GAO Report Looked at Facilities in VISN 12
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CHICAGO — Facilities in VISN 12 did not consistently identify veterans who are eligible for community care, inform veterans of their eligibility or correctly process requests for appointments, according to a new VA Office of the Inspector General (OIG) report.
Patients at VA facilities across the country have been vocal about these issues for years. Republican legislators have used those complaints as proof that VA hospitals are deliberately sabotaging efforts to expand community care in an attempt to protect their direct-care budgets.
The report laid much of the blame, however, on structural mismanagement rather than deliberate malice and noted that VA also made errors in the other direction, sending veterans to community care who should not have been. Included in VISN 12 are VA facilities in Illinois, Indiana, Michigan and Wisconsin.
OIG investigators looked at the first quarter of FY2024, during which VISN 12 processed 30,300 community-care consults and saw 178,900 direct-care appointments. The team replicated the wait-time and drive-time eligibility decision-making process, as well as examining records to determine whether the patients who were eligible for community care but received direct care were informed that they had options.
They found that about 23% of those community-care consults did not meet the wait-time or drive-time standards and that 37% of patients seen at VA facilities were eligible for community care, but there was no indication the staff checked their eligibility.
According to the report, these errors were a result of VISN 12 lacking an effective process to identify available appointments at other VAMCs, either inside or outside VISN 12. This lack was due to limitations in the Consult Toolbox, which uses geographic data to show all VAMCs within a 90-minute drive of a veteran’s home that may offer the needed clinical service.
But that function is where the toolbox ends, the investigators said. “VHA staff who use the Consult Toolbox told the review team they cannot access or even see these other medical facilities’ calendars, so they cannot schedule veterans at those facilities. Some schedulers noted they have established relationships with local facilities to request scheduling information, but this is not the case for all schedulers.”
Also, while VA guidance requires schedulers to check all eligibility criteria for new patients, established patients only need to be assessed for excessive wait times. It does not take into consideration that an established veteran could have moved, extending their previous drive time.
“Although this has been a common practice across VHA since the MISSION Act was implemented, the OIG determined this practice is not consistent with the Act, and it hindered veterans’ awareness of all care options,” the report noted.
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Sending veterans to community care when a quicker direct-care option exists can have an impact on health outcomes, the report found. In one case, a patient requiring physical therapy was provided a consult for community care because wait times at the VA facility were long. However, OIG determined three other VA facilities existed within the veteran’s drive time that could have provided the care up to 2 weeks sooner.
“The OIG found no evidence that VHA staff had considered any other VA facilities to provide care to the patient,” the investigators said.
In one concerning instance, the team identified a mental-health scheduler at the Jesse Brown VAMC in Chicago who had been using the opt-out code for patients who had not agreed to opt out of community care.
“This scheduler said speaking with veterans about their eligibility for community care was unnecessary because wait times in the community exceeded the more-than-20‑day wait-time standards within VA for the specific mental health services requested. As a result, the scheduler arranged for services within VA without documenting that eligibility in the Consult Toolbox,” the report stated. “Although the review team did not find any ill intent on the scheduler’s part, these veterans should have been told of their eligibility for community care. In addition, the review team identified 1,400 appointments across different services at the Jesse Brown facility that were not eligible for community care, but the appointment notes erroneously included the opt-out code.”
The lack of transparency both in community care wait times and within VA’s own scheduling systems will need to be addressed if VA hopes to get veterans the fastest, closest treatment available.
“Until medical facility staff have the capability to effectively identify appointment availability not only across VA medical facilities but also within the community, VA will continue to miss opportunities to fully comply with the [MISSION Act] and ensure veterans are informed of all their care options,” the investigators concluded.
Since the OIG review, VISN leaders have conducted training courses on the Consult Toolbox and the proper use of opt-out codes, as well as created service line agreements between VA facilities to help facilitate appointments for certain specialties.
While this might solve some of VISN 12’s issues, the investigation has spurred OIG to conduct two nationwide audits. One is a deep dive into how VISNs determine eligibility and inform veterans of their care options, and the other is comparing the timeliness of care received at VA compared to care in the community.
