VA Health Care
Access for Chattanooga-Area Veterans Needs Improvement
Gao ID: GAO-04-162 January 30, 2004
Veterans residing in Chattanooga, Tennessee, have had difficulty accessing Department of Veterans Affairs (VA) health care. In response, VA has acted to reduce travel times to medical facilities and waiting times for appointments with primary and specialty care physicians. Recently, VA released a draft national plan for restructuring its health care system as part of a planning initiative known as Capital Asset Realignment for Enhanced Services (CARES). GAO was asked to assess Chattanooga-area veterans' access to inpatient hospital and outpatient primary and specialty care against VA's guidelines for travel times and appointment waiting times and to determine how the draft CARES plan would affect Chattanooga-area veterans' access to such care.
Almost all (99 percent) of the 16,379 enrolled veterans in the 18-county Chattanooga area, as of September 2001, faced travel times that exceeded VA's guidelines for accessing inpatient hospital care. During fiscal year 2002, only a few Chattanooga-area veterans were admitted to non-VA hospitals in Chattanooga--constituting about 5 percent of inpatient workload. In addition, over half (8,400) of Chattanooga-area enrolled veterans faced travel times that exceeded VA's 30-minute guideline for outpatient primary care. Also, waiting times for scheduling initial outpatient primary and specialty care appointments frequently exceeded VA's 30-day guideline. VA's draft CARES plan would shorten travel times for some Chattanooga-area veterans but lengthen travel times for others. Under the plan, the amount of inpatient care VA purchases from non-VA hospitals in Chattanooga would increase from 5 percent to 29 percent, thereby reducing those veterans' travel times to within VA's guidelines. The plan also proposes to shift some inpatient workload from VA's Murfreesboro hospital to its Nashville hospital. As a result, an estimated 54 percent of inpatient workload for Chattanooga-area enrolled veterans will be provided in Nashville compared to 40 percent in fiscal year 2002, thereby lengthening some veterans' travel times by about 20 minutes. The plan also proposes opening four new community-based clinics, which would bring about 2,700 more Chattanooga-area enrolled veterans within VA's 30-minute travel guideline for primary care, leaving about 5,700 enrolled veterans with travel times for such care that exceed VA's guideline. These clinics likely would not open before fiscal year 2011, given priorities specified in the plan.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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GAO-04-162, VA Health Care: Access for Chattanooga-Area Veterans Needs Improvement
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Report to Congressional Requesters:
United States General Accounting Office:
GAO:
January 2004:
VA Health Care:
Access for Chattanooga-Area Veterans Needs Improvement:
GAO-04-162:
GAO Highlights:
Highlights of GAO-04-162, a report to Congressional Requesters
Why GAO Did This Study:
Veterans residing in Chattanooga, Tennessee, have had difficulty
accessing Department of Veterans Affairs (VA) health care. In
response, VA has acted to reduce travel times to medical facilities
and waiting times for appointments with primary and specialty care
physicians. Recently, VA released a draft national plan for
restructuring its health care system as part of a planning initiative
known as Capital Asset Realignment for Enhanced Services (CARES). GAO
was asked to assess Chattanooga-area veterans‘ access to inpatient
hospital and outpatient primary and specialty care against VA‘s
guidelines for travel times and appointment waiting times and to
determine how the draft CARES plan would affect Chattanooga-area
veterans‘ access to such care.
What GAO Found:
Almost all (99 percent) of the 16,379 enrolled veterans in the 18-
county Chattanooga area, as of September 2001, faced travel times that
exceeded VA‘s guidelines for accessing inpatient hospital care. During
fiscal year 2002, only a few Chattanooga-area veterans were admitted
to non-VA hospitals in Chattanooga”constituting about 5 percent of
inpatient workload. In addition, over half (8,400) of Chattanooga-area
enrolled veterans faced travel times that exceeded VA‘s 30-minute
guideline for outpatient primary care. Also, waiting times for
scheduling initial outpatient primary and specialty care appointments
frequently exceeded VA‘s 30-day guideline.
VA‘s draft CARES plan would shorten travel times for some Chattanooga-
area veterans but lengthen travel times for others. Under the plan,
the amount of inpatient care VA purchases from non-VA hospitals in
Chattanooga would increase from 5 percent to 29 percent, thereby
reducing those veterans‘ travel times to within VA‘s guidelines. The
plan also proposes to shift some inpatient workload from VA‘s
Murfreesboro hospital to its Nashville hospital. As a result, an
estimated 54 percent of inpatient workload for Chattanooga-area
enrolled veterans will be provided in Nashville compared to 40 percent
in fiscal year 2002, thereby lengthening some veterans‘ travel times
by about 20 minutes. The plan also proposes opening four new community-
based clinics, which would bring about 2,700 more Chattanooga-area
enrolled veterans within VA‘s 30-minute travel guideline for primary
care, leaving about 5,700 enrolled veterans with travel times for such
care that exceed VA‘s guideline. These clinics likely would not open
before fiscal year 2011, given priorities specified in the plan.
