous variability in wait times for health care
appointments exists throughout the United States, ranging from same day
service to several months.'' \4\ In addition, veterans have mentioned
problems accessing care in the private sector, including a veteran in a
major East Coast city who reported a minimum of 90-100 days to get a
simple dermatology consult, no better, and in many cases far worse than
veterans would be receiving utilizing local VA health care centers.
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\3\ New York Times The Health Care Waiting Game - Elisabeth
Rosenthal, July 5, 2014
\4\ Science Daily Wait times for health care services differ
greatly throughout US - July 29, 2015
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The American health care system as a whole has problems with wait
times, and sometimes it is important to reflect on VA's position not
solely as an island, but as a barometer that can help forecast what to
expect. The American Legion believes that this is an area the Committee
could more fully explore by focusing on how to underpin the existing
system so that we not only shore up VA, but set the example of how the
national health care industry should operate. This wouldn't be the
first time innovation at VA would lead the Nation, and The American
Legion believes that this Committee has provided excellent oversight
and analysis with a comprehensive slate of hearings examining the VHA.
In addition, The American Legion believes that a hearing or series of
hearings examining VHA in relation to the larger health care picture of
America would prove beneficial. Wait times, opioid pain killer
prescription, elder care, mental health care, these are all problems
that VA must tackle, but they are also problems the American health
care landscape as a whole is grappling with, and the comparison and
contrasts are illuminating.
While emergency measures such as the Veterans Access, Choice and
Accountability Act of 2014 \5\ (VACAA) provided the opportunity for
some relief while utilizing private sector resources as a pressure
release valve, the private sector has many of its own struggles with
wait times and cannot be seen as a sole solution to the problems of
waiting veterans. VACAA and subsequent efforts to consolidate care in
the community under a single streamlined system should make the process
easier when veterans need help accessing care, and reforming this
portion of the system is important. However, this only addresses part
of the access problem.
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\5\ P.L. 113-146
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The American Legion recognizes the importance of communication and
coordination between all components of the health care community - VA
facilities, private sector resources, public-private partnerships such
as agreements with teaching hospitals and universities, Veterans
Service Organizations (VSOs) and others who provide resources to help
veterans, Congressional as well as local governments, and most
importantly the veterans themselves. When all of these stakeholders
communicate it is easier to determine what resources are available to
serve the needs of the veteran. That cooperation can only occur when
the communication is open and free from fear of reprisal.
The real and striking problem identified by watchdogs like The
American Legion well before the Phoenix scandal broke which was
confirmed by the scandal itself, was the culture in VA that led to
systemic false reporting of critical information. Without accurate
information about the delays veterans were facing, there is no way to
correctly identify where help is needed. When self-reporting continued
to signify that all was well, those connected to the veterans who were
struggling had to find alternative ways of gaining access to more
accurate information.
The American Legion made independent, third party oversight visits
to facilities through the System Worth Saving Task Force and tried to
highlight the problems we saw through testimony before Congress as
noted above. Representative Beto O'Rourke from this very committee,
frustrated with incongruities of data reported by VA with what the
veterans in his district reported regarding mental health care wait
times, commissioned private surveys to develop a more accurate picture.
When criticism comes forward to address problems, it must be met
productively. Where change is necessitated, it must occur to meet the
needs of veterans. As a result of the Phoenix wait time scandal
veterans now have new management at VA; from Secretary Bob McDonald, to
Undersecretary for Health Dr. David Shulkin, as well as most of VA's
senior leadership team. These new leaders have stressed the importance
of retraining employees and management at every level to fix these
problems.
According to the Independent Assessment \6\ VA is inconsistent from
region to region. In some regions, VA does an excellent job of managing
the health care needs of veterans. Veterans receive treatment within
the VA where possible, and overwhelmingly veterans report favorably on
the treatment they receive within VA even when they are frustrated with
the administrative aspects such as appointments. \7\ In some locations
when they cannot deliver the care veterans need, they can smoothly make
appointments to get the veterans care in the community. This indicates
the system has the capacity to deliver the care veterans want and
deserve, utilizing the best VA resources and private sector resources
in places where this is necessary, but while the capacity is there the
consistency of this execution is falling short.
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\6\ http://www.va.gov/opa/choiceact/documents/assessments/
integrated--report.pdf
\7\ Vet Voice Foundation polling data, November 2015
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The foundation to build that consistency requires better reporting,
better communication between all parties, and better teamwork between
all partners. Regional problems can't be fixed unless awareness of
those problems filters up to those who can commit the resources
necessary to fix the problems and it will take new and innovative
solutions to succeed. Representative Ryan Costello has proposed the VET
Act \8\ which builds on the example set by American Legion VCCCs and
sets up a pilot program using Veteran Engagement Teams to help connect
veterans with resources. Representative O'Rourke's Ask Veterans Act \9\
proposes surveying veterans directly to get outside the closed loop of
VA management reporting on its own progress, and Representative Corrine
Brown has introduced legislation that would make VA establish a
quadrennial plan for committing funds and coordinating care
effectively. These and other ideas will be necessary to help restore
trust in the system; even as VA's new management works to do the same.
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\8\ H. R. 3936
\9\ H. R. 1319
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The American Legion is committed to ensuring that veterans have the
best health care system available to meet their unique needs and we are
encouraged by some of the progress VA is making \10\. VA's MyVA
initiative combined with the successful implementation of VISTA
evolution, My Healthy Vet, working weekends to knock down the
appointment and consult wait times, and expanding telehealth are just a
few examples where VA is showing promise and improvement. The Wait Time
scandal illuminated problems within that health care system. In the
time of immediate crisis, the most obvious answer to that problem
seemed to be that the resources to meet need weren't there and
therefore veterans must be turfed off to community providers, but we
all see now that it is just not that simple. The solution will require
patience and diligence to be sure, but above all honesty and the
humility to admit that you need help. Management and employees cannot
be afraid of poor reviews causing them to hide their inability to admit
they aren't meeting needs. VA cannot be so afraid of criticism that
they fall back on knee jerk habits to deny and deflect accusations
rather than owning their shortcomings and providing a plan for how they
aim to make up for them.
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\10\ http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2775
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Overwhelmingly - VA still delivers a ``System Worth Saving''. This
is the Nation's largest, most extensive, most comprehensive integrated
health care system and is a system that has led the way on integrated
health records, on treatment for heart disease, on new and innovative
treatments for mental health issues, and especially Posttraumatic
Stress Disorder. But this is also a system that needs to be viewed
through a lens that not only observes VA's own internal struggles but
also the struggles of the Nation's health care landscape as a whole.
The American Legion thanks this Committee for their diligence in
pursuing improvements to the VA health care system and for their
attentiveness to the struggles of veterans who seek to access care.
This Committee was instrumental in calling attention to the initial
Wait Time problem, and has been at the forefront of oversight through
the past two years of reform efforts. As we continue to work toward the
future of veterans' health care, we look forward to continuing the
important partnership and dialogue with all partners at the table from
veterans to VA to Congress, toward building the robust and dynamic
health care system veterans have earned with their service and
sacrifice.
Questions concerning this testimony can be directed to The American
Legion Legislative Division (202) 861-2700, or [email protected]
Questions and Answers
PASSBACK
QUESTIONS FOR THE RECORD FROM CHAIRMAN JEFF MILLER
Question 1: What is the VHA-wide average wait time for Veterans
seeking primary care at VA? Please provide the number for new patients
and established patients. Does that average take into account the time
from the first contact the Veteran makes with VA until the appointment
actually occurs? In other words, does it include the time from the
create date to the appointment date, not just from the preferred date
to the appointment date.
