Veterans Choice Program: Improvements Needed to Address Access-Related Challenges as VA Plans Consolidation of its Community Care Programs

Congress created the Choice Program in 2014 to address longstanding challenges with veterans' access to care at VHA medical facilities. The Joint Explanatory Statement for the Consolidated Appropriations Act, 2016 included provisions for GAO to review veterans' access to care through the Choice Program.

This report examines for Choice Program care (1) VA's appointment scheduling process, (2) the timeliness of appointments and the information VHA uses to monitor veterans' access; and (3) the factors that have adversely affected veterans' access and the steps VA and VHA have taken to address them for VA's future community care program.

GAO reviewed applicable laws and regulations, VA's TPA contracts, and relevant VHA policies and guidance. Absent reliable national data, GAO also selected 6 of 170 VAMCs (selected for variation in geographic location and the TPAs that served them) and manually reviewed a random, non-generalizable sample of 196 Choice Program authorizations. The authorizations were created for veterans who were referred to the program between January and April of 2016, the most recent period for which data were available when GAO began its review. The sample of authorizations included 55 for routine care, 53 for urgent care, and 88 that the TPAs returned without scheduling appointments. GAO also obtained the results of VHA's non-generalizable analysis of wait times for a nationwide sample of about 5,000 Choice Program authorizations that were created for selected services between July and September of 2016.

Through the Veterans Choice Program (Choice Program), eligible veterans may receive care from community providers when it is not readily accessible at Veterans' Health Administration (VHA) medical facilities. The Department of Veterans Affairs (VA) uses two contractors—or third party administrators (TPA)—to schedule most veterans' Choice Program appointments after receiving referrals from VA medical centers (VAMC). GAO found that veterans who are referred to the Choice Program for routine care because services are not available at VA in a timely manner could potentially wait up to 70 calendar days for care if VAMCs and the TPAs take the maximum amount of time VA allows to complete its appointment scheduling process. This is not consistent with the statutory requirement that veterans receive Choice Program care within 30 days of their clinically indicated date (when available), which is the soonest date that it would be appropriate for the veteran to receive care, according to a VHA clinician. Without designing appointment scheduling processes that are consistent with this requirement, VA lacks assurance that veterans will receive Choice Program care in a timely manner.

GAO and VHA found that selected veterans experienced lengthy actual wait times for appointments in 2016, after manually reviewing separate samples of Choice Program authorizations. For example, when GAO analyzed 55 routine care authorizations that were created between January and April of 2016, it found that the process took at least 64 calendar days, on average. When VHA analyzed about 5,000 authorizations created between July and September of 2016, it took an average of 51 calendar days for veterans to receive care.

a GAO excluded from its analysis the amount of time the TPA took to schedule the appointment and the overall wait time because its sample selection methodology differed from VHA's in a way that would have skewed these two averages but not the averages for the other segments of the process.

GAO also found that VHA cannot systematically monitor the timeliness of veterans’ access to Choice Program care because it lacks complete, reliable data to do so. The data limitations GAO identified include:

A lack of data on the timeliness of referring and opting veterans in to the program. GAO found that the data VHA uses to monitor the timeliness of Choice Program appointments do not capture the time it takes VAMCs to prepare veterans’ referrals and send them to the TPAs, nor do they capture the time spent by the TPAs in accepting VAMCs’ referrals and opting veterans in to the Choice Program. VHA has implemented an interim solution to monitor overall wait times that relies on VAMC staff consistently and accurately entering unique identification numbers on VHA clinicians’ requests for care and on Choice Program referrals, a process that is prone to error.

Inaccuracy of clinically indicated dates. GAO found that clinically indicated dates (which are used to measure the timeliness of care) are sometimes changed by VAMC staff before they send Choice Program referrals to the TPAs, which could mask veterans’ true wait times. GAO found that VAMC staff entered later clinically indicated dates on referrals for about 23 percent of the 196 authorizations it reviewed. It is unclear if VAMC staff mistakenly entered incorrect dates manually, or if they inappropriately entered later dates when the VAMC was delayed in contacting the veteran, compiling relevant clinical information, and sending the referral to the TPA.

Unreliable data on the timeliness of urgent care. GAO found that VAMCs and TPAs do not always categorize Choice Program referrals and authorizations in accordance with the contractual definition for urgent care. According to the contracts, a referral is to be marked as “urgent,” and an appointment is to take place within 2 days of the TPA accepting it, when a VHA clinician has determined that the needed care is (1) essential to evaluate and stabilize the veteran’s condition, and (2) if delayed would likely result in unacceptable morbidity or pain. GAO reviewed a sample of 53 urgent care authorizations and determined that about 28 percent of the authorizations were originally marked as routine care authorizations but were changed to urgent by VAMC or TPA staff, in an effort to administratively expedite appointment scheduling.

Without complete, reliable data, VHA cannot determine whether the Choice Program has helped to achieve the goal of alleviating veterans’ wait times for care.

GAO found that numerous factors adversely affected veterans’ access to care through the Choice Program. These factors include: (1) administrative burden caused by complexities of referral and appointment scheduling processes, (2) poor communication between VHA and its VAMCs, and (3) inadequacies in the networks of community providers established by the TPAs, including an insufficient number, mix, or geographic distribution of community providers. VA and VHA have taken numerous actions throughout the Choice Program’s operation that were intended to help address these factors, though not all access factors have been fully resolved. For example, to help address administrative burden and improve the process of coordinating veterans’ Choice Program care, VA established a secure e-mail system and a mechanism for TPAs and community providers to remotely access veterans’ VA electronic health records. However, these mechanisms only facilitate a one-way transfer of necessary information. They do not provide a means by which VAMCs or veterans can view the TPAs’ step-by-step progress in scheduling appointments or electronically receive medical documentation associated with Choice Program appointments.

While the Choice Program will soon end, VA anticipates that veterans will continue to receive community care under a similar program that VA plans to implement, which will consolidate the Choice Program and other VA community care programs. Incorporating lessons learned from the Choice Program into the implementation and administration of the new program could help VHA avoid similar challenges.

For VA's future consolidated community care program, GAO is making 10 recommendations, which include:

establishing an achieveable wait-time goal for the community care program that will permit VHA to monitor whether veterans are receiving care within time frames that are comparable to the amout of time they would otherwise wait for care at VHA medical facilities;

designing an appointment scheduling process that (1) is consistent with the wait-time goal and (2) sets forth time frames within which veterans' referrals must be processed, appointments must be scheduled, and appointments must occur;

allow VHA to systematically monitor the amount of time taken to prepare referrals, schedule appointments, and complete appointments;

prevent veterans' clinically indicated dates from being modified by individuals other than VHA clinicians; and

separate clinically urgent referrals and authorizations from those for which the VAMC or the TPA has decided to expedite appointment scheduling for administrative reasons; and

establishing a system that will help facilitate seamless, efficient care coordination and exchanges of information among VAMCs, VHA clinicians, TPAs, community providers, and veterans.

VA generally agreed with all but one of GAO's recommendations, which was to separate clinically urgent referrals from those that are administratively expedited. GAO maintains that implementing this recommendation will help improve future monitoring of urgent care timeliness for reasons explained in the report.

The majority of veterans utilizing health care services delivered by the  Veterans Health Administration (VHA) of the Department of Veterans  Affairs (VA) receive care in VHA-operated medical facilities, including 170  VA medical centers (VAMC) and more than 1,000 outpatient facilities. In  recent years, we and others have expressed concerns about the ability of  VHA’s medical facilities to provide health care services in a timely  manner. Serious and long-standing problems with veterans’ access to  care were also highlighted in a series of congressional hearings in the  spring and summer of 2014, after several well-publicized events raised  additional concerns about wait times for appointments at VHA medical  facilities. In some cases, delays in care or VHA’s failure to provide care  reportedly have resulted in harm to veterans. Due to these and other  concerns, we concluded that VA health care is a high-risk area and added  it to our High Risk List in 2015.

In response to the problems with veterans’ access to care at VHA medical  facilities that were highlighted during the 2014 congressional hearings,  Congress enacted the Veterans Access, Choice, and Accountability Act  of 2014 (Choice Act) on August 7, 2014. Among other things, the law  established a temporary program—called the Veterans Choice Program  (Choice Program)—and provided up to $10 billion in funding for veterans  to obtain health care services from non-VA community providers when  they faced long wait times, lengthy travel distances, or other challenges  accessing care at VHA medical facilities. The temporary authority and  funding for the Choice Program was separate from that of other  previously existing programs through which VA has the option to  purchase care from community providers. Legislation enacted in August  and December of 2017 provided an additional $4.2 billion for the Veterans  Choice Fund. VA may continue to authorize Choice Program care until  all amounts in the Choice Fund are exhausted. Currently, VA is in the  process of planning its future community care program, which (as  described in an October 2015 plan VA submitted to Congress) will  consolidate the Choice Program and six other VA community care  programs into one program.

In accordance with the Choice Act, VA and VHA had up to 90 days to  prepare for Choice Program implementation from the time the Choice Act  was enacted. To cope with the compressed implementation time frame,  VA modified contracts it had previously established with Health Net  Federal Services (Health Net) and TriWest Healthcare Alliance (TriWest)  to administer a different VA community care program and gave them certain responsibilities related to Choice Program administration,  including the scheduling of routine and urgent care appointments for  veterans needing care in the community. VA and VHA refer to Health  Net and TriWest as third-party administrators (TPA). The Choice Program  implementation tasks included designing a framework to administer the  program (which involved dividing responsibilities between VAMCs and  TPAs), negotiating contract modifications to add Choice Program  administration responsibilities to the TPAs’ existing contracts with VA,  designing referral and appointment scheduling processes for VAMCs and  the TPAs, strengthening the community provider networks the TPAs had  established under their existing VA contracts, creating TPA call centers,  training VAMC and TPA staff, producing and distributing Veterans Choice  Cards to veterans, and educating veterans and community providers  about the new program.

External reviews, media reports, and congressional hearings held over  the course of the Choice Program’s implementation and operation have  highlighted programmatic weaknesses, such as insufficient provider  networks, significant delays in scheduling appointments, and a lack of  timely payments to network providers. The Joint Explanatory Statement  for the Consolidated Appropriations Act, 2016 included two provisions for  us to review veterans’ access to care and the delivery of health care services through the Choice Program, with a focus on rural areas. In  addition, you asked us to conduct a comprehensive review of the Choice  Program, focusing on (among other things) the effect the Choice Program  has had on reducing veterans’ wait times for care. In March 2017, we  presented preliminary observations from this work at a hearing of the  House Committee on Veterans’ Affairs. This report updates our  preliminary findings and examines:  1.  the potential wait times for veterans to receive routine care through  the Choice Program, according to VA’s appointment scheduling  process;  2.  selected veterans’ actual wait times to receive routine care and urgent  care through the Choice Program and the information VHA uses to  monitor access to care under the program; and  3.  the factors, if any, that have adversely affected veterans’ access to  care under the Choice Program and the actions, if any, that VA and  VHA have taken to address them for VA’s future community care  program.

To examine the potential wait times for veterans to receive routine care  through the Choice Program according to VA’s appointment scheduling  process, we reviewed applicable laws and regulations; VA’s contracts  with the TPAs; and relevant VA and VHA policy directives, guidance, and  training materials for VAMCs. In addition, we exchanged written  correspondence with VA’s Office of General Counsel about the  application of VHA’s wait time goals to the Choice Program. We also  interviewed a VA contracting official and officials from VHA’s Office of  Community Care (the office responsible for implementing and overseeing  the Choice Program), as well as officials from the two Choice Program  TPAs, Health Net and TriWest. We analyzed this evidence in the  context of the federal internal control standard for control activities, which  includes the design of policies and procedures that will help an entity  achieve its objectives and respond to risks.

To examine selected veterans’ actual wait times to receive routine care  and urgent care through the Choice Program and the information VHA  uses to monitor access to care under the program, we took five key steps.  We (1) analyzed Choice Program appointment wait times for selected  veterans using a sample of 196 Choice Program authorizations for routine  and urgent care; (2) reviewed VHA’s analysis of appointment wait times  for a sample of about 5,000 Choice Program authorizations; (3) reviewed  data VHA uses to monitor the timeliness of Choice Program care and  reasons that the TPAs have returned Choice Program referrals without  making appointments; (4) interviewed VA, VHA, and TPA officials; and (5)  reviewed federal internal control standards. See Appendix I for more  information on these methodological steps.

