Veterans Health Administration: Opportunities Exist for Improving Veterans' Access to Health Care Services in the Pacific Islands

Veterans' access to timely health care at VA medical facilities has been a long-standing problem identified by GAO and VA's Office of Inspector General. The remote nature of the Pacific Islands creates some unique challenges for VAPIHCS, which may affect its ability to provide the approximately 50,000 veterans it serves in American Samoa, Guam, Hawaii, and the Commonwealth of the Northern Mariana Islands with timely access to primary, mental health, and specialty care.

House Report 114–497 included a provision for GAO to review VHA's efforts to provide timely access to health care within VAPIHCS. Among other things, this report examines: the extent to which the VAPIHCS veterans received (1) timely primary and mental health care, and (2) timely specialty care; and (3) any challenges VAPIHCS faced in recruiting and retaining physicians, and strategies to resolve them. GAO reviewed relevant policy documents and a randomly selected, non-generalizable sample of 164 medical records, and interviewed VHA, VAPIHCS, and DOD officials.

For the sample of veterans' medical records that GAO reviewed, most veterans received primary and mental health care from the Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS) within timeliness goals set by VA's Veterans Health Administration (VHA). However, GAO also found that some of these veterans experienced delays related to the processing of their enrollment applications, contacting them to schedule appointments, and completing comprehensive mental health evaluations. These delays were similar to some GAO had identified in previous work pertaining to veterans' access to care nationwide.

For the sample of veterans' medical records that GAO reviewed, VAPIHCS referred nearly all specialty care to non-VA providers within VHA's timeliness goal, but the time taken to provide care was variable and sometimes lengthy. Specifically, VAPIHCS sent specialty care referrals to

the Veterans Choice Program (Choice Program)—for veterans that GAO reviewed, the number of days to receive care from the Choice Program was, on average, 75 days.

Department of Defense (DOD) military treatment facilities—for veterans that GAO reviewed, the number of days to receive care from the two DOD facilities for which VAPIHCS has agreements was, on average, 37 days from one facility and 47 days from the other.

GAO identified weaknesses in VAPIHCS' management of its referral process for sending veterans for specialty care services at one of the two military treatment facilities. GAO found VAPIHCS did not always manage referrals to the military treatment facility in a timely way and there was inconsistent guidance describing the roles and responsibilities of the VAPIHCS staff involved in the process. These weaknesses may have contributed to the amount of time it took for veterans to receive specialty care services.

GAO also found that VAPIHCS faces challenges recruiting and retaining physicians. As of October 2017, 17 of approximately 100 VAPIHCS physician positions were vacant, as were several other types of health care providers. Some of the challenges VAPIHCS faced are unique to the Pacific Islands, such as the availability of only one local medical school from which to recruit, along with travel burdens and a high cost of living that may discourage physicians from relocating there. Other challenges were similar to those GAO has previously identified as faced by VA medical centers across the country, such as differences in interpretation of hiring and recruiting policies. VAPIHCS officials said they use several strategies to help recruit and retain physicians, including VHA strategies used by other VA medical centers such as financial incentives and an educational debt reduction program. Although they described limits to the success of some of these strategies, they have not evaluated their effectiveness. Without completing an evaluation of its strategies, VAPIHCS may not be optimizing its resources to improve its hiring efforts and may continue to struggle with physician shortages.

GAO makes four recommendations, including that VAPIHCS improve monitoring of referrals to one DOD facility and evaluate the effectiveness of physician recruitment and retention strategies. VA concurred with three recommendations and partially concurred with the fourth. GAO maintains that monitoring referrals to the DOD facility is needed, as discussed in the report.

The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), operates one of the nation’s largest health care  systems. In fiscal year 2016, VHA provided care to about 6.9 million  veterans and obligated about $65 billion for their care through 170 VA  medical centers (VAMC) and 1,082 clinics nationwide. The VA Pacific  Islands Health Care System (VAPIHCS) is part of Veterans Integrated  Service Network (VISN) 21 and includes 1 of VHA’s 170 VAMCs—the  Spark M. Matsunaga VAMC, located in Honolulu, Hawaii—and 10 clinics  located across the Pacific Islands. VAPIHCS provides health care  services to approximately 50,000 veterans that reside in the Pacific  Islands of Hawaii, American Samoa, Guam, and the Commonwealth of  the Northern Mariana Islands. While some outpatient specialty care is  provided at the Spark M. Matsunaga VAMC and the 10 clinics, VAPIHCS  primarily provides outpatient primary and mental health care services.  Unlike most VAMCs, the Spark M. Matsunaga VAMC does not include an  inpatient hospital. For most inpatient and other specialty care, veterans  are referred to local military treatment facilities through joint venture and  sharing agreements with the Department of Defense (DOD) or to non-VA  providers in the community. In particular, VAPIHCS partners with Tripler  Army Medical Center (TAMC) through a joint venture in Hawaii and U.S.  Naval Hospital Guam (NHG) through a sharing agreement, and also  offers veterans access to non-VA providers in the community through the  Veterans Choice Program (Choice Program).

In recent years, we and the VA Office of the Inspector General (OIG)  have expressed concerns about veterans’ ability to access timely medical  care and VHA’s oversight of its appointment scheduling practices. VHA  has timeliness goals outlined in policies that measure the amount of time  it should take to schedule appointments, and for veterans to receive  health care services. Additionally, we and the VA OIG have expressed  concerns about whether VHA is able to ensure that it has the appropriate  clinical workforce to meet the needs of veterans. The VA OIG also has  found that VAPIHCS faces unique challenges in providing patient care  given the geographic remoteness of the Pacific Islands, and identified  concerns including about lengthy wait times for primary care.

House report 114-497, which accompanied the Military Construction,  Veterans Affairs, and Related Agencies Appropriations Bill, 2017,  included a provision for us to review the scheduling, staffing, outreach,  and access management practices at VAPIHCS. This report examines:  1.  the extent to which veterans in the Pacific Islands receive primary and  mental health care from VA providers within VHA’s timeliness goals;  2.  the extent to which veterans in the Pacific Islands are referred to and  receive specialty care from non-VA providers within VHA’s timeliness  goals;  3.  the challenges, if any, in the recruitment and retention of physicians in  the Pacific Islands, and the extent to which strategies are used to help  resolve any such challenges; and  4.  the challenges, if any, veterans in the Pacific Islands face in  accessing care, and the strategies used to improve veterans’ timely  access to care.

To examine all four objectives, we focused our review on services  provided to veterans in 3 of the 10 clinics—located on the islands of  American Samoa, Guam and Maui—because they provided the most  comparable types of primary and mental health care services across all  clinics. We interviewed VAPIHCS officials, DOD officials, and a local  representative of TriWest, the third-party administrator for the Choice  Program in VISN 21, the program through which most veterans in the  Pacific Islands receive non-VA care, and we conducted site visits to the  VA and DOD facilities in Guam and Honolulu in April 2017. We  interviewed VA and DOD officials, and the local TriWest representative  about policies and guidance for scheduling veterans for outpatient  primary, mental health, and specialty care; arranging for and providing  specialty care at a DOD military treatment facility or with a non-VA  provider in the community; physician recruitment and retention  challenges; and challenges veterans have with accessing health care  services in the Pacific Islands. In addition, we discussed access to care  challenges with community stakeholders, including with members from a  local advisory council that represents veterans on Guam.

To examine the extent to which veterans accessed primary and mental  health care from VA providers, and specialty care services from non-VA  providers, within VHA’s timeliness goals, we reviewed relevant VHA  policies for veteran enrollment application processing and appointment  scheduling within VA facilities, and for facilitation of health care services  referred outside a VA facility. We also examined VAPIHCS’ joint venture  and sharing agreements with DOD and VA’s Choice Program contract  with TriWest. In addition, we compared the processes VAPIHCS followed  to refer veterans to care outside a VA facility to appropriate federal  internal control standards. Additionally, we interviewed officials from  VHA’s Office of Veteran Access to Care, Office of Mental Health  Services, and Office of Community Care to obtain information on VHA’s  scheduling policies. To measure the timeliness of care provided by VA  and non-VA providers, we reviewed a sample of 164 medical records of  veterans enrolled at clinics on the islands of American Samoa, Guam,  and Maui. The results from our review cannot be generalized to all  veterans within VAPIHCS, or to other VAMCs, but provide insights into  the extent to which veterans were able to receive timely access to health  care services. Our sampling methodology for the 164 medical records  included requesting and obtaining lists of veterans from VHA, unless  otherwise noted, that satisfied the following criteria:  Initial primary care appointments. Those veterans who applied for  enrollment and were successfully enrolled in VHA health care  benefits; requested on their enrollment applications that VA contact  them to schedule medical appointments; and received their first  primary care appointment from Oct. 1, 2016, through Mar. 31, 2017.

Initial mental health appointments. Those veterans that received  their first appointment with a mental health care provider from Oct. 1,  2016, through Mar. 31, 2017.

Follow-up appointments. Those established veterans—veterans  who were seen by a VA primary or mental health provider within the  last 2 years—who saw a provider for a follow-up primary or mental  health care appointment in March 2017.