Department of Veterans Affairs (VA) Response: In April 2016, the
average wait time for Primary Care was 4.66 days. This number includes
both new and established patient appointments and a new method of
computation. This new method uses either the date that an appointment
is deemed clinically appropriate by a VA health care provider, the
Clinically Indicated Date (CID), or, if no such clinical determination
has been made, the date a Veteran prefers to be seen, the Preferred
Date (PD), to calculate wait times. The current method reports the wait
times for all patients combined, and does not include the create date.
This is consistent with the wait time goals of the Veterans Health
Administration (VHA) published in the Federal Register on October 17,
2014. \1\
---------------------------------------------------------------------------
\1\ Available at: https://www.federalregister.gov/articles/2014/
11/05/2014-26274/publication-of-wait-times-for-the-department-for-the-
veterans-choice-program.
---------------------------------------------------------------------------
The previous method used to calculate wait times was based on the
create date (the date an appointment is made) and the desired date for
scheduling an appointment. The create date time stamp provided valuable
information for new patients but not for established patients. So, the
desired date time stamp required further definition based on the source
of the appointment request. VA now uses CID for provider driven
appointment requests and PD for patient driven appointment requests.
The majority of appointments are made from provider driven requests,
and providers must document CID. Use of CID makes the scheduling of
appointments less susceptible to manipulation.
Question 2: VA has used the excuse of training problems for more
than a decade when addressing wait times errors or manipulation. One
very simple way to address training deficiencies is to ensure your over
25,000 schedulers are trained properly, both the trainer and the
trainee certify that training is in compliance with VHA policy, and
then hold them accountable for actions outside of training. Will VA
implement this simple step of requiring a written attestation of
competency in order to hold people accountable for the continuing
abuses in the scheduling system?
VA Response: In response to the events of 2014, VHA simplified the
scheduling procedures and published a Deputy Under Secretary for Health
for Operations and Management memorandum on June 9, 2015, which revised
procedures to require providers to write a return-to-clinic order and
schedulers to enter the date contained in that order as the CID. This
new process keeps future appointment decision-making with the provider
and patient, rather than the scheduler. Associated training was updated
at that point and provided to employees who could schedule
appointments. A written attestation is included as part of the
training. Additionally, VHA uses the ``scheduling trigger tool''
database to identify and notify facility leadership of scheduling
irregularities. Of note, a root cause of scheduling errors is the
highly manual, 30-year old scheduling software. VHA will implement
VistA Scheduling Enhancement (VSE) this summer. VSE updates the legacy
command line scheduling application with a modern graphical user
interface. This capability reduces the time it takes schedulers to
enter new appointments, and makes it easier to see provider
availability. VSE provides critical, near-term enhancements, including
a graphical user interface, aggregated facility views, profile
scheduling grids, single queues for appointment requests, and resource
management reporting. VHA anticipates this new scheduling software will
reduce the number of scheduling errors.
Several initiatives are planned for VHA's ``Summer of Scheduling,''
including:
National Rollout of VSE: The rollout of VSE will be
achieved through a train the trainer or ``Super User'' approach,
developing local experts to train others. The rollout will occur
between May and July 2016, with ongoing sustainment training.
Hire Right, Hire Fast: This project's goal is to ensure
that every facility has the right number of Medical Support Assistants
(MSA), with the right skills, and who can provide the right experience
for Veterans.
Own the Moment: VA knows that every moment between an
employee and a Veteran matters. This project reinforces the importance
of serving with a focus on principles and values, empowering VA
employees to pursue what's right for the Veteran when procedures serve
to limit services.
Standardized MSA Onboarding/Training: New MSA Onboarding
would include a two-week training program that draws its curriculum
from scheduling rules for technical training, customer experience
training, and medical center policies. The onboarding will provide a
mentor for all new MSAs and use the VSE ``Super Users'' model.
Deployment will follow the National Rollout of VSE.
Question 3: Who at VA Central Office is responsible for training,
and has anyone been held accountable for this, since it has been used
as an excuse for wait time manipulation and errors for so long?
VA Response: VHA's Access and Clinical Administration Program
Office is responsible for developing scheduler training and policy.
This office is creating, in collaboration with the VA Talent Management
Service, a simulation-based learning platform that enhances decision-
making by allowing organizations to easily create assessment,
education, and training programs to improve outcomes through ``real-
world'' engagement. Simulation-based training is interactive and allows
a scheduler to choose various pathways in a decision tree. Once the
training is developed and released, each facility will ensure their
staff successfully completes the training prior to issuing the
scheduling menu options.
Question 4: GAO pointed out in its report that medical center
directors are responsible for ensuring any staff who access the
scheduling system have completed the appropriate training. Given the
numerous instances of improper scheduling that continue to this day,
how many directors have been disciplined specifically for the failure
to ensure his/her staff is properly trained? Please provide a list of
each director, the discipline received, and the specific charge that
successfully led to the received discipline.
VA Response: VA's goal continues to be strengthening its culture of
accountability and putting a renewed focus on employee-led, Veteran-
centric change. Regarding disciplinary actions, no director has been
disciplined ``specifically for the failure to ensure his/her staff is
properly trained;'' however, as of July 8, 2016, VA has taken
disciplinary action against 52 employees for wait time data
manipulation. The breakdown of these actions includes: 17 Suspensions -
Less than 14 days, 9 Reprimands, 8 Removals, 5 Admonishments, 4
Suspensions - 14-29 days, 3 Demotions, 2 Employees retired in lieu of,
1 Employee resigned in lieu of, 1 Suspension - over 60 days, 1
Settlement Agreement, and 1 Probationary Termination.
Question 5: Whistleblower disclosures that have been in the media
\2\ show that Phoenix has had about 33,500 cancelled clinic
appointments since October 2015, 10,000 of which had not been
rescheduled at least as of February 2016. Please explain this.
---------------------------------------------------------------------------
\2\ Available at: http://www.azfamily.com/story/31371254/va-
insider-comes-forward-regarding-recent-controversy-in-vet-health care.
VA Response: From October 1, 2015, through March 3, 2016, a total
of 33,789 appointments were identified as being cancelled by clinics
across all services in the Phoenix VA Health Care System (PVAHCS). This
number includes individual appointments, group appointments,
Compensation & Pension, and telephone clinics.
VA identified 10,604 of the cancelled appointments as having ``No
Action Taken.'' ``No Action Taken'' could indicate such things as a
future appointment scheduled in a different stop code or appointments
made in error (e.g., scheduled into the wrong clinic, with the wrong
date, for the wrong patient, etc.). A random audit of 100 patient
records demonstrated that 14 need to be contacted to attempt to
reschedule. Based on the random audit, the facility will review further
to determine if any of the Veterans require a follow-up. Additionally,
PVAHCS is developing an action plan to review the 10,000 records, with
a target completion date of mid-June 2016.
Question 6: According to a recent OIG report on Colorado Springs,
36 percent of the consults reviewed identified that Veterans waited
from between 31 to 148 days for a specialty care consult and 78 percent
waited for from between 32 to 229 days for a primary care appointment.
How is VA addressing the specific problems identified by the OIG?
VA Response: VA Eastern Colorado Health Care System (VAECHCS) has
already implemented measures to improve access and to ensure the
facility has trained staff to timely process consults. Scheduling staff
at the PFC Floyd K. Lindstrom Outpatient Clinic at Colorado Springs
received multiple formal training sessions on appropriate scheduling
practices in the last several months, which included use of the
earliest appropriate date when scheduling new patient appointments. A
``stand-down'' on December 5, 2015, was also held, where all schedulers
were brought in on a Saturday to review and train on all of the
critical components of scheduling. Detailed refresher training for all
scheduling staff was additionally conducted on March 8-10, 2016. All
new schedulers are required to attend and complete formal classroom
training, followed by a practicum and assessment of scheduling
competencies, before transitioning permanently to their respective
clinics. Moreover, scheduling audits continue, with 100 percent of
required audits being completed for all scheduling staff in February,
March, and April 2016. Based upon the results of the audit reviews,
supervisors provide immediate feedback to schedulers, along with any
necessary corrective action. In addition to these efforts, consult
metrics are being closely monitored as part of the VHA Consult
Improvement Initiative.
