VAPIHCS and Primary and Mental Health Care Services

VAPIHCS generally provides outpatient primary and mental health care  services to the veterans it serves. Most Veterans in Our Review Received Primary and Mental Health Care from VA Providers within VHA’s Timeliness Goals, although Some Faced Delays

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

Our review of 30 medical records of newly enrolled veterans accessing  initial primary care services at the American Samoa, Guam, or Maui clinic  found some delays in processing of health care benefits enrollment  applications and contacting of veterans to schedule appointments. within 7 days of their eligibility determination as required by VHA policy. Timeliness of comprehensive mental health evaluations. The remaining  veteran had not completed an evaluation as of February 2018. VAPIHCS Referred Most Specialty Care to Non-VA Providers within VHA’s Timeliness Goal, but Time Taken to Provide Care Was Variable and Sometimes Lengthy

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

We found that VAPIHCS referred 67 of 69 randomly selected specialty  care referrals in our sample to non-VA providers in the Choice Program or  through DOD within 7 days, in accordance with the timeliness goal set in  VHA policy. Time Taken for Veterans in Our Review to Receive Specialty Care from Choice Program and DOD Providers Was Variable and Sometimes Lengthy

We found that once specialty care referrals in our review were sent to the  Choice Program or one of the two DOD military treatment facilities— TAMC and NHG—the amount of time it took veterans to receive care  from these non-VA providers varied, and sometimes was lengthy. Weaknesses in VAPIHCS’ Referral Process May Have Contributed to the Time Taken to Provide Care at One DOD Military Treatment Facility

When reviewing VAPIHCS’ referrals to NHG, we found weaknesses with  the VAPIHCS’ referral process, including (1) incorrectly canceling  referrals, (2) inconsistent guidance describing roles and responsibilities,  and (3) untimely referral management. Military Treatment Facility Referral  Process  After the Department of Veterans Affairs (VA)  Pacific Islands Health Care System  (VAPIHCS) staff review a referral and decide  care should be rendered at a military  treatment facility, there are two different  processes for sending the referral to Tripler  Army Medical Center (TAMC) or Naval  Hospital Guam (NHG). Ultimately, in our review of the veterans’ medical records, we  did not find documentation that these veterans received the  recommended care included in the canceled referrals. VAPIHCS did not always manage referrals to NHG in a timely way. VAPIHCS Has Faced Physician Recruitment and Retention Challenges, but Has Not Evaluated the Strategies It Used to Help Resolve Them

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

We found that VAPIHCS has faced physician recruitment and retention  challenges that are both unique to the Pacific Islands, such as the limited  number of local physicians from which to recruit, and challenges that are  common across VHA, such as the amount of time it takes to hire a new  physician. Overall, there were at least 17  physician vacancies out of approximately 100 positions across VAPIHCS  as of October 2017, as well as several more vacancies for other types of  health care providers, some of which have been unfilled for some time. The Veterans Health  Administration supports VAMCs in recruiting  and retaining providers by providing system- wide strategies for their use. VAPIHCS and VHA officials told us they have recruited and retained  physicians to the Pacific Islands by promoting attributes of its location and  by using VHA strategies, similar to other VAMCs nationwide. Financial incentives. Education Debt Reduction Program. Veterans Face a Number of Challenges Accessing Health Care in the Pacific Islands, and VAPIHCS Uses Several Strategies to Improve Access

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

According to VAPIHCS officials, veterans face challenges accessing  health care services on the Pacific Islands due to the lack of certain  specialty care providers on many of the islands, the significant travel that  is required to obtain these services, and limitations associated with  telehealth services. Without completing such an  evaluation, VAPIHCS does not know if it is optimizing its resources to  improve its hiring efforts and ameliorate long-standing physician  shortages. In its written comments, VA concurred with three of our four  recommendations and provided information on its plans to address them. VA partly concurred with our recommendation for VAPIHCS to improve  the monitoring of referrals and communication with NHG to ensure the  timely management of referrals to NHG. Because VAPIHCS relies  on NHG to provide inpatient and specialty care services for veterans from  Guam and the Commonwealth of the Northern Mariana Islands, it is  important for VAPIHCS to monitor the entire referral management  process to ensure that veterans receive needed care in a timely manner.
Why GAO Did This Study

Veterans' access to timely health care at VA medical facilities has been a long-standing problem identified by GAO and VA's Office of Inspector General. The remote nature of the Pacific Islands creates some unique challenges for VAPIHCS, which may affect its ability to provide the approximately 50,000 veterans it serves in American Samoa, Guam, Hawaii, and the Commonwealth of the Northern Mariana Islands with timely access to primary, mental health, and specialty care.
House Report 114–497 included a provision for GAO to review VHA's efforts to provide timely access to health care within VAPIHCS. Among other things, this report examines: the extent to which the VAPIHCS veterans received (1) timely primary and mental health care, and (2) timely specialty care; and (3) any challenges VAPIHCS faced in recruiting and retaining physicians, and strategies to resolve them. GAO reviewed relevant policy documents and a randomly selected, non-generalizable sample of 164 medical records, and interviewed VHA, VAPIHCS, and DOD officials.

What GAO Found

For the sample of veterans' medical records that GAO reviewed, most veterans received primary and mental health care from the Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS) within timeliness goals set by VA's Veterans Health Administration (VHA). However, GAO also found that some of these veterans experienced delays related to the processing of their enrollment applications, contacting them to schedule appointments, and completing comprehensive mental health evaluations. These delays were similar to some GAO had identified in previous work pertaining to veterans' access to care nationwide.
For the sample of veterans' medical records that GAO reviewed, VAPIHCS referred nearly all specialty care to non-VA providers within VHA's timeliness goal, but the time taken to provide care was variable and sometimes lengthy. Specifically, VAPIHCS sent specialty care referrals to
the Veterans Choice Program (Choice Program)—for veterans that GAO reviewed, the number of days to receive care from the Choice Program was, on average, 75 days.
Department of Defense (DOD) military treatment facilities—for veterans that GAO reviewed, the number of days to receive care from the two DOD facilities for which VAPIHCS has agreements was, on average, 37 days from one facility and 47 days from the other.
GAO identified weaknesses in VAPIHCS' management of its referral process for sending veterans for specialty care services at one of the two military treatment facilities. GAO found VAPIHCS did not always manage referrals to the military treatment facility in a timely way and there was inconsistent guidance describing the roles and responsibilities of the VAPIHCS staff involved in the process. These weaknesses may have contributed to the amount of time it took for veterans to receive specialty care services.
GAO also found that VAPIHCS faces challenges recruiting and retaining physicians. As of October 2017, 17 of approximately 100 VAPIHCS physician positions were vacant, as were several other types of health care providers. Some of the challenges VAPIHCS faced are unique to the Pacific Islands, such as the availability of only one local medical school from which to recruit, along with travel burdens and a high cost of living that may discourage physicians from relocating there. Other challenges were similar to those GAO has previously identified as faced by VA medical centers across the country, such as differences in interpretation of hiring and recruiting policies. VAPIHCS officials said they use several strategies to help recruit and retain physicians, including VHA strategies used by other VA medical centers such as financial incentives and an educational debt reduction program. Although they described limits to the success of some of these strategies, they have not evaluated their effectiveness. Without completing an evaluation of its strategies, VAPIHCS may not be optimizing its resources to improve its hiring efforts and may continue to struggle with physician shortages.

What GAO Recommends

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