Specialty care referrals. Those routine outpatient specialty care  referrals that were created from Oct. 1, 2016, through Mar. 31, 2017,  that VAPIHCS sent to either (1) DOD military treatment facilities  working in partnership with VAPIHCS: TAMC and NHG, or (2)  community providers through the Choice Program. The majority of  veterans enrolled in VAPIHCS received non-VA care in fiscal year  2016 through the Choice Program. From these lists, we selected a  random sample that included referrals for orthopedics—a mission- critical physician specialty—as well as the specialty care service most  frequently referred to TAMC, NHG, and the Choice Program from  each of the three selected clinics in fiscal year 2016. These referrals  resulted in a face-to-face consultation with a specialty care provider.  Additionally, we also reviewed a select sample of general surgery  referrals sent to NHG that were subsequently canceled by VAPIHCS;  we reviewed these referrals to further assess reasons for the  cancelations.

See Table 1 for information on the number of medical records reviewed,  by type of appointment and health care service, number of records  sampled, and location of veteran.

To identify any challenges in the recruitment and retention of physicians  in the Pacific Islands, and the extent to which strategies have been used  to help resolve such challenges, we reviewed key VHA documents  related to physician recruitment and retention and workforce and  succession planning; directives related to staffing and pay administration;  and guidance regarding the composition of primary care and mental  health providers within clinics. Additionally, we reviewed information on  the current physician staffing and vacancy levels for each clinic within  VAPIHCS. We assessed VAPIHCS’ strategies to address challenges it  faces to recruit and retain physicians within the context of federal  standards for internal control. Finally, we interviewed VHA, VISN, and  VAPIHCS officials involved in physician recruitment and retention,  including from VHA’s Office of Workforce Management and Consulting,  VISN 21’s Office of Human Resources, and VAPIHCS’ Office of Human  Resources.

To identify any challenges veterans in the Pacific Islands face in  accessing care, and the strategies used to improve access, we reviewed  VHA’s handbook and guidance related to its beneficiary travel program.  This program is intended to improve veterans’ access to timely care by  reimbursing certain travel costs to medical appointments. Additionally, we  reviewed VAPIHCS materials used to inform veterans about their access  options. We also collected and assessed information on the number of  outreach efforts conducted by VAPIHCS to inform veterans about access  to care. We also interviewed officials from VAPIHCS and VHA’s Office of  Rural Health and TriWest to obtain information about any access  challenges for veterans they have identified and strategies used to  address them.

We conducted this performance audit from January 2017 to April 2018 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

VAPIHCS provides comprehensive health care to eligible veterans who  reside in Hawaii and the three U.S. territories in the Pacific— American  Samoa, Guam, and the Commonwealth of the Northern Mariana Islands.  According to VAPIHCS officials, the geographic distances between the  Pacific Islands and the use of multiple sources of health care to provide  services to veterans in this region create complex care delivery and  coordination challenges for VAPIHCS.

VAPIHCS and Primary and Mental Health Care Services

VAPIHCS generally provides outpatient primary and mental health care  services to the veterans it serves. These services are provided through its  ambulatory care clinic, housed at the Spark M. Matsunaga VAMC in  Honolulu, Hawaii, on the island of Oahu, and 10 clinics located in other  communities across the Pacific Islands. These 10 clinics include

7 in the state of Hawaii on the islands of Oahu (1 clinic); Hawaii (2  clinics); Maui (1 clinic); Lanai (1 clinic); Molokai (1 clinic); and Kauai (1  clinic);

1 in the Commonwealth of the Northern Mariana Islands on the island  of Saipan.

VAPIHCS provides some outpatient specialty care services through the  ambulatory care clinic and through traveling VAPIHCS specialty care  providers. Table 2 shows the number of enrolled veterans and the  number of veterans that have used outpatient services in fiscal year 2017  at each VAPIHCS facility.

VAPIHCS and Specialty Care and Inpatient Services

According to VAPIHCS officials, VAPIHCS provides most specialty care  and inpatient services to veterans at military treatment facilities through  joint venture and sharing agreements with DOD or through non-VA  providers in the community. In fiscal year 2017, VAPIHCS sent 50,000  referrals outside of VA, mostly to DOD or through the Choice Program.

Military treatment facilities. Two military treatment facilities located in  the Pacific Islands provide care for veterans through joint venture and  sharing agreements with VAPIHCS: TAMC and NHG. According to  VAPIHCS’ data, VAPIHCS made more than 8,000 referrals to these  facilities in fiscal year 2017.

VAPIHCS’ joint venture with TAMC: VAPIHCS’ joint venture  agreement with TAMC—1 of 10 joint venture agreements in place  between VA and DOD as of December 2017—states that VAPIHCS  may refer veterans to TAMC providers for specialty care and inpatient  services and, in return, for VAPIHCS to provide services for DOD  beneficiaries, such as psychiatric and post-traumatic stress disorder  services.

VAPIHCS’ sharing agreement with NHG: VAPIHCS’ sharing  agreement with NHG—1 of more than 200 active sharing agreements  in place between VA and DOD as of December 2017—states that  VAPIHCS may refer patients from the Saipan and Guam clinics to  NHG for available specialty care, laboratory, emergency care, and  inpatient services. NHG is located within a mile of the Guam clinic.

Choice Program. VAPIHCS may also refer veterans to a non-VA  provider in the community when veterans need care that is not offered by  VAPIHCS, or cannot obtain the needed care in a timely manner. In fiscal  year 2017, 61 percent of VAPIHCS referrals sent to community providers  were through the Choice Program. (See fig. 1 for the breakdown of the  number and percent of referrals sent to care outside of VAPIHCS in fiscal  year 2017.) Veterans may opt to obtain health care services from a  network of community providers through the Choice Program if they meet  certain criteria, including:  1.  the next available medical appointment with a VHA clinician is more  than 30 days from the veteran’s preferred appointment date or the  date the veteran’s physician determines he or she should be seen;  2.  the veteran lives more than 40 miles driving distance from the nearest  VHA facility with a full-time primary care physician;  3.  the veteran needs to travel by air, boat, or ferry to the VHA facility that  is closest to his or her home;  4.  the veteran faces an unusual or excessive burden in travelling to a  VHA facility based on geographic challenges, environmental factors,  or a medical condition;   5.  the veteran’s specific health care needs, including the nature and  frequency of care needed, warrants participation in the program; or  6.  the veteran lives in a state or territory without a full-service VHA  medical facility.

As the third-party administrator of the Choice Program for VAPIHCS,  TriWest is responsible for establishing networks of community providers,  scheduling appointments with community providers for eligible veterans,  and paying providers for their services. TriWest has contractual time  frames in which to accept and schedule the appointment, or return the  referral to VAPIHCS for further action.

Most Veterans in Our Review Received Primary and Mental Health Care from VA Providers within VHA’s Timeliness Goals, although Some Faced Delays

Veterans in Our Review Faced Some Enrollment Delays, but Once Contacted, Most Received Initial Primary Care from VA Providers within VHA’s Timeliness Goal

Our review of 30 medical records of newly enrolled veterans accessing  initial primary care services at the American Samoa, Guam, or Maui clinic  found some delays in processing of health care benefits enrollment  applications and contacting of veterans to schedule appointments. Once  contacted, however, most veterans in our sample received initial primary  care within VHA’s timeliness goal. These enrollment delays may have  contributed to the time taken for veterans to see primary care providers,  consistent with findings from our prior work.

Enrollment for VA Health Care Benefits   To receive VA health care benefits, a veteran  may submit an enrollment application by mail,  telephone, through VA’s website, or by  applying in person at a VA health care facility.  Once a veteran submits an application, there  are three key steps for processing the  application: (1) intake of application, (2)  verification of eligibility, and (3) enrollment  determination. In fiscal year 2016, most  enrollment applications were processed by VA  medical center staff. According to Veterans  Health Administration policy, staff are required  to process applications within 5 business days  of receipt. applications within the timeliness goal set in VHA policy. For 27 of the  30 veterans in our sample, VHA staff recorded the date the application  was received, which enabled us to assess the timeliness of enrollment  processing for these veterans. We found that 22 of these 27 applications  were processed within VHA’s required 5 business days, with an average  of 1 day for processing. (See table 3.) Five applications were not  processed within the 5-day requirement; for four of these veterans, it took  an average of 10 days to process the enrollment applications. For the fifth  veteran, it took 627 days for VHA to process the application, and for  which VAPIHCS staff could not explain the delay.

New Enrollee Appointments   Veterans can request on their enrollment  applications that Department of Veterans  Affairs (VA) staff contact them to schedule an  initial outpatient appointment. After a  veteran’s enrollment application has been  processed, VA staff are to initiate the  scheduling of appointment requests within 7  days. within 7 days of their eligibility determination as required by VHA policy.  We found that 15 of the 30 veterans in our review had contact initiated  within 7 days to schedule an appointment, with an average of 4 days.  (See table 4.) Fifteen veterans did not have contact initiated within the 7  day requirement; for 14 of these veterans, it took an average of 20 days  to initiate contact. For the 15th veteran, it took 183 days to initiate contact.  According to clinic staff, gaps in communication between clinic and  VAPIHCS staff responsible for veteran enrollment, as well as staffing  shortages, may have contributed to delays in contacting newly enrolled  veterans. Clinic staff reported differences in how they are notified that a  veteran’s enrollment application has been processed and that  appointment scheduling should be initiated. In addition, staff from two  clinics said there were staffing vacancies for primary care appointment  schedulers in their clinics during the time of our medical record sample  selection (October 2016 through March 2017), which may have caused  delays in contacting veterans.

