Friday, December 28, 2007

VA, House Subcommittees Spar Over Outpatient Waiting Times

VA disputes IG's findings on appointments

VA, House Subcommittees Spar Over Outpatient Waiting Times
By Stephen Spotswood
Posted: 27-December-2007
WASHINGTON—Three months after a Department of Veterans Affairs (VA) Inspector General’s (IG) audit showed that the agency is overstating success on decreasing waiting times for outpatients seeking an appointment, VA is still not agreeing with the findings, contending the IG’s methodologies were flawed. However, at a hearing on Capitol Hill in December, legislators seemed convinced of the report’s validity, and VA officials did admit that its patient scheduling process was still evolving and that the process needed evaluating.

VA policy requires that all veterans requiring care for service-connected disabilities be scheduled for outpatient care within 30 days of desired appointment dates—the date requested by the patient or the physician. All other veterans are required to be scheduled within 120 days of the requested date.

VA had reported that 96 per cent of all veterans seeking primary care and 95 per cent of veterans seeking specialty care were seen within 30 days of their desired dates. The IG audit released in September shows those percentages to be much lower. The audit found that only 75 per cent of veterans seeking care had been seen within 30 days of the desired date.

Some of the discrepancies were due to VA schedulers, who waited inordinate amounts of time before scheduling an appointment—in one case as long as seven months for a follow-up appointment—and what IG described as the disregard for the desired appointment date listed in the physician’s notes. Also, there was disagreement between the IG and VA about how to define "new" patients. The IG auditors argued that a patient already in the VA system who visits a specialty clinic should not be considered a new patient just because he or she had not visited that particular clinic before.

VA officials disagreed and called the report a worst-case scenario that did not take into account such things as patients’ preference for later appointment dates and delays on the patients’ part in scheduling follow-up appointments.

A similar IG report released in 2005 found many of the same problems, including some accounts of schedulers reporting having been instructed to falsify their entries into the electronic waiting list to make wait times seem shorter. VA officials did not disagree with the findings of the 2005 report. IG made several recommendations to VA to shore up its scheduling procedures, such as ensuring that facility managers require schedulers to create appointments following established procedures, monitoring the scheduler’s use of correct procedures, and requiring annual scheduler training on the electronic waiting list. According to IG, while some of those recommendations from 2005 have been taken, some have not, allowing the same problems to continue through today.

At a joint hearing of the House VA Subcommittee on Health and the Subcommittee on Oversight and Investigations, legislators expressed frustration at the continued problems with getting patients who need care before a VA caregiver.

"The VA has discounted the IG’s report because it disagrees with how wait times were calculated. This is unacceptable," declared Rep. Harry Mitchell (D., Ariz.), chairman of the health subcommittee. "I’m not willing to walk away from this audit over a disagreement about methodology. This is a real problem that we must look into. When our veterans encounter long waiting times, their conditions go undiagnosed and serious disease goes untreated."

"Furthermore," he said, "until we have a clearer picture about waiting times, the VA can’t improve the situation because we can’t identify problem facilities or effectively allocate resources."

Belinda Finn, IG’s Assistant Inspector General for Auditing, said that she did not understand why VA was resisting the IG’s newest findings.

"VA disagreed with our findings and said that patient preferences caused the discrepancies," Finn explained. "We find it contradictory that VA agreed with our 2005 report, but disagreed with our 2007 audit. We used the same methodology and saw a continuation of the same problems."

She added, "In 2006 and 2007, VA reported high performance on affecting appointments within 30 days. [They continued reporting this] even after we reported that the scheduling system includes inaccurate or incomplete data."

Asked what VA could do to improve its procedures, Finn said, "We made recommendations in both of our reports that VA should provide oversight of the schedulers, monitor what the schedulers do, and provide quality assurance of the data in the scheduling system. They agreed with the recommendations in 2005, but we found that they had not [fixed the problem and IG made the same recommendations in its 2007 report]."

Some legislators were worried about the reporting in 2005 in which schedulers were being directed to enter inaccurate information.

According to Larry Reinkemeyer, director of the Kansas City Audit Operations Division of the VA IG, that question was not asked in the 2007 audit; however, 7 per cent of those schedulers surveyed in the 2005 report said that they had been directed to intentionally circumvent procedure.

"So, in 2005, we did have some evidence that schedulers were directed to schedule in a particular way to affect waiting times [data]," Reinkemeyer said.

Rep. Zachary Space (D., Ohio) wondered if it is possible that bonuses for VA medical center directors were at least in part calculated on wait times that were not accurate. Controversy arose last year when legislators questioned why some VA officials were receiving bonuses as high as $30,000 when there were so many problems in the VA system, including long appointment waiting times.

