[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




 
    TRUE TRANSPARENCY? ASSESSING WAIT TIMES FIVE YEARS AFTER PHOENIX

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, JULY 24, 2019

                               __________

                           Serial No. 116-27

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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              U.S. GOVERNMENT PUBLISHING OFFICE 
40-856                 WASHINGTON : 2021         


          
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

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hearing records of the Committee on Veterans' Affairs are also 
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                            C O N T E N T S

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                        Wednesday, July 24, 2019

                                                                   Page

True Transparency? Assessing Wait Times Five Years After Phoenix.     1

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
Honorable David P. Roe, Ranking Member...........................     2

                               WITNESSES

Dr. Debra Draper, Ph.D., M.S.H.A., Director, Health Care Team, 
  U.S. Government Accountability Office..........................     4
    Prepared Statement...........................................    43

Dr. Teresa S. Boyd, Assistant Deputy Under Secretary for Health 
  for Clinical Operations, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     5
    Prepared Statement...........................................    57

        Accompanied by:

    Dr. Susan R. Kirsh, Acting Assistant Deputy Under Secretary 
        for Health for Access to Care, Veterans Health 
        Administration

    Dr. Clinton "Leo" Greenstone, Deputy Executive Director for 
        Clinical Integrity, Office of Community Care, Veterans 
        Health Administration

The Honorable Kenneth W. Kizer, MD, MPH, Chief Healthcare 
  Transformation Officer & Senior Executive Vice President, Atlas 
  Research, Inc..................................................     7
    Prepared Statement...........................................    61


    TRUE TRANSPARENCY? ASSESSING WAIT TIMES FIVE YEARS AFTER PHOENIX

                              ----------                              


                        Wednesday, July 24, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:00 a.m., in 
Room 210, House Visitors Center, Hon. Mark Takano [Chairman of 
the Committee] presiding.
    Present:Representatives Takano, Brownley, Lamb, Levin, 
Brindisi, Rose, Pappas, Lee, Cunningham, Cisneros, Peterson, 
Allred, Underwood, Roe, Radewagen, Bost, Dunn, Bergman, Banks, 
Meuser, and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good morning. I call this hearing to order.
    This year marks the 5-year anniversary of a watershed 
moment for VA and for this Committee: the 2014 VA wait time 
scandal. Whistleblowers from the Phoenix VA health care system 
exposed an elaborate scheme by supervisors and senior leaders 
to conceal the amount of time veterans were waiting to receive 
health care. Some patients' conditions deteriorated, while 
other veterans died after waiting too long for VA appointments.
    After months of hearings and independent investigations, we 
concluded that serious appointment scheduling improprieties and 
delays in veterans' access to care were not limited to Phoenix, 
but were occurring at dozens of other VA facilities nationwide. 
And this had been going on for years.
    To address this, Congress passed the Veterans Choice 
Program in August 2014 with the goal of helping veterans' 
access more timely health care by sending them to community 
providers.
    Five years ago today, we held a hearing with VA's then- 
Acting Secretary, Sloan Gibson, and leaders from several 
veteran's service organizations, to learn how VA planned to 
restore the trust of veterans, Congress, and the American 
people.
    In his statement for that hearing, Mr. Gibson presented a 
stark, but honest assessment of VA's challenges. Three of the 
main challenges he identified are on this chart behind me: 
widespread scheduling improprieties, inadequate IT resources, 
and a culture of fear and retaliation.
    Honestly, after reviewing our witnesses' written testimony 
and several articles that have appeared recently in the 
national media, I am alarmed that too much of what Acting 
Secretary Gibson observed 5 years ago still rings true today. 
This is, frankly, just unacceptable. We simply cannot put 
veterans' lives at risk while they wait for care.
    Today, it is time to assess VA's progress in earning back 
the trust of veterans, Congress, and the American people.
    Within the last couple of months, several media outlets 
published articles where whistleblowers allege that VA is still 
keeping secret waiting lists. This doesn't come as a surprise.
    Our Committee staff also have been approached by several 
whistleblowers with these allegations, and some have faced 
retaliation after raising their concerns with VA. They allege 
that VA has mass-canceled pending requests for certain types of 
care without sufficient clinical review, and that front-line 
employees have been ordered to schedule veteran patients in 
imaginary clinics as a means of concealing wait times.
    Some of these whistleblowers recently testified before our 
Committee. Yet, as we learned from the whistleblower hearing 
that wrapped up yesterday, VA's Office of Accountability and 
Whistleblower Protection is failing to protect whistleblowers.
    We rely on whistleblowers to speak truth to power and hold 
VA accountable. OAWP must do its job and immediately end the 
toxic culture of retaliation at VA.
    Dr. Boyd, you claim in your written statement that, quote, 
``no veterans were harmed,'' end quote, as a result of being on 
wait lists like those mentioned in the news. You also state 
that VA is operating with, quote, ``unprecedented 
transparency,'' end quote. Those are two very bold statements.
    With the MISSION Act, more and more veterans will be 
eligible for community care. However, as you will hear from 
some of our witnesses today, VA has never reliably tracked or 
reported veterans' wait times for community care, yet there is 
evidence that wait times in the community are often longer than 
wait times for VA care. VA's own data on wait times for 
appointments at VA facilities remain incomplete and unreliable.
    The policy goal of the Choice Act and the MISSION Act was 
to reduce wait times for veterans and increase access.
    Therefore, the lack of accurate information on wait times 
at VA hospitals and with community providers should cause us 
all to question whether the policy to send more veterans to 
community care providers is sound or even if it is working.
    Veterans have a right to make informed choices about where 
to receive care; however, that choice is dependent on 
transparent and accurate information about wait times. This 
Committee will not allow our veterans to be harmed by the same 
deceptive practices that led to the Phoenix VA scandal.
    I look forward to engaging our witnesses and my colleagues 
in this conversation, and with that, I will recognize Ranking 
Member Dr. Roe for 5 minutes for any opening remarks that he 
may have.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman.
    A little over 5 years ago, as the Chairman stated, on April 
14th, 2014, this Committee held a hearing very similar to this 
one on ``Access to Care for Veterans in the Department of 
Veterans Affairs.''
    During that hearing, then-Chairman Miller disclosed that a 
Committee investigation had uncovered a secret list, a waiting 
list at the Phoenix VA Medical Center, and that as many as 40 
veterans on that list had died waiting for care. That 
disclosure embroiled VA in a nationwide access-and-
accountability crisis that is still reverberating across the VA 
health care system today.
    We would be remiss if we do not take a moment to 
acknowledge the many ways in which access to care for veterans 
has improved since 2014. VA is seeing more veteran patients 
today than ever before.
    Last year alone, VA completed more than 1 million more 
appointments than it had the year before. In many cases, those 
appointments occurred faster within VA than they would have in 
the private sector, according to the Journal of the American 
Medical Association. We should all be proud of those 
achievements, particularly the thousands of VA employees across 
the country whose hard work is what led us to that.
    However, despite how far VA has come in the last 5 years, 
there is no doubt that VA has further still to go. While I was 
preparing for this hearing yesterday morning, the VA Inspector 
General released an alarming report about delays in care for 
veterans seeking mental health appointments at the Albuquerque 
VA Medical Center. That report paints a heartbreaking picture 
of why we must continue to focus on access to care for our 
Nation's veterans, until we are assured that every veteran, 
every time, receives the care that they need when they need it.
    In a system as large and dynamic and as evolving as VA, 
there will never be a perfect way to measure access; it is as 
much of an art as it is a science. That is why I am grateful to 
have the experts from VA and the Government Accountability 
Office, and the private sector, here with us today to discuss 
not only how access has improved for veterans over the last 5 
years, but also how it can continue to improve for veterans 
over the next 5 years.
    I am particularly grateful to have Dr. Kenneth Kizer with 
us. Dr. Kizer is a veteran of the United States Navy, a 
physician with a long and distinguished career as a public 
health leader in government, the private sector, and academia. 
He also served as Under Secretary for Health in the mid-'90s 
during the last critical transformation period for the VA 
health care system.
    Thank you, Dr. Kizer, for taking time out of your busy 
schedule to share your expertise with us this morning. I am 
very much looking forward to your testimony and that of your 
fellow panelists.
    With that, Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Roe.
    With us today are Dr. Debra Draper, Director of the Health 
Care Team at the U.S. Government Accountability Office, 
otherwise known as the GAO. We have also Dr. Teresa Boyd, 
Assistant Deputy Under Secretary for Health for Clinical 
Operations, accompanied by Dr. Susan Kirsh and Dr. Clinton 
Greenstone.
    We also have with us the Honorable Kenneth Kizer, Chief 
Healthcare Transformation Officer and Senior Executive Vice 
President of Atlas Research, Incorporated.
    And with that, I will begin with Dr. Draper for her opening 
statement.

                  STATEMENT OF DEBRA A. DRAPER

    Dr. Draper. Chairman Takano, Ranking Member Roe, and 
Members of the Committee, thank you for the opportunity to be 
here today to discuss VA's medical appointment wait times on 
the 5th anniversary of this Committee's hearing following the 
Phoenix wait times crisis in 2014. While Phoenix was the 
epicenter of the crisis, the identified problems were 
widespread, affecting the entire VA health care system.
    Access to timely health care is critical for veterans 
seeking needed medical care; however, long wait times and 
weaknesses in the schedule system have been persistent, and 
have hindered veterans' ability to access care. For the past 20 
years, we have conducted an extensive body of work on veterans' 
access to care. We have reported significant and wide-ranging 
weaknesses that contributed to the addition of veterans' health 
care to the GAO's high-risk list for the first time in 2015 and 
where it remains today.
    In 2012, we conducted a comprehensive review of VA's 
outpatient medical appointment scheduling policy and processes. 
We found that the medical appointment wait times reported by VA 
were unreliable, in part because VA did not ensure consistency 
in how schedulers recorded dates that provided the basis for 
measuring wait times. We found these dates to be subject to 
interpretation and prone to scheduler error. We recommended 
that VA clarify its definition of these dates. VA concurred and 
has taken some actions since 2012 to improve wait time 
measurement, such as improved oversight through ongoing audits 
of schedulers.
    VA provided us new information related to this 
recommendation on July 12th. Once we have had the opportunity 
to fully review this information, we will be able to determine 
what additional actions and information are needed. However, at 
this time we continue to be concerned that VA has not 
sufficiently addressed the reliability of its wait time data.
    For example, in its first internal audit in August 2018, VA 
was unable to evaluate the accuracy or reliability of its wait 
time data, data posted to its website or used by veterans.
    In 2012, we found that the medical appointment wait times 
reported by VA were also unreliable because VA did not ensure 
the schedulers received the required training. We recommended 
that VA ensure consistent implementation of a scheduling policy 
and ensure that all schedulers complete the required training. 
VA concurred with this recommendation and has taken action 
since 2012 to update its scheduling policy and complete 
training for schedulers.
    We believe that these actions, along with the additional 
information VA provided us earlier this month, sufficiently 
address this recommendation.
    While improvements to the VA's scheduling policy and 
processes will help ensure veterans timely access to health 
care, it is important to acknowledge that there are also other 
factors that may affect access that are not currently reflected 
in VA's wait time data. For example, we have found that VA's 
wait times do not capture the time it takes the Department to 
enroll veterans in VA health care benefits, which we found 
could be quite lengthy.
    Issues with appointment scheduling have not been limited to 
VA's internal delivery of care, but have also existed for its 
community care programs. Our prior work on appointment 
scheduling in VA's Choice Program found weaknesses resulting in 
recommendations to address the lack of timeliness goals and 
reliance on incomplete and inaccurate wait time data.
    In June 2018, for example, we found that the data VA used 
to monitor the timeliness of appointments for the Choice 
Program captured only a portion of the total appointment-
scheduling process. Although VA had a wait time goal of 30 days 
under this program, the timeliness data did not capture certain 
processes such as the time taken to prepare veterans' referrals 
and send those to a third party administrator. We found that, 
if those processes were accounted for, veterans could wait up 
to 70 days to see a provider.
    As of July 2019, our recommendations in this area have not 
been implemented. VA officials told us that these 
recommendations would be addressed by the tools and systems 
created for the new Veterans Community Care Program. According 
to VA officials, for example, one of the new systems that will 
support the management and monitoring of referrals, appointment 
scheduling, and authorizations will be fully implemented across 
all VA medical facilities in fiscal year 2021.
    In closing, we have identified weaknesses in VA's wait time 
measurement and scheduling processes over the years, affecting 
not only VA's internal delivery of care, but also that provided 
through community care providers. We have made a number of 
related recommendations. We are pleased that VA has taken 
actions to address some of these recommendations, but 
additional work is needed.
    The implementation of enhanced technology such as a new 
scheduling system is crucial and will provide an important 
foundation for improvements; however, this is not a panacea for 
addressing all of the identified problems. Moving forward, VA 
must also continue to ensure that its policies clearly 
delineate roles and responsibilities; oversight and 
accountability remain front and center; and training is ongoing 
and effective.
    Mr. Chairman, this concludes my opening remarks. I am happy 
to answer any questions.

    [The prepared statement of Debra A. Draper appears in the 
Appendix]

    The Chairman. Thank you, Dr. Draper.
    I will now turn to Dr. Teresa Boyd.

                  STATEMENT OF TERESA S. BOYD

    Dr. Boyd. Good morning, Chairman Takano, Ranking Member 
Roe, and Members of the Committee. I appreciate the opportunity 
to discuss VA's current practices for measuring veterans' 
access to health care and to provide a clearer picture 
concerning wait times in light of the 5-year anniversary of the 
issues in Phoenix.
    I am accompanied today by Dr. Susan Kirsh, Acting Assistant 
Deputy Under Secretary for Health for Access, and Dr. Clinton 
Leo Greenstone, Deputy Executive Director, Clinical 
Integration, Office of Community Care.
    VHA has undergone a tremendous transformation since 2014, 
operating with a renewed focus, unprecedented transparency, and 
increased accountability. We recognize that there are still 
challenges ahead of us, but it is important to keep in mind 
that veterans continue to receive the highest quality care, 
often with shorter wait times than in the private sector.
    As in the community, most VA patients come to us for 
routine or elective care. For established patients, VA's 
average wait times for primary care and mental health care 
appointments are under 5 days and 7 days for specialty care. To 
ensure that veterans with more urgent needs are accommodated 
appropriately, as of 2017 the VA began offering same-day 
services for mental health and primary care at all VA medical 
centers and community-based outpatient clinics across VA.
    So what does that mean? Well, it means that when a veteran 
contacts us seeking same-day services for primary care and 
mental health care, we address the need that day with perhaps 
an appointment, if that's appropriate; by refilling a 
prescription; answering a question over the phone or by secure 
messaging; or even scheduling clinically appropriate follow-up 
care.
    We have also simplified the consult management process and 
resolution of these referrals has made it easier for veterans 
to be seen in a timelier manner. When in 2014 it took an 
average of 19 days to complete a stacked consult, we are now 
completing these referrals in under 48 hours, which is the 
industry target.
    Listening to our employees and sharing strong practices 
across the enterprise, as well as lessons learned from 
implementing the Veterans Access, Choice, and Accountability 
Act of 2014 were among the reasons we have seen these 
improvements, and we expect continued success under the 
implementation of the MISSION Act of 2018.
    As a learning organization, VA encourage employees who have 
ideas or concerns to report them; VA will not tolerate efforts 
to retaliate against employees for doing so.
    In January, VA Assistant Secretary for Accountability and 
Whistleblower Protection, Dr. Tamara Bonzanto, was sworn in, 
and for the last several months she and her team have been 
working closely with the VA Inspector General to ensure her 
office is operating as Congress has intended and with maximum 
efficiency.
    When it became apparent that VHA needed to improve the 
scheduling process, we created the Office of Veterans' Access 
to Care, or OVAC, to lead VA's new approach, which has included 
updated scheduling software, standardized national processes, 
national audits, and scheduler trainings at the local level. 
More than 58,000 VHA employees, including medical support 
assistants, clinicians, nurses, and health care technicians 
have completed this training, which includes technical and 
customer service skills, as well as in-depth training on 
standard processes and procedures per VHA's scheduling 
directive.
    Over the last 5 years, we have transformed how we deliver 
care, and our success has been realized due to strategic 
planning and cooperative implementation efforts across the 
enterprise; once again, listening to our staff, our veterans, 
and their families.
    Recently, OVAC implemented a three-phase initiative to 
improve capacity, efficiency, and productivity to help 
facilities and our national teams better understand demand and 
increased access to care at specific sites. So, overall, this 
work has helped us to improve access to high-quality care for 
our Nation's veterans, more closely aligning capacity to meet 
demand.
    We also recognize that quality care comes from having 
adequate levels of staff available to provide and coordinate 
that care. Today, there are more than 200,000 health care 
professionals, including doctors and nurses, who treat veterans 
in the VA system.
    VHA values what veterans have to say, and we know that, 
ultimately, it is our veterans who will determine whether we 
are meeting their expectations as health care partners. To 
better understand that perspective, VA has moved to the 
industry standard for assessing patient satisfaction, the 
Consumer Assessment of Health Providers and Systems Survey.
    Based on survey results, veterans are telling us we are 
moving in the right direction. VA has seen improvement in 
patient satisfaction scores across every category related to 
veterans getting care when they needed it. More than 77 percent 
of those who responded to the survey said they were treated as 
a valued customer during their most recent VA encounter, and 
three in four veterans say they trust VA with their health 
care.
    Placing veterans at the center of their care helps ensure 
they receive that care when and where they need it, and is 
fundamental to all we do. We have made significant progress and 
are committed to earning the trust of our veterans and the 
American people. We will continue to improve veterans' access 
to timely, high-quality care from VA facilities, while also 
providing veterans with more choice to receive community care 
where and when they want it. Your continued support is 
essential to providing this care for veterans and their 
families.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I are prepared to respond to any questions you may have.

    [The prepared statement of Teresa S. Boyd appears in the 
Appendix]

    The Chairman. Thank you, Dr. Boyd.
    I now recognize Secretary Kizer for 5 minutes.

                 STATEMENT OF KENNETH W. KIZER

    Dr. Kizer. Good morning, Chairman Takano, Ranking Member 
Roe, and Members of the Committee. Thank you for the 
opportunity for allowing me to offer some comments about 
assessing and tracking wait times and timely access to care, 
and also to comment about what timely access to care means or 
the evolving nature of what that means today.
    You have my written testimony, so I am going to take the 5 
minutes I have here just to highlight a few points that were 
made there. And I would note also that my comments here are 
informed by more than 40 years of experience in a variety of 
health care roles, from being a practitioner to managing the 
largest health care system in the United States, to being a 
researcher and a variety of other perspectives on issues 
related to access.
    Perhaps the first point I would make is that, while 
assuring timely access to care is widely recognized as an 
important dimension of high-quality health care and has been a 
priority for American health care for many years, consistently 
achieving timely access to care continues to be a challenge 
throughout American health care. Unfortunately, long wait times 
for care are all too common for patients and families 
everywhere, although especially for those who are on publicly-
funded insurance such as Medicaid.
    I think the problems related to long wait times are known 
and I won't go into that. Suffice it to say that when patients 
have to wait weeks or months to see a physician, bad things 
tend to happen.
    There are multiple reasons why we have problems in timely 
access to care in this country, much has been written about 
this and I won't take the time now to delve into all of those 
reasons. I would just note that one of the problems simply is 
the lack of national standards about what constitutes timely 
access to care in the variety of settings in which patients 
receive care.
    I would also comment that wait times, while seemingly a 
straightforward or simple thing to measure, actually, 
technically, turns out to be exceedingly complex and difficult 
to capture, all the variables that go into wait times. And I 
would also note that even if wait times were accurately 
measured, they have many limitations. They are just one 
dimension of looking at access and access is a multi-
dimensional issue that includes many factors other than just 
wait times.
    I was gratified to hear that VA has moved to using HCAHPS 
as a patient-reported measure of timeliness of access. I would 
note that leading health care systems around the country are 
increasingly looking to patient-reported measures of timeliness 
of care in addition to looking at wait times, but they find 
that patients' perceptions of the timeliness of care is very 
revealing as to how well their health system is functioning. 
And we can talk more about that later, if there is interest.
    I think I would be remiss if I didn't also take the 
opportunity here to comment that in considering timeliness of 
care and how accessibility to care should be measured, we need 
to ask a basic or very fundamental question about what access 
to care means in an era of enhanced connectivity through all of 
the information and communication technologies that exist today 
that, candidly, 10, 15, 20 years ago were simply not available.
    In a time when a large proportion of the population 
accomplishes many critically important and sensitive 
activities, such as their banking through the Internet, we need 
to ask ourselves why do we continue to view access to care only 
or primarily through the lens of face-to-face visits. And, 
indeed, I would posit that measuring access to care simply by 
counting face-to-face encounters is increasingly anachronistic 
and really does not promote patient-centered care. We know that 
70 to 80 percent of patients when queried would like to be able 
to take care of their health care needs just like they take 
care of their banking and shopping and other needs through 
technology-enabled devices, and when those folks are queried, 
more than 90 percent of them say that they are satisfied and 
happy with their interactions through telehealth and health, 
other technology-assisted ways.
    And I would just perhaps, recognizing that the clock is 
running out, note that while VA is an acknowledged leader in 
telehealth and virtual care, I believe that it is has only 
scratched the surface of what could be done to enhance access 
to care through technology-assisted means. And I offer in my 
written comments a number of suggestions for where I think VA 
could go and should go to enhance access to care using 
technology-enabled means and engaging entities like the 
National Academy of Sciences, Engineering, and Medicine, and 
the National Quality Forum, to help them address some of the 
technical issues attendant to getting there.
    With that, let me close, and I am happy to respond to your 
questions.