Timeliness of initial primary care services. For the 30 newly enrolled  veterans’ medical records we reviewed, we found that, once contacted,  27 veterans received initial primary care services within VHA’s timeliness  goal of 30 days of their preferred appointment dates (the date a veteran  requests health care services), with an average wait time of 7 days.  (See table 4.) Three veterans did not receive initial primary care  appointments at the Guam clinic within the 30-day requirement, and  waited an average of 62 days. However, as we have previously reported,  VHA’s timeliness goal monitors only a portion of the overall time it takes  newly enrolled veterans to access primary care, and does not account for  the time it takes to process enrollment applications, to notify clinic staff of  successful enrollments, or to contact veterans to schedule their  appointments. In our March 2016 report, we recommended that VA  monitor the full amount of time newly enrolled veterans wait to be seen by  primary care providers, starting with the date veterans request they be  contacted to schedule appointments. When accounting for the time to  process applications and contact veterans, we found 6 of the 30 veterans  in our review waited more than 90 days to see a provider while 9 waited  30 days or less.

Most Veterans in Our Review Received Initial Mental Health Care from VA Providers within VHA’s Timeliness Goal, but There Were Some Delays Completing Comprehensive Mental Health Evaluations

Our review of a randomly selected sample of 30 medical records for  veterans who accessed mental health care services for the first time at  one of the selected three clinics found that most veterans received initial  mental health care within VHA’s timeliness goal. Although most veterans  in our sample received timely initial services, our review found that those  veterans needing comprehensive mental health evaluations often  experienced delays receiving them.

Mental Health Care Appointments   Veterans can either request mental health  care services, or be referred for these  services, such as by their primary care  providers. Once care is requested for non- emergent mental health care needs,  appointments are to be scheduled within 30  days of the referral’s clinically indicated date,  or in the absence of a clinically indicated date,  the veteran’s preferred date for their first  mental health care appointment. In addition to  scheduling the initial appointment, veterans  are to receive a comprehensive mental health  evaluation within 30 days of that initial  referral’s clinically indicated date, or in the  absence of a clinically indicated date, the  veteran’s preferred date for their first mental  health care appointment. This comprehensive  mental health evaluation occurs during a  mental health appointment, and includes a  diagnosis and a plan for treatment. While this  evaluation does not necessarily have to occur  during the first mental health care  appointment, it is expected to be completed  within the timeliness goals as noted.

Timeliness of initial mental health care services. Our review found  that 21 of the 30 veterans in our sample who needed mental health care  received their initial mental health care appointments within VHA’s  timeliness goal of 30 days of their documented clinically indicated dates  (the date an appointment is deemed clinically appropriate by the referring  provider), or in the absence of clinically indicated dates, their preferred  dates. (See table 5.) These 21 veterans were seen by a mental health  care provider within an average of 7 days of their clinically indicated date  or preferred date. Nine veterans did not receive initial mental health care  appointments within VHA’s 30-day timeliness goal, and waited an  average of 46 days to receive care from a mental health provider.

Timeliness of comprehensive mental health evaluations. Although 21  of 30 veterans in our sample received initial mental health care  appointments in a timely manner, our review found that most veterans  needing comprehensive mental health evaluations experienced delays  receiving them. Of the 30 veterans in our sample, 25 were identified as  needing a comprehensive mental health evaluation, and only 9 received  that evaluation within VHA’s timeliness goal of 30 days of their clinically  indicated date, or in the absence of a clinically indicated date, the  veteran’s preferred date. (See table 6.) These 9 veterans received their  evaluations within an average of 8 days. For the 16 veterans that did not  receive a comprehensive mental health evaluation within the 30-day  requirement, it took between 35 and 217 days (an average of 82 days) for  15 veterans to receive an evaluation from the initial referral’s clinically  indicated date or veteran’s preferred appointment date. The remaining  veteran had not completed an evaluation as of February 2018.

The process by which veterans received comprehensive mental health  evaluations varied by clinic, and this sometimes resulted in the  evaluations being completed outside of VHA’s timeliness goal:

American Samoa clinic staff stated that they provide veterans with a  hard-copy comprehensive mental health evaluation at the veteran’s  first appointment. The veteran is instructed to complete the form at  home, and return to the clinic at a later date to discuss with a  provider. Staff stated that allowing veterans to fill out the form on  their own saves time at the clinic, and allows veterans to be more  thorough in their answers. A staff member stated that the  comprehensive mental health evaluation is just one piece of the  diagnostic interview and that, presumably, the provider obtains  sufficient information from the veteran to develop a treatment plan and  initiate services for the veteran while waiting for the veteran to  complete the form.

Guam clinic staff said that they generally complete the comprehensive  mental health evaluation during the veteran’s first mental health care  appointment, but do sometimes need to schedule a second  appointment to complete the entire evaluation. Staff stated that the  first priority is to treat and address what is clinically indicated, so they  are sometimes delayed in completing all form requirements until a  later time.

Maui clinic staff stated that they typically schedule the first  appointment with a veteran, and if it becomes clear that the veteran  needs to continue receiving mental health services, they will schedule  a comprehensive mental health evaluation at a future appointment.

Most Veterans in Our Review Received Follow- Up Primary and Mental Health Care from VA Providers within VHA’s Timeliness Goal

Follow-Up Appointments   After a veteran is seen for an appointment at  a Department of Veterans Affairs (VA) facility,  the provider is to document in the veteran’s  medical record a clinically appropriate specific  return date or interval (such as 2, 3, or 6  months), when the provider determines the  veteran should return for care. This is also  known as the clinically indicated date. The  follow-up appointment should then be  scheduled within 30 days of the clinically  indicated date.

Our review of a randomly selected sample of medical records for 30  veterans in the Pacific Islands (15 veterans needing primary care and 15  veterans needing mental health care) who received follow-up  appointments found that most of these veterans received care within  VHA’s timeliness goal. Specifically, we found that of the 30 veterans, 25  veterans received follow-up care within 30 days of the clinically indicated  date determined by each veteran’s provider, in accordance with VHA  policy. (See table 7.) This included 10 veterans needing follow-up  primary care (who received care an average of 6 days within the  veteran’s clinically indicated date), and all 15 veterans needing follow-up  mental health care (who received care an average of 3 days within the  veteran’s clinically indicated date). The 5 veterans needing follow-up  primary care that were not seen within the required 30 days were seen  between 109 and 584 days (an average of 299 days) from their clinically  indicated dates. Explanations for the length of time it took for these 5  veterans to receive care varied; for example, Guam clinic staff told us that  one veteran’s follow-up care was delayed due to clinical and scheduling  staffing shortages.

VAPIHCS Referred Most Specialty Care to Non-VA Providers within VHA’s Timeliness Goal, but Time Taken to Provide Care Was Variable and Sometimes Lengthy

VAPIHCS Met VHA’s Timeliness Goal for Almost All Specialty Care Referrals in Our Sample Sent to Choice Program and DOD Providers

We found that VAPIHCS referred 67 of 69 randomly selected specialty  care referrals in our sample to non-VA providers in the Choice Program or  through DOD within 7 days, in accordance with the timeliness goal set in  VHA policy. Specifically, VAPIHCS met this goal for 28 of 30 specialty  care referrals sent to Choice Program providers, and all 39 specialty care  referrals sent to DOD providers at two military treatment facilities.  VAPIHCS staff took an average of 2 days to review and send referrals to  VAPIHCS staff responsible for Choice Program referrals, and an average  of 1 day to review and send specialty care referrals to TAMC and NHG.  VAPIHCS staff responsible for Choice Program referrals also are  responsible for uploading the referrals into TriWest’s portal, the Choice  Programs’ third-party administrator within VAPIHCS. Although VHA  policy applies to referrals sent to in-house providers, a VHA official told us  that VHA expects VAMCs to manage non-VA referrals as they would  those referred in-house. A VAPIHCS official confirmed that it holds staff  to the 7-day requirement found in VHA policy.

Time Taken for Veterans in Our Review to Receive Specialty Care from Choice Program and DOD Providers Was Variable and Sometimes Lengthy

We found that once specialty care referrals in our review were sent to the  Choice Program or one of the two DOD military treatment facilities— TAMC and NHG—the amount of time it took veterans to receive care  from these non-VA providers varied, and sometimes was lengthy.

Time taken to receive care from a Choice Program provider. Once  VAPIHCS staff reviews and uploads each referral into TriWest’s portal,  TriWest is required to meet VA’s timeliness requirements for the Choice  Program, which specify the amount of time TriWest has to (1) contact the  veteran, (2) schedule the appointment, (3) and provide veterans with  care.