Question 7: In the same report, the OIG found that VA staff did not
fully use Veterans Choice Program funds to afford CBOC Veterans the
opportunity to receive timely care. Please explain, in detail, where
and how that money was spent.
VA Response: The omission of 100 patients from the Veterans Choice
List (VCL) occurred in the infancy of the program. Early in
implementation, a report to add patients to the VCL did not include all
sites of care within VAECHCS. This issue was identified and resolved
through training for the Community Care manager, as stated in the
facility's initial published response to VA's Office of Inspector
General. Veterans Choice Program (VCP) funding that would have been
spent for the care of these Veterans remained in the VCP Fund for
purposes of paying for other care under the program.
VAECHCS fully supports an eligible Veteran's choice to receive care
through VCP. VAECHCS is currently in the top five facilities in the
Nation in volume of VCP referrals. Through March of fiscal year (FY)
2016, VAECHCS has referred 27,716 episodes of care to our region's
third party administrator, Health Net Federal Services, resulting in
17,251 appointments in the community. To ensure we maintain this
success, VAECHCS added VCL entry criteria to the performance plans of
schedulers and issued the revised plans during mid-year review in March
2016.
Question 8: GAO noted, as this Committee has for years, that VA's
reported wait times data only includes a portion of the time it takes a
newly enrolled Veteran to access primary care, by using a Veteran's
desired date as opposed to the time the Veteran first contacts VA.
Given the fact that calculating wait times in this manner understates
actual wait times, why does VA do it this way?
VA Response: There is no clear standard to evaluate appointment
wait times. While using the create date is easier to capture and
appears to calculate wait times simply, it is not clinically relevant
and doesn't reflect the Veterans' preference for when to be seen. In
the private sector, most large health care organizations focus on
patient satisfaction, and that's where we think VA needs to go.
The create date time stamp may provide useful information for new
patients but not for established patients. Our patient population is
older and has more chronic conditions. As a result, a very large
portion of appointments are ``return to clinic.'' For example, if a
Veteran sees a doctor for diabetes and the doctor wants a follow-up
appointment in 6 months, it doesn't make sense to report that as a 180
day wait time. While the follow-up care would be delivered at the
clinically appropriate time, it would inaccurately inflate a facility's
wait time average. A Veteran could see extraordinarily long wait times
at a facility due to this inflation and may be discouraged from seeking
care there. The desired date time stamp must be further defined based
on the source of the appointment request. However, reporting wait times
based on create date in addition to our current, more appropriate,
practice would risk creating even more confusion. VA now uses the CID
for provider driven appointment requests and PD for patient driven
requests.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS)
is a widely used survey throughout health care in America. A standard
set of questions deals with timely access to routine care and care
needed right away. Historically, VA has underperformed industry
averages. Notably, however, Veteran responses in the first and second
quarters of FY2016 were the most favorable since 2013. More than 83
percent of respondents indicated they usually or always received access
to routine care when they needed it, and 72 percent of respondents
indicated they received access to care needed right away.
Question 9: Officials from each of the facilities audited by GAO
stated that they periodically audit scheduled appointments to help
ensure schedulers are complying with scheduling practices. Is that a
uniform policy across all VHA facilities? If not, please explain why.
VA Response: Yes. Current VHA policy requires scheduling
supervisors to audit schedulers on a yearly basis, at a minimum. An
updated scheduling directive, currently in the concurrence process,
will require quarterly audits. The audit format was standardized and is
now a national auditing tool. Some sites are piloting the audit tool.
Once the scheduling directive is released, all sites will be trained on
the use of the audit tool for quarterly audits for all staff assigned
the scheduling menu options.
Question 10: In a December 2012 report, GAO recommended VA improve
efficiency and oversight of its scheduling process, including use of
the EWL and ensuring appropriate training. Now, over three years later,
that recommendation remains open, and VA continues to blame wait time
manipulation on improper training. When is VA planning on fixing its
training procedures so it can stop improperly characterizing its
attempts to pad numbers on those deficiencies?
VA Response: In May 2014, VA began retraining every employee whose
position includes the responsibility of scheduling appointments, to
eliminate inconsistencies across VHA or within any VA facility. This
training clearly directed that all scheduling of appointments must use
the official VA scheduling software and Electronic Wait List (EWL) so
that we can better track demand and need for additional resources.
Additional training was added and is provided to front line staff on an
on-going basis. To ensure compliance with required directives and
policies, VA conducted another review of all schedulers in August 2015.
Employees who had not received the required training had their
scheduling authority removed and were blocked from scheduling until
properly trained.
In spring 2016, VA launched a 2-week, enhanced training program
specifically for schedulers and other front line staff, which will
focus on critical customer service skills. MSA onboarding, to include
its mentorship program, will also support technical and policy
training. Additionally, VA requires each Veterans Integrated Service
Network (VISN) Director and Medical Center Director to conduct
Scheduling Inspections on a regular basis at VA hospitals and clinics.
Over 11,500 of these inspections have occurred, and this practice will
continue. Finally, an interactive training program is being developed
for scheduling staff, which will be released after the scheduling
directive is approved.
Question 11: A consistent weakness that has been highlighted with
regard to scheduling practices is the lack of effective oversight. What
is the role of VISNs and central office with regard to oversight?
VA Response: In May 2014, VA began retraining every employee whose
position includes the responsibility of scheduling appointments, to
eliminate inconsistencies across VHA or within any VA facility. This
training clearly directed that all scheduling of appointments must use
the official VA scheduling software and EWL so that we can better track
demand and need for additional resources. Additional scheduler training
on updated scheduling procedures was conducted in the summer of 2015.
To ensure compliance with these new procedures, VHA directors certified
that all schedulers completed the appropriate training. Employees who
were not properly trained had their scheduling authority removed and
were blocked from scheduling until properly trained.
Additionally, VA requires each VISN Director and Medical Center
Director to conduct Scheduling Inspections on a regular basis at VA
hospitals and clinics. Over 11,500 of these inspections have occurred,
and this practice will continue. We have made a deliberate effort to
educate our staff. In addition to training, we have multiple audit
tools in place that actively scan VA's metadata to look for
abnormalities in the scheduling process. Use of the ``scheduling
trigger tool'' database to identify and notify facility leadership of
scheduling irregularities is an additional protection against
scheduling errors. Any such abnormalities are flagged and provided to
facility leadership for appropriate follow-up. VA's tracker tools
identify the error and log the appropriate action taken to remediate
that error.
VA's new scheduling software, VSE, will change the business
processes that schedulers use to make, cancel, and reschedule
appointments. These business processes are anticipated to make
scheduling more reliable and reduce errors. Specifically, VSE will:
Eliminate the ability to ``zero out'' appointments;
Improve the accuracy of lists;
Eliminate cancellation by clinic errors;
Improve the accuracy of CID/PD for multiple book
appointments; and
Eliminate ``next available'' errors.
Question 12: Why are audits and external reviews still finding
errors in scheduling appointments in spite of training? What is VA
doing to ensure these errors stop?
