[House Hearing, 113 Congress]
[From the U.S. Government Printing Office]




 
          WAITING FOR CARE: EXAMINING PATIENT WAIT TIMES AT VA

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

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, MARCH 14, 2013

                               __________

                           Serial No. 113-11

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida            Minority Member
DAVID P. ROE, Tennessee              CORRINE BROWN, Florida
BILL FLORES, Texas                   MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
JON RUNYAN, New Jersey               DINA TITUS, Nevada
DAN BENISHEK, Michigan               ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MARK E. AMODEI, Nevada               GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN KIRKPATRICK, Arizona, Ranking 
DAVID P. ROE, Tennessee              Minority Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
DAN BENISHEK, Michigan               ANN M. KUSTER, New Hampshire
JACKIE WALORSKI, Indiana             BETO O'ROURKE, Texas
                                     TIMOTHY J. WALZ, Minnesota

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             March 14, 2013

                                                                   Page

Waiting For Care: Examining Patient Wait Times At VA.............     1

                           OPENING STATEMENTS

Hon. Mike Coffman, Chairman, Subcommittee on Oversight and 
  Investigations.................................................     1
    Prepared Statement of Hon. Coffman...........................    22
Hon. Ann Kirkpatrick, Ranking Minority Member, Subcommittee on 
  Oversight And Investigations...................................     2
    Prepared Statement of Hon. Kirkpatrick.......................    22
Hon. McCarthy (CA-23)............................................     3
Hon. Jackie Walorski, Prepared Statement only....................    23
Hon. Jeff Duncan (SC-03), Prepared Statement only................    23

                               WITNESSES

William Schoenhard, FACHE, Deputy Under Secretary for Health for 
  Operations and Management, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     5
    Prepared Statement of Mr. Schoenhard.........................    24
    Accompanied by:

      Thomas Lynch, M.D., Assistant Deputy Under Secretary for 
          Health Clinical Operations and Management, Veterans 
          Health Administration, U.S. Department of Veterans 
          Affairs
      Philip Matkovsky, Assistant Deputy Under Secretary for 
          Health for Administrative Operations, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
      Michael Davies, M.D., National Director of Systems 
          Redesign, Veterans Health Administration, U.S. 
          Department of Veterans Affairs
Debra A. Draper, Director, Health Care, Government Accountability 
  Office.........................................................     7
    Prepared Statement of Ms. Draper.............................    27
Roscoe Butler, National Field Service Representative, Veterans 
  Affairs and Rehabilitation Commission, The American Legion.....     8
    Prepared Statement of Mr. Butler.............................    32


          WAITING FOR CARE: EXAMINING PATIENT WAIT TIMES AT VA

                        Thursday, March 14, 2013

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 1:00 p.m., in 
Room 334, Cannon House Office Building, Hon. Mike Coffman 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Coffman, Huelskamp, Walorski, 
Kirkpatrick, O'Rourke, and Walz.
    Also present: McCarthy of California.

             OPENING STATEMENT OF CHAIRMAN COFFMAN

    Mr. Coffman. Good afternoon. This hearing will come to 
order. I want to welcome everyone to today's hearing titled, 
``Waiting for Care: Examining Patient Wait Times at VA.''
    I would also like to ask unanimous consent that several of 
our colleagues be allowed to join us here on the dais today to 
hear about this issue that has directly impacted many of their 
constituents.
    Hearing no objection, so ordered.
    We should always be working to ensure veterans have timely 
access to quality care. However, today's hearing is necessary 
because evidence reviewed by the Subcommittee, the Government 
Accountability Office and VA's own inspector general shows 
little improvement in that area. GAO recently completed its 
study that was appropriately titled ``Appointment Scheduling 
Oversight and Wait Time Measures Need Improvement.''
    Despite claims of improvement under higher standards, we 
will hear today that a lack of reliable information when VA is 
measuring patient wait times, VA's own testimony supports that 
premise as it discusses what it sees as no reliable standard 
and an inability to accurately measure what constitutes a 
patient wait time.
    While the topic of patient wait times may sound like a very 
narrow issue, the problems, inaccurately monitoring improving 
wait times for veterans at VA facilities has spread throughout 
the whole Department of Veterans Affairs. Schedulers at the 
facilities themselves have to use a cumbersome system that 
creates a significant chance of error. The problem runs all the 
way up to the Veterans Health Administration, which has an 
unclear policy on patient scheduling practices and still seems 
to struggle to best define its policy on patient scheduling.
    I understand that defining these policies is not easy and 
that perfecting a process for appointment scheduling is a 
significant challenge, but VA has been well behind in this area 
for a long time. However, none of this excuses VA from its 
obligation to veterans. While I understand the system may not 
always be perfect, it does not mean that VA shouldn't make 
every effort to ensure veterans receive necessary care.
    Backlogs are a fairly common theme at the Department, but 
that is no reason for VA to gain the numbers to simply show 
better performance instead of providing medical appointments, 
sometimes for life-threatening conditions. Sadly, evidence 
obtained by this Subcommittee clearly shows that in many cases, 
VA did not do the right thing. Instead, that evidence has shown 
that many VA facilities, when faced with a backlog of thousands 
of outstanding unresolved consultations, decided to 
administratively close out these requests. Some reasons given 
included that the request was years old, too much time had 
elapsed, or the veterans had died. This Subcommittee asked VA 
for updates on these consultation backlogs beginning in October 
2012.
    Despite multiple follow-up requests to VA, no information 
was ever provided, and it was only when this hearing was 
scheduled that the Department offered a briefing on this 
subject.
    I would note that the Subcommittee asked for information, 
not a briefing. Regardless, we should not be where we are now. 
This goes to reinforce that the Veterans Affairs Committee 
wants to work with the Department on this and other issues, but 
that requires a willingness on VA's side to be forthcoming 
about its problem so that together we can identify ways to 
solve them.
    I now yield to the Ranking Member for opening statement.

    [The prepared statement of Chairman Coffman appears in the 
Appendix]

           OPENING STATEMENT OF HON. ANN KIRKPATRICK

    Mrs. Kirkpatrick. Thank you, Mr. Chairman, for holding this 
hearing this afternoon on the Veterans Health Administration's 
scheduling process and how that affects patient wait times for 
veterans.
    Improving access to health care is a continuous effort by 
VHA, and it is not surprising that we are here today. Excessive 
wait times and the failures of scheduling processes have been 
longstanding problems with the Veterans Health Administration. 
The Government Accountability Office has been reporting on this 
issue for over a decade. In 2001, the GAO reported that two-
thirds of the specialty care had wait times longer than 30 
days.
    In 2007, the VA Office of Inspector General reported that 
VHA facilities did not always follow VHA's scheduling policies 
and process.
    In 2012, the VA OIG reported that VHA was not providing all 
new veterans with timely access to full mental health 
evaluations. In that same year, the GAO again examined the 
issue and found that, among other things, there was 
inconsistent implementation of VHA's scheduling policy that 
could result in increased wait times or delays in scheduling 
timely medical appointments.
    In my Arizona district, in the City of Casa Grande, one of 
my caseworkers recently met with an Iraq veteran who made the 
brave decision to seek VA mental health care after 2 years of 
being back in the United States from Iraq. The VA required a 
physical exam before this veteran in my district could schedule 
an appointment with a mental health care provider. 
Unfortunately, they weren't able to schedule him for an initial 
physical for 6 months. That is 6 months of waiting before he 
could have even an initial consultation with a mental health 
care provider, and this was after 2 years of not seeing a 
doctor at all.
    These situations were able to be resolved by our veterans 
caseworker in the district, but the point is veterans should 
not have yet another hoop to jump through. Access to health 
care should be easy to schedule. I also understand that VHA is 
operating with a reportedly outdated system that is cumbersome 
and slow. GAO reported numerous work realms that some 
facilities are using which may adversely affect timely health 
care delivery to veterans.
    Delayed care is denied care. This is all too evident with 
the rash of recent consult backlogs experienced at some of the 
VHA medical centers. It has been reported that thousands of 
consults in 2011 and 2012 were backlogged at various facilities 
which may have resulted in adverse events due to the delay in 
diagnosis and treatment.
    This, of course, is unacceptable. Veterans deserve timely 
accessible health care. They have earned it. What I would like 
to hear about today is a sound plan that will assist VHA in 
transforming into a 21st century organization and will 
eliminate as much as possible the needless waits, unclear 
policies and procedures and frustrating technology that only 
serves to slow down the process, and I yield back.
    Thank you, Mr. Chairman.

    [The prepared statement of Hon. Ann Kirkpatrick appears in 
the Appendix]

    Mr. Coffman. Thank you.
    I ask that all Members waive their opening remarks as per 
this Committee's custom. However, I understand that Congressman 
McCarthy is going to have to depart early, and he was a main 
requester of GAO's work on this issue. I will yield 5 minutes 
to him for remarks.
    Congressman McCarthy.

               OPENING STATEMENT OF HON. MCCARTHY

    Mr. McCarthy. Well, thank you, Chairman Coffman, for 
holding this oversight hearing for the Department of Veterans 
Affairs, specifically the Veterans Health Administration 
regarding the scheduling of a timely medical appointment and 
for allowing me to make some remarks.
    You know, Chairman Miller and I led, along with 28 other 
Members, in requesting the GAO to conduct this audit on the VHA 
in the scheduling of medical appointments because I was 
receiving numerous complaints from veterans in my district who 
were waiting months for crucial medical appointments at either 
local VA clinic in Bakersfield or the VA medical center in Los 
Angeles.
    One of the most common and disconcerting complaints for my 
veterans is that the VA health care administration lacks a 
sense of urgency when scheduling their medical appointments. 
This poor customer service mean veterans are forced to wait 
months for the care when needed. One horror story a veteran 
shared with me was his experience replacing a set of broken 
dentures. The VA schedule the veteran for five different 
appointments and took 6 months before finally replacing the 
dentures. As a result, this veteran had to eat three meals a 
day in half a year just in pain.
    In addition, veterans stress to me that the VA is 
unsympathetic and unhelpful when it comes to ensuring that they 
are taken care of from start to finish. When veterans in my 
district are scheduled for appointment in the VA medical center 
in Los Angeles, they must travel over 2 hours, over mountain 
roads and through LA traffic. Smarter scheduling equals fewer 
trips to LA for my constituents and more efficient use of VA 
staff type.
    One veteran who came to me was having difficulty obtaining 
appointment with the VA to receive a knee replacement. After 
removing the first faulty knee replacement, the VA then 
required the veteran to make six different trips--this is a 
200-mile round trip from Bakersfield to LA--in order to sign 
releases and take tests before the VA would proceed with his 
surgery. It was not until our office contacted the Greater Los 
Angeles Healthcare System that he was finally scheduled for his 
knee replacement, bringing the situation to a close after eight 
grueling months.
    Finally, when the VA does schedule a veteran for an 
appointment, all too often I hear they fail to notify the 
veteran in adequate time for he or she to make an appropriate 
travel arrangements.
    One local veteran, who was waiting for an eye surgery 
appointment, was notified that he had been scheduled for his 
surgery in Los Angeles less that 24 hours before he needed to 
arrive. He was forced to cancel his appointment as he was 
unable to find transportation to the surgery on such short 
notice. Even though our office attempted to assist him with the 
VA-approved surgery, the veteran grew so tired of waiting for 
the VA to reschedule, he had the surgery conducted with a non-
VA ophthalmologist having to pay for the procedure himself.
    These are just several stories that I have heard from my 
veterans and are far from isolated incidents in my district, as 
evidenced by the GAO report but are indicative of a larger 
systematic problem within the VA medical centers. The 
experience these veterans have faced are inexcusable and should 
not have to happen to our Nation's finest. I think all of us 
here today can agree that this is a problem that needs to be 
immediately fixed, especially since we are facing a reverse 
surge, due to Department of Defense in reducing the troop 
levels and drawing down in Afghanistan.
    So I thank you, Chairman Coffman, for your work on this, 
Chairman Miller's, and the entire Committee because this is an 
issue that is not partisan. This is an issue about the respect 
that we give to those that risk their entire lives for all of 
us to have our freedom, and how we treat individuals of this 
nature is unacceptable and what has gone on.
    So I thank this Committee for their work on the GAO study 
and I thank them and will pledge to do everything in our power 
to make sure we correct this as well, and I yield back.
    Mr. Coffman. Thank you, Congressman McCarthy.
    With that, I invite the first panel to the witness table.
    Mr. Coffman. On this panel, we will hear from Mr. William 
Schoenhard, Deputy Under Secretary for Health for Operations 
and Management at the Veterans Health Administration. Mr. 
Schoenhard is accompanied by Dr. Thomas Lynch, Assistant Deputy 
Under Secretary for Health Clinical Operations and Management; 
Mr. Philip Matkovsky, if I am saying that right, Assistant 
Deputy Under Secretary for Health for Administrative 
Operations; and Dr. Michael Davies, National Director for 
Systems Redesign.
    We will also hear from Ms. Debra Draper, Director of Health 
Care at the Government Accountability Office; and Mr. Roscoe 
Butler, National Field Service Representative for the Veterans 
Affairs and Rehabilitation Commission at the American Legion.
    All of your complete written statements will be made part 
of the hearing record.
    Mr. Schoenhard, you are now recognized for 5 minutes.