We found that for all 30 referrals in our sample, TriWest first  attempted to contact the veteran within the 4 business days  required once TriWest received and accepted the referral from  VAPIHCS. However, we also found that TriWest did not follow the  requirements for mailing letters for 3 of the referrals when it was  unable to reach the veterans by phone. If TriWest is unable to reach a  veteran after calling a minimum of three times over 4 business days, a  letter is to be mailed to the veteran on the 7th business day after  receiving the referral notifying them that they have 10 business days  from the date of the letter to contact TriWest to schedule an  appointment. For these 3 referrals, TriWest mailed a letter, but did not  do so until one day later than the required 7th business day after  receiving and accepting the referral.

We found that after reaching the veteran, TriWest staff scheduled  appointments for 17 of the 25 referrals within the 5 business  days required for scheduling an appointment after the veteran  opts in to the Choice Program. (See table 8.) We found varying  reasons that may have delayed the scheduling of an appointment. For  example, some records showed that TriWest staff did not begin to call  a provider until 4 or more days after they reached the veteran and  confirmed they wanted to utilize, or opt in to, the Choice Program to  receive care. In addition, some providers required time to review the  veteran’s medical record before scheduling the appointment with  TriWest.

We found that 20 of the 30 veterans referred to Choice Program  providers received care within VHA’s 30-day timeliness goal that  VA used to evaluate TriWest’s performance under its contract.  TriWest has an overall timeliness goal from VHA to provide veterans  care through Choice Program providers, although the way this was  calculated changed during our review due to changes in their practice  and modifications to the contract. The 20 veterans that received  care within the timeliness goal did so within an average of 14 days.  The 10 veterans that did not receive care within the 30-day timeliness  goal waited between 31 and 126 days (an average of 62 days).  Veteran preferences and specific provider tendencies sometimes led  to delays in scheduling, causing care to be completed outside VHA’s  timeliness goal. For example, our review of TriWest records found that  two veterans in Guam noted that they preferred to stay on island for  their ophthalmology referrals, rather than flying to Honolulu, and the  non-VA Guam orthopedist sometimes took a week or more to review  a veteran’s file before scheduling the appointment with TriWest.

The 30-day timeliness goal that VA used to evaluate TriWest’s  performance captured a portion of the overall amount of time that it took  for these veterans to receive care. We found that the number of days  from the referral’s creation to the date that veterans received care from  Choice Program providers varied by clinic, and ranged from 19 to 239  days, with the average being 75 days. (See table 9.) This range and  average includes circumstances outside of TriWest’s control; for example,  four veterans in our sample chose to reschedule their appointments  for a later date. One veteran from American Samoa was originally  scheduled for an appointment within 40 days of the referral’s creation  date; however, the veteran chose to reschedule the appointment and,  in doing so, it took a total of 166 days for the veteran to be seen.  three other veterans experienced delays in care after VAPIHCS  initially sent their referrals to TAMC or NHG and later redirected the  referrals to the Choice Program. VAPIHCS referred one veteran from  Guam for specialty care at NHG. However, when VAPIHCS  discovered that NHG could not provide care to the veteran, the  veteran’s referral was redirected to the Choice Program 88 days after  the referral creation date. This veteran encountered additional delays  because of the time it took the Choice Program provider to review  medical records before scheduling the appointment. As a result, it  took a total of 180 days for the veteran to be seen.

Time taken to receive care from a DOD provider. After referring a  veteran to a DOD provider, VHA does not have any timeliness goals or  requirements in place related to the scheduling of appointments, or when  the veteran should receive care. Our review found wide ranges in the time  it took for the 39 veterans in our sample to receive care at TAMC and  NHG. (See table 10.)

TAMC: It took up to 95 days for 29 veterans from the American  Samoa, Guam, and Maui clinics referred to TAMC to receive specialty  care, with an average of 37 days from the creation of the referral to  receiving care. These time frames include some veterans that  rescheduled their appointments for later dates. For example, one  veteran from Maui did not show up to the originally scheduled  appointment (which was scheduled for approximately a month after  the referral creation date), and the appointment was rescheduled for  two months later.

NHG: It took up to 107 days for 10 veterans from the Guam clinic  referred to NHG to receive specialty care, with an average of 47 days  from the creation of the referral to receiving care.

Weaknesses in VAPIHCS’ Referral Process May Have Contributed to the Time Taken to Provide Care at One DOD Military Treatment Facility

When reviewing VAPIHCS’ referrals to NHG, we found weaknesses with  the VAPIHCS’ referral process, including (1) incorrectly canceling  referrals, (2) inconsistent guidance describing roles and responsibilities,  and (3) untimely referral management. These weaknesses may have  contributed to the amount of time it took for veterans to receive care, or  resulted in the veteran not receiving care.

Military Treatment Facility Referral  Process  After the Department of Veterans Affairs (VA)  Pacific Islands Health Care System  (VAPIHCS) staff review a referral and decide  care should be rendered at a military  treatment facility, there are two different  processes for sending the referral to Tripler  Army Medical Center (TAMC) or Naval  Hospital Guam (NHG). If it is determined that  a veteran needs care at TAMC, VAPIHCS  staff review and send the referral to TAMC’s  VA Referral Center. There, TAMC staff enters  the referral information into DOD’s electronic  medical record system and completes the  appointment scheduling process. If it is  determined that a veteran needs care at NHG,  VAPIHCS staff review and send the referral to  designated staff on Guam who have access to  enter the referral directly into NHG’s electronic  medical record. After the designated staff on  Guam enter the referral into the system, NHG  staff are then responsible for scheduling the  veteran’s appointment.

Some referrals sent to NHG were incorrectly canceled by VAPIHCS  staff. Specifically, in addition to the 10 completed referrals we reviewed,  we also examined 5 referrals sent to NHG that were subsequently  canceled by VAPIHCS staff responsible for referral management, but with  no indication of appointments ever being scheduled. The reason for  cancelations recorded in the veterans’ medical records was that the  referrals had been open for more than 90 days; however, this practice is  not in alignment with VHA policy. According to VHA policy confirmed by a  VHA official, canceling a referral is an action taken by the receiving  service to alert the sending provider that additional information is needed,  or to correct an obvious error in the referral; a referral should not be  canceled due to the length of time the referral has been open without care  being provided. VHA policy also states that canceled referrals older than  90 days are not to be resubmitted by the sending provider; instead, the  sending provider must reassess the patient’s needs, as the clinical  circumstances may have changed, and create a new referral, as  necessary. Based on our review, it is unclear why VAPIHCS staff  responsible for referral management were not following VHA policy for  canceling referrals, whether it was because they did not understand the  policy or for other reasons. Federal internal control standards require  management to review processes in a timely manner to ensure that  control activities are appropriately designed and implemented. Because  our review found that in some cases VAPIHCS staff were not following  VHA’s referral policy, it is important for VAPIHCS to determine why staff  are not adhering to the policy and take needed steps to ensure  compliance. Ultimately, in our review of the veterans’ medical records, we  did not find documentation that these veterans received the  recommended care included in the canceled referrals. Additionally, we did  not find evidence that four of the five referrals had been updated and  resubmitted, or that any new referrals had been submitted in their place,  which may have delayed needed care; or that the five affected veterans  were contacted by VAPIHCS to understand why appointments had not  been scheduled.

Inconsistent guidance exists describing the roles and  responsibilities of VAPIHCS staff involved in the NHG referral  process. We identified different VAPIHCS guidance that provided  inconsistent descriptions of the referral process with NHG. For example, a  VAPIHCS flowchart depicting the referral process states that, after  review, the referral is to be sent to a VAPIHCS staff member embedded  within NHG to enter the referral information into NHG’s electronic medical  record. However, language in the referral itself states that, after review,  the referral is sent to Guam clinic staff to enter into NHG’s record.  Federal internal control standards call for management to assign  responsibility and delegate authority to achieve an agency’s objectives.

A VAPIHCS official stated that the embedded member within NHG  entering in referrals in NHG’s electronic medical record was an interim fix  and that there are plans in place for those responsibilities to be  transferred to NHG staff. Specifically, VAPIHCS and NHG officials  reported that NHG plans to hire two staff members to manage the referral  process, but as of December 2017, these 2 staff members had not yet  been hired due to budgetary constraints. Whether or not NHG hires  additional staff, it is important for VAPIHCS to clarify and document the  roles and responsibilities of their staff for sending, managing, and  monitoring referrals to NHG. Without such clarification, there is the risk for  confusion about responsibilities for entering referrals into NHG’s  electronic medical record, which could potentially create delays in  appointment scheduling and veterans’ receiving care.

VAPIHCS did not always manage referrals to NHG in a timely way.  Our review found instances throughout the NHG referral process where  lack of timely referral management by VAPIHCS staff may have  contributed to delays in veterans receiving care. VHA policy states that  the referral process should include appropriate staff to manage referral  notification, disposition, scheduling and completion; and designate staff to  run referral reports, which must be reviewed at least weekly to resolve  issues. In addition, federal internal control standards state than an  organization should establish and operate monitoring activities to  determine appropriate corrective actions on a timely basis.

One factor that contributed to the lack of timely referral management was  that VAPIHCS does not effectively monitor the referrals sent to NHG.