    [The prepared statement of Honorable Kenneth W. Kizer 
appears in the Appendix]

    The Chairman. Thank you, Secretary Kizer. I now recognize 
myself for 5 minutes.
    Dr. Boyd, I will begin with you. Where can veterans go to 
find out about the wait times to see a community provider?
    Dr. Boyd. So currently the VA does not have a roll-up or 
even a provider's specific information about a specific 
community care provided.
    The Chairman. Okay, so the VA doesn't currently provide 
that, so there's no way for a veteran right now to be able to 
assess how long it will take to see a community provider.
    When a veteran makes an appointment, is that veteran given 
information about the wait time to see a VA provider versus a 
community provider, so they can make an informed decision about 
which is better?
    Dr. Boyd. So that is a great question and as I--and I was 
remiss in not mentioning this, but all three of us, the 
physicians here from VA, practicing physicians within the VA at 
some time--
    The Chairman. I only have so much time. I'm sorry, Doctor, 
I don't mean to be rude. But--
    Dr. Boyd. So I will answer that for you, I will answer that 
for you.
    The Chairman [continued]. --it would seem to me that since 
you can't find out any times for a wait time for a community 
provider that a comparison tool is also not possible; is that 
correct?
    Dr. Boyd. What I will answer is this. In my conversation 
with my patient, which is very sacred, I do mention what our 
eligibility wait times are within the VA and by the MISSION 
Act. And I do discuss with my patient, you need to be seen 
within X, Y, and Z time. So it is the patient preference to go 
out to the community, knowing when that needs to be done, or 
stay within the VA.
    The Chairman. But, nevertheless, there is not really a tool 
or information available to say this is how long it will take 
for the VA, this is how long it will take to go to the 
community, you don't have that capability right now?
    Dr. Boyd. We have that within what we call our Decision 
Support Tool that was rolled out on June 6th that all of our 
providers use when they meet with their patient and they 
discuss their options for care.
    The Chairman. We have--so that--but that is not available 
generally to the veteran outside on a website someplace, right?
    Dr. Boyd. That is correct.
    The Chairman. And we haven't seen this tool independently 
tested for the accuracy of these comparative wait times?
    Dr. Boyd. Well, I could pass off to Dr. Greenstone, who 
is--
    The Chairman. So, wait, does--
    Dr. Boyd.--effectively the developer of that.
    The Chairman [continued]. --does the tool actually show 
wait times?
    Dr. Boyd. The DST does.
    Dr. Greenstone. So, Mr. Chairman, the tool actually shows 
average wait times within the VA and we are now beginning to 
collect data that we intend to put into the tool to show 
comparative data in the community.
    The Chairman. So an average over how long, an average over 
30 days?
    Dr. Greenstone. Yes, it is a rolling 30-day average that we 
actually show.
    The Chairman. So, at the point of consultation, there is no 
real-time comparison, you know, within that day or the week for 
that veteran to know the real-time wait time at the facility, 
at the VA, or in the community?
    Dr. Greenstone. That is correct. So that is determined at 
the time that a scheduler is working with a veteran.
    The Chairman. So real-time wait times are not available. 
The average is available in a limited sense.
    Dr. Greenstone. That is correct.
    The Chairman. VA uses the Consumer Assessment Health Care 
Providers and Systems Survey, mentioned earlier, to collect 
data on whether a veteran received care when they need it and 
it is the health care industry standard. Why isn't this 
information made easier for veterans to find and why isn't VA 
publishing this same data from its community providers, so 
veterans know if they can expect to receive care in the 
community when they need it? Dr. Boyd.
    Dr. Boyd. So, currently, our veterans are able to look 
online. We have Access to Care website that our veterans can go 
online and look for their specific medical center or their CBOC 
as well.
    The Chairman. I understand that, but I specifically asked 
you about the Consumer Assessment Health Care Providers and 
Systems Survey data. My understanding is that VA does not 
publish this for community care providers.
    Dr. Boyd. That is correct.
    The Chairman. Yeah. So and why aren't we publishing that 
data?
    Dr. Boyd. That is--I could pass it off to Dr. Greenstone, 
who is more informed about that particular part.
    The Chairman. Dr. Greenstone, go ahead.
    Dr. Greenstone. Sure. So we do not have the specific HCAHPS 
data on the community providers. We have data on the veterans' 
experiences when those veterans go and see providers in the 
community, and we ask them the question about how satisfied 
were they with their community care experience with a provider 
they--
    The Chairman. But I have heard testimony here that these 
consumer reports are actually a pretty good way to figure out 
how timely the service is.
    Dr. Kizer, did you want to comment on this?
    Dr. Kizer. Well, a couple things I would say is, one, the 
private providers, community providers are not routinely 
required to report wait time data the same way that the VA is, 
and in the instances where some of that information is 
available, it certainly has not been subjected to the scrutiny 
for its accuracy and validity as has the VA data.
    The information on HCAHPS, while that could be gleaned from 
various sources and made available, that does tend to lag 
behind. Whether it is available in realtime or close to 
realtime may be more difficult to achieve, but some of that 
information is reported to the CMS and other bodies and one 
could basically mine those data sources to get some of that 
information.
    The Chairman. Well, thank you, Dr. Kizer.
    Dr. Roe, you are recognized for 5 minutes.
    Mr. Roe. Thank you, Mr. Chairman.
    Dr. Boyd, I guess one of the questions I have is that why 
does it take 3 months to enroll somebody in the VA health care 
system?
    Dr. Boyd. So I am not aware of a standard time for 
enrollment. We have multiple entryways for veterans to be 
enrolled; they can walk into a medical center, to the 
eligibility center, and sign up.
    Mr. Roe. Well, it says--I mean, I read the script today and 
the data in here and it said that--let me ask another question.
    And I read something in your testimony that I have a hard 
time believing--and I hope it is true, but I just have a hard 
time believing it is true, is if you call up, you can get an 
appointment that day for mental health or for primary care at 
any CBOC and at any VA medical center, 172 of them in the 
country.
    Let me just ask you this question: if a patient calls up 
and says I am having real problems coping and I am concerned 
about my safety, what does the scheduler tell this person and 
what do they do? Do they get in that day? And, if that is true, 
then what is going on in Albuquerque?
    Dr. Boyd. Okay. So that is a great question, it is about 
same-day services. So in that particular case, when that 
veteran calls in to that clinic, the scheduler is not clinical. 
That would be handed off to a clinical person who would assess 
the needs with the veterans, is this something that can be 
taken care of on the phone, with another health care provider 
through telehealth, a video-connect session, or is it of an 
urgent need and the veteran needs to go more of an urgent care 
center or to an ER.
    So, we assess the needs, and it is at very VA medical 
center and at every CBOC.
    Mr. Roe. Well, my bet is that I will call before the end of 
the day that refutes that, that would be my bet.
    Dr. Boyd. And, Dr. Roe, if I may add? Twenty percent of our 
completed appointments every single day--and we look at this 
every morning at 7:45--so 20 percent of our completed 
appointments every day are same-day appointments. So it is 
those same-day service requests that actually go on to making 
an appointment.
    Mr. Roe. Oh, I think it is a noble goal, I mean, I 
absolutely do, it is just hard for me to believe it can be 
carried out.
    Now, the VA is seeing over a million more patients in '18 
or '17, which is remarkable--or appointments, I should say--how 
does that occur? Is it new hires or are they not seeing a 
doctor, maybe they are seeing a nurse practitioner or a PA or 
something? How has that occurred? And then I have got a follow-
up question.
    Dr. Boyd. So I will be brief then; so, in a myriad of ways. 
We look at efficiencies of the actual clinics and to make sure 
that our grids are open, that is how we schedule patients, to 
making sure that we are effectively supporting a provider, 
whether it be a nurse practitioner, PA, or a physician. And so 
we have found efficiencies, we have found some extra time in 
there for bookable hours, if you will. So that is part of it.
    The other part is, you know, what we heard about 
telehealth, we have different modalities with which to actually 
see patients, if you will, to complete those appointments as 
well.
    So in some areas we have increased staff, because there was 
an increased demand and high-growth areas, and also using the 
actual team around say our primary care team or our mental 
health team, not always having to be just the provider.
    Mr. Roe. I guess the thing that I have looked at--and, Dr. 
Kizer, I would like to have--you are absolutely right, I don't 
know that we ever measured wait times; I know I didn't in our 
practice. And if one of the measurements is somebody calls in 
to get a refill, boy, I did really well with that, if you look 
at those--that is the standard that you are using, because I 
didn't even look at that as a contact with somebody that day. 
And typically, how a private--and I'm sure it does at the VA 
too works--you know, at the end of the day I would have 15 to 
30 phone calls that I would make to patients and contact them. 
Talk about telehealth, I used to telephone. We didn't have 
Internet then, but I did that, and I guarantee Dr. Kizer has 
done the same thing.
    Going forward--and I want to commend the VA for it has 
absolutely improved since 2014, there is no question about 
that. It has been a Herculean effort to do right by our 
Nation's veterans, there is no question about that. And I have 
got, Dr. Draper, just a couple of very quick questions. My time 
is about expired, but if you had today to improve the accuracy 
and consistency of this, what would you have the VA do today?
    Dr. Draper. Well, I think they need not to consider this as 
a one-off like training. This needs to be consistent. I mean, 
one of the issues is that the schedulers are among the top ten 
highest turnover positions in the VA. So, you know, there is 
constant turnover, there is, you know, really educating those 
schedulers and making sure that they are consistently 
implementing the scheduling policy, that is one big thing.
    Oversight and accountability, you know, we continue to find 
pockets of that where that is not so effective, and that really 
needs--as I said in my oral comments, that needs to be front 
and center and just on the mind, you know, pervasive on 
everything that they do.
    And I think that the--you know, the new scheduling system 
that is expected to roll out in the next couple of years, that 
will be very helpful, but that will not solve all the problems. 
You still have to, you know, as I said, have training, 
oversight and accountability, and other things that, you know, 
together.
    Mr. Roe. Just one last comment. The two most important 
people in my office was the first person to answer the phone 
when the patient called in to make that appointment and the 
person that greeted them when they came in, because if they had 
a bad experience there, it was going to be hard to get a good 
clinical experience.
    So I would encourage you to do exactly that, is train those 
folks that are doing the scheduling and meeting people. They 
are the front line, they are the face of the VA.
    I yield back.
    The Chairman. Thank you, Dr. Roe.
    I now recognize Mr. Allred for 5 minutes.
    Mr. Allred. Well, thank you, Mr. Chairman and Ranking 
Member Roe for holding today's hearing. I want to thank our 
witnesses for being here.
    Wait times for veterans in North Texas are too long. Every 
day, 40 to 80 veterans are in temporary care awaiting a bed at 
a VA facility, and that is why I led a bipartisan letter with 
my colleagues in North Texas to ask the VA to work with us in 
facilitating the acquisition of a donated hospital in Garland 
to help us meet the growing demand. This hospital is an easy 
solution to growing access problems and will help North Texas 
address the gaps in our capacity to provide for a growing 
number of veterans.
    So I will ask you, Dr. Boyd, to take that back to your 
colleagues in the VHA and the VA. Secretary Wilke has appeared 
before us in this Committee and has said that he is interested 
in doing it, the Dallas VA wants to do it, the City of Garland 
wants to do it, and I am a little bit frustrated at the amount 
of time that this is taking for us to move forward. It is 
something that we critically need to meet our capacity and it 
is I think the smart thing for the VA, for our veterans, and 
will save us a lot of money as well.
    Dr. Boyd. So, if I could just briefly comment. In many 
meetings recently there is an urgency with this discussion, so 
I just want you to know it is front and center. It is being 
discussed at all levels of VA and VHA. As you can only imagine, 
it is a very complex--it sounds easy, but it is a complex 
discussion, but no doubt we want to do the right thing for 
veteran care. So, just so you know, we are working it.
    Mr. Allred. Good. I am glad to see that it is getting 
discussed. It is a matter of urgency, I think, and I am glad 
that you all are recognizing that.
    Texas is proud to be home to the most women veterans of any 
state, and yet wait times for women's health care services can 
be longer than wait times for other services, and I want to ask 
if you have a specific plan to address wait times for our women 
veterans.
    Dr. Boyd. So, roughly, in working with our National Program 
for Women Veterans, Dr. Patty Hayes, we are absolutely 
accelerating the footprint with which, if you will, the 
capacity for women-specific providers in all of our areas.
    And the other thing, just so you know--and I am a Texan, by 
the way--the other thing is that when we recruit providers now, 
it is not a perhaps do you want to do women's health, it is 
going to be something that is part of the recruitment package. 
So I think that is another thing that we will do, but 
absolutely we are very well aware of that.
    Mr. Allred. Well, that is good to hear, because I think 
that we are going to have to continue to change and grow our 
VHA services to deal with our new community of veterans and 
especially here in Texas with us having the most women 
veterans, it is a big issue for us.
    I want to also talk about community care, and I want to 
talk about how we are going to monitor this. I think you 
addressed it briefly, you could go into a little more what the 
plans are, where we are in the implementation of that, and how 
we in Congress can help you oversee how the community care 
system is being enacted.
    Dr. Boyd. So I will hand that off to Dr. Greenstone, who 
can speak very eloquently about that.
    Dr. Greenstone. Yes, certainly. Thank you very much.
    So, as you know, we have undergone a great deal of 
transformation overall in our programs, that is with new 
technology, new legislation under MISSION, we have new 
contracts that have been awarded and are now coming on line, 
and a significant amount of change in our business processes 
for overseeing community care. That means we have the ability 
to now, which we never had before, using new technology in 
identifying the time that it takes for us from when a colleague 
or a provider, like Dr. Kirsh or myself or Dr. Boyd, places a 
consult, a request for care, the time that care actually takes 
place in the community and every important step along the way.
    And that way we will have an opportunity to measure what 
matters, that means measuring that veterans are getting 
appropriate, timely, high-quality care, and when they are not, 
we have an idea now of where the problems are taking place. How 
can you really drill down and make the appropriate changes to 
actually improve upon the work that all of our staff are 
working on to improve getting veterans timely care. So that is 
going to be one of the ways we have the opportunity to oversee 
that data now.
    Mr. Allred. Well, I hope you understand that this Committee 
wants to work with you on it. We want this to be a success. I 
don't want it to also take away from our initial mission at the 
VHA, providing and improving the care we are providing there, 
as I said, to address our diversifying community of veterans.
    So I hope that you will stay in touch with us. I hope that 
we have a productive conversation around this, because I have 
heard from some of our VSOs a lot of concerns about how this is 
going to be implemented. And so it is certainly going to be a 
focus for us here in the Committee and I look forward to 
staying in touch with you on it.
    And, with that, I yield back.
    Dr. Greenstone. Absolutely. Thank you.
    The Chairman. Thank you, Mr. Allred.
    Mr. Bost, you are recognized for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman.
    This is for Dr. Draper and Dr. Kizer both. The Journal of 
American Medical Association released a study in January, and 
they found the VA generally outperformed the private sector 
with respect to wait times. Are you both familiar with that 
study--
    Dr. Draper. Yes, I am.
    Mr. Bost [continued]. --and do you agree with the findings?
    Dr. Draper. Well, this is what I would say. It is really a 
piece of the story, because it looked at 15 major metropolitan 
market areas and we know across VA's 172 medical centers there 
is great variation. And a lot of the access issues are more 
prominent for rural markets or rural--less urban markets. So I 
think it is important to really understand the implications or 
what happens in those markets as well, because, as I said, 
there is a great deal of variability, as we all know, across 
medical centers. So I think it is a piece of the story.
    I think it also has implications for community care, 
because the wait times are really--if they are worse in the 
private sector, then, you know, that suggests that VA is more 
able to provide care within its own facilities. But I would say 
the variability piece and particularly looking at rural markets 
is really important to consider.
    Dr. Kizer. Yes, sir. I am familiar with the paper, although 
it has been a while since I looked at it. I think it was a 
sound study, good results. If I recall correctly, in the paper 
it did discuss some of the limitations that it has and some of 
which have been alluded to already.
    But I would also take this occasion or opportunity to 
comment on something that Dr. Roe made, as well as the person 
before you, and that one of the predictable and foreseeable 
problems that VA is going to have in assessing community wait 
times is the fact that there is no standard way of assessing 
wait times in the private sector. There are no national 
standards, there is no widely-accepted or single way of doing 
this. So, even though they may procure lots of information, 
there is no certainty that there is going to be apples-to-
apples type comparisons, and so there is going to be difficulty 
comparing the information that is made available from community 
providers.
    Mr. Bost. Thank you.
    And, Dr. Boyd, you know, during the period of 2014, 
following the scandal of Phoenix, have veterans' satisfaction 
ratings increased or decreased with the VA or do you think the 
wait times are--is wait times a factor in that?
    Dr. Boyd. With regards to the tremendous increase in the 
satisfaction scores with our veterans, I think the wait times 
have a piece of that, but really going back to what Dr. Kizer 
was really--it is meeting their needs. So whatever that means, 
and that is--you know, it is an individual. It may be 
different. And it could be, as Dr. Roe said, it could be 
because they had a great experience, too, an appropriate 
experience.
    But no doubt our satisfaction scores are going up, and I do 
think that that is a piece of it. It absolutely is.
    Mr. Bost. Well, let me just say that as Members of the 
Committee, all of us are wanting the VA as a whole to succeed 
and to do their job to the best of its ability.
    That being said, each one of us have our own districts and 
see the particular VAs in our districts and we use the 
scientific studies that we have, which is how many complaints 
come and say how bad is our local VA in comparison to how many 
say, hey, they are doing a great job.
    And so as we do that, as we move forward, I hope that we 
find some kind of system which we can truly make that judgment 
call. I am the state legislator in the State of Illinois, and 
this is a scientific--we have a deer season. And the deer 
season and the amount of permits is released based on the 
amount of people who call in and say, there are too many deer 
in comparison that there is not enough. And that is how they 
issue the amount of permits.
    I am afraid that when we move forward with our veterans, 
that that is not the real--really the best way. What the best 
way would be is truly find a way to track the numbers. And 
right now I am concerned that we are not able to track those 
numbers. And I hope we can get through that.
    So with that, Mr. Chairman, I yield back.
    The Chairman. I now recognize Mr. Brindisi for 5 minutes.
    Mr. Brindisi. Thank you, Mr. Chairman.
    Dr. Boyd, I recently had a meeting of my veterans' advisory 
council back in my district and one of the issues that was 
raised by several of the veterans who attended the meeting was 
about the committee providers under the Mission Act, being able 
to search them on the VA's website.
    But in an area like mine, which is very rural, and where 
high speed internet is spotty at best, and cell phone service 
is almost non-existent in certain areas, if you don't have 
access to a website or can't pull up the VA's website on your 
phone, how does a veteran go about searching what community 
providers are available under the Mission Act?
    Dr. Boyd. So just a couple of things for that.
    First of all, before we rolled out, you know, the June 6th 
Mission Act, we ensured that every VA medical center had the 
capability from the incoming phone lines to press 6 for more 
mission information. That is the one thing. But what you are 
asking is something that has a different twist to it as well.
    Veterans need to engage with their facility, with their VA 
clinic, their provider in order to get into that system. There 
is no direct reaching out to the committee providers. And that 
discussion then will be had at the VA center.
    And if Dr. Greenstone has anything to add on that because 
he truly is in that area.
    Dr. Greenstone. Thank you.
    It is a very important question, reaching out to our rural 
veterans who may not have access. And so clearly, you know, 
like Dr. Roe mentioned, the telephone is going to be one way 
that you can certainly get information. And if you contact 
someone, we can actually go to our directory and find out where 
that veteran lives and what kind of providers are in their sort 
of neighborhood, if you will, or close to them.
    But then as Dr. Boyd mentioned, in order to access those 
providers in the community, it has to be initiated by a request 
for care from a provider within the VA. So that would be one 
thing.
    And then at that time, anytime you are working directly 
with a provider and a veteran, that provider has access to see 
the providers in the community, the average wait times in the 
VA, and eventually we plan on being able to demonstrate the 
average wait times in the community for a comparison to take 
place at that point in time.
    Mr. Brindisi. Okay. So and another question I wanted to ask 
was about the same day services initiative. I wanted you to 
just expand a little bit on that initiative. Does that always 
mean a face to face appointment? Are there other areas where 
you can get help, telehealth? What does that exactly mean?
    Dr. Boyd. You are absolutely right. And I will let Dr. 
Kirsh answer that. It is from her office. But you are 
absolutely right, and that is a super question.
    Dr. Kirsh. Thank you for that question.
    And I wanted to provide some further detail in that this 
has been a pretty robust effort over the last couple of years 
to ensure that primary care, mental health, substance use 
disorder, that we have the ability for a veteran to contact us 
and for us to take an action, essentially.
    While as we heard previously, 20 percent of the time it may 
result in a face to face appointment, we know, as has been 
pointed out previously, that this can be addressed through 
fulfilling a medication or assessing the patient and 
determining that that patient needs to be seen for some knee 
pain in 2 weeks as the appropriate follow up.
    So it really is about addressing the need of the veteran 
that day, ensuring that there is not something urgent that is 
happening, and then ensuring that that happens in the way the 
veteran wants that, whether it is in a text message follow up 
or if it is in a phone call follow up. That is our goal is to 
be veteran-centric.
    Mr. Brindisi. And just to follow up on that a little bit, 
in the written testimony GAO said that ongoing staffing and 
space shortages have created challenges for implementing and 
sustaining same-day services.
    What are you doing to help those facilities with that 
challenge?
    Dr. Kirsh. So overall since 2013 we have increased staff 
very significantly by approximately 50,000 staff. And 63 of 
that percentage, 63 percent has been an increase in schedulers 
specifically.
    Our office was engaged with GAO and I think the report is 
not yet final, but the recommendation was really only around 
measuring what we do. As you heard previously, having a 
telephone follow up or a secure messaging follow up is not as 
easy to measure and to roll that and understand how we are 
doing in that area.
    And to that end, I have been engaged with the National 
Quality Forum to help assist us in understanding the best way 
to measure a same-day service.
    Mr. Brindisi. Thank you.
    I see I am out of time, so thank you for your responses.
    The Chairman. Thank you, Mr. Brindisi.
    Dr. Dunn, you are recognized for 5 minutes.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    Dr. Kizer, I read your resume, very impressive. You have a 
great depth of experience. I, too, am a physician. I appreciate 
your insightful comments on your opening statement there.
    So just doctor to doctor here, what do you think is the 
value of wait time measures as we are performing them in the VA 
given the inherent technical problems in doing those measures, 
and are we guilty of an overly microscopic focus on a set of 
macroscopic problems?
    Dr. Kizer. Let me try to answer you in a couple of ways. I 
think wait times are an important metric to assess and to 
track. I think they, what many private or leading private 
health systems find is that they are more useful for quality 
improvement purposes. There are targets to try to achieve. That 
from an accountability or compliance point of view, just the 
technical issues make it very difficult.
    So while they are an important metric to track, they are 
but one metric. As I said before, it is a uni-dimensional way 
of looking at a multi-dimensional issue. Access is much more 
complicated than just wait times, and as Dr. Roe--
    Mr. Dunn. I appreciate you saying that, and I wanted you to 
underscore that because I think it is important that we don't 
get too far chasing down wait times.
    But on the same subject, are you aware of any wait time 
measure that is immune to faulty interpretation or scheduling 
errors?
    Dr. Kizer. No, I am not.
    Mr. Dunn. Yeah. I am not either. Dr. Draper, are you?
    Dr. Draper. Well, one thing that has greater accuracy is 
the create day. So that has, that is the time stamp that the 
system creates, and it doesn't allow manipulation of days like 
some of the other days.
    Mr. Dunn. Good. I think there is a lot of things we could 
look at in the VA besides just wait times.
    Dr. Boyd, your testimony notes that the Choice Act, now the 
Mission Act, is a large factor behind many improvements. And 
the Department has made far access, recognizing that the 
implementation of the Mission Act really just started a few 
weeks ago. What impact do you think it has had on access so far 
and what impact do you think it will have going forward?
    Dr. Boyd. So in several areas. And you are right. We just 
started. But it seems like we have been living it now, you 
know, in preparation.
    The access portion is that when we look at community care, 
our new community care network, as a senior leader when I am 
looking at the world of capacity of where my veteran patients 
can go is a combination of my internal systems and my 
integrated outside network. So that is huge, and it gives 
veterans choices. There are--no one, no 2 veterans are the same 
with regards to where they live and so forth.
    The part of the mission that I wanted to thank the group 
for is that we have certain authorities now that will improve 
our ability to not only recruit, but to retain our employees. 
So that to me, those 2 big things just stand right out.
    Mr. Dunn. So, also, Dr. Boyd, on this note, the VA now 
provides many more appointments than it did back in '14. What 
do you attribute that capacity do, and what role do you think 
the community care plays in that?
    Dr. Boyd. So currently we--year to date we have had 1.75 
million more completed appointments. That is amazing.
    Mr. Dunn. Year on year.
    Dr. Boyd. That is internal.
    Mr. Dunn. Is that year to year comparison?
    Dr. Boyd. Yes, sir.
    Mr. Dunn. Okay.
    Dr. Boyd. Yes, sir. So we are already 1.75 million ahead. 
And a couple of things as I had mentioned earlier. One is our 
attention to detail with regards to efficiencies. I, too, came 
from the private sector and we didn't have a lot of fluff. You 
know, people needed to have a good working environment, to have 
the good support so everyone could practice up to the top of 
their licensure.
    So we have paid really close attention to that through Dr. 
Kirsh's office with regards to efficiencies and productivity. 
That is a big piece of it.
    But, also, I also want to believe that it is the regaining 
the trust of our veterans as well.
    Mr. Dunn. Well, that's good. And, specifically, sort of 
following the end of that question was the community care. What 
does it do for that, increasing your ability to give 
appointments?
    Dr. Boyd. Okay. So having the options for our veterans in 
the community, especially for services that may be in some 
areas, they just don't have.
    Mr. Dunn. Yeah. In rural areas like mine.
    Dr. Boyd. Rural areas. Yeah. Exactly.
    Mr. Dunn. Yeah.
    Dr. Boyd. Or there is not enough volume to support that 
service internally. We have a partner now in the community that 
we can coordinate that care and that is that continued mode of 
care that we promise our veteran patients.
    Mr. Dunn. I appreciate that. So in my remaining 20 seconds, 
Dr. Draper, what do you think is our single biggest opportunity 
to improve access to care and what do you think the biggest 
barrier to improving access to care is?
    Dr. Draper. One of the biggest barriers I think is to have 
the sufficiency of providers to see patients. I mean, that has 
been an ongoing issue with VA, their recruitment and retention.
    Mr. Dunn. But we sort of solved that with the community 
care, right?
    Dr. Draper. Well, it depends on the community, I think. 
Some communities probably--
    Mr. Dunn. Fair enough.
    Dr. Draper. You know, I think it--
    Mr. Dunn. And the opportunity?
    Dr. Draper. Opportunity for the biggest improvement?
    Mr. Dunn. Yeah. What's the biggest barrier? Well, I guess 
barrier and opportunity. I'll take that as an answer to both 