STATEMENTS OF WILLIAM SCHOENHARD, FACHE, DEPUTY UNDER SECRETARY 
   FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, 
   ACCOMPANIED BY THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER 
SECRETARY FOR HEALTH CLINICAL OPERATIONS AND MANAGEMENT, PHILIP 
  MATKOVSKY, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR 
 ADMINISTRATIVE OPERATIONS AND MICHAEL DAVIES, M.D., NATIONAL 
DIRECTOR OF SYSTEMS REDESIGN; DEBRA A. DRAPER, DIRECTOR, HEALTH 
  CARE, GOVERNMENT ACCOUNTABILITY OFFICE; AND ROSCOE BUTLER, 
  NATIONAL FIELD SERVICE REPRESENTATIVE, VETERANS AFFAIRS AND 
         REHABILITATION COMMISSION, THE AMERICAN LEGION

                STATEMENT OF WILLIAM SCHOENHARD

    Mr. Schoenhard. Thank you, Chairman Coffman, Ranking Member 
Kirkpatrick, Members of the Committee, thank you for the 
opportunity to come today to speak regarding a subject that is 
important to the care of our Nation's veterans and to their 
satisfaction for veterans who have sacrificed all, as 
Congressman McCarthy referenced, on our behalf.
    Let me first just express regret for the incidents of 
breakdown in care that was described by the Ranking Member and 
by Congressman McCarthy. Any veteran who goes without timely 
care where their care and satisfaction is impacted is one 
veteran too many in terms of our commitment to serve those who 
have served us.
    I am accompanied today, as you said, Mr. Chairman, by two 
assistant deputies, Mr. Matkovsky and Dr. Lynch for 
Administrative and Clinical Services, respectfully, and Dr. 
Michael Davies, the National Director of Systems Redesign.
    As I mentioned earlier and as was mentioned by Members of 
the Committee and Congressman McCarthy, timely access to care 
is important to both clinical care as well as the satisfaction 
of our veterans. We are grateful for the oversight of this 
Subcommittee. We are also grateful for the report of the GAO 
and the IG. We have been on a long journey to see what steps 
can be taken to ensure we have reliable and valid measures to 
measure wait time and the methods and implementation practices 
to ensure consistent implementation of those across our system.
    We are also informed by our own study of millions of 
veterans' appointments as well as patient satisfaction surveys 
that suggests that there is need for improvement, as we 
acknowledged if our acceptance of the four recommendations of 
the GAO, as we determine how to go forward in better improving 
our care to increase patients' experience with our system.
    I think it is important to say there are two parts to this 
effort going forward: First is to have reliable and valid 
measures to measure wait time. And as is indicated in our 
written testimony, we have changed the measure for new patients 
in order for that to be more valid and reliable, and we have 
undertaken a change with regard to the agreed upon date that 
the provider and the patient will establish together as a 
patient visit is completed.
    That is informed, as I mentioned before, by the various 
reviews and our own study. It is important that we have 
measures that we know will better serve our veterans and 
reliably be implemented across this system.
    Having said that, as important as that is for a foundation, 
execution is the most important part going forward, and I would 
offer that in our experience of the past 20 years and what we 
have learned from the recent studies is that we need to do a 
better job of integrating our administrative and clinical 
implementation of this effort going forward. That is why I am 
accompanied today by the two assistant deputies.
    We need to ensure, as we have for the measure for new wait 
times, that we have effectively piloted these measures with 
providers in the real world to determine that they work, that 
they better serve veterans. We need to ensure that we have 
going forward more robust and complete training of our staff, 
who actually implement these practices and schedule our 
patients.
    We need to ensure that we have staffing guidelines for 
schedulers to ensure we have sufficient supply and training of 
those who do this important work, and I have sat with those who 
actually go through the scheduling process, and as mentioned by 
the Ranking Member, we need to have better tools for their use 
and automated scheduling system to go forward.
    Finally, we must have feedback loops to ensure that we have 
continuous improvement and reality check on what we do going 
forward.
    I pledge to you and to the Subcommittee that this is an 
effort that will be implemented in an unprecedented way.
    As we go forward, this requires joint, administrative and 
clinical engagement, and we will ensure, as part of that 
process, accountability and oversight to ensure at all levels 
of our organization that this is implemented in a way that it 
is veteran-centric and important to their care.
    We thank you for the opportunity to be here, and my 
colleagues and I will be happy to answer questions.

    [The prepared statement of William Schoenhard appears in 
the Appendix]

    Mr. Coffman. Ms. Draper, you are now recognized for five 
minutes.

                  STATEMENT OF DEBRA A. DRAPER

    Ms. Draper. Chairman Coffman, Ranking Member Kirkpatrick 
and Members of the Subcommittee, good afternoon. I am pleased 
to be here today to discuss VA's reported outpatient medical 
appointment wait times. The bottom line is that it is unclear 
how long veterans are waiting to receive care in VA's medical 
facilities because the reported data are unreliable.
    Access to timely medical appointments is critical to 
ensuring veterans are getting needed medical care. However, 
long wait times and a weak scheduling policy and process have 
been persistent problems for VA. For more than a decade, both 
we and the VA's Office of the Inspector General have reported 
on these problems.
    In my statement today, I will discuss key findings from a 
report we issued this past December that examined the 
reliability of VA's reported medical appointment wait times as 
well as the scheduling policy and process.
    We found that VA's reported wait times are unreliable 
because scheduling staff do not always correctly record the 
required appointment desired date. That is the date on which 
the veteran or provider wants the veteran to be seen. This is 
due in part to lack of clarity in the scheduling policy and 
related training documents on determining and recording desired 
date, a situation made worse by the large number of staff who 
can schedule medical appointments, which at the time of our 
review was estimated to be more than 50,000 people.
    During our site visits to four medical centers, we found 
more than half of the schedulers that we observed did not 
record the desired date correctly, which may have resulted in a 
reported wait time that was shorter than what the veteran 
actually experienced. Some staff also told us they change 
medical appointment desired dates so that the dates align with 
VA's related wait time performance goals.
    We found additional problems in how the scheduling policy 
was implemented, which may have also resulted in increased wait 
times and delays in care. For example, an electronic wait list, 
which is required for tracking veterans needing medical 
appointments, was not always used, putting veterans at risk of 
not receiving timely care. We also found follow-up appointments 
being scheduled without communication with the veteran, who 
would then receive notification of their appointment through 
the mail.
    Additionally, the completion of required scheduler training 
was not always done, even though officials stressed the 
importance of training for ensuring adherence to the scheduling 
policies. We also found a number of other factors that 
negatively impacted the scheduling process. These included the 
VistA system used for scheduling, which officials described as 
antiquated, cumbersome and error prone, shortages and turnover 
of scheduling staff, and high telephone call volumes without 
sufficient staff dedicated to answering these calls.
    VA is implementing or piloting a number of initiatives in 
an effort to improve veterans' access to medical care. For 
example, one such as initiative is Project ARCH, which aims to 
provide health care through contracts with community providers 
to reduce travel and wait times for veterans who are unable to 
receive certain types of care from VA in a timely manner. While 
information is being collected on wait times for Project ARCH, 
these wait times may not actually reflect how long veterans are 
waiting to receive care because the wait times are measured 
from the time authorization is received from VA rather than 
from the time the veteran first requests the appointment.
    In our December report, we recommended that VA take actions 
to improve the reliability of medical appointment wait time 
measures, ensure the consistent implementation of a scheduling 
policy, allocate scheduling resources based on needs, improve 
telephone access, including the implementation of identified 
best practices. VA concurred with our recommendations and 
identified actions planned or under way to address them.
    To conclude, while VA officials have expressed an ongoing 
commitment to providing veterans with timely access to medical 
appointments and have reported continued improvements in 
achieving this goal, unreliable wait time measurement has 
resulted in a discrepancy between the positive, the wait time 
performance VA has reported, and veterans' actual experiences. 
More clarity in and consistent adherence to the scheduling 
policy, improved oversight of the process, allocation of staff 
resources to better match scheduling demands, and resolution of 
problems with telephone access are needed to reduce medical 
appointment wait times.
    VA's ability to ensure and accurately monitor access to 
timely medical appointments is critical to providing quality 
health care for veterans, who may have medical conditions that 
worsen if care is delayed.
    Mr. Chairman, this concludes my opening remarks. I am happy 
to answer any questions.

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

    Mr. Coffman. Thank you for your testimony.
    Mr. Butler, you are now recognized for 5 minutes.

                   STATEMENT OF ROSCOE BUTLER

    Mr. Butler. Good afternoon, Chairman Coffman, Ranking 
Member Kirkpatrick and Members of the Committee. On behalf of 
our National Commander, James Koutz, and the 2.4 million 
members of the American Legion, I want to thank you for looking 
into the problems American veterans are having access in their 
health care. Whether it is frustration with repeatedly being 
put on hold, waiting three-quarters of a year for a basic 
primary care appointment, or being forced repeatedly to adjust 
to new primary care providers, the needs of veterans are not 
being met.
    I want to ask you really to take the time to read through 
Appendix A of our testimony. These are real veteran stories, 
raw and unfiltered that provide a realistic picture of what is 
happening to the people of the system. Time and time again, we 
see veterans who love the care they receive when they can get 
it. The frustration of the ability to access what is otherwise 
excellent care has been a factor we have seen in our System 
Worth Saving visits for the 10 years we have been performing 
these visits. It is important to remember these veteran stories 
because that is the real impact we are talking about.
    This is not about meeting targeted numbers or looking at 
where results fall on a chart. This is about what happens to 
real people who have sacrificed for their country with their 
military service and are now frustrated by an otherwise 
excellent health care system. Some of the wait time could be 
improved if VA did a better job delivering on extended hours 
for health services, especially mental health. We know VA is 
trying to address this, and they released a VHA directive on 
January 9th of this year. Unfortunately, from our experience 
with visits in the field, this directive would not go far 
enough to meet the needs of veterans.
    The new policy states that any facility that treats more 
than 10,000 veterans a year has to have an extended session 
during the week and one on the weekend end, but the required 
sessions are only 2 hours. The American Legion is concerned 
that four hours a week simply won't be enough to meet the 
demands of veterans at these facilities. We believe VA needs to 
continue to refine the policy to make sure they really are 
meeting the needs of the veterans.
    To address one of the other major problems with wait times, 
VA must address the problems with their scheduling system. 
After nearly a decade of indecision between off-the-shelf 
software and in-house designs, the entire project was dropped 
in late 2009. Now, 3 and a half years later, there is still no 
fix in place. There is an open call for submission from the 
Federal Register to end in July of this year, but our veterans 
deserve a clear and better plan in place.
    We hope VA can provide details on how they will be able to 
implement a 21st Century scheduling software system. The most 
frustrating part of the process, something has been since 
Commander Conley started the System Worth Saving visits in 
2003, is that when veterans can access the VA system, they 
really have good things to say about the care they receive. The 
American Legion believes VA needs to do a better job getting 
veterans to this care and on a more timely basis.
    Read through the reports. There is no reason that veterans 
should face 9-month delays just to see a primary care provider. 
I thank you and the Committee again for looking into this, and 
I would be happy to answer any questions you might have.

    [The prepared statement of Roscoe Butler appears in the 
Appendix]