What GAO Recommends:
When considering the costs and benefits of options for realigning
assets to enhance services, GAO recommends that VA explore
alternatives to further improve access to health care for Chattanooga-
area veterans, such as: (1) purchasing a larger proportion of these
veterans‘ inpatient workload locally, (2) expediting the opening of
four community-based clinics proposed by the draft CARES plan, and (3)
providing primary care locally for more of those veterans whose access
remains outside VA‘s travel guideline after those clinics open. VA
agreed to consider our recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-162.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Cynthia A. Bascetta
at (202) 512-7101.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Chattanooga-Area Veterans Faced Travel and Waiting Times That
Frequently Exceeded VA Guidelines:
Draft CARES Plan Would Enhance Access for Some Veterans but Diminish
Access for Others:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Figures:
Figure 1: VA Mid South Network's Central Market and Hospitals and
Clinics, Fiscal Year 2004:
Figure 2: Eighteen-County Chattanooga Area:
Figure 3: Estimated Changes in Veteran Population and Enrollment in the
Chattanooga Area from Fiscal Years 2001 through 2022:
Figure 4: Chattanooga-Area Veterans' Travel Times to VA's Murfreesboro
Hospital, Fiscal Year 2001:
Figure 5: Enrolled Veterans Living More Than 30 Minutes from VA Primary
Care Clinics, by County (Fiscal Year 2001):
Figure 6: Number of Enrolled Veterans Who Would Have Traveled More Than
30 Minutes to VA Facilities Had Four Proposed Clinics Been Operational
in Fiscal Year 2001:
Abbreviations:
CARES: Capital Asset Realignment for Enhanced Services:
IG: Inspector General:
VA: Department of Veterans Affairs:
United States General Accounting Office:
Washington, DC 20548:
January 30, 2004:
The Honorable Charles Taylor:
The Honorable Zach Wamp:
House of Representatives:
The Department of Veterans Affairs (VA) operates a nationwide health
care system that is organized into 21 integrated health care networks
comprising over 160 hospitals and 600 community-based outpatient
clinics. Over 7 million veterans are enrolled nationwide; during fiscal
year 2002, almost 4.3 million veterans received VA health care, at a
cost of $22.6 billion. Generally, VA assigns each enrolled veteran to a
primary care provider who manages his or her care, including making
referrals for hospital admission or consultation with specialists on an
outpatient basis.
Veterans residing in Chattanooga, Tennessee, have encountered
difficulties accessing VA inpatient and outpatient health care
services. For example, in a 1999 report,[Footnote 1] VA's Inspector
General (IG) cited waiting times for outpatient specialty care that
frequently exceeded 90 days, which raised concern about VA's capacity
to meet veterans' health care needs at the Chattanooga clinic and the
nearest VA hospitals located in Murfreesboro and Nashville, Tennessee.
The report also highlighted long distances between VA's Chattanooga
clinic and those hospitals--110 and 125 miles, respectively. Following
the 1999 report, VA took several steps specifically designed to enhance
veterans' access to health care, including expanding service capacity
at the Chattanooga clinic and contracting for inpatient hospital care
and outpatient primary and specialty care with local providers in
Chattanooga, including the Erlanger Medical Center.
To enhance services for veterans across its entire health care system,
VA began a nationwide strategic planning initiative in October 2000,
known as Capital Asset Realignment for Enhanced Services (CARES). We
support the goals of this initiative, which was undertaken in response
to our 1999 recommendation that VA restructure its delivery of health
care to reduce spending on underutilized or inefficient buildings and,
in turn, reinvest the savings in enhanced health care resources closer
to where veterans live.[Footnote 2] The CARES process is designed to
address, among other things, veterans' access to health care and the
cost and quality of health care. As part of this initiative, VA
conducted analyses of needs and alternatives at both the national and
local levels, using the 77 designated health care markets in VA's
health care networks. In August 2003, VA released its draft CARES plan,
which presented a wide range of health care service enhancement
proposals based on veterans' projected health care needs and related
capacity requirements.[Footnote 3] After reviewing the plan and
collecting additional information,[Footnote 4] an independent CARES
Commission will, in February 2004, make specific recommendations to the
Secretary of Veterans Affairs for restructuring VA's health care
system; the Secretary is expected to make a final decision within 30
days of receiving the Commission's recommendation.
To measure the accessibility of its health care services, VA
established guidelines for travel times and waiting times. As part of
its CARES initiative, VA established national travel time guidelines to
help define reasonable access to health care. Specifically, VA defines
reasonable access to inpatient hospital care to be a travel time--from
a veteran's residence to the nearest appropriate VA hospital--of no
more than 60 minutes for those residing in urban counties and 90
minutes for rural county residents. VA defines reasonable access to
outpatient primary care to be a travel time of no more than 30 minutes
from a veteran's residence to the nearest VA primary care clinic in
urban and rural counties. Prior to its CARES initiative, VA had already
established 30 days or less as a reasonable waiting time for initial
primary care and outpatient specialty care appointments.
At your request, we assessed how (1) Chattanooga-area veterans' access
to inpatient hospital and outpatient primary and specialty care
compared to VA's established travel time and appointment waiting time
guidelines and (2) VA's draft CARES plan, if implemented, could affect
Chattanooga-area veterans' access to such care.
To perform our work, we discussed the provision of VA-financed health
care services with officials of VA's Chattanooga Clinic, the Mid South
Network office[Footnote 5] located in Nashville, the IG's office, and
VA headquarters, as well as representatives of the Erlanger Medical
Center. To assess travel and waiting times, we defined Chattanooga-area
veterans to be those residing in Hamilton County, which includes the
city of Chattanooga, and 17 surrounding counties; those 18 counties are
all closer (as measured by travel time) to the VA clinic and non-VA
hospitals in Chattanooga than to VA hospitals and clinics in
Murfreesboro and Nashville. Using VA's CARES databases, we analyzed
demographic and workload information for 16,379 veterans from those 18
counties who were enrolled in VA's health care system as of fiscal year
2001. Our analyses of travel times focused on hospital services and
outpatient primary care because VA did not have guidelines for
outpatient specialty care travel times. Also, we examined fiscal year
2002 data on inpatient hospital admissions for medicine and surgery
services as well as primary care and specialty care scheduling data for
Chattanooga-area veterans. Regarding the impact of VA's draft national
CARES plan, we reviewed the plan and a wide array of supporting
documents and discussed those documents with VA officials. As agreed
with your office, we focused on access to care for Chattanooga-area
veterans. We performed our work from November 2002 through December
2003 in accordance with generally accepted government auditing
standards. For additional details of our scope and methodology, see
appendix I.