questions. Thank you very much, Dr. Draper.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Dunn.
    Ms. Underwood, you are recognized for 5 minutes.
    Ms. Underwood. Thank you, Mr. Chairman, and thank you to 
all the witnesses for joining us today.
    I recently surveyed veterans in my district outside of 
Chicago and learned that the vast majority of respondents are 
satisfied overall with the care that the VA provides, including 
the wait times to see a physician at a local facility like the 
Level Healthcare Center.
    Despite these local success stories, nationwide wait times 
remain a serious concern. Veterans prefer VA for many reasons, 
and we owe it to them to provide convenient, patient-centered 
access to quality care.
    Dr. Patricia Hayes, VA's chief consultant for women's 
health services said in February that a ``small, but persistent 
disparities' exist for women veterans accessing care at the VA. 
Overall, she said ``women veterans are still waiting longer for 
appointments than males.''
    And so I know my colleague, Congressman Allred touched on 
this, but women are a growing proportion of the veteran 
population. And Dr. Boyd, I believe it was Dr. Boyd, you said 
that--or maybe--okay. Yes. That the VA is ``accelerating the 
footprint in all areas for women veterans.''
    I was wondering if you might be a little bit more specific 
about the timeline to closing the gap on wait times.
    Dr. Boyd. I wish it was, you know, said and done yesterday. 
But the reality is that with the enhanced recruitment 
capabilities, the authorities that we have within Mission, that 
will get us a little further.
    But as Dr. Hayes I am sure has probably testified before, 
we continue to accelerate the many residencies and to stay on 
top of women's health needs and their special concerns.
    Ms. Underwood. Right.
    Dr. Boyd. And so we are not losing focus on that. And we 
are actually integrating that even into our mental health world 
as well to make it an actual crosswalk, to make it part of the 
fabric as well.
    So we do have work to do. And I wish I had an exacting 
timeline, but as you know, Dr. Hayes, she will not let us, you 
know, at all lose urgency on this one. And, in fact, we just 
recently set up another governing board, if you will, that is 
primarily focused on women veterans and some--to keep that 
fresh and also to keep the opportunities in line and on our 
mind with leadership as well.
    Ms. Underwood. Sure. I appreciate those steps. Are there 
any kind of internal goals or metrics that you all are working 
towards?
    Dr. Boyd. I would have to get back to you on that 
specifically and speak with her office on that.
    Ms. Underwood. Okay. Please do.
    Dr. Boyd. I would sure be glad to.
    Ms. Underwood. Connecting veterans to timely care at the VA 
is especially important, as you said, regarding mental health 
and addressing the veteran suicide crisis.
    Some of our veterans will not self-report their suicidal 
ideations which could limit the benefits of same day care. 
Right. They have to proactively say that they need to come in 
because they are having these kinds of thoughts.
    So, Dr. Boyd, does the VA collect data on average wait 
times for veterans specifically seeking mental health care 
treatments?
    Dr. Boyd. Yes, we do.
    Ms. Underwood. Okay. Mental health care is one of the 
several critical risk factors in addressing the suicide crisis. 
According to the CDC, access to effective clinical care for 
mental, physical and substance abuse disorders can help protect 
people from suicidal thoughts and behaviors.
    Dr. Boyd, does the VA collect data on wait times for 
veterans waiting to be seen for pain management, substance 
abuse disorders or other chronic medical conditions?
    Dr. Boyd. Yes, we do.
    Ms. Underwood. Oh, that's good.
    Okay. My last set of questions is in both the GAO and the 
VA testimonies, the need for consistent and comprehensive 
training of VA staff was highlighted. I commend the steps that 
you have taken to increase scheduling training completion rates 
and would like your perspective on how that was achieved.
    Dr. Boyd, how do you track the completion rates for staff 
who require scheduling training?
    Dr. Boyd. I will ask that Dr. Kirsh answer that for you. 
She has the specifics for that.
    Ms. Underwood. Thank you.
    Dr. Boyd. You are welcome.
    Dr. Kirsh. Thank you for that question.
    Our office oversees scheduling policy, standardizing 
processes, trainings and audits. And the trainings have been 
very robustly engaged with our 58,000 staff out there who do 
schedule.
    Ms. Underwood. So how do you track the rates?
    Dr. Kirsh. We have our talent management system through the 
employee education system. It is trackable across all sites. 
You have to log in as a VA employee and complete trainings.
    But more important or in addition to that is really when 
anything, a nuance is brought up or there are bi-communication 
calls every week--
    Ms. Underwood. Yeah.
    Dr. Kirsh [continued]. --with the scheduling community.
    Ms. Underwood. Can I ask one other follow up question? Is 
there an incentive to complete the training?
    Dr. Kirsh. It is an expectation as a component of your job 
that you complete the training, if that is in your job 
description as a role.
    Ms. Underwood. So it is in like your PDP?
    Dr. Kirsh. Yes, it is.
    Ms. Underwood. I see. Okay. Thank you so much.
    The Chairman. Thank you, Ms. Underwood.
    General Bergman, you are recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    Thanks to all of you for being here. This is complex to say 
the least. You know, putting my airline pilot hat on from 
decades, you know, at one point we were graded on how much we 
supported our passengers to make sure they didn't miss their 
flights. The next time you turn around we are being graded on 
our on-time performance.
    And as an airline captain, I had the challenge to decide 
what do we do. The gate agents wanted to close the door even 
though there were passengers running between flights because 
they were going to get a ding on their record because of the 
fact that they didn't shut that door on time.
    My plan was and is always the passenger first. I said I 
will take the hit. If someone wants to call me as to why the 
flight left three minutes late, they can deal with me and don't 
worry. I will take you off the hook.
    So as we look at what we are trying to do here, which is 
not only identify wait times, but to accommodate our veterans 
who need care, it is going to be, again, a complex challenge to 
make sure that nobody gets hung out to dry for the wrong 
reasons. So it is the accountability and the structure all the 
way up and down the line.
    But having said that, Michigan's first district, my home, 
is a combination of small towns, rural, and remote. So when--
and you noticed that I didn't say urban or suburban. That 
doesn't fit. So when you think about wait times and what it 
means with the combination of services that we would have in 
our district with one small VA hospital in Iron Mountain, but 
the accommodation of the CBOC or a community care, it is kind 
of a microcosm of all other, not that big organized system that 
is within Uber distance. In fact, we don't have really much 
Uber in our district at all.
    Are we in some cases--and by the way, anybody can answer 
this? Are we in some cases comparing apples and oranges when we 
try to talk about wait times at a VA hospital, wait times at a 
CBOC, wait times in community care? I mean, are we just--we 
have separate silos here and are we trying to compare, again, 
apples and oranges? Anybody want to take a shot at that one?
    Dr. Boyd. I will start off. So when we go into the access 
to care website, you know, where our veterans can go on and 
look, if you go on and click onto Michigan, it will be bring up 
the VA medical Center and then all the clinics. And they will 
have posted a 30-day average, and it is an average, of the wait 
times, if you will. And so it is specific geographically and to 
that particular area.
    So I am not sure if that answers your question.
    Mr. Bergman. Well, it does kind of in a way. Its kind of 
basically means that the comparisons, if you don't have big VA 
hospitals and you don't have your--you may fall outside of the 
80 percent norm of that bell curve. Okay. I mean, that is--I 
mean, we are trying to make here an 80 percent solution. If we 
can get 8 out of 10 right. Think about even Ted Williams only 
hit 400. You know, if we could hit 800, we would be doing very 
well.
    I would like to go down a different road here for a second. 
Can VA solve the problem that we are trying to deal with her, 
the wait times, can they solve it from within? In other words, 
does VA have that capability or, said a different way, is there 
a model, Dr. Kizer, that already exists somewhere outside of 
the VA that we can modify, again, to the 80 percent level to 
make it work? We are open to anything that will work to make 
sure the veterans are realistic about what the wait times are 
where they live and for the condition they have, and we also 
want the VA and the CBOCs and the community providers to be 
realistic about what they can provide and not--you know, I 
would rather have them under promise and over produce.
    Dr. Kizer. Yes, sir. A few things.
    One, there is no model. No one has solved this problem. 
There is no single model out there that the VA could just 
modify and adapt. There are glimpses of what are what we might 
call promising practices and I am encouraged to hear that VA 
has implemented and is pursuing a number of those, such as 
same-day service and what they have done in that regard. 
Certainly, expanding telehealth and other technology assisted 
options which may be particularly useful in rural and 
underserved areas.
    But I also want to go back to your first point underscoring 
the complexity of this issue and the need that exists for 
standards that are setting specific, whether that is primary 
care or specialty care, a hospital, a clinic. All of the 
different settings really have--we should be thinking about 
different standards for those settings of care.
    And there may be opportunities for the VA to engage with 
entities like the National Quality Forum or with the National 
Academy of Sciences to help solve or at least address some of 
the technical issues that may provide better answers for where 
we need to go in that regard.
    Mr. Bergman. Thank you. And I appreciate your answer.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, General Bergman.
    Mr. Pappas, you are recognized for 5 minutes.
    Mr. Pappas. Well, thank you, Mr. Chairman. Thank you to the 
Ranking Member, and to our panel. I appreciate your testimony 
here today.
    I want to take a step back. We are marking 5 years since 
Phoenix. We are here having these discussions, talking about 
some steps that have been taken forward because of 
whistleblowers.
    And I noted, Dr. Boyd, in your testimony you said, ``due to 
the recent media reports of a whistleblower indicating issues 
with the electronic wait lists, we conducted a top to bottom 
review.'' And I think that is great.
    But let's unpack that a bit. You say, ``due to recent media 
reports.'' And I am wondering why it took media reports and not 
a disclosure from a whistleblower with valuable information to 
spur that review.
    Dr. Boyd. So at the facility level where this may have 
occurred, there is always--that is just the practice. That is 
the ongoing practice is to always look at harm, unintended harm 
if you will.
    And it should not take a media, a piece of paper, you know, 
a story in the media to call our attention. We should be very 
responsive to when, as I mentioned, when employees or any 
staff--I don't care where they work or hat their role is-- 
comes forward and says, something doesn't look right.
    So this is an ongoing practice at facilities to look at 
things that rise to the top. So it should not take a media 
story.
    Mr. Pappas. Well, I appreciate that.
    Dr. Boyd. Sure.
    Mr. Pappas. And we are working. As the oversight and 
investigation subcommittee we have done a couple of panels on 
whistleblower issues. We want to ensure that they are heard, 
that we improve processes to protect their rights and prevent 
retaliation which we have seen.
    We recently heard from a few whistleblowers in our June 
25th session who raised some serious concerns that have a 
connection to the wait time issue that we are talking about 
today. The whistleblowers told us that they saw 12,000 canceled 
radiology orders in Iowa City, ``imaginary opioid clinics in 
Baltimore set up to hide wait lists,'' and 400,000 plus 
consults opened over 90 days across 5 districts.
    I am wondering what steps the VA is taking to identify and 
curtail any sort of practice of hiding and masking the problem 
that exists with wait times.
    Dr. Boyd. So it is multi-fold. One thing that is, I think, 
at the core is changing the culture. When I go around to sites, 
one of the first things that I do is meet with various staff, 
usually at town hall, frontline staff. I don't want leadership 
there, don't want supervisors there, to get a feel for is there 
a good culture there, is there a culture of, I will raise my 
hand and stop the line.
    So I think it really, it goes to us as senior leaders to 
walk the talk and to make sure that our facility leadership 
does that as well because without that we could have every 
possible process in place, but no one is going to feel 
comfortable raising their hand because no process is perfect. 
We want people to put holes in it. So it is all about changing 
that culture.
    Mr. Pappas. Well, thank you. You know, reading some of the 
terms that have been used with scheduling, I can understand why 
there has been some confusion. We are talking about terms like 
patient-indicated date, desired date, preferred date, 
clinically indicated date. Is there a difference between these 
terms or are they interchangeable?
    Dr. Boyd. I will have Dr. Kirsh answer that one. Thank you.
    Dr. Kirsh. Thank you for your question.
    And you bring up an important point that is that names have 
changed over time. The patient indicated date was a decision 
made a few years ago really with an emphasis and focus on that 
it is about the patient preference in the equation.
    As a doctor, when I make a follow up appointment for a 
patient, and that is what patient indicated date is used for, 
it is a clinical timeline when the patient should be seen and 
then when the patient as well can--is agreeable to the 
appointment within a certain amount of time. That is what the 
patient indicated date is. It has evolved after the clinically 
indicated date and preferred date. It is now the replacement 
for follow up appointments.
    Mr. Pappas. Okay.
    Dr. Kirsh. I hope that answers your question.
    Mr. Pappas. Yeah. And I think that the GAOs indicated some 
improvement here at logging these terms. 18 percent improvement 
in manually entering dates, but also there still exists an 
error rate that is of some substance that has an impact.
    So I am wondering in terms of the GAOs perspective on this, 
how are we doing and are they on track to be in compliance?
    Dr. Kirsh. Well, since our implementing our recommendation, 
the VA has taken a number of actions. One is bi-annual audits 
of schedulers. And the most recent, in 2018 they audited about 
667,000 appointments and they found an 8 percent error rate. So 
that effected about 53,000 appointments.
    So there is improvement. There is more work to be done, 
definitely, and I think that as we talked about in our written 
statement, you know, a lot of the scheduling, the terms are 
pretty, they are pretty much the same. They are just different 
names. The patient indicated day is basically, it is a, you 
know, the schedule, we used a clinically indicated date if a 
provider provides one. And if not, in the absence of that they 
will use the veterans preferred date, which is essentially the 
same as the desired date.
    So not much difference--
    Mr. Pappas. Thank you.
    Dr. Kirsh [continued]. --between the terms.
    Mr. Pappas. Thank you, Mr. Chair.
    The Chairman. Mr. Banks, you are recognized for 5 minutes.
    Mr. Banks. Thank you, Mr. Chairman.
    Well, I am encouraged by the Jamma study published earlier 
this year that found VA has significantly shorter wait times 
for primary care than private doctors. I remain concerned about 
VA's ability to provide urgent mental health services to our 
veterans in crisis.
    Dr. Boyd, in your testimony you discuss how VA began 
offering same-day appointments for mental health at every VA 
medical center in CBOC in 2017. According to VA, when veterans 
request a same-day appointment, they are assessed for the level 
of urgency and either provided a form of consultation or a 
future appointment.
    I have a constituent veteran who had quite a different 
experience last year and I would like to take a moment to 
quickly summarize his story for you.
    This veteran was having a mental health episode and was 
found walking down the highway by police. The veteran was 
turned over to his mother who picked him up and was instructed 
by a county VSO to immediately drive him to our local VA 
medical center for a mental health assessment.
    The VSO called ahead, but was informed that the local VA 
medical center didn't have room or a doctor that could see the 
veteran at the time. The VA medical center recommended that 
they go to the next closest VA facility which was over an hour 
away.
    Upon arrival, this VA medical center also refused to see 
him due to ``lack of space.'' 2 police officers were in the 
waiting room and saw that something was wrong with the veteran 
and told the hospital staff that the veteran must be admitted, 
and yet they refused. The officers then went on and got a court 
order from a judge to mandate that the veteran be admitted.
    Dr. Boyd, this situation may very well be an outlier or an 
anomaly. And for all intents and purposes I really hope that it 
is. But can you explain what VHA is doing to ensure that 
veterans in crisis are not being turned away and that these 
mental health assessments are available and consistent across 
all VA medical centers?
    Dr. Boyd. First of all, I want to make a comment. If, in 
fact, we have not looked at that particular case, I would 
appreciate that, if your staff could get that to us.
    Mr. Banks. Indeed.
    Dr. Boyd. If it happens one time, that is one time too 
many. Okay.
    With regards to the process, we do have oversight of how 
patients are triaged and by what discipline. And when I mean 
that, I mean by social work, a licensed social worker, or a 
psychologist or a psychiatrist. So our central office or our 
national program office meets regularly with the field, and 
when I say the field, I mean their regional leads who know 
exactly what is going on in facilities.
    So do I know for certain that there is not another one out 
there like that, I do not. That would be--it would be perfect 
if we did. But we make every intent to ensure that the urgency 
is assessed first. And so I have a lot of concern with what--
with the story that you just relayed to me. It doesn't fit with 
what we expect and what we see when I go out.
    Mr. Banks. Yeah. Very well.
    Dr. Draper, I understand that GAO has studied the 
availability of same-day services within VA and we can expect 
the findings and recommendations of the reports to be released 
soon.
    That being said, can you shed any light on how frequently 
situations like what my constituent experienced occur and, if 
so, do you have any recommendations for us on how VA can better 
prevent situations like this from happening in the future?
    Dr. Draper. Well, according to the information based on our 
work, the same-day services are available to anyone who comes 
into the VA and presents. You know, I think there is some 
expectations on veterans because it was really intended for 
those with more urgent needs or more immediate needs. But we 
have heard from the facilities that we visited that basically 
any veteran can show up and request same-day services.
    So it seems out of character for what you are talking 
about, but, I mean, I can't explicitly talk about that 
particular case because I am not familiar with it.
    But one of the things I do want to clarify that I know that 
there has been information about that 20 percent of all 
appointments are same-day services. There is a lot of noise in 
that information, in that data. So, for example, it could 
include like a veteran--a provider will call in sick and his 
appointments are canceled, his or her appointments are canceled 
for the day and then they get rescheduled with another 
provider. That looks like a same-day services when, in fact, 
the veterans may have been waiting quite some time to see the 
provider.
    So that is one instance. So that number is not as clean 
as--you know, it is not necessarily that 20 percent of all 
appointments are truly same-day services.
    It is also, I think, that there is some confusion about 
what same-day services are. It is not just a face to face with 
a provider, but it could be a nurse providing education. It 
could be medication refills. It could be scheduling a future 
appointment.
    None of those other than the provider, face to face with 
the provider, none of those types of activities are captured. 
So we don't really know how much, what those different 
activities are and how frequent they happen. We did visit one 
VA medical center who had a pretty sophisticated group of staff 
who were able to set up a system, so they were able to track 
it. But that was just one facility that we saw that was able to 
provide information about the different types of same-day 
services.
    Mr. Banks. Thank you. My time has expired.
    The Chairman. Thank you, Mr. Banks.
    Mr. Cisneros, you are recognized for 5 minutes.
    Mr. Cisneros. Thank you, Mr. Chairman.
    Dr. Boyd, you know, like Mr. Pappas said, we have had 
several hearings, you know, regarding the whistleblowers and 
those coming forward and how they have been treated after they 
come forward. And some of those whistleblowers were talking 
about the secret wait list that are being held at--you know, 
that has happened. And I guess Phoenix is our big example of 
what has happened there.
    In your opinion, what can be done to increase transparency 
culture, and you talked about the culture a little bit, and 
policy in the VA so that its recurrence of secret VA wait lists 
doesn't keep resurfacing?
    Dr. Boyd. Well, first of all, I want to be really clear. We 
are not 5 years ago. There is no secret wait lists. What we 
have are tools that are getting, are somewhat obsolete in their 
tracking capabilities that can be misinterpreted. And really, 
so they don't fit the mold of what we had said back 5 years ago 
that truly were the wait list. And we don't need to go back and 
re-litigate and re-talk about all of that.
    But what can we do moving forward? I think we are on a 
really good path moving forward. And I know it is the soft 
stuff, but we are on a journey of high reliability. And you may 
have already heard about this, where we are really focusing on 
a just culture, and for 0 harm, and for raising your hand, 
stopping the line. Those who are the surgeons in the room or 
have been in the OR, that is extremely important, or even on 
the aircraft. Right. Stop the line. Something is not right.
    So it is a matter of doing that, of developing that through 
all of our 18 regions, our facilities and in central office 
where we all live. It is a matter of providing that environment 
for folks to raise their hand and for us to say, it is okay.
    Mr. Cisneros. You know, I get that, and I keep hearing 
that, right, how we need to adjust the culture at the VA.
    Dr. Boyd. We do.
    Mr. Cisneros. And there is a lot of work. You know, people 
are going to talk to the individuals, those that are working at 
the VA. You said it yourself. You are having town halls with 
those individuals.
    But what are we doing to talk to the supervisors at the 
facilities? They are the ones that are conducting the culture. 
They are the ones that are overseeing it all. How are we 
changing their mindset and what is being done there?
    Dr. Boyd. And that is an extremely good point since I did 
come from the field within the VA after private sector.
    We have not traditionally done a great job of setting our 
supervisors and mid-managers up for success. And you are 
absolutely right. There is a gap in there. And so part of this 
education or this journey that we are on is to give our 
supervisors, many of them new, and our mid-managers the tools 
and the skillsets with which to be a successful supervisor, to 
be a servant leader.
    It is a rigorous program that we are embarking on and you 
really touched on what I am seeing in the field more and more. 
There is that mid-management gap. You are right.
    Mr. Cisneros. Now the other thing you mentioned, too, was 
that your tracking methods are behind. How are we going to 
update these? What needs to be done? How can we in congress 
help you bring your systems up to date, so we don't have these, 
you know, archaic systems that are like 15, 20 years old and we 
are still trying to track things that way? How do we modernize?
    Dr. Boyd. So I am going to let Dr. Greenstone talk about it 
because we are transitioning, as we went from Choice where you 
are purchasing care and had a much different process. And so we 
were using a tracking tool, a software. I will let him talk 
about where we are going.
    Dr. Greenstone. You know, one of the things, you know, that 
you raised is so important about, you know, secret wait lists 
and not having wait lists and having old, archaic systems. So 
we are moving to new technology that allows us to actually put 
people, when we are using administrative lists, be able to have 
triggers automatically.
    Helping schedulers have triggers so when--in my realm of 
community care when we are buying care in the community for 
veterans and coordinating that care, we have new commercial off 
the shelf Cots products that we have configured to work with 
our old systems so as not to lose integrity, but to have those 
new systems help our schedulers, for example, more effectively 
and efficiently get veterans care in the community and have 
little reminders that come up and the like, and drive those 
schedulers to follow policy. They can't go outside of their 
realm.
    And so eliminating things like the electronic wait list, so 
it is not even available is things that we have done in the 
Chairman's district recently to make sure that no one gets put 
erroneously on a list because we eliminate the list altogether. 
You can't even use it. And the technology allows us now moving 
forward to do those kinds of things to have more guidance and 
more support, and give the people the tools they need to be 
successful.
    Mr. Cisneros. I want to thank you all for your testimony 
today. My time is expired. Thank you.
    The Chairman. Thank you, Mr. Cisneros.
    Mr. Roy, you are recognized for 5 minutes.
    Mr. Roy. I thank the Chairman. Thank you all very much for 
your time and thanks for being here today.
    One quick question maybe for you, Dr. Boyd, and then maybe 
you, Mr. Kizer, as well. And I realize that we have had a 
number of hearings on this topic and will likely have more with 
respect to electronic health records.
    But a question because it is something that I have raised 
to me all the time at Audie Murphy and San Antonio as well as 
in Kerrville, Texas is the extent to which the trouble with 
accessing records is interfering with, well, I will say Choice, 
now Mission, and the ability to go get the care that veterans 
are seeking and because there is some difficulty in dealing 
with records. How much is that impacting wait times? I mean, we 
talk about wait times statistically. But in practice for a 
veteran, right, who is going in and saying, well, I want to get 
care, and he can't get care because they are going to seek care 
and then they are having to get kicked to the VA and they are 
kind of in an infinite do loop. What can you say about that as 
its impact on wait times?
    Dr. Boyd. So I will let Dr. Greenstone comment on that, but 
that is an extremely critical observation.
    Dr. Greenstone. Yeah. Really important. So one of the thing 
that we were able to create in terms of new information 
technology is, it was taking our staff about 20 minutes on 
average to compile all the medical records that might be 
appropriate for a provider in the community to have access to 
in order to appropriately care for a veteran.
    We created a new tool we called, you know, the referral 
document tool which allows the staff with several clicks to 
grab that information and put it all together in one document. 
And it actually saved 15 minutes of their time on average to be 
able to do that.
    And then how do you get it to them. So we have a new 
referral and authorization system that is essentially a portal. 
So the providers in the community, web-based, can log in and 
they can actually see the entire medical record of a veteran 
for the duration of the episode of care. So that is called our 
community viewer.
    So we have created ways in which we can facilitate getting 
the providers in the community a medical information. We also 
need to get those records back. And so that inter-operability 
is something that we are working on diligently, and one of them 
is using the health information exchange. So if a provider in 
the community actually uses these new electronic records, they 
have the opportunity to create a computer readable and human 
readable document that the VA can actually pull and see 
readily, right, without having to worry about faxes and mail 
and all these other things.
    So they can use our portal. They can use the health 
information exchange, the information back to us, and vice 
versa. So we are really trying to enhance this issue because it 
is a very important issue for us.
    Mr. Roy. So you all would agree that has been a part of 
delays and wait times in the past?
    Dr. Greenstone. I would say it would contribute. So if I am 
a scheduler in the VA, I can see the exact schedule. So my 
scheduler can see my next available appointment. When I am 
scheduling in the community, it may take longer because I may 
need to call 3 different cardiologists in the community. So it 
takes me longer to make that one appointment for a veteran in 
the community. So I can get fewer amount of schedules done in a 
day. So that does attribute somewhat to that process.
    Mr. Roy. I appreciate that. Let me move on really quickly 
because of limited time.
    Dr. Boyd, in your prepared statement you noted that 
veterans often face shorter wait times in VA than in the 
private sector. Are there any regions of the country and/or 
clinical specialties where VA is particularly challenged with 
respect to wait times compared to the private sector? And 
forgive me if you already answered that question.
    Dr. Boyd. Oh, that is okay. I would have to roll that up 
all for you. But, absolutely, there would be pockets--well, we 
already heard from a few of the Committee Members. There are 
areas where we just don't have that expertise in-house and 
there is a very limited amount within the community as well.
    So we do have a fix for that. We have a solution and that 
is going to be telemedicine is all through our clinical 
resource hubs. But you are right. But I don't have that off the 
top of my head, a long list.
    Mr. Roy. Okay. That would be great if we could get that in 
response to the hearing.
    Dr. Draper, a quick question for you. In your testimony you 
reference, you know, findings and some of the recommendations 
that go back, you know, a number of years, you know, going back 
to 2012 and so forth.
    Obviously, the VA health system has changed quite a bit 
over this last 6, 7 years since that point. Are those findings 
and recommendations relevant today and how would you comment on 
that?
    Dr. Draper. Yes. Absolutely. They still remain relevant. So 
our recommendations from our 2012 work was to really improve 
the reliability of the wait time measurement and ensure 
consistent implementation of the scheduling policy and 
scheduler training. So those were 2. Those were 2 that we have 
subsequently identified as priority recommendations.