    Mr. Coffman. Thank you, Mr. Butler.
    Mr. Schoenhard, GAO reports significant failures in 
scheduling appointments that span at least 7 years. In addition 
to this, this Subcommittee has identified a backlog of hundreds 
of thousands of appointments based on VA's own documentation. 
How is VA addressing this tremendous appointment backlog?
    Mr. Schoenhard. Sir, we are addressing this in a variety of 
different ways, and in terms of new patients, we are creating a 
new measure to go to create date to ensure, particularly for 
those who are needing access to our system for the first time, 
that within 14 days, we would schedule their appointment from 
the time the appointment is scheduled, not when the patient 
desires to be scheduled, but the clock starts the time the 
appointment is being made because we believe that is a more 
reliable and valid measure of making sure veterans are able to 
access our system, so that is an important first part.
    Also, we are in the process of undertaking a complete 
review of consultation requests. We have developed new 
information system tools to be able to have visibility of this 
at all levels, and we are addressing that in a system-wide 
review and putting in place work groups that will ensure that 
we have better visibility than we have had in the past of these 
consult delays and that we are acting on them in a way that 
provides proper oversight and audit of that going forward.
    Mr. Coffman. Mr. Schoenhard, my concern is that VA has or 
will clear this backlog by simply administratively closing 
appointments, as they did with 13,000 appointments in Dallas 
and approximately 40,000 appointments in Los Angeles. Why isn't 
VA using community providers more efficiently?
    Mr. Schoenhard. Sir, you touch on a very important aspect 
of our care and that is being able to use community providers 
in order to better serve our veterans if we are unable to serve 
them. I wonder if I could ask Mr. Matkovsky, please, to expand 
further on the non-VA care efforts we are making to ensure this 
is done.
    Mr. Coffman. Please.
    Mr. Matkovsky. Thank you.
    Mr. Chairman, we have begun in fiscal year 2012 rolling out 
a care coordination module for non-VA care. It allows us to 
actually be more systematic in how we review referrals to the 
non-VA care provider, so the care in the community, rather than 
ad hoc, it allows us to collect all of the referrals for non-VA 
care, ensure that folks are scheduled timely and that they can 
be seen in a timely basis. We do that by actually collecting 
the referral request, having a standard form of authorization 
for each referral and then being able to monitor how that 
referral is worked in the community. What we don't want to do 
is have someone who might be experiencing a wait time in the VA 
experience the same wait time in the community. This allows us 
to monitor them both.
    That process will be fully deployed across all of our 
medical centers by the end of fiscal 2013. It is an important 
change. It may not sound like it, but it allows us to more 
strategically and more systematically use our non-VA partners 
in delivery of care.
    We have also begun a few larger contracting initiatives, 
which we have briefed this Committee last year on--
Subcommittee, sorry--that will give us standardized access to 
care based on performance.
    Mr. Coffman. I am still unclear on how we are talking about 
hundreds of thousands of backlog appointments. I mean, what are 
you going to do today to get that, to take care of this?
    Mr. Matkovsky. We are not going to administratively close 
any appointment for care for a veteran. I think you referenced 
a couple of instances where there may have been referrals that 
were actually completed but simply not closed out, sir.
    Mr. Coffman. You mean the 13,000 in Dallas and 40,000 in 
Los Angeles, the couple that are the few that I referred to?
    Mr. Matkovsky. Sorry, sir. I meant the few examples you 
gave, but no, we will not close out any appointment 
administratively where a veteran is waiting for care at all.
    Mr. Coffman. Mr. Schoenhard, according to VA documentation, 
in many instances, veterans were harmed or died due to delays 
in getting treatment. How many adverse events nationwide is VA 
aware of due to these delays?
    Mr. Schoenhard. Sir, we have undertaken review of our 
facilities, and we are in the process of completing that 
review. We have instances of institutional disclosure that has 
occurred throughout our system.
    I ask Dr. Lynch to expand on this, but if I could turn to 
you and if you could give the report.
    Dr. Lynch. Thank you, Mr. Schoenhard.
    If I could begin by backtracking for just a second in 
discussing the process by which consults have been reviewed 
across VA. The VA consult system is not an ideal system, and 
unfortunately, it contains not only clinical consults, but also 
the consult process that has been used for administrative 
purposes. In certain cases, consults have been used to schedule 
tests rather than specific patient visits. In some cases, 
consults have been used to schedule advanced appointments 3 or 
4 years in the future. These are called queuing consults.
    The process of reviewing consults has been very careful. We 
have looked at the reasons for all of the, what we term 
unlinked consults, carefully evaluated whether they are of 
clinical significance before making a decision whether or not 
they can be administratively closed. Any of the consults that 
have been closed to date have been evaluated and there has been 
assurance that there has been no risk to patient care or to 
patient life, sir.
    Mr. Coffman. Ranking Member Kirkpatrick.
    Mrs. Kirkpatrick. Ms. Draper, how confident are you that 
the Veterans Health Administration will be able to effectively 
make improvements in the reliability of the reported medical 
appointment wait times, scheduling oversight and initiatives to 
improve access to timely medical appointments?
    Ms. Draper. There is a lot of work to be done, and I think, 
as we reported, for more than a decade, there have been a lot 
of initiatives started and the problems still persist. So, I 
think they have undertaken a number of initiatives to improve 
the measurement of wait times. And let me just say the 
measurement of wait times is really important for a number of 
different reasons, one of which is work load management, so you 
don't really know --how much capacity you have which is an 
indication of what other resources you might need to get 
veterans in to be seen in a timely manner.
    So, it remains to be seen. It is a hard question to answer 
based upon previous experience. As I said in my testimony, we 
have reported on these problems for more than a decade, and 
there is a lot of work to be done. And I will say, it is not 
just the wait time measurement, but it is having clear policies 
and better allocation of staff. We heard that there are a lot 
of problems around telephone access, so better management of 
the telephone system is needed at the four sites that we 
visited, we found evidence of long on-hold times and also of 
high call abandonment rate, so it is a very complex issue, and 
it is not just one thing that is going to fix this. There are a 
lot of things that need to be addressed.
    Mrs. Kirkpatrick. In your opinion, what do you believe is 
the number one challenge VHA faces as they move forward to 
making improvements and moving the scheduling process into the 
21st Century?
    Ms. Draper. Well, it is very important to have a clear 
policy. Right now, there is a lot of ambiguity in the policy, 
so it left a lot of discretion resulting in considerable 
variation from one facility to another. So, one thing is clear 
policy, clear implementation of that policy, and oversight. You 
know, one of the things that VA did in 2007 was to require 
individual medical centers to do a self-assessment and report 
their compliance with the scheduling policy, and I think that 
what we saw was more than 80 percent, or close to 80 percent of 
the facilities that completed that self-assessment said that 
they were in full compliance with the scheduling policy, and we 
know from two of the facilities that we visited that said that 
they were in full compliance, that was not the case.
    Mrs. Kirkpatrick. Again, Ms. Draper, GAO reported that a 
scheduler at one of the primary care clinics specifically 
stated that she changes the recorded desired date to the 
patient's agreed upon date in order to show shorter wait times 
for the clinic. Clearly, that should not happen. I think we all 
agree with that.
    While visiting the facilities and talking to staff, did you 
get a sense that the employees were unduly influenced to make 
sure that shorter wait times for the clinic were reflected, 
even if it weren't true?
    Ms. Draper. I can tell you we heard this across several 
facilities. So, as you mentioned, in one primary care clinic, 
we did hear that the scheduler changed the dates to show that 
there were no long wait times. In another specialty care 
clinic, we heard that providers were changing dates to make 
sure that their data showed that they were within the 14 day 
wait time goals of VA.
    We also went to one specialty clinic, which reported a 
zero-day wait time because they were changing the desired date 
to the appointment date. So what happened is, in reality, there 
was a 6- to 8-week backlog, at least. So someone in another 
part of the facility can look at the scheduling system and it 
looked like there was no wait time so they would send someone 
over when, in reality, there was a long, long backlog of 
appointments.
    So, while we weren't specifically told that they were 
directed by management, I think the current situation provides 
ample opportunity to change dates, whether intentional or not, 
to really reflect the results that you want to achieve.
    And I just want to say, too, that these measures are used 
in a lot of different ways. They are included in the network 
and medical director performance plan. They are also included 
with VA's budget submissions, and they are also included in the 
VA's annual performance and accountability report, so there is 
a lot of incentive around these measures.
    Mrs. Kirkpatrick. Thank you.
    Thank you for your testimony, and I will yield back the 
balance of my time.
    Mr. Coffman. Thank you, Ranking Member Kirkpatrick.
    Mrs. Walorski, Congresswoman Walorski.
    Mrs. Walorski. Thank you, Mr. Chairman, and thank you to 
the panel. I think, in the State of Indiana, in my district, 
have 52,000 veterans just in my district alone, and our little 
State of 6.5 million people that sits in the middle of the 
country plays a significant role in military operations around 
the country and has the fourth largest National Guard.
    I find it shocking to sit and to hear these stories time 
and time again.
    And Mr. Schoenhard, in your testimony today, you talked 
about reliable valid measures and you talked about having these 
feedback loops, and I am shocked about it. Before I ask you 
this question, I am shocked about it because when the military 
is in need and our country is in need, Hoosiers to respond in a 
rapid form? Our Hoosiers are often the first line of defense 
and the first folks to go.
    So, when our Nation calls them, they go. When they need 
help from our Nation, to have the kind of stories that we hear, 
it is very sad and it is shocking to me. So, what feedback 
loops have you put in place that are going to try to correct 
these problems, given the past of how long it has taken to 
actually unveil these issues in the form of hearing?
    Mr. Schoenhard. Congresswoman, I would say that the first 
feedback loop we have used is to pilot test the new measure for 
new patients, moving it from desired date to create date. This 
will be a hard timestamp at the time a veteran is making an 
appointment until the appointment is actually made.
    Part of the problem we have had in the past is that as the 
scheduler has asked a new patient when they would like their 
desired date, sometimes the veteran may ask to put it out 
somewhere in the future. They may be going on a trip or 
somewhere and they may want to not feel an urgent need to get 
in, and so we have been measuring the wait time around that 
desired date. Moving it to the create date will put emphasis on 
the day the appointment is being made, is that appointment made 
within 14 days or not? And part of what we have experienced in 
the past is that veterans, like myself, often are appreciative 
of the care VHA renders, and they will ask, well, when do you 
have a spot available? They are trying to be accommodating, 
unless they have an urgent need, and you get into this circular 
conversation. Well, it is not when we are available; it is when 
you want to be seen. All of that will go away with the new 
create date where we will work to get them in the system 
because I couldn't agree more from my visits with veterans and 
our own review, the perception of care is higher among those 
who use VHA than those who have not. And so we want to get them 
in our system and we owe it to Hoosier veterans; we owe it to 
veterans throughout this Nation for all that they have 
sacrificed, particularly in these wars, to get them in as soon 
as we can.
    Mrs. Walorski. I appreciate it.
    And Ms. Draper, I appreciate the GAO's summary as well and 
find it revealing. Is it your belief that the recommendations 
that we have talked about today and the recommendations in the 
report will suffice in turning some of this stuff around? And 
my counter question to that is, is there a competency level at 
the staffing level that needs to be addressed, or can this 
completely be streamlined through programming?
    Ms. Draper. Well, it is interesting you ask about this. I 
assume you are talking about scheduling staff. We have heard 
that these are high-stress demanding jobs and that they are 
really entry level pay grade, so we saw a high amount of 
turnover in these positions. We heard in the facilities that we 
visited that high performers tend to get promoted quickly out 
of their scheduling role, so you have a lot of turnover.
    And you know one of the issues is that VA really has not 
determined what its scheduling staff needs are. Just to give 
you a sense of what happens when you don't have sufficient 
scheduling staff, providers are picking up where schedulers are 
not completing their responsibility which takes away time from 
their direct patient care. So, there is just a lot of issues 
that come up and it is not simple and straightforward because a 
lot of things happen when you don't have sufficient staff.
    Mrs. Walorski. Thank you.
    I yield back my time, Mr. Chairman. Thank you.
    Mr. Coffman. Thank you.
    Mr. O'Rourke, Texas.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Ms. Draper, in some of your comments, you touched upon 
capacity, and in El Paso, you know, I often hear from veterans 
that when they are seen by a doctor at the VA, it is excellent 
care and they have no complaints and really are just full of 
praise for the quality of care, the professionalism, the 
attentiveness. The challenge is getting in a lot of times and 
having an appointment set and then canceled and reset, and it 
is particularly acute for mental health care.
    And we recently found that there are nearly 20 unfilled 
positions for mental health professionals in the El Paso VA. 
When you look at the fact that we have 80,000 veterans in our 
service area, and we don't have a full service VA hospital, we 
have this shortfall in our mental health professionals, and if 
you want to go see, go to an acute care hospital. It is in 
Albuquerque, a 10-hour drive roundtrip. Did you find that 
capacity in terms of mental and physical health care 
professionals was part of the problem in getting the wait times 
that were desired?
    Ms. Draper. We did not look at mental health care because 
the VA IG addressed that issue, but we did look at specialty 
and primary care. What we heard was that part of the reason for 
backlogs is not having enough providers. Officials at the 
medical centers told us that their providers are often really 
stretched. For example, consults are supposed to be triaged 
within 7 days of receipt, which typically falls on a clinician. 
Some specialty clinics can get 40, 50, 60 consults a day, and 
someone has to take care of those. So if you have a short 
staffed clinic to begin with and then add on these other 
ancillary duties, it really does become a scheduling nightmare.
    Mr. O'Rourke. Mr. Schoenhard, how can we work with you? You 
know, we met with the VHA director in El Paso, Mr. Mendoza. 
Again, they are doing a great job, but I think they are working 
with limited resources and they need more help, and they are 
challenged by not just having these unfilled positions in their 
manning table, but we also have a great active duty full 
service hospital at William Beaumont East, which I think at 
times poaches health professionals there. Are we not paying 
enough for, in this case, mental health professionals or 
primary care professionals? Are we having a hard time 
attracting and retaining talent at our clinics and VA 
hospitals?
    Mr. Schoenhard. Congressman, first, I will follow up with 
the El Paso situation.
    Mr. O'Rourke. Thank you.
    Mr. Schoenhard. Look into that personally. We are in a 
major effort, as I am sure the Subcommittee is aware, of hiring 
additional mental health professionals. We are doing site 
visits to our facilities. It is important not only that we 
recruit, but that we retain mental health professionals. That 
is part of the vacancy. That is part of the turnover situation 
going forward. We need to create the best practice environment 
for our mental health providers and anywhere in this United 
States.
    We should lead in that effort in VHA. And it is important 
that we not only address new positions, but that we fill 
vacancies. As it relates to benefits and salaries, we have had, 
historically, some struggle in being competitive in the 
recruitment of psychiatrists. Steps have been taken to ensure 
that. Psychiatry is a shortage everywhere. Having come from the 
private sector, I can say, particularly in rural areas, of 
course, El Paso is not that case, it is very difficult to 
recruit psychiatrists. And so we use telemental health and 
other ways in which to be able to provide care, which actually 
has been very well received by our veterans, but we need to 
ensure we have the wherewithal to effectively retain and 
recruit mental health providers, and we continue to evaluate 
that with a major effort in human resources.
    Mr. O'Rourke. Thank you, and thanks for your offer to 
follow up on these vacancies in El Paso.
    Mr. Chairman, I yield back.
    Mr. Coffman. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman, and thank you all for 
being here.
    Ms. Draper, thank you for your work. I made it no secret in 
here I am a big fan of GAO, IG and the oversight.
    And Mr. Schoenhard, thank you. I have also made it clear I 
am the VA's staunchest supporter and the harshest critic, and 
if I am not mistaken, you yourself are a veteran.
    Mr. Schoenhard. Yes, sir.
    Mr. Walz. As are what percentage of your people who work?
    Mr. Schoenhard. Sir, I would need to check, but at least 30 
percent.
    Mr. Walz. I was just going to say, I wish the distinguished 
Whip would have waited for answers today, and I do bristle a 
bit at the idea of indifference. I would like to know a name of 
which person in the VA was indifferent because I think to paint 
with a broad brush the number of people at VA that are out 
there doing a good job. I am not going to defend you when you 
fall down, and simply think we can do better, but I think 
painting with a broad brush.
    I have some statistics here. This is a 3-year-old study. 
These are average wait times in the civilian sector for a 
doctor appointment: 63 days in Boston; 59 days in Los Angeles; 
good here, 27 days in Detroit; 47 in Minneapolis. I think many 
times what we forget here is comparing apples to apples across 
there.
    I know, Ms. Draper, that was not your charge to the private 
sector, but we pay a lot of money to the private sector in the 
form of Medicare and things like that, so when we are talking 
best practice and we are adding things, it is certainly not for 
the desire to care.
    The thing that frustrates me is that I see an unevenness in 
application. And Ms. Draper, are all VA facilities created 
equal in your mind on how they do this?
    Ms. Draper. Are you referring to how they implement their 
policy?
    Mr. Walz. Yes.
    Ms. Draper. No. We found considerable variance from 
facility to facility.
    Mr. Walz. Are there some that are doing this outstanding, 
and it could be made to say that they are doing it world class?
    Ms. Draper. I would say in the four facilities we visited, 
we found issues in all four.
    Mr. Walz. Okay.
    Ms. Draper. And they range in size and geographic location.
    Mr. Walz. I see it in very small geographic areas between 
St. Cloud and Minneapolis, I see a difference in wait times on 
there and how that works, so I think it is trying to both 
integrate a unified, putting the system in and allowing for 
geographic variance, but I think one of the most frustrating 
things for me is, is the uneven care that veterans receive at 
different facilities.
    Mr. Schoenhard, can you talk about that on how you address 
that or how you deal with the competing desire of local control 
versus a centralized system that provides that uniform quality 
care?
    Mr. Schoenhard. Well, sir, let me begin with a statement 
that veterans should expect the same standard of timeliness, 
access, quality in their care whether its Manila or Maine. It 
should be throughout our system. We are a national system.
    Mr. Walz. And ironically enough, I was just in Manila. It 
might be better there than anywhere I have been, just as a side 
note to you, but please go on.
    Mr. Schoenhard. We will learn from them, but we owe it to 
our veterans to ensure more consistent delivery of timely 
quality care. That is an expectation we have here in the 
central office in Washington of our VISNs. We rely on our VISNs 
to ensure that they are providing consistent care within their 
regional footprint, and it is our responsibility to ensure 
oversight and monitoring of the VISNs doing their work with the 
facilities. We have that responsibility.
    Mr. Walz. So, these implementations or these corrections 
that were given to us, will these help improve system-wide, or 
will these help improve these four facilities that were looked 
at?
    Mr. Schoenhard. It will help the four, and it will help the 
others who also are in need of improvement. I would like Mr. 
Matkovsky to expand on the plan going forward because I think 
it is a more robust effort than we have had in this case.
    Mr. Matkovsky. Thank you, Mr. Schoenhard.
    And I would indicate that I would agree with Ms. Draper's 
analysis. For a program, we require good, clear measurable 
policy. So, as we work on the new set of dates, it has to be 
clearly defined and we have to be able to relay that to 
everybody in the field who we are expecting to hold accountable 
to this new set of standards.
    Our first step was adjusting some of our policies using a 
date that is easy to understand. After we do that, we have to 
test this policy. Rather than roll it out system-wide via memo, 
it is our responsibility as a program to test it in its 
application, make sure that the training we provided staff on 
the front line, training we providing the providers was 
adequate, that it answered the mail, any changes we made to 
systems were easy to use and resulted in a measure that was 
reliable in each of the clinics that we applied this change.
    After we roll it out, the next thing that we require, you 
mention the tension between local care--all care is local--and 
oversight. It is our job to pay attention as well, to look at 
the performance, to establish measures that allow us to track 
the averages, but also allow us to track some of the stories 
that Mr. Butler relayed, anywhere where there might be a wait 
that is too long. It is our job to actually evolve our 
management, our oversight and have that constant feedback that 
is always looking at how to improve performance, and that is 
what we are doing differently this time.
    Mr. Walz. Well, I appreciate that, and with the outrage 
that we express, I would just ask you to always ask us this: 
how long you have been waiting for us to do a budget and 
sequestration? What is fair is fair. Emerson might have been 
right, ``how much of life is lost in waiting,'' but thanks.
    I yield back.
    Mr. Coffman. Thank you, Mr. Walz.
    Mrs. Kirkpatrick. Mr. Chairman, may I have just a moment?
    Mr. Coffman. Oh, yes. Go ahead.
    Mrs. Kirkpatrick. Thank you very much for having this 
hearing. I want to thank the panel and the guests. The 
Democrats on the Committee are leaving to go meet with the 
President, so I didn't want you to think we are just walking 
out of the hearing, but we need to meet with him at 2 o'clock, 
so thank you.
    Mr. Coffman. Thank you.
    Dr. Lynch, I believe you stated in your testimony that you 
were not aware of any deaths of any veterans due to delayed 
care; is that correct?
    Dr. Lynch. We were talking about consults to begin with, 
and let me, if I may, explain a little bit about how the 
consult process works.
    There are two sides to a consult. There is the consult 
itself, the ask, and there is the response or the physician 
reply. There is a third component to that which links the two. 
When the team from VHA undertook to assess consults, they did 
it in a standardized fashion. We looked, first of all, at all 
of the consults over a --
    Mr. Coffman. May I rephrase the question?
    Are you aware of any deaths of any veterans due to delayed 
care?
    Dr. Lynch. With respect to the consult look back, no, sir. 
With respect to what had occurred in Columbia and Augusta, we 
are aware that there were some clinical disclosures made and 
that there were veterans who had died with a disease process 
that could potentially have been related to consult delay.
    Mr. Coffman. Well, yeah, I think you have via the internal 
documents here, and you are actually fairly specific. It is in 
May that it, in fact, the delay in treatment did cause the 
death of a veteran in South Carolina, and another date in May--
another internal document, last year, May 15, speaks to the 
Dorn facility, speaks to another death due to delay in care, so 
I think that clearly there are, by your own internal documents, 
there are issues concerning the quality of care related to 
timeliness and, unfortunately, the loss of life unnecessarily 
of veterans, and that is particularly alarming.
    Mr. Schoenhard, when did you become aware of this problem?
    Mr. Schoenhard. The problem being consult backlog or back -
-
    Mr. Coffman. The very problem we are discussing here today, 
when did you become aware of it?
    Mr. Schoenhard. Well, I would say the overall issue of wait 
times, I would say, is a matter that I have been concerned 
about since arriving when I was appointed in 2009.
    Mr. Coffman. In 2009?
    Mr. Schoenhard. Yes, sir.
    Mr. Coffman. Now, it is 2013, and we are having this 
discussion?
    Mr. Schoenhard. Yes, sir.
    Mr. Coffman. Why are we here today?
    Mr. Schoenhard. I think we are here today because of a 
number of factors, most of which deal with better execution 
going forward and the consistent training, testing and 
implementation of our scheduling package with measures that are 
more reliable and valid than we have had in the past.
    As I said in my opening statement, I think it begins with 
the measurement system itself. And I am convinced from what we 
have learned from the GAO, the IG, particularly the IG review 
of mental health. That was very helpful last year.
    Mr. Coffman. Mr. Schoenhard has VA's medical inspector Dr. 
John Pierce come to any conclusions as a result of the large-
scale failure to care for veterans?
    Mr. Schoenhard. I think that, from Dr. Pierce's report, it 
showed clearly that we had the important need to do two things: 
Address the delays in the facilities that he had visited in 
Columbia, South Carolina and Augusta, Georgia. As important as 
it was for us to vigorously respond to that report from Dr. 
Pierce and the OMI of those two facilities, it was as important 
as that was to ensure we were providing system resources and 
VISN resources to those two facilities, it was equally 
important that we do a systemwide review to see if this was of 
an issue anywhere else. And that is the process that Dr. Lynch 
was describing. Because whenever we have a problem arise in a 
particular facility, or two facilities, we have a 
responsibility to ensure veterans throughout VHA that we are 
undertaking a review to see if this is the case anywhere else.
    Mr. Coffman. When can the Committee see that report?
    Mr. Schoenhard. I would have to take that for the record, 
sir. I don't know, but I would certainly take that for the 
record.
    Mr. Coffman. Well, when can the Committee see that report?
    Mr. Schoenhard. Sir, if I could take that for the record, I 
will provide an answer as soon as we can.
    Mr. Coffman. You will provide the report.
    Major Shepard. I would have to check and make sure that I 
can tell you the time within which the report would be 
rendered.
    Mr. Coffman. Is the--well--Mr. Butler, you mentioned that 
the Legion's task force had identified a list of 14,000 
veterans waiting months for appointments in Bay Pines. Can you 
cite other locations?
    Mr. Butler. Our System Worth Saving Task Force has visited 
a number of VA facilities. And while I can't specifically 
identify at this time facilities that have excessive wait time, 
I will take that information for the record. But I can tell you 
that on as recent as a visit on yesterday, we found that there 
are some facilities where when we talk about the electronic 
wait lists, we are still finding facilities that are still 
using paper lists. So not all the appointments are being 
recorded electronically. So, therefore, the wait time is not 
accurately being reported as it should be.
    Mr. Coffman. Thank you.
    Mr. Huelskamp.
    Mr. Huelskamp. Thank you, Mr. Chairman. I apologize for any 
tardiness in arriving.
    I would like to ask Ms. Draper a question of her report and 
piecing through that, the one issue in particular that 
disturbed me was you note that staff at some clinics told us 
they change medical appointment desire dates to show clinic 
wait times within performance goals. How widespread was that 
pattern of behavior? And can you describe that a little further 
for the Committee?
    Ms. Draper. We actually found this in several places. So it 
was not a one-time occurrence. For example, in one primary 
clinic, a scheduler told us that they changed the dates to make 
it look like they had short wait times. And at a specialty care 
clinic in another facility, a scheduler told us providers 
changed the dates to ensure that it reflected wait times within 
the 14-day performance goal. We had quite a few examples. 
Another specialty clinic in another facility matched the 
desired date to the appointment date so that it showed a zero 
wait time. In actuality, when we went there it had a 6- to 8-
week backlog of appointments. I think this question came up 
earlier. Part of the issue is that there is a lot of confusion 
among schedulers about what they are supposed to be doing. No 
one specifically told us that they were asked to change the 
date by leadership. But I think the situation as it currently 
exists provides ample opportunity for dates to be changed, 
whether intentional or not, to reflect the results that you 
want to achieve.
    Mr. Huelskamp. I appreciate that. I apologize.
    Mr. Chairman, if the question has been asked before. I want 
to follow up a little bit more. Is this, in your understanding, 
is this illegal under --
    Ms. Draper. Well, it is against scheduling policy, so they 
are not in compliance with the policy or the process.
    Mr. Huelskamp. I will ask the VA, how do you handle these 
employees and what have you done with this information?
    Mr. Schoenhard. Sir, gaming the system, if that is what is 
being suggested here, by changing dates in order to ensure that 
the results look better for performance reviews is entirely 
unacceptable. Entirely unacceptable. And we--are visible, when 
that is visible to us, we will take appropriate action. And I 
will follow up with the GAO report to determine this more 
specifically. What we need to be doing is ensuring we are 
taking care of veterans.
    Mr. Huelskamp. Assuming what we have seen matches up with 
what you are seeing, sir, what is the--the penalty for an 
employee that is violating this policy? What would you--how 
would you handle that?
    Mr. Schoenhard. Well, sir, we would review the case in each 
individual case to determine what was the facts and the 
circumstances and --
    Mr. Huelskamp. Let's just establish that the facts indeed 
occurred as indicated. What is the penalty for--I wouldn't call 
it gaming the system. That is cheating. What is the penalty?
    Mr. Schoenhard. The penalty would depend on the seriousness 
of the offense.
    Mr. Huelskamp. So if they changed it and moved it 6 weeks, 
and did this repeatedly, what would be the penalty in those 
circumstances?
    Mr. Schoenhard. Sir, I would have to say it would depend on 
the individual circumstance, but it could lead up to 
termination.
    Mr. Huelskamp. I look forward for a report on that.
    Mr. Chairman, I might note, I want to reiterate a request I 
have had to the VA for, I think we are up to 6 or 7 months now 
in reference to budget data. I think we have 23 unanswered 
questions in reference torch data out of the VA. And I 
appreciate you coming forward to this Committee and 
Subcommittee and giving some information. But I have had, 
again, multiple unanswered questions, basic budget data in 
reference to travels and activities by your employees that your 
agency has refused to provide information. And it is very hard 
to build a level of trust that we need to move forward to help 
and achieve the goal of helping our veterans when you refuse to 
answer, again, basic budget questions. So I would appreciate it 
if you would take that back to the folks in charge. And it has 
been a number of months. Certainly, we can figure out what 
responses we need to get to the Congressman other than simply 
ignoring those.
    I yield back, Mr. Chairman.
    Mr. Coffman. Thank you.
    Mr. Schoenhard, and I'd like to thank the entire panel, Mr. 
Butler, for your testimony, and Ms. Draper, Mr. Schoenhard and 
your staff.
    I just want to say that you have been here since--in this 
position since 2009. You came in, obviously, the system was in 
chaos and not serving the veterans' community. You have been 
there, you haven't made a difference. And I have no reason to 
think that, under your leadership, unfortunately, that this job 
is going to get done.
    With that, Committee is recessed.