To examine the factors, if any, that have adversely affected veterans’  access to care under the Choice Program and the actions, if any, that VA  and VHA have taken to address them for VA’s future community care  program, we reviewed documentation and interviewed officials from VA,  VHA, and the TPAs; as well as leadership officials and community care  managers and staff from six selected VAMCs. (See Appendix I for  information about how we selected the six VAMCs.) In cases where we  identified actions VA and VHA had taken to address factors that  adversely affected veterans’ access, we interviewed VA and VHA officials  and reviewed documentation they provided to gain a better understanding  of their rationale for taking those actions and the extent to which they had  evaluated the outcomes or effectiveness of selected actions. Between  May and September of 2016, we interviewed community care managers  and staff at the six selected VAMCs, and we followed up with the  managers in June and July of 2017. During these interviews, we  discussed certain actions VA and VHA had taken and obtained their  perspectives on implementation of the actions and the extent to which  these actions improved veterans’ access to Choice Program care. We  examined the actions VA and VHA took in the context of federal  standards for internal control.

We conducted this performance audit from April 2016 through May 2018  in accordance with generally accepted government accounting 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.

Responsibilities of the Choice Program TPAs

In October 2014, VA modified its existing contracts with two TPAs that  were administering another VA community care program to add certain  administrative responsibilities associated with the Choice Program. For  the Choice Program, each of the two TPAs—Health Net and TriWest—is  responsible for delivering care in a specific multi-state region (See figure  1.). Specifically, the TPAs are responsible for establishing networks of  community providers, scheduling appointments with community providers  for eligible veterans, and paying community providers for their services.

As stated in VA’s December 2015 guidance, the Choice Program allows  eligible veterans to opt to obtain health care services from the TPAs’  network providers rather than from VHA medical facilities when the  veterans are enrolled in the VA health care system and meet any of the  following criteria:  the next available medical appointment with a VHA clinician is more  than 30 days from the veteran’s preferred date or the date the  veteran’s physician determines he or she should be seen;  the veteran lives more than 40 miles driving distance from the nearest  VHA facility with a full-time primary care physician;  the veteran needs to travel by air, boat, or ferry to the VHA facility that  is closest to his or her home;  the veteran faces an unusual or excessive burden in traveling to a  VHA facility based on geographic challenges, environmental factors,  or a medical condition;  the veteran’s specific health care needs, including the nature and  frequency of care needed, warrants participation in the program; or  the veteran lives in a state or territory without a full-service VHA  medical facility.

Over the life of the Choice Program, VA has taken various approaches to  care for veterans for whom services are not available at a particular VHA  medical facility. In May and October of 2015, VHA issued policy  memoranda to its VAMCs that required them to offer veterans referrals to  the Choice Program before they authorized care through one of VA’s  other community care programs, which existed prior to the creation of the  Choice Program. Before May 2015, VA provided VAMCs the flexibility to  decide on a case-by-case basis whether to refer veterans to the Choice  Program or one of VA’s other community care programs when services  were not available. In June 2017, VHA issued another policy  memorandum that rescinded the referral hierarchy that required VAMCs  to refer to the Choice Program first. It directed VAMCs to refer veterans to  the Choice Program only if they met the Choice Act’s wait-time, distance,  and geographic eligibility criteria, and to instead use other VHA medical  facilities, facilities with which VA has sharing agreements, and other VA  community care programs to deliver care to veterans when services were  not available at a VHA medical facility and veterans did not qualify under  the Choice Act’s eligibility criteria. In August 2017, after Congress  provided an additional $2.1 billion for the Choice Program, VHA again  changed its guidance on referral patterns for the Choice Program and  VA’s other community care programs. Specifically, VA issued a fact  sheet saying that the new funding will allow VAMCs to refer veterans to  the Choice Program to the maximum extent possible. This allowed  VAMCs to again offer veterans Choice Program referrals when services  are unavailable at VHA medical facilities (until available funds have been  exhausted), and also permitted VAMCs to refer veterans to other VA  community care programs when services are unavailable.

Process for Choice Program Appointment Scheduling

Through policies and standard operating procedures for VAMCs and  contracts with the TPAs, VA and VHA have established two separate  processes for Choice Program routine and urgent appointment  scheduling: one process for time-eligible veterans and another for  distance-eligible veterans.

Table 1 provides an overview of the appointment scheduling process that  applies when a veteran is referred to the Choice Program because the  veteran is time-eligible. (Appendix II contains additional detail about the  Choice Program appointment scheduling process for time-eligible  veterans—including differences between the routine and urgent care  appointment scheduling process.)

When veterans reside more than 40 miles from a VHA medical facility or  meet other travel-related criteria, VHA uses the appointment scheduling  process it developed for distance-eligible veterans. The process for  distance-eligible veterans differs from that for time-eligible veterans in that  VAMCs do not prepare a referral and send it to the TPA. Instead,  distance-eligible veterans contact the TPA directly to request Choice  Program care. See table 2 for an overview of the Choice Program  appointment scheduling process that applies for distance-eligible  veterans. (See appendix III for additional detail about the Choice Program  appointment scheduling process for distance-eligible veterans—including  differences between the routine and urgent care appointment scheduling  process.)

Choice Program Utilization from Fiscal Year 2015 through Fiscal Year 2016

Data we obtained from the TPAs indicate that VHA and the TPAs used  the time-eligible appointment scheduling process about 90 percent of the  time from fiscal year 2015 through fiscal year 2016 (the first 2 years of the  Choice Program’s implementation). More than half of the veterans who  were referred to the Choice Program and for whom the TPAs scheduled  appointments were referred because the services they needed were not  available at a VHA medical facility. The second-most-common reason  for referral was that the wait time for an appointment at a VHA medical  facility exceeded 30 days. (See figure 2.) The distance-eligible  appointment scheduling process was used for about 10 percent of the  veterans who used the Choice Program between fiscal year 2015 through  fiscal year 2016.

Choice Act Wait-Time Requirements for Care Furnished Under the Program

In coordinating the furnishing of care to eligible veterans under the Choice  Program, VA is required to ensure that veterans receive appointments for  Choice Program care within the wait-time goals of VHA for the furnishing  of hospital care and medical services. Although the Choice Act defined  VHA’s wait-time goals as not more than 30 days from the date a veteran  requests an appointment from the Department, the Choice Act gave VA  the authority to change this definition if it did not reflect VHA’s actual wait- time goals. If VA wanted to exercise this authority, it was required to notify  Congress of VHA’s actual wait-time goals within 60 days of the law’s  enactment (i.e., by October 6, 2014). VA did so in an October 3, 2014,  report to Congress. To “ensure that care provided through the Veterans  Choice Program is delivered within clinically appropriate timeframes,” VA  notified Congress that VHA’s wait-time goals were “not more than 30  days from either the date that an appointment is deemed clinically  appropriate by a VA health care provider, or if no such clinical  determination has been made, the date a Veteran prefers to be seen for  hospital care or medical services.” By incorporating VHA’s reported wait- time goal, the Choice Act required VA to ensure the furnishing of care to  eligible veterans within 30 days of the clinically indicated date or, if none  existed, within 30 days of the veteran’s preferred date.

VA’s Other Community Care Programs and Planned Consolidation

VA has purchased health care services from community providers  through various programs since as early as 1945. Currently, there are six  community care programs other than the Choice Program through which  VA purchases hospital care and medical services for veterans. These six  community care programs offer different types of services and have  varying eligibility criteria for veterans and community providers. VA’s six  non-Choice community care programs include:  Individually authorized VA community care. The primary means by  which VHA has traditionally purchased community care is through  individual authorizations, where local VAMC staff determine veteran  eligibility, create authorizations, and assist veterans in arranging care  with community providers that are willing to accept VA payment.  Traditionally, VAMCs have approved the use of individually authorized  community care when a veteran cannot access a particular specialty  care service from a VHA medical facility because the service is not  offered or the veteran would have to travel a long distance to obtain it  from a VHA medical facility. (See appendix IV for an illustration of how  appointment scheduling and care coordination processes for the  Choice Program compare to those for individually authorized VA  community care.)

Two emergency care programs. When VA community care is not  preauthorized, VA may reimburse community providers for emergency  care under two different community care programs: 1) emergency  care for a condition related to a veteran’s service-connected disability  and 2) emergency care for a condition not related to a veteran’s  service-connected disability, commonly referred to as Millennium Act  emergency care. For emergency care to be covered through these  two programs, a number of criteria must be met, including (1)  community providers must file claims in a timely manner (within 2  years of the date services were rendered for service-connected  emergency care and within 90 days for Millennium Act emergency  care); (2) the veteran’s condition must meet the prudent layperson  standard of an emergency; and (3) a VA or other federal medical  facility must not have been feasibly available to provide the needed  care, and an attempt to use either would not have been considered  reasonable by a prudent layperson.

Patient-Centered Community Care (PC3). In September 2013, VA  awarded contracts to Health Net and TriWest to develop regional  networks of community providers to deliver specialty care, mental  health care, limited emergency care, and maternity and limited  newborn care when such care is not feasibly available from a VHA  medical facility. VA and the TPAs began implementing the PC3  program in October 2013, and it was fully implemented nationwide as  of April 2014—prior to the creation of the Choice Program. In August  2014, VA expanded the PC3 program to allow community providers of  primary care to join the PC3 networks. PC3 is a program VA created  under existing statutory authorities, not a program specifically  designed by law. To be eligible to obtain care from PC3 providers,  veterans must meet the same criteria that are required for individually  authorized VA care in the community services.

Agreements with federal partners and academic affiliates. When  services are not available at VHA medical facilities, VA may also  obtain specialty, inpatient, and outpatient health care services for  veterans through two types of sharing agreements—those with other  federal facilities (such as those operated by the Department of  Defense and the Indian Health Service), and those with university- affiliated hospitals, medical schools, and practice groups (known as  academic affiliates).

Dialysis contracts. In June 2013, VA awarded contracts to numerous  community providers nationwide to deliver dialysis—a life-saving  medical procedure for patients with end-stage renal disease  (permanent kidney failure). When dialysis services are not feasibly  available at VHA medical facilities, veterans may be referred to one of  VA’s contracted dialysis providers, and veterans may receive dialysis  at local clinics on an outpatient basis, or at home (if the contractors  offer home-based dialysis services).

The VA Budget and Choice Improvement Act, which was enacted on July  31, 2015, required VA to develop a plan for consolidating all of its  community care programs into a new, single program to be known as the  “Veterans Choice Program.” VHA submitted this plan, including  proposed legislative changes, to Congress on October 30, 2015. VA has  moved forward with some aspects of the planned community care  program consolidation that it believes can be accomplished without  statutory changes. In December 2016, VA issued a request for proposals  (RFP) for contractors to help administer the consolidated community care  program, through “community care network” contracts. The consolidated  community care program VA described in the October 2015 plan it  submitted to Congress and the December 2016 RFP, as amended, would  be similar to the current Choice Program in certain respects. For  example, VA is planning to award community care network contracts to  TPAs, which would establish regional networks of community providers  and process payments to those providers. In contrast, other aspects of  the consolidated community care program VA has planned may differ  from the existing Choice Program. For example, VA’s RFP for the  community care network contracts, as amended, requires VAMCs—rather  than TPAs—to carry out appointment scheduling, unless they exercise a  contract option for the TPAs to provide such services.

Annual Obligations for the Choice Program and Other VA Community Care Programs

In fiscal year 2015, the first year of the Choice Program’s implementation,  total obligations for Choice Program health care services accounted for  about 4.7 percent of the $8.7 billion VA obligated for all community care  services that year.  However, as more care was provided through the  Choice Program in fiscal years 2016 and 2017, obligations for Choice  Program care grew steadily, while obligations for care delivered through  other VA community care programs decreased. In fiscal year 2017, total  obligations for Choice Program health care services accounted for about  39 percent of the $11.16 billion VA obligated for all community care  services that year. See table 3.

As shown in Table 4, below, of the $10.37 billion in Choice Program funds  that were obligated between fiscal year 2015 and fiscal year 2017, $6.28  billion (or about 61 percent) of the funds were obligated for Choice Program health care services. About $1.76 billion (or 17 percent) of total  Choice Program funds obligated between fiscal year 2015 and fiscal year  2017 were obligated for administrative costs. The remaining $2.33 billion  (about 22 percent) were obligated for medical services other than those  authorized under the Choice Program. As we previously reported, VHA  experienced a projected funding gap in its medical services appropriation  account in fiscal year 2015, largely due to lower-than-expected  obligations for the Choice Program, higher-than-expected obligations for  other VA community care programs, and unanticipated obligations for  hepatitis C drugs. To address the projected funding gap, on July 31,  2015, VA obtained temporary authority to use Choice Program funds  between July 31, 2015 and September 30, 2015 for amounts obligated on  or after May 1, 2015 to furnish medical services other than those that it  authorized under the Choice Program. Later, in fiscal year 2016 and fiscal  year 2017, VA de-obligated about $420 million of the Choice Program  funds it had obligated for other VA community care programs and  hepatitis C drugs in fiscal year 2015 because they were never expended.

