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The oversight agency found a slew of deficiencies as the temporary program is set to be replaced by a permanent incarnation.
A veteran salutes during 2018 Memorial Day proceedings at Arlington National Cemetary. Photo credit: Eugene Russell, photographer to VA Secretary. Imagine found on Department of Veterans’ Affairs Flickr page.
The Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) was meant to address serious problems with wait times for veterans’ access to care by opening a door to the private sector. A report released today by the Government Accountability Office (GAO), however, found that the flawed implementation of the Choice Program led to substantial wait times—and might have once again resulted in US Department of Veterans’ Affairs (VA) staffers falsifying dates to minimize the problem.
The Choice Program is set to eventually expire, though the massive VA reform bill passed just weeks ago makes its core mission permanent. But the problems unearthed by the new GAO report will need to be addressed for the long-term incarnation of the Choice Program to be successful.
The program would allow a veteran to receive care from an outside provider if the soonest availability for a VA clinician was more than 30 days from a veteran’s preferred date. The GAO, however, found that veterans using the program could have waited 70 days or more. And in some examples, an inability to book an outside appointment led to patients being referred back to VA care after lengthy delays.
In one case, it took VA staff nearly 3 weeks to prepare a Choice Program referral for a veteran requiring an MRI, which was followed by a 2-month wait for the veteran to undergo the scan. Their appointment with a VA physician to discuss the results didn’t occur for weeks after that. In all, it took 6 months from the time that the need was assessed for the patient to have a follow-up meeting.
In another case, VA staff took nearly 6 weeks to refer a patient for maternity care after the pregnancy was confirmed. The third-party administrator (TPA) hadn’t set a prenatal appointment by the time the patient was 18 weeks pregnant, and she ended up scheduling one on her own.
Program design oversight might be partly to blame. The GAO report states that “a key reason” for the excessive wait times could be that “the process VA and [Veterans’ Health Administration] designed did not include a limit on the number of days VA medical centers (VAMC) have to complete a key step of the process—compiling relevant clinical information and sending referrals to the TPAs after veterans have agreed to be referred to the Choice Program.” It continues that the health system had “no comprehensive policy directive for the Choice Program” and has failed in the past to outline and implement care timeliness goals.
“Timeliness of appointments is an essential component of quality health care,” the report states. “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.”
There were also critical problems with data surrounding the program. Both VAMCs and third-party administrators (TPAs) did not consistently document referrals correctly, including “urgent” referrals. Cases were supposed to be marked “urgent” if immediate action was needed to ensure a veteran’s condition was stable and to avoid “unacceptable morbidity and pain.” An appointment was required to be scheduled within 2 days in such scenarios.
But that message sometimes got lost in translation. A sample of 53 urgent care authorizations reviewed by GAO found that more than a quarter of them (28%) had been originally marked for routine care but later changed to urgent by either VA or TPA staff to expedite appointment scheduling.
Further, the report found that VA health system data on care timeliness did not include the time it took VA medical centers to prepare and transmit patient referrals, nor the time it took for the TPAs to then accept them. The report says that there is an interim solution in place that requires staff to “consistently and accurately” enter unique identification numbers on the referral requests, but that the process is prone to error.
And clinically indicated dates used to measure timeliness of care were not always entered accurately. The new report reviewed nearly 200 referrals and found that 23% of the time, VA medical center staff entered dates later than when they actually occurred.
“It is unclear if VAMC staff mistakenly entered incorrect dates manually,” according to the GAO, “or if they inappropriately entered later dates when the VAMC was delayed in contacting the veteran, compiling relevant clinical information, and sending the referral to the TPA.”
The report outlines 10 recommendations designed to avoid similar challenges under the new program outlined in May’s reform bill. They include setting an “achievable” wait time goal, designing a useful and consistent scheduling process that covers the entire referral protocol, preventing staff from manually modifying clinically indicated dates, and separating urgent referrals from those that staff have decided to expedite for other administrative reasons.
According to the GAO, the VA “generally agreed with all but one of GAO’s recommendations, which was to separate clinically urgent referrals from those that are administratively expedited.” The watchdog agency, however, maintains the necessity of this change.
“When implementing a new program, it is important that agencies establish the program’s structure, responsibilities, and authorities at the beginning to help ensure that the new program’s objectives are met,” the report concludes. “Without issuing a comprehensive policy directive and operations manual before the start of the new program, VA risks experiencing untimely communication issues similar to those that affected veterans’ access to care throughout the Choice Program’s implementation.”