    [Whereupon, at 2:05 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

           Prepared Statement of Hon. Mike Coffman, Chairman

    Good morning. This hearing will come to order.
    I want to welcome everyone to today's hearing titled ``Waiting for 
Care: Examining Patient Wait Times at VA.''
    We should always be working to ensure veterans have timely access 
to quality care. However, today's hearing is necessary because evidence 
reviewed by this Subcommittee, the Government Accountability Office, 
and VA's own Inspector General shows little improvement in that area.
    GAO recently completed its study that was appropriately titled 
``Appointment Scheduling Oversight and Wait Time Measures Need 
Improvement.'' Despite claims of improvement under higher standards, we 
will hear today about a lack of reliable information when VA is 
measuring patient wait times. VA's own testimony supports that premise 
as it discusses what it sees as no reliable standard and an inability 
to accurately measure what constitutes a patient wait time.
    While the topic of patient wait times may sound like a very narrow 
issue, the problems in accurately monitoring and improving wait times 
for veterans at VA facilities is spread throughout the whole Department 
of Veterans Affairs. Schedulers at the facilities themselves have to 
use a cumbersome system that creates a significant chance of error. The 
problem runs all the way up to the Veterans Health Administration, 
which has an unclear policy on patient scheduling practices, and still 
seems to struggle to best define its policy on patient scheduling. I 
understand that defining these policies is not easy, and that 
perfecting a process for appointment scheduling is a significant 
challenge, but VA has been well behind in this area for a long time.
    However, none of this excuses VA from its obligation to veterans. 
While I understand a system may not always be perfect, it does not mean 
that VA shouldn't make every effort to ensure veterans receive 
necessary care. Backlogs are a fairly common theme at the Department, 
but that is no reason for VA to game the numbers to simply show better 
performance instead of providing medical appointments, sometimes for 
life-threatening conditions.
    Sadly, evidence obtained by this Subcommittee clearly shows that, 
in many cases, VA did not do the right thing. Instead, evidence has 
shown that many VA facilities, when faced with a backlog of thousands 
of outstanding or unresolved consultations, decided to administratively 
close out these requests. Some reasons given included that the request 
was years old, too much time had elapsed, or the veteran had died.
    This Subcommittee asked VA for updates on these consultation 
backlogs beginning in October 2012. Despite multiple follow-up requests 
to VA, no information was ever provided, and it was only when this 
hearing was scheduled that the Department offered a briefing on this 
subject. I would note that the Subcommittee asked for information, not 
a briefing. Regardless, we should not be where we are now, and this 
goes to reinforce that the Veterans' Affairs Committee wants to work 
with the Department on this and other issues, but that requires a 
willingness on VA's side to be forthcoming about its problems so that 
together we can identify ways to solve them.

                                 
               Prepared Statement of Hon. Ann Kirkpatrick

    Thank you, Mr. Chairman, for holding this hearing this afternoon on 
the Veterans Health Administration's scheduling processes and how that 
affects patient wait times for veterans.
    Improving access to health care is a continuous effort by VHA, and 
it is not surprising that we are here today.
    Excessive wait times and the failures of the scheduling processes 
have been longstanding problems within the Veterans Health 
Administration.
    The Government Accountability Office has been reporting on this 
issue for over a decade.
    In 2001, the GAO reported that two-thirds of the specialty care had 
wait times longer than 30 days.
    In 2007, the VA Office of Inspector General reported that VHA 
facilities did not always follow VHA's scheduling polices and 
processes.
    In 2012, the VA OIG reported that VHA was not providing all new 
veterans with timely access to full mental health evaluations. In that 
same year, the GAO again examined the issue and found that, among other 
things, there was inconsistent implementation of VHA's scheduling 
policy that could result in increased wait times or delays in 
scheduling timely medical appointments.
    In my Arizona district, in the city of Casa Grande, one of my 
caseworkers recently met with an Iraq veteran who made the brave 
decision to seek VA mental health care after two years of being back in 
the U.S. from Iraq.
    The VA required a physical exam before this veteran in my district 
could schedule an appointment with a mental health care provider. 
Unfortunately, they weren't able to schedule him for the initial 
physical for six full months. That's six months of waiting before he 
could even have his initial consultation with a mental health care 
provider. And this is after two years of not even seeing a doctor.
    These situations were able to be resolved by our veterans 
caseworker in the district, but the point is that veterans should not 
have yet another hoop to jump through - access to health care should be 
easy to schedule.
    I also understand that VHA is operating with a reportedly outdated 
system that is cumbersome and slow. GAO reported numerous workarounds 
that some facilities are using, which may adversely affect timely 
health care delivery to veterans.
    Delayed care is denied care. This is all too evident with the rash 
of recent consult backlogs experienced at some of VHA's medical 
centers.
    It has been reported that thousands of consults in 2011 and 2012 
were backlogged at various facilities which may have resulted in 
adverse events due to the delays in diagnosis and treatment.
    This of course is unacceptable. Veterans deserve timely, 
accessible, health care.
    What I would like to hear about today is a sound plan that will 
assist VHA in transforming into a 21st Century organization and will 
eliminate, as much as possible, the needless waits, unclear policies 
and procedures, and frustrating technology that only serves to slow 
down progress.