Time Allowed to Complete VA’s Choice Program Appointment Scheduling Process Significantly Exceeds the Choice Act’s Required 30-Day Time Frame for Routine Care

Our analysis of VA’s scheduling process indicates that veterans who are  referred to the Choice Program for routine care because they are time- eligible could potentially wait up to 70 calendar days to obtain care, if  VAMCs and TPAs take the maximum amount of time allowed by VA’s  process. About 90 percent of Choice Program referrals in fiscal years  2015 and 2016 were scheduled under the time-eligibility process, which  means that the majority of veterans referred to the program would have  been subject to this potential wait time for an appointment for routine  care. This 70-day potential wait time is in contrast to the Choice Act’s  required time frame, which is that eligible veterans receive Choice  Program care no more than 30 days from the date an appointment is  deemed clinically appropriate by a VHA clinician (referred to as the  clinically indicated date), or if no such determination has been made, 30  days from the date the veteran prefers to receive care. According to VHA  policy, a VHA clinician’s clinically indicated date determination must be  based upon the needs of the patient, and it should be the earliest date  that it would be clinically appropriate for the veteran to receive care.  Therefore, if there is no clinical reason that care should be delayed, a  veteran’s clinically indicated date could be the same date that the VHA  clinician determined the veteran needed care.

The potential wait time of about 70 calendar days for time-eligible  veterans to receive routine care through the Choice Program  encompasses 18 or more calendar days for VAMCs to prepare veterans’  Choice Program referrals and potentially another 52 calendar days for  appointments to occur through the TPAs’ scheduling process, as follows:

VAMCs’ process for preparing routine Choice Program referrals.  According to VHA policies and guidance, VAMC staff have at least 18  calendar days to confirm that veterans want to be referred to the  Choice Program and to send veterans’ referrals to the TPAs:

They have 2 business days (or up to 4 calendar days) after a VHA  clinician has determined the veteran needs care to begin  contacting an eligible veteran by telephone to offer them a referral  to the Choice Program.

They have up to 14 calendar days after initiating contact to reach  the veteran by telephone or letter and confirm that the veteran  wants to be referred to the Choice Program.

After confirming that a veteran wants to be referred to the Choice  Program, however, VA has not set a limit on the number of days  VAMCs should take to compile relevant clinical information and  send referrals to the TPAs.

TPAs’ process for scheduling routine Choice Program  appointments. Through its contracts with the TPAs, VA has  established a process under which a veteran could potentially wait  another 52 calendar days from the date the TPA receives the VAMC’s  Choice Program referral for a routine care appointment to take place.  This includes up to 16 business days (or 22 calendar days) after  receiving a referral to confirm the veteran’s decision to opt in to the  Choice Program and create an authorization. The contracts further  state that, for time-eligible veterans, an appointment shall take place  within 30 calendar days of the clinically indicated date, the  authorization creation date, or the veteran’s preferred date, whichever  occurs later:

The TPA has 2 business days to review the VAMC’s referral and  accept it if it contains sufficient information to proceed with  appointment scheduling.

The TPA has 4 business days to contact the veteran by telephone  and confirm they want to opt in to the Choice Program (which  means that the veteran wants to receive care through the Choice  Program and have the TPA proceed with appointment  scheduling).

If the veteran is not reached by telephone, the TPA has 10  business days for the veteran to respond to a letter confirming that  they want to opt in, at which point the TPA creates the Choice  Program authorization.

If the authorization is created after the veteran’s preferred date or  after the clinically indicated date on the VAMC’s referral has  already passed, the TPA has 30 calendar days from the  authorization creation date for an appointment for routine care to  take place. The TPA can use up to 15 business days of this 30- calendar-day time frame to contact providers and successfully  schedule the veteran’s Choice Program appointment.

See figure 3 for an illustration of the potential wait time of approximately  70 calendar days for time-eligible veterans to receive routine care through  the Choice Program.

The process VA established for time-eligible veterans to receive routine  care through the Choice Program—which could potentially take 70 days  to complete—is not consistent with the requirement that veterans receive  care within 30 days of their clinically indicated dates (where available) as  applicable under the Choice Act. Furthermore, according to the federal  internal control standard for control activities, agencies should design  control activities—such as through policies and procedures—that will help  ensure federal programs meet their objectives and respond to any risks to  meeting those objectives.

A key reason that veterans’ overall wait times for Choice Program care  could potentially exceed the Choice Act’s 30-day wait-time requirement is  that the process VA and VHA designed did not include a limit on the  number of days VAMCs have to complete a key step of the process— compiling relevant clinical information and sending referrals to the TPAs  after veterans have agreed to be referred to the Choice Program. While  the process sets forth time frames for the other steps VAMCs and TPAs  must complete to process referrals and schedule appointments, VA and  VHA have not specified how many days VAMCs have to send veterans’  Choice Program referrals to the TPAs. VHA has no comprehensive policy  directive for the Choice Program, and neither its consult management  directive nor its outpatient appointment scheduling directive specifies an  amount of time within which VAMCs should prepare Choice Program  referrals.

Another reason that veterans’ overall wait times for Choice Program care  could potentially exceed the Choice Act’s 30-day wait-time requirement is  that after VA and VHA implemented their policies, they did not review and  address risks that were identified through their actual experience in  operating the program. In response to a letter we sent in March 2017,  VA’s Deputy General Counsel for Legal Policy said that, based on VA’s  and VHA’s experiences with actual operation of the Choice Program  since November 2014, “the practical reality” has been that the 30-day  wait-time goal VA established just prior to the program’s implementation  cannot always be met.

VA has not disclosed what timeliness goals it would apply under a future  consolidated community care program. We note, however, that VA  currently has no timeliness goals for its existing individually authorized  community care program and cannot determine the amount of time  veterans wait, on average, to receive care through that program, which  has accounted for a significant portion of veterans’ community care  utilization. We recommended in May 2013 that VA analyze the amount of  time veterans wait to see providers in its individually authorized  community care program and apply the same wait-time goals to that care  that it uses to monitor wait times at VHA medical facilities. VA concurred  with the recommendation to conduct an analysis and reported that it was  in the process of building wait-time indicators to measure wait-time  performance for individually authorized VA community care. VHA has  since updated its wait-time goal for care delivered within VHA medical  facilities—which is that care must be delivered within 30 days of veterans’  clinically indicated dates (where available). However, VA has not applied  that same goal to its individually authorized VA community care program  nor begun measuring wait-time performance for that program.

Timeliness of appointments is an essential component of quality health  care; delays in care have been shown to negatively affect patients’  morbidity, mortality, and quality of life. Without specifying wait-time goals  that are achievable, and without designing appointment scheduling  processes that are consistent with those goals, VA lacks assurance that  veterans are receiving care from community providers in a timely manner.  It also lacks a means for comparing the timeliness of veterans’ community  care with that of care delivered within VHA medical facilities.

Actual Wait Times for Choice Program Care Have Been Lengthy for Selected Veterans, and VHA’s Monitoring of Veterans’ Access Is Limited by Incomplete and Unreliable Data

In 2016, Selected Veterans Experienced Lengthy Overall Wait Times to Receive Routine Care and Urgent Care through the Choice Program

To examine selected veterans’ actual wait times to receive routine care  and urgent care through the Choice Program, we conducted a manual  review of a random, non-generalizable sample of 196 Choice Program  authorizations. The TPAs created these authorizations between January  2016 and April 2016 in response to referrals sent by six selected  VAMCs. Our manual review of veterans’ VA electronic health records  and the TPAs’ records for our non-generalizable sample of 55 routine  care authorizations and 53 urgent care authorizations for which the TPAs  succeeded in scheduling appointments identified the following review  times:

For the 55 routine care authorizations in our sample, it took VAMC  staff an average of 24 calendar days after the veterans’ need for  routine care was identified to contact the veterans and confirm that  they wanted to be referred to the Choice Program, compile relevant  clinical information, and send veterans’ referrals to the TPAs. It took  an average of 27 calendar days for the VAMCs to complete these  actions for the 53 urgent care authorizations in our sample.

For these routine care authorizations, it took the TPAs an average of  14 calendar days to accept referrals and reach veterans by telephone  or letter for the veterans to opt in to the Choice Program. It took the  TPAs an average of 18 calendar days to complete these actions for  the urgent care authorizations in our sample.

After the TPAs succeeded in scheduling veterans’ appointments for  routine care, an average of 26 calendar days elapsed before veterans  in our sample completed their initial appointments with Choice  Program providers. For urgent care authorizations in our sample, it  took an average of 18 days for the veterans to complete their initial  appointments after the TPAs scheduled them.

See the following text box for specific examples of the overall wait times  experienced by some veterans in the samples of routine and urgent  Choice Program authorizations we reviewed.

Examples of Delays Experienced by Veterans for Whom the Choice Program  Third Party Administrators (TPA) Scheduled Appointments

One veteran was referred to the Choice Program for magnetic resonance imaging  (MRI) of the neck and lower back because these services were unavailable at a  Veterans Health Administration (VHA) medical facility. It took almost 3 weeks for  Department of Veterans Affairs (VA) medical center (VAMC) staff to prepare his  Choice Program referral for routine care and send it to the TPA, and then it took  an additional 2 months after the VAMC sent the referral for the veteran to receive  care. Notes in the veteran’s VA electronic health record indicated that his follow- up appointment with a VHA neurosurgeon was at risk of being rescheduled  because the VAMC had not received the results of the MRI after the appointment  with the Choice Program provider occurred. Ultimately, the veteran’s appointment  with the VHA neurosurgeon—where the imaging results and treatment options  were discussed—did not occur until almost 6 months after the VHA clinician  originally identified the need for the MRI.

One veteran was referred to the Choice Program because she needed maternity  care, which is generally not available at VHA medical facilities. Almost a month  and a half elapsed from the time VAMC staff confirmed her pregnancy (when she  was 6 weeks pregnant) to when the VAMC sent the Choice Program referral for  urgent care to the TPA. It then took 2 additional weeks for the TPA to make an  unsuccessful attempt to contact the veteran to schedule a prenatal appointment;  by that point, she was almost 15 weeks pregnant. The veteran called the TPA  back, but when the TPA had yet to schedule an appointment by the time she was  18 weeks pregnant, the veteran finally scheduled her initial prenatal appointment  herself, almost 3 months after her pregnancy was confirmed by VAMC staff.

One veteran was referred to the Choice Program for thoracic surgery to address a  growth on his lung because there was a wait for care at a VHA medical facility.  TPA documentation we reviewed indicated that VAMC staff contacted the TPA  four times to inquire about the status of the veteran’s appointment, and the TPA  contacted five Choice Program providers in its unsuccessful attempts to schedule  the urgent appointment for the veteran. Ultimately, the veteran scheduled his own  initial appointment with a thoracic surgeon in the community and informed the  TPA that he had done so. The veteran’s initial appointment occurred 3 weeks  after the VAMC sent his referral to the TPA.

We also found that veterans in our sample experienced lengthy overall  wait times to receive care when the TPAs returned their authorizations to  the VAMC without scheduling appointments. When veterans’ Choice  Program authorizations are returned, VAMCs must attempt to arrange  care through other means—such as through another VA community care  program, a new Choice Program referral, or at another VHA medical  facility. Among the 88 returned authorizations in our sample, we  determined that 53 veterans eventually received care through other  means after their authorizations were returned. These 53 veterans  ended up waiting an average of 111 days after the VHA clinician originally  determined they needed care until their first appointment with a VHA  clinician or with a community provider occurred. See the text box below  for some examples of delays experienced by veterans in the sample of 88  returned Choice Program authorizations we reviewed.

Examples of Delays Experienced by Veterans Whose Authorizations Were  Returned to Department of Veterans Affairs Medical Centers (VAMC) by the  Choice Program Third Party Administrators (TPA)

The VAMC took almost 3 ½ months to refer one veteran to a physical therapist to  address her pelvic floor prolapse. When the preferred provider listed in the  VAMC’s referral was outside the TPA’s network, the TPA sent a message to the  VAMC via its web-based portal to ask if it should try scheduling the appointment  with a different provider. By the time VAMC staff responded to the message in the  TPA’s portal, the TPA had already returned the authorization—almost 2 weeks  after accepting it. Two months later, the VAMC realized that the veteran still  needed this care and sent a new Choice Program referral to the TPA. It then took  the veteran another 2 ½ months to attend her first appointment. Overall, this  veteran waited more than 8 months to receive physical therapy.