First, VAPIHCS staff did not always monitor the availability of services  at NHG with the frequency necessary to ensure the timeliness of  referral management. NHG is to provide VAPIHCS with a list of  available outpatient services no less than quarterly so VAPIHCS can  determine if a referral for a specific service can be made to NHG; we  confirmed that NHG provided these lists quarterly during our review  time frame. However, VAPIHCS staff did not monitor whether services  remained available after sending referrals to NHG in a timely manner.  For example, one veteran in our review was originally referred to NHG  in late November 2016, but it was not until VAPIHCS staff followed up  on the referral in early February 2017 that they were informed that  NHG could not accommodate the veteran at that time and that they  instead should refer the veteran to a non-VA provider. This may have  contributed to delay in care for the veteran by more than 2 months.

Second, VAPIHCS staff did not ensure that referrals were entered into  NHG’s electronic medical record system in a timely manner to begin  the appointment scheduling process; under the process agreed to by  VAPIHCS and NHG, it is the responsibility of designated VAPIHCS  staff to enter referrals into the NHG electronic medical record system.  For example, VAPIHCS staff referred one veteran for care to NHG in  November 2016. However, it was not until December 2016—one  month later—that VAPIHCS staff checked on the status of the referral.  Finding no evidence of actions taken to schedule an appointment,  staff added a reminder for the embedded VAPIHCS staff member at  NHG to enter the referral into NHG’s electronic medical record, to  restart the appointment scheduling process.

Third, VAPIHCS staff did not always manage referrals to ensure the  timely disposition and scheduling of appointments. Among the five  canceled referrals that we reviewed, we found VAPIHCS staff noticed  appointments had not been scheduled only when they reviewed the  referrals months later. For example, of the five referrals VAPIHCS  sent to NHG, one referral, sent in mid-November 2016, was canceled in early  February 2017 after VAPIHCS staff found no evidence that an  appointment had or would be scheduled. another referral was sent in late November 2016. After VAPIHCS  staff reviewed the referral and found no evidence that an  appointment had or would be scheduled, they noted that the  referral was 101 days old and canceled it in late January 2017.

VAPIHCS staff referred another veteran to NHG in mid-March  2017. After VAPIHCS staff reviewed the referral and found no  evidence that an appointment had or would be scheduled, they  noted that the referral was almost 4 months old and canceled it in  June 2017.

VAPIHCS’ lack of timely referral management was also due to poor  communication between VAPIHCS staff and NHG. Federal internal  control standards state that an organization should communicate with  external bodies to receive the necessary quality information required to  achieve the entity’s objectives. A VAPIHCS official stated that VAPIHCS  staff do not have the same level of communication with NHG as they do  with TAMC, which has its own staff to schedule veteran appointments and  communicate that information back to VAPIHCS on a weekly basis,  including if they cannot schedule a veteran. Instead, the official stated  that VAPIHCS staff have to independently monitor the status of referrals  to NHG, or ask the embedded VAPIHCS staff member at NHG to  complete referral research for them. In addition, our review of the referral  notes for these veterans found no evidence of communication between  VAPIHCS staff and NHG staff regarding NHG’s efforts to schedule  appointments for veterans before VAPIHCS staff canceled them.  Furthermore, we also found no evidence of communication regarding  outreach by NHG staff to VAPIHCS staff to discuss any scheduling  difficulties, such as being unable to contact a veteran.

Because VAPIHCS relies on NHG to provide inpatient and specialty care  services for veterans from Guam and the Commonwealth of the Northern  Mariana Islands, it is essential that referrals sent to NHG are managed in  a timely manner, including verifying the availability of services and  ensuring referrals are entered into NHG’s electronic medical record  system, as well as communicating with NHG about the status of veterans’  appointments. Without a more robust referral management process,  VAPIHCS is unable to ensure that veterans receive needed care in a  timely manner, if they receive care at all.

VAPIHCS Has Faced Physician Recruitment and Retention Challenges, but Has Not Evaluated the Strategies It Used to Help Resolve Them

VAPIHCS Has Faced Physician Recruitment and Retention Challenges, Including Those Unique to the Pacific Islands, and Others Common across VHA

We found that VAPIHCS has faced physician recruitment and retention  challenges that are both unique to the Pacific Islands, such as the limited  number of local physicians from which to recruit, and challenges that are  common across VHA, such as the amount of time it takes to hire a new  physician. Having an adequate physician workforce is key to ensuring  veterans’ timely access to health care. Overall, there were at least 17  physician vacancies out of approximately 100 positions across VAPIHCS  as of October 2017, as well as several more vacancies for other types of  health care providers, some of which have been unfilled for some time.  For example, Guam clinic staff told us that at one point between October  2016 and March 2017, the period of our medical record review, the clinic  had 1.8 primary care physician full-time equivalents even though it was  authorized for 4. VAPIHCS officials told us they are constantly trying to  recruit physicians for their facilities.

Recruitment and Retention Challenges Unique to VAPIHCS. Through  our review of relevant literature and interviews with VAPIHCS officials, we  learned that physician recruitment is challenging for VAPIHCS in the  following ways, particularly because of its geographic remoteness:

There is one local medical school and limited local providers  from which VAPIHCS recruits. The University of Hawaii’s John A.  Burns School of Medicine is the only local medical school across  Hawaii, Guam, and American Samoa from which VAPIHCS recruits  physicians.

The islands of American Samoa, Guam, and Hawaii all include  counties, facilities, or populations designated as Health  Professional Shortage Areas, which indicate health care provider  shortages in primary, dental, or mental health care. These  designations indicate a limited number of local physicians for  VAPIHCS to target in the event of a vacancy. A 2015 University of  Hawaii study further highlighted these shortages. It found that the  Hawaiian Islands had a deficit of more than 600 physicians, with a  projected shortage of between 800 and 1,500 physicians by 2020.  This requires VAPIHCS to focus its recruitment efforts on medical  schools and physicians located on the mainland United States.

Travel options for VAPIHCS staff and their families are limited.

Finding physicians that are willing to relocate to such remote locations  is difficult, according to VAPIHCS officials. In prior work, we found that  other VAMCs experienced challenges recruiting physicians who were  reluctant to practice in rural or geographically remote areas. This  challenge is likely more pronounced for VAPIHCS, given the location  of its clinics. Both American Samoa and Guam are thousands of miles  from the mainland United States and travel to and from these islands  requires significant time and money. For example, American Samoa  only has two direct commercial flights a week (on Mondays and  Fridays) and Guam has only a daily direct commercial flight to  Honolulu. While the Hawaiian Islands are more accessible to the  mainland, they are still geographically isolated relative to the rest of  the United States, and face some of the same travel challenges as  American Samoa and Guam.

Residents face a high cost of living, limited community  resources, and trade-offs associated with island living. While  other regions of the country face similar challenges, they may be  more pronounced living on an island where alternatives are limited.  The cost of living in Hawaii is higher than the nationwide average, and  VAPIHCS officials told us that the real estate market in Hawaii is  extremely expensive. These officials also said that physician  candidates have raised concerns about the quality of the public school  system in some areas of the islands, which could add a potential  expense of sending their children to private schools and thus deter  them from accepting employment. Other concerns include, for  example, the lack of a veterinarian on American Samoa. According to  an official, VAPIHCS lost a candidate who had agreed to relocate to  the island until learning of the lack of veterinary services.

Technical issues due to locations. One physician in American  Samoa told us that it can take almost 1.5 hours to access the web- based program VHA offers for voice-activated dictation of medical  notes, and thus, instead, he often uses services offline, although  doing so means he has to enter his notes into VA’s medical record at  a later time. Guam clinic staff, including physicians, also face unique  challenges due to working across the International Date Line from the  Spark M. Matsunaga VAMC. Specifically, the Guam clinic information  technology system operates off of a server located in Honolulu that is  20 hours, or almost a day, behind Guam. Veterans being treated in  Guam are essentially being treated in the “future” according to VA’s  server in Honolulu, as the date of a health care appointment in Guam  is always one day ahead of the server in Honolulu. For example, if a  Guam physician sees a patient on Monday at 3:00 pm, it is 7:00 pm  on Sunday in Honolulu. As a result, physicians must wait until the next  day to retroactively complete clinical notes. Officials also said that  physicians are frustrated working in a system that may require  multiple days to complete clinical notes, and that this issue has  impacted physician recruitment and retention. Guam clinic staff also  said that, due to the time change, they only have about 16 business  hours per week that the clinic is open that overlap with business hours  of VAPIHCS officials working in Honolulu, which limits the amount of  time physicians at the Guam clinic can consult with other VAPIHCS  physicians or administrators in Honolulu.

Recruitment and Retention Challenges across VHA. VAPIHCS has  encountered some of the same physician recruitment and retention  challenges that we have previously found are common across VHA,  although some of these challenges may be compounded by the Pacific  Islands’ geographic remoteness. For example:

Differences in interpretation of recruiting and hiring policies may  have contributed to lengthy recruiting times. In prior work, we  found that differences in VAMC officials’ understanding of some of  VHA’s recruitment and hiring policies contributed to lengthy  recruitment and hiring processes. We also heard differences in  policy interpretations during our discussions with VAPIHCS officials  for this review. For example, some officials mentioned that a physician  vacancy must be posted to USAJobs; however, VHA’s hiring  authorities allow facilities to hire physicians for positions without  regard to civil service requirements, such as requiring public notice of  the vacancy. Some VAPIHCS officials also mentioned having to wait  to post a position until after the predecessor had vacated it, while  another official correctly noted that the recruitment process to replace  a departing physician can begin before the position is vacated. Failure  to understand VHA’s hiring authorities and use an expeditious hiring  process most suitable for a particular vacancy may contribute to the  length of the recruitment process.