    And then a third recommendation was something that Dr. Roe 
had eluded to about telephone access. We have found telephone 
access to be problematic and, you know, VA had a set of best 
practices that they never implemented. So that remains an open 
recommendation.
    And then the fourth one is to really identify the 
scheduling resources needed and allocate them appropriately 
based on need.
    So all those recommendations still remain open. And I will 
say we are going to close one of the priority recommendations, 
but it took 7 years to close. And so we are still moving 
forward with, you know, we still have 3 that are open that are 
open for at least 7 years.
    Mr. Roy. Thank you, ma'am.
    Thank you, Chairman.
    The Chairman. Thank you, Mr. Roy.
    Ms. Brownley, you are recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    Dr. Boyd, you stated in your written testimony anyway that 
the VA in a RAND study it concluded that the VA performed 
similarly or even better than non-VA systems. And so I went 
back to find that report. And so first I want to say, I want to 
applaud the VA because I think that data point is consistent 
with what I hear from veterans all the time is once I am in the 
VA and getting my health care, I am very satisfied.
    But this report had nothing to do with wait times. And I 
just want to make that clear.
    A few months ago I had a town hall in my district and the 
greater Los Angeles people came into my local town hall and 
they read statistics on wait times for veterans in my district. 
And the whole room erupted in laughter. And I think the reason 
they erupted in laughter is because the definition of wait time 
from a veteran's perspective is polar opposite to how the VA 
defines wait time and how they measure it.
    A veteran or any average citizen would think wait time 
means from the time I called to ask for an appointment to when 
I receive the appointment. That would be what--their parameters 
of wait time. But yet in the VA system, in a typical situation 
the veteran will call and ask for an appointment. 6 or 7 days 
later the VA gets back to them and says, yes, you know, we want 
to see you, what is your preferred date. They give the 
preferred date and then the preferred date can't be met.
    So, you know, let's say on day 8 they said my preferred 
date is on the 13th. They can't meet the 13th, but the next 
available appointment is on the 18th. But the way the VA 
calculates that wait time is from day 13, the day that they 
wanted the appointment and the day that they got it. So they 
say that's a 5 day wait time as opposed to all of the preceding 
days which were, you know, 10, 11, 12 days before they were 
actually able to state their preferred time.
    So I think this is--you know, that's why my veterans 
erupted in laughter because they were coming from a completely 
different perspective.
    So I just want to ask a very simple question. And I hope I 
can get a very simple answer. Why is it that the VA makes this 
so complicated and not just measure it from the time the 
veteran calls to the time he or she gets her appointment?
    Dr. Boyd. That is a good question. And Dr. Kirsh is here 
from that office. I would be more than happy for her to take a 
stab at that one.
    `Dr. Kirsh. Thank you for that question.
    I want to make sure that I am understanding whether it is a 
new patient or a follow up patient.
    Ms. Brownley. Okay. I understand a follow up patient can be 
a little bit different. Okay. And so in this case probably it 
is more relevant to a new patient. But I don't want anybody who 
is listening to this meeting think that there is a huge 
difference between one and the other.
    But go ahead.
    Dr. Kirsh. I appreciate that.
    So for a new patient calling in to get an appointment, that 
patient then, the scheduler accommodates that patient if they 
are on the phone and they are ready to make that appointment. 
The time that the scheduler goes into the system--
    Ms. Brownley. No. No. No. I know how the system works.
    Dr. Kirsh. Okay.
    Ms. Brownley. And I am just asking why is it that you don't 
measure from the time, whether it is a new patient or an 
existing patient, why don't you measure wait times from the 
time the veteran asks for an appointment and the time he or she 
receives an appointment? That is the only answer I want. Why is 
that you don't measure it that way?
    Dr. Kirsh. If the veteran calls and the appointment is made 
that day and until the completed time, that is the same 
measurement. I think there are some factors in there about 
requests in a follow up appointment where it is requested and 
the time to reach to the veteran, call them, get back to them, 
determine when they want to be seen. There can be some 
variability in that component.
    Ms. Brownley. Okay. Well, my time is up. And I just don't 
feel like I have gotten an answer. But I personally think going 
to Dr. Kizer's point and his comment saying that we lack 
national standards with regards to wait times, I would love to 
have a longer conversation with you about what that should look 
like. But I just don't understand why it is not simple.
    Everybody keeps saying, it is hard to answer your question 
because it is so complicated. But I feel like the VA has made 
it so complicated when it is really very simple, from the time 
they call to the time they receive their appointment.
    I know I am over time. I yield back, Mr. Chair.
    The Chairman. Thank you, Ms. Brownley.
    Ms. Radewagen, you are recognized for 5 minutes.
    Ms. Radewagen. Thank you, Chairman Takano, and Ranking 
Member Dr. Roe for holding this hearing. And I want to thank 
the panel for being here today.
    First off, I just simply want to associate myself with the 
concerns that were just raised by Ms. Brownley because in my 
home district of American Samoa I go through this with our 
veterans all the time. And I am very accessible to our 
veterans. As a matter of fact, many of them think nothing of 
calling me at 3:00 in the morning to tell me about their wait 
time definition that was misinterpreted or whatever.
    But at any rate I do hope that sometime in the future VA is 
able to find a way to simplify a very simple problem rather 
than doing it with a complicated kind of a definition.
    Anyway, so, Dr. Kizer, I understand that as the co-chair of 
the National Quality Task Force you recently participated in a 
conversation with some of the country's top health experts 
about access to care in 2019 and how our increasing reliance on 
technology is changing how access is defined and measured.
    What were the key conclusions of that conversation and how 
do they apply to our conversation today regarding access to 
care for veterans within the VA health care system?
    Dr. Kizer. Thank you for that question.
    I think if I were to distill down what was a perhaps 
several hour conversation to a couple of points it was this. 
One is that all of the utilization measures that are used to 
measure wait times have problems and are technically difficult. 
And as a result many health systems are increasingly moving to 
patient-reported outcomes and what the patient perceptions are 
as to whether they got in in a timely manner and how they were 
handled.
    And that while these health systems are not abandoning 
using wait times, they are using then in perhaps a different 
way, but putting increasing reliance on what the patients feel 
about the timeliness of the accessibility of care.
    The second point was the need to increasingly use 
technology enabled means to facilitate access of care, whether 
it is telehealth or Mhealth or secure e-mail or a variety of 
other tools that are now available that simply weren't 
available not that long ago. And that, you know, for example, 
Kaiser Permanente, a system that sees more than 100,000 million 
outpatient encounters a year, are now accomplishing more than 
half of those encounters through various telehealth means.
    Los Angeles County, as another example, has gone to using 
e-consults to support its community based clinics and has 
dramatically reduced wait times for specialty consultations by 
using, again, technology enabled means.
    So I think if I, again, were to distill down a several hour 
conversations, it would be to those 2 points about using 
patient reported measures and using telehealth and other 
technology means to facilitate access to care.
    Ms. Radewagen. Thank you.
    Dr. Kizer. Which has particular relevance to your district.
    Ms. Radewagen. Yes. And going back to this definition of 
wait times, my veterans and I are extremely honored that 
Secretary Wilke and I will be flying down in a few days to 
American Samoa. I am sure he is going to get it in the neck 
about the definition of wait times.
    Dr. Boyd, please respond to allegations made by a VA 
employee, Jeremy Whiteman, in a June 3rd Washington Post 
article regarding the electronic waiting list. Are you familiar 
with that?
    Dr. Boyd. Yes, I am. Peripherally, that is an ongoing, 
active investigation at this time, very complex, and if there 
were any other specifics, it is not a closed case yet.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back the 
balance of my time.
    The Chairman. Thank you, Ms. Radewagen.
    Ms. Lee, you are recognized for 5 minutes.
    Ms. Lee. Thank you, Mr. Chairman, and thank all of you for 
the service you provide to our veterans and, Dr. Kizer, for 
your leadership, Dr. Boyd as well, and GAO, of course, for your 
shining the light on this issue.
    Dr. Kizer, while you were at the VA you no doubt saw 
challenges that the organization experienced with technology 
modernization. And as of now the VA has many modernization 
projects in process, including this transition to the 
electronic health record from the Vista program.
    And it is our understanding that this transition will 
entail implementing Cerner's scheduling software which will 
replace the current antiquated scheduling system.
    But this is going to happen nationwide at first despite the 
fact that the Cerner rollout is going to be a step by step 
rollout over a 10 year period. And based on your past 
experience, Dr. Kizer, what is your view of this transition and 
what do you think the impact it will have on wait times and 
quality of delivery?
    Dr. Kizer. Thank you for the question. And I would 
certainly give the colleagues, my friends here from the VA, the 
opportunity to respond after I try to address your comments.
    I think there are 2 aspects of what you are asking. One has 
to do with the scheduling, the new scheduling system, the 
underlying scheduling system that is being implemented 
concomitant with the implementation of the overall new Cerner 
electronic health record.
    I am encouraged by what I have seen so far with the 
scheduling system. I was particularly encouraged by the fact 
that the VA reached out to the National Academy of Medicine to 
hold a workshop on what should be the key operating 
characteristics and functionalities of that scheduling system. 
That workshop was held a couple of months ago. The report is, I 
got the draft actually of the report this week and it should be 
released soon. And I think it will provide a lot of useful 
guidance to the VA as they implement this new scheduling 
system.
    As far as the rollout of the overall electronic health 
record, again, based on what I know and what I have heard from 
colleagues, and I do keep some presence in the IT sector, I 
have to confess that I have rather serious concerns about the 
implementation of the entire rollout and whether either the VA 
or the vendor is ready to accomplish all that needs to be done 
in the timeframes that have been laid out.
    Ms. Lee. Thank you. I would love to chat with you more 
about those concerns as well.
    Would anyone from the VA like to comment?
    Dr. Kirsh. I would like to address the Cerner stand-alone 
scheduling.
    As you know that was a request last fall from the congress 
about VHA's plan, VA's plan in accelerating the scheduling 
component of our electronic health record. And we since had 
purchased Cerner, spoke to the vendor about the capability and 
our collaborating with the Office of Electronic Health Record, 
VA OI&T and Cerner, about accelerating that program.
    We believe that there will be benefits gained in 
efficiencies there and plan to begin that next June.
    Ms. Lee. Okay. Thank you.
    I just wanted to talk to Dr. Boyd, or it might be Dr. 
Greenstone, on your written testimony you cite the use of an 
online scheduling app. Are you referring to Myhealthyvet app? 
Is that what is being referred to?
    Dr. Greenstone. So I can speak to that. Sure. Thank you.
    So there is VA online scheduling. We call it VAOS, and that 
allows veterans to actually go in and if they are established 
within a VA medical center to request appointments and actually 
go in and make their own appointments in the grids of their 
primary care providers and even mental health.
    We have created a similar capability for community care. So 
using Mission Act eligibility criteria, we allow veterans to go 
into the VA online scheduling. It shows their ability to use 
this for community care if the system knows that that veteran 
has eligibility: They live in the state or territory with no 
full service VA; they were a grandfathered in under Mission.
    Ms. Lee. So is that done through this app? I am--
    Dr. Greenstone. Yes.
    Ms. Lee. Yes. So it is--
    Dr. Greenstone. Through the app.
    Ms. Lee [continued]. --done through--
    Dr. Greenstone. So you can access it through Myhealthyvet.
    Ms. Lee. Okay. And I just want to, do you have any idea 
about the utilization rate of this app by veterans and what are 
the demographics of the veterans using it?
    Dr. Greenstone. Dr. Kirsh may have that for internally. I 
don't have those data, but we can get those for you as we have 
just rolled it out for community care. But for internal VA, Dr. 
Kirsh may have some information.
    Dr. Boyd. No. I agree with that. If we could get that 
information back to you because--
    Ms. Lee. Yeah. That would be great.
    Dr. Boyd [continued]. --it is very telling for us as well.
    Ms. Lee. Good. And I would love if you could also, any 
information you have about the satisfaction and the 
effectiveness of the use of that app would be helpful.
    Dr. Boyd. Certainly.
    Ms. Lee. Thank you.
    I yield the remainder of my time.
    The Chairman. Thank you, Ms. Lee.
    Mr. Meuser, you are recognized for 5 minutes.
    Mr. Meuser. Thank you, Mr. Chairman. Thank you all very 
much for being here. It is appreciated. Certainly, we are very 
encouraged by your work, what the Mission Act, I believe, has 
also helped improve. There is always more to do and certainly 
our shared goals are to take care of our country's veterans to 
the best of our abilities with the highest level of quality 
health care.
    The number of VAs, Mr. Kizer, I will direct these questions 
to you, please. About 170 VA hospitals and 1,063 outpatient 
sites, are they all monitored for wait times?
    Dr. Kizer. I think it might be best that someone from the 
VA respond to that question.
    Mr. Meuser. Oh, all right. Would somebody like to respond 
to that, please?
    Dr. Kirsh. Absolutely. The accesstocare.va.gov website, 
veteran or family member can go in and look at wait times in 
primary care, mental health and 10 other specialties for a new 
patient appointment.
    Mr. Meuser. Okay. Dr. Kirsh, I will continue then my 
questioning with you.
    And is the rating system, is it the 4 star or 5 stars, how 
do you set a rating system?
    Dr. Kirsh. So the rating system applies to in-patient 
hospital care and this access to care website is around 
receiving outpatient new appointments.
    Mr. Meuser. Is there a percentage of the VA hospitals, 
let's say, that are rated the best? Is there 5 percent that are 
in the top echelon for wait times?
    Dr. Kirsh. We can identify which sites because all sites do 
have wait times in primary care, mental health and if they 
offer specialty services. We have wait times for every facility 
available and we can provide that information for you and your 
staff.
    Mr. Meuser. Okay. I would actually like to see that. And do 
you believe that the Mission Act has helped?
    Dr. Kirsh. Absolutely. I think one of the biggest drivers 
in my role in leading the internal access office has been to 
think about increasing our capacity, efficiency and 
productivity really over the last year in preparation. We want 
to be able to offer veterans an opportunity to stay in the VA 
if that is their preference or then provide an integrated, 
expanded network.
    Dr. Greenstone. And, Congressman, the other value to the 
Mission Act is the provision for urgent care. We have had over 
14,000 veterans that we think have actually received urgent 
care under the Mission act. So that is another way that we have 
expanded the capacity for veterans to be seen when they think 
they actually need care.
    Mr. Meuser. All right. Great.
    And I do know the Mission Act, the Lebanon VA, which is in 
my district, Pennsylvania's 9th, does a fantastic job and they 
are improving all the time. And they also get a tremendous 
amount of feedback from their veterans. I don't know if that is 
a customary practice in other Vas, Dr. Boyd?
    Dr. Boyd. Yes. With the Veterans Experience Office we have 
an amazing tool now where it is called Vsignals. I mean, we can 
call it most anything. But we get realtime feedback, comments, 
congratulations, positive things, but we also concern from 
veteran's realtime, whether they are an in-patient or they are 
maybe that housekeeping didn't come in at a certain time, or 
they have concerns about medications, most anything.
    And we are--and we rapidly--well, the Veterans Experience 
Office rapidly gets those down to your site, down to your 
medical center and your folks there, your leadership there tend 
to that and address that. So they close that loop. We don't 
have to wait months for something to kind of fester. So we do 
realtime owning that moment.
    Mr. Meuser. Okay. Great.
    Are there certain model VAs? I mean, there must be that 
when it comes to wait times or maybe it is many of the pieces 
of the overall operation that 1 VA or 10 VAs do better and you 
identify the reasons why, people, process, technology, whatever 
it might be and obviously do our very best to model the other 
VAs after them? Either one would be fine. Thank you.
    Dr. Boyd. So we do have. We call those best practices. I 
tend to call them good practices. And we want to socialize 
those rapidly, vertically and horizontally throughout our 
enterprise. And the way to do that is as we are going forward 
with our VHA modernization plan, which I would be glad to talk 
about that at some other time, where we are linking together 
like programs, like services, clinical services, and the 
facility all the way on up to the national offices so we can 
help spread those practices. We don't have to wait for 2 years 
for a policy to come out, but share those things.
    So we do encourage that.
    Mr. Meuser. Well, thank you all for your service. And, 
Chairman, I yield back.
    The Chairman. Thank you, Mr. Meuser.
    Mr. Levin, you are recognized for 5 minutes.
    Mr. Levin. Thank you, Mr. Chairman. I want to thank you for 
holding this important hearing, and thank you to our witnesses 
for the work that you do to serve our veterans. I particularly 
want to thank the folks at the VA back home in my community in 
La Jolla and in Oceanside for the excellent work that they are 
doing. There is always room for improvement, and with that in 
mind I wanted to ask a few questions.
    Our veterans deserve clear information when making 
decisions about where to seek care, and Congress needs more 
reliable measures to understand veterans' access to care in our 
districts and districts across the country.
    Dr. Kizer, can you speak to best practices for patient 
access measures across the U.S. health care system and how 
commonly are wait times used as opposed to the CAPS survey or 
other measurements?
    Dr. Kizer. As I indicated previously, there currently are 
no industry wide or sector wide standards that are used to 
assess wait times which makes it difficult for an entity like 
the VA health care system to compare itself to community 
providers because in the community a variety of different 
methods may be used and certainly they don't receive the same 
degree of oversight or scrutiny as to the rigor with which 
their data has been collected or how valid are the methods they 
are using.
    So there is some difficulty there. And in my written 
testimony one of the suggestions that I offered is that the VA 
might want to work with the National Quality Forum to try to 
establish some national standards about what would be 
appropriate access standards or time limit standards for the 
different settings of care, whether that be primary care or 
specialty care of different flavors as well as hospital care 
and post-acute care, et cetera.
    Mr. Levin. Thank you. And I appreciated that suggestion. I 
am sure we will follow up.
    Dr. Boyd, you also noted in your testimony that VA uses the 
CAP survey to assess patient satisfaction for primary care and 
for mental health care.
    Has VA explored the possibility of expanding this survey to 
other aspects of specialty care and, if so, can you walk me 
through the cost benefit analysis?
    Dr. Boyd. I will let Dr. Kirsh answer that. But we have 
some great answers for that.
    Mr. Levin. Okay.
    Dr. Kirsh. So mental health and other specialty clinics 
have been added in the last few years, so we can get 
information and we do feed that information back through our 
group practice manager program. As a result of VACAA 303 
legislation, we have a practice manager much like private 
sector who is in charge of and really the point person for 
access of every single medical center. There are 238 practice 
managers that report to leadership there.
    So they really are overseeing and governing and looking at 
things like the Vsignals and the CAHPS information. I can get 
you some specifics and follow up for you and your staff around 
specialty care, cardiology, mental health, et cetera, and what 
are some of the questions asked and those responses nationally 
or locally.
    Mr. Levin. Thank you. I would appreciate that.
    I wanted to go back to this question about how dates are 
determined. As the GAO, Inspector General and even VA's own 
internal audits have found, patient indicated dates are often 
entered incorrectly resulting in inaccurate wait time data.
    Dr. Boyd, I would like to ask you a few follow ups on this 
to kind of understand better how these dates are determined.
    You described the patient indicated data as the appointment 
date agreed upon by the patient and provider. So what happens 
when the patient and provider disagree?
    Dr. Boyd. It goes with the patient's preferred date then.
    Mr. Levin. Okay. How--go ahead.
    Dr. Boyd. Because it is all about veteran preference. It 
really is.
    Mr. Levin. That is what I was going to ask next. So how 
does the veteran's personal preference such as a work or 
vacation schedule factor into the determination?
    Dr. Boyd. It does. And if I could just elude, being from 
Texas, although I practiced up in Maine up in the VA as well, 
and it was not uncommon for me to try to be able to convince a 
veteran that, oh, you really do need to be seen in 45 days. Oh, 
no. That was salmon running time up in the river, so couldn't 
do it then.
    So I use that because it was a reality to me that that was 
the important, that was important to that veteran. So we would 
push out the appointment and went to Option B. So we do go with 
veteran preference.
    Mr. Levin. Okay. Thanks for that clarification.
    Dr. Kizer or Dr. Draper, are there any other factors that 
you think VA should clarify?
    Dr. Kizer. Well, again, in my written comments I suggested 
that the VA work with the National Academy of Sciences to try 
to define what access means in this era that we live in now of 
increased connectivity through advanced communications and 
information management technology.
    What access meant 10 years ago, certainly 15 years ago, is 
different than what it means today. And the fact that we can 
accomplish so many of our day to day important and sensitive 
activities through technology enabled means has not carried 
over into health care. And there is much that we need to do to 
move health care as a sector into the same status, say, that 
banking and some other sectors have moved to as far as using 
the internet as a vehicle to enhance communication to services 
or a connection with services.
    Mr. Levin. Thank you. And I am out of time, but I want to 
thank the Chairman again for his attention to this important 
matter. And thank you all again for your testimony.
    The Chairman. Thank you, Mr. Levin.
    Dr. Roe, you are recognized for any closing remarks you 
might have.
    Mr. Roe. Well, thank you very much, Mr. Chairman. It has 
been good, and I am going to close by remembering a 
conversation I had over four decades ago when I started my 
medical practice. And this was an old country doctor. He sat 
down and he said, son, he said, I am going to tell you how to 
be a successful doctor. And I said, how is that, and he said, I 
am going to give you the three A's of practicing medicine. A 
Number 1 is availability. A Number 2 is affability, and A 
Number 3 is ability. And he said you get those 3 rights, if 
they don't like you or if they can't get in and they don't know 
how good you are, if they don't like you, they are not going to 
come back.
    So that is a challenge that we all have. It is very simple, 
but it still works today. And like I said at the very 
beginning, you can do all these measurements if you want to, 
but when somebody calls in and they have a bad experience 
calling in to make an appointment, when the person that comes 
in to greet them, when they come into the VA or into my office 
makes them mad I spend the first 10 or 15 minutes trying to get 
everybody calmed down so I can actually find out why are you 
here today.
    So I think you can take those things in training and do 
that, whether it is in the private or the public sector.
    And, secondly, Dr. Kizer made several great points. And we 
do have huge challenges in rural America where I live in 
practicing medicine. We know there are going to be huge 
shortages in the practice, and that is one of the things this 
Committee did when we wrote the VA Mission Act.
    And it struck me when I was out in Greg Walden's district 
in Oregon a little less than 2 years ago when he said, my 
congressional district has more square miles than the State of 
Tennessee does. And it does by several thousand more square 
miles, just one congressional district. So we had to put 
together a replacement of choice with something that worked in 
urban America and also tried to work in rural America, which is 
why you have to partner with the private sector.
    And one of the reasons for that in we know that the 
estimates are there will be as many as 100 to 120,000 fewer 
physicians or lack of physicians in 2030 than there are today. 
And if we start training these doctors today, if you are a 
freshman in college today, you are not going to be ready to go 
live until the early 2030s to get your training done. So it was 
a huge problem.
    We also added in the Mission Act residency and how to pay 
for it. We know that medical debt is a huge--or debt, student 
loan debt, I mean, is a huge problem. So we put that in there.
    A lot of things. So if you can't get your appointment at 
the VA in a timely fashion, can you get it out in the community 
where you live? If you live 5 hours from the VA and the doctor 
is sick that day, you don't want to drive 5 hours down there 
and find out you don't have an appointment and then turn around 
and drive 5 hours back. So those are the things that we tried 
to remedy making this right in the Mission Act.
    I think that the VA--as a matter of fact I can 
unequivocally say that between when I came on this Committee in 
2009 and now, the VA is doing a much better job. I really 
believe that. I think you are more attentive. And I believe 
that the solution to the problems is local leadership. If I am 
a local VA hospital administrator, assistant administrator, and 
I don't have the doctors, the personnel to take care of the 
patients that are going to be coming to my facility, I am going 
to be recruiting those people.
    Number 2, if I can't get them, I am going to go out in the 
community and recruit the community providers. I am going to go 
out and say to them, to the cardiologists, hey, we are short 
here, can you help us out.
    And then what I am going to do because of the tools we gave 
you in the Mission Act, I am going to pay you promptly so you 
will continue to see VA patients.
    So I think it is a lot of things. But it has to be done not 
at the 30,000 foot level where we are right here today. It has 
got to be done at the local level, at the local CBOC. When I 
was out in--and one of the visits I made, as a Chairman we do 
in many of these, I realized that the incentives were different 
for a VA provider than they were for me in private practice. If 
I hired someone, I got an extra night or two off call a week, a 
month. So that was a little more sleep that I got. I was highly 
motivated to recruit a new obstetrician, believe me. And our 
overhead didn't go up much. We could keep our overhead down.
    So those motivations are different. But the primary goal 
for all of us is to provide the best quality of care that you 
can possibly provide for that patient and a veteran. And to me, 
I am agnostic about it. If it is in the VA system, I am 
perfectly happy with that. If it is out in the community, I am 
perfectly happy with that. It is--I want the best care for the 
veteran.
    I thank all of you all certainly for taking your time and 
being here today, and, Mr. Chairman, thank you for having this 
hearing. I really appreciate it.
    The Chairman. Thank you, Dr. Roe.
    Well, let me just say that we know that the VA, echoing Ms. 
Brownley's remarks about the RAND study, we know that the VA 
offers excellent care as compared to private sector care. And 
so, you know, I am not quite as agnostic. I believe the VA 
offers great care. The problem was access.
    The VA wait list scandal posed serious, serious doubts 
about access to care and that scandal brought to light 
accessibility and manipulation of wait lists across the 
country. In response to that, we had put in place a piece of 
legislation, the Choice Act, that was intended to address these 
wait list scandals and accessibility.
    As Dr. Roe mentioned, we included medical residencies. We 
included money to hire people at competitive salaries. But 
persistent, what seems to be persistent is, frankly, a lack of 
transparency for the veteran in terms of being able to assess 
what are the wait times in realtime at VA facilities. And there 
is no ability currently to really assess wait times at private 
sector community care facilities. And looming over all of this 
is what Dr. Kizer had mentioned is a lack of any national 
standards or a common understanding of what wait times mean in 
the context of today's medicine.
    So I believe we have an opportunity for the VA to play a 
leadership role in terms of helping to set those standards. If 
the VA can get that right, make it simple for veterans to 
understand, I believe we will do not only veterans a great 
service, but we will do the American people a great service by 
setting these standards that the private sector, I think, will 
have to adopt, as community care provider networks will have to 
also be just as transparent as VA health care.
    I remain concerned that we pay attention to building and 
maintaining the internal capacity of the VA to deliver the care 
that independent studies have said is excellent care. And we 
need to pay attention to efforts to increase accessibility to 
that internal care, and to rely on our community partners to 
supplement what the VA cannot do internally.
    With that, I thank all the witnesses for their testimony 
today. I thank you for your hard work. All Members will have 5 
legislative days to revise and extend their remarks, and 
include extraneous material.
    Again, thank you for appearing for us today. And this 
hearing is now adjourned.