VA Response: One reason is that schedulers are generally entry
level employees who experience a 25 percent turnover each year. The
Hire Right, Hire Fast initiative is intended to ensure MSAs with the
right skills are in the right place to provide a premium experience to
Veterans. Medical center directors will certify required administrative
baselines to ensure successful implementation. Additionally, the
current scheduling process is complex, requiring schedulers to manually
apply many of the business rules and procedures that could be done by
an electronic scheduling system. VA deployment of VSE will update VA's
legacy ``roll and scroll'' scheduling application with a modern
graphical user interface. This capability will reduce the time it takes
for schedulers to enter new appointments and make it easier to see
provider availability. VSE implementation creates a need to update
schedulers on new software functions and procedures. VA will combine
VSE training with a module focused on critical customer service skills.
Question 13: With regard to the designation of Veteran's health
care as one of GAO's high-risk programs, what does VA expect to
accomplish in this regard through the end of the current
administration?
VA Response: VA's Under Secretary for Health, Dr. David Shulkin,
has a vision for a system that provides same day access to primary care
and mental health care. Same day access is defined as the ability of a
facility to address a Veteran's clinical needs the day that a Veteran
calls or visits a VHA medical center. Central to this vision is a
commitment to enhanced access and a consistent set of expectations
regarding what a Veteran deserves when s/he enters any VHA facility.
This commitment is summarized in the MyVA Access Declaration and the
Veteran experience statement.
Our goal is to provide same day access for primary care and mental
health care by December 2016. This means that when Veterans call or
visit a VHA medical facility, VHA will connect them to their primary
care provider, connect them to an alternate provider, such as a walk-in
clinic or emergency room, or attend to their needs by telephone,
through telemedicine or other available methods, on the same day as
when the care they need is deemed medically necessary. In addition,
Veterans reporting or identified as being in crisis, including
suicidality, will receive an immediate crisis response. When Veterans
call for a new mental health appointment, they will receive a suicide
risk screening and immediate care, if needed. Veterans already engaged
in mental health care identifying a need for urgent attention will
speak with a provider that same day.
We will accomplish this through a firm commitment to our
foundational principles, known as the MyVA Access Declaration. These
foundational principles support our collective commitment to our
Veteran population and serve as a pledge to Veterans regarding their
ability to access care in a timely manner. The MyVA Access Declaration
is as follows:
1. Provide timely care, including same-day services in Primary
Care, as needed;
2. Provide timely Mental Health care, including same day services,
as needed;
3. Provide Veterans medically necessary care from another VA
Medical Center while away from their primary facility;
4. Respond to routine clinical inquiries within 2 business days;
5. Offer appointments and other follow-up options upon leaving a
clinic;
6. Actively engage Veterans for timely follow-up if a clinic is
canceled due to unforeseen circumstances;
7. Integrate community providers, as appropriate, to enhance
access;
8. Offer Veterans extended clinic hours and/or virtual care
options, such as Telehealth, when appropriate; and
9. Transparently report access to care data to Veterans and to the
public.
Dr. Shulkin recognizes VHA medical facilities' efforts, the
collective commitment to the above MyVA Access Declaration, and the
need for additional support to achieve same day access to care.
Accordingly, he charged a team of clinical and administrative field and
central office leaders to identify, evaluate, and recommend high impact
solutions for application across the health care system. Multiple high
impact solutions were selected for rapid deployment.
Local deployment of these solutions is supported by VHA's Veteran
Engineering Resource Center (VERC). VERC's mission is to facilitate
innovative solutions to health care delivery challenges identified by
national, network, and facility leadership, as well as to propose
important opportunities for change and improvement. In support of MyVA
Access, the VERC provides a continuum of support, including face-to-
face training and support to the VHA medical facilities as they
implement the solutions critical for improving access. Local deployment
is also supported by other trained improvement professionals, such as
Systems Redesign Coordinators, Transformation Coaches, and other
internal subject matter experts.
Specific planned accomplishments prior to December 2016 include:
MyVA Access VERC partners are engaging VHA health systems
and coordinating implementation planning through local leadership
teams.
In May 2016, VHA's Office of Operations and Management
commenced training to 116 Group Practice Managers (GPM) from 92 VHA
facilities across the country. GPMs provide oversight of all VA Medical
Facility Ambulatory Care Services, including Primary Care, Mental
Health, Specialty Care, and outpatient surgical clinics. This oversight
includes resource utilization, patient scheduling, Veteran access, and
clinic efficiency. GPMs facilitate critical discussions related to the
clinical practice and identify potential alternatives and subsequent
outcomes.
The GPM training focused on the tools and resources
needed for successful clinical operations management. Topic areas
included open access in primary care, optimizing the health operations
dashboard, and meeting the mental health needs of Veterans in a timely
manner. The training will continue in August 2016.
VSE will begin implementation in late 2016 and will
facilitate Veteran-centric and consistent experience when scheduling
follow-up appointments. The scheduler is able to quickly and easily see
multiple clinic profiles in one calendar view, and the enhanced
graphical user interface allows users to seamlessly navigate through
the scheduling process. An improved reporting structure will also
create a quick report to measure and track supply, demand, and
utilization.
Direct Scheduling for audiology and optometry will be in
place nationally by December 2016. Through direct scheduling, audiology
and optometry clinics will be able to immediately see Veterans upon
request, without first requiring a consult from their primary care
provider.
The Telemental Health Hub Expansion initiative includes
four regional hubs that have defined relationships with several
facilities with particular challenges in their ability to provide
timely mental health care. The first hub will begin providing services
on zJune 6, 2016, and the other hubs will commence later this summer.
All hubs will be operational by the end of the calendar year.
Question 14: Has VA conducted any analyses of its capacity,
including health care providers, specialty services, and other needs,
by facility, and if so, what do these analyses show, and what are VA's
plans for ensuring adequate capacity?
VA Response: Yes. VA assesses the capacity and staffing of each VA
medical facility. Establishing, filling, and projecting requirements
for VA's health care system is a complex task. There is no ``one size
fits all'' solution, making it particularly challenging for VA's large
health care system. Many factors influence the ability of VA to meet
the critical needs of a medical facility. Specifically, Primary Care
panel capacity varies by facility, but, as of May 2016, the average is
88 percent. This means that approximately 740,000 additional Veterans
can be accommodated at present staffing levels. Currently, 33 sites are
above 95 percent of capacity, with 8 of them over 100 percent. As
demand increases, sites generally add Primary Care teams within local
constraints on budget, space, and recruitment ability.
VHA has taken a number of steps in recent years to improve clinical
staffing management of medical professionals and support staff. This
includes establishing team based, patient-centered care, development of
productivity standards, and integration of workforce and succession
planning.
Question 15: The GAO report discusses the lack of a comprehensive
national scheduling policy, which has contributed to at least some of
the observed scheduling problems. In your response to GAO's
recommendation to finalize and disseminate such a policy, you noted a
completion date of May 1, 2016. If the scheduling policy was rescinded
in 2014, why has it taken so long to revise it? Further, what steps are
you taking to ensure you will meet the May 1 completion date?
VA Response: The Outpatient Scheduling directive was ready for
review in February 2016; however, the directive had to be rewritten to
include content from the handbook. The directive was submitted for
review on May 20, 2016. In the meantime, the 2010 scheduling directive
has not been rescinded. Once the 2016 directive is released, it will
replace the 2010 scheduling directive.
In the last four years, VHA has undergone changes that affected the
policies and procedures in the directive. With the implementation of
VSE, Veteran Appointment Requests, the Direct Patient Scheduling
Application, the Choice initiative, and changes to performance
measures, the directive has been under a constant state of revision. A
scheduling directive stand down was held in Washington, DC, inviting
individuals on a concurrence list to attend and review the draft
directive. Following the stand down, 74 questions/comments from the
group were forwarded for action. These questions/comments have been
addressed in the current draft of the directive and are now awaiting
final review. Once approved, the directive will return to concurrence
for final signature.
