Practice Notes

What we can learn about access from the VA scandal

by Anita Joseph

Schedulers at the Phoenix Department of the Veterans' Health Administration falsified wait times almost half of the time to disguise the long waits that veterans faced when trying to secure an appointment. An official VA audit concluded  that similar scheduling failures occurred at facilities across the country.

This comes in light of the fact that in its 2013 report to the United States Congress, the VA alleged that its second-biggest achievement was that “93 percent of primary and specialty care, and 95 percent of mental health appointments for established patients were completed within 14 days of desired appointment date.”

What accounts for the discrepancy between official reports and internal practice?

Congress has made much of the fact that the VA is understaffed, and in early June the House of Representatives approved a bill allowing veterans to see private physicians (thereby expanding the provider base). However, the physician supply gap rationalizes but does not fully explain why so many VA staffers lied about their performance. Instead, a close look at the VA’s access targets provides a more nuanced understanding of the problem.

The VA expected staff to treat patients within 14 days of their appointment request. This expectation trickled down into the salaries of top-level executives. In FY 2011, 60% of the performance review of senior Veterans’ Health Administration executives was based on 15 “organizational performance goals”; two of these were that patients not wait more than 14 days for primary and specialty care appointments.

However, this goal was out of step with access realities across the nation. In a 2014 audit, Merritt Hawkins found that the average wait time in 15 major markets for a new patient to see a family physician was 19.5 days; far off the VA target. 

Progressive, realistic access metrics are all about context

Physicians should be expected to outperform their peers–but the VA had established access standards that would have placed its performance well above the top provider organizations in the country.

Two ways that the VA could have crafted better access metrics are:

  1. Benchmarking the metrics based on regional or national metrics or to the previous year’s outcomes
  2. Using a bundle of access metrics, such as time to the third next available appointment, and percentage of queries successfully resolved

Aspirational metrics are not necessarily a problem. We have spoken to numerous organizations that have set firm targets around expanded access, and successfully used them to motivate their medical staff around the access imperative. 

Aurora Health Care in Wisconsin, for example, mandated that its physicians switch eight working hours a month to “family-friendly” access hours (weekend or evening). This was a rigorous standard that was not easy to comply with, but the challenge involved in achieving this request sent the message of how important performance improvement was.

Still, in retrospect, it’s clear that the VA lacked sufficient resources to meet its own care access expectations.  In light of this fact, the VA should have established performance thresholds that were realistic enough to provide a viable road map for access expansion.

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