    [Whereupon, at 11:39 a.m., the Committee was adjourned.]




                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Debra A. Draper
Why GAO Did This Study

    The majority of veterans utilizing VA health care services receive 
care in VA- operated medical facilities, including 172 VA medical 
centers and more than 1,000 outpatient facilities. For nearly 20 years, 
GAO has reported on the challenges VA medical facilities have faced 
providing health care services in a timely manner. When veterans face 
wait times at VA medical facilities, they may be able to receive 
services from VA's community care programs, which VA estimates will be 
19 percent of its $86.5 billion in health care obligations in fiscal 
year 2020.
    This testimony focuses on GAO's large body of work on veterans' 
access to care and the status of VA's efforts to address GAO's 
recommendations, including those from GAO's June 2018 report on VA's 
community care programs and from GAO's December 2012 report on VA's 
scheduling of timely medical appointments that VA has provided 
information on through July 2019. It also includes preliminary 
observations on related ongoing work.

What GAO Recommends

    GAO has made a number of recommendations to VA to address timely 
scheduling and reliable wait-time data for outpatient appointments and 
through community care. VA generally agreed with GAO's recommendations. 
As of July 2019, VA has taken actions to fully implement one 
recommendation discussed in this statement. GAO continues to believe 
that all of the recommendations are warranted.

What GAO Found

    GAO has issued several reports recommending that the Department of 
Veterans Affairs (VA) take action to help ensure its facilities provide 
veterans with timely access to medical care. VA has taken a number of 
steps to address GAO's recommendations to improve wait-time measurement 
and its appointment scheduling policy. However, additional actions are 
needed to fully address most of GAO's recommendations.

      GAO found in 2012 that outpatient appointment wait times 
reported by VA were unreliable because VA did not ensure consistency in 
schedulers' definitions of the dates by which wait times were measured. 
GAO recommended that VA clarify these definitions. VA concurred and has 
taken a number of actions in response, including improved oversight 
through scheduling audits. However, VA's first internal audit in August 
2018 was unable to evaluate the accuracy and reliability of its wait-
time data due to the lack of business rules for calculating them, 
indicating that additional efforts are needed to address this issue.
      GAO also found in 2012 that not all facilities GAO 
visited used the electronic wait list to track new patients that needed 
medical appointments, as required by VA's scheduling policy. This put 
patients at risk for being lost for appointment scheduling. GAO 
recommended VA ensure consistent implementation of its policy, and that 
all schedulers complete required training. VA concurred, and with the 
information VA provided in July 2019 GAO considers VA's actions, 
including updating its scheduling policy and completing scheduler 
training, sufficient to fully address the recommendation.
      While improvements to VA's scheduling policy and 
processes will help ensure veterans receive timely access to care, 
there are other factors that may also affect access that are not 
currently reflected in VA's wait- time data. For example, GAO found 
instances in which the time it took the agency to initially enroll 
veterans in VA health care benefits was more than 3 months.

    GAO has also made recommendations to improve appointment scheduling 
and ensure timely access to care from non-VA providers in VA's 
community care programs that remain unimplemented. GAO found in June 
2018 that the data VA used to monitor the timeliness of the Veterans 
Choice Program's appointments captured only a portion of the total 
appointment scheduling process. Although VA had a wait-time goal of 30 
days, VA's timeliness data did not capture certain processes, such as 
the time taken to prepare veterans' referrals and send them to a third-
party administrator. GAO found that if these were accounted for, 
veterans could potentially wait up to 70 calendar days to see a 
community care provider. VA officials stated that most recommendations 
will be addressed with new program tools it plans to implement. For 
example, VA is implementing a system for referral management and 
appointment scheduling expected to be available in all VA medical 
facilities by fiscal year 2021. While technology may be an important 
tool, VA will also need clear and consistent policies and processes, 
adequate oversight, and effective training to help avoid past 
challenges.

    Chairman Takano, Ranking Member Roe, and Members of the Committee:

    I am pleased to be here today to discuss our work on appointment 
wait times for veterans seeking care provided by the Department of 
Veterans Affairs (VA) and for those veterans referred to non-VA 
providers through VA's community care programs. Access to timely 
medical appointments is critical to ensuring that veterans obtain 
needed medical care. In particular, access to timely primary care 
appointments is essential as a gateway to obtaining other health care 
services such as specialty care.
    The majority of veterans utilizing health care services delivered 
by the VA's Veterans Health Administration (VHA) receive care in VA-
operated medical facilities, including 172 VA medical centers and more 
than 1,000 outpatient facilities. For nearly 20 years, we have reported 
on the challenges VA medical facilities have faced providing health 
care services in a timely manner.\1\ Since 2000, we have issued several 
reports recommending that VA improve appointment scheduling, ensure the 
reliability of wait-time and other performance data, and improve 
oversight. Implementing these recommendations would help ensure VA 
medical facilities provide veterans with timely access to outpatient 
primary and specialty care, as well as mental health care. Due to these 
and other concerns about VA's management and oversight of its health 
care system, we concluded that VA health care is a high-risk area and 
added it to our High Risk List in 2015, with updates in 2017 and 
2019.\2\
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    \1\ See, for example, GAO, VA Health Care: More National Action 
Needed to Reduce Waiting Times, but Some Clinics Have Made Progress, 
GAO-01-953 (Washington, D.C.: Aug. 31, 2001); and 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).
    \2\ GAO, High-Risk Series: Substantial Efforts Needed to Achieve 
Greater Progress on High-Risk Areas, GAO-19-157SP (Washington, D.C.: 
Mar. 6, 2019); High-Risk Series: Progress on Many High-Risk Areas, 
While Substantial Efforts Needed on Others, GAO-17-317 (Washington, 
D.C.: Feb. 15, 2017); and High-Risk Series: An Update, GAO-15-290 
(Washington, D.C.: Feb. 11, 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.
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    Serious and long-standing problems with veterans' access to care 
were also highlighted in a series of congressional hearings in the 
spring and summer of 2014, after several well-publicized events raised 
additional concerns about wait times for appointments at VA medical 
facilities.\3\ Legislation subsequently enacted in 2014 and 2018 
established new community care programs, where veterans have the option 
to receive hospital care and medical services from a non-VA provider if 
certain conditions are met.\4\ VA estimates that community care 
programs will be 19 percent of its $86.5 billion in health care 
obligations in fiscal year 2020. The length of VA outpatient 
appointment wait times is one of the eligibility criteria for several 
community care programs, and in fiscal years 2015 and 2016 about half a 
million veterans were referred to one of these programs under the wait-
time eligibility criteria.
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    \3\ In some cases, delays in care or VA's failure to provide care 
reportedly have resulted in harm to veterans.
    \4\ Pub. L. No. 113-146, 128 Stat. 1754 (2014); Pub. L. No. 115-
182, tit. I, 132 Stat. 1393 (2018).
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    You asked GAO to testify today on appointment wait times at VA 
medical facilities and through community care programs, including the 
wait-time information the agency makes available to veterans and the 
reliability of these data. My remarks focus on

    1.our work on VA outpatient appointment scheduling and the status 
of VA's efforts to address our recommendations;
    2.our work on community care program appointment scheduling and the 
status of VA's efforts to address our recommendations; and
    3.our ongoing work on one of VA's efforts to improve access to 
care.

    My remarks today are based on our extensive body of work on 
veterans' access to care, including our December 2012 report on VA's 
scheduling of timely outpatient medical appointments and our June 2018 
report on VA's community care programs, as well as department 
information through July 2019 in response to recommendations that we 
have made.\5\ For a list of our previous work in this area, see the 
Related GAO Products page at the end of this report. Those reports 
provide further details on our scope and methodology. This testimony 
also includes preliminary observations from our current review 
assessing VA's efforts to offer veterans access to routine care without 
an appointment (known as VA's same-day services initiative). That 
review is based on our review of VA's policies, guidance, and 
requirements related to same-day services, and interviews with various 
officials, including from relevant VA offices and six VA medical 
centers and affiliated outpatient clinics.
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    \5\ See GAO-13-130; and GAO, Veterans Choice Program: Improvements 
Needed to Address Access-Related Challenges as VA Plans Consolidation 
of Its Community Care Programs, GAO-18-281 (Washington, D.C.: June 4, 
2018).
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    We conducted all of the work on which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.