One veteran who was eligible for the Choice Program because he resided more  than 40 miles from a VHA medical facility contacted the TPA to request an  appointment with a urologist. More than a month later, the TPA contacted the  VAMC via its web-based portal to request a referral for the veteran. VAMC staff  responded to the TPA two days later and stated (correctly) that because the  veteran was distance-eligible, no referral was required. Four days after receiving  the VAMC’s response, the TPA succeeded in scheduling an appointment.  However, the veteran declined it because the TPA had scheduled the  appointment with a neurologist (a specialist who treats conditions affecting the  brain, spinal cord, and nerves) rather than a urologist (a specialist who treats  conditions affecting the urinary tract and male reproductive organs). Ultimately,  the veteran ended up seeing a urologist at a VAMC nearly 5 months after he  originally contacted the TPA to request care.

It took about 2 ½ weeks for the VAMC to send one veteran’s referral for pain  management to the TPA after a VHA clinician originally determined he needed  these services. However, information the TPA needed for scheduling the Choice  Program appointment was missing from the VAMC’s referral. The TPA requested  the information from the VAMC twice using its web-based portal, but VAMC staff  did not reply, and the TPA returned the authorization 2 weeks after receiving it. It  then took another month before the veteran ended up receiving pain management  services at a VAMC. Overall, this veteran waited almost 2 ½ months for pain  management services.

After we shared the results of our preliminary analysis with VHA officials  in December 2016, VHA required its medical facilities to manually review  a sample of about 5,000 Choice Program authorizations that were  created in July, August, and September of 2016 for four types of Choice  Program care—mammography, gastroenterology, cardiology, and  neurology. The purpose of this review was to analyze (1) the timeliness  with which VAMCs sent referrals to the TPAs, and (2) veterans’ overall  wait times for Choice Program care. VHA calculated the average wait  times across these four types of care for each of its 18 Veterans  Integrated Service Networks (VISN).

VHA’s analysis of data collected by VAMCs identified the following  average review times when veterans were referred to the Choice  Program because there was a greater-than-30-day wait time for an  appointment at a VHA medical facility.

Referral wait times. VISN-level averages ranged from 6 to 53 days  for VAMC staff to contact veterans and confirm that they wanted to be  referred to the Choice Program, compile relevant clinical information,  and send veterans’ referrals to the TPAs. The national average was  19 days.

Overall wait times. From the time veterans’ need for care was  identified until they attended initial Choice Program appointments,  average overall wait times ranged from 34 to 91 days across VHA’s  18 VISNs. The national average was 51 days.

When veterans were referred to the Choice Program because services  were unavailable at a VHA medical facility, VHA’s analysis of VAMCs’  self-reported data identified the following average review times:

Referral wait times. VISN-level averages ranged from 6 to 21 days  for VAMC staff to contact veterans and confirm that they wanted to be  referred to the Choice Program, compile relevant clinical information,  and send veterans’ referrals to the TPAs. The national average was  15 days.

Overall wait times. From the time veterans’ need for care was  identified until they attended initial Choice Program appointments,  average overall wait times ranged from 39 to 56 days across VHA’s  18 VISNs. The national average was 47 days.

VHA’s Monitoring of Veterans’ Access to Choice Program Care Is Limited by a Lack of Complete, Reliable Data

Our analysis indicates that VHA’s ability to monitor Choice Program  access is limited because the data VHA uses are not always accurate  and reliable, and VHA lacks certain data that are needed to effectively  monitor the program. As discussed below, multiple factors contribute to  these data limitations. According to federal internal control standards for  information and communication and for monitoring, agencies should use  quality information to achieve the entity’s objectives, internally and  externally communicate quality information, and establish activities to  monitor the quality of performance over time and evaluate the results.  Without complete, reliable Choice Program data, VHA cannot determine  whether the Choice Program has achieved the goals of (1) alleviating the  wait times veterans have experienced when seeking care at VHA medical  facilities, and (2) easing geographic burdens veterans may face to access  care at VHA medical facilities.

VHA Cannot Systematically Calculate the Average Number of Days VAMCs Take to Prepare Choice Program Referrals

The data VHA currently uses to monitor the timeliness of Choice Program  appointment scheduling and completion do not capture the days it takes  for VAMCs to prepare veterans’ referrals and send them to the TPAs.  This is because VHA has not standardized the manner in which VHA  clinicians and VAMC staff categorize consults that lead to Choice  Program referrals.

We observed inconsistency in the titles of consults that were associated  with the non-generalizable sample of Choice Program authorizations we  reviewed. For example,  consult titles sometimes included the word “Choice,” but in other  cases they included the words “non-VA care.”

Some of the consult titles indicated the criterion under which the  veteran was eligible for the Choice Program and the type of care the  veteran needed (for example, “Choice-First Physical Therapy”), while  other consult titles only indicated the type of care the veteran needed  (for example, “pain management”).

We observed this variability among consult titles both within single  VAMCs and across all six of the VAMCs we selected for review.

According to documentation VHA officials provided to us in December  2016, they planned on implementing a process for standardizing the  consult titles associated with Choice Program referrals over the course of  calendar year 2017. Originally, they planned on piloting the process at  four VAMCs beginning in February 2017 and expected to gradually roll  out standardized consult titles across all other VAMCs over the remainder  of calendar year 2017. However, in late June and early July 2017, we  followed up with the six VAMCs in our sample, and at that time, managers  from only one of the VAMCs said that they had implemented the new  process for standardizing consult titles associated with Choice Program  referrals. When we interviewed VHA officials again in September 2017,  they acknowledged that they had been delayed in implementing  standardized consult titles, and they provided documentation indicating  that they were just beginning to roll out the new process nationwide.

In the absence of standardized consult titles for the Choice Program, VHA  has no automated way to electronically extract data from VA’s electronic  health record and calculate the average number of days it takes for  VAMC staff to prepare veterans’ Choice Program referrals after veterans  have agreed to be referred to the program. Further, without standardized  consult titles, VHA cannot monitor veterans’ overall wait times—from the  time VHA clinicians determine veterans need care until the veterans  attend their first appointments with Choice Program providers. The lack of  standardized consult titles also prevents VHA from tracking average  overall wait times and monitoring the timeliness of care for veterans  whose Choice Program authorizations are returned by the TPAs without  scheduled appointments.

Available VHA Data Do Not Capture the Time Spent By TPAs in Accepting VAMCs’ Referrals and Opting Veterans in to the Choice Program

The data VHA currently uses to monitor the timeliness of Choice Program  appointments capture only a portion of the process that the TPAs carry  out to schedule veterans’ appointments after they receive referrals from  VAMCs. Specifically, VHA’s data reflect the timeliness of appointment  scheduling and completion after the TPAs create authorizations in their  appointment scheduling systems, which (according to VA’s contracts, as  of June 1, 2016) the TPAs must do only after they have received all  necessary information from VA and the veteran has opted in to the  Choice Program. Therefore, VHA’s timeliness data do not capture the  time TPAs spend (1) reviewing and accepting VAMCs’ referrals, and (2)  contacting veterans to confirm that they want to opt in to the Choice  Program.

Data related to the timeliness of Choice Program appointment  scheduling. When we asked how they monitor the timeliness of  Choice Program appointment scheduling, VHA officials provided us  the following types of data, all of which reflect the time that elapses  only after veterans have opted in to the Choice Program and the  TPAs have created authorizations:  the average number of business days the TPAs take after creating  authorizations to schedule appointments for routine and urgent  care,  the percentage of appointments for routine care that the TPAs  schedule within 5 business days after they create authorizations,  and  the percentage of appointments for urgent care that the TPAs  schedule within 2 business days after they create authorizations.

Data related to the timeliness with which initial Choice Program  appointments occur. VHA officials provided us data on the  timeliness with which initial Choice Program appointments have  occurred; however, as shown below, almost all of these data reflect  the timeliness with which appointments occur only after veterans have  opted in to the Choice Program and the TPAs have either created  authorizations or successfully scheduled veterans’ appointments:  the average number of business days after the TPAs create  authorizations in which appointments for routine and urgent care  occur;  the percentage of appointments for routine care that are  completed within 30, 60, 90, and 120 business days or more after  the TPAs create an authorization;  the percentage of appointments for routine care that are  completed within 30 calendar days of either (1) the TPA’s  scheduling of the appointment, (2) the clinically indicated date on  the VAMC’s referral, or (3) the veteran’s preferred date; and  the percentage of appointments for urgent care that are completed  within 2 calendar days of the TPAs creating the authorizations.

See figure 4 for an illustration of how VHA’s data capture only a portion of  the Choice Program process to obtain care.

In September 2017, VHA officials told us that they recently began  implementing an interim solution that would allow them to track veterans’  overall wait times for Choice Program and other VA community care— from the time VHA clinicians determine veterans need the care until the  veterans attend their first appointments with community providers.  Specifically, this interim solution requires VAMC staff to enter unique  identification numbers on VHA clinicians’ requests for care and on the  Choice Program referrals they send to the TPAs. This unique  identification number is then carried over to the Choice Program  authorizations that are created in the TPAs’ systems. According to VHA  officials, the unique identification number creates a link between VHA’s  data and the TPAs’ data, so that VHA can monitor the timeliness of each  step of the Choice Program referral and appointment scheduling process.  However, the success of VHA’s interim solution relies on VAMC staff  consistently and accurately entering the unique identification numbers on  both the VHA clinicians’ requests for care and on Choice Program  referrals, a process that is prone to error. VHA officials said it is their long- term goal to automate the process by which VHA’s data are linked with  TPAs’ data in the consolidated community care program they are  planning to implement.

Because, as previously explained, VHA lacks data on the average  timeliness with which VAMCs prepare Choice Program referrals, and  VHA also lacks data on the average amount of time that elapses between  when the TPAs receive VAMCs’ referrals and when veterans opt in with  the TPAs, VHA cannot track veterans’ overall wait times for Choice  Program care—from the time VHA clinicians determine that veterans  need care until the veterans attend their first appointments with Choice  Program providers. In addition, the lack of data on the timeliness with  which the TPAs have (1) accepted VAMCs’ referrals and (2) determined  that veterans wish to opt in to the program also prevents VHA from  assessing whether the TPAs’ average timeliness in completing these  actions has improved over time.

Clinically Indicated Dates Are Sometimes Changed by VAMC Staff Before They Send Choice Program Referrals to the TPAs

Our analysis of a sample of 196 Choice Program authorizations shows  that another way in which VHA’s monitoring of veterans’ access to care is  limited by available data is that the clinically indicated dates included on  referrals that VAMCs send to the TPAs may not be accurate. We found  that the clinically indicated dates on VAMCs’ referrals were not always  identical to the clinically indicated dates that were originally entered into  VA’s electronic health record by the VHA clinicians who treated the  veterans.

VHA’s policy directive on consult management and its Choice Program  standard operating procedure for VAMCs state that the clinically indicated  date is to be determined by the VHA clinician who is treating the veteran.  However, in reviewing VA’s electronic health records for our sample of  196 Choice Program authorizations, we identified 60 cases where the  clinically indicated dates VAMC staff entered on Choice Program referrals  they sent to the TPAs differed from the clinically indicated dates that were  originally entered by VHA clinicians. In 46 of these 60 cases, VAMC  staff entered clinically indicated dates on the Choice Program referrals  that were later than the dates originally determined by the VHA clinicians,  which would make the veterans’ wait times appear to be shorter than they  actually were.

VHA could not explain why the dates differed. Clinically indicated dates  are manually entered on VAMCs’ electronic referrals to the TPAs, a  practice that is subject to error or manipulation. It is unclear if VAMC staff  mistakenly entered incorrect dates, or if they inappropriately entered later  dates when the VAMC was delayed in contacting the veteran, compiling  relevant clinical information, and sending the referral to the TPA. If  VAMCs’ Choice Program referrals have clinically indicated dates that are  different from the ones VHA clinicians originally entered without additional  supporting documentation, there is a risk that VHA’s data will not  accurately reflect veterans’ actual wait times. Specifically, VHA will not be  able to determine how often veterans receive Choice Program care within  the Choice Act’s required 30-day time frame.

VAMCs and TPAs Frequently Re-Categorize Routine Choice Program Referrals as Urgent Referrals, Sometimes Inappropriately

Another limitation of VHA’s monitoring of veterans’ access to Choice  Program care is that VAMCs and TPAs do not always categorize referrals  in accordance with the contractual definition for urgent care when they  are processing referrals and scheduling appointments for veterans.  According to VA’s contracts with the TPAs, Choice Program referrals are  to be marked as “urgent” when a VHA clinician has determined that the  veteran needs care that (1) is considered essential to evaluate and  stabilize conditions and (2) if not provided would likely result in  unacceptable morbidity or pain when there is a significant delay in  evaluation or treatment. It is VA’s goal that the TPAs schedule  appointments for urgent care and ensure that they take place within 2  business days of accepting the referrals from VA.