Question 16: The GAO report also recommended improved efforts to
ensure newly enrolled Veterans requesting an appointment are contacted
in a timely manner, and the importance of monitoring the full amount of
time newly enrolled Veterans wait to be seen. In your response to the
GAO's recommendations, you noted a completion date of December 31,
2016. What steps are you taking to ensure you will meet the completion
date?
VA Response: Welcome to MyVA (W2MyVA) provides newly enrolled
Veterans a warm welcome to VA, an overview of benefits for which they
may qualify, and assistance with scheduling their first appointment by
a warm transfer of the Veteran to the facility of their choice. After
hours, the facility's phone number is provided to the Veteran to call
at his/her convenience. Outbound calls are completed within 5 business
days from the enrollment date.
VA is developing a monitoring plan to gauge the ``Veteran Feel''
(how long it actually takes/overall time) from application to scheduled
appointment. VHA will monitor timeframes on a consistent, frequent
basis to detect deficiencies in the processes of providing newly
enrolled Veterans with access to care. The National Elapsed Time report
will be updated to calculate the time between application and
appointment. Time frames will be monitored to improve visibility and
accountability, allowing oversight of successful scheduling for newly
enrolled Veteran appointments.
Steps that are in place to meet the completion date include the
following:
Submit revised specifications to VSSC - target June 2016;
Update W2MyVA Report and National Elapsed Time Report -
target July 2016;
Test the revised reports - target September 2016;
Submit Communication Plan to VISN and facility level -
target September 2016; and
Complete revised W2MyVA Report and National Elapsed Time
Report - target October 1, 2016.
Question 17: Does VA know which facilities are in greatest need of
using contracted, non-VA care, and does it know the specialties for
which Veterans are most likely to use such care? If so, what plans are
VA undertaking to ensure that these services are available on a
contracted basis to Veterans and that Veterans receive timely access to
this care?
VA Response: There is very similar utilization of community care
across VHA; however, the top 5 facilities utilizing community care
include VAECHCS, the Kansas City VA Medical Center (VAMC), the Alaska
VA Healthcare System, the Spark M. Matsunaga VAMC, and PVAHCS, which
collectively encompass 11.4 percent of total utilization in FY2016 by
all medical centers. There were two significant front runners for
categories of care being requested: Ophthalmology and Optometry;
closely followed by Primary Care and Physical Therapy.
Based on data trends and forecasting, VA works with HealthNet and
TriWest to identify and target specialties and providers of need. Both
contractors have continuously worked with local VA medical facilities
and VISNs to identify needed specialties and bring those providers into
the network. As of May 2016, the Choice Provider Network has grown by
85 percent. In April 2015, the network had 191,237 providers and
facilities contracted. As of May 31, 2016, the network has 353,674
providers and facilities contracted. In the event that either
contractor is unable to provide the necessary service and returns the
authorization to VA, VA may utilize Veterans Choice Provider Agreements
in accordance with established protocol to purchase the care directly.
Question 18: Does VA ever cancel Veteran applications for health
care without receiving written authorization from the Veteran? If so,
when is doing so proper?
VA Response: In accordance with 38 Code of Federal Regulations
Sec. 17.36(d)(5), a Veteran enrolled in the VA health care system will
be disenrolled only if the Veteran submits a signed and dated document
stating that the Veteran no longer wishes to be enrolled or VHA
determines that the Veteran is no longer in a priority category
eligible to be enrolled.
Question 19: In Dr. Shulkin's written testimony, he stated that VA
has ``gone to such lengths to make sure that we document every aspect
of wait time data.'' How can VA say that it documents every aspect of
wait time data when it only captures a small portion of the time a
Veteran actually waits?
VA Response: In the past, VA computed wait times for new patients
based on the create date - the date on which an appointment was made.
Under this method, a computer-generated time stamp was applied that did
not reflect the Veteran's preference or what was deemed clinically
necessary by a health care clinician. VA computed wait times for
established patients using a desired date - the date the patient wanted
to be seen or the date clinically indicated by a provider when the
Veteran needs care.
The create date time stamp may provide useful information for new
patients but not for established patients. Our patient population is
older and has more chronic conditions. As a result, a very large
portion of appointments are ``return to clinic.'' For example, if a
Veteran sees a doctor for diabetes and the doctor wants a follow-up
appointment in 6 months, it doesn't make sense to report that as a 180
day wait time. While the follow-up care would be delivered at the
clinically appropriate time, it would inaccurately inflate a facility's
wait time average. A Veteran could see extraordinarily long wait times
at a facility due to this inflation and may be discouraged from seeking
care there. The desired date time stamp must be further defined based
on the source of the appointment request. However, reporting wait times
based on create date in addition to our current, more appropriate,
practice would risk creating even more confusion. VA now uses the CID
for provider driven appointment requests and PD for patient driven
requests.
As VA refocused its efforts on Veterans' perceptions, VA sought
best practices from several industry experts, Veterans, and Veteran
service organizations to develop a wait time metric that balances
Veterans' preferences and provides the best clinical care. VA
determined that the preferred date would be used for all patients and
reported in a consistent manner, as it most accurately reflects the
Veteran's and physician's preference.
As the health care industry and private sector have demonstrated,
patient wait time data is but one of many indicators used to monitor
access and measure customer satisfaction. VHA is now utilizing realtime
Veteran responses to access - a system called VetLink, where Veterans
check in at kiosks and are asked if they were satisfied with their
ability to get an appointment on time. Our VetLink data shows that
Veterans who were surveyed at the time of clinic check-in report that
they are satisfied or very satisfied with their scheduled appointment
nearly 90 percent of the time. In our new survey of Care in the
Community, 85 percent of Veterans were satisfied with their experience
of Care in the Community and 77 percent scored their VA Community Care
Provider an 8 or higher on a scale of 10.
Question 20: In his testimony, Dr. Shulkin stated VA is planning to
measure access to care by simply asking Veterans whether they were
satisfied with being able to get care when they need it. How will such
a vague, subjective standard alone provide more accurate data than also
objectively monitoring the full time a Veteran waits for care?
VA Response: We recognize that Veterans are still waiting too long
for care. However, in an effort to determine how we can better meet
Veterans' needs, Veteran satisfaction is an essential and complementary
component. Veterans have expressed that wait times are not the only
worthwhile indication of their experience with VA, and that's why we
must transform the way we do business. We have learned that figures
measuring the wrong metric can cause unintended consequences and
confusion, like the 14 day metric in 2014 that was central to employees
working to a metric rather than the real needs of patients. Further,
arbitrary wait time metrics, alone, are clinically irrelevant. For
example, if a patient's condition requires an appointment within a
week, a 14 day wait is a failure, albeit within the stated limit. VA
will not do away with wait time metrics, but we must expand how we
assess access, in the same way the private sector does.
VA is working hard to increase access to care. We have hired more
doctors and nurses; increased clinic space; extended clinic hours; and
worked more closely with community providers to refer Veterans.
Additionally, we focus first on patients with the most urgent health
care needs. To improve customer service, VA is collaborating with
private sector companies known for providing positive experiences to
their customers to understand how we can ensure the highest quality
care to the Veterans we serve. Hearing directly from Veterans that we
are effectively serving them is the best gauge of success.
VHA is the only health care system in the country that publicly
reports wait times, but we have also come to realize the shortcomings
in how this figure was captured in our scheduling systems. For
instance, we cannot readily distinguish appointments for urgent needs
(for which same or next-day access is critical) from appointments for
routine check-ups or follow-up. Nor can we parallel our performance
with private sector providers, because they do not routinely collect or
publish comparable data. At best, our wait time metric is an
``operational indicator'' that we will continue to use on a daily basis
to address the match between patient demand and capacity to deliver
care.