Results in Brief:
Chattanooga-area veterans faced travel and waiting times that
frequently exceeded VA guidelines. Almost all (99 percent) of the
16,379 Chattanooga-area enrolled veterans, as of September 2001, faced
travel times that exceeded VA's guidelines for accessing inpatient
hospital care. Almost two-thirds of the Chattanooga-area veterans whose
travel times exceeded VA's guidelines lived in five urban counties to
which the 60-minute travel guideline applied. However, their travel
time to the nearest VA hospital in Murfreesboro exceeded 90 minutes
and, for most of them, was well beyond 120 minutes. Few veterans,
however, had their travel times reduced through admissions to non-VA
hospitals in Chattanooga, due in part to VA's restrictive referral
practices; about 5 percent of Chattanooga-area enrolled veterans'
inpatient workload was purchased locally during fiscal year 2002. In
addition, about 8,400 (over 50 percent) of all Chattanooga-area
enrolled veterans faced travel times that exceeded VA's 30-minute
guideline for outpatient primary care. Also, Chattanooga-area veterans'
waiting times for initial outpatient primary care and specialty care
appointments frequently exceeded VA's 30-day guidelines. For example,
during fiscal year 2002, less than 7 percent of the approximately 1,850
veterans awaiting their initial primary care visits at the Chattanooga
clinic received appointments within VA's 30-day guideline. During
fiscal year 2003, VA officials took several steps to shorten
appointment waiting times for initial outpatient primary care and
specialty care, although waits generally remained longer than 30 days.
VA's draft CARES plan proposes a major realignment of inpatient
hospital care that would shorten travel times for some Chattanooga-area
veterans but lengthen travel times for others. Under the proposal, an
estimated 29 percent of Chattanooga-area veterans' inpatient care would
be purchased from non-VA hospitals in Chattanooga--a more than fivefold
increase over the fiscal year 2002 level. On the other hand, the draft
CARES plan proposes to shift inpatient workload from VA's Murfreesboro
hospital to its Nashville hospital resulting in an estimated 54 percent
of Chattanooga-area veterans' inpatient care being provided in
Nashville. Travel times for those veterans affected--already more than
90 minutes to the Murfreesboro hospital--would increase by 20 minutes
or more in order to reach the Nashville hospital. Regarding outpatient
care, the draft CARES plan calls for a range of actions, including
opening four new community-based clinics and using
telemedicine,[Footnote 6] that could shorten both travel and
appointment waiting times for Chattanooga-area veterans seeking
outpatient primary and specialty care. Once opened, approximately 2,700
more Chattanooga-area enrolled veterans would have travel times for
outpatient primary care that meet VA's 30-minute guideline, leaving
about 5,700 enrolled veterans with travel times for such care that
exceed VA's guideline. However, veterans would not immediately realize
the benefits of these clinics as they would not likely open before
fiscal year 2011, given priorities specified in the plan.
In making nationwide CARES decisions, we recognize that the Secretary
of Veterans Affairs will need to make trade-offs regarding the costs
and benefits of alternatives for better aligning VA's capital assets
and services. As part of this process, the Secretary will need to
decide whether additional improvements to access, beyond those in the
draft national CARES plan, are warranted in the Chattanooga area. We
are recommending that when considering the trade-offs regarding the
costs and benefits of alternatives for better aligning assets and
services in Chattanooga, the Secretary of Veterans Affairs explore
alternatives such as (1) purchasing inpatient care locally for a larger
proportion of Chattanooga-area veterans' workload, particularly
focusing on those veterans who may experience longer travel times as a
result of the proposed shift of inpatient workload from Murfreesboro to
Nashville; (2) opening the four proposed community-based clinics in the
Chattanooga area on an expedited basis; and (3) providing primary care
locally for more of those veterans whose access will remain outside
VA's travel guidelines despite the opening of the four new clinics.
Background:
Chattanooga is located in VA's Mid South Healthcare Network, which
comprises Tennessee and portions of nine other states. For CARES
purposes, the Mid South Network designated a 75-county area as a health
care delivery market--referred to as the Central Market. In fiscal year
2001, 78,656 enrolled veterans resided in this market.[Footnote 7] As
figure 1 shows, Chattanooga, Tennessee, is located in the southeastern
part of the Central Market, which serves veterans residing in the
central portion of Tennessee, as well as veterans in southern Kentucky
and northern Georgia. Within this market, VA currently operates
hospitals located in Murfreesboro and Nashville, Tennessee, and six
community-based clinics (including one located in Chattanooga).
Figure 1: VA Mid South Network's Central Market and Hospitals and
Clinics, Fiscal Year 2004:
[See PDF for image]
[End of figure]
Although VA does not operate a hospital in the Chattanooga area, a
broad range of non-VA medical services and providers is available in
the Chattanooga area, including 16 hospitals. Of 5 hospitals located in
the city itself, the largest is the Erlanger Medical Center--a tertiary
care referral center and the region's only Level One trauma center. In
addition, there is a wide variety of specialty care, such as cardiology
and rheumatology, provided by non-VA physicians in the Chattanooga
area. Imaging, diagnostic, and laboratory services, such as endoscopy,
colonoscopy, or nuclear medicine scanning, are also available. The
range of inpatient medicine and surgery services available at
Chattanooga-area hospitals is comparable to services provided at VA
hospitals in Nashville and Murfreesboro, according to VA Mid South
Network officials.
For purposes of our study, we defined the Chattanooga area as Hamilton
County, which includes the City of Chattanooga, and 17 surrounding
counties.[Footnote 8] In fiscal year 2001, 21 percent (16,379 enrolled
veterans) of all enrolled veterans in the Central Market resided in
this area. Figure 2 highlights the 18-county Chattanooga area.
Figure 2: Eighteen-County Chattanooga Area:
[See PDF for image]
[End of figure]
As figure 3 shows, VA estimates that the veteran population in the
Chattanooga area will decline by about 25,600 veterans from fiscal year
2001 through fiscal year 2022--a decrease of almost 27 percent. During
that same period, however, VA projects that Chattanooga-area veterans
enrolled in VA's health care system will rise by about 5,000--an
increase of more than 30 percent.
Figure 3: Estimated Changes in Veteran Population and Enrollment in the
Chattanooga Area from Fiscal Years 2001 through 2022:
[See PDF for image]
[End of figure]
Moreover, within the Central Market, VA expects the enrolled veterans'
workload[Footnote 9] for inpatient hospital and outpatient primary and
specialty care to double through fiscal year 2022, in large part, as a
result of the projected growth in the Chattanooga-area enrolled
population as well as the aging of that population. For example, 43
percent of the 16,379 enrolled veterans were 65 years of age or older
as of September 2001.