Background

Scheduling Outpatient Appointments in VA Medical Facilities

    Enrollment is generally the first step veterans take to obtain 
health care services, within VA or through community care. VA's Health 
Eligibility Center manages the process of accepting applications, 
verifying eligibility, and determining enrollment, in collaboration 
with VA medical centers. VA requires veterans' enrollment applications 
be processed within 5 business days of receipt, including pending 
applications that require additional information from the applicant to 
process.\6\
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    \6\ If veterans request that VA contact them to schedule an initial 
appointment on their application, they are placed on the New Enrollee 
Appointment Request list, and VA medical center staff are required to 
initiate the scheduling process 7 calendar days after the veteran is 
fully enrolled.
---------------------------------------------------------------------------
    Once enrolled, veterans can access VA health services by scheduling 
an appointment. VA's scheduling policy establishes the procedures for 
scheduling medical appointments, as well as sets the requirements for 
staff directly or indirectly involved in the scheduling process (e.g., 
training). A scheduler at the VA medical facility is responsible for 
making appointments for new and established patients (i.e., patients 
who have visited the same VA medical center in the previous 24 months), 
which are then recorded in VA's electronic scheduling system. VA 
scheduling policy requires patients who have requested an appointment 
and have not had one scheduled within 90 days to be placed on VA's 
electronic wait list. VA determines wait times at each facility based 
on outpatient appointment information from its scheduling system.
    If veterans request that VA contact them to schedule an initial 
appointment on their application, they are placed on the New Enrollee 
Appointment Request list, and VA medical center staff are required to 
initiate the scheduling process 7 calendar days after the veteran is 
fully enrolled.

VA's Public Websites with Appointment Wait-Time Information

    VA is required to publish information on appointment wait times at 
each VA medical facility for primary care, specialty care, and hospital 
care and medical services, which it does through two public websites. 
In November 2014, VA began posting monthly wait times for scheduling 
appointments at all VA medical facilities. One public website provides 
links to spreadsheets containing data for each VA medical facility, 
such as the average wait times for primary, specialty, and mental 
health care appointments and the number of patients on the electronic 
wait list.\7\ In April 2017, VA created a second public ``Access and 
Quality in VA Healthcare'' website to post both patient access data and 
information on VA medical facilities' performance on various quality 
metrics. This website aims to help veterans find wait times at a 
specific facility.\8\ This information would allow veterans and their 
family members to use the wait-time data on this website to determine 
the best option for obtaining timely care.\9\
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    \7\ See https://www.va.gov/health/access-audit.asp.
    \8\ See https://www.accesstopwt.va.gov/. According to VA's website, 
average wait times are based on appointments completed at VA medical 
facilities during the previous month. The Veterans Access, Choice, and 
Accountability Act of 2014 required VA to publish the wait times for 
scheduling an appointment and quality and outcome measures in the 
Federal Register and on a publicly accessible website.
    \9\ According to officials, VA does not currently have the 
necessary data to publicly report wait times for non-VA providers in 
its community care programs. Officials stated that VA has future plans 
to measure and report aggregated data for the time elapsed from a 
veteran's request for care to the time of a community care appointment.

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VA's Community Care Programs

    In order to receive needed care in a timely manner, veterans may 
need to obtain care outside of VA medical facilities through one of 
VA's community care programs. VA has purchased health care services 
from community providers through various community care programs since 
1945. Veterans may be eligible for community care when they are faced 
with long wait times or travel long distances for appointments at VA 
medical facilities, or when a VA facility is unable to provide certain 
specialty care services.
    Since 2014, Congress has taken steps to expand the availability of 
community care for veterans. The Veterans Access, Choice, and 
Accountability Act of 2014 provided up to $10 billion in funding for 
veterans to obtain health care services from community providers.\10\ 
The law established a temporary program-called the Veterans Choice 
Program (Choice Program)-to offer veterans the option to receive 
hospital care and medical services from a community provider when a VA 
medical facility could not provide an appointment within 30 days, or 
when veterans resided more than 40 miles from the nearest VA facility 
or faced other travel burdens. VA contracted with two third-party 
administrators (TPA) to establish networks of community providers, 
schedule veteran appointments with those providers, and pay those 
providers for services rendered through the Choice Program.
---------------------------------------------------------------------------
    \10\ Pub. L. No. 113-146, Sec. Sec.  101, 802, 128 Stat. 1754, 
1755-1765, 1802-1803 (2014). Additional funding for the Choice Program 
was provided on three separate occasions. Legislation enacted in August 
and December of 2017 provided an additional $4.2 billion for the 
Veterans Choice Fund. VA Choice and Quality Employment Act of 2017, 
Pub. L. No. 115-46, Sec.  101, 131 Stat. 958, 959 (2017) (providing an 
additional $2.1 billion for the Veterans Choice Fund); An Act to amend 
the Homeland Security Act of 2002 to require the Secretary of Homeland 
Security to issue Department of Homeland Security-wide guidance and 
develop training programs as part of the Department of Homeland 
Security Blue Campaign, and for other purposes, Pub. L. No. 115-96. 
Div. D, Sec.  4001, 131 Stat. 2044, 2052-53 (2017) (providing an 
additional $2.1 billion for the Veterans Choice Fund). In addition, the 
VA MISSION Act provided an additional $5.2 billion for the Veterans 
Choice Fund and authorized VA, beginning March 1, 2019, to use 
remaining amounts in the Fund for the Community Care Program, along 
with any other available amounts in other appropriation accounts for 
such purposes. Pub. L. No. 115-182, Sec. Sec.  142, 510, 132 Stat. 
1393, ** (2018).
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    In June 2018, the VA MISSION Act of 2018 was enacted to further 
address some of the challenges faced by VA in ensuring timely access to 
care.\11\ The Act required VA to implement within 1 year a permanent 
community care program-the Veterans Community Care Program (VCCP). The 
act identified criteria that all veterans enrolled in the VA health 
care system would be able to qualify for care through the VCCP; for 
example, if VA does not offer the care or service needed by the veteran 
or VA cannot provide the veteran with care and services that comply 
with its designated access standards. The access standards include 
appointment wait times for a specific VA medical facility; for example, 
veterans may be eligible for care through the VCCP if VA cannot provide 
care within 20 days for primary and mental health care, and 28 days 
from the date of request for specialty care, unless veterans agree to a 
later date in consultation with their VA health care provider.
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    \11\ Pub. L.No. 115-182, tit. I, 132 Stat. 1393 (2018).

VA Has Taken Actions to Address Deficiencies in Appointment Scheduling 
    and Timeliness Identified in Prior Work, but Additional Actions Are 
---------------------------------------------------------------------------
    Needed

VA Has Taken Steps to Address Our Recommendation to Improve Wait-Time 
    Measurement and Has Implemented Our Recommendation to Improve 
    Implementation of Scheduling Policy
    VA has taken a number of actions to address our recommendations 
regarding deficiencies we found in wait-time measurement and 
implementation of its scheduling policy. For wait-time measurement, 
these actions included changes to the wait-time measurement 
definitions, provision and documentation of scheduler training, and 
improved oversight through audits, all of which have been in a state of 
flux for the past 6 years. On July 12, 2019, VA provided us additional 
updates on efforts to implement our related recommendations. This new 
information fully addresses one of our recommendations.

VA Wait-Time Measurement

    In December 2012, we found that outpatient medical appointment wait 
times reported by VA were unreliable, and, therefore, VA was unable to 
identify areas that needed improvement or mitigate problems for 
veterans attempting to access care.\12\ VA typically has measured wait 
times as the time elapsed between the `start date'-a defined date that 
indicates the beginning of the measurement-and the `end date', which is 
the date of the appointment. At the time of our 2012 report, VA 
measured wait times as the number of days elapsed from the start date 
identified as the desired date-the date on which the patient or health 
care provider wants the patient to be seen-to the date of the 
appointment.\13\ We found that the reliability of the reported wait-
time measures was dependent on the consistency with which schedulers 
recorded the desired date in the scheduling system, as required by VA's 
scheduling policy. However, VA's scheduling policy and training 
documents for recording the desired date were unclear and did not 
ensure consistency. We observed that not all schedulers at VA medical 
centers that we visited recorded the desired date correctly. Therefore, 
we recommended that VA either clarify its scheduling policy to better 
define the desired date, or identify clearer wait- time measures that 
are not subject to interpretation and prone to scheduler error. VA 
concurred with the recommendation, which we have identified as among 
those recommendations that warrant priority attention.\14\
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    \12\ See GAO-13-130.
    \13\ The desired date was defined in VHA Directive 2010-027, VHA 
Outpatient Scheduling Processes and Procedures (June 9, 2010). VA 
rescinded this policy by memorandum, effective July 31, 2014, and 
replaced it with interim guidance.
    \14\ We send letters each year to the heads of key departments and 
agencies, including VA, that give the overall status of the 
department's or agency's implementation of our recommendations and 
identify open recommendations that should be a priority for 
implementation. In March 2019, we sent the Secretary of VA this year's 
letter, which identified 30 recommendations as being a priority for 
implementation. See GAO, Priority Open Recommendations: Department of 
Veterans Affairs, GAO-19-358SP (Washington, D.C.: Mar. 28, 2019).
---------------------------------------------------------------------------
    Actions VA has taken or is taking to address this recommendation 
include:

      changes to the start date and definitions for wait-time 
measurement,
      provision and documentation of scheduler training, and
      improved oversight through scheduler audits.

    In addition, we are currently assessing new information VA provided 
in July 2019, which will include obtaining additional evidence and 
clarification from VA to see whether it has fully addressed our 
concerns.

VA's Actions to Change Start Dates for Wait-Time Measurement

    While the terminology for the start dates of the wait-time 
measurement has changed several times over the past 6 years, we believe 
that the current definitions of the start dates are substantively the 
same as those we reviewed-and found to be deficient-in our 2012 report. 
VA subsequently introduced new terms with similar definitions-from 
``desired date'' to ``preferred date''-without fundamentally addressing 
the deficiency. See table 1 for the changes to and definitions of the 
start dates for measuring outpatient appointment wait times and wait-
time goals since June 2010.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 


    (a) VHA Directive 2010-027 was the scheduling directive in effect 
during our 2012 audit of wait times and scheduling processes.
    (b) VA introduced but did not define ``create date'' in its July 7, 
2014, memo; it is specified elsewhere as the date the appointment is 
created in the scheduling system.

    As table 1 shows, for new patients and established patients seeking 
appointments without a return-to-clinic date specified by their 
provider, VA changed the terminology of the start date to preferred 
date in its July 2016 scheduling policy from what it had established in 
its June 2010 policy. However, the definition of preferred date is 
substantively the same as the definition of desired date in the 
previous scheduling policy, the latter of which we found to be subject 
to interpretation and prone to scheduler error in our 2012 report.\15\ 
We continue to believe that the preferred date is also subject to 
interpretation and prone to scheduler error, which poses concerns for 
the reliability of wait times measured using the patient's preferred 
date.
---------------------------------------------------------------------------
    \15\ VHA Directive 1230(1) and VHA Directive 2010-027. See also 
GAO-13-130.
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    In its updated July 2016 scheduling policy, VA also changed the 
terminology of the start date to the ``clinically indicated date'' for 
established patients whose provider has documented a clinically 
appropriate return-to-clinic date in the patient's electronic health 
record. The clinically indicated date is substantively the same as the 
definition of desired date for established patients in the previous 
scheduling directive.
    While VA has not clarified the definitions of start dates, VA has 
taken actions intended to improve the accurate recording of the 
clinically indicated date in three ways:

    1.VA requires clinical leadership (such as the Associate Chief of 
Staff) at each VA medical facility to ensure that providers enter the 
clinically indicated date in the electronic health record for future 
appointments;
    2.VA standardized the entry of the clinically indicated date in the 
electronic health record to improve the accuracy of the date, which was 
implemented across all VA medical facilities as of July 2018; and
    3.VA created a technology enhancement to enable the automatic 
transfer of the clinically indicated date from the electronic health 
record to the scheduling system. As a result, the scheduler no longer 
has to retrieve the date from veterans' electronic health records and 
manually enter it into the scheduling system. VA reported that this 
enhancement was implemented at all but three VA medical facilities as 
of January 2019.

    In July 2019, VA reported to us that the error rate for the patient 
indicated date (either the clinically indicated date, or in the absence 
of that date, the patient's preferred date) was 8 percent of about 
667,000 appointments audited in the most recent biannual audit cycle, 
ending March 31, 2019. VA cites an almost 18 percent improvement in 
reducing the number of errors caused by manual entry of the clinically 
indicated date due to the use of the technology enhancements.

VA's Actions to Provide and Document Scheduler Training

    Although VA updated its scheduling policy in 2016, we believe the 
instructions, which form the basis for wait-time measurement, are still 
subject to interpretation and prone to scheduler error, making training 
and oversight vital to the consistent and accurate implementation of 
the policy. VA reported that 97 percent of all staff who scheduled an 
appointment within 30 days completed the required scheduling training 
as of July 2, 2019. VA stated that the department will closely monitor 
compliance with scheduler training completion for the remaining staff. 
Given the high turnover among schedulers, it is important that VA 
remain vigilant about scheduler training, ensuring all who need it 
receive it.

VA's Actions to Improve Oversight through Scheduler Audits

    VA has taken a number of actions to improve oversight of the 
scheduling process through biannual scheduling audits at VA medical 
centers and second level audits, as well as completion of the first 
system-wide internal audit of scheduling and wait-time data.
    Biannual scheduler audits. VA's July 2016 scheduling policy 
required biannual audits of the timeliness and appropriateness of 
schedulers' actions and accuracy of entry of the clinically indicated 
date and preferred date, the start dates of wait-time measurement as 
identified by the revised scheduling policy. In June 2017, VA deployed 
a standardized scheduling audit process for staff at VA medical centers 
to use. As part of our recommendation follow-up in July 2019, VA 
reported 100 percent completion of the required biannual scheduling 
audits in fiscal year 2018. As noted above, VA reported to us that the 
error rate for the patient indicated date (either the clinically 
indicated date, or in the absence of that date, the patient's preferred 
date) was 8 percent of about 667,000 appointments audited. While VA 
asserts that errors in the clinically indicated date have decreased, an 
error rate of 8 percent still yields errors in more than 53,000 
appointments audited. Given these errors, we remain concerned about the 
reliability of wait times measured using preferred date (one part of 
the patient indicated date), and have requested additional information 
from VA about these errors.

      Second level scheduler audits. In November 2018, VA 
implemented a second-level scheduling audit (Audit the Auditors 
program), which is overseen by the VA integrated service networks 
tasked with oversight of VA medical facilities within their regions. 
Each medical center within a network region is paired with another 
medical center and they audit each other's scheduling audit. Throughout 
the cycle, medical centers share their findings with each other and the 
network. The goal is to standardize scheduling audit practices across 
the network and to ensure reliability of the scheduler audit results. 
According to VA, the first cycle was completed April 30, 2019, by all 
VA medical centers.
      First internal system-wide audit of wait-time data and 
scheduling. In its first internal audit completed in August 2018, VA 
was unable to evaluate the accuracy and reliability of scheduling and 
the wait-time data. Specifically, VA was unable to determine the 
accuracy and reliability of the scheduling and wait-time data, 
databases, and data flow from the electronic health record and 
scheduling system to the VA Access and Quality website because they 
were not able to obtain the rules for calculating wait times.\16\ Given 
our continued concerns about VA's ability to ensure the reliability of 
the wait-time data, we plan to obtain additional information from VA 
about its methodology and assessment of evidence underlying the audit 
findings.
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    \16\ From November 2017 through August 2018, VHA's Office of 
Internal Audit conducted its first performance audit, which assessed 
the accuracy and reliability of the wait times published on the VA 
Access and Quality website. VHA issued the audit report in February 
2019, which is an internal report and not publicly available. The 
methodology included an evaluation of compliance against requirements 
in VHA Directive 1230 related to the accuracy and reliability of 
veteran wait times.

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Scheduling Policy

    In December 2012, we also found inconsistent implementation of VA's 
scheduling policy that impeded VA medical centers' scheduling of timely 
medical appointments. Specifically, we found that not all of the 
clinics across the medical centers we visited used the electronic wait 
list to track new patients that needed medical appointments as required 
by VA's scheduling policy, putting these patients at risk of being lost 
for appointment scheduling.\17\ Furthermore, VA medical centers' 
oversight of compliance with VA's scheduling policy, such as ensuring 
the completion of required scheduler training, was inconsistent across 
facilities. Scheduler training was particularly important given the 
high volume of staff with access to the scheduling system-as of July 2, 
2019, VA reported there were approximately 33,000 staff that had 
scheduled an appointment within the last 30 days. We also found that VA 
medical centers identified the outdated and inefficient scheduling 
system as one of the problems that can impede the timely scheduling of 
appointments and may impact their compliance with VA's scheduling 
policy.\18\ We recommended VA ensure that VA medical centers 
consistently and accurately implement VA's scheduling policy, including 
use of the electronic wait list, as well as ensuring that all staff 
with access to the scheduling system completes the required 
training.\19\ VA concurred with this recommendation, which we also have 
identified as among those recommendations that warrant priority 
attention.
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    \17\ VHA Directive 2010-027, in effect during our 2012 audit, 
defined the electronic wait list as the official VA wait list that is 
used to list patients waiting to be scheduled, or waiting for 
assignment to a provider's panel. In general, the electronic wait list 
is used to keep track of patients with whom the clinic does not have an 
established relationship (e.g., the patient has not been seen before in 
the clinic).
    \18\ See GAO-13-130.
    \19\ We also made two recommendations regarding the allocation of 
staffing resources to respond to demand for appointment scheduling and 
the oversight of telephone access and implementation of telephone 
systems best practices. Both of these recommendations remain 
unimplemented as of July 2019.
---------------------------------------------------------------------------
    VA's actions to improve implementation of the scheduling policy, 
including updated information VA provided in July 2019, fully addresses 
this recommendation. VA issued an updated scheduling policy in July 
2016 that provided clarification on scheduling roles and 
responsibilities for implementing the policy and business rules for 
scheduling appointments, such as using the electronic wait list, and 
required biannual scheduler audits. VA also ensured almost all 
schedulers received training on the updated scheduling policy and 
improved oversight through audits, as previously described.
    In addition, VA plans to rapidly deploy a single nationwide 
scheduling system that is intended to simplify the operating 
environment for schedulers and may mitigate challenges identified in 
our 2012 report. The new scheduling system will be a resource-based 
system where each provider's schedule is visible on one screen, instead 
of requiring the need to toggle through multiple screens as it 
currently exists. VA plans to roll out the new scheduling system 
starting in 2020, which is expected to be implemented in coordination 
with the planned modernization of the electronic health records system 
across VA facilities. According to VA, the scheduling system will be 
available for use in advance of the completion of the electronic health 
record implementation at some sites.\20\
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    \20\ VA does not have an end date for the completion of the 
scheduling system or electronic health record deployment.

VA Has Taken Steps to Address Our Recommendations to Strengthen 
    Enrollment Processes and Management of Initial Requests for Care 
---------------------------------------------------------------------------
    That Affect Veterans' Timely Appointments

    In addition to the recommendations we made to improve VA's wait-
time data and implementation of its scheduling policy, we have also 
made recommendations to address other factors that affect the 
timeliness by which veterans obtain appointments. These recommendations 
have targeted VA's enrollment processes and its management of veterans' 
initial requests for care. While VA has taken some steps to address 
these recommendations, they have not yet been fully addressed. For 
example, we have found that VA's wait-time measures do not yet capture 
the time it takes the agency to enroll veterans in VA health care 
benefits, or manage a veterans' initial request for care.\21\
---------------------------------------------------------------------------
    \21\ Veterans can request VA contact them to schedule an initial 
appointment on their enrollment application, and if eligible, they are 
placed on VA's New Enrollee Appointment Request list. According to VA's 
scheduling policy, scheduling appointments for veterans on the New 
Enrollee Appointment Request list must start within 7 days of a veteran 
being determined eligible for VA health care benefits.

---------------------------------------------------------------------------
Enrollment Process

    In September 2017, we found that VA did not provide its medical 
centers, who historically receive 90 percent of enrollment 
applications, with clear guidance on how to resolve pending 
applications, which led to delays in veteran's enrollment.\22\ For 
example, we found instances in which pending applications remained 
unresolved for more than 3 months. We concluded these delays in 
resolving pending applications, along with previously documented delays 
due to errors in enrollment determinations, may result in veterans 
facing delays when obtaining health care services or incorrectly denied 
benefits.
---------------------------------------------------------------------------
    \22\ GAO, VA Health Care: Opportunities Exist for Improving 
Implementation and Oversight of Enrollment Processes for Veterans, GAO-
17-709 (Washington, D.C.: Sept. 5, 2017).
---------------------------------------------------------------------------
    We made several recommendations to address these deficiencies, two 
of which we determined to be priority recommendations for VA to clearly 
define roles and responsibilities for (1) resolving pending 
applications and (2) overseeing the enrollment process. VA has made 
progress in addressing these priority recommendations by beginning to 
update, but not yet finalizing, its policies, procedures, and guidance 
on enrollment processing. In 2017, VA's Health Eligibility Center began 
conducting secondary reviews of enrollment determinations. However, in 
fiscal year 2018, Health Eligibility Center staff found that 18 percent 
of rejected enrollment determinations and 8 percent of ineligible 
enrollment determinations that underwent secondary reviews were 
incorrect.\23\ These recommendations remain unimplemented as of July 
2019.
---------------------------------------------------------------------------
    \23\ We also recommended that VA develop procedures for 
consistently collecting reliable enrollment processing data. Although 
VA is working on data systems enhancements and plans to regularly test 
the reliability of its data, it has not completed those system 
enhancements or begun to regularly audit its enrollment processing data 
for reliability. VA did implement our recommendation of clarifying the 
5-day timeliness standard for processing enrollment applications.