Among the sample of 53 Choice Program authorizations for urgent care  we reviewed, VHA and TPA documentation showed that in 35 cases  (about 66 percent), VHA clinicians originally determined that veterans  needed routine care, but VAMC or TPA staff later re-categorized the  referrals or authorizations as urgent. In 4 of these 35 cases, we found  documentation showing that VHA clinicians had reviewed the pending  referrals and determined that the veterans’ clinical conditions or  diagnoses warranted re-categorizing the veterans’ routine care referrals  or authorizations as urgent. In 31 other cases we reviewed, however,  we found no documentation indicating that a VHA clinician had identified  a clinical reason for the veteran to receive care faster. In at least 15 of  these 31 cases, it appeared that the VAMC or TPA staff changed the  status of the referral or authorization in an effort to administratively  expedite appointment scheduling when they were delayed in sending  referrals and scheduling veterans’ Choice Program appointments.

According to the VA contracting officer who is responsible for the Choice  Program contracts, VA’s contracts with the TPAs do not include  provisions for separating clinically urgent Choice Program referrals and  authorizations from those that the VAMC or the TPA has decided to  expedite for administrative reasons (such as when the veteran or VAMC  staff has expressed frustration with a delay in the referral or appointment  scheduling process). If Choice Program referrals for routine care are  inappropriately categorized as urgent care referrals under the Choice  Program, VHA’s data on the timeliness of urgent appointment scheduling  and completion will not accurately reflect the extent to which veterans  who have a clinical need for urgent care are receiving it within the time  frames required by the TPAs’ contracts.

The TPAs’ Choice Program Performance Data Did Not Become Comparable until 18 Months After the Program Began, Which Limits VA’s Ability to Monitor Whether Access Has Improved

The authorization creation date is the primary starting point from which  VHA monitors the TPAs’ timeliness in appointment scheduling and the  extent to which veterans’ initial Choice Program appointments occur in a  timely manner. However, when initially implementing the Choice  Program—beginning in November 2014—the two TPAs had differing  interpretations of contractual requirements relating to when they should  create authorizations in their appointment scheduling systems. According  to VA contracting officials and VHA community care officials we  interviewed, at the start of the program, one of the TPAs was creating  authorizations as soon as it accepted referrals from VAMCs, but the other  was waiting until after veterans opted in to the Choice Program to create  authorizations. It was not until May 2016 (about 18 months into the  Choice Program’s implementation) that VA modified its contracts to clarify  that the TPAs are to create Choice Program authorizations only after they  have contacted the veterans and confirmed that they want to opt in to the  program.

Due to these differing interpretations, VA lacked comparable performance  data for the two TPAs for the first 18 months of the Choice Program’s  expected three-year implementation. Therefore, it could not compare the  timeliness of access nationwide. In addition, since VA modified the TPAs’  contracts midway through the Choice Program’s implementation, officials  can only comparatively examine whether the timeliness of both TPAs’  appointment scheduling and completion has improved since June 2016,  which is when the relevant contract modification took effect.

TPAs Sometimes Select Incorrect Return Reasons or Inappropriately Return Choice Program Authorizations without Making Appointments

VHA collects data and monitors various reasons the TPAs return Choice  Program authorizations to VAMCs without making appointments. Each  month, VA monitors how each TPA performs on Choice Program  performance measures related to the timeliness of appointment  scheduling. Authorizations that are returned for reasons that are  attributable to the TPA—such as a lack of network providers in close  proximity to the veteran’s residence—negatively impact the TPAs’  monthly performance measures.

In our sample, we found that VHA’s data on the TPAs’ reasons for  returning Choice Program authorizations are not reliable. Specifically, we  questioned the validity of the TPAs’ return of 20 out of the 88  authorizations in our sample, for the following reasons:  In 11 of the 20 cases, we found VHA or TPA documentation that  substantiated the return, but the TPAs selected the incorrect return  reasons when they sent the authorizations back to VA. For example,  in one case, the TPA was unable to schedule an appointment with a  primary care provider—even after contacting 11 different network  providers—but the TPA staff returned the authorization to the VAMC  indicating that the veteran had declined care. TPA officials who  reviewed this authorization with us agreed that it was inappropriate to  mark this authorization as having been returned because the veteran  declined care and that their staff instead should have indicated that  they had been unable to schedule an appointment with a network  provider.

In the remaining 9 of the 20 cases, we could find no VHA or TPA  documentation to substantiate the reasons the TPAs selected when  they returned the authorizations to VA, nor any other reasons for  return. For example, the TPAs incorrectly selected “missing VA data”  as the reason they returned 5 of these 9 authorizations. Based on  VHA and TPA documentation we reviewed, the VAMCs’ referrals  were complete and not missing any of the information the TPAs  needed to proceed with appointment scheduling.

TPA officials could not explain why their staff selected incorrect return  reasons or inappropriately returned authorizations for which they should  have kept attempting to schedule appointments. However, TPA staff must  manually select return reasons when they send authorizations back to  VAMCs, a process that is subject to error or manipulation. There is a  process by which VA’s contracting officer’s representatives validate the  monthly data submitted by the TPAs, but it cannot identify the data  reliability issues we found when manually reviewing VHA and TPA  documentation associated with a sample of returned Choice Program  authorizations. VHA officials told us that VA’s contracting officer’s  representatives do not have access to veterans’ electronic health records,  which means that they cannot check whether VHA documentation  substantiates the return reasons selected by the TPAs.

Without reliable data on reasons that veterans have been unable to  obtain appointments through the Choice Program, VHA cannot properly  target its efforts to address challenges—such as network inadequacy— that may be causing the TPAs to return authorizations without making  appointments. In addition, the lack of reliable data makes it difficult for  VA to monitor whether the TPAs are meeting their contractual obligations,  such as establishing adequate networks of community providers.

VHA Does Not Have Performance Measures for Monitoring Average Driving Times between Veterans’ Homes and the TPAs’ Choice Program Network Providers

Another way in which VHA’s monitoring of veterans’ access is limited is  that VA lacks contract performance measures that would provide VA and  VHA with data related to veterans’ driving times to access care from the  TPAs’ Choice Program network providers. Such performance measures  would help VA monitor the TPAs’ network adequacy. In contrast, for PC3,  VA does collect data from the TPAs to monitor urban, rural, and highly  rural veterans’ maximum commute times to specialty care providers,  providers of higher level care, primary care providers, and mammography  and maternity care providers.

When we asked why VA had not established driving time performance  measures for the Choice Program, a VHA official responsible for  monitoring the Choice Program contracts told us he thought that these  performance measures had simply been overlooked in the haste to  implement the Choice Program. VA concurred with a recommendation we  made in our December 2016 report about VA health care for women  veterans, in which (among other things) we stated that the department  should monitor women veterans’ driving times to access sex-specific care  through the Choice Program and VA’s future community care contracts.  However, VA stated in its June and October 2017 written updates on  actions it has taken to address this recommendation that it does not  intend to modify the current Choice Program contracts to address our  recommendation because the contracts will be ending soon and it would  be too costly to do so. Without driving time performance measures for the  Choice Program, VHA lacks assurance that the TPAs’ networks include a  sufficient number of community providers in close proximity to where  veterans live, and it cannot monitor the extent to which veterans’  geographic access to care has improved or diminished.

Multiple Factors Have Adversely Affected Veterans’ Access to Care under the Choice Program, Providing Potential Lessons Learned for VA’s Future Community Care Program

Officials we interviewed from VA’s contracting office, VHA’s Office of  Community Care, and both of the TPAs, along with leadership officials,  managers, and staff from the six selected VAMCs told us about various  factors that have directly or indirectly affected veterans’ access to care  throughout the Choice Program’s implementation. Chief among these are  (1) administrative burden associated with the Choice Program’s complex  referral and appointment scheduling processes; (2) inadequate VAMC  staffing and poor communication between VHA and the VAMCs; and (3)  the TPAs’ slow development of a robust provider network. We also  identified actions VA and VHA have taken to address these factors. (See  appendix VI for additional information about actions that VA and VHA  took to address these three access-related issues for the Choice  Program.) To the extent that these factors persist under the consolidated  community care program that VA plans to establish, they will continue to  adversely affect veterans’ access to care.

VA and VHA Took Several Actions to Address Administrative Burden Caused by Complex Choice Program Processes, but Opportunities Still Exist to Improve Care Coordination

VHA and TPA officials, as well as managers and staff from the six  selected VAMCs, told us they encountered administrative burden  associated with the complexities of the Choice Program’s referral and  appointment scheduling processes. Further, they lacked care  coordination tools throughout the time they were operating the Choice  Program, which affected their ability to provide timely care to veterans.  Among the main issues cited were the following:

Manual referral processes and lack of TPA access to veterans’  records. To prepare veterans’ Choice Program referrals, VAMC staff  had to follow a manual, time-consuming process to retrieve and  collate key contact and clinical information from veterans’ VA  electronic health records. This was because—throughout most of the  Choice Program’s implementation—VA had no system for  automatically generating referral packages that contained all of this  information; nor did TPA staff have access to veterans’ VA electronic  health records. If VAMC staff made mistakes (such as mistyping or  inadvertently omitting veterans’ telephone numbers or addresses) or if  the referrals were missing clinical information that the TPAs needed  for appointment scheduling purposes, the TPAs had to either contact  the VAMC to correct or obtain the missing information or return the  referrals to VA without attempting to schedule appointments. These  manual processes impeded the VAMCs’ progress in preparing  referrals and the TPAs’ progress in scheduling veterans’ Choice  Program appointments.

Limited availability of care coordination tools and dependence  on telephone-based customer service for appointment  scheduling. A lack of care coordination tools and near-constant  telephone calls also delayed VAMC and TPA staff from efficiently  processing veterans’ referrals for appointments. For example, the  Choice Program had no web-based portal through which VAMC staff  and veterans could view the TPAs’ step-by-step progress in  scheduling appointments. While both of the TPAs had portals that  allowed VAMC staff (but not veterans) to obtain certain information— such as whether the TPA had already scheduled an appointment—the  portals did not show if, or when, veterans’ referrals had been  accepted, the dates and times of the TPAs’ attempts to contact  veterans, or the number of community providers the TPA had  contacted in its attempts to schedule an appointment. VAMC staff we  interviewed said that while they could submit written messages to the  TPAs through the portals, TPA staff did not always answer these  messages in a timely manner. This, in turn, made telephone calls  between veterans, the VAMCs, and the TPAs the most effective form  of follow-up regarding veterans’ Choice Program referrals, according  to VAMC managers and staff. Officials from one selected VAMC  estimated that their community care staff (which included about 30  employees) was answering approximately 10,000 calls per month,  and another VAMC had hired a full-time staff person just to answer  telephone calls.

Workload associated with re-authorizing veterans’ care. VAMC  and TPA staff also told us they faced a lengthy administrative process  to re-authorize care if veterans’ Choice Program authorizations  expired before veterans received care or if veterans needed services  that were outside the scope of their original authorizations. The TPAs  referred to these as “secondary authorization requests” or “requests  for additional services.” Without these re-authorizations, veterans’  care from community providers could be delayed or interrupted.  VAMC and TPA staff had to process a high volume of these requests  for two main reasons. First, the Choice Program originally had a 60- day limit on episodes of care, which meant that all appointments  within the episode of care had to be completed within 60 days of the  initial date of service. Even if the veteran needed care that could  routinely be expected to outlast this 60-day time frame (such as  maternity care or cancer treatment), community providers and the  TPAs would still have to request additional referrals from the VAMCs  to authorize the remaining care. Second, TPAs would have to request  additional referrals if an episode of Choice Program care was already  in progress and the veteran needed services that were not specifically  authorized in the VAMC’s original referral. According to some VAMC  managers and staff, this generated significant workload for the  VAMCs. Officials from one of the selected VAMCs said it had to hire a  full-time nurse just to process secondary authorization requests.