We made the commitment in 2016 to use feedback from the Veterans we
serve as our most important accountability measure for Access. We have
adopted the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) patient survey, which is the industry standard used by every
large integrated health care delivery system in the United States. The
CAHPS survey includes several questions about Veteran's experience
getting care for routine and urgent needs over the prior 6 month
period. We know, from CAHPS, that Access is a problem for a significant
proportion of our Veterans, although they do give us high marks for the
quality and comprehensiveness of our care once they are seen. Asking
the Veteran what their experience with Access has been will ensure our
efforts will stay truly focused on their needs. This Veteran-centric
approach to assess Veteran satisfaction is also in line with the MyVA
Access Declaration Statement principles.
QUESTIONS FOR THE RECORD FROM CONGRESSWOMAN JACKIE WALORSKI
Question 1: VA has stated that IT scheduling software was the
reason for manipulated wait times, but as we discussed in the April 14
joint Subcommittee hearing, this is a self-inflicted wound. Will VSE
and VSR prevent employees from manipulating data, and will it have
audit controls that cannot be shut-off so that any changes are
documented?
VA Response: VSE is VA's new scheduling software. Among other
things, it will change the business processes that schedulers use to
make, cancel, and reschedule appointments. These updated business
processes are anticipated to make scheduling more reliable in VA,
reduce scheduling errors, and eliminate scheduling manipulation.
Specific process improvements will include:
Eliminating the ability to ``zero out'' appointments:
- In legacy VistA, the application allows schedulers to first enter
a preferred date and then search for available appointment slots. Once
available slots are found, the scheduler can go back and change the
preferred date to match the open appointment slot. This is known as
``zeroing out'' waiting times.
- VSE does not allow zeroing out appointments. In VSE, the first
step is to create an appointment request document by entering the date
the patient wants or needs to be seen. Once entered, the date cannot be
changed. The second step is to display the calendar and make the
appointment. Even if multiple calendar queries are necessary to find an
open appointment date in the calendar, the original preferred date
remains ``greyed out'' and unable to be changed.
Improving the accuracy of lists:
- In legacy VistA, when an appointment is made from any of numerous
lists, the scheduler must both make the appointment and intentionally
remove the patient request from the list. If the scheduler fails to
remove the patient from the list, duplicate appointments may be made.
- VSE consolidates all of the current waiting lists (Appointment,
Electronic Wait List, Consults, New Enrollee Appointment Request, and
Recall) into a single request queue. Appointments may only be made by
opening the request from the consolidated list. Appointment creation in
VSE automatically closes out the request resulting in improved accuracy
of the ``lists.''
Eliminating cancellation by clinic errors:
- In legacy VistA, when a user cancels a patient by clinic, they
must write down the CID/PD on a piece of paper. Then the user makes a
new appointment and transfers the CID/PD manually to the correct field
in the new appointment. This is the standard way that the correct CID/
PD is preserved.
- In VSE, when the user chooses cancel by clinic, the original CID/
PD is ``greyed out'' and preserved. The cancellation request then
reverts to the request list. When a new appointment is made from that
request, the original CID/PD is automatically entered into the new
appointment.
Improving the accuracy of CID/PD for multiple book
appointments:
- In legacy VistA, when making sequential appointments, for
example, for group clinics, the CID/PD from the first appointment in
the sequence was used as the reference point for each subsequent
appointment. This inflated wait time measurements.
- In VSE, when making sequential appointments, the CID/PD is
entered once when making the first appointment in the sequence and the
computer calculates the correct CID/PD for each subsequent appointment.
If future appointments in the sequence are cancelled and rescheduled,
the correct CID/PD is used for the rescheduled appointment.
Eliminating ``next available'' errors:
- In legacy VistA, the user must respond to the question ``is this
a next available appointment?'' If the user answers ``yes,'' the CID/PD
is set to ``today.'' If the user answers ``no,'' the CID/PD must be
entered by the user. The easiest way to use legacy VistA is to respond
``yes'' to this question, artificially inflating wait times.
- In VSE, the workflow is totally redesigned. The user enters the
CID/PD as a first step. Once entered, it cannot be changed. When
entered correctly, the application displays the appropriate times on
the calendar, making appointing more efficient.
However, we recognize that a technical response, alone, will not
serve to develop a premium Veteran-centric mindset in VA employees. To
foster enthusiasm for Veteran service in VA's workforce, VA will
implement structural processes to reinforce a high performing ethos
with passionate leadership. In the fall of 2014, the Secretary of
Veterans Affairs, Robert A. McDonald, announced the transformational
initiative, MyVA, with an emphasis on executing and cascading
principles embedded in the 2014-2020 Strategic Plan. Wait time goals
were eliminated from network and facility directors' performance plans,
and managers will be trained to use performance indicators, goals, and
awards that are appropriate for the Veteran service environment. This
will help VA leaders to use performance data in the appropriate way, to
identify challenges and begin a conversation about root causes and
potential remedies; not as input solely for punishment and reward.
To address Secretary McDonald's MyVA Breakthrough Priority of
improving employee experience, the Leaders Developing Leaders program
was established. Leaders Developing Leaders will transform VA from a
rules-based to a principles-based organization by developing authentic
servant leaders. Leaders Developing Leaders will reach approximately
7,300 VA leaders and front line staff and will result in more than 400
projects to strengthen leadership skills and enhance the culture of VA.
As leaders and their teams adopt this mindset and put it into
practice, teams will experience greater levels of trust, engagement,
and enhanced productivity. The MyVA ultimately effect culture change
within the organization that is more closely aligned to, and more
effectively supports, long-term organizational goals and innovation.
Question 2: A VA Policy from the Northern Indiana Health Care
System states that a Primary Care Provider ``has no obligation to
follow a treatment plan or medication provided by the community
provider if they disagree with the plan..'' How is that Veteran-
centric? Are VA physicians required to at least contact the Choice
provider to discuss the recommended treatment and coordinate any
changes prior to substituting their own treatment? If not, why not?
VA Response: There is both a VHA policy and a local policy that
outline processes for co-management of patient care. Outlined in the
Plan to Consolidate Programs of Department of Veterans Affairs to
Improve Access to Care report, care coordination for all Veterans in
the future will fall along a continuum of intensity, from basic care
coordination or patient navigation to care or disease management to
case management. This continuum is influenced by a variety of factors:
the complexity of clinical conditions, Veteran preference for
engagement, the primary care provider, and the care setting. VA
currently offers many diverse care coordination programs that can be
difficult to understand and navigate, but we plan to consolidate these
programs into an integrated, enterprise-wide model implemented locally.
As care coordination matures at VA, it will be provided as a service to
community providers who care for Veterans in need of more intensive
coordination. The impact of this coordination continuum is to enable
Veterans to receive the type of care management and coordination
necessary to achieve positive health care outcomes.
Question 3: At the Marion VAMC, a Veteran with Alzheimer's was seen
by a non-VA specialist. That physician prescribed non-formulary
medication that VA then would not authorize. VA required its formulary
drugs to be tried first, with suitable time for evaluation for each of
these drugs separately, before allowing a non-formulary request to even
be considered. How is that Veteran-centric? Are VA physicians required
to first contact the non-VA specialist to discuss the situation? If
not, why not?
VA Response: As with all other VA medical centers, the Marion VAMC
has a policy which requires providers to first prescribe medications
that are on our formulary. If a request is made to utilize a non-
formulary medication, either by a community provider or a VA provider,
we first see if we have a suitable medication on our formulary that has
the same indication and efficacy. If it is found that a formulary
medication is either not tolerated or is insufficiently efficacious,
then a provider may request a medication that is not on the VA
formulary.
VHA would happily provide more specific information regarding this
Veteran if more details and a privacy release from the Veteran are
provided. In addition, VHA could ensure ongoing coordination of
services for this Veteran.