                                 
               Prepared Statement of Hon. Jackie Walorski

    Mr. Chairman, it's an honor to be here today.
    I thank you for holding this hearing on an issue that is very 
important to current and future veteran care.
    Indiana's Second Congressional District is home to over 50,000 
veterans. \1\
---------------------------------------------------------------------------
    \1\ There are an estimated 53,318 veterans in IN-02. This data was 
compiled on 09/30/2012, based on the district lines from the 112th 
Congress. http://www.va.gov/vetdata/Veteran--Population.asp
---------------------------------------------------------------------------
    These men and women have served their country and endured the 
struggles and triumphs that come with wearing the uniform. I am proud 
of these Hoosiers and indebted to them for their sacrifices.
    When the Hoosier veterans were called for duty, they promptly 
responded. It is saddening and disgraceful that our Veterans 
Administration fails to respond to the needs of these veterans with the 
same timeliness. Veteran calls for help should not go unanswered.
    I appreciate the time the panelists have taken today. I know my 
colleagues share the same commitment, as I do, to ensuring the veterans 
of this great Nation receive the care they have rightfully earned.
    Thank you.

                                 
                 Prepared Statement of Hon. Jeff Duncan

    It was once said that ``the legacy of heroes is the memory of a 
great name and the inheritance of a great example.'' In our country, 
some of our greatest heroes are our veterans; individuals who answered 
our Nation's call to protect and defend our freedom. Our veterans are 
one of our Nation's greatest treasures and as such our country has 
given them a firm promise:
    Because of their willingness to protect us through their service, 
when their service ends we promise to look after them. Unfortunately, 
when I talk to veterans today, they don't believe that our government 
is living up to our promises. When we made the commitment to take care 
of troops when they return home we never said anything about making 
them jump through hoops or navigate a complicated a bureaucracy. We 
promised our veterans the moon but instead we have failed in many 
instances to provide our veterans with the most basic of care.
     When I heard this Committee was holding this hearing, my staff 
reached out to our veterans in our district to hear their perspective. 
The VA testifies here today that its ``wait time goal'' is 14 days. 
Well, I spoke to my constituents. As of Monday, March 4, 2013, the 
Columbia VA Regional Office has 22,565 claims pending. The current wait 
time is an average of 282.6 days. Survivor benefits for veteran's 
spouses can between 10 and 18 months to be dispersed, and sometimes 
even longer depending on the health status of the beneficiary.
    My staff spoke with the Oconee County Veterans Affairs office last 
week, and they tell me that up until a few weeks ago, the local 
Veterans Affairs office hadn't been able reach the Columbia Regional 
Office by telephone since early November. In fact, the staff of this 
particular Veterans Affairs office told us that they often have to take 
files home with them, so they can call down to Columbia at 10 or 11 
o'clock at night just so they can leave a message, which they aren't 
even able to get through to do during the day!
    Last year, my office assisted a constituent who contacted us 
because he has had 12 claims pending before the Veteran's 
Administration which dated all the way back to 2004.
    Tommy Wilbanks, a Vietnam and Gulf War Veteran from Oconee County, 
currently has five cases pending before the VA dating back to June of 
2010. He told us that veterans constantly feel like they're getting the 
run around from the VA.
    Another constituent who we've worked with had her claims delayed 
over 18 months because she has been told by the Veteran's 
Administration that they didn't have her medical records, this is 
despite the fact she sent the VA her medical records twice by certified 
mail.
    When we connect these disabilities claims backlogs to the wait 
times for appointments that veterans are currently experiencing in my 
district, the lack of doctors and inefficiency in the system, we see a 
large systemic problem that the VA has failed to address. This is 
utterly unacceptable.
    I've heard frequently from a younger veteran, a marine, who served 
two tours in Iraq. He's concerned about the cleanliness of the 
facilities in Columbia, and angered at what he's described as 
disrespect shown by some of the staff directed towards veterans. He's 
also deeply troubled by the wait times of support hotlines for veterans 
with PDST.
     The VA has failed our veterans in these ways, and you must do 
better. You say the problem is resolved. Veterans in my district 
disagree. You say that you've fixed it. I want to know how. We know 
that in other facilities you have administratively closed cases, and 
veterans have died. What are you going to do to fix these problems?

                                 
              Prepared Statement of William C. Schoenhard

    Good afternoon, Chairman Coffman, Ranking Member Kirkpatrick, and 
Members of the Subcommittee. Thank you for the opportunity to discuss 
an important topic that impacts every Veteran's experience with 
Department of Veterans Affairs (VA) health care services - the 
reliability and timeliness of outpatient medical appointments. I am 
accompanied today by Thomas Lynch, M.D., Assistant Deputy Under 
Secretary for Health for Clinical Operations; Philip Matkovsky, 
Assistant Deputy Under Secretary for Health for Administrative 
Operations; and, Michael Davies, M.D., National Director of Systems 
Redesign
    The Veterans Health Administration's (VHA) mission is to honor 
America's Veterans by providing exceptional healthcare that improves 
their health and well-being. Providing timely access to that care is a 
critical aspect of our mission. Access enables VHA to provide 
personalized, proactive, patient-driven health care; achieve measurable 
improvements in health outcomes; and, align resources to deliver 
sustained value to Veterans. VHA is continually assessing wait times 
and making adjustments as needed to ensure that Veterans have access to 
the best care anywhere.

VHA Wait Time Determination: Early Efforts
    VHA has been transforming its health care delivery system for two 
decades, moving from a hospital-based system to an ambulatory care 
model. The ability of Veterans to access health care at the right time 
and in the right place is at the heart of keeping our promise to 
America's Veterans. For this reason, VA's effort to manage timely 
access is critically important.
    We know timeliness of appointments has improved since we began 
tracking it, but determining a reliable and valid way to measure 
timeliness has been difficult. In the 1990s, VHA started measuring wait 
times using capacity measures, such as next available appointment date 
that are widely used in the health care industry today. VHA found that 
capacity measures proved inadequate to portray each individual 
patient's experience because they showed clinic availability rather 
than what occurred for the individual patient. In the absence of an 
effective industry standard, VHA has had to develop, test, and refine 
new methods for measuring wait time that align with our goal to provide 
patient-centered care. Much of this work has been iterative and is 
reflected by the numerous wait time measures VHA has developed over the 
past ten years.
    In retrospect, we now know that some of our reporting on wait times 
was not as reliable as our Veteran patient and stakeholders deserve. 
For instance, while the information VHA submitted for the President's 
annual Performance and Accountability Reports did provide the current 
level of performance against the existing measures, these measures did 
not accurately capture the experience of Veterans. Measuring outpatient 
medical appointment wait times was uncharted territory and we relied on 
the best information and experience available at the time.
    In 1999, Veterans waited an average of 60-90 days for a primary 
care appointment. In 2011, VHA established a wait time goal of 14 days, 
rather than 30 days, for both primary and specialty care appointments. 
VHA challenged itself to provide more timely care to increase patient 
satisfaction since most patients were being seen within the earlier 
established 30 day goal. Currently, approximately 40% of new patients 
and 90% of established patients meet this 14 day goal.
    Over the past few years, the U.S. Government Accountability Office 
(GAO) and VA's Office of Inspector General (OIG) have assessed VHA's 
outpatient medical appointment wait times. OIG made multiple 
recommendations to improve scheduler accuracy and ``establish 
procedures to test the accuracy of reported wait times.'' VHA 
acknowledges the shortcomings in our past approaches and appreciates 
these findings and recommendations. Through these analyses, we are 
better able to understand the gaps in our processes and incorporate 
best practices into future policy and operations.

VHA's Wait Times Study
    In 2009, VA commissioned a retrospective study partly in response 
to concerns raised by GAO and OIG to assess the association between 
multiple measures of timeliness and patient satisfaction. Using data 
from 2005 - 2010, researchers obtained and analyzed information from 
nearly 400 million VHA appointments and over 220,000 patient 
satisfaction surveys. VHA received the study's results in 2012.
    The study showed that new and established patients have different 
needs and require different approaches for capturing wait times. Also, 
the data identified that the Create Date, the date that an appointment 
is made is the optimal method for new patients, since most new patients 
want their visit or clinical evaluation to occur as close to the time 
they make the appointment as possible. For established patients, VHA 
has determined that using the Desired Date is the most reliable and 
patient-centered approach. Desired Date is the ideal time a patient or 
provider wants the patient to be seen. Although not perfect, this 
measure provides the best association with patient satisfaction for 
established patients. VHA's Wait Time Study, consistent with the 
literature in this area, shows that shorter wait times are associated 
with better clinical care and positive health outcomes. Armed with 
evidence that the Create Date and the Desired Date best predict patient 
satisfaction and health outcomes for new and established patients 
respectively, VHA adopted these methods on October 1, 2012.
    In December 2012, GAO issued its report urging VA to improve 
oversight of the reliability of reported outpatient medical appointment 
wait times and scheduling for outpatient appointments. VA concurred 
with GAO's findings and their four recommendations that are important 
to improving VHA's wait time measures. We will discuss in more detail 
VHA's action plan to address GAO's recommendations below.

The Way Forward
    With the recent evidence from our wait time study, ongoing VHA 
performance measures, as well as findings and recommendation from 
oversight entities, VHA believes it now has reliable and valid wait 
time measures that allow VHA to accurately measure how long a patient 
waits for an outpatient appointment. VHA's action plan is aimed at 
ensuring the integrity of wait time measurement data so that VHA has 
the most reliable information to ensure Veterans have timely access to 
care and high satisfaction.
    VHA is focused on implementing new wait time measurement practices, 
policies, and technologies along with aggressive monitoring of 
reliability through oversight and audits. VHA is working to implement 
the action plan and expects to have the majority of the efforts in 
place in the next 12 months. Following is a discussion of VHA's efforts 
to implement reliable measures so that we can ensure that Veterans 
receive the care they need when they need it.
    In response to the first GAO recommendation, identifying weaknesses 
in scheduler procedures for accurately and reliably establishing the 
patient's desired appointment date, VHA is both establishing more 
accurate wait time measures and revising its scheduling policy. The old 
scheduling policy relied on the scheduler to ascertain and correctly 
record the Desired Date for established patients. The new policy 
requires the provider to record the patient-provider decision on the 
projected next appointment date. This `Agreed-Upon-Date' (AUD) process 
provides clear documentation and will improve the reliability of the 
recorded desired appointment date. AUD also includes the patient 
actively in the decision-making process and more accurately portrays 
the patient expectation. VHA piloted these new procedures and found 
them to be feasible to implement.
    In order to improve the accuracy of wait time measures, VHA is 
using methodology that relies on recorded time stamps. For new 
patients, VHA will report the length of time that elapses between 
appointment creation and completion. For established patients, VHA will 
report the time between the AUD and the scheduled appointment. The VA's 
wait time study that began in 2009 demonstrated that of all possible 
measure combinations, these particular methods best reflect patient 
satisfaction.
    Regarding GAO's second recommendation to improve scheduling policy 
and procedures for the use of the Electronic Wait List (EWL), VHA is 
updating policy and training. Also, VHA is ensuring all staff with 
access to the Veterans Health Information Systems and Technology 
Architecture (VistA) appointment scheduling system completes required 
training. The EWL is used to keep track of patients waiting to be 
scheduled with a provider in Primary Care, Specialty Care, or Mental 
Health. When the new process goes into effect within the next year, 
only new patients will be placed on an EWL if they cannot be scheduled 
within 90 days. In the past, VHA did not specify the 90-day standard. 
Patients on the EWL will continue to have their wait times tracked from 
the time they are entered on the list. Standardizing all clinics to 
this procedure will allow managers to better understand clinic 
operations and resource needs.
    VHA has updated its training program for the more than 50,000 staff 
that uses the VistA scheduling system. Schedulers are trained on how to 
properly record the AUD in VistA. VHA acknowledges that the VistA 
scheduling system is outdated and inefficient. Schedulers must open and 
close multiple screens to check a providers' availability. It can take 
a scheduler between 30 seconds and five minutes and many keystrokes to 
make an appointment in VistA, compared to a point and click process in 
modern scheduling programs. This cumbersome process leads to user 
error. To optimize scheduler efficiency, VHA requires training of 
schedulers making appointments. VA medical centers are able to track 
schedulers' compliance with training requirements.
    While training ensures that staff know the proper scheduling 
procedures, VHA also requires audits to ensure compliance with these 
procedures. The implementation of new AUD procedures enables more 
comprehensive auditing capabilities. In the future, supervisors will 
have the capability to electronically audit proper entry of the AUD by 
the scheduler. For a typical Patient Aligned Care Team (PACT) practice, 
this could range from 1,000 to 2,000 appointments per year for every 
provider. Supervisors will not need to pull and review charts, but 
rather more efficiently retrieve reports from central databases. This 
process will audit appointment requests generated internally from 
health care providers, where the majority of appointments are made. 
These procedures do not apply to patients who call-in or walk-in from 
``outside'' the practice. VHA will continue to require manual audits of 
these cases.
    Complying with GAO's third recommendation, to ensure adequate 
scheduling staff is present in VHA facilities, VHA is working to ensure 
that each medical center has adequate scheduling staff. Schedulers are 
entry-level positions with high turnover rates and may have multiple 
responsibilities. VHA has launched efforts to study and select the best 
way to track staff occupying these positions. In addition, VHA has made 
progress in developing analytical tools that will help schedulers and 
managers select the best methods to manage access based on individual 
clinic patterns of operation. For instance, clinics have differing 
amounts of no-shows, cancellations, and different utilization and 
revisit rates.
    GAO's fourth recommendation to VHA is to improve responsiveness to 
Veterans accessing services by phone. To improve telephone service for 
Veterans calling into health care facilities for appointments, VHA will 
require facilities to complete a standardized telephone assessment and 
implement improvements. VHA will monitor the progress quarterly and 
align resources as needed.
    In addition to actions taken to comply with GAO's recommendations, 
VHA continues to develop technology for improving the scheduling 
system. VHA has completed programming for version 1.0 of the Veteran 
Appointment Request Application that is currently being pilot tested. 
This ``App'' resides on a Veteran's handheld device or desktop computer 
and accepts up to three preferences for each appointment request. VHA 
databases will capture the Veteran-entered first choice as the Desired 
Date. VHA has also contracted for the development of a Scheduler 
Calendar View. This ``overlay'' to the VistA scheduling system is 
envisioned as a way to decrease user error that can occur during the 
scheduling process. The Scheduler Calendar View will be a more user-
friendly, point-and-click interface. VHA continues to pursue efforts to 
replace VistA scheduling with a commercial off-the-shelf product. The 
Department has issued a challenge on Challenge.gov for a medical 
patient scheduling solution.