Manual post-appointment follow-up processes. According to  VAMC managers and staff we interviewed, the manual processes  used for post-appointment follow-up also added to delays for veterans  seeking care through the Choice Program. After an episode of care is  complete—whether services are delivered at a VHA medical facility or  in the community—VHA’s policy requires VAMC staff to document  that care was provided and make the results of encounters available  to VHA clinicians by entering medical records or other clinical  information into the veteran’s VA electronic health record. When  medical records from the community provider became available,  VAMC staff had to retrieve copies from the TPAs’ portals and scan  them into veterans’ VA electronic health records. (See appendix V for  an illustration of this process.) VAMC staff described this as a very  time-consuming process because it could take months for claims or  medical records from Choice Program appointments to appear in the  TPAs’ portals. At the time of our interviews in the summer of 2016,  managers from two of the VAMCs in our sample said they each had  backlogs of more than 6,000 Choice Program and other community  care consults to complete. These backlogs adversely affected  veterans’ access to Choice Program care because the time VAMC  staff spent attempting to complete some veterans’ consults could not  be spent on preparing other veterans’ Choice Program referrals.

Over the course of the Choice Program’s implementation, VA and VHA  took multiple actions to address administrative burden, including the  following. Opportunities exist to improve or build on these actions as VA  moves forward with the consolidated community care program it plans to  implement.

Implementation of a web-based tool to automate Choice Program  referral preparation. In early 2016, to improve the process of  gathering information from veterans’ VA electronic health records to  prepare Choice Program referrals, staff from two VAMCs developed a  web-based tool—called the “referral documentation” (REFDOC) tool.  According to VHA documentation, the REFDOC tool automates the  process of gathering necessary information and assembling it in a  standardized format for veterans’ Choice Program referrals. VHA’s  initial analyses of the REFDOC tool’s effectiveness found that it sped  up the process of preparing Choice Program referrals by about 20  minutes per referral, which helped reduce the administrative burden  associated with preparing referrals. However, VHA’s nationwide  dissemination of the tool to all of the VAMCs was slowed by  limitations of VA’s information technology systems. As of November  2016 (about 9 months after the tool was created), it had only been  implemented at 18 of VHA’s 170 VAMCs. VHA gradually made the  tool available at the remaining VAMCs between November 2016 and  May 2017.

Standardized episodes of care. In April 2017, VHA approved  standardized episodes of care—or “bundles” of clinically necessary  medical services and procedures—that are to be authorized whenever  veterans are referred to community providers for specified types of  care. This was intended to help address administrative burden  associated with clinical review processes and improve veterans’  access to care. To start, VHA approved standardized episodes of care  for 15 different types of care, including physical therapy, maternity  care, and optometry. VA and VHA documentation indicate that they  intend to roll out additional standardized episodes of care over time  and continue using them once VA transitions to the consolidated  community care program it is planning to implement.

Acquisition of a secure e-mail system and a mechanism for TPAs  and community providers to remotely access veterans’ VA  electronic health records. VA recently established two different care  coordination tools that were intended to make the process of providing  veterans’ medical records to Choice Program and other VA  community care providers more efficient.

Secure e-mail system. In the spring of 2017, VA acquired software  that allows VAMC managers and staff to e-mail encrypted files  containing veterans’ medical records to the TPAs and community  providers. Only the intended recipient can decrypt and respond to  messages containing the files. According to VHA documentation,  this secure e-mail system was intended to improve the efficiency  of coordinating veterans’ Choice Program care and address  potential security risks associated with printing paper copies of  veterans’ medical records and sending them to the TPAs or  community providers via fax or U.S. mail.

Remote access to veterans’ VA electronic health records. In May  2017, VHA began offering a secure, web-based application called  the Community Viewer as a tool for community providers  nationwide to have access to assigned veterans’ VA electronic  health records. Like the secure e-mail system, this tool is intended  to improve the efficiency of coordinating veterans’ Choice  Program care.

However, VHA’s ability to seamlessly coordinate care with community  providers remains limited—even with the secure e-mail system and the  Community Viewer—because these tools only facilitate a one-way  transfer of the information needed to coordinate the care veterans receive  at VHA medical facilities and in the community. For the purposes of care  coordination, it is important that information sharing among all participants  concerned with a veteran’s Choice Program or other VA community  care—including VHA clinicians, the TPAs, community providers, and the  veteran—is as seamless as possible. According to the federal internal  control standard for information and communication, agencies should  internally and externally communicate the necessary information to  achieve their objectives. While the secure e-mail system and  Community Viewer tool provide an interim solution for VAMCs to transfer  information from veterans’ VA electronic health records to the TPAs and  community providers, they do not provide a means by which VAMCs or  veterans can (1) view step-by-step progress in scheduling appointments,  or (2) electronically receive the clinical results of Choice Program or other  VA community care encounters. Building such a capability into the future  consolidated community care program that VA plans to implement would  allow VHA to improve the care coordination processes that exist in the  Choice Program.

Pilot programs for VAMC staff to schedule Choice Program  appointments. In July 2016 and October 2016, VHA began  implementing pilot projects, whereby staff at two VAMCs took over  from the TPAs the responsibility of scheduling veterans’ Choice  Program appointments. Specifically, VA modified its contracts with  TriWest and Health Net to implement the two VAMC scheduling pilots  at the Alaska VA Health Care System and the Fargo VA Health Care  System, respectively. In these two locations, VAMC staff schedule  veterans’ appointments and send relevant clinical documentation to  the Choice Program providers. According to VHA officials, this had  the potential to improve veterans’ access to care by improving the  efficiency of the Choice Program appointment scheduling process.

The results of these two VAMC scheduling pilots are particularly  relevant, given that VA’s RFP, as amended, for its planned  consolidated community care program indicates that VAMCs—rather  than TPAs—will carry out community care appointment scheduling,  unless VA exercises a contract option for the TPAs to provide such  services for VAMCs that request them. However, while VHA officials  told us that while they have taken some steps to begin evaluating the  effectiveness of the pilots in improving appointment scheduling, these  efforts have not been completed. The lack of an evaluation of the two  VAMC scheduling pilots is inconsistent with the federal internal control  standard for risk assessment, which stipulates that an agency should  identify, analyze, and respond to risks related to achieving defined  objectives. In addition, the federal internal control standard for  monitoring calls for ongoing monitoring to assess the effectiveness of  management strategies, make needed corrections if shortcomings are  identified, and determine if corrective actions are achieving desired  outcomes. Without evaluating the results of the scheduling pilots at  the Alaska and Fargo VA Health Care Systems, VA lacks assurance  that VAMC staff have the potential to schedule veterans’ community  care appointments in a more timely manner than TPA staff otherwise  would schedule them. Furthermore, VA is missing an opportunity to  inform its planning and decisions for scheduling under its planned  consolidated community care program.

Inadequate Staffing and Ad Hoc Communication Contributed to Choice Program Access Delays, and Actions Taken Have Been Focused on the Staffing Concerns

TPA officials and managers and staff from the six selected VAMCs  frequently discussed staffing- and communication-related factors that  adversely affected the timeliness of veterans’ Choice Program care.  During the course of our review, they cited the following factors that  delayed VAMCs’ processing of veterans’ referrals and TPAs’ scheduling  of appointments:

Staff vacancies and turnover. TPA officials and managers and staff  at selected VAMCs said that VAMCs and TPAs were initially  understaffed as Choice Program implementation began.

VAMCs. Managers at the six selected VAMCs told us that after  implementing the Choice Program, they hired additional  community care staff, with one of them increasing its community  care staffing level almost five-fold by July 2016. Some VAMC  managers told us in 2016 and again in 2017 that they still  struggled with staff retention and vacancies—among both  managers and staff. Five of the VAMCs said they relied on  overtime for their existing staff to keep up with the Choice  Program workload. According to community care managers from  four of the selected VAMCs, it takes about 6 months to recruit,  hire, and train new community care staff, and this process could  take more time if the VAMC’s human resources office is also  understaffed, which was the case for at least one of the six  VAMCs. That VAMC had not had a permanent community care  manager for more than 2 years as of July 2017—which covered  the majority of the Choice Program’s original 3-year  implementation.

TPAs. Officials from both TPAs also told us that they initially  underestimated the workload associated with scheduling Choice  Program appointments, and they brought on additional staff,  including sub-contractors, to better manage their workloads as  utilization of the program increased. One TPA opened eight  operations centers in addition to the two it already had when the  Choice Program was initially implemented.

Ineffective mechanisms for VAMCs to resolve problems. VAMC  managers and staff we interviewed also said they lacked useful  mechanisms and points-of-contact when they needed to resolve  issues and problems they were having with referral and appointment  scheduling processes. VHA established a web-based Choice Program  “issue tracker” system for VAMCs to report problems to VHA’s Office  of Community Care. However, staff at four of the selected VAMCs told  us they rarely used the tracker and some had stopped using the  tracker altogether because it took too long for VHA’s Office of  Community Care or the TPAs to respond and resolve the issues (if  they responded at all), and they did not see the value in taking the  time to report them via this mechanism. Managers at one of the  VAMCs also told us about a phone line that their TPA had established  to escalate and resolve urgent issues, but the TPA told the VAMC  only to use it for emergencies.

VHA’s untimely communication of Choice Program policy and  process changes. According to managers and staff at the six  selected VAMCs, VA and VHA have issued numerous contract  modifications and policy changes with little advanced notice  throughout the Choice Program’s implementation. According to these  VAMC managers and staff, the untimely communication of changes  created confusion at the VAMC level that affected veterans’ access to  Choice Program care. We reviewed documentation showing that from  October 2014 (when it modified the TPAs’ contracts to add  responsibilities related to Choice Program administration) until July  2017, VA modified each TPA’s contract about 40 times. Many of these  contract modifications—along with other legislative and regulatory  changes that VA implemented during this period—changed VAMC or  TPA processes related to Choice Program referrals and appointment  scheduling. Many of the VAMC managers and staff we interviewed  said they struggled to keep up with the contract modifications and  policy changes, that VHA’s Office of Community Care did not always  leave adequate time to prepare for them, and they felt they were  never really able to become proficient at new processes before  additional changes occurred. This meant that training sometimes  happened after the contract modifications or VHA policy changes had  already gone into effect. For example, managers and staff at three of  the selected VAMCs told us that they were not informed in advance  about a June 2016 contract modification that required the TPAs to  return Choice Program authorizations to VAMCs if they failed to  schedule appointments within required time frames. This contract  modification had the potential to significantly increase VAMCs’  workloads, because they would have to arrange veterans’ care  through other means once the authorizations were returned.  According to individuals at two of these three VAMCs, they first heard  about this change from TPA staff, rather than from VHA.

VHA took the following two actions intended to help address staffing- related factors that adversely affected the timeliness of veterans’ Choice  Program care.

Staffing tool for VAMCs to estimate needs. In the spring of 2017,  VHA developed a tool that is intended to help VAMCs project their  staffing needs for the consolidated community care program VA plans  to implement. VHA used workload data and site visit observations to  develop the tool. Among the six selected VAMC managers we  interviewed, impressions about the reasonableness of the staffing  estimates generated by the community care staffing tool were mixed.  For example, managers at two of the VAMCs said that the tool likely  underestimated the number of staff they would need to handle  referrals and appointment scheduling once VA transitions to the  consolidated community care program. In contrast, managers from  two other VAMCs thought that the tool’s staffing estimates seemed  about right.

Co-locating TPA staff at selected VAMCs to assist with  resolution of problems. To help facilitate problem resolution  between VAMCs and the TPAs as they work to schedule veterans’  Choice Program appointments, VA modified the TPAs’ contracts in  November 2015 to allow for TPA staff to be co-located at selected  VAMCs. VHA officials expected that one potential benefit of co- locating TPA staff would be that fewer veterans’ Choice Program  referrals would be returned to VAMCs because of missing clinical  information because TPA staff could help resolve such problems  locally before the TPA returned referrals. As of May 2017, TPA staff  were working at 70 of VHA’s 170 VAMCs—or about 40 percent of all  VAMCs. Similar care coordination arrangements may exist under the  consolidated community care program VA is planning to implement, if  VA exercises a contract option for the TPAs to provide such services  at VAMCs that request them.

However, the communication-related factors that VHA and TPA officials  identified as affecting the timeliness of veterans’ Choice Program care  remain. VHA relied on ad hoc communications such as memoranda, fact  sheets, e-mails, national conference calls, and occasional web-based  trainings to communicate policy and process changes to VAMCs  throughout the Choice Program’s implementation. Our interviews with  VAMC managers and staff suggest that these were not the most effective  methods of communication because messages about key changes  sometimes lacked sufficient detail or failed to reach the VAMC staff  responsible for implementing them in a timely manner. According to the  federal internal control standard for control activities, agencies should  implement control activities through their policies and procedures, which  document the responsibilities of managers and staff who are responsible  for implementing a program. Among other things, this may include  management reviewing and updating policies and day-to-day procedures  in a timely manner after a significant change in the program has occurred.  VHA has no comprehensive policy directive or operations manual for the  Choice Program, and its broader policy directive for VA community care  programs has not been updated since January 2013. As a result, VAMC  staff have operated in an environment that is frequently changing with no  definitive reference source or sources of up-to-date policy and processes  to consult, such as a comprehensive policy directive or operations  manual. Instead, VAMC staff have had to keep track of the Choice  Program’s policy and process changes through VHA’s various ad hoc  communications. This poses a risk to VHA, as it increases the likelihood  that VAMCs will implement new policies and processes inconsistently. In  addition, there is risk that VAMC managers and staff will not always be  aware of the most current policies and processes. Unless a  comprehensive policy directive or operations manual is created, those  risks could remain for the consolidated community care program VA is  planning to establish.