Chattanooga-Area Veterans Faced Travel and Waiting Times That
Frequently Exceeded VA Guidelines:
Almost all Chattanooga-area veterans faced travel times that exceeded
VA's travel time guidelines for accessing inpatient hospital care.
Also, about half faced travel times that exceeded VA's guideline for
outpatient primary care. In addition, appointment waiting times for
initial outpatient primary care and specialty care consultations
exceeded VA's guidelines, although VA officials recently have taken
several steps to shorten appointment waiting times.
Travel Times for Most Chattanooga-Area Veterans to VA Hospitals in
Murfreesboro and Nashville Exceeded VA's Guidelines:
Almost all (99 percent) of the 16,379 Chattanooga-area enrolled
veterans, as of September 2001, faced travel times that exceeded VA
guidelines for travel to the nearest VA hospitals in Murfreesboro and
Nashville. Almost two-thirds of Chattanooga-area veterans whose travel
times exceeded VA guidelines lived in five urban counties to which the
60-minute guideline applies--Hamilton and Bradley counties in Tennessee
and Catoosa, Walker, and Whitfield counties in Georgia. The rest (36
percent) lived in rural counties to which the 90-minute guideline
applies. As figure 4 shows, Chattanooga is about 120 minutes by car
from Murfreesboro, the nearest VA hospital. Therefore, those veterans
residing in the five urban counties faced travel times to Murfreesboro
or Nashville that were double VA's 60-minute urban travel guideline;
veterans living in most of the 13 rural counties also faced travel
times well beyond VA's 90-minute rural guideline.[Footnote 10]
Figure 4: Chattanooga-Area Veterans' Travel Times to VA's Murfreesboro
Hospital, Fiscal Year 2001:
[See PDF for image]
[A] Urban county.
[End of figure]
Moreover, VA provided over 95 percent of its inpatient hospital
workload for Chattanooga-area veterans at VA hospitals in Murfreesboro
and Nashville during fiscal year 2002, with less than 5 percent
provided by non-VA hospitals in Chattanooga. During that fiscal year,
Chattanooga-area veterans had a total of 685 admissions that resulted
in a total workload of 7,213 bed days of care. Of these admissions, 580
(6,895 bed days of care) were to the VA hospitals in Murfreesboro or
Nashville; the remaining 105 admissions (318 bed days of care) were to
Chattanooga hospitals, primarily the Erlanger Medical Center.
Local admissions were few, in part, because Mid South Network officials
imposed restrictions on the VA Chattanooga clinic's referral practices.
For example, when purchasing care on a fee-for-service basis, providers
were to refer veterans to local hospitals only when care was not
available at VA hospitals in Murfreesboro or Nashville or the veterans'
medical conditions precluded travel to those sites. Also, in
implementing a contract with the Erlanger Medical Center,[Footnote 11]
network officials instructed VA clinic providers to limit referrals to
Erlanger to only veterans with less severe medical conditions, such as
those who did not require surgery or hospital stays longer than 5 days.
Network officials stated that restrictions were not related to the
availability of local care, in that the array of services available at
Chattanooga-area hospitals was comparable to services provided at VA
hospitals in Murfreesboro and Nashville. Rather, they said that such
restrictions were necessary to manage resources effectively, as well as
to ensure the patient workload needed to support medical education
activities at VA's Murfreesboro hospital.
We estimate that during fiscal year 2002, these referral restrictions
applied to 246 admission decisions that were recommended by Chattanooga
clinic providers.[Footnote 12] Of these admissions, almost 60 percent
were to VA hospitals in Murfreesboro or Nashville rather than non-VA
hospitals in Chattanooga and were generally consistent with the
restrictions imposed by the Mid South Network. The remaining 40 percent
(101 admissions)[Footnote 13] were to non-VA hospitals in Chattanooga,
with about two-thirds financed on a fee-for-service basis and the rest
through the VA-Erlanger contract.
Travel Times to Obtain Outpatient Primary Care Frequently Exceeded VA
Guidelines:
In fiscal year 2001, more than half (about 8,400) of the 16,379
Chattanooga-area enrolled veterans faced travel times that exceeded
VA's 30-minute travel guideline for accessing care at VA's nearest
primary care clinic. The remaining 8,000 Chattanooga-area enrolled
veterans lived within 30 minutes of VA community-based clinics in
Chattanooga, Tullahoma, or Knoxville. Although VA also operates
outpatient primary care clinics in its hospitals in Murfreesboro and
Nashville, these clinics are all considerably farther than the 30
minutes travel time from the Chattanooga-area veterans' residences.
Of the 8,400 enrolled veterans who faced travel times to a VA primary
care clinic that were longer than 30 minutes, about 3,375 (40 percent)
were in four counties, each of which had from 775 to 884 such enrolled
veterans. The remaining 5,030 enrolled veterans were in 14 other
Chattanooga-area counties, each of which had from 117 to 608 enrolled
veterans who faced travel times that exceeded VA's guideline. As figure
5 shows, 4 counties had fewer than 250 such veterans.
Figure 5: Enrolled Veterans Living More Than 30 Minutes from VA Primary
Care Clinics, by County (Fiscal Year 2001):
[See PDF for image]
[End of figure]
Waiting Times for Initial Outpatient Primary Care Appointments
Frequently Exceeded VA's Guideline:
Of 1,858 Chattanooga-area veterans awaiting initial visits with
Chattanooga clinic outpatient primary care providers during fiscal year
2002, fewer than 7 percent (126) received appointments within VA's
appointment waiting time guideline of 30 days or less from the time of
the request. Chattanooga clinic officials explained that these
scheduling delays were exacerbated by increased requests for outpatient
primary care initial appointments--averaging 50 per week.
In response, Chattanooga clinic officials have taken a variety of
actions to expedite the scheduling of initial outpatient primary care
appointments. For example, they have increased the number of providers
and necessary support personnel and extended the clinic's hours of
operation to include Saturdays and evenings. Also, they made
arrangements for a provider at VA's Tullahoma, Tennessee, clinic to see
some Chattanooga-area enrolled veterans for initial outpatient primary
care appointments, with subsequent outpatient primary care appointments
scheduled with Chattanooga clinic providers.
