Veterans treatment delays not a new issue for VA

As Congress looks for answers about patient treatment delays for veterans in the VA system, a 2010 memo from a senior VA official shows the issue of “Inappropriate Scheduling Practices” was certainly on the radar of the Department of Veterans Affairs well before recent stories about veterans dying while waiting for care in Phoenix.

Referred to as “gaming strategies” by William Schoenhard, VA’s deputy undersecretary for health operations and management, the 2010 missive showed a major review of VA scheduling practices had been undertaken at the time, as he flatly told VA executives to crack down on efforts to paper over delays in treatment for veterans.

“These practices will not be tolerated,” Schoenard wrote.

But Schoenard’s orders were seemingly ignored.

“They disregarded a directive from the central office about this very problem,” said Stuart Hickey of the group AmVets.  

“They need to be held accountable,” Hickey told reporters, asking the VA Secretary to discipline those in charge of VA health centers and the schedulers who help veterans get appointments for medical care, arguing this is exactly the problem uncovered in Phoenix.

While an interim Inspector General report noted four different “Scheduling Schemes” used by VA workers to disguise treatment delays for veterans, this 2010 memo went into much greater detail on how schedulers were manipulating appointment requests to make it seem like vets were getting timely treatment and care

Here are some of the key details of that part of the memo, titled, “Scheduling Practices to Avoid.”

* 30-day scheduling – By blocking appointments more than 30 days in the future, if nothing is available, veterans are asked to call back later to see if an appointment has opened. That means the VA system does not note exactly when a veteran first asks for a medical appointment, limiting access and distorting the official number of days a veteran has to wait for care.

* Creation and cancellation of New patient visits – One way to limit official wait times for veterans is to note that an appointment time was ‘cancelled by patient’ instead of by the VA clinic. The 2010 memo listed these ways this strategy was used:
+ Scheduling the New patient visit at a time the patient would prefer not to come in and then re-scheduling
+ Creating a New patient appointment without notifying the patient. This creates a very high likelihood that the patient will no-show which allows for another rebooking with a restarted wait time

* Date and Switch – The 2010 memo lists a variety of ways that schedulers would find a future appointment date. “Once a date/time is found, the clerk exits the system and then starts over using the identified date/time as the Desired Date” – thus limiting the official delay time for a veteran seeking care.

* Rescheduling a patient appointment – If a clinic has to cancel operations and patients need to be rescheduled, then the new patient appointment date will be entered in the system as the “desired date” for care – thus clouding statistics on waiting time for veterans.

The document is filled with suggestions to executives at VA medical facilities on how to make sure their schedulers aren’t using these type of ‘workarounds’ to make the numbers look better on the time that veterans wait for an appointment.

The suggestions included:

– Conduct random audits of patient appointments
– Critically assess the scheduling process
– Interview schedulers and check on how they schedule vets
– Call a sampling of patients to ask about dates, waiting times
– Directly observe schedulers while appointments are being scheduled
– Run consult tracking reports to further check for delays
– Also look at other system statistics to double check dates and waiting times

The 2010 memo also included a sample template for VA health facilities, to allow officials to better monitor the work of their schedulers, and how that may be impacting veterans seeking medical care appointments.

The detail of the 2010 memo indicates that this review was not done in a shallow manner – and it also seems to hint that there had been other reviews of work by VA schedulers.

“Please be cautioned that since 2008, additional new or modified gaming strategies may have emerged, so do not consider this list a full description of all current possibilities of inappropriate scheduling practices that need to be addressed,” Schoenhard wrote.

The 2010 memo on scheduling can be read in full here.