Inadequate Provider Networks Affected Timely Access, but VHA Plans to Improve Available Information Related to Provider Capacity and Veteran Demand for Future TPAs

According to VAMC managers and TPA officials we interviewed, the  TPAs’ inadequate networks of community providers affected both the  timeliness with which veterans received Choice Program care and the  extent to which veterans were able to access community providers  located close to their homes. In September 2015, about 11 months after  the Choice Program was implemented, VA contracting officials sent  corrective action letters to both TPAs, citing network adequacy (i.e., the  number, mix and geographic distribution of network providers) as a  concern. TPA officials we interviewed acknowledged that their networks  initially were not adequate to meet demand for Choice Program care.  From the TPAs’ perspective, the brief transition period before the Choice  Program began operations in November 2014 was not enough time to  strengthen the community provider networks they had previously  established under PC3, another VHA community care program.  Furthermore, the TPAs told us that VA had not provided them with  sufficient data on the expected demand for Choice Program care—by  clinical specialty and zip code—prior to or after the Choice Program’s  implementation.

The overall number of community providers participating in the TPAs’  Choice Program networks nationwide grew dramatically over the following  year—from almost 39,000 providers in September 2015 to more than  161,000 providers as of September 2016. However, at the time of our  review, managers at five of the six selected VAMCs told us that they still  observed TPA network inadequacies that impeded veterans’ access to  Choice Program care. Similarly, managers at three VAMCs in our sample  said that key community providers—including large academic medical  centers—have refused to join the TPAs’ networks or dropped out of the  networks after joining them, often because the TPAs had not paid them in  a timely manner for the services they provided.

Establishing adequate networks of Choice Program providers in rural  areas has been particularly difficult. Officials at two of the three of the  rural VAMCs in our sample pointed to general health care workforce  shortages in rural areas as one cause for the TPAs’ network  inadequacy—a challenge that is not limited to the Choice Program or  VA’s health care system. According to a December 2015 analysis by VHA  researchers, the majority of network providers in two of the three VISNs  examined were located within 40 miles of VAMCs, leaving large  geographic areas of these VISNs (particularly rural areas) outside the 40- mile radius with few network providers. For example, only 3.8 percent of  primary care providers and 3.2 percent of behavioral health providers in  VISN 20 (which covers Alaska, Idaho, Oregon, and Washington) were  located more than 40 miles from VAMCs within that VISN. While the  areas lacking network providers generally have fewer veterans relative to  other areas within these VISNs, the analysis by VHA researchers  suggests that veterans living in these areas are likely to have difficulty  accessing Choice Program network providers that are located closer to  their homes than the nearest VAMC, which is over 40 miles away.

VA and VHA have tried to address network inadequacy that existed under  the Choice Program and either have taken or plan to take additional  actions to address this issue for the community care program VA plans to  implement, including the following.

Establishment of Choice Program provider agreement process.

To help address inadequacies in the TPAs’ provider networks and  improve veterans’ access to care under the Choice Program, VHA  established the Choice Program provider agreement process in  February 2016. This process allowed VAMCs to establish agreements  with community providers, schedule veterans’ appointments, and  reimburse the providers directly (using Choice Program funds) when  the TPAs failed to schedule veterans’ appointments for reasons  relating to network inadequacy, among others. Originally, the  VAMCs were required to send veterans’ referrals to the TPAs and  wait for them to be returned before they could proceed with arranging  care through a Choice Program provider agreement. While this  process had the potential to increase the availability of providers for  the Choice Program, it did not immediately improve the timeliness of  veterans’ Choice Program care because veterans still had to wait for  as long as it took the VAMCs to send their referrals to the TPAs and  for TPAs to return them before the VAMCs could proceed with  arranging care through Choice Program provider agreements.  According to the policies and contractual requirements that were in  effect at the time, it could have taken up to 40 calendar days after a  VHA clinician first identified the veteran’s need for care until the TPA  returned the referral and the VAMC could proceed with arranging care  through a Choice Program provider agreement. However, in March  2017, VHA updated the Choice Program provider agreement process  so that—if the TPAs were returning a high volume of a VAMC’s  referrals for one or more types of care—the VAMC could seek  approval from its VISN and VHA’s Office of Community Care to  bypass the TPA and proceed directly to arranging that type of care  through Choice Program provider agreements. This had the potential  to improve the timeliness of veterans’ access to Choice Program care  because it eliminated the steps of sending referrals to the TPAs and  waiting for them to be returned.

Improving quality of information given to future TPAs. To help  inform the recruitment of network providers for the consolidated  community care program VA plans to establish, VA plans to provide  future TPAs more robust data than they provided the current TPAs at  the start of the Choice Program. In particular, VA’s RFP for the  consolidated community care program, as amended, indicates that VA  will provide (1) zip-code-level data on the number of authorizations  that were issued in fiscal year 2015 for specific types of care (e.g.,  chemotherapy and obstetrics) and (2) VAMC-level data on the clinical  specialties with the greatest wait times for appointments at VAMCs.  These local-level data could help TPAs estimate the number of  network providers of various specialties they will need to recruit in  specific localities if awarded a contract for the consolidated  community care program that VA is planning to implement.

Performing market assessments. In preparation for the  consolidated community care program VA plans to establish, VA and  VHA officials are planning to conduct market assessments in 96  markets nationwide. Through these market assessments, officials told  us, VA will (1) examine the clinical capacity that currently exists within  VHA medical facilities and among community providers, (2) assess  veterans’ current and future demand for health care services, and (3)  develop long-term plans for ensuring that veterans will have access to  high-quality health care services—whether they receive care from  VHA clinicians or from community providers. According to VHA  officials, the market assessments will help inform network provider  recruitment efforts for the consolidated community care program VA is  planning to implement. In addition, VHA officials told us that the  market assessments will help VISN- and VAMC-level leaders make  more informed, strategic decisions about whether it is more efficient to  maintain or build capacity for delivering particular types of care within  VHA medical facilities, or if they should routinely purchase certain  types of care in the community. In November 2017, VHA officials told  us that they expect to begin conducting the market assessments early  in calendar year 2018, and the officials estimate that it will take about  18 months to complete assessments for all 96 markets.

The Choice Program is approaching the end of its life, and with plans to  consolidate it with VA’s other community care programs, opportunities to  improve the program are diminishing. Congress created the Choice  Program in 2014 in response to longstanding challenges in veterans’  access to care delivered within VHA medical facilities. However, we found  numerous operational and oversight weaknesses with VHA’s  management of scheduling veterans’ medical appointments through the  Choice Program. While it may not be feasible for VA and VHA to  implement corrective actions to address all of our findings before the  Choice Program ends, it is imperative that VA incorporate lessons  learned from the Choice Program when it implements the consolidated  community care program it has planned.

First, we found VHA’s process for scheduling appointments for veterans  through the Choice Program was not consistent with statutory  requirements. The Choice Act requires veterans to receive care no more  than 30 days from the date an appointment is deemed clinically  appropriate or from the date the veteran prefers to receive care; however,  we found that veterans could potentially wait up to 70 calendar days to  receive routine care through the Choice Program. In effect, we found that  in 2016, some veterans’ actual wait times far exceeded 30 days. Although  VA has made some relevant contract modifications and issued guidance  to address Choice Program wait times, VHA has not adjusted the Choice  Program’s appointment scheduling process or established timeliness  standards for all steps of the process. In addition, VHA’s monitoring of  access to Choice Program care has been limited by incomplete and  unreliable data. In particular, the data VHA uses preclude it from  accurately identifying the number of days that occur within each phase of  the process, from initial referral to the actual appointment. Furthermore, a  lack of controls has allowed for inappropriate changes to be made in  veterans’ clinically indicated dates and routine versus urgent care  categorizations, affecting VA’s ability to monitor whether veterans are  receiving Choice Program care in a timely manner. The lack of reliable  data and performance measures also hinders VHA’s ability to oversee the  program and identify problems and corrective actions. Further, we found  that VHA is missing out on opportunities to enhance its design of the  planned consolidated community care program. For example, VHA has  not fully evaluated its pilot programs for scheduling appointments nor  developed tools such as a mechanism that would allow the seamless  sharing of information between VHA and the TPAs. Lastly, we found that  VHA often relied on inefficient, ad hoc methods of sharing information  (such as memoranda, fact sheets and emails), which often failed to reach  the VAMC managers and staff responsible for implementing the program.

After the Choice Program ends, VA anticipates that veterans will continue  to receive care from non-VHA providers under the consolidated  community care program that it is planning to implement. VA’s and VHA’s  design of the future program can benefit from the lessons learned under  the Choice Program. Ignoring these lessons learned and the challenges  that have arisen under the Choice Program as VA and VHA design the  future consolidated program would only increase VA’s risk for not being  able to ensure that all veterans will receive timely access to care in the  community.

To ensure that VA and VHA incorporate lessons learned from the Choice  Program as they develop and implement a consolidated VA community  care program, we are making the following 10 recommendations:

The Under Secretary for Health should establish an achievable wait- time goal for the consolidated community care program that VA plans  to implement that will permit VHA to monitor whether veterans are  receiving VA community care within time frames that are comparable  to the amount of time they would otherwise wait to receive care at  VHA medical facilities. (Recommendation 1)

The Under Secretary for Health should design an appointment  scheduling process for the consolidated community care program that  VA plans to implement that sets forth time frames within which (1)  veterans’ referrals must be processed, (2) veterans’ appointments  must be scheduled, and (3) veterans’ appointments must occur, which  are consistent with the wait-time goal VHA has established for the  program. (Recommendation 2)

The Under Secretary for Health should establish a mechanism that  will allow VHA to systematically monitor the average number of days it  takes for VAMCs to prepare referrals, for VAMCs or TPAs to schedule  veterans’ appointments, and for veterans’ appointments to occur,  under the consolidated community care program that VA plans to  implement. (Recommendation 3)

The Under Secretary for Health should implement a mechanism to  prevent veterans’ clinically indicated dates from being modified by  individuals other than VHA clinicians when veterans are referred to  the consolidated community care program that VA plans to  implement. (Recommendation 4)

The Under Secretary for Health should implement a mechanism to  separate clinically urgent referrals and authorizations from those for  which the VAMC or the TPA has decided to expedite appointment  scheduling for administrative reasons. (Recommendation 5)

The Under Secretary for Health should (1) establish oversight  mechanisms to ensure that VHA is collecting reliable data on the  reasons that VAMC or TPA staff are unsuccessful in scheduling  veterans’ appointments through the consolidated community care  program VA plans to implement, and (2) demonstrate that it has  corrected any identified deficiencies. (Recommendation 6)

The Secretary of Veterans Affairs should ensure that the contracts for  the consolidated community care program VA plans to implement  include performance metrics that will allow VHA to monitor average  driving times between veterans’ homes and the practice locations of  community providers that participate in the TPAs’ networks.  (Recommendation 7)

The Secretary of Veterans Affairs should establish a system for the  consolidated community care program VA plans to implement to help  facilitate seamless, efficient information sharing among VAMCs, VHA  clinicians, TPAs, community providers, and veterans. Specifically, this  system should allow all of these entities to electronically exchange  information for the purposes of care coordination. (Recommendation  8)

The Under Secretary for Health should conduct a comprehensive  evaluation of the outcomes of the two appointment scheduling pilots it  established at the Alaska and Fargo VA Health Care Systems (where  VAMC staff, rather than TPA staff, are responsible for scheduling  veterans’ Choice Program appointments), which should include a  comparison of the timeliness with which VAMC staff and TPA staff  completed each step of the Choice Program appointment scheduling  process, as well as the overall timeliness with which veterans  received appointments. (Recommendation 9)

The Under Secretary for Health should issue a comprehensive policy  directive and operations manual for the consolidated community care  program VA plans to implement and ensure that these documents are  reviewed and updated in a timely manner after any significant  changes to the program occur. (Recommendation 10)

VA provided written comments on a draft of this report, which are  reprinted in Appendix VII. In its comments, VA concurred with 8 of our 10  recommendations and described its plans for implementing them. VA  stated that VHA’s Office of Community Care will work collaboratively with  other VA and VHA offices to evaluate modifications to the current wait- time goals and measurement processes so that wait times for VA  community care can be compared to wait times for care delivered at VHA  medical facilities.