Conclusion
    In conclusion, VHA is aggressively addressing access for patients 
in many ways. In 2011, VHA raised the bar for the industry by setting a 
wait time goal of 14 days for both primary and specialty care 
appointments. Last year, VHA added a goal of completing primary care 
appointments within 7 days of the Desired Date. The intent is to come 
as close as possible to providing just-in-time care for patients. The 
ultimate goal is same day access. VHA is making improvements in 
delivering timely care to our Veterans and in the reliability of 
reporting wait time information. We have identified the issues and are 
taking steps to address them. We recognize that there is more to do, 
and we will continue to make this a priority.
    VA is committed to honoring America's Veterans by providing them 
the health care they have earned and deserve. Thank you for the 
opportunity to speak to you about this issue. My colleagues and I are 
ready to respond to any questions you might have.

                                 
                 Prepared Statement of Debra A. Draper

    Chairman Coffman, Ranking Member Kirkpatrick, and Members of the 
Subcommittee:
    I am pleased to be here today to discuss improvements needed in the 
Department of Veterans Affairs' (VA) outpatient medical appointment 
scheduling oversight and wait time measurement. \1\ In fiscal year 
2011, the Veterans Health Administration (VHA), within VA, provided 
nearly 80 million medical appointments to veterans through its primary 
and specialty care clinics, which are managed by VA medical centers 
(VAMC). \2\ Although access to timely medical appointments is critical 
to ensuring that veterans obtain needed medical care, long wait times 
and inadequate scheduling processes at VAMCs have been persistent 
problems, as we and the VA Office of Inspector General have reported. 
\3\ Most recently, in December 2012, we reported that VHA's medical 
appointment wait times are unreliable and problems with VHA's oversight 
of outpatient medical appointment scheduling processes impede VHA's 
ability to schedule timely medical appointments. \4\
---------------------------------------------------------------------------
    \1\ Throughout this statement, we will use the term ``medical 
appointments'' to refer to outpatient medical appointments.
    \2\ Outpatient clinics offer services to patients that do not 
require a hospital stay. Primary care addresses patients' routine 
health needs, and specialty care is focused on a specific specialty 
service such as orthopedics, dermatology, or psychiatry.
    \3\ See 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). See also Department of Veterans 
Affairs, Office of Inspector General, Audit of the Veterans Health 
Administration's Outpatient Waiting Times, Report No. 07-00616-199, 
(Washington, D.C.: Sept. 10, 2007). Finally, see Department of Veterans 
Affairs, Office of Inspector General, Veterans Health Administration: 
Review of Veterans' Access to Mental Health Care, Report No. 12-00900-
168, (Washington, D.C.: Apr. 23, 2012).
    \4\ GAO, 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).
---------------------------------------------------------------------------
    VHA has a scheduling policy designed to help its VAMCs meet its 
commitment to scheduling medical appointments with no undue waits or 
delays. \5\ The policy establishes processes and procedures for 
scheduling medical appointments and ensuring the competency of staff 
directly or indirectly involved in the scheduling process. It includes 
several requirements that affect timely appointment scheduling, as well 
as accurate wait time measurement. \6\ For example, the policy requires 
schedulers to record appointments in VHA's Veterans Health Information 
Systems and Technology Architecture (VistA) medical appointment 
scheduling system; schedulers also are to record the date on which the 
patient or provider wants the patient to be seen--known as the desired 
date. \7\
---------------------------------------------------------------------------
    \5\ VHA medical appointment scheduling policy is documented in VHA 
Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures 
(June 9, 2010). We refer to the directive as ``VHA's scheduling 
policy'' from this point forward.
    \6\ VHA has a separate directive that establishes policy on the 
provision of telephone service related to clinical care, including 
facilitating telephone access for medical appointment management. VHA 
Directive 2007-033, Telephone Service for Clinical Care (Oct. 11, 
2007).
    \7\ VistA is the single integrated health information system used 
throughout VHA in all of its health care settings. There are many 
different VistA applications for clinical, administrative, and 
financial functions, including the scheduling system.
---------------------------------------------------------------------------
    At the time of our review, VHA measured medical appointment wait 
times as the number of days elapsed from the patient's or provider's 
desired date, as recorded in the VistA scheduling system by VAMCs' 
schedulers. According to VHA central office officials, VHA measures 
wait times based on desired date in order to capture the patient's 
experience waiting and to reflect the patient's or provider's wishes. 
In fiscal year 2012, VHA had a goal of completing primary care 
appointments within 7 days of the desired date, and scheduling 
specialty care appointments within 14 days of the desired date. \8\ VHA 
established these goals based on its performance reported in previous 
years. \9\ To help facilitate accountability for achieving its wait 
time goals, VHA includes wait time measures--referred to as performance 
measures--in its Veterans Integrated Service Network (VISN) directors' 
and VAMC directors' performance contracts \10\ and VA includes measures 
in its budget submissions and performance reports to Congress and 
stakeholders. \11\
---------------------------------------------------------------------------
    \8\ In 2012, VA also had several additional goals related to 
measuring access to mental health appointments specifically, such as 
screening eligible patients for depression, post-traumatic stress 
disorder, and alcohol misuse at required intervals; and documenting 
that all first-time patients referred for or requesting mental health 
services receive a full mental health evaluation within 14 days of 
their initial encounter. As noted earlier, in its Report No. 12-00900-
168, the VA OIG found that some of the mental health performance data 
were not reliable. VA is dropping several of these mental health 
measures in 2013.
    \9\ In 1995, VHA established a goal of scheduling primary and 
specialty care medical appointments within 30 days to ensure veterans' 
timely access to care. In fiscal year 2011, VHA shortened the wait time 
goal to 14 days for both primary and specialty care medical 
appointments. In fiscal year 2012, VHA added a goal of completing 
primary care medical appointments within 7 days of the desired date.
    \10\ Each of VA's 21 VISNs is responsible for managing and 
overseeing medical facilities within a defined geographic area. VISN 
and VAMC directors' performance contracts include measures against 
which directors are rated at the end of the fiscal year, which 
determine their performance pay.
    \11\ VA prepares a congressional budget justification that provides 
details supporting the policy and funding decisions in the President's 
budget request submitted to Congress prior to the beginning of each 
fiscal year. The budget justification articulates what VA plans to 
achieve with the resources requested; it includes performance measures 
by program area. VA also publishes an annual performance report--the 
performance and accountability report-- which contains performance 
targets and results achieved compared with those targets in the 
previous year.
---------------------------------------------------------------------------
    My statement today highlights key findings from our December 2012 
report that describes needed improvements in the reliability of VHA's 
reported medical appointment wait times, scheduling oversight, and VHA 
initiatives to improve access to timely medical appointments. \12\ For 
that report, we reviewed VHA's scheduling policy and methods for 
measuring medical appointment wait times and interviewed VHA central 
office officials responsible for developing them. \13\ We also visited 
23 high-volume outpatient clinics at four VAMCs selected for variation 
in size, complexity, and location; these four VAMCs were located in 
Dayton, Ohio; Fort Harrison, Montana; Los Angeles, California; and 
Washington, D.C. At each VAMC we interviewed leadership and other 
officials about how they manage and improve medical appointment 
timeliness, their oversight to ensure accuracy of scheduling data and 
compliance with scheduling policy, and problems staff experience in 
scheduling timely medical appointments. We examined each VAMC's and 
clinic's implementation of elements of VHA's scheduling policy and 
obtained documentation of scheduler training completion. In addition, 
we interviewed schedulers from 19 of the 23 clinics visited, and also 
reviewed patient complaints about telephone responsiveness, which is 
integral to timely medical appointment scheduling. We interviewed the 
directors and relevant staff of the four VISNs for the sites we 
visited. We also interviewed VHA central office officials and officials 
at the VAMCs we visited about selected initiatives to improve veterans' 
access to timely medical appointments. We performed this work from 
February 2012 through December 2012 in accordance with generally 
accepted government auditing standards.
---------------------------------------------------------------------------
    \12\ GAO-13-130.
    \13\ We did not include mental health appointments in the scope of 
our work, because this issue was already being reviewed by VA's Office 
of Inspector General.
---------------------------------------------------------------------------
    In brief, we found that (1) VHA's reported outpatient medical 
appointment wait times are unreliable, (2) there was inconsistent 
implementation of certain elements of VHA's scheduling policy that 
could result in increased wait times or delays in scheduling timely 
medical appointments, and
    (3) VHA is implementing or piloting a number of initiatives to 
improve veterans' access to medical appointments. Specifically, VHA's 
reported outpatient medical appointment wait times are unreliable 
because of problems with correctly recording the appointment desired 
date--the date on which the patient or provider would like the 
appointment to be scheduled--in the VistA scheduling system. Since, at 
the time of our review, VHA measured medical appointment wait times as 
the number of days elapsed from the desired date, the reliability of 
reported wait time performance is dependent on the consistency with 
which VAMC schedulers record the desired date in the VistA scheduling 
system. However, aspects of VHA's scheduling policy and related 
training documents on how to determine and record the desired date are 
unclear and do not ensure replicable and reliable recording of the 
desired date by the large number of staff across VHA who can schedule 
medical appointments, which at the time of our review was estimated to 
be more than 50,000. During our site visits, we found that at least one 
scheduler at each VAMC did not record the desired date correctly, 
which, in certain cases, would have resulted in a reported wait time 
that was shorter than the patient actually experienced for that 
appointment. Moreover, staff at some clinics told us they change 
medical appointment desired dates to show clinic wait times within 
VHA's performance goals. Although VHA officials acknowledged 
limitations of measuring wait times based on desired date, and told us 
that they use additional information, such as patient satisfaction 
survey results, to monitor veterans' access to medical appointments, 
reliable measurement of how long veterans wait for appointments is 
essential for identifying and mitigating problems that contribute to 
wait times.
    At the VAMCs we visited, we also found inconsistent implementation 
of certain elements of VHA's scheduling policy, which can result in 
increased wait times or delays in scheduling timely medical 
appointments. For example, four clinics across three VAMCs did not use 
the electronic wait list to track new patients that needed medical 
appointments as required by VHA's scheduling policy, putting these 
clinics at risk for losing track of these patients. Furthermore, VAMCs' 
oversight of compliance with VHA's scheduling policy was inconsistent 
across the facilities we visited. Specifically, certain VAMCs did not 
ensure the completion of scheduler training by all staff required to 
complete it even though officials stressed the importance of the 
training for ensuring correct implementation of VHA's scheduling 
policy. VAMCs also described other problems that impede the timely 
scheduling of medical appointments, including VA's outdated and 
inefficient VistA scheduling system, gaps in scheduler staffing, and 
issues with telephone access. The current VistA scheduling system is 
more than 25 years old, and VAMC officials reported that using the 
system is cumbersome and can lead to errors. \14\ In addition, 
shortages or turnover of scheduling staff, identified as a problem by 
all of the VAMCs we visited, can result in appointment scheduling 
delays and incorrect scheduling practices. Officials at all VAMCs we 
visited also reported that high call volumes and a lack of staff 
dedicated to answering the telephones impede the scheduling of timely 
medical appointments.
---------------------------------------------------------------------------
    \14\ In October 2012, VA announced a contest seeking proposals for 
a new medical appointment scheduling system from commercial software 
developers.
---------------------------------------------------------------------------
    VHA is implementing or piloting a number of initiatives to improve 
veterans' access to medical appointments that focus on more patient-
centered care; using technology to provide care, through means such as 
telehealth and secure messaging between patients and their health care 
providers; and using care outside of VHA to reduce travel and wait 
times for veterans who are unable to receive certain types of 
outpatient care in a timely way through local VHA facilities. For 
example, VHA is piloting a new initiative to provide health care 
services through contracts with community providers that aims to reduce 
travel and wait times for veterans who are unable to receive certain 
types of care from VHA in a timely way. Although VHA collects 
information on wait times for medical appointments provided through 
this initiative, these wait times may not accurately reflect how long 
patients are waiting for appointments because they are counted from the 
time the contracted provider receives an authorization from VA, rather 
than from the time the patient or provider first requests an 
appointment from VHA.
    In conclusion, VHA officials have expressed an ongoing commitment 
to providing veterans with timely access to medical appointments and 
have reported continued improvements in achieving this goal. However, 
unreliable wait time measurement has resulted in a discrepancy between 
the positive wait time performance VA has reported and veterans' actual 
experiences. More consistent adherence to VHA's scheduling policy and 
oversight of the scheduling process, allocation of staff resources to 
match clinics' scheduling demands, and resolution of problems with 
telephone access would potentially reduce medical appointment wait 
times. VHA's ability to ensure and accurately monitor access to timely 
medical appointments is critical to ensuring quality health care to 
veterans, who may have medical conditions that worsen if access is 
delayed.
    To ensure reliable measurement of how long veterans are waiting for 
appointments and improve timely medical appointment scheduling, we 
recommended that the Secretary of VA direct the Under Secretary for 
Health to take actions to (1) improve the reliability of its medical 
appointment wait time measures, (2) ensure VAMCs consistently implement 
VHA's scheduling policy, (3) require VAMCs to routinely assess 
scheduling needs for purposes of allocation of staffing resources, and 
(4) ensure that VAMCs provide oversight of telephone access and 
implement best practices to improve telephone access for clinical care. 
VA concurred with our recommendations and identified actions planned or 
underway to address them.
    Chairman Coffman, Ranking Member Kirkpatrick, and Members of the 
Subcommittee, this concludes my prepared remarks. I would be pleased to 
respond to any questions you or other members of the subcommittee may 
have at this time.
    For questions about this statement, please contact Debra A. Draper 
at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this statement. Individuals making key contributions to this 
testimony include Bonnie Anderson, Assistant Director; Rebecca Abela; 
Jennie F. Apter; Lisa Motley; Sara Rudow; and Ann Tynan.