Lack of interoperable electronic medical record systems between  VA and DOD. We have reported for more than a decade that VA and  DOD lack interoperable electronic medical record systems that permit  the efficient electronic exchange of patient health information. VA  and DOD partly addressed the lack of interoperability by utilizing a  web-based Joint Legacy Viewer to facilitate information-sharing for VA  and DOD patients, including those at VAPIHCS, NHG, and TAMC.  The Joint Legacy Viewer provides VAPIHCS physicians with access  to clinical notes on a veteran being treated at a military treatment  facility. However, VAPIHCS and DOD officials told us that there are  challenges using the Joint Legacy Viewer, including the absence of  robust information found in electronic medical records, the need for  physicians to toggle between multiple applications to obtain a patient’s  full history, slow networks, and reduced worker productivity as a result  of operating several different systems simultaneously. Retention of  physicians may be difficult in an environment where the administrative  burdens associated with information technology may take time away  from providing patient care.

VAPIHCS Has Used, but Not Evaluated, VHA Strategies to Support Physician Recruitment and Retention

Primary responsibility for physician  recruitment and retention rests with each  Veterans Affairs medical center (VAMC)  While each Veterans Integrated Service  Network has a Human Resources office  responsible for overseeing the VAMC-level  Human Resources offices within its network,  individual VAMCs are responsible for  managing their employee recruitment and  retention programs. The Veterans Health  Administration supports VAMCs in recruiting  and retaining providers by providing system- wide strategies for their use.

VAPIHCS and VHA officials told us they have recruited and retained  physicians to the Pacific Islands by promoting attributes of its location and  by using VHA strategies, similar to other VAMCs nationwide. Locally,  officials told us they have advertised the Pacific Islands’ weather and  scenery during their recruitment efforts. Officials also said they promoted  VAPIHCS’ unique relationship with DOD through its joint venture with  TAMC in Honolulu as an incentive for moving to Hawaii. For example,  some VAPIHCS physicians working in Honolulu have the opportunity to  work alongside DOD physicians at TAMC—including the ability to consult  face-to-face regarding care for a veteran referred to TAMC and provide  care to DOD beneficiaries in certain settings.

VAPIHCS also used many of the VHA strategies used at VAMCs  nationwide to help with its physician recruitment and retention efforts.  VAPIHCS officials discussed the use of the following VHA strategies, and  noted limitations associated with some of them.

Financial incentives. VAPIHCS officials reported that they  sometimes used recruitment and retention bonuses and relocation  allowances for physicians. For example, in fiscal year 2017,  VAPIHCS paid $217,257 in recruitment incentives to three specialty  care providers (for an average of $72,419 per physician). VAPIHCS  did not offer any other financial incentives that year.

Education Debt Reduction Program. Through the Education Debt  Reduction Program, VHA reimburses qualifying education loan debt  for employees, including physicians, in hard-to-recruit positions. In  fiscal year 2017, three primary care physicians in VAPIHCS had  applications approved for this program. Each recipient was awarded,  on average, $17,000. VAPIHCS officials said the program was  generally considered a “great recruiting tool,” but that its success was  inconsistent given uncertainties regarding the amount of funding that  would be available to the facility in a given year. Funds for the  Education Debt Reduction Program, which are centrally managed by  VHA’s Healthcare Retention and Recruitment Office, are based on the  availability of funds and demand each year. In instances where  centralized funding is not available, VAPIHCS and other VAMCs are  authorized to use local funds to support program offers, but VAPIHCS  officials said they have not used any local funds to support the  program in the last 5 years.

National Recruitment Program. VHA’s National Healthcare  Recruitment Service, a division of VHA’s Workforce Management and  Consulting Office, operates the National Recruitment Program, which  provides direct physician recruitment services to VAMCs for hard-to- recruit positions by using private-sector recruiting techniques,  including representing VHA at medical conferences and screening  resumes. As part of VISN 21, VAPIHCS may also use the services of  the network’s one dedicated recruiter responsible for serving the nine  facilities in the VISN. In the almost 6 years since this recruiter has  worked for VISN 21, he reported recruiting seven physicians and one  social worker for VAPIHCS, and is in the process of recruiting a  nephrologist. The recruiter observed that with recent leadership  changes, VAPIHCS officials have been more engaged with his office  and the recruiting assistance he can provide. VAPIHCS officials  shared these sentiments, echoing their interest in increasing utilization  of the VISN recruiter.

Rural Health Training and Education Initiative. According to VHA  officials, VAPIHCS is one of five facilities to participate in VHA’s Office  of Rural Health’s Rural Health Training and Education Initiative to  enhance its physician recruitment efforts. This program works with  academic affiliates to help place physicians in rural areas and  enhance VAMCs’ recruitment efforts and educate trainees about  working within a VA rural health environment. According to VAPIHCS  officials, 3 out of 16 physicians from this program who are eligible to  be hired have taken positions at its clinics, including positions in  Guam and Molokai.

Enhanced Physician Recruiting and Onboarding Model. In 2015,  VHA issued its Enhanced Physician Recruiting and Onboarding Model  to standardize interpretation of its recruitment policy, strengthen  overall physician recruitment at VAMCs, and shorten hiring  processing time. VAMCs were not required to implement the model,  and in our prior work, we found that implementation has been limited  due to, for example, the lack of resources to implement the  recommendation for a dedicated VAMC-based physician recruiter.

VAPIHCS officials we spoke with said they were unaware of the  Enhanced Physician Recruitment and Onboarding Model, but  reported that they use 20 of the 30 best practices listed under the  model, when asked about those practices. These best practices  include, for example, leveraging increased pay rates when recruiting  physicians, engaging with the VISN recruiter for hard-to-fill vacancies,  and identifying interview questions and an interview panel before  recruitment begins. VAPIHCS officials reported that they do not use  other best practices such as utilizing VA’s human resources program  for tracking recruitment actions and having a dedicated physician  recruiter because they already have an alternate practice in place or a  practice does not match their needs, among other reasons. However,  officials told us they plan to examine whether there are opportunities  to leverage any of these remaining best practices.

As noted, in a prior report we recommended that VHA should conduct a  comprehensive, system-wide evaluation of the physician recruitment and  retention strategies used by VAMCs to determine their overall  effectiveness, identify and implement improvements, ensure coordination  across VHA offices, and establish an ongoing monitoring process.  However, because VAMCs are primarily responsible for managing their  own employee recruitment and retention programs and given the unique  and ongoing challenges VAPIHCS has experienced with recruiting and  retaining physicians, it is also important for VAPIHCS to similarly evaluate  whether the strategies it uses are effective. An evaluation conducted by  VHA on system-wide recruitment and retention strategies would not  preclude the need for VAPIHCS to evaluate the strategies it uses; rather,  it would further help identify those specific strategies that are most  effective for recruiting and retaining physicians in the Pacific Islands.

Federal standards for internal control related to monitoring calls for  agencies to perform monitoring activities, including completing  evaluations to monitor the design and effectiveness of the operations at a  specific time. Agencies are to then evaluate the results of these activities  and take corrective actions as needed. Ensuring veterans have timely  access to health care services is one of VA’s objectives, which is  dependent upon having an adequate number of physicians to provide the  care. VAPIHCS officials told us that as of December 2017 they have not  conducted any type of evaluation of their current strategies for facilitating  physician recruitment and retention due to recent changes in leadership  positions. Without evaluating the strategies currently used to determine  their effectiveness, or determining if additional strategies offered by VHA  might be appropriate, VAPIHCS risks missing the opportunity to target its  efforts to those strategies that have the greatest potential to ameliorate  long-standing staffing shortages.

Veterans Face a Number of Challenges Accessing Health Care in the Pacific Islands, and VAPIHCS Uses Several Strategies to Improve Access

Lack of Certain Specialties on the Pacific Islands and Significant Travel Are among Challenges Veterans Face Accessing Heath Care

According to VAPIHCS officials, veterans face challenges accessing  health care services on the Pacific Islands due to the lack of certain  specialty care providers on many of the islands, the significant travel that  is required to obtain these services, and limitations associated with  telehealth services.

Lack of certain specialty care providers. VAPIHCS officials told us that  several Pacific Islands lack certain specialty care services entirely or  significantly enough that there may be only one or a few of a certain  provider type available to serve all residents, including veterans. Overall,  VAPIHCS officials noted that the availability of different types of  physicians across the islands is constantly in flux, but said that notable  shortages are in gastroenterology, audiology, podiatry, rheumatology,  dermatology, and neurology. For example, according to VAPIHCS  officials,  there is only one dermatologist on Guam practicing at NHG, and there  is only one gastroenterologist in the community providing certain  services;

Maui has a shortage of cardiologists; and

American Samoa has a shortage of almost all types of specialty care  providers because it only has one hospital—the Lyndon B. Johnson  Tropical Medical Center—to provide medical care to its approximate  55,000 residents. VAPIHCS officials said the hospital is lacking many  specialty services. According to VA, it does not authorize non-VA care  there because the hospital receives funding from other federal  agencies to provide medical services. Additionally, the hospital is not  accredited for safety and quality. TriWest officials reiterated that  there are virtually no specialty providers available on American  Samoa for them to contract with; as of July 2017, there was only one  Choice Program provider contracted on the island. As a result,  essentially all eligible veterans must travel to Hawaii for specialty care  services.