VA did not concur with our recommendation to implement a mechanism  to separate clinically urgent referrals and authorizations from those that  are designated as urgent for administrative reasons. VA stated that  because VAMC staff (rather than TPA staff) will be responsible for  scheduling veterans’ appointments under the consolidated community  care program it plans to implement, there would no longer be a need to  separate clinically urgent referrals from those that need to be  administratively expedited. However, we maintain that our  recommendation is warranted. In particular, we found that VA’s data did  not always accurately reflect the timeliness of urgent care because both  VAMC and TPA staff inappropriately re-categorized some routine care  referrals and authorizations as urgent ones for reasons unrelated to the  veterans’ health conditions. Regardless of whether VAMC staff or TPA  staff are responsible for appointment scheduling, VA will need to ensure  that it uses reliable data to monitor the extent to which veterans receive  urgent care within required time frames. Without a means of separating  clinically urgent referrals and authorizations from ones for which the  scheduling process must be administratively expedited, VA’s data on the  timeliness of urgent care will continue to be unreliable.

VA agreed in principle with our recommendation to issue a  comprehensive policy directive and operations manual, but stated in its  comments that it would wait to determine whether a comprehensive policy  directive is needed until after the consolidated community care program  has been fully implemented and any interim implementation challenges  have been resolved. However, when implementing a new program, it is  important that agencies establish the program’s structure, responsibilities,  and authorities at the beginning to help ensure that the new program’s  objectives are met. Relying on outdated policies and unreliable  communication methods increases VA’s risk of encountering foreseeable  challenges. Without issuing a comprehensive policy directive and  operations manual before the start of the new program, VA risks  experiencing untimely communication issues similar to those that affected  veterans’ access to care throughout the Choice Program’s  implementation. A comprehensive policy directive and operations manual  that could be updated as changes occur would give VAMCs a definitive  source of real-time, up-to-date information and reduce the likelihood that  VAMCs will implement new policies and processes inconsistently under  the future program.

We are sending copies of this report to the Secretary of Veterans Affairs,  the Under Secretary for Health, appropriate congressional committees,  and other interested parties. This report is also available at no charge on  the GAO Web site at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  Sharon M. Silas at (202) 512-7114 or silass@gao.gov or A. Nicole  Clowers at (202) 512-7114 or clowersa@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs are on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix VIII.

Appendix I: Scope and Methodology for Examining Choice Program Wait Times and the Data VHA Uses to Monitor Access

To examine selected veterans’ actual wait times to receive routine care  and urgent care through the Choice Program and the information VHA  uses to monitor access to care under the program, we took five key steps.  We (1) analyzed Choice Program appointment wait times for selected  veterans using a sample of 196 Choice Program authorizations for routine  and urgent care; (2) reviewed VHA’s analysis of Choice Program  appointment wait times for a sample of about 5,000 Choice Program  authorizations; (3) reviewed data VHA uses to monitor the timeliness of  Choice Program care and reasons that the TPAs have returned Choice  Program referrals without making appointments; (4) interviewed VA, VHA,  and TPA officials; and (5) reviewed federal internal control standards, as  follows.  1.  Our analysis of Choice Program wait times for a sample of 196  authorizations. To analyze the timeliness of Choice Program  appointment scheduling and completion for a sample of veterans, we  selected six VAMCs and a random, non-generalizable sample of 196  authorizations for veterans who were referred to the Choice Program  by those six VAMCs between January 2016 and April 2016. We  judgmentally selected the six VAMCs to include variation in  geographic location, with three VAMCs that serve rural veteran  populations and three VAMCs that serve urban veteran populations.  In addition, three of the VAMCs were served by Health Net, and three  were served by TriWest. (See table 5.)

To select our random, non-generalizable sample of 196 Choice  Program authorizations, we obtained VA data on all authorizations  created by the TPAs between January and April 2016 for veterans  who were referred to the program by the six VAMCs we selected—a  universe of about 55,000 authorizations. From these 55,000  authorizations, we randomly selected:

55 routine care authorizations (about 10 authorizations per VAMC)  for which the TPAs scheduled appointments for veterans,

53 urgent care authorizations (about 10 authorizations per VAMC)  for which the TPAs scheduled appointments for veterans, and

88 routine and urgent care authorizations (about 15 authorizations  per VAMC) that the TPAs returned to VA without scheduling  appointments for any one of the following three reasons—(1) VA  requested the authorization be returned, (2) VA data were missing  from the referral, and (3) the veteran declined or did not want  Choice Program care.

For all 196 Choice Program authorizations in our sample, we  manually reviewed VHA documentation (specifically, the veterans’ VA  electronic health records) and TPA documentation to track the  number of calendar days that elapsed at each step of the Choice  Program appointment scheduling process. For the authorizations that  the TPAs returned to the VAMCs without making appointments, we  examined VHA and TPA documentation to determine whether the  veterans eventually obtained care through other means—such as  through another VA community care program, a different Choice  Program referral, or at a VHA medical facility—and how long it took to  receive that care. Determining whether veterans in our sample  experienced clinical harm or adverse clinical outcomes because of  delays in the VAMCs’ or TPAs’ processing of their referrals and  authorizations was outside the scope of our review.

We selected our sample of 55 routine care and 53 urgent care  authorizations for which the TPAs succeeded in scheduling  appointments to include only authorizations for which the TPAs did  not meet VA’s appointment scheduling goals at one phase of the  appointment scheduling process: when the TPAs attempt to schedule  appointments after the veterans have opted in to the program. This  was to ensure that our sample included only authorizations for which  scheduling was delayed, so that we could examine the potential  causes of appointment scheduling delays and whether delays also  occurred at other phases of the process (such as when VAMCs were  preparing the veterans’ referrals or when the TPAs were attempting to  reach the veterans for them to opt in to the program). We omitted this  phase of the appointment scheduling process when calculating the  timeliness of appointment completion for the 55 routine care  authorizations and 53 urgent care authorizations in our sample.  Rather than reporting veterans’ overall wait times for these  authorizations, we report the average number of calendar days that  elapsed (1) while VAMCs were preparing veterans’ Choice Program  referrals, (2) while the TPAs were attempting to reach veterans for  them to opt in to the program, and (3) while veterans waited to attend  their appointments after the TPAs succeeded in scheduling them. To  assess the reliability of the authorization data we used, we  interviewed knowledgeable agency officials, manually reviewed the  content of the data, and electronically tested it for missing values. We  concluded that these data were sufficiently reliable for the purposes of  our reporting objectives. The findings from our review of Choice  Program authorizations cannot be generalized beyond the VAMCs  and the veterans’ Choice Program authorizations we reviewed.  2.  VHA’s analysis of Choice Program wait times for a sample of  about 5,000 authorizations. We obtained from VHA’s Office of  Community Care the results of a nationwide analysis of Choice  Program appointment timeliness it conducted in February 2017.  Specifically, VHA directed its VAMCs to manually review veterans’  health records and TPA documentation and report observations for a  non-generalizable sample of about 5,000 randomly selected Choice  Program authorizations that were created between July and  September of 2016. The sample was limited to authorizations for  Choice Program appointments that had been scheduled for time- eligible veterans who needed four types of specialty care— mammography, gastroenterology, cardiology, and neurology.  According to VHA officials, they limited their analysis to these four  types of care because delayed treatment for any of these specialties  could cause adverse health outcomes for patients. To assess the  reliability of VHA’s data, we manually reviewed the results of its  analysis and interviewed knowledgeable agency officials about  potential outliers. We concluded that VHA’s data were sufficiently  reliable for the purposes of our reporting objective. The results of  VHA’s analysis cannot be generalized beyond the sample of Choice  Program authorizations that it reviewed.  3.  VHA data on timeliness of Choice Program appointments and the  reasons TPAs return referrals without making appointments. To  evaluate the information VHA uses to monitor access to care under  the Choice Program, we reviewed data that VHA collects to monitor  the timeliness with which the TPAs schedule appointments and the  timeliness with which appointments occur after the TPAs have  scheduled them. We also reviewed and tested the reliability of VHA  data on the reasons the TPAs have returned Choice Program  referrals to VAMCs without scheduling appointments, which may offer  insights about access to care (e.g., the percentage of referrals that  are returned due to a lack of providers in the TPAs’ networks).  4.  Interviews with officials. We interviewed VA, VHA, and TPA officials  responsible for administering the Choice Program contracts and  overseeing implementation of the program. We interviewed these  officials to gain an understanding of the processes they followed and  the information they used to monitor veterans’ access to Choice  Program care.  5.  Federal internal control standards. We examined the results of our  and VHA’s analyses and the information VHA uses to monitor  veterans’ access to care under the program in the context of federal  standards for internal control for (1) information and communication  and (2) monitoring. The internal control standard for information and  communication relates to management’s ability to use quality  information to achieve the entity’s objectives. The internal control  standard for monitoring relates to establishing activities to monitor the  quality of performance over time and evaluating the results.

Appendix II: Process for Veterans to Obtain Department of Veterans Affairs (VA) Choice Program Care if They Are Time-Eligiblea

Appendix II: Process for Veterans to Obtain  Department of Veterans Affairs (VA) Choice  Program Care if They Are Time-Eligiblea If the veteran does not respond to the letter within 14 calendar days, a notification is sent to the  veteran’s VA clinician so that they can determine if additional action should be taken.

Appendix III: Process for Veterans to Obtain Department of Veterans Affairs (VA) Choice Program Care if They Are Distance-Eligiblea

Appendix IV: Comparison of Processes for Arranging Choice Program and Individually Authorized Community Care

Appendix IV: Comparison of Processes for  Arranging Choice Program and Individually  Authorized Community Care The Veterans Health Administration (VHA) uses the time-eligible appointment scheduling process  when the services needed are not available at a VHA medical facility or are not available within  allowable wait times.

Appendix V: Process for Obtaining the Clinical Results of Choice Program Appointments

Appendix VI: Selected Actions Taken by VA and VHA to Address Choice Program Access Issues

We found 21 actions that the Department of Veterans Affairs (VA) and the  Veterans Health Administration (VHA) took after the Choice Program’s  November 2014 implementation that were intended to help address  issues related to veterans’ access to care. Table 6, below, provides a  chronological summary of the actions VA and VHA had taken as of  August 2017 and the issues they were intended to address.

Appendix VIII: GAO Contacts and Staff Acknowledgments

In addition to the contact named above, Marcia A. Mann (Assistant  Director), Alexis C. MacDonald (Analyst-in-Charge), Daniel Powers, and  Michael Zose made major contributions to this report. Also contributing  were Muriel Brown, Christine Davis, Helen Desaulniers, Krister Friday,  Sandra George, Jacquelyn Hamilton, and Vikki Porter.

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

VA Health Care: Improved Monitoring Needed for Effective Oversight of  Care for Women Veterans, GAO-17-52 (Washington, D.C.: December 2,  2016).

VA’S Health Care Budget: In Response to a Projected Funding Gap in  Fiscal Year 2015, VA Has Made Efforts to Better Manage Future  Budgets, GAO-16-584 (Washington, D.C.: June 3, 2016).

Veterans’ Health Care: Proper Plan Needed to Modernize System for  Paying Community Providers, GAO-16-353 (Washington, D.C.: May 11,  2016).

VA Health Care: Actions Needed to Improve Monitoring and Oversight of  Non-VA and Contract Care. GAO-15-654T (Washington, D.C.: June 1,  2015).

VA Health Care: Further Action Needed to Address Weaknesses in  Management and Oversight of Non-VA Medical Care, GAO-14-696T  (Washington, D.C.: June 18, 2014).

VA Health Care: Actions Needed to Improve Administration and Oversight  of VA’s Millennium Act Emergency Care Benefit, GAO-14-175  (Washington, D.C.: March 6, 2014).

VA Health Care: Management and Oversight of Fee Basis Care Need  Improvement, GAO-13-441 (Washington, D.C.: May 31, 2013).

If services are not readily accessible at VA medical facilities, the Veterans Choice Program allows eligible veterans to receive care from non-VA providers. Congress created the temporary program in 2014, aiming to alleviate the excessive wait times some veterans faced at VA.

However, we found that it’s unclear if the Choice Program improved the timeliness of veterans’ care because VA’s data are incomplete and unreliable.

When the Choice Program ends, veterans will still receive care from non-VA providers through a new program. We made recommendations related to improving VA’s ability to monitor veterans’ access to care through the new program.