Question 4: In another example, a disabled Veteran rated at 60% for
back and nerve damage has been denied for care closer to home and
instead VA is requiring the Veteran to drive 64 miles round trip three
times a week for treatment at VA. How is this Veteran-centric care?
VA Response: VHA would happily provide more specific information
regarding this Veteran if more details and a privacy release from the
Veteran are provided. VA authorizes care in the community in accordance
with applicable law, including the Choice Act, and VA policy. With
respect to VCP, Veterans may be eligible based on wait-times,
residence, or because they face an unusual or excessive burden in
travel. Eligibility determinations based on the unusual or excessive
burden criterion are made at the local level based on the particular
facts of the Veteran's circumstances.
Question 5: In Evansville, Indiana, VA staff discussed a provider
staffing shortage that required the Call Center to stop making and/or
rescheduling appointments for primary care. The facility specifically
indicated ``appointment slots are limited, and we are hoping this will
decrease the amount of movement of the patients.'' This is alarming.
Please tell me what VA Central Office is doing to correct these types
of actions.
VA Response: Capacity at the Evansville Health Care Center is
adversely affected by five Patient Aligned Care Team (PACT) clinician
vacancies. To assure patients are scheduled appropriately, appointments
are triaged by clinical staff so that each Veteran's needs are properly
addressed through the correct appointment type. Types of appointments
include face-to-face appointments with a provider; phone appointments
with a provider; appointments with ancillary services as indicated;
appointments at other locations; or CHOICE.
Calls to the Evansville Health Care Center (HCC) do not go through
the Call Center. The facility uses the nationally approved call tree
for Primary Care and calls go directly to the clinic. If the extension
is busy, the call will route to the next available clinic in the
Primary Care queue. In the event a Veteran would call the Marion VA
Medical Center number and request to speak to an Evansville HCC clinic,
the call would be transferred to the appropriate location with a warm
hand-off or a message entered in the Computerized Patient Record System
for the clinic to return the call to the Veteran.
Question 6: The Evansville VA has assigned Veterans to ``vacant
panels,'' which, according to a whistleblower, means there is a
documented appointment but no doctor to see the Veteran. Why are these
patients not sent to Choice?
VA Response: Evansville HCC currently has five PACT clinician
vacancies and two float position vacancies. Provider vacancies resulted
from clinician retirement, transfer, or separation. No new Veterans
have been assigned to panels without a provider to see the Veteran. For
Veterans previously assigned to a vacant panel, several options for
appointment are offered to each Veteran:
The six staffed PACT teams utilize two slots a day for
appointments for Veterans assigned to vacant panels.
Vacant panels are clinically reviewed to determine how
best to meet each Veteran's needs - through face-to-face or phone
appointments with PACT or appointments with an ancillary service such
as Behavioral Medicine, Social Work, Nutritionist, etc.
If appointments are not available on the Veteran's
preferred date, the Veteran is offered an appointment at other
Community Based Outpatient Clinic locations.
If no other location with earlier appointments is
acceptable to the Veteran, the Veteran is offered the next available
appointment at the Evansville HCC. If the wait time is greater than 30
days, the Veteran is offered community care through VCP.
Letter From Michael J. Missal to Chairman Jeff Miller
The Honorable Jeff Miller Chairman
Committee on Veterans' Affairs United States House
of Representatives Washington, DC 20515
Dear Chairman Miller:
At the Committee's April 19, 2016, hearing on ``A Continued
Assessment of Delays in Veterans' Access to Health Care,'' the Office
of Inspector General (OIG) indicated that it would provide additional
information in response to questions asked by Congressmen Hueslkamp,
Coffman, and Abraham regarding the number of OIG referrals made to the
U.S. Department of Justice in connection with our investigations into
allegations of manipulation of appointment wait times throughout the
Veterans Health Administration. Additionally, Congressman Abraham
inquired about the scope of the OIG's work in response to allegations
of secret wait lists at the Edward Hines, Jr., VA Hospital in Hines,
Illinois, and the Overton Brooks VA Medical Center in Shreveport,
Louisiana. Enclosed is our response to those questions.
Thank you for the opportunity to provide this information for the
hearing record.
Sincerely,
MICHAEL J. MISSAL
Enclosure
Copy to: The Honorable Corrine Brown, Ranking Minority Member
The Honorable Tim Huelskamp
The Honorable Mike Coffman
The Honorable Ralph Abraham
Additional Questions and Answers
Mr. Huelskamp: I understand we had 58 cases referred to the
Department of Justice for possible criminal charges. What has the
response been from the Justice Department for those 58 criminal cases
and the disposition of those?
Mr. Coffman: How many criminal referrals occurred of people who
were involved in this [wait times] scandal?
Mr. Abraham: Were there any criminal charges that were sent up to
the DOJ for prosecution that you know of?
OIG Response: The VA Office of Inspector General (OIG) opened 116
investigations at 100 unique Veterans Health Administration (VHA) sites
regarding allegations that wait times for outpatient appointments were
manipulated to give the appearance of a shorter wait for care or that
consult appointments were inappropriately cancelled with apparent false
justifications. We opened more than one investigation at some
individual VHA facilities when allegations appeared to be unrelated
schemes.
To date, the OIG made formal referrals to the Department of Justice
for 57 of the 116 investigations. Federal prosecutors indicated that 51
of the investigations do not warrant further consideration. Opinions
regarding prosecutorial merit for four investigations are currently
pending. One case was accepted for prosecution in Georgia, and the
defendant, Cathedral Henderson, was indicted on July 8, 2015. \1\ The
trial in this case is scheduled for May 23, 2016. A second case, which
initially started as a wait times investigation but became a conflict
of interest case, was accepted for prosecution, and the defendant,
Sharon Helman, pled guilty on March 1, 2016, to making a false
statement.
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\1\ http://www.justice.gov/usao-sdga/pr/va-employee-charged-
falsifying-medical-records-numerous- veterans.
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To date, we have referred supporting evidence or detailed memoranda
regarding 81 sites to VA's Office of Accountability Review for any
administrative action VA deems appropriate. In February 2016, we began
releasing the findings of the completed investigations by state so that
veterans and Congress could have a complete picture of the work
completed in their state. To date, we have published 76 administrative
summaries of investigation. As we continue to complete these
investigations, we intend to post them to this webpage.
Mr. Abraham: In a February 25, 2016, letter to the President from
the Office of Special Counsel, [OSC] said that VA OIG investigations of
whistleblower disclosures regarding wait times at Hines, Illinois, and
Shreveport, Louisiana, which is in my state, were inadequate. OSC found
that, ``the OIG investigations found evidence to support the
allegations that the employees were using separate spreadsheets outside
of the VA's electronic scheduling and patient record systems. However,
the OIG largely limited its review to determine whether the separate
spreadsheets were `secret.''' Please explain why the OIG limited these
reviews?
OIG Response: Thank you for the opportunity to explain this matter
more fully. OSC has two specific functions under Title 5 U.S.C. Section
1213 and 1214.
Under Section 1213, OSC has the authority to accept
complaints or disclosures of violations of law, rule, regulation, gross
mismanagement, gross waste of funds, an abuse of authority, or a
substantial and specific danger to public health and safety. OSC does
not, however, have authority to investigate these allegations. If OSC
determines that the matter should be investigated, OSC is required,
within 15 days of receiving the allegations, to refer the matter to the
head of the agency for investigation. For disclosures specific to VA,
the Secretary of Veterans Affairs is the individual to whom the
referral is sent under Title 5 U.S.C. Section 1213. Under the statute,
the head of the agency is required to conduct an investigation and
provide a written report that includes specific information defined in
the statute within 60 days. The OIG does not receive Section 1213
referrals from OSC and has no statutory responsibility to conduct an
investigation or provide a written report to OSC. If the OIG has
ongoing work relating to a Section 1213 referral, that work is provided
to VA and may be the basis for VA's report to OSC.