Significant travel required of veterans. Because many of the islands  lack certain specialty providers, VAPIHCS officials said that veterans  often must fly elsewhere to obtain care. While travelling such distances  helps improve veterans’ access to health care services, it also creates  challenges. For example, such travel requires time away from their  homes and families, which may be particularly difficult for veterans in poor  health. The time and distance required for travel can also be quite  significant—for example, veterans from American Samoa, Guam, and the  Commonwealth of the Northern Mariana Islands must travel thousands of  miles by plane to receive services in Honolulu. A Guam veterans group  said that veterans were frustrated with having to fly 8 hours to Hawaii for  health care services. In instances where the necessary services are  beyond those available in Honolulu, veterans must fly to the mainland  United States for care—a flight from Honolulu to California adds about 5  hours. The flight times are even longer for veterans travelling from  American Samoa, the Commonwealth of the Northern Mariana Islands,  and Guam. Figure 2 illustrates the locations of veterans enrolled in  VAPIHCS and the distances and flight times they may need to travel to  receive care.

According to VAPIHCS data, most VAPIHCS veterans travelling for health  care services over the years have received care in Honolulu, although  some have had to travel to the mainland United States for subspecialty  care or highly specialized care such as organ transplants. Eligible  veterans are provided reimbursement for travel-related expenses under  VHA’s Beneficiary Travel Program. In fiscal year 2017, VAPIHCS  provided beneficiary travel funds to 348 veterans from American Samoa  and 92 veterans from Guam to travel to Honolulu for care, for a total of  678 trips. During this same year, 15 veterans traveled to the mainland  United States for care. VAPIHCS reported that, overall, 830 VAPIHCS  veterans used beneficiary travel benefits to travel to Honolulu or the  mainland United States for care that year. This represents approximately  2 percent of the total number of veterans (51,213) who received some  type of care through VAPIHCS in fiscal year 2017. Veterans are  responsible for paying for travel if they are ineligible for travel benefits and  travel is required to receive care. The significant costs associated with  travel among the Pacific islands—flights, lodging, meals—could be cost  prohibitive for these veterans and, as a result, they may be unable to  access VA or non-VA health care services off island.

Limitations with telehealth services. Veterans face challenges  accessing health care services due to limitations with telehealth services.  For example, VAPIHCS officials told us there are limitations with the  availability of internet services on the islands of Guam and American  Samoa. This could lead to disruptions—or even cancellations—of  veterans’ telehealth appointments. For example, VAPIHCS officials  shared that damaged cables in the Pacific Ocean due to natural disasters  and equipment failure on the part of internet service providers on the  islands have led to disrupted and cancelled appointments for veterans. In  March 2018, VAPIHCS reported that it had increased bandwidth and  purchased new equipment to help support its telehealth efforts.  Additionally, the extent to which a veteran can receive telehealth in his or  her home versus the local clinic may depend upon the licensure of the  provider delivering care. If a veteran is receiving telehealth services while  he or she is physically located in a clinic, under federal law, the provider  is not required to be licensed in the state in which the facility is  located. When the patient is receiving telehealth services at home,  however, a state may require that the provider be licensed in the state in  which the patient is located. An official said that this is currently  hampering VAPIHCS’ telehealth expansion efforts into the home.

VAPIHCS Uses Several Strategies to Improve Veterans Access to Health Care, including the Use of Travelling Providers and Increased Use of Telehealth

VAPIHCS has utilized a system of travelling VAPIHCS providers and is  working to improve its use of telehealth services to better ensure  veterans’ timely access to care, among other strategies, according to  VAPIHCS officials.

Use of travelling providers. VAPIHCS officials reported that travelling  providers enable VAPIHCS to better ensure access for veterans who are  not eligible for beneficiary travel, and reduce the travel burden on  veterans who are. Furthermore, they noted that it can be more cost  effective for VAPIHCS to send a travelling provider to an island on a set  schedule than it is to fly veterans to Honolulu for care. These providers  also help expand access by providing specialty care that is in short supply  or missing entirely in some communities. For example, a VAPIHCS  optometrist travels to American Samoa for one week each month,  according to officials, because there is no board-certified optometrist on  the island. In addition, the travelling providers offer veterans the  opportunity to receive specialty care from a VA provider.

Officials said they adjust the travelling providers’ schedules to reflect  changes in service availability in the local communities. Table 11  illustrates the types of VAPIHCS travelling providers and the frequency  with which they visit different clinics, as of December 2017.

Increased use of telehealth services. Even though internet service on  the Pacific Islands is not always reliable as previously noted, VAPIHCS  has been increasing its use of telehealth services to improve veterans’  access to health care services. In fiscal year 2017, VAPIHCS reported  that 3,046 VAPIHCS veterans utilized clinic-based telehealth services  compared to 1,299 veterans in fiscal year 2011, an increase of more than  134 percent.

VAPIHCS launched two new telehealth hubs in June 2017:

According to VA officials, VAPIHCS was 1 of 8 VAMCs selected to  establish a hub, or center for delivery of teleprimary care from the  VAMC to distant clinics within its system. According to VAPIHCS  officials, the teleprimary care hub in the Spark M. Matsunaga VAMC is  currently providing services to veterans at the Guam clinic and is  exploring opportunities to provide teleurgent care in partnership with  VAPIHCS’ call center. Officials further noted this would allow  telehealth staff to provide veterans with “almost instant access” to  health care services and, if successful, help improve veterans’ timely  access to care by increasing the number of appointments at the  clinics that could be dedicated to more complex concerns. VAPIHCS  officials also said that the teleprimary care hub would also be used for  long-term coverage for clinics with provider vacancies.

Similarly, VAPIHCS was one of 11 VAMCs selected to establish a  telemental health hub. According to VAPIHCS officials, this hub is  currently serving veterans at the Oahu, Guam, and Molokai clinics  and one of the Hawaii clinics (Hilo), with plans to expand services to  the Kauai clinic in the future.

Overall, officials said that feedback from veterans using these hubs has  been “overwhelmingly positive,” as veterans appreciate receiving care  from VAPIHCS providers, the privacy afforded by telehealth, and not  having to travel for their services. The number of telehealth users in  VAPIHCS is likely to continue increasing as a result of these new hubs.

While feedback has been positive, VAPIHCS officials said they have  experienced some challenges with the launch of these hubs, including the  time and date difference between Guam and Honolulu where the staff for  both hubs are located. Staff from the hubs had to adjust their schedules  to support Guam’s hours given that only 16 business hours per week  overlap between the two islands. Having sufficient space in the clinics for  telehealth services is another challenge. To address this, one official said  they are encouraging veterans to hold video visits with their providers  from their homes if clinical exams are not required during their  appointments.

Improvements to clinical space. Because sufficient examination and  treatment space is lacking in many of its clinics, VAPIHCS is in the  process of building new or expanding existing clinics to increase the  number and type of services available to veterans. According to a  VAPIHCS official, as of August 2017, VAPIHCS has plans to replace six  of its existing clinics and open one new clinic. These new clinics are  expected to be open by fiscal year 2020. For example, the American  Samoa clinic will be expanded to include additional space for mental  health consultations and group meeting spaces, while the Guam clinic will  be expanded to include additional primary and mental health care clinic  space. This may help address a concern of the Guam veterans group we  spoke with in Guam, who said the clinic was too small and did not offer  sufficient patient privacy. According to VAPIHCS officials, VAPIHCS’ new  clinic, expected to open in 2020, is to be located on the island of Oahu  and will be a multi-specialty outpatient clinic offering many different  services, including primary care, mental health, telemedicine, women’s  care, dental care, a pain clinic, physical and occupational therapy,  prosthetic, laboratory and pathology, pharmacy, and imaging services.

Improvements to the beneficiary travel process. VAPIHCS is in the  process of updating its process for arranging beneficiary travel, which  ultimately could improve veterans’ access to care. Under the old process,  officials told us that much of the responsibility for coordinating veterans’  travel fell on nursing and administrative staff, creating stress and reducing  the amount of time nurses could spend on providing patient care. As a  result, VAPIHCS decided to centralize its beneficiary travel process in the  Office of Beneficiary Travel in Honolulu. The goal, according to VAPIHCS  officials, is to remove the clinic staff from the process—thereby increasing  the amount of time dedicated to their clinical duties—and instead  encourage veterans to work directly with the staff in Honolulu to arrange  their travel. As of September 2017, VAPIHCS was still in the process of  implementing this new process. VAPIHCS also created a task force to  improve the process for arranging travel for American Samoa veterans  needing care off-island. As a result of their efforts, VAPIHCS officials  reported in December 2017 that they had managed to reduce the time  clinic staff in American Samoa dedicated each day to addressing travel  issues from an average of 408 minutes to 64 minutes.