As a result of these efforts, waiting times for many Chattanooga-area
veterans were shorter than they otherwise would have been, although
they continued to exceed VA's 30-day guideline. For example, in the
first quarter of fiscal year 2002, 99 percent of veterans seeking
initial primary care appointments waited longer than 6 months; by the
fourth quarter of fiscal year 2002, 66 percent waited 6 months or
longer. Moreover, Chattanooga clinic officials told us that
appointments for enrolled veterans seeking initial outpatient primary
care visits, as of July 2003, were generally scheduled within 60 days-
-a significant improvement but still twice as long as VA's 30-day
appointment waiting time guideline. Clinic officials said that given
the challenges involved in hiring providers and support staff at the
clinic and the increasing workload, further waiting time reductions
will be difficult to achieve.
Waiting Times for Outpatient Specialty Care Exceeded VA's Guideline:
Waiting times for outpatient specialty care appointments that exceed
VA's 30-day guideline have been a long-standing problem for
Chattanooga-area veterans. For example, using data from VA's 1999 IG
report on Chattanooga veterans' care,[Footnote 14] we found that for
veterans served at the Chattanooga clinic, only 9 percent of 353
sampled outpatient specialty consultation requests were scheduled
within 30 days. Moreover, 45 percent of Chattanooga-area veterans
seeking outpatient specialty care appointments waited more than 60
days, including 16 percent who waited longer than 90 days.
Similarly, our analysis of 468 requests for outpatient specialty care
appointments made by Chattanooga clinic providers during October 2002
found long waiting times. For example, 21 percent of these specialty
care appointments took more than 90 days to be scheduled, compared to
16 percent in 1999, based on data from the IG report. However, a
slightly higher percentage of the October 2002 requests for
appointments were scheduled within 30 days--13 percent compared to 9
percent, based on the IG's data.
However, during fiscal year 2003, VA officials took several steps--such
as expanded use of non-VA specialists in the Chattanooga area--that
they said significantly shortened the long waiting times that enrolled
veterans previously experienced to obtain outpatient specialty care
appointments. Chattanooga clinic officials informed us that as of July
2003, providers' requests for outpatient specialty care appointments--
with the exception of dermatology, neurology, and urology appointments-
-were generally scheduled within VA's 30-day waiting time guideline.
Chattanooga clinic officials attributed the fiscal year 2003 reduction
in the time necessary to obtain an outpatient specialty care
appointment primarily to the expanded use of local specialists on a
fee-for-service basis.
Other steps that VA officials took to reduce the time necessary to
obtain outpatient specialty care appointments included increased use of
telemedicine--a system that allows patients and providers physically
located in a specially equipped Chattanooga clinic exam room to consult
with VA specialists in Murfreesboro and Nashville without actually
traveling to those locations. Also, support staff in the Chattanooga
clinic was increased, including the addition of an administrator to
coordinate the scheduling of local fee-basis specialty care. To
emphasize the importance of VA's 30-day appointment waiting time
guideline to clinic staff and the flexibility of obtaining care
locally, the clinic manager said that when one provider could not
schedule an appointment within 30 days, the manager contacted other
local providers to determine who could meet the time frame, so that
VA's waiting time guideline could be met as often as possible.
Draft CARES Plan Would Enhance Access for Some Veterans but Diminish
Access for Others:
VA's draft CARES plan includes a proposal to shorten Chattanooga-area
veterans' travel times by purchasing inpatient care from non-VA
hospitals in Chattanooga. However, it also proposes to shift inpatient
workload from VA's Murfreesboro hospital to VA's Nashville hospital,
which would lengthen travel times for Chattanooga-area veterans who are
unable to receive care locally and who would have otherwise been served
at the Murfreesboro hospital. Regarding outpatient care, the draft
CARES plan calls for a range of actions, including opening new
community-based clinics, that could shorten both travel and appointment
waiting times for initial outpatient primary care and specialty care
appointments.
Shifting Inpatient Workload Would Decrease Travel Times for Some
Veterans but Increase Travel Times for Others:
As a result of the draft CARES plan, travel times for inpatient care
for some veterans would decrease while it would increase for others.
The plan proposes increased purchasing of inpatient medicine and
surgery from non-VA hospitals in Chattanooga, as well as shifting
inpatient surgery and medicine workload not necessary to support the
needs of long-term psychiatry and nursing home patients in the
Murfreesboro facility to its hospital in Nashville. The plan, however,
does not describe the extent to which these changes could affect
veterans in the 18-county Chattanooga area.
To assess the potential impact of the proposed changes, we compared
VA's workload data for Chattanooga-area veterans during fiscal year
2002 and Mid South Network officials' estimates of Chattanooga-area
veterans' workload to be provided in Murfreesboro, Nashville, and non-
VA hospitals as a result of the proposed workload shifts. During fiscal
year 2002, about 5 percent of Chattanooga-area veterans' workload was
purchased locally and 95 percent was provided in VA hospitals in
Murfreesboro and Nashville.
The draft national CARES plan does not quantify the extent to which VA
plans to contract locally for the inpatient medicine and surgery
workload in Chattanooga. Based on our analysis of workload projections
contained in the plan's supporting documents, we estimate that local
purchases would amount to 29 percent of the inpatient medicine and
surgery workload from the 18 Chattanooga-area counties, compared to 5
percent that VA purchased in fiscal year 2002--a fivefold increase.
While this represents a significant improvement, it nonetheless means
that over 70 percent of the inpatient medicine and surgery workload
generated by Chattanooga-area veterans would continue to be served at
the VA hospitals in Murfreesboro or Nashville. Furthermore, three-
quarters of all local purchases are expected to benefit enrolled
veterans in Hamilton and Bradley counties, primarily because these two
counties have the largest enrolled populations.
Mid South Network officials told us that as in the past, the inpatient
workload to be purchased from non-VA hospitals in Chattanooga would be
based on the severity of veterans' medical conditions. Chattanooga-area
veterans with less severe conditions would be served in Chattanooga;
those with more severe conditions would continue to travel to Nashville
to receive inpatient care.[Footnote 15] However, VA expects to place
fewer restrictions on local purchases of hospital care than under the
VA-Erlanger contract. For example, under the draft CARES plan,
inpatient surgeries would be performed locally. All such surgeries were
routinely referred to VA hospitals in Murfreesboro or Nashville during
fiscal year 2002.