Under Section 1214, OSC has the authority to investigate
allegations of prohibited personnel practices. When OSC conducts an
investigation that requires the production of records maintained by the
OIG, OSC sends a written request to the OIG's Information Release
Office and the records are provided as allowed by statute. We are not
aware of any request by OSC for documents that have not been timely
provided to OSC pursuant to its Section 1214 authority.
On June 5 and December 22, 2014, respectively, OSC, under its
statutory authority granted under Title 5 U.S.C. Section 1213, referred
allegations to the Secretary of Veterans Affairs for investigation
concerning the Edward Hines, Jr., VA Hospital (Hines VA Hospital) in
Hines, Illinois, and the Overton Brooks VA Medical Center (VAMC) in
Shreveport, Louisiana. VA submitted its responses to OSC in July and
August 2015, respectively. VA's responses to OSC relied on two prior
OIG investigations conducted at each facility. In its February 25,
2016, letter to the President, OSC opined that:
``The OIG investigations that the VA submitted in response to both
referrals are incomplete. They do not respond to the issues that the
whistleblowers raised. The OIG investigations found evidence to support
the whistleblowers' allegations that employees were using separate
spreadsheets outside of the VA's electronic scheduling and patient
records systems. However, the OIG largely limited its review to
determining whether these separate spreadsheets were ``secret.''
However, neither of the OIG wait time investigations cited by OSC
in its letter to the President was conducted in response to a Section
1213 referral from OSC to the VA Secretary. In both cases, OSC made a
Section 1213 referral to the VA Secretary months after the OIG
investigations had begun.
Overton Brooks VAMC, Shreveport, Louisiana
This OIG investigation was conducted in response to a complaint to
the OIG Hotline on June 11, 2014, to which the complainant attached
what was referred to as a ``secret wait list'' that was ``obtained from
the Mental Health shared drive in Shreveport.'' The complainant alleged
that a specific VA employee had ordered other employees that she
supervised to ``not have clerks place persons on the electronic wait
list and keep a separate list.'' The complainant stated that he ``got
his hands on the list after a Nurse gave [him] her password to the
list.'' The OIG interviewed the complainant on June 18, 2014, more than
6 months prior to OSC's December 22, 2014, Section 1213 referral to VA.
During that taped interview, the complainant stated that he did not
have personal knowledge of the purpose of the list and told the
investigators that other individuals had told him about the list.
Further, the individuals the complainant identified as having knowledge
of the ``secret list'' were interviewed but did not support the
complainant's allegations. In this case, the OIG investigation did not
substantiate the allegations the complainant raised in his OIG Hotline
complaint. The allegations attributed to the complainant in the
December 22, 2014, Section 1213 OSC referral to the Secretary were not
raised by the complainant during the OIG investigation. In addition,
neither the complainant nor OSC provided any documentation or other
information to support the allegations in the Section 1213 referral.
As discussed in the Administrative Summary of Investigation
published on our website, the investigation was expanded proactively to
look at wait time manipulation in non-mental health areas. Mental
health was not included in the investigation because mental health
issues were the subject of a separate health care inspection that was
initiated in response to a September 19, 2014, request by the then
Ranking Member of the Senate Veterans' Affairs Committee, Senator
Richard Burr. During that inspection, additional issues relating to
mental health were raised and made part of the inspection. The
inspection report was published on the OIG website in January 2016, a
month before OSC wrote a letter to the President.
The OIG completed investigation was referred to VA's Office of
Accountability Review (OAR) in August 2015. It is our understanding
that VA then provided the required Section 1213 written report to OSC
on or around August 26, 2015. Unfortunately, there were no
communications between the OIG and OSC regarding the Section 1213
referral to VA before or after VA sent the written report to OSC. In
addition, we are not aware of any communications between OSC and VA
regarding the written report between August 26, 2015, and OSC's
February 25, 2016, letter to the President.
Edward Hines, Jr. VA Hospital, Hines, Illinois
The OIG investigation at the Hines VA Hospital began in response to
reports by various Chicago and national media outlets regarding
``secret backlog lists.'' The media reports were generated by
information provided to the media by a complainant. After seeing the
media reports, the OIG immediately began an investigation. Beginning on
May 14, 2014, OIG investigators made numerous attempts to interview the
complainant. She agreed to be interviewed on May 27, 2014. In addition,
on May 21, 2014, the OIG received a letter from Senator Mark Kirk
requesting that the OIG investigate allegations that ``veterans at the
Hines VA facility were provided informational briefings and general
consultations in lieu of medical care in order to meet the VA's
mandated fourteen-day window for appointments.'' In addition, Senator
Kirk advised that his office had ``received additional reports that
veterans seen within the fourteen-day window were sometimes not able to
see a doctor, and instead met in group consultation/informational
sessions without actually receiving medical care.'' Senator Kirk
requested that the OIG investigate three specific issues, which are
addressed in our Administrative Summary of Investigation. OSC did not
submit a Section 1213 referral to the Acting VA Secretary until June 5,
2014, after our investigation into the complainant's allegations and
Senator Kirk's request for an investigation had begun.
As noted in our Administrative Summary of Investigation relating to
the Hines VA Hospital that is published on our web site, during the
interview the complainant made a number of allegations but did not
provide documentation or other information to support her allegations.
The complainant did provide two emails that she claimed supported the
allegations; however, investigative interviews with the authors of the
emails did not support the complainant's claim. The complainant
admitted to having no personal knowledge of any other scheduling
manipulations or improprieties at the Hines VA Hospital or first-hand
knowledge of patient deaths or drastic changes in patient conditions
relating to wait times or scheduling manipulation at Hines. Although
the complainant stated that they had been contacted by 20-25 people who
claimed to have knowledge of these issues, the complainant refused to
provide names or further information such as details of these contacts.
Further, the complainant also claimed to have relevant documentation
but refused to provide it without written assurance that they would not
be held responsible for violating the Health Insurance Portability and
Accountability Act, an assurance the OIG has no authority to make. In
addition, the complainant specifically denied that they had any
additional emails, documents, or evidence to provide. Despite the fact
that the allegations lacked specificity and the complainant could or
would not provide any supporting evidence, the OIG conducted an
investigation of the allegation relating to the mental health service
and an investigation into scheduling issues in other clinical areas.
The June 5, 2014, Section 1213 referral to VA consisted of general
allegations from the complainant but also lacked specificity,
investigative leads, and supporting documentation. In addition, the
discussion in the referral letter did not include the names of the
employees who complained to the complainant or would have relevant
information, the names of the supervisors who engaged in the conduct, a
specific date or timeframe during which the conduct occurred, or a
specific clinic. Although several services were listed, the list is
followed by ``and other units.'' Such vague allegations coupled with
the fact that the complainant did not provide more specific information
to the investigators rendered it difficult, if not impossible, to fully
investigate.
OIG work at the Hines VA Hospital was not limited to wait time
allegations. In April 2014, we issued a report concerning unnecessary
cardiac interventions and poor management of cardiovascular care. We
are currently doing follow-up work on this issue. In the original work,
we engaged the services of consultants, including a non-VA thoracic
surgeon to review patient records and to identify if any patients were
harmed. In the follow-up work, we engaged a non-OIG consultant to
assist in the evaluation of clinical cases.
The Hines VA Hospital investigation was sent to VA's OAR on January
26, 2015. It is our understanding that VA provided OSC with a written
report compliant with Section 1213 in September 2015. It was not until
we saw OSC's letter to the President that we learned OSC had concerns.
There was no communication between OSC and OIG staff regarding this
matter.
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