Communicating with veterans about VA and Non-VA services.  VAPIHCS uses a variety of mechanisms to communicate with veterans  about access to VA and non-VA health care services. Veterans are  introduced to these services through New Veteran Orientations that are  offered at some of the clinics. VAPIHCS also gives newly enrolled  veterans handbooks that are specific to the clinics where they enrolled.  VAPIHCS also communicates with veterans through town hall meetings,  health forums, its Facebook page, television and radio shows, and  community events. For example, staff from the American Samoa clinic  told us that they partner with a local television station to host a 30-minute  monthly segment to educate veterans about available VA services.  VAPIHCS officials reported they had planned to conduct approximately  170 outreach events, spanning 9 islands and targeting about 6,000  veterans, for fiscal year 2017. VAPIHCS officials told us that they try to  provide culturally appropriate communications with veterans of the  different Pacific Islands. For example, they said they are planning to  translate materials into Samoan for veterans from American Samoa. They  also recognize that many veterans prefer face-to-face interactions with  VA officials rather than receiving information electronically; for example,  the Hawaiian tradition known as “talk story” focuses on informal  conversations and sharing information with friends in the community.

VAPIHCS has generally provided primary and mental health care within  VHA’s timeliness goals for most veterans reviewed, but there are  weaknesses in the referral process for specialty care services. Because  most specialty care services are provided to veterans outside of VA  through DOD providers or through non-VA providers in the community, it  is crucial that VAPIHCS improve its management of these referrals to  ensure adherence to VHA policy. Without improvements to adherence to  VHA policy in the referral process, inconsistent guidance on roles and  responsibilities, and lack of timeliness of referral management, these  weaknesses are likely to persist, and may add to the amount of time it  takes for some veterans to receive care, or may result in some veterans  not receiving care at all.

In addition, maintaining an adequate clinical workforce to meet the health  care needs of veterans is necessary to ensuring veterans’ timely access  to care. Doing so is particularly important for VAPIHCS given the unique  challenges it faces in recruiting and retaining physicians in the  geographically remote Pacific Islands. It is therefore critical that VAPIHCS  identify and use the most effective recruitment and retention strategies  offered by VHA. However, VAPIHCS has not evaluated the strategies that  it has used to determine if they are the most optimal or if other available  strategies would be more effective. Without completing such an  evaluation, VAPIHCS does not know if it is optimizing its resources to  improve its hiring efforts and ameliorate long-standing physician  shortages.

We are making the following four recommendations to VA:  1.  The Secretary of VA should ensure that VAPIHCS review its referral  process for referrals to DOD providers, including referral cancellation,  to determine why VHA policy is not being adhered to and make  changes as needed. (Recommendation 1)  2.  The Secretary of VA should ensure that VAPIHCS clarify guidance to  clearly define and document roles and responsibilities for VAPIHCS  staff involved in the referral process with NHG. (Recommendation 2)  3.  The Secretary of VA should ensure that VAPIHCS improves the  monitoring of referrals and communication with NHG to ensure the  timely management of referrals to NHG, including verifying the  availability of services for veterans; ensuring referrals are entered into  NHG’s electronic medical record system; and obtaining information  about the status of scheduling appointments for veterans.  (Recommendation 3)  4.  The Secretary of VA should ensure that VAPIHCS evaluates the  effectiveness of strategies it currently uses to promote physician  recruitment and retention, including how the strategies could be  improved. The plan should also include an assessment of whether  additional strategies currently offered by VHA would be beneficial.  (Recommendation 4)

We provided a draft of this report to VA and DOD for review and  comment. VA provided written comments, which are reproduced in  appendix I. In addition, both VA and DOD provided technical comments,  which we have incorporated as appropriate.

In its written comments, VA concurred with three of our four  recommendations and provided information on its plans to address them.  VA partly concurred with our recommendation for VAPIHCS to improve  the monitoring of referrals and communication with NHG to ensure the  timely management of referrals to NHG. For this recommendation, VA  agreed that it should improve its monitoring of referrals by verifying the  availability of services at NHG for veterans and obtaining the status of  their appointments to be scheduled, and noted that VAPIHCS is  developing a standard operating procedure that includes, among other  things, monitoring referrals weekly to resolve issues.

However, VA did not agree with ensuring referrals are entered into NHG’s  electronic medical record system as part of its monitoring efforts and  stated that it does not have the authority to do so. During our review, we  found that designated VAPIHCS staff on Guam have access to, and are  responsible for entering referrals directly into, NHG’s electronic medical  record. Only after VAPIHCS staff enter referrals directly into NHG’s  electronic medical record did NHG staff assume responsibility for  scheduling veterans’ appointments. We confirmed this practice through  interviews with VAPIHCS and DOD staff and through our review of a  sample of referrals sent to NHG, which showed that VAPIHCS staff had  entered the referrals. Furthermore, the sharing agreement between  VAPIHCS and NHG documented the arrangement for VAPIHCS staff to  be granted access to NHG’s electronic medical record. As long as  VAPIHCS staff continue to be responsible for entering referrals into  NHG’s electronic medical record system, we believe that it is also their  responsibility to monitor the status of these referrals, including ensuring  that referrals are entered correctly and timely. Because VAPIHCS relies  on NHG to provide inpatient and specialty care services for veterans from  Guam and the Commonwealth of the Northern Mariana Islands, it is  important for VAPIHCS to monitor the entire referral management  process to ensure that veterans receive needed care in a timely manner.

We are sending copies of this report to the appropriate congressional  committees and the Secretaries of Veterans Affairs and Defense. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or at DraperD@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.

Appendix I: Department of Veterans Affairs Comments

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Ann Tynan, Assistant Director,  Kaitlin Coffey (Analyst in Charge), Kate Tussey, Jennie Apter, and Jackie  Hamilton made key contributions to this report. Also contributing were  Emily Binek, Muriel Brown, Natalie Hagy, Alexis MacDonald, and Brienne  Tierney.

Veterans Health Administration: Better Data and Evaluation Could Help  Improve Physician Staffing, Recruitment, and Retention Strategies,  GAO-18-124. Washington, D.C.: October 19, 2017.

VA Health Care: Opportunities Exist for Improving Implementation and  Oversight of Enrollment Processes for Veterans, GAO-17-709.  Washington, D.C.: September 5, 2017.

VA Health Care: Improvements Needed in Data and Monitoring of Clinical  Productivity and Efficiency, GAO-17-480. Washington, D.C.: May 24,  2017.

Veterans Health Care: Preliminary Observations on Veterans’ Access to  Choice Program Care, GAO-17-397T. Washington, D.C.: March 7, 2017.

Veterans Health Administration: Management Attention Is Needed to  Address Systemic, Long-standing Human Capital Challenges,  GAO-17-30. Washington, D.C., December 23, 2016.

Veterans Health Care: Improvements Needed in Operationalizing  Strategic Goals and Objectives, GAO-17-50. Washington, D.C.: October  21, 2016.

Veterans Health Administration: Personnel Data Show Losses Increased  for Clinical Occupations from Fiscal Year 2011 through 2015, Driven by  Voluntary Resignations and Retirements, GAO-16-666R. Washington,  D.C.: July 29, 2016.

VA Health Care: Actions Needed to Improve Newly Enrolled Veterans’  Access to Primary Care, GAO-16-328. Washington, D.C.: March 18,  2016.

VA Mental Health: Clearer Guidance on Access Policies and Wait-Time  Data Needed, GAO-16-24. Washington, D.C.: October 28, 2015.

VA Primary Care: Improved Oversight Needed to Better Ensure Timely  Access and Efficient Delivery of Care. GAO-16-83. Washington, D.C.:  October 8, 2015.

VA Health Care: Oversight Improvements Needed for Nurse Recruitment  and Retention Initiatives, GAO-15-794. Washington, D.C.: September 30,  2015.

VA Health Care: Actions Needed to Ensure Adequate and Qualified  Nurse Staffing, GAO-15-61. Washington, D.C.: October 16, 2014.

VA Health Care: Management and Oversight of Consult Process Need  Improvement to Help Ensure Veterans Receive Timely Outpatient  Specialty Care, GAO-14-808. Washington, D.C.: September 30, 2014.

VA Health Care: Reliability of Reported Outpatient Medical Appointment  Wait Times and Scheduling Oversight Need Improvement, GAO-13-130.  Washington, D.C.: December 21, 2012.

VA and DOD Health Care: Department-Level Actions Needed to Assess  Collaboration Performance, Address Barriers, and Identify Opportunities,  GAO-12-992. Washington, D.C.: September 28, 2012.

Veterans’ Health Care: Service Delivery for Veterans on Guam and the  Commonwealth of the Northern Mariana Islands, GAO/HEHS-99-14.  Washington, D.C.: November 4, 1998.

Veterans’ Benefits: Availability of Benefits in American Samoa,  GAO/HRD-93-16. Washington, D.C.: November 18, 1992.

VA medical facilities have struggled to provide timely care. For veterans who live in American Samoa, Guam, Hawaii, and the Northern Marianas, these areas' remoteness can add challenges, such as long flights to see specialists.

We examined the timeliness of the primary, mental health, and specialty care provided by the VA Pacific Islands Health Care System.

Most veterans in our review received timely primary and mental health care. We found some delays and weaknesses in the referral process to community providers, such as inconsistent guidance on staff roles and responsibilities.

We recommended actions to improve the referral process.