National

VA struggling to shorten waits

U.S. Army veteran Kenneth Chavis undergoes a glaucoma examination at the Fayetteville Veterans Affairs Medical Center. The Fayetteville VA hopes to celebrate its 75th anniversary this fall with the opening of a new outpatient health care center that could ease chronic delays.
U.S. Army veteran Kenneth Chavis undergoes a glaucoma examination at the Fayetteville Veterans Affairs Medical Center. The Fayetteville VA hopes to celebrate its 75th anniversary this fall with the opening of a new outpatient health care center that could ease chronic delays. AP

A year after Americans recoiled at new revelations that sick veterans were getting sicker while languishing on waiting lists – and months after the Department of Veterans Affairs instituted major reforms costing billions of dollars – government data show that the number of patients facing long waits at VA facilities has not dropped at all.

Many delay-prone facilities are clustered within a few hours’ drive of each other in a handful of Southern states, including North Carolina – often in areas with a strong military presence, a partly rural population and patient growth that has outpaced the VA’s sluggish planning process.

No one expected that the VA mess could be fixed overnight. But The Associated Press has found that since summer, the number of vets waiting more than 30 or 60 days for non-emergency care has largely stayed flat. The number of medical appointments that take longer than 90 days to complete has nearly doubled.

Nearly 894,000 appointments completed at VA medical facilities from Aug. 1 to Feb. 28 failed to meet the health system’s timeliness goal, which calls for patients to be seen within 30 days.

That means roughly one in 36 patient visits to a caregiver involved a delay of at least a month. Nearly 232,000 of those appointments involved a delay of longer than 60 days – a figure that doesn’t include cancellations, patient no-shows, or instances where veterans gave up and sought care elsewhere.

A closer look reveals deep geographic disparities.

Of the 75 clinics and hospitals with the highest percentage of patients waiting more than 30 days for care, 12 are in Tennessee or Kentucky, 11 are in Eastern North Carolina and the Hampton Roads area of Virginia, 11 more are in Georgia and southern Alabama, and six are in north Florida.

Seven more were clustered in the region between Albuquerque, N.M., and Colorado Springs, Colo.

Those 47 clinics and hospitals represent just a fraction of the more than 1,000 VA facilities nationwide, but they were responsible for more than one in five of the appointments that took longer than 60 days to complete, even though they accounted for less than 6 percent of patient visits.

Delays for N.C. Marine

That has meant big headaches for North Carolina veterans such as Rosie Noel, a retired Marine gunnery sergeant who was awarded the Purple Heart in Iraq after rocket shrapnel slashed open her cheek and broke her jaw.

Noel, 47, said it took 10 months for the VA to successfully schedule her for a follow-up exam and biopsy after an abnormal cervical cancer screening test in June 2013.

First, she said, her physician failed to mention she needed the exam at all. Then, her first scheduled appointment in February 2014 was postponed due to another medical provider’s “family emergency.” She said her makeup appointment at the VA hospital in Fayetteville, one of the most backed-up facilities in the country, was abruptly canceled when she was nearly two hours into the drive from her home in Sneads Ferry on the coast.

Noel said she was so enraged, she warned the caller that she had post-traumatic stress disorder, she wasn’t going to turn around – and they better have security meet her in the lobby.

“I served my country. I’m combat wounded. And to be treated like I’m nothing is unconscionable,” Noel said.

The AP examined wait times at 940 individual VA facilities from Sept. 1 through Feb 28 to gauge any changes since a scandal over delays and attempts to cover them up led to the resignation of VA Secretary Eric Shinseki in May and prompted lawmakers to pass the Veterans Access, Choice and Accountability Act in August.

It is difficult to quantify exactly how things have changed because the VA introduced a new method for measuring wait times at the end of the summer. VA officials say the new methodology is more accurate, but its adoption also meant that about half of all patient appointments previously considered delayed are now being classified as meeting VA timeliness standards. That means published wait times now can’t be directly compared with data the VA released last spring.

The trend, however, is clear: Under the VA’s old method for calculating delays, the percentage of appointments that took longer than 30 days to complete had been steadily ticking up, from 4.2 percent in May to nearly 5 percent in September. Under the new method – the one that counts half as many appointments as delayed – the percentage went from 2.4 percent in August to 2.9 percent in February.