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Highlights

VA HEALTH CARE
Appointment Scheduling Oversight and Wait Time Measures Need 
        Improvement
Why GAO Did This Study
    VHA provided nearly 80 million outpatient medical appointments to 
veterans in fiscal year 2011. Although access to timely medical 
appointments is important to ensuring veterans obtain needed care, long 
wait times and inadequate scheduling processes have been persistent 
problems.
    This testimony is based on a December 2012 report, VA Health Care: 
Reliability of Reported Outpatient Medical Appointment Wait Times and 
Scheduling Oversight Need Improvement (GAO-13-130), that described 
needed improvements in the reliability of VHA's reported medical 
appointment wait times, scheduling oversight and VHA initiatives to 
improve access to timely medical appointments. To conduct that work, 
GAO made site visits to 23 clinics at four VAMCs, the latter selected 
for variation in size, complexity, and location. GAO also reviewed 
VHA's policies and interviewed VHA officials.

What GAO Recommends
    In its December 2012 report, GAO recommended that VHA take actions 
to (1) improve the reliability of its medical appointment wait time 
measures, (2) ensure VAMCs consistently implement VHA's scheduling 
policy, (3) require VAMCs to allocate staffing resources based on 
scheduling needs, and (4) ensure that VAMCs provide oversight of 
telephone access and implement best practices to improve telephone 
access for clinical care. VA concurred with GAO's recommendations.

What GAO Found
    Outpatient medical appointment wait times reported by the Veterans 
Health Administration (VHA), within the Department of Veterans Affairs 
(VA), are unreliable. Wait times for outpatient medical appointments--
referred to as medical appointments--are calculated as the number of 
days elapsed from the desired date, which is defined as the date on 
which the patient or health care provider wants the patient to be seen. 
The reliability of reported wait time performance measures is dependent 
on the consistency with which schedulers record the desired date in the 
scheduling system. However, aspects of VHA's scheduling policy and 
training documents for recording desired date are unclear and do not 
ensure consistent use of the desired date. Some schedulers at VA 
medical centers (VAMC) that GAO visited did not record the desired date 
correctly, which, in certain cases, would have resulted in a reported 
wait time that was shorter than the patient actually experienced for 
that appointment. VHA officials acknowledged limitations of measuring 
wait times based on desired date, and described additional information 
used to monitor veterans' access to medical appointments; however, 
reliable measurement of how long patients are waiting for medical 
appointments is essential for identifying and mitigating problems that 
contribute to wait times.
    While visiting VAMCs, GAO also found inconsistent implementation of 
certain elements of VHA's scheduling policy that impedes VAMCs from 
scheduling timely medical appointments. For example, four clinics 
across three VAMCs did not use the electronic wait list to track new 
patients that needed medical appointments as required by VHA scheduling 
policy, putting these clinics at risk for losing track of these 
patients. Furthermore, VAMCs' oversight of compliance with VHA's 
scheduling policy, such as ensuring the completion of required 
scheduler training, was inconsistent across facilities. VAMCs also 
described other problems with scheduling timely medical appointments, 
including VHA's outdated and inefficient scheduling system, gaps in 
scheduler staffing, and issues with telephone access. For example, 
officials at all VAMCs GAO visited reported that high call volumes and 
a lack of staff dedicated to answering the telephones impede scheduling 
of timely medical appointments.
    VHA is implementing a number of initiatives to improve veterans' 
access to medical appointments such as use of technology to interact 
with patients and provide care, which includes the use of secure 
messaging between patients and their health care providers. VHA also is 
piloting a new initiative to provide health care services through 
contracts with community providers that aims to reduce travel and wait 
times for veterans who are unable to receive certain types of care 
within VHA in a timely way.

                                 
                  Prepared Statement of Roscoe Butler

    A veteran in crisis, suffering from mental health problems, became 
so furious with the telephone delays he faced while trying to make a 
mental health appointment at the VA, assaulted his wife and dog after 
being repeatedly placed on hold. Veterans are struggling to access 
their healthcare across the country, and in Richmond, Virginia 
appointments for mental health (PTSD) issues are at least a six to 
eight month wait. Further, when calling for assistance, veterans are 
placed on hold before being asked whether the call is regarding an 
emergency, or whether the veteran is currently a danger to them self or 
to someone else.
    Chairman Miller, Ranking Member Michaud and distinguished Members 
of the Committee: On behalf of National Commander James Koutz and the 
2.4 million veterans of The American Legion, thank you for the 
opportunity to address this critical issue affecting veterans across 
the nation.
    In VISN 21, a veteran has informed us that it takes approximately 
twelve weeks to obtain primary care appointments at the VAMC. 
Addressing wait times within VA is nothing new to The American Legion. 
Our System Worth Saving Task Force, the renowned third party oversight 
of VA medical facilities, was created, in part, as a response to 
growing wait times at VA facilities. When Past National Commander 
Ronald F. Conley of Pennsylvania became National Commander in 2002, he 
helped create two initiatives: First was the year-long ``I Am Not A 
Number'' campaign which sought to put faces on the veterans waiting 
months and years for appointments and service from VA, and second was 
the annual System Worth Saving report - designed to address the fact 
that, as Commander Conley noted,

    ``Among veterans, I heard profound gratitude voiced for the quality 
of care they receive. But from nearly everyone, I also found acute 
frustration over the lack of timely access to VA health care.''

    That year the System Worth Saving Report found that over 300,000 
veterans were waiting for health care appointments. Of those, over half 
were waiting more than eight months for primary care appointments. At 
Bay Pines, Florida the VA Medical Center had a list of 14,000 veterans 
waiting longer than six months for an appointment, and 14,000 was a 
celebrated improvement!
    It's been more than 10 years, and The American Legion continues to 
make System Worth Saving Task Force visits to dozens of medical 
facilities across the country every year. We have determined that many 
of these scheduling problems remain, and veterans are still being 
delayed and denied access to otherwise excellent care. VA needs to 
begin implementing real solutions to its problems and these solutions 
need to start with an improved appointment scheduling system.
    Unfortunately, the only metric we have to track whether veterans 
are being seen on time relies on self-reporting from VA, and according 
to the Government Accounting Office (GAO), VA is a poor barometer of 
whether or not they are meeting appointment time guidelines. GAO 
specifically noted problems with VA schedulers repeated erroneous 
recording the ``desired date'' for appointments, and explained `` . . . 
schedulers changed the desired date based on appointment availability; 
this would have resulted in a reported wait time that was shorter than 
the patient actually experienced.'' \1\ Because the figures are being 
manipulated by employees to look better, statistics such as VA's 
reported 94 percent of primary care appointments within the proper 
period, mean very little.
---------------------------------------------------------------------------
    \1\ GAO-13-130, Reliability of Reported Outpatient Medical 
Appointment Wait Times and Scheduling Oversight Need Improvement, 
December 2012
---------------------------------------------------------------------------
    The real measure, of whether VA is meeting the needs of veterans is 
how long the ACTUAL veterans have been waiting for appointments. For 
example, a veteran in VISN 18 told the Legion that they were waiting 
more than 8 months for a primary care appointment, and when he finally 
went in for the appointment, he was not seen, but rescheduled to return 
a month later. A three quarter of a year wait for a primary care 
appointment is not meeting the needs of veterans.
    As we are now a decade into the 21st Century, The American Legion 
believes that VA should also begin implementing 21st Century solutions 
to its problems. In 1998, GAO released a report that highlighted the 
excessive wait times experienced by veterans trying to schedule 
appointments, and recommended that VA replace its VistA scheduling 
system. \2\ To address the scheduling problem, the Veteran's Health 
Administration (VHA) solicited internal proposals from within VA to 
study and replace the VistA Scheduling System, with a Commercial Off-
the-Shelf (COTS) software program. VA selected a system, and about 14 
months into the project they significantly changed the scope of the 
project from a COTS solution to an in-house build of a scheduling 
application. After that, VHA ended up determining that it would not be 
able to implement any of the planned system's capabilities, and after 
spending an estimated $127 million over 9 years, The American Legion 
learned that VHA ended the entire Scheduling Replacement Project in 
September 2009. \3\ We believe that this haphazard approach of fits and 
starts is crippling any hope of progress.
---------------------------------------------------------------------------
    \2\ U.S. Medicine Magazine, VA Leadership Lacks Confidence in New 
$145M Patient Scheduling System, May 2009
    \3\ GAO-10-579, Management Improvements Are Essential to VA's 
Second Effort to Replace Its Outpatient Scheduling System, May, 2010
---------------------------------------------------------------------------
    It has now been over three years since VHA cancelled the 
Replacement Scheduling Application project, and as of today, The 
American Legion understands that there is still no workable solution to 
fixing VA's outdated and inefficient scheduling system. In 2012 The 
American Legion passed Resolution number 42 that asked the VA to 
implement a system ``To allow VA patients to be able to make 
appointments online by choosing the day, time and provider and that VA 
sends a confirmation within 24 hours''. Last December, VA published an 
opportunity for companies to provide adjustments to the VistA system 
through the federal Register - all submissions are due by June 2013. 
While this is laudable attempt to address the problem, it hardly seems 
sufficiently proactive given that the problem has been identified for 
over fifteen years, and the persistence of excessive wait times still 
experienced by many veterans across the nation.
    The American Legion recognizes that over the past decade, VA has 
taken some steps aimed at to improving its scheduling and access to 
care, we believe that there is still much to be done. In order to 
adequately address the problems of veterans, The American Legion 
believes VA should adopt the following steps towards a solution:

    1. Devote full effort towards filling all empty staff positions. 
The problems with mental health scheduling clearly indicate how a lack 
of available medical personnel can be a large contributing factor to 
long wait times for treatment. Despite VA's efforts to hire 1,600 new 
staff, as recently as last month VA was noting only two thirds of those 
positions had been filled. This does not even address the previous 
1,500 vacancies, and stakeholder veterans' groups are left to wonder if 
VA is adequately staffed to meet the needs of veterans.

    We believe they are not.

    If VA needs more resources to address these staffing needs, The 
American Legion hopes they will be forthright and open about their 
need, and ask for the resources they need to get the job done. The 
Veteran Service Organizations and Congress have been extremely 
responsive to get VA the resources they need to fulfill their mission, 
but VA must be transparent about what their real needs are.

    2. Develop a better plan to address appointments outside 
traditional business hours. With the growing numbers of women veterans 
who need to balance family obligations and other commitments hamper our 
veterans' abilities to meet appointments during regular business hours. 
The American Legion believes VA can better address the community's 
needs with more evening and weekend appointment times. American 
Resolution number 40 calls on the VA to provide more extended hour 
options, and believes VA should recruit and hire adequate staff to 
handle the additional weekend and extended hour appointments for both 
primary and specialty care.

    3. Improve the IT solution. Last year The American Legion also 
passed resolution number 44 , that called on the VA to create a records 
system that both VBA and VHA could share to better facilitate 
information exchange. A common system could even synchronize care 
visits in conjunction with compensation and pension examinations. We 
had hoped such a system might be included in the improvements brought 
by the Virtual Lifetime Electronic Record, however VA and DOD appear to 
be content to pursue individual legacy systems for that project, so 
veterans must continue to contend with VBA and VHA systems that do not 
communicate as well as they should. In any case, as VA looks outward 
for a solution to their scheduling program, all can agree that the 
current system is not serving the needs of veterans and needs to be 
updated.

    Tragically, the end result is that although VA has a truly first 
rate standard of care, veterans aren't able to access it with anywhere 
near the ease with which they should. Even the best care in the world 
is of little service to veterans if they cannot easily schedule timely 
appointments. If these problems with scheduling and appointments can be 
remedied, and veterans can access the care VA is delivering through the 
system, there would be little to complain about.
    The American Legion thanks the committee for their diligence to 
pursue these failings of oversight, and while these are solvable 
problems, the solutions will require the participation and input from 
all community stakeholders. The outstanding care veterans receive in VA 
is, and should be, a point of national pride. Let's not tarnish the 
good work the VA accomplishes because we insist on wrestling with 
legacy IT systems.
    For additional information regarding this testimony, please contact 
Mr. Shaun Rieley at The American Legion's Legislative Division, (202) 
861-2700 or srieley@legion.org.
List of attachments;
    Attachment A Statements from veterans as reported to us through our 
Department Service Officers

    Attachment B The American Legion Resolution #40

    Attachment C The American Legion Resolution #42

    Attachment D The American Legion Resolution #44

Attachment A:
    Statements from veterans as reported to us through our Department 
Service Officers

VISN 1
    Generally the access to healthcare in the VISN is excellent when 
everything goes right, weather and vacations hamper the process though 
and there are a few issues. Scheduling continues to be tricky for 
certain specialties and the clinics are cancelling appointments if the 
veteran is not checked in prior to the assigned time. In the winter 
months that is tricky . Vets ( including myself) were listed as missing 
an appointment on the day of the big snow storm earlier in the month. 
My rheumatology clinic was rescheduled four months from now. VHA has 
expanded the capacity at one of the CBOC's as it has moved to a larger 
facility and they have in turn brought on additional providers. This 
eases the strain at the VAMC's, although I cannot say without checking 
the numbers if they are seeing more veterans then last year at this 
time, or if the load has been spread out across more providers. Mental 
Health Care at the CBOC's is getting good reviews , both on access and 
availability to Psychologists and Psychiatrists. In VHA the problem 
appears to be, as was mentioned at the Washington Conference in DC, 
that only about half of the enrolled vets are using the services. I 
cannot say what the functionality would be if 80-90% of enrollees began 
to actively seek health care, or if a higher percentage of eligible 
veterans enrolled.

VISN 6
    Appointments for Mental Health, i.e Ptsd. Veterans are having to 
wait at least 6-8 months to be seen. When calling this clinic for 
assistance, you are immediately placed on hold, before being asked ``Is 
this an Emergency'' Are you in any danger to yourself, or someone else. 
One Veteran, after he was placed on hold, became so furious, he beat 
his dog and wife, then they both went to the emergency room outside the 
VA.
     Another concern is Veterans being sent for QTC exams, and because 
the doctors are not clear as to the test VA wants, they are given 
options to decline the tests.
     Female Veterans are not seeing, nor getting the treatment, or time 
spent as males are. Story- Two married veterans with Diabetes. Her 
husband (takes pills only), VA doctor took 20 minutes with him, 
observed his feet, spoke to him about nutrition, shoes, socks 
medication and so on. Her doctor, crossed his legs, asked what can he 
do for her, took 10 minutes, made one or two notes, and said I refilled 
your medicines and I will see you in six months. This veteran is 
Insulin dependent, takes Medformin (pill), had recently stepped on a 
thumb tack, and her feet and ankles were swollen. She asked him to 
check her feet, doctor asked why, what's going on and reminded her that 
other patients are time slotted, she may have to reschedule. Last - VHA 
-Interns are telling the veteran, they are not experienced enough to 
write nexus letter to support claim, diagnoses or justify conditions. 
They are telling the veteran, it's in their records, tell who ever is 
processing your claim to read it.