---------------------------------------------------------------------------
Initial Requests for Care

    Once enrolled, we have found that VA's management of veterans' 
initial request for care have led to delays; and although VA has 
clarified timeliness requirements, it has yet to fully capture the wait 
veterans experience in scheduling initial appointments. In a number of 
reports from 2015 to 2018, we found instances in which newly enrolled 
veterans were not contacted to schedule initial primary care 
appointments, and did not complete initial primary care appointments 
and mental health evaluations according to VA timeliness 
requirements.\24\ These delays may be understated in VA data, because 
VA's wait-time measures do not take into account the time it takes VA 
medical center staff to contact the veteran to determine a preferred 
date (the starting point for wait-time measurement) from the veteran's 
initial request or referral. We found that the total amount of time it 
took for veterans to be seen by providers was often much longer when 
measured from the dates veterans initially requested to be contacted to 
schedule an appointment or were referred for an appointment by another 
provider than when using the veterans' preferred dates as the starting 
point. See figure 1 for an example of how the two wait-time 
calculations differ for an initial primary care appointment.\25\
---------------------------------------------------------------------------
    \24\ 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: Actions Needed to Improve Newly Enrolled Veterans' Access 
to Primary Care, GAO-16-328 (Washington, D.C.: Mar. 18, 2016); and 
Veterans Health Administration: Opportunities Exist for Improving 
Veterans' Access to Health Care Services in the Pacific Islands, GAO-
18-288 (Washington, D.C.: Apr. 12, 2018).
    \25\ We found that although some of the delays may have been 
attributed to VA medical center staff not being able to contact 
veterans after repeated attempts, or veterans' preferences to delay 
treatment, in some cases the delays were caused because VA medical 
center officials did not initiate contact according to VA requirements, 
did not complete the required number of contact attempts, or did not 
have appointments available due to provider and space shortages.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 

    We made several recommendations to VA, including a priority 
recommendation to monitor the full amount of time newly enrolled 
veterans wait to be seen by a provider.\26\ VA has taken several steps 
to address the priority recommendation, including revising an internal 
report to help identify and document newly enrolled veterans and 
monitor their appointment request status. The report is intended to 
help VA and its medical centers oversee the enrollment and appointment 
process by tracking the total time from application to appointment. 
However, VA is still in the process of enhancing its electronic 
enrollment system to capture the application date for all newly 
enrolled veterans. Until the enhancements are implemented, VA may not 
consistently capture the start date for newly enrolled veterans, which, 
in turn, affects the reliability of its wait-time data. The priority 
recommendation remains unimplemented as of July 2019.
---------------------------------------------------------------------------
    \26\ We also made recommendations that VA review and revise its 
process for identifying and documenting newly enrolled veterans 
requesting appointments, clarify timeliness requirements for scheduling 
mental health evaluations, and clarify definitions, such as how a new 
patient is defined, used to calculate wait times. VA concurred with and 
implemented all of these recommendations.

VA Has Not Implemented Recommendations to Address Wait Times and Other 
---------------------------------------------------------------------------
    Choice Program Issues That Could Affect VCCP Implementation

    VA has not implemented several of our recommendations related to 
the Choice Program that could impact veterans' timely access to care 
under the VCCP. These recommendations address (1) establishing 
achievable community care wait-time goals and a scheduling process 
consistent with those goals, (2) collecting accurate and complete data 
to systematically monitor veteran community care wait times, and (3) 
other factors that could adversely affect veterans' access to community 
care. VA has begun taking steps to address these recommendations as it 
implements the VCCP.

VA Still Needs to Establish Achievable Wait-Time Goals and a Scheduling 
    Process Consistent with Those Goals to Ensure Veterans' Timely 
    Access to Care under the VCCP

    Our review of the Choice Program in June 2018 found that despite 
having a wait-time goal, VA developed a scheduling process for the 
Choice Program that was not consistent with achieving that goal. The 
Veterans Access, Choice, and Accountability Act of 2014 required VA to 
ensure the provision of care to eligible veterans within 30 days of the 
clinically indicated date or, if none existed, within 30 days of the 
veteran's preferred date. However, we found that those veterans who 
were referred to the Choice Program for routine care because services 
were not available at VA in a timely manner could potentially wait up 
to 70 calendar days for care. Under VA's scheduling processes, this 
potential wait time included VA medical centers having at least 18 
calendar days to prepare veterans' Choice Program referrals to TPAs and 
another 52 calendar days for appointments to occur as scheduled by 
TPAs.
    Based on this finding, we recommended that VA establish an 
achievable wait-time goal for the VCCP that will permit VA to monitor 
whether veterans are receiving community care within time frames that 
are comparable to the amount of time they would otherwise wait to 
receive care at VA medical facilities.\27\ We also recommended that VA 
should design an appointment scheduling process for the VCCP that sets 
forth time frames within which (1) veterans' referrals must be 
processed, (2) veterans' appointments must be scheduled, and (3) 
veterans' appointments must occur that are consistent with the wait-
time goal VA has established for the program. VA agreed with both 
recommendations, which remain unimplemented, and officials stated that 
they are in the process of finalizing metrics to capture wait-time 
performance and designing an appointment scheduling process. Without 
specifying wait- time goals that are achievable, and without designing 
appointment scheduling processes that are consistent with those goals, 
VA lacks assurance that veterans are receiving care from community 
providers in a timely manner.
---------------------------------------------------------------------------
    \27\ The report in which we made these recommendations refers to 
the VCCP as the ``consolidated community care program VA plans to 
implement'' because at the time of the report, the name of the program 
had not yet been announced. See GAO-18-281.

---------------------------------------------------------------------------
VA's Monitoring of Care

under VCCP Could Still Be Compromised by Incomplete and Inaccurate Data

    In June 2018, we reported that VA could not systematically monitor 
wait times for veterans accessing care under the Choice Program due to 
incomplete and inaccurate data. Without complete and accurate data, VA 
was not able to determine whether the Choice Program was achieving its 
goals of (1) alleviating the wait times veterans experienced when 
seeking care at VA medical facilities, and (2) easing geographic 
burdens veterans may have faced when accessing care at VA medical 
facilities.\28\ We made three recommendations to address VA's 
incomplete and inaccurate data related to the Choice Program, and VA is 
taking steps to implement two of those recommendations.
---------------------------------------------------------------------------
    \28\ GAO selected 6 of 170 VA medical centers (selected for 
variation in geographic location and the TPAs that served them) and 
manually reviewed a random, non-generalizable sample of 196 Choice 
Program authorizations. The authorizations were created for veterans 
who were referred to the program between January and April of 2016, the 
most recent period for which data were available when we began our 
review. The sample of authorizations included 55 for routine care, 53 
for urgent care, and 88 that the TPAs returned without scheduling 
appointments. The sample of authorizations we reviewed included only 
authorizations for which VA's data indicated there were delays when the 
TPAs attempted to schedule appointments after the veterans had opted in 
to the program; however, our analysis of these authorizations indicates 
that delays occurred at other phases of the referral and appointment 
scheduling process as well. See GAO-18-281.

---------------------------------------------------------------------------
Incomplete Data

    We found that the data VA used to monitor the timeliness of Choice 
Program appointments captured only a portion of the total appointment 
scheduling process. Though VA had a 30-day wait-time goal to provide 
veterans with care under the Choice Program, VA's timeliness data did 
not capture (1) the time VA medical centers took to prepare veterans' 
referrals and send them to the TPAs, and (2) the time spent by TPAs in 
accepting the referrals and opting veterans into the Choice Program. 
For example, we found that it took VA medical center staff an average 
of 24 calendar days after the veteran's need for care was identified to 
contact the veteran, compile relevant clinical information, and send 
the veteran's referral to the TPAs. For those same authorizations, it 
took the TPAs an average of 14 calendar days to accept referrals and 
reach veterans to opt them into the Choice Program.\29\
---------------------------------------------------------------------------
    \29\ Similarly in April 2018, we found that while 20 of 30 veterans 
accessing specialty care under the Choice Program in the Pacific 
Islands received care within VA's 30 day wait- time goal, the actual 
wait time from when the referral was created to when the veteran 
received care ranged from 19 to 239 days, with the average being 75 
days. Our non- generalizable sample included 30 routine Choice Program 
authorizations that were created from October 2016 through March 2017 
by three selected VA medical facilities. See GAO-18-288.
---------------------------------------------------------------------------
    In 2016, VA also conducted its own manual review of appointment 
scheduling times and found that wait times could be longer than the 30 
days (see fig. 2). Specifically, out of a sample of about 5,000 Choice 
Program authorizations, VA analyzed (1) the timeliness with which VA 
medical centers sent referrals to the TPAs, and (2) veterans' overall 
wait times for Choice Program care. VA's analysis identified average 
review times when veterans were referred to the Choice Program to be 
greater- than-30-day wait time for an appointment at a VA medical 
facility. For example, for overall wait times (i.e., the time veterans' 
need for care was identified until they attended initial Choice Program 
appointments), wait times ranged from 34 to 91 days across the 18 VA 
integrated service networks. The national average was 51 days.\30\
---------------------------------------------------------------------------
    \30\ GAO obtained the results of VA's non-generalizable analysis of 
wait times for a nationwide sample of about 5,000 Choice Program 
authorizations that were created for selected services between July and 
September of 2016. Authorizations were for four types of Choice Program 
care-mammography, gastroenterology, cardiology, and neurology. VA 
calculated the average wait times across these four types of care for 
each of the 18 VA integrated service networks.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 

    Note: GAO excluded from its analysis the amount of time the TPA 
took to schedule the appointment and the overall wait time because its 
sample selection methodology differed from VA's in a way that would 
have skewed these two averages but not the averages from the other 
segments of the process.
    In September 2017, VA began implementing an interim solution to 
monitor overall wait times, but this solution relied on VA medical 
center staff consistently and accurately entering data on referrals, a 
process that is prone to error. In June 2018, we recommended that VA 
establish a mechanism to monitor the overall wait times under the VCCP. 
VA agreed with this recommendation, and stated that it is developing a 
monitoring mechanism that will be incorporated into a new system that 
will be fully implemented across all VA medical facilities by fiscal 
year 2021.

Inaccurate Data

    We also reported that the clinically indicated dates included on 
referrals that VA medical centers sent to the TPAs, which are used to 
measure the timeliness of care, may not have been accurate, further 
limiting VA's monitoring of veterans' access to care. Our review of 196 
Choice Program authorizations found that clinically indicated dates 
were sometimes changed by VA medical center staff before they were sent 
to the TPAs, which could mask veterans' true wait times. We found that 
VA medical center staff entered later clinically indicated dates on 
referrals for about 23 percent of the 196 authorizations reviewed. We 
made two recommendations to improve the accuracy of the Choice Program 
data. For example, we recommended that VA establish a mechanism under 
the VCCP that prevents clinically indicated dates from being modified. 
VA agreed with our recommendation, and stated that a new system will 
interface with VA's existing referral package to allow a VA clinician 
to enter in a clinically indicated date while restricting schedulers 
from making alterations to it.\31\
---------------------------------------------------------------------------
    \31\ VA did not agree with one of our recommendations related to 
urgent care referrals. However, we maintain that our recommendation is 
still warranted.

VA Has Not Addressed Other Factors That Could Adversely Affect 
---------------------------------------------------------------------------
    Veterans' Access to Care under the VCCP

    In June 2018, we also reported that numerous factors adversely 
affected veterans' timely access to care through the Choice Program and 
could affect access under the VCCP.\32\ These factors included the 
following: (1) administrative burden caused by complexities of VA's 
referral and appointment scheduling processes; (2) poor communication 
between VA and its medical facilities; and (3) inadequacies in the 
networks of community providers established by the TPAs, including an 
insufficient number, mix, or geographic distribution of community 
providers.
---------------------------------------------------------------------------
    \32\ See GAO-18-281.
---------------------------------------------------------------------------
    VA has taken steps to help address these factors; however, none 
have been fully addressed. For example, to help address administrative 
burden and improve the process of coordinating veterans' Choice Program 
care, VA established a secure e-mail system and a mechanism for TPAs 
and community providers to remotely access veterans' VA electronic 
health records. However, these mechanisms only facilitate a one-way 
transfer of necessary information. They do not provide a means by which 
VA medical facilities or veterans can view the TPAs' step-by-step 
progress in scheduling appointments or electronically receive medical 
documentation associated with Choice Program appointments. We made five 
recommendations to VA to address the factors that adversely affected 
veterans' access to Choice Program care. VA agreed or agreed in 
principle with all five recommendations and has taken some steps in 
response to these recommendations. However, our recommendations remain 
unimplemented.

As It Implements the VCCP, VA Has Taken Some Steps to Address Community 
    Care Wait- Time Data and Monitoring Issues

    On June 6, 2019, VA began implementing the VCCP, which created a 
consolidated community care program. Under the VCCP, VA began 
determining veteran eligibility based on designated access standards, 
such as wait-time goals of 20 days for primary and mental health care 
and 28 days for specialty care and other criteria identified in the 
MISSION Act.\33\ According to VA officials, the implementation of the 
VCCP also included the use of the new Decision Support Tool-a system 
that combines eligibility and other information to help veterans, with 
assistance from VA staff, decide whether to seek care in the community. 
VA officials previously identified the Decision Support Tool along with 
another new system-known as the Health Share Referral Management 
system-as key efforts in addressing many of our recommendations related 
to VA's community care wait-time data and monitoring issues. VA expects 
the Health Share Referral Management system, which will manage 
community care referrals and authorizations as well as facilitate the 
exchange of health information between VA and community providers, to 
be fully implemented across all VA medical facilities in fiscal year 
2021. We began work in May 2019 to review VA's implementation of the 
VCCP, including how it will address issues such as appointment 
scheduling.
---------------------------------------------------------------------------
    \33\ 84 Fed. Reg. 26278-01 (June 6, 2019).

Preliminary Observations on VA's Provision of Same- Day Services- 
---------------------------------------------------------------------------
    Another Access Initiative

    In addition to the actions described above, VA has taken other 
steps to improve veterans' access to care by, for example, offering 
veterans access to routine care without an appointment. We have ongoing 
work related to same-day services provided in VA primary care and 
mental health clinics. In order to improve access, VA implemented the 
same-day service initiative in 2016, and by 2018 offered same-day 
services in over 1000 facilities.\34\ As part of the initiative, VA 
medical facility staff are directed to address veterans' primary care 
and mental health needs that day through a variety of methods, 
including face-to-face visits, telehealth, prescription refills, or by 
scheduling a follow-up appointment. Our ongoing work indicates that the 
six VA medical facilities we visited were generally providing same-day 
services prior to the initiative; however, according to VA officials, 
ongoing staffing and space shortages created challenges implementing 
the initiative. Our ongoing work also indicates that VA does not have 
performance goals and measures to determine same-day services' impact 
on veterans' access to care. We plan to issue our report on VA's same-
day services initiative in August 2019.
---------------------------------------------------------------------------
    \34\ In January 2018, VA announced that same-day services in 
primary care and mental health had been achieved not only in all VA 
medical centers, but also in all of VA's community-based outpatient 
clinics.
---------------------------------------------------------------------------
    In closing, we have identified various weaknesses in VA's wait-time 
measurement and scheduling processes over the years. These weaknesses 
have affected not only VA's internal delivery of outpatient care, but 
also that provided through community providers. As we have highlighted 
here, we have made a number of recommendations to address these 
weaknesses. VA has taken actions to address our recommendations, but 
additional work is needed for some. The implementation of enhanced 
technology, such as a new scheduling system, is crucial and will 
provide an important foundation for improvements. However, this is not 
a panacea for addressing all of the identified problems. Moving 
forward, VA must also continuously ensure that it has clear and 
consistent policies and processes, adequate oversight, and effective 
training.
    Chairman Takano, Ranking Member Roe, and Members of the Committee, 
this completes my prepared statement. I would be pleased to respond to 
any questions that you may have at this time.

GAO Contact and Staff Acknowledgments

    If you or your staff have any questions about this testimony, 
please contact Debra A. Draper, Director, Health Care 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. GAO staff who made key contributions to this testimony were 
Sharon Silas (Acting Director), Ann Tynan (Assistant Director), Cathy 
Hamann, Aaron Holling, Akbar Husain, Kate Tussey, and E. Jane Whipple. 
Also contributing were Jacquelyn Hamilton and Vikki Porter.

Related GAO Reports

    Veterans Health Care: VA Needs to Address Challenges as It 
Implements the Veterans Community Care Program, GAO-19-507T 
(Washington, D.C.: April 10, 2019).
    Priority Open Recommendations: Department of Veterans Affairs, GAO-
19-358SP (Washington, D.C.: March 28, 2019).
    High-Risk Series: Substantial Efforts Needed to Achieve Greater 
Progress on High-Risk Areas, GAO-19-157SP (Washington, D.C.: March 6, 
2019).
    Veterans Health Administration: Opportunities Exist for Improving 
Veterans' Access to Health Care Services in the Pacific Islands, GAO-
18-288 (Washington, D.C.: April 12, 2018).
    Veterans Choice Program: Improvements Needed to Address Access- 
Related Challenges as VA Plans Consolidation of Its Community Care 
Programs, GAO-18-281 (Washington, D.C.: June 4, 2018).
    VA Health Care: Opportunities Exist for Improving Implementation 
and Oversight of Enrollment Processes for Veterans, GAO-17-709 
(Washington, D.C.: September 5, 2017).
    High-Risk Series: Progress on Many High-Risk Areas, While 
Substantial Efforts Needed on Others, GAO-17-317 (Washington, D.C.: 
February 15, 2017).
    Veterans' Health Care: Preliminary Observations on Veterans' Access 
to Choice Program Care, GAO-17-397T (Washington, D.C.: March 7, 2017).
    VA Health Care: Actions Needed to Improve Newly Enrolled Veterans' 
Access to Primary Care, GAO-16-328 (Washington, D.C.: March 18, 2016).
    High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 
2015).
    VA Primary Care: Improved Oversight Needed to Better Ensure Timely 
Access and Efficient Delivery of Care, GAO-16-83 (Washington, D.C.: 
October 8, 2015).
    VA Mental Health: Clearer Guidance on Access Policies and Wait-Time 
Data Needed, GAO-16-24 (Washington, D.C.: October 28, 2015).
    VA Health Care: Further Action Needed to Address Weaknesses in 
Management and Oversight of Non-VA Medical Care, GAO-14-696T 
(Washington, D.C.: June 18, 2014).
    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.: September 30, 2014).
    VA Health Care: Actions Needed to Improve Administration and 
Oversight of VA's Millennium Act Emergency Care Benefit, GAO-14-175 
(Washington, D.C.: March 6, 2014).
    VA Health Care: Management and Oversight of Fee Basis Care Need 
Improvement, GAO-13-441 (Washington, D.C.: May 31, 2013).
    VA Health Care: Reliability of Reported Outpatient Medical 
Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-
13-130 (Washington, D.C.: December 21, 2012).
    VA Mental Health: Number of Veterans Receiving Care, Barriers 
Faced, and Efforts to Increase Access, GAO-12-12 (Washington, D.C.: 
October 14, 2011).
    Information Technology: Management Improvements Are Essential to 
VA's Second Effort to Replace Its Outpatient Scheduling System, GAO-10-
579 (Washington, D.C.: May 27, 2010).
    VA Health Care: More National Action Needed to Reduce Waiting 
Times, but Some Clinics Have Made Progress, GAO-01-953 (Washington, 
D.C.: August 31, 2001).
    Veterans' Health Care: VA Needs Better Data on Extent and Causes of 
Waiting Times, GAO/HEHS-00-90 (Washington, D.C.: May 31, 2000).

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7814, Washington, DC 20548

                                 
                 Prepared Statement of Teresa Boyd, DO
    Good morning, Chairman Takano, Ranking Member Roe, and Members of 
the Committee. I appreciate the opportunity to discuss VA's current 
practices for measuring Veterans' access to health care and to provide 
a clearer picture concerning wait times in light of the 5-year 
anniversary of the issues in Phoenix. I am accompanied today by Dr. 
Susan Kirsh, Acting Assistant Deputy Under Secretary for Health (ADUSH) 
for Access, and Dr. Clinton L. Greenstone, Deputy Executive Director, 
Clinical Integration, Office of Community Care.

Introduction

    VHA has undergone tremendous transformation since 2014, operating 
with a renewed focus, unprecedented transparency, and increased 
accountability. We recognize there are still challenges ahead of us, 
but it is important to keep in mind that Veterans continue to receive 
the highest quality care, often with shorter wait times than in the 
private sector. VHA will continue to identify opportunities to share 
strong practices, standardize processes, educate staff, and provide 
oversight to ensure these efforts are being effective. Providing 
Veterans the care they need, when and where they need it, is central to 
all we do. Even with implementation of the new Veterans Community Care 
Program through the VA MISSION Act of 2018, Veterans are choosing to 
stay within VA to receive their care.

Care When It Is Needed

    VHA is providing care to more patients than ever. We completed over 
1 million more appointments in 2018 than the previous year while wait 
times continue to decline across VA. In fact, the Journal of the 
American Medical Association found in a study released in January 2019, 
that by 2017 VA had significantly shorter wait times for primary care, 
cardiology, and dermatology than the wait times seen for private 
doctors. VA had longer wait times for orthopedic care; however, these 
wait times improved from 2014 and are still improving.
    VA offers Veterans same-day services for mental health and primary 
care when clinically indicated at all VA medical centers (VAMC) and 
community-based outpatient clinics (CBOC) across VA - an effort 
completed by 2017. Same-day primary care and mental health services are 
offered when a Veteran contacts us. Accordingly, we will either address 
the need that day or schedule appropriate follow up care, depending on 
the urgency. We may address the health care needed by providing a face-
to-face visit, returning a phone call, arranging a telehealth or video-
care visit, responding by secure email, or scheduling a future 
appointment.
    VA has improved the average time to complete a stat consult, which 
is a critically time-sensitive referral to specialist that should be 
completed in less than 48 hours, from 19.3 days in 2014 to just 1.4 
days in 2019, a 90 percent decrease. Simplifying the consult management 
process and timely resolution of these referrals has made it easier for 
Veterans to be seen in a timelier manner. A large factor in these 
improvements was VA's response to the Veterans Access, Choice, and 
Accountability Act of 2014 and we expect this to continue under the 
implementation of the MISSION Act of 2018.