The number of appointments delayed by more than 90 days abruptly jumped to nearly 13,000 in January and more than 10,000 in February, compared to an average of around 5,900 the previous five months. That’s not a change that can simply be blamed on bad winter weather; many of the places reporting the largest gains are warm year-round.

VA officials cite numerous efforts to ramp up capacity by building new health centers and hiring more staff; between April and December, the system added a net 8,000 employees, including 800 physicians and nearly 2,000 nurses.

“I think what we are seeing is that as we improve access, more veterans are coming,” Deputy Secretary of Veterans Affairs Sloan Gibson told the AP.

He also acknowledged that the VA has historically been “not very adroit as a bureaucracy” in responding to those changes. It takes too long to plan and build new clinics when they are needed, he said, and the VA isn’t flexible in its ability to reallocate resources to places that need them most.

“We are doing a whole series of things – the right things, I believe – to deal with the immediate issue,” Gibson said. “But we need an intermediate term plan that moves us ahead a quantum leap, so that we don’t continue over the next three or four years just trying to stay up. We’ve got to get ahead of demand.”

Disparities abound

In many parts of the country, the VA can boast of being able to deliver care that is just as fast, or even faster, than patients would get in the private sector. Relatively few VA facilities in the Northeast, Midwest and Pacific Coast states reported having significant numbers of patients waiting extended periods for care.

The difference between the haves and have-nots can be stark.

The Minneapolis VA, one of the system’s busiest medical centers, completed 276,094 medical appointments between Sept. 1 and Feb. 28. Only 424 of them involved a wait of more than 60 days.

At the VA’s outpatient clinic in Jacksonville, Fla., a facility handling a third of the volume, 7,117 appointments involved a wait of more than 60 days.

That means there were more vets experiencing extended delays at that one clinic than in the entire states of New York, New Jersey and Connecticut combined.

Equally surprising: The Jacksonville clinic is practically brand-new. It opened in 2013 with the express intent of improving access to care in a fast-growing city with a lot of military retirees and a close relationship with three U.S. Navy bases.

But the clinic took so long to plan and build – 12 years – that it was too small the day it opened, despite late design changes that added significantly more space.

In recent months, the clinic has been enrolling another 25 new patients per day – a growth rate that would require the VA to hire another doctor, nurse and medical support assistant every 10 weeks to keep up with demand, said Thomas Wisnieski, the health system’s director.

A slow pace of change

The Fayetteville VA hopes to celebrate its 75th anniversary this fall with the opening of a huge new outpatient health care center that could ease the types of chronic delays that caused Rosie Noel so much anxiety. (After her canceled exam, the VA paid for Noel to get care at a private-sector clinic; she doesn’t have cervical cancer.)

With 250,000 square feet of usable space, the center will be almost as large as the main hospital building itself. It is sorely needed for a region that is home to two of America’s largest military bases, the Army’s Fort Bragg and the Marines’ Camp Lejeune, and one of the highest concentrations of veterans in the country.

Yet the new building is also emblematic of the slow pace of change at the VA.

Planning for the facility began in 2008, and Congress approved funding the next year. Construction hadn’t even begun when the first target completion date came and went in June 2012.

The hospital’s director since 2010, Elizabeth Goolsby, cited the VA’s failure to expand quickly as a primary reason for why Eastern North Carolina now has some of the longest waits for care in the country.

“The contracting and building time in the Department of Veterans Affairs is a lengthy process,” she said.

During her tenure in Fayetteville, Goolsby has opened new outpatient clinics in Wilmington, Goldsboro, Pembroke and Hamlet. All now rank among the VA locations with the highest percentage of appointments that fail to meet timeliness standards.

At the VA’s clinic in Jacksonville, N.C., – a small medical office built in a shopping plaza near Camp Lejeune’s main gate in 2008 – nearly one in nine appointments completed between Sept. 1 and Feb. 28 involved a wait of longer than 60 days.

“It’s not big enough to accommodate the number of veterans we are seeing or the number of providers we need,” Goolsby acknowledged.

One solution, she said, has been to keep building.

