Choice Program Eligibility Criteria

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. VA did so in an October 3, 2014,  report to Congress. 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. 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. 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. 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. 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. Overall wait times. 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. 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. 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. 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. 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. VHA could not explain why the dates differed. 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. 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. 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). Therefore, it could not compare the  timeliness of access nationwide. We also  identified actions VA and VHA have taken to address these factors. This was intended to help address administrative burden  associated with clinical review processes and improve veterans’  access to care. Acquisition of a secure e-mail system and a mechanism for TPAs  and community providers to remotely access veterans’ VA  electronic health records. 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. VHA took the following two actions intended to help address staffing- related factors that adversely affected the timeliness of veterans’ Choice  Program care. Recommendations for Executive Action

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 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. 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. 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. 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.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.