"We know that waiting times are part of the performance standards for directors," Finn said. "It’s one of many factors. But we don’t have much information today on how that’s factored into a particular bonus."

Asked if there is evidence in the 2005 report that waiting times were intentionally fabricated to lower national waiting time rates, Finn said, "We know that some of the practices that schedulers have told us about would serve to understate wait times. Whether that was a widespread practice or not, [we don’t know]."

Reinkemeyer said that at least two of the common procedures by schedulers recorded in 2005 that lower documented wait times—whether intentionally or not—still exist today.

The first procedure, he said, "Is taking longer than allowed before putting [a patient] on the electronic waiting list." If a patient is not scheduled for an appointment within seven days, that patient goes on the electronic wait list.

"By holding on to those referrals for more than seven days and not put them on the wait list, that serves to understate the wait list," Reinkemeyer said.

"The second procedure is a common practice for a scheduler to find out what the first available appointment [is] and use that as the desired date of care, which effectively reduces the wait to 0," he explained.

Testifying before the joint subcommittees, Dr. Gerald Cross, VA’s Deputy Under Secretary for Health, continued to refute the calculations in the IG report.

"VA has several concerns about the OIG’s audit methodology that was used in the 2007 report," Dr. Cross said. "There was a difference in our analysis [of wait times] and our review of the IG report of 2007, and there were significant differences that we found."

Dr. Cross did not elaborate on why the same IG methodology did not concern VA when it reviewed the 2005 IG report.

Dr. Cross also argued that VA is still in the process of implementing recommendations made by IG in 2005, including comprehensive training of anyone using VA’s scheduling system, including physicians who like to schedule their own patient appointments. To date, VA has trained 40,000 people to use the scheduling system, and plans to revise the training annually and retrain its employees annually.

"VA is proactively taking steps to review the total scheduling process," Dr. Cross said. "To this end, VA has contracted with an independent third party to conduct an evaluation of VA’s scheduling practices and waiting time metrics. The contractor is beginning the pilot program phase of its assessment, and VA anticipates receiving the final report in spring of 2008." VA is also in the process of developing a new scheduling software package, as well as developing short-term software solutions for its current scheduling package, which Dr. Cross called "antiquated software."

However, that new software package will not be up and running until 2011.

Impact Of Delay On The Front Lines Of Care
To help understand the front-line picture of what dealing with VA scheduling procedures is like, the legislators heard from Mary Jones, a county veterans service officer in Licking County, Ohio. Jones has helped veterans find their way through VA bureaucracy for 12 years, and testified that, no matter whether you believe the VA’s data or the IG’s audit, the waiting times are long and frustrating.

"My concern with outpatient waiting times is our inability to get veterans into an appointment in a timely manner," Jones said. "Their appointments are scheduled so far out—often two to three months—that their condition worsens and they are left angry and frustrated at a system that is supposed to be in place to care [for them]."

One example she gave is of a veteran recently discharged, who was promised dental care within 90 days of discharge. VA scheduled his appointment for almost the full 90 days later, but when he arrived at the dental clinic he was told that appointment needed to be cancelled.

"They did not have any appointments available within the 90-day period he was entitled to dental care, and therefore he was not seen."

Another rising concern is getting care for veterans with post-traumatic stress disorder (PTSD) when their benefits claim is still being processed.

"Usually, when we file a claim, we have a veteran who has a diagnosis for a condition, but PTSD is different," Jones contended. "Most veterans can get into the VA to see a social worker and can get assigned to group counseling fairly quickly. Most can see a psychiatrist within three to four months for an initial exam, but within the 12 to 18 months that a service-connected claim takes to adjudicate, the veteran is still left without a diagnosis for PTSD because the wait times prohibit the doctor from seeing the patient often enough to provide a definitive diagnosis of any mental health."

Because no diagnosis exists, the Veterans Benefits Administration must deny the claim for service connection, Jones said, adding that seeing private psychologists is a financial burden for most veterans.

Rep. Ginny Brown-Waite (R., Fla.), whose proposed bill, H.R. 92, the "Veterans Timely Access To Health Care Act," would require VA to reimburse veterans for care at non-VA facilities if VA is unable to furnish the patient with an appointment within 90 days, asked Jones whether such a measure would be a good or bad idea from her point of view.

"I have to say that it’s encouraging to think we’re looking outside of the box," Jones said. "For me, the possibility to use outside physicians might be a good idea. These are outside physicians who would treat veterans eventually, anyway, [and they] might get some training on treating [veterans] right now. Most don’t even ask [their patients], ‘Are you a veteran?’"

Rep. Brown-Waite stressed that she was not seeking to privatize any part of VA care with her legislation, but argued, "Care not rendered in an expeditious manner is not quality care."

The bill is still awaiting action in the House VA Committee.

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