VA Health Care:

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care

GAO-16-328: Published: Mar 18, 2016. Publicly Released: Apr 18, 2016.

Additional Materials:

Contact:

Debra A. Draper
(202) 512-7114
draperd@gao.gov

 

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What GAO Found

GAO found that not all newly enrolled veterans were able to access primary care from the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA), and others experienced wide variation in the amount of time they waited for care. Sixty of the 180 newly enrolled veterans in GAO's review had not been seen by providers at the time of the review; nearly half were unable to access primary care because VA medical center staff did not schedule appointments for these veterans in accordance with VHA policy. The 120 newly enrolled veterans in GAO's review who were seen by providers waited from 22 days to 71 days from their requests that VA contact them to schedule appointments to when they were seen, according to GAO's analysis. These time frames were impacted by limited appointment availability and weaknesses in medical center scheduling practices, which contributed to unnecessary delays.

VHA's oversight of veterans' access to primary care is hindered, in part, by data weaknesses and the lack of a comprehensive scheduling policy. This is inconsistent with federal internal control standards, which call for agencies to have reliable data and effective policies to achieve their objectives. For newly enrolled veterans, VHA calculates primary care appointment wait times starting from the veterans' preferred dates (the dates veterans want to be seen), rather than the dates veterans initially requested VA contact them to schedule appointments. Therefore, these data do not capture the time these veterans wait prior to being contacted by schedulers, making it difficult for officials to identify and remedy scheduling problems that arise prior to making contact with veterans. Further, ongoing scheduling errors, such as incorrectly revising preferred dates when rescheduling appointments, understated the amount of time veterans waited to see providers. Officials attributed these errors to confusion by schedulers, resulting from the lack of an updated standardized scheduling policy. These errors continue to affect the reliability of wait-time data used for oversight, which makes it more difficult to effectively oversee newly enrolled veterans' access to primary care.

Illustration of How the Time It Takes a Veteran to See a Provider May Differ from the Wait Time Calculated by the Veterans Health Administration (VHA)

Illustration of How the Time It Takes a Veteran to See a Provider May Differ from the Wait Time Calculated by the Veterans Health Administration (VHA) img  data-cke-saved-src=

Why GAO Did This Study

Primary care services are often the entry point for veterans needing care, and VHA has faced a growing demand for outpatient primary care services over the past decade. On average, 380,000 veterans were newly enrolled in VHA's health care system each year in the last decade.

GAO was asked to examine VHA's efforts to provide timely access to primary care services. This report examines, among other things, (1) newly enrolled veterans' access to primary care and (2) VHA's related oversight. GAO interviewed officials from six VA medical centers selected to provide variation in factors such as geographic location, clinical services offered, and average primary care wait times; reviewed a randomly selected, non-generalizable sample of medical records for 180 newly enrolled veterans; and interviewed VHA and medical center officials on oversight of access to primary care. GAO evaluated VHA's oversight against relevant federal standards for internal control.

What GAO Recommends

GAO recommends that VHA (1) ensure veterans requesting appointments are contacted in a timely manner to schedule one; (2) monitor the full amount of time newly enrolled veterans wait to receive primary care; and (3) issue an updated scheduling policy. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In March 2016, GAO recommended the Secretary of Veterans Affairs, direct the Under Secretary for health, to review VHA's processes for identifying and documenting newly enrolled veterans requesting an appointment and revise as appropriate to ensure that all veterans requesting appointments are contacted in a timely manner to schedule one; and institute an oversight mechanism to ensure VA medical centers are appropriately implementing the processes. VA agreed with this recommendation, and in June 2017, reported taking actions to address it. Specifically, VA officials indicated that they conducted internal reviews of the process for identifying and documenting newly enrolled veterans requesting primary appointments?including an audit of 400 recently recorded contacts with these veterans. Based on the findings of these reviews, VA revised its process to ensure that newly enrolled veterans receive requested primary care appointments. Additionally, VA reported revising internal reports to enhance oversight of its process for identifying and scheduling newly enrolled veterans who requested primary care appointments. This report is intended to enable VHA and its medical centers to oversee the enrollment and appointment process by tracking the following timeframes: (1) application to enrollment, (2) enrollment to initial contact, and (3) Initial contact to Primary Care appointment, and (4) total time from application from appointment. Officials can view information in this report for specific veterans or at the National, VISN, and VAMC levels. Among other things, the enhanced report will help VA determine which veterans still need follow up to schedule an appointment.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to review VHA's processes for identifying and documenting newly enrolled veterans requesting appointments, revise as appropriate to ensure that all veterans requesting appointments are contacted in a timely manner to schedule them, and institute an oversight mechanism to ensure VA medical centers are appropriately implementing the processes.

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Priority recommendation

    Comments: In March 2016, GAO recommended that VA monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. VA concurred with this recommendation, and in June 2017, reported to GAO that it had taken actions to address this recommendation. Specifically, VA indicated that it revised an internal report to help identify and document all newly enrolled veterans and monitor their appointment request status. The report is intended to enable VHA and its medical centers to oversee the enrollment and appointment process by tracking the following timeframes: (1) application to enrollment, (2) enrollment to initial contact, (3) initial contact to primary care appointment, and (4) total time from application from appointment. However, VA also indicated in its response that it does not have data that captures application dates for all newly enrolled veterans. As a result, this report cannot be used to consistently monitor the full amount of time these veterans wait to be seen by primary care providers. To fully implement this recommendation VA needs to capture the application date for all newly enrolled veterans. Upon receiving further information about how and when VA plans to capture this information, we will assess whether VA's actions are sufficient to warrant closure of this recommendation.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. This could be accomplished, for example, by building on the data collection efforts currently being implemented under the "Welcome to VA" program.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: In its report, GAO recommended the Secretary of Veterans Affairs, direct the Under Secretary for health, to finalize and disseminate a comprehensive national scheduling directive, which consolidates memoranda and guidance disseminated since July 2014 on changes to scheduling processes and procedures, and provide VA medical center staff appropriate training and support to fully and correctly implement the directive. VA officials agreed with this recommendation, and finalized a revised scheduling directive in July, 2016. In January, 2017, VA provided information on the training program offered to schedulers and other staff, and documentation showing that over 70,000 staff had completed required training.

    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to finalize and disseminate a comprehensive national scheduling directive, which consolidates memoranda and guidance disseminated since July 2014 on changes to scheduling processes and procedures, and provide VA medical center staff appropriate training and support to fully and correctly implement the directive.

    Agency Affected: Department of Veterans Affairs

 

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