Veterans Health Administration: Opportunities Exist for Improving Veterans' Access to Health Care Services in the Pacific Islands
Fast Facts
VA medical facilities have struggled to provide timely care. For veterans who live in American Samoa, Guam, Hawaii, and the Northern Marianas, these areas' remoteness can add challenges, such as long flights to see specialists.
We examined the timeliness of the primary, mental health, and specialty care provided by the VA Pacific Islands Health Care System.
Most veterans in our review received timely primary and mental health care. We found some delays and weaknesses in the referral process to community providers, such as inconsistent guidance on staff roles and responsibilities.
We recommended actions to improve the referral process.
VA Community Based Outpatient Clinic in Guam.
Photograph of the exterior of the VA community based outpatient clinic in Guam.
Highlights
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.
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.
Recommendations
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.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of VA should ensure that VAPIHCS review its referral process for referrals to DOD providers, including referral cancellation, to determine why VHA policy is not being adhered to and make changes as needed. (Recommendation 1) |
VA concurred with this recommendation, and VAPIHCS took steps to review and update its practices as needed to adhere to VHA policy. VAPIHCS revised its referral procedures with Tripler Army Medical Center (TAMC), which identified TAMC staff as being responsible for contacting veterans within 3 days of receiving the referral to schedule all appointments at TAMC. TAMC staff are no longer allowed to "blind schedule" veterans for appointments, meaning schedule appointments without contacting the veterans first. If TAMC staff is unable to contact a veteran to schedule an appointment, the referral is sent back to VAPIHCS staff. VAPIHCS also provided additional trainings in February, March, and June 2018 for VAPIHCS staff on VHA policies for referrals; officials indicated the trainings focused on appropriate reasons for cancelling referrals and which staff were authorized to do so. Further, in March 2018 VAPIHCS instituted monthly audits of cancelled referrals to ensure adherence to VHA policy. VAPIHCS indicated that the audits would continue until staff achieved a minimum of 90 percent adherence rate over three consecutive months. Finally, VAPIHCS developed a document to facilitate staff's decision-making for referral management or referral cancellation, accompanied by a process chart to aid decision-making. Based on evidence provided for these actions, we are closing this recommendation as implemented.
|
| Department of Veterans Affairs | The Secretary of VA should ensure that VAPIHCS clarify guidance to clearly define and document roles and responsibilities for VAPIHCS staff involved in the referral process with U.S. Naval Hospital Guam (NHG). (Recommendation 2) |
VA concurred with this recommendation, and in December 2018 provided documentation of a new standard operating procedure that VAPIHCS created in September 2018 to define and document the roles and responsibilities of VAPIHCS and NHG staff involved in the referral of veterans to the NHG. Further, VAPIHCS reported that NHG had hired two additional staff members to coordinate the referral process from VAPIHCS to NHG, and VAPIHCS was in the process of hiring a second staff member to be stationed at NHG to assist with veterans' care. Based on evidence provided for these actions, we are closing the recommendation as implemented.
|
| Department of Veterans Affairs | The Secretary of VA should ensure that VAPIHCS improves the monitoring of referrals and communication with NHG to ensure the timely management of referrals to NHG, including verifying the availability of services for veterans; ensuring referrals are entered into NHG's electronic medical record system; and obtaining information about the status of scheduling appointments for veterans. (Recommendation 3) |
To ensure timely referrals, VAPIHCS took several actions to address this recommendation. Specifically, VAPIHCS provided documentation that in September 2018 it implemented a standard operating procedure with NHG that identifies, among other things, NHG staff as responsible for entering referrals into NHG's electronic medical record system. Additionally, VAPIHCS staff started receiving weekly reports of pending referrals from NHG to monitor availability of services and ensure timely disposition of referrals. VAPIHCS indicated it planned to monitor referral data to NHG for one year. Finally, NHG provides service availability reports to VAPIHCS, which indicate services that are available at the hospital to provide veterans with care. VAPIHCS shared copies of these reports with us, along with examples of email exchanges from NHG to VAPIHCS providing updates on the hospital's availability to serve veterans. Based on evidence provided for these actions, we are closing this recommendation as implemented.
|
| Department of Veterans Affairs | The Secretary of VA should ensure that VAPIHCS evaluates the effectiveness of strategies it currently uses to promote physician recruitment and retention, including how the strategies could be improved. The plan should also include an assessment of whether additional strategies currently offered by VHA would be beneficial. (Recommendation 4) |
VA concurred with this recommendation, and in May 2018, VAPIHCS created a physician recruitment and retention taskforce, comprised of VAPIHCS physicians of different specialties, that was tasked with developing recommendations for improving VAPIHCS' physician recruitment and retention. The group's efforts included conducting exit interviews with departing VA providers to help determine actions to improve physician retention. Additionally, the task force reviewed physician recruitment and retention strategies leveraged by other VA medical centers, and identified10 additional strategies to adopt. VAPIHCS shared a copy of the signed decision memo outlining the 10 additional strategies and the plans to implement them by December 2018. Based on evidence provided for these actions, we are closing this recommendation as implemented.
|