Also, we estimate that shifting inpatient workload from the VA hospital
in Murfreesboro to Nashville would result in lengthened travel times
for Chattanooga-area veterans who do not have care purchased locally
and who otherwise would have been served at the Murfreesboro hospital.
We estimate that 14 percent of the Chattanooga-area veterans' workload
would be affected by the shift, given that an estimated 54 percent of
the total workload would be handled in Nashville, compared to 40
percent in fiscal year 2002. Affected veterans would experience
diminished access to inpatient care, in that their travel times, which
already exceed VA's travel time guidelines, would be about 20 minutes
longer than the travel times they would experience if care were
provided in Murfreesboro.
Opening New Clinics Would Shorten Travel and Appointment Waiting Times
for Outpatient Primary and Specialty Care:
The draft CARES plan calls for opening new community-based clinics and
other changes that would reduce travel and waiting times for enrolled
veterans residing in the 18-county Chattanooga area. In fiscal year
2001, about 8,400 Chattanooga-area enrolled veterans faced travel times
for primary care that exceeded VA's 30-minute guideline. The proposed
clinics, to be located in McMinn, Roane, and Warren counties in
Tennessee and Whitfield County in Georgia, would reduce travel times
for about 2,700 (one-third) of those enrolled veterans so that they
would be within the 30-minute guideline.[Footnote 16] The remaining
5,700 enrolled veterans would continue to face travel times longer than
VA's 30-minute guideline. Figure 6 shows the distribution by county of
those Chattanooga-area enrolled veterans who, as of September 2001,
would have lived more than 30 minutes from a VA primary care clinic had
the four proposed clinics been operational in that year.
Figure 6: Number of Enrolled Veterans Who Would Have Traveled More Than
30 Minutes to VA Facilities Had Four Proposed Clinics Been Operational
in Fiscal Year 2001:
[See PDF for image]
[End of figure]
The draft CARES plan does not provide a target date for opening the
Chattanooga-area clinics because VA did not classify them as the
highest national priorities, and as such, did not include them on the
list of clinics to be opened by the end of fiscal year 2010.[Footnote
17] To be considered the highest priority, the number of enrolled
veterans who do not meet access guidelines would have to be greater
than 7,000 enrollees per clinic. The four proposed clinics are
significantly smaller in that they are expected to provide 30-minute
access for a total of about 2,700 additional Chattanooga-area enrolled
veterans.
If opened, Mid South Network officials expect the four new community-
based clinics to shift a portion of the outpatient primary and
specialty care workload away from the Chattanooga clinic.
Redistributing workload in this way would likely benefit many veterans
whose outpatient primary and specialty care appointment waiting times
exceed VA's guidelines. Moreover, these new clinics would be expected
to complement other actions that could enhance outpatient primary and
specialty care access, including reduced appointment waiting times for
Chattanooga-area veterans. For example, the draft CARES plan proposes
to expand capacity at existing community-based clinics and increase the
use of telemedicine and purchases of specialty outpatient services from
non-VA providers. The plan does not provide specifics or time frames
for what, where, or when such actions would occur.
Conclusions:
In making nationwide CARES decisions, we recognize that the Secretary
of Veterans Affairs will need to make trade-offs regarding the costs
and benefits of alternatives for better aligning VA's capital assets
and services. As part of this process, the Secretary will need to
decide whether additional improvements to access, beyond those in the
draft national CARES plan, are warranted in the Chattanooga area.
Although the draft CARES plan proposes actions that could enhance
Chattanooga-area veterans' access to VA health care, the majority of
Chattanooga-area veterans are expected to continue to face travel times
for inpatient medicine and surgery services that far exceed VA's
inpatient travel guidelines, even if VA purchases an estimated 29
percent of inpatient workload from non-VA, Chattanooga-area providers
as the draft CARES plan proposes. Moreover, access to hospital care for
some Chattanooga-area veterans could actually worsen because the
proposed transfer of inpatient workload from VA's Murfreesboro hospital
to its Nashville hospital would require some veterans previously served
in Murfreesboro to drive farther for inpatient care, affecting an
estimated 14 percent of Chattanooga-area veterans' workload. Given that
the non-VA hospitals in Chattanooga can provide an array of inpatient
medicine and surgery services comparable to VA's hospitals in
Murfreesboro and Nashville, it seems possible that VA could purchase
more than 29 percent of Chattanooga-area veteran's inpatient workload
locally.
Moreover, even though the draft CARES plan proposes opening four
community-based clinics, these clinics would likely not be opened
before fiscal year 2011. Although they would enhance outpatient access
for 2,700 Chattanooga-area veterans, about 5,700 enrolled veterans
would continue to face travel times for outpatient primary care that
exceed VA's guideline because existing and proposed clinics are more
than 30 minutes from where they live.
Recommendations for Executive Action:
We recommend that as part of his deliberations concerning whether
additional access improvements for Chattanooga-area veterans beyond
those contained in the draft CARES plan are warranted, the Secretary of
Veterans Affairs explore alternatives such as:
* purchasing inpatient care locally for a larger proportion of
Chattanooga-area veterans' workload, particularly focusing on those
veterans who may experience longer travel times as a result of the
proposed shift of inpatient workload from Murfreesboro to Nashville;
* expediting the opening of the four proposed community-based clinics;
and:
* providing primary care locally for more of those veterans whose
access will remain outside VA's travel guideline, despite the opening
of the four clinics.
Agency Comments:
In written comments on a draft of this report, VA's Under Secretary for
Health thanked us for our recommendations and stated that he will
provide them to the Secretary for consideration during his review of
the CARES Commission's report and ask that he consider them in the
final CARES decision-making process. VA also provided technical
comments that we included, where appropriate, to clarify or expand our
discussion.
We are sending copies of this report to the Secretary of Veterans
Affairs and other interested parties. In addition, this report will be
available at no charge on GAO's Web site at http://www.gao.gov. We will
also make copies available to others upon request.
If you or your staff have any questions about this report, call me at
(202) 512-7101. Other GAO staff who contributed to this report are
listed in appendix II.
Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
Signed by Cynthia A. Bascetta:
[End of section]
Appendix I: Scope and Methodology:
Our objectives were to (1) assess how Chattanooga-area veterans' access
to inpatient hospital and outpatient primary and specialty care
compared to the Department of Veterans Affairs' (VA) established travel
time and appointment waiting time guidelines and (2) determine how VA's
draft Capital Asset Realignment for Enhanced Services (CARES) plan
could affect Chattanooga-area veterans' access to such care. For
purposes of our work, Chattanooga-area veterans comprise those residing
in 18 counties--Hamilton County, which includes the city of
Chattanooga, and 17 surrounding counties; the 18 counties are all
closer (as measured by travel time) to the VA clinic and non-VA
hospitals in Chattanooga than to VA hospitals and clinics in
Murfreesboro and Nashville.
We obtained information from and interviewed officials at VA's Mid
South Network and its Chattanooga clinic; VA headquarters, including
the CARES National Program Office; the Erlanger Medical Center in
Chattanooga, Tennessee; and the VA Inspector General's Office of
Healthcare Inspections. Regarding travel times, we examined how
Chattanooga-area veterans' access to VA health care compared to VA
guidelines by using a model developed by the Department of Energy to
calculate the time needed for enrolled veterans to travel from their
residences to the nearest VA hospitals and clinics. This model takes
into account key variables affecting travel times, including speed
limits attainable on different types of roads, such as rural roads or
interstate highways. We evaluated its methodology and assumptions and
found them to be sufficiently accurate for our purposes. We used VA's
CARES databases for demographic and workload information for the 16,379
veterans from those 18 counties who were enrolled in VA's health care
system as of fiscal year 2001. We compared these results with the
inpatient and outpatient primary care travel time guidelines that VA
used in its CARES planning to determine the percentage of enrollees, by
county, who lived within the inpatient and outpatient access
guidelines. We did not analyze travel times for outpatient specialty
care because VA did not have guidelines for such care.
In addition, we determined Chattanooga veterans' access to inpatient
care at non-VA Chattanooga hospitals by obtaining inpatient admissions
data and other information from officials of the Mid South Network; the
VA Chattanooga clinic; the Erlanger Medical Center in Chattanooga; and
VA's network data service centers in Atlanta, Georgia, Chicago,
Illinois, Tuscaloosa, Alabama, and Durham, North Carolina. We used VA's
Computerized Patient Record System to extract data from 60 of 580
medical records to compile a generalizable profile of all fiscal year
2002 admissions of Chattanooga-area veterans to VA hospitals in
Murfreesboro and Nashville. To evaluate information contained in the
VA-Erlanger inpatient contract, we reviewed contract documents and
conducted interviews with VA's clinic staff and network officials,
including those in the network's business office, as well as legal and
other officials from the Erlanger Medical Center.
Regarding waiting times, we interviewed Mid South Network and
Chattanooga clinic staff and analyzed workload data compiled by clinic
staff. For example, we analyzed the clinic's fiscal year 2002 waiting
lists to identify the number of veterans who enrolled for primary care
and the number of days they waited for their first appointment with a
primary care provider. We compared these results to VA's 30-day
appointment waiting time guideline.
In addition, using automated medical records and clinic data, we
collected information on Chattanooga clinic providers' requests for
specialty consultations. We used this information to determine the
number of days needed to obtain an appointment with a specialist. In
May 2003, we reviewed all such requests made by clinic providers in
October 2002, selecting this time frame to ensure that VA staff had
sufficient time to schedule the requested appointments by the time we
conducted our review. We then analyzed the results from this review and
compared these results to VA's 30-day waiting time guidelines and also
to the waiting times reported by VA's Inspector General in his office's
1999 performance review of the Chattanooga clinic.
To determine how VA's draft CARES plan could affect Chattanooga-area
veterans' access to VA inpatient health care services, we examined the
draft national CARES plan;[Footnote 18] the Mid South Network's CARES
planning documents; and workload data produced by VA's CARES Program
Office, the Mid South Network office, and the Chattanooga clinic. We
also held discussions with VA officials. To evaluate effects of the
CARES proposal to shift inpatient workload from VA's Murfreesboro
hospital to Nashville and non-VA hospitals in Chattanooga, we analyzed
Mid South Network data for Chattanooga-area veterans' inpatient
workload at those locations during fiscal year 2002 and estimated the
workload that would be served at those locations if the CARES proposal
were implemented. In addition, we used the Department of Energy driving
time model to analyze the extent to which access would change if VA
opened the additional primary care clinics proposed in the national
draft CARES plan.
Also, we analyzed the reliability of key databases to ensure that there
were no material errors or inconsistencies. For example, we used
information obtained through our medical record review to cross-check
inpatient workload data regarding admissions to Murfreesboro and
Nashville during fiscal year 2002 and found those data to be
sufficiently reliable. Also, we compared outpatient specialty
consultation information with appointment scheduling information
contained in VA's computerized record system. Lastly, we compared CARES
demographic data on Chattanooga-area veterans with data in VA's
national enrollment data file for fiscal year 2002.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
DEPARTMENT OF VETERANS AFFAIRS
UNDER SECRETARY FOR HEALTH
WASHINGTON DC 20420:
JAN 12 2004:
Ms. Cynthia A. Bascetta
Director:
Health Care Team:
U.S. General Accounting Office
441 G Street, NW Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed your draft report,
VA HEALTH CARE: Access for Chattanooga-Area Veterans Needs Improvement
(GAO-04-162). Your report deals with an issue critical to the future of
the Department. At this time, the independent Commission on Capital
Asset Realignment for Enhanced Services (CARES) is preparing a report
on its comprehensive review of the future needs of our Nation's
veterans and how best to align VA's services to meet those needs. Thank
you very much for your recommendations. I have asked the Secretary to
take them under advisement when he reviews the CARES Commission's
report and to consider them in the decision process.
Enclosed are technical comments that should help clarify or correct
some of the statements in your draft report. I appreciate your efforts
as we cooperatively seek to align VA's resources in the best manner to
serve those who have served our Nation.