VISN 8, 10, 18
    I've been enrolled in three different VISN's and health care 
facilities in the last twenty some odd years. The first was at the VA 
OPC, in VISN 8. The care there was second to none and I could get 
appointments within two to three weeks. My second experience was with A 
medical center in VISN 10. Although overcrowded, I received excellent 
care and appointments within two to three weeks. I am now residing in 
VISN 18. It took me eight months to get my initial appointment, when I 
arrived, they had given me the wrong time and cancelled the 
appointment. It took another four or five weeks to reschedule their 
error. My appointment was in early January. They were supposed to set 
up upper-GI and audiology appointments. Also, I asked for more pain 
medications (non-narcotic) for my service connected back. I am still 
waiting for the appointments and the meds. I do not intend to go back 
to this medical center. It appears to be poorly managed. I should not 
have had to wait 8 months for my first appointment, and they should 
have made arrangements to see me that day when I reported late for the 
appointment, as it was their error which caused me to be late. I lost 
one hour of sick leave because of their error.

VISN 10
    Treatment - The mental health department seems to have a cookie 
cutter method for treating all veterans. As a result veterans have 
stopped seeking Mental Health treatment. This makes veterans not want 
to seek help.
    VHA Phone - When you do get through on the phones, you are 
transferred to the wrong department or told you will be called back, 
and never get a call back.

VISN 17
    We do not receive too many complaints and about my facility in VISN 
17, but a few more complaints about another VAMC in VISN 17 with regard 
to scheduling appointments. Some of the veterans indicate that it is a 
bit difficult to schedule an appointment, especially with the 
outpatient clinics. Most of the complaints seem to center around being 
timely notified of the date and time of the appointments. Additionally, 
there have been complaints about the length of time it would take to 
get into a specialty clinic, especially PTSD at the clinics. Of course, 
the majority of the complaints about the VA healthcare facilities come 
from those individuals using the medical center.

VISN 18
    Here in VISN 18 we have a great VA hospital. However, medical 
personnel is an issue. We have a great women's clinic but because of 
staff shortages it takes sometime for our women veterans to have an 
appointment. In addition, the east side CBOC is also experiencing staff 
issues. One primary care physician at a medical center in VISN 18 has 
not been replaced and since his departure last summer, his patients 
have a difficulty being seen.

VISN 19 & 22
    Another major issue is having to wait up to 12 weeks to get a 
primary care appointment. Fortunately, the individual can go to triage 
for emergent issues but we don't want triage to become primary care. 
Another issue would be obtaining a diagnosis of PTSD or mental health 
issue. It can take weeks for a WWII or a Viet Nam vet to get a 
diagnosis as the only priority care for PTSD issues is the OEF/OIF 
office. Now these WWII and Viet Nam and Korea vet who begin to 
experience issues at this later time in life after retirements etc, 
have to first get to primary care (12 weeks) and then obtain a referral 
to mental health which can take weeks to months due to loading.
    While I hear great things about the staff and care in VISN 19 AND 
22, the wait times and availability for appointments and issues are 
approximately 8-12 weeks out.
    We are not considered `rural' but `frontier', which means we are 
even more remote than rural. We have an approximate population of 50K 
and are 4 hours drive from the nearest VAMC. The local CBOC does not 
have a full time nor even part time doctor on site which means 4 hour 
trips one way. Emergency and urgent care and coordination there of for 
veterans seems to be an issue with the local hospital also.

VISN 23
    One of the biggest complaints I hear time and time again is when a 
veteran wants to call in (or the doc has asked them to contact them) 
and they call up the Clinic to leave message or etc and they cannot be 
connected to the doctor. Either they get a triage nurse or someone in 
another clinic and they are not sure the provider even got the message 
to start with. This is a huge problem. Many times the vets get seen in 
the ER or the doc says call me and let me know and they can't get that 
message back to them. This makes the vets feel like they have no 
connection to the doctor they just saw.
    My other issue is this: I am soooooo tired of getting a provider 
and 2 months later having to start from scratch with yet another 
provider. I hate hashing and rehashing my medical concerns time and 
time again or something that was so far in the past that it's no longer 
an issue but since we are starting from scratch we have to go back to 
it. That means the quick appointment I thought I was going to get to 
refill my meds now takes 2 hours and there is absolutely no reason for 
it.
    We hear a lot about the inability to provide certain medications 
for veterans as they are not authorized on the list. For example 
certain medications for Diabetes control.

Attachment B
   NATIONAL EXECUTIVE COMMITTEE OF THE AMERICAN LEGION INDIANAPOLIS, 
                                INDIANA
                         OCTOBER 17 - 18, 2012
    Resolution No. 40: Extended Hours & Weekends for Veterans' Health 
Care

    Origin: Veterans Affairs and Rehabilitation Commission

    Submitted by: Veterans Affairs and Rehabilitation Commission

    WHEREAS, The Department of Veteran Affairs' (VA) mission is to 
provide for those who have borne the battle; and
    WHEREAS, Veterans employed in the civilian workforce may require 
more flexible hours to meet their health care needs, because they have 
not accrued an adequate amount of personal leave to use for health care 
appointments; and
    WHEREAS, Eligible veterans should not be denied access to VA 
healthcare due to a lack of flexible health care appointments; and
    WHEREAS, Veterans with children also may require flexible hours to 
meet their health care needs; and
    WHEREAS, Extended hours such as early mornings, evenings and 
weekend appointments should be made available at all VA facilities to 
include primary and specialty care; and
    WHEREAS, Offering extended hours for veterans may reduce no-show 
rates by providing flexible appointments; and
    WHEREAS, Additional clinic hours are not possible due to chronic 
short staffing; and
    WHEREAS, Staffing limitations would affect patients from receiving 
health care on a timely basis; and
    WHEREAS, The VA's premium and overtime compensation should be 
competitive with the private sector for employees who contribute 
overtime and weekend work; and
    WHEREAS, The Veterans Health Administration developed Directive 
2012-023, Extended Hours Access For Veterans Requiring Primary Care 
Including Women's Health and Mental Health Services At Department Of 
Veterans Affairs Medical Centers And Selected Community Based 
Outpatient Clinics on September 5, 2012; and
    WHEREAS, The directive was rescinded on September 11, 2012 by VHA 
Notice 2012-13; now, therefore, be it
    RESOLVED, By the National Executive Committee of The American 
Legion in regular meeting assembled in Indianapolis, Indiana, on 
October 17-18, 2012, The Department of Veteran Affairs (VA) provide 
extended hours and weekend appointments for both primary and specialty 
care at all VA medical facilities in addition to their regular hours of 
operation; and, be it finally
    RESOLVED, That the VA recruits and hires additional staff to 
accommodate the rising need of weekend and extended hours for 
appointments in both primary and specialty care.

Attachment C

   NATIONAL EXECUTIVE COMMITTEE OF THE AMERICAN LEGION INDIANAPOLIS, 
                                INDIANA
                         OCTOBER 17 - 18, 2012
    Resolution No. 42: Virtual Lifetime Electronic Record

    Origin: Veterans Affairs and Rehabilitation Commission

    Submitted by: Veterans Affairs and Rehabilitation Commission

    WHEREAS, On April 9, 2009, President Obama provided direction to 
the Department of Defense (DoD) and Department of Veterans Affairs (VA) 
to develop a Virtual Lifetime Electronic Record (VLER), which would 
create a unified lifetime electronic record for members of the Armed 
Services; and
    WHEREAS, The VLER plans to include administrative and medical 
information for service members from when they first join the service 
throughout their lives until they are laid to rest; and
    WHEREAS, The VLER plan seeks to expand the departments' health 
information sharing capabilities by enabling access to private sector 
health data as well; and
    WHEREAS, VLER is a federal, inter-agency initiative to provide 
portability, accessibility and complete health, benefits and 
administrative data for servicemembers, veterans and their 
beneficiaries; and
    WHEREAS, DoD and VA for years have yet to fully implement a 
bilateral medical record between both agencies with no target end date 
in sight; and
    WHEREAS, Approximately 2.1 million members of the military have 
served in Operation Enduring Freedom, Operation Iraqi Freedom, and 
Operation New Dawn and are returning home in unprecedented numbers 
needing care for their injuries and illnesses sustained in service to 
our nation; and
    WHEREAS, Failure to implement a bilateral medical record and VLER 
to date has caused significant delays in the veterans' treatment 
process from DoD to VA because the VA treatment team does not have full 
access to the patient's DoD records and have to rely on a patient's 
self report of their medical history and symptoms; and
    WHEREAS, Servicemembers and veterans are forced to make copies of 
their records at their last duty station or submit a request to the 
National Personnel Records Center in St. Louis, which can take months 
to process; and
    WHEREAS, Veteran service organizations, such as The American 
Legion, have not been invited to VLER meeting to provide stakeholder 
input and sharing of mutual concerns; and
    WHEREAS, The American Legion has over 2,000 accredited department 
(state) and county veteran service officers that will continue to need 
access to Veteran Benefit Administration databases in order to file for 
VA benefits and claims for those claimants represented; and
    WHEREAS, The American Legion is concerned that within VA's three 
branches - Veterans Health Administration (VHA), Veterans Benefits 
Administration, and National Cemetery Administration - there are 
numerous computer-based programs that are inoperable between these 
branches which are not addressed in the VLER plan; and
    WHEREAS, Because a bilateral medical record is not currently 
available, there is not an ability for a patient's record to be flagged 
at the time of injury/illness occurred during military service, which 
makes it difficult and more time-consuming for DoD/VA physicians and 
raters to find proof of service connection; and
    WHEREAS, Currently VA has the ability to send patients encrypted 
email messages and a VHA program, Myhealthyvet, allows patients to 
refill their VA prescriptions, view their labs and receive VA wellness 
reminders but does not allow VA patients to schedule appointments 
online; now, therefore, be it
    RESOLVED, By the National Executive Committee of The American 
Legion in regular meeting assembled in Indianapolis, Indiana, on 
October 17-18, 2012, That The American Legion urge Congress to provide 
oversight to the Department of Defense (DoD) and Department of Veterans 
Affairs (VA) to ensure that the Virtual Lifetime Electronic Record 
(VLER) is fully implemented by Fiscal Year 2013; and, be it further
    RESOLVED, That The American Legion urge DoD and VA to implement 
VLER no later than FY 2013 to ensure returning servicemembers' medical 
records are able to be accessed by both agencies which will improve the 
timeliness and delivery of VA health care and claims benefits; and, be 
it finally
    RESOLVED, That The American Legion recommend the following be 
included in design and implementation of VLER:

      Include veteran service organizations, such as The 
American Legion, in VLER meetings to offer stakeholder input and 
sharing of mutual concerns;
      Allow servicemember records to be flagged at the time of 
injury/illness in the military to speed up processing of VA benefits 
(health care and claims) during and after discharge;
      Ensure computer systems and programs within the Veterans 
Health Administration, Veterans Benefits Administration, and National 
Cemetery Administration are interoperable and able to communicate with 
each other;
      Allow VA patients to be able to make appointments online 
by choosing the day, time and provider and that VA sends a confirmation 
within 24 hours.

Attachment D

   NATIONAL EXECUTIVE COMMITTEE OF THE AMERICAN LEGION INDIANAPOLIS, 
                                INDIANA
                         OCTOBER 17 - 18, 2012
    Resolution No. 44: Decentralization of Department of Veterans 
Affairs Programs

    Origin: Veterans Affairs and Rehabilitation Commission

    Submitted by: Veterans Affairs and Rehabilitation Commission

    WHEREAS, The Department of Veterans Affairs (VA) has been gearing 
towards a centralized model of decision-making within the Veterans 
Health Administration (VHA) and Veterans Benefits Administration (VBA); 
and
    WHEREAS, Centralization of contracting has created problems for 
individual facilities such as a two-day pileup of hazardous waste 
outside a Boston VA Medical Center (VAMC) due to a lapse in contract 
that could have been prevented by local contracting officers; and
    WHEREAS, Centralization of Internet Technology (IT) removed the 
ability of individual facilities to be flexible with their programming 
needs; and
    WHEREAS, Centralization of information leads to siloing among the 
Administrations; for example when processing a claim, the VBA and the 
VHA do not have the ability to access or view the other 
administration's records in their entirety; nor can the Appeals 
Management Center (AMC) view images in records that might be useful in 
rating decisions; and
    WHEREAS, According to an article published in the Annual Review of 
Public Health in 2009 called ``Extreme Makeover: Transformation of the 
Veterans Health Care System'' by Drs. Kizer and Dudley, centralization 
of decision-making authority markedly slows down the process; and
    WHEREAS, Centralization fosters animosity between agencies that are 
forced to compete for IT funding; for example the Office of Research 
and Development (ORD) reported that it was unable to finance select 
projects because all resources went to the VBA claims IT program 
programs; and
    WHEREAS, The VistA computer program that the VHA uses to track 
medical records was created by doctors at local facilities, and is now 
regarded as one of the best IT systems in the world; and
    WHEREAS, If the VBA and VHA shared a common appointment scheduling 
system for Compensation and Pension (C&P) exams, their respective 
employees would be able to schedule and reschedule appointments as 
needed; and
    WHEREAS, If VBA liaisons were placed within VAMCs, communication 
between administrations, namely the communication between raters and 
physicians, would be increased, therefore reducing error and turnaround 
time for processing claims; now, therefore, be it
    RESOLVED, By the National Executive Committee of The American 
Legion in regular meeting assembled in Indianapolis, Indiana, on 
October 17-18, 2012, That The American Legion supports decentralization 
of programs associated with the Veterans Benefits Administration (VBA) 
and the Veterans Health Administration (VHA); and, be it further
    RESOLVED, That the Department of Veteran Affairs (VA) decentralizes 
its decision making, accompanied by a demarcation of responsibilities 
and a plan for holding its decision-makers accountable; and, be it 
further
    RESOLVED, That the VA restores contract-making authority and 
Internet Technology programs to VA Medical Centers at the local level 
and Regional Offices (ROs); and, be it further
    RESOLVED, That VBA and VHA structure their relationship using a 
bottom-up approach similar to Baldrige's Model of Excellence, which 
will allow for a rapid model of change to occur at the operator level; 
and, be it finally
    RESOLVED, That VBA and VHA share a common records system and 
increased access to one another's programs in order to facilitate 
information exchange and process claims more efficiently.