A new 15,000-square-foot clinic is under construction to serve the area around Camp Lejeune. The VA also is trying to develop a clinic in Sanford, north of Fort Bragg. And there have been stopgap measures, like the construction of modular buildings at the Fayetteville hospital this winter to host mental health clinics, and an emergency lease for a temporary medical office that allowed it to bolster staff in Jacksonville.

Some vets whose doctors were moved over to the new Jacksonville space said things improved immediately, even if that has not yet been reflected in the statistics.

“It used to take me six months to a year to get a doctor’s appointment,” Jim Davis, a retired Marine who fought in the first Gulf War and now has Lou Gehrig’s Disease. Since he transferred to the temporary clinic, he said, “I’ve called, and within three or four days I can get in to see the doctor.”

No easy fix

The centerpiece of the legislation signed over the summer was a plan to expand the number of veterans who are approved to get care outside of VA facilities. Yet the Choice program has barely gotten off the ground.

ID cards for the program were mailed starting in November, but many vets still don’t understand how it works. It theoretically is open to patients who can’t been seen within 30 days, or who have to drive longer distances for care, but enrollees still have to get VA approval to see a private-sector doctor, and only some physicians participate in the payment system.

“It’s not working the way it needs to work,” said Gibson, the deputy VA secretary, though he added that he was enthusiastic about its potential.

In a meeting with congressional aides and state veterans service officials in March, Goolsby gave some figures to illustrate how the program was working in southeastern North Carolina: Of the 640 patients offered an opportunity for outside care through mid-March, only four were ultimately seen by a private-sector doctor.

“We’re finding that a lot don’t want an outside appointment,” she said.

Reasons vary, she said, but one factor is that switching to a new doctor can be disruptive for someone with an ongoing medical issue.

Peak usage yet to come

Obama’s secretary of Veterans Affairs, Robert McDonald, warned in recent testimony to Congress that the system may still be decades away from seeing peak usage by the generation of servicemen and servicewomen who fought in Iraq and Afghanistan.

“Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care,” McDonald said.

That could mean that without further change, waits will only grow.

Nearby regions

The Veterans Affairs system operates more than 1,000 facilities. A look at some regions where waits were longest over a six-month period beginning on Sept. 1 and ending Feb. 28:

Eastern North Carolina

North Carolina is home to the Army’s Fort Bragg, the Marines’ Camp Lejeune, and nine of the 50 VA medical facilities with the most patients waiting more than 30 days for care. Around 16 percent of the vets getting treatment at the clinic in Jacksonville had to wait longer than 30 days for an appointment. Close to 1 in 9 patients there had to wait longer than 60 days to see a caregiver. The VA has opened several new clinics in the state in recent years to deal with long waits, but those new and expanded sites haven’t met expanding demand.

Hampton Roads, Va.

A home to U.S. naval power and a popular spot for military retirees, the Hampton Roads region of southeastern Virginia also ranks among the worst places for a vet to get a timely appointment at the VA. About 7.3 percent of the appointments completed at the VA hospital in Hampton failed to meet the department’s timeliness standards. At the outpatient clinic in Virginia Beach, 18 percent of patient visits involved a wait of longer than 30 days – although things have been improving. The clinic completed nearly 89 percent of its visits in a timely fashion in February, compared to 76 percent six months earlier.

Tennessee and Kentucky

The VA has opened a host of small medical clinics in rural Tennessee and southern Kentucky, and while they treat a modest number of patients, those that do come are among the most likely to face a long wait for care. Thirteen of the 100 VA sites with the highest percentage of patients waiting more than 30 days are in the two states. The outpatient clinic in Hopkinsville, Ky., has the highest percentage of delayed appointments of any VA clinic in the country. Nearly 20 percent of the 5,377 appointments completed at that facility involved a wait of longer than 30 days, and things have been getting steadily worse since summer.

Third clinic

coming to Raleigh

To address growing demand and reduce wait times for appointments, the Department of Veterans Affairs said in January it will open a third clinic in the Raleigh area, with mental health services and primary care for men and women.

Two existing clinics served more than 12,000 patients in 2014, an increase of 19 percent in the past two years. The new clinic is expected to serve an additional 3,600. A VA official said the new clinic will have have five patient care teams, consisting of a doctor or nurse practitioner plus a registered nurse, a licensed practical nurse and an administrator.

From staff reports

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