Sincerely yours,
Signed by:
Robert H. Roswell, M.D.
Enclosure:
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Frederick Caison, (202) 512-7269:
Acknowledgments:
Lisa Gardner, Julian Klazkin, John Mingus, Daniel Montinez, Keith
Steck, and Paul Reynolds made major contributions to this report.
[End of section]
Related GAO Products:
VA Health Care: Framework for Analyzing Capital Asset Realignment for
Enhanced Services Decisions. GAO-03-1103. Washington, D.C.: August 18,
2003.
Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.
VA Health Care: Improved Planning Needed for Management of Excess Real
Property. GAO-03-326. Washington, D.C.: January 29, 2003.
High-Risk Series: Federal Real Property. GAO-03-122. Washington, D.C.:
January 2003.
Major Management Challenges and Program Risks: Department of Veterans
Affairs. GAO-03-110. Washington, D.C.: January 2003.
VA Health Care: More National Action Needed to Reduce Waiting Times,
but Some Clinics Have Made Progress. GAO-01-953. Washington, D.C.:
August 31, 2001.
VA Health Care: Community-Based Clinics Improve Primary Care Access.
GAO-01-678T. Washington, D.C.: May 2, 2001.
Veterans' Health Care: VA Needs Better Data on Extent and Causes of
Waiting Times. GAO/HEHS-00-90. Washington, D.C.: May 31, 2000.
VA Health Care: VA Is Struggling to Address Asset Realignment
Challenges. GAO/T-HEHS-00-88. Washington, D.C.: April 5, 2000.
VA Health Care: Improvements Needed in Capital Asset Planning and
Budgeting. GAO/HEHS-99-145. Washington, D.C.: August 13, 1999.
VA Health Care: Challenges Facing VA in Developing an Asset Realignment
Process. GAO/T-HEHS-99-173. Washington, D.C.: July 22, 1999.
Veterans' Affairs: Progress and Challenges in Transforming Health Care.
GAO/T-HEHS-99-109. Washington, D.C.: April 15, 1999.
VA Health Care: Capital Asset Planning and Budgeting Need Improvement.
GAO/T-HEHS-99-83. Washington, D.C.: March 10, 1999.
Executive Guide: Leading Practices in Capital Decision-Making. GAO/
AIMD-99-32. Washington, D.C.: December 1998.
VA Health Care: Status of Efforts to Improve Efficiency and Access.
GAO/HEHS-98-48. Washington, D.C.: February 6, 1998.
FOOTNOTES
[1] Department of Veterans Affairs, Office of Inspector General, Office
of Healthcare Inspections, Inspections of Alleged Substandard Patient
Care and Administrative Discrepancies, Chattanooga Outpatient Clinic,
Chattanooga, Tennessee (Washington, D.C.: July 30, 1999).
[2] See U.S. General Accounting Office, VA Health Care: Improvements
Needed in Capital Asset Planning and Budgeting, GAO/HEHS-99-145
(Washington, D.C.: Aug. 13, 1999). See the Related GAO Products section
at the end of this report for products related to federal capital asset
management and veterans' health care issues.
[3] The draft national CARES plan is available at VA's CARES Web site,
http://www.va.gov/cares/.
[4] The CARES Commission has conducted over 40 public hearings
nationwide, including one in Nashville on September 10, 2003, that
discussed proposals in the draft CARES plan that involve veterans in
the Chattanooga area.
[5] Officials of the Mid South Network, also known as Veterans
Integrated Service Network 9, are responsible for making basic
budgetary, planning, and operating decisions concerning the delivery of
health care to Chattanooga-area veterans.
[6] The use of telecommunications equipment to transmit patients' video
images, X rays, electronic medical records, and laboratory results from
distant sites.
[7] VA used fiscal year 2001 as its base year for CARES planning
purposes.
[8] As part of its CARES planning activities, VA defined 27 counties as
a submarket, within the Central Market, based on the assumption that
the Chattanooga clinic serves as VA's core health care delivery
location. This submarket contained the 18 counties that we define as
the Chattanooga area and 9 other counties that are west and north of
that 18-county area; we did not consider those 9 counties to be
Chattanooga-area counties for purposes of this study because they are
closer (measured by travel time) to VA's hospitals and clinics in
Murfreesboro than to non-VA hospitals and other providers in
Chattanooga.
[9] VA measures hospital workload in "bed days of care," which
constitute the total number of hospital days in a medical, surgical, or
psychiatric bed used by patients during a given period. For example,
hospital workload for a veteran who has a 7-day hospital stay would be
counted as 7 bed days of care. To measure outpatient workload, VA uses
the number of encounters that a patient has with care providers during
a clinic visit.
[10] The Nashville VA hospital provides complex surgical procedures in
the Mid South Network's Central Market. VA's access guideline for such
care is 240 minutes. Chattanooga-area enrolled veterans are within the
access guideline for this care.
[11] The VA-Erlanger contract was in effect from September 2000 through
August 2002.
[12] Chattanooga clinic providers were not directly involved in the
remaining 439 admissions during fiscal year 2002; rather, 236 were made
by VA specialists at the Murfreesboro or Nashville hospitals and 203
resulted from veterans' self-referrals or transfers from other
hospitals.
[13] Another 4 admissions involved veterans who self-referred to non-VA
hospitals in Chattanooga on an emergency basis, bringing the local
admissions total to 105.
[14] U.S. Department of Veterans Affairs, Office of Inspector General.
[15] VA plans to continue to perform complex surgical procedures and
provide psychiatry and long-term care services at its own facilities.
[16] These enrolled veterans are concentrated in eight counties--
Loudon, McMinn, Monroe, and Roane in Tennessee and Catoosa, Murray,
Walker, and Whitfield in Georgia.
[17] Mid South Network officials, as part of their preliminary planning
efforts in support of the CARES process, had tentatively identified the
clinic in Warren County as their highest priority--targeting its
opening for fiscal year 2007. That opening would have been followed by
the opening of clinics in Roane and Whitfield counties in fiscal year
2008 and McMinn County in fiscal year 2009.
[18] We downloaded the draft CARES plan from www.va.gov/CARES on August
5, 2003, and revisions issued on August 15, 2003.
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