Quality Care

    In 2018, the RAND Corporation released a study, Comparing Quality 
of Care in Veterans Affairs and Non-Veterans Affairs Settings, that 
said VA hospitals on average performed the same or significantly better 
on 21 of 26 measures than private sector hospitals, including inpatient 
safety and mortality. VA hospitals performed better than commercial and 
Medicaid Health Maintenance Organizations on 28 of 30 measures. An 
increased emphasis on patient-centered care is a large contributor to 
these improvements. Our Veterans Experience Office is constantly 
assessing our performance throughout VA and giving us the feedback we 
need to identify and resolve problems.
    VHA values what Veterans have to say and have made it an Agency 
priority. We have been using the industry standard Consumer Assessment 
of Health Providers and Systems (CAHPS) survey to assess patient 
satisfaction for primary care and mental health. Through this data, our 
Veterans have voiced their appreciation with patient satisfaction 
scores improving in every category related to getting care when they 
needed it. We also recognize that quality care comes from having 
adequate levels of staff available to provide the care. Today, there 
are more than 200,000 health care professionals, including doctors and 
nurses, who treat Veterans in the VA system. VA has hired more than 
14,000 new employees in support of health care since October 2016.

Electronic Wait List

    The number of Veterans waiting for clinical care appointments to be 
made is commonly referred to as the Electronic Wait List (EWL). It is 
important to note that the EWL is the name of the software used to 
create reports. Reports include those that track Veterans waiting to 
schedule an appointment for clinical care, as well as administrative 
requests. The most common administrative requests are Veterans who are 
already receiving care and prefer another provider within the same 
health care facility area such as from a primary care provider at the 
main facility instead of one at a VA Community Based Outpatient Clinic 
(CBOC). There is no other health care system that VA is aware of that 
tracks transfer requests at a regional or system-wide level, it is 
tracked locally.
    EWL was developed in 2002 by the VHA Office of Informatics and 
Technology in response to a rapid increase in demand for clinical 
services. After 2014, VA made the decision to track these 
administrative requests using EWL software. These administrative 
requests are not included as part of wait list numbers because these 
are requests from Veterans who are already receiving care. Due to 
recent media reports of a whistleblower indicating issues with EWL, we 
conducted a top to bottom review, and while no Veterans were harmed 
while on the administrative EWL, this review has allowed us to 
streamline processes and eliminate confusion for VA staff and Veterans.
    We are developing plans to phase out use of EWL altogether by 
offering Veterans the choice of care in the community or to be 
scheduled for an appointment that could be more than 90 days (patients 
waiting this long do not have an urgent clinical need, i.e., waiting 
more than 90 days for an optometry appointment to get new prescription 
eyeglasses) in the future. Because we respect and value our patients' 
preferences, VHA is both implementing new scheduling software that can 
track these requests and identifying new tools to track transfer 
requests until the new scheduling tools are in place.

Culture of Accountability and Transparency

    Since 2014, VHA established an organizational structure, assigned 
responsibilities, and delegated authority to ensure multi-level 
oversight of access objectives. VHA's Office of Veterans Access to Care 
(OVAC) is the primary responsible program office that provides national 
oversight and direction for improving access to care. OVAC is headed by 
a Senior Executive Service-level Assistant Deputy Under Secretary for 
Health.
    VA's Access to Care website (https://www.accesstocare.va.gov/) was 
created in 2017 to transparently provide helpful information on topics 
including wait times, patient satisfaction, and quality. Measuring the 
time a new patient waits for an appointment from the date the 
appointment request was initiated is a more objective way of measuring 
patient wait times. For the majority of our appointments, those with 
established patients, measuring from the date the patient says he or 
she wants to be seen is a better indicator for patient experience. This 
information assists Veterans with decisions about where they can 
receive their care in a timely manner. This is a widely used website 
with millions of hits.
    Additionally, VHA created the Health Improvement Center to track 
and trend performance in terms of quality, access, safety, and Veteran 
experience across multiple indicators and to identify medical 
facilities with unfavorable data trends or those not meeting goals and 
targets. In response to data trends, VHA contacts sites of concern or 
those not meeting targets and mobilizes a team of experts as needed to 
provide collaborative on-site consultation and follow-up to ensure 
progress is made and to support ongoing process improvement.

Scheduling and Training

    Since 2014, when reports indicated that VHA needed improvement in 
scheduling processes and scheduler training, OVAC took the lead to 
modernize VA's approach to scheduling appointments and consults. These 
efforts have resulted in standardized national processes, national 
audits, and standardized scheduler trainings. More than 58,000 VHA 
employees, including Medical Support Assistants (MSA), clinicians, 
nurses, and health care technicians have completed this training, which 
includes technical and customer service skills, as well as in-depth 
training on standard processes and procedures per VHA's scheduling 
directive. Overall, this has improved access to high-quality care for 
our Nation's Veterans.

Continuing to Improve

    We continue to look at ways to improve how we deliver care, 
utilizing a team-based approach. Recently, OVAC began implementing a 
three-phased initiative named Improving Capacity, Efficiency, and 
Productivity (ICEP) to help facilities, working through Veterans 
Integrated Service Network (VISN) teams, administrative and clinical 
staff, along with Group Practice Managers (GPM), to meet the access 
standards established by VA pursuant to the VA MISSION Act of 2018. As 
a result, more than 98.5 percent of VA sites have wait times under 20 
days for new patients who want a mental health care appointment. This 
compares favorably to wait times in the private sector.
    More than 60 percent of VA sites currently meet the 20-day 
threshold for new patient wait times in primary care, with the average 
primary care wait time in 2018 for new patients down to 21.2 days and 
moving closer to VA's access standards. VA continues working 
strategically to help each facility improve in key areas through the 
ICEP initiative.
    In 2016, VHA began offering Veterans the ability to directly 
schedule appointments in audiology and optometry without a consult from 
their primary care provider. The following year, VHA expanded direct 
scheduling to include podiatry, nutrition, prosthetics, oncology, 
screening mammography, amputee clinic, and wheelchair clinic. Using the 
Veterans Appointment Online Scheduling application, patients can make 
and cancel appointments via a smartphone, tablet, or computer. This 
application has improved customer satisfaction, increased data 
reliability, and reduced scheduling errors by putting Veterans at the 
center of their own care. Using this application, Veterans can also 
request a call from VA to help with scheduling primary care and mental 
health appointments.
    VHA enhanced the VistA Scheduling software to automate the entry of 
the correct date, which is the agreed upon appointment date between the 
provider and the patients, directly into VistA Scheduling, eliminating 
the opportunity for human error in the process. Additionally, in 
association with the Veterans, Access, Choice, and Accountability Act 
of 2014, all VAMCs have at least one GPM. GPMs, who are a critical 
field position supporting Veteran access and every facility, coordinate 
with OVAC and their local team to implement best practices to improve 
scheduling processes and increase efficiencies to reduce wait times. 
OVAC often works with sites, through GPMs, to help them improve access 
to care.

Putting Technology to Work

    Today's VA is using technology to create opportunities for better 
access to care, better care overall, and more convenience for our 
Veterans. For example, in 2018, VHA launched a new software named 
VEText that enabled us to send more than 98 million text message 
appointment reminders to more than 6.2 million Veterans. This resulted 
in significant improvements in no-show rates, decreasing from 13.7 
percent to 11.7 percent, creating the opportunity for about 1 million 
new appointments for Veterans who needed to be seen. In 2019, VHA began 
offering earlier appointment times for Veterans when slots become 
available through the VEText software, resulting in over 3,800 
rescheduled appointments to date because of this technology.
    VA has invested in telehealth, providing Veterans the option of 
virtual visits using a smartphone, tablet, or laptop, resulting in more 
than 1 million video telehealth visits in Fiscal Year 2018, a 19 
percent increase in video telehealth visits over the prior fiscal year. 
Networks are creating virtual care hubs for primary care and mental 
health coverage. The hubs are established in more than half of the 
country and will be nationwide in 2020.

Better Integrated Care - The VA MISSION Act of 2018

    The VA MISSION Act of 2018 strengthens VA's health care system by 
improving both aspects of care-delivery - internal and community care - 
and by empowering Veterans to find the balance in the system that is 
appropriate for them. We believe VA's new Veterans Community Care 
Program is already working better for Veterans, their families, and 
providers.
    More Veterans are now eligible for community care, allowing them to 
choose care in their community if that is their preference. Scheduling 
appointments is easier, and care-coordination between VA and community 
providers will be better. With implementation of the VA MISSION Act of 
2018, Veterans have more ways to access world-class care through VA 
than ever before, and the data show that Veterans are choosing VA 
health care in record numbers. Veterans continue to tell us they trust 
us with their health care. VHA is completing more medical appointments 
than ever before, even as the total population of Veterans is 
shrinking.

Conclusion

    Veterans' care is our mission. We are committed to building the 
trust of Veterans and will continue to improve Veterans' access to 
timely, high-quality care from VA facilities, while providing Veterans 
with more choice to receive community care where and when they want it. 
Your continued support is essential to providing this care for Veterans 
and their families. Mr. Chairman, this concludes my testimony. My 
colleagues and I are prepared to respond to any questions you may have.

                                 
            Prepared Statement of Kenneth W. Kizer, MD, MPH
    Good morning, Chairman Takano, Ranking Member Roe, and Members of 
the Committee. Thank you for the opportunity to appear before you today 
to comment about assessing and tracking wait times and timely access to 
care and the evolving nature of what access to care means in a world 
that is increasingly connected by advanced communications and 
information technology. Thank you also for asking me to offer some 
thoughts about steps that the Department of Veterans Affairs (VA) might 
take to improve the transparency and availability of its wait time data 
to assist veterans make informed choices about where to receive care.
    My comments to you today are informed by my prior experience in 
multiple different professional capacities in which assessing access to 
care was an important part of my duties. Among others, these roles have 
included serving as:

      A physician in military, private practice and academic 
health care settings;
      California's top health official where my 
responsibilities included managing the nation's largest Medicaid 
program (Medi-Cal), as well as numerous public health programs serving 
disadvantaged populations;
      VA's Under Secretary for Health for five years in the 
late 1990s, where I oversaw an internationally acclaimed transformation 
of VA health care, which included materially improving access to care 
and decreasing wait times;
      Founding President and CEO of the National Quality Forum, 
a public- private partnership organization which endorses performance 
measures that are widely used today by health plans and insurers, 
health systems and individual health care providers throughout the 
nation;
      Chief Medical Officer for the California Department of 
Managed Health Care, where my duties included assessing health plan 
network adequacy to ensure time////ly access to care;
      Director of the Institute for Population Health 
Improvement at the University of California, Davis, where, among other 
things, I oversaw programs and research studies aimed at improving 
access to care; and
      A health care consultant to various private and publicly 
funded health systems seeking to improve access to care, including the 
Los Angeles County Department of Health Services which manages the 
second largest publicly funded metropolitan health system in the 
nation.

BACKGROUND AND CONTEXT

    Assuring timely access to care is widely recognized as an important 
dimension of high-quality health care and has been a priority 
throughout American health care for many years. However, consistently 
achieving timely access to care continues to be a challenge for most 
health plans, health care providers, patients and families throughout 
the U.S., as it is in other countries. Wait times for health care vary 
greatly across the nation, ranging from same day service to waits of 
many months, depending on the health care provider, the type of service 
sought, and individual patient factors such as type of health insurance 
and place of residence.
    Except for certain well-defined emergent situations in which time 
to treatment is definitively linked to care outcomes there are no 
industrywide standards for timely access to care. Situations in which 
widely accepted timeliness of care standards exist include time between 
onset of symptoms and administration of thrombolytic medication in 
cases myocardial infarction (heart attack) or stroke, the time to 
surgical treatment in cases of severe trauma, and the time to 
administration of systemic antibiotics in cases of sepsis. In contrast 
to these emergency care situations, however, many different sets of 
timeliness standards are variously used by health plans and health care 
providers when assessing timeliness of care for primary, specialty, 
hospital or post-acute care. As a result, numerous different methods 
are used to assess wait times and access to care, making it difficult 
to understand and compare the timeliness of care across health systems 
and among individual providers. Further compounding this, information 
about wait times for private health care providers are not routinely 
made publicly available.
    A good review of the many different methods used for measuring and 
tracking the timeliness of care is provided in the Institute of 
Medicine's 2015 report on patient scheduling and access.\1\ Of note, 
this study was commissioned by the VA.
---------------------------------------------------------------------------
    \1\ Institute of Medicine. Transforming Health Care Scheduling and 
Access: Getting to Now. Washington, DC. National Academies Press. 2015.
---------------------------------------------------------------------------
    The problems related to long wait times (e.g., poorer health 
outcomes; patient inconvenience, frustration and dissatisfaction; and 
increased utilization and costs due to delayed care, among other 
things) are well known. As Drs. Jaewon Ryu and Thomas Lee succinctly 
summarized this in an article in the New England Journal of Medicine in 
2017 when they said, ``When patients wait weeks or months for 
physician's appointments, bad things happen.''\2\ Clearly, the goal of 
all health plans and health systems should be to ensure the timely 
delivery of care for each patient every time in every setting.
---------------------------------------------------------------------------
    \2\ Ryu J, Lee TH. The Waiting game - Why Providers May Fail to 
reduce Wait Times. N Engl J Med 2017; 376 (24):2309-2311.
---------------------------------------------------------------------------
    In 2001, in its landmark report Crossing the Quality Chasm,\3\ the 
Institute of Medicine identified six defining properties of high-
quality health care - that it be safe, effective, patient-centered, 
efficient, equitable, and timely. Given all that we know about the 
adverse consequences of untimely or delayed care, it is ironic that of 
the defining attributes of high-quality health care, timeliness of care 
is the least-well studied and least-well tracked as a health care 
performance metric. Forums such as today's hearing are important in 
focusing greater attention on better understanding and assuring the 
timeliness of care.
---------------------------------------------------------------------------
    \3\ Institute of Medicine. Crossing the Quality Chasm. Washington, 
DC. National Academies Press. 2001.
---------------------------------------------------------------------------
    There are multiple reasons for the widespread problems in timely 
access to care in this country, and much has been written on this 
subject. Delving into these reasons is beyond the scope of this 
statement. Suffice it to say that among the patient-related reasons for 
delayed care, lack of health insurance or the type of a one's health 
insurance (e.g., Medicaid) continue to be the most common reasons for 
lack of timely access to care.
    From a health system perspective, however, problems in timely 
access to care are primarily the result of the extreme complexity of 
American health care and the generally non-systematic approach to the 
design, implementation and assessment of patient scheduling protocols 
and scheduling systems and the absence of national performance 
standards for timeliness of care. The lack of reliable performance 
standards that can be used to assess and improve health care scheduling 
is due in significant part to the technical difficulties in reliably 
capturing all the data variables that go into accurately measuring wait 
times and the resultant paucity of good data on which to provide care 
setting-specific guidance on reasonable timeliness for care.
    Measuring wait times seems on one level like it should be very 
straightforward, if not simple; however, in practice it turns out to be 
extremely complicated. For example, it is very difficult for scheduling 
systems to capture all the variables that go into patient preference 
and how one's preference for when he or she would like to be seen may 
change quickly and repeatedly due to real life circumstances. Likewise, 
it is very difficult for scheduling systems to capture clinical issues 
related to the appropriate urgency of being seen by a clinician. The 
same presenting complaint or reason for seeking care in different 
people with different histories and circumstances may translate into 
very different timeliness of care needs.
    Notwithstanding what is said above, and despite the many technical 
challenges, health systems are developing systems-based approaches to 
improving access, and there are emerging best practices for scheduling 
and for improving timely access to care. A number of these approaches 
are highlighted in the previously referenced 2015 report from the IOM. 
I am hopeful that additional research and validation of some of these 
promising practices will soon provide the foundation for consensus 
standards for timely access to care.
    Especially important to note in this regard are patient-reported 
measures of the timeliness of the care. Increasingly, health systems 
are finding that among the most useful ways to assess whether they are 
providing timely care is to ask patients to rate their ability to get 
the appointment they wanted or to report back on how satisfied they 
were with the length of time it took to schedule an appointment and 
whether the person scheduling the appointment seemed to care about them 
as a person and making sure they were seen as quickly as possible. 
While not as quantitative as wait time measures, patient-reported 
qualitative measures are very revealing as to how well a health system 
works.
    Given the inherent difficulties is accurately measuring wait times, 
many health systems are increasingly relying upon patient reported 
measures for accountability purposes. They are not abandoning measuring 
wait times but are using wait times data more for quality improvement 
purposes. That is, they use wait time targets more for quality 
improvement than accountability.
    I think what is clear from the evidence available today is that to 
measure and track timeliness of care we need to rely on multiple 
methods of assessment using a balanced mix of quantitative (e.g., wait 
times) and qualitative (e.g., patient-reported satisfaction) measures 
and that more attention needs to be focused on specifying setting-
specific timeliness of care performance standards.

THE NEED TO REFRAME OR REDEFINE WHAT ACCESS TO CARE MEANS

    In considering the timeliness of care and how accessibility should 
be measured today, we need to ask a basic question about what access to 
care means in an era of enhanced connectivity through information and 
communication technologies. In a time when a large proportion of the 
population accomplishes many critically important activities (e.g., 
banking) via the internet, why do we continue to view access to health 
care only or primarily through a lens of in-person face-to-face visits.
    Measuring access to care by only counting face-to-face encounters 
between the patient and caregiver is anachronistic and does not promote 
patient-centered care.
    Indeed, a variety of public opinion surveys indicate that 70 to 80 
percent of respondents would welcome the opportunity to accomplish 
their health care needs through technology-assisted means such as 
telehealth.
    Increasingly, health systems are finding that a large proportion, 
if not the majority, of patient-caregiver interactions can be 
accomplished through technology- assisted methods such as telehealth or 
secure e-mail. For example, Kaiser Permanente reports that more than 
half of its more than100 million annual outpatient encounters are now 
completed through various types of telehealth communications. In the 
same vein, the Los Angeles County Department of Health Services has 
dramatically reduced wait times for specialty care through 
implementation of an e-consult program.
    The VA is widely acknowledged as a leader in telehealth and virtual 
care, but I believe it has only scratched the surface of what could be 
done to enhance access to care through technology-assisted methods. The 
VA was the first health system in the country to hire a chief 
telehealth officer when it did so in 1999, and it has made commendable 
progress in telehealth in the intervening 20 years. However, VA has not 
fully capitalized on its potential to enhance access to care by 
combining technology- assisted care with more traditional face-to-face. 
This remains an unfulfilled opportunity.

A PRESCRIPTION FOR ENHANCED VA ACCESS TO CARE

    Mr. Chairman let me close these comments by responding to your 
request that I offer some thoughts about what VA could do to improve 
the transparency and availability of wait time data to assist veterans 
make informed choices about where to receive care. I would preface my 
suggestions by first noting that I believe the VA health care system 
has an unparalleled opportunity to become the nation's leader in 
assuring timely access to care. I believe the VA has the potential to 
define the future of what timely access to care could and should be.
    With the right leadership and technical assistance, I believe the 
VA could quickly become the nation's gold standard for timely access to 
care for several reasons. These reasons include the VA being the 
nation's only truly national health care system, having health care 
facilities and other care delivery assets in every state - indeed in 
essentially every major metropolitan area of the country; because it is 
a federal system that is not encumbered by state practitioner licensure 
laws, among other things; and because it uses a global method of 
allocating resources (i.e., payment) and functions as both an insurer 
and provider so the distinction between cost and lost revenue to 
providers is much less important than in the private sector. Further, 
the VA has extensive research and training capabilities that could be 
applied to evaluating and implementing new methods of access to care.
    I believe there are several things that the VA could do to 
facilitate the transparency and availability of data while making sure 
that veterans have access to care whenever and wherever they need it. 
Toward that end, let me note six things here.
    One, the VA should set a goal of becoming the nation's leader in 
assuring timely access to care through a coordinated combination of 
virtual and in-person care utilizing technology-assisted encounters, 
face-to-face visits, in-home and group visits, mobile delivery assets, 
and expanded use of non-physician caregivers, among other means.
    Two, the VA should engage the National Academies of Sciences, 
Engineering and Medicine to help it define what 21st century access to 
care means and to delineate the key operating characteristics and 
functionalities required to operationalize the definition.
    Three, the VA should enlist the help of the National Quality Forum 
in identifying and endorsing performance measures to monitor and track 
access to care in ways that are transparent, reliable and 
understandable.
    Four, the VA should take immediate and aggressive steps to increase 
access to care through virtual means such as tele-health and M-health. 
A systemwide initiative should be launched commensurate with 
implementation of the Mission Act that would increase the number of 
encounters by virtual means by an order of magnitude within two years. 
I suggest that an initial high priority target for such an initiative 
would be virtual or telehealth urgent care visits.
    Five, while the above efforts are in progress, the VA should 
increase the use of veteran-satisfaction measures of access to care, 
being informed in this regard by its work with the National Quality 
Forum. In doing this, VA should use this information, along with the 
wait times data, within the construct of a health care learning system 
that uses continuous quality improvement methods to feed information 
back to the system that leads to continuous improvement.
    Six, the VA should call upon its Health Services Research & 
Development Service to evaluate the most effective strategies and 
methods to ensure timely access to care that meet the diverse needs of 
veterans in the many varied communities and settings where veterans 
live.
    Thank you, Mr. Chairman and members of the Committee for the 
opportunity to appear before you today. That concludes my comments, and 
I would be pleased to respond to your questions.