With $16.3B, Why Are Veterans Still Waiting for Care?

By ThinkReliability Staff

Concerns regarding the timeliness of treatment within the Veterans Administration (VA)’s network of hospitals and clinics have been around nearly as long as the VA itself. In 1995, a goal was set to have veterans seen for appointments within 30 days. VA doctors’ and executives’ bonuses are based at least in part on meeting timeliness targets. Many believe this is a key reason that waiting lists were doctored (by being kept on a separate “secret” waiting list, before being moved onto the real, computerized waiting list within 14 days of their scheduled appointment). The scandal, which is believed to have contributed to the deaths of dozens of veterans while they waited for appointments, led to much consternation and a call for significant reform to improve the waiting time of veterans.

It was found that veterans were waiting too long for appointments not only in Phoenix (where the “secret waiting list” scandal was discovered) but at many VA sites around the country. This was determined to have significant (though not always easily quantifiable) impact on patient safety as well as patient services to the large numbers of veterans who were unable to get timely appointments. (Read our previous blog about a veteran who lost much of his nose after waiting more than 2 years for a biopsy.)

In order to lessen the waiting times, $16.3 billion in spending to hire more doctors, open more clinics, and create a program that allows veterans to seek private-sector care was approved July 31, 2014. However, a study by the Associated Press has found that from August 1, 2014 to February 28, 2015, over 890,000 appointments failed to meet the timeliness goal. More than 230,000 appointments were delayed more than 60 days. While the number of vets waiting more than 30 and more than 60 days has stayed about flat, the number of appointments that take more than 90 days has nearly doubled. Some specific problem areas have been identified.

Challenges remain with the “Choice Program”: The Choice Program began to cover non-VA care for eligible veterans November 5, 2014. However, eligibility remains limited to those who have to wait more than 30 days from their “preferred date” or a date medically determined by their doctor or those who are more than 40 miles (straight line) from the nearest VA facility or face an unusual travel burden to access it.   Only some private physicians participate. The program is being expanded so that the 40 miles is based on driving distance rather than a straight line calculation, and telephone lines and other programs are being implemented to assist veterans using the program to seek care.

Medically underserved areas have the worst delays: During the government’s investigation, it was found that many VA facilities have inadequate providers for the number of veterans in their care. These areas tend to be areas that are medically underserved, which compounds the problem because civilian options in the area are also limited, limiting the effectiveness of the program that allows veterans to seek private-sector care. Says Dr. Kevin Dellsperger, chief medical officer at Georgia Regents Medical Center and former chief of staff at the VA medical center in Iowa City, Iowa, “Not a lot of medical students want to go work for the VA in a rural community medical clinic.” While 8,000 employees were added to the VA between April and December 2014, it’s hoped that increasing salaries in the underserved areas will attract more providers.

Physical space is also an issue: Any government contracting and building process can be cumbersome, and the VA has been identified as having particular difficulty managing the contracting process. When buildings are (finally) constructed, they’re usually already too small.

Enrollment is increasing: Enrollment in VA programs has been expanding rapidly. From 2002 to 2013, enrollment increased from 6.8 million to 8.9 million and spending increased from $19.9B to $44.8B.   Says Robert McDonald, Secretary of Veterans Affairs, “Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care.” It’s hoped that the increased enrollment is actually a positive, buoyed by the efforts made to increase access and shorten waiting times. “I think what we are seeing is that as we improve access, more veterans are coming, ” says Sloan Gibson, the Deputy Secretary of Veterans Affairs.

It may get worse: “The cost of fulfilling those obligations to our veterans grows and we expect it will continue to grow for the foreseeable future. We know that services and benefits for veterans do not peak until roughly four decades after conflict ends . . . we project the benefits for recent veterans in recent conflicts will peak around 2055,” testified VA Secretary McDonald.

The VA administration is asking for patience. Deputy Secretary Gibson says “We are doing a whole series of things – the right things, I believe – to deal with the immediate issue. But we need an intermediate term plan that moves us ahead a quantum leap, so that we don’t continue over the next three or four years just trying to stay up. We’ve got to get ahead of demand.”

To view an overview of these issues in a visual cause-and-effect diagram (or Cause Map), as well as some of the associated solutions, click on “Download PDF” above. To read more about the AP’s analysis, click here.