Steven Lieberman, MD, Discusses Positive Trends in VA Wait Times

In a podcast hosted on Veterans Health Today, Steven Lieberman, MD, acting principal deputy under secretary for health at the Veterans Health Administration, explained the history of wait times within the VA and discusses how they have improved in recent years and why improvements in this area are important. The following is an edited excerpt from that podcast.

Since about January of 2016, I have worked on improving access and wait times at the two Veteran Affiars locations that I have worked at, both in Boston and in East Orange, New Jersey. Most recently, in August of 2018, I assumed the position of the Acting Principal Deputy Under Secretary.

Being a pulmonary and critical care physician, my usual research interests fall under the areas of respiratory dysfunction and neuromuscular disorders, pulmonary rehabilitation, and exercise physiology. It was only when I began working formally at the national level on improving access in VA that I began looking at research related to access to care for veterans.

Now, I would like to tell you a little bit about the history of wait times within VA. What we know is that for over 30 years, VA has been measuring wait times. We know that in VA, just like in the private sector, that when there are problems with access to health care in a timely manner, that this leads to higher costs and worst outcomes for patients wherever they are receiving their care.

VA is truly the only system that has really looked at wait times, and looked at different ways to measure them. What’s really put VA aside though from all other health care institutions is that for the past two years we have published our wait times at our facilities, and for even longer we have been publishing national wait times. There are no other health care systems of which we are aware that do it on this level, on this scale. We think it’s really important to publish it because that’s a part of how we are transparent in VA. We also think it helps us to drive change.

VA has certainly struggled at times with the best way to measure wait times. It has been a cause for criticism because of inaccuracies in the way that things are entered into our scheduling system. We set performance metrics that at the time seemed like a good idea, but perhaps were unrealistic. Ultimately, in 2014 the VA found itself in an access crisis because of this. In response to that, the VA set up the Office of Veterans Access to Care, of which I was in charge.

Since, VA has really been striving to make our access metrics as reliable as they can be. For us, our gold standard is patient satisfaction scores, because those scores are independently measured outside of VA. We also have changed the way that we measure wait times for new patient appointments. We measure that wait time from the date the appointment is first requested. If I go in and request an appointment today and my appointment is scheduled 20 calendar days from today, then my wait time is 20 days. This continues to evolve in VA, but I believe we are setting the standard for how all health care systems should be looking at wait times.

Next, I’d like to talk about our study to evaluate wait times for new patients receiving care at VA medical centers. This study was a retrospective, repeated cross-sectional study of new appointment wait times in primary care, dermatology, cardiology, and orthopedics at 15 VA medical centers in major metropolitan areas in 2014 and 2017 and compared with private sector wait times at these same 15 major metropolitan areas also during 2014 and 2017.

In 2014, the overall mean VA wait times for these four different clinic specialties combined was similar to the private sector, with no significant difference (18.7 days in the private sector and 22.5 days in the VA). VA wait times in 2014 were similar to those in the private sector across the individual specialties that I mentioned as well as in individual regions of the country. 

In 2017, overall wait times for new patient appointments in VA were shorter than in the private sector. In VA, the average was 17.7 days, whereas in the private sector, it was 29.8 days. In primary care, the average wait time was 20.0 days in VA, and in the private sector it was 40.7 days in these 15 large metropolitan areas. In dermatology, the wait times was 15.6 days in VA vs 32.6 days in the private sector. In cardiology, the wait time again was shorter in VA at 15.3 days vs 22.8 days in the private sector. As far as orthopedics wait times, they remained longer in VA than the private sector in 2017: 20.9 days in VA vs 12.4 days in the private sector.

Overall, the wait times did improve from 2014 to 2017 in VA, though wait times did not improve in the private sector in the orthopedics arena.

In the same study, initial analysis demonstrated an increase by about 122,000 in the number of unique patients seen and also an increase in appointment counters by 855,000 in VA between 2014 and 2017. Finally, VA also saw increases in patient satisfaction related to access in both specialty care and primary care.

Based upon our findings in the study, how has access to care within VA improved, and how does it compare to the private sector? VA, as I mentioned earlier, has really been working on many fronts to optimize access to care. One of the things that we’ve been focusing on since the beginning of 2014 are veterans with urgent medical needs. The reason we did that is because we were getting concerns and criticism from the public, from veterans, and from Congress that veterans were being harmed while waiting for care. We did not want that to be of a concern. We wanted to make sure that veterans with urgent needs have those needs met in a timely fashion.

One of the things that we have done over the past few years is we implemented what we call same-day services for care needed right away. We implemented that in 100% of our more than 1000 clinics across this country in both primary care and mental health. It could be through a traditional face-to-face appointment, or it might be just as easily and preferentially handled by speaking to a nurse on the phone where a veteran might describe that they have some symptoms. The nurse just reassures them that it sounds like you have a cold. You don’t need to come in. If you start to develop high fevers, maybe then give us a call or go to the emergency room. That’s something that we implemented.

Same thing for mental health. We want to make sure that if someone needs something urgently in mental health, we’re going to take care of them the same day. It may also be just referring them to a specialist.

Additionally, we made sure that when a veteran is referred to a specialist with an urgent need, that that urgent referral gets completed in a timely fashion. Back in 2014, at the time of the access crisis, it was taking 19.3 days on average to get a veteran seen and that evaluation completed. As of December of 2018, we were down to 1.5 days. We continue to work on this and continue to see reductions in that number. Overall, when compared to 2014, VA is now completing 3.4 million more appointments per year in fiscal year 2018 than we did in fiscal year 2014. Last fiscal year 2018, we completed over 58 million appointments for the first time.

We also are investing in telehealth and encouraging our staff to provide care. This is particularly helpful in remote parts of the country where it’s more challenging to hire providers. In fiscal year 2018, 2.3 million patient encounters were completed via telehealth.

Similarly, we’re rolling out a program called Anywhere to Anywhere. This is where a provider can be located anywhere in the country. They can provide care to anywhere the veteran chooses to be located. The veteran has, for example, a mental health appointment. They want to receive it in their home or in their workplace on a break. We can increasingly ensure that that kind of an appointment happens. We also are seeing more appointments than ever—over 6 million appointments—and have continued to increase in the number of veterans seeking care in VA every year.

We also have been working on reducing no-shows for appointments. We have a large number of no-shows. One of the items we implemented is called Vet Text where we send a reminder to a veteran that their appointment is coming up. If they can’t keep the appointment, we ask that they respond so that we can automatically cancel that appointment and make it available for another veteran.

We also have been working to reduce our wait times for all of our clinic appointments. In primary care, this is going back to 2014 and comparing to 2018. In 2014, in primary care, we were at 24.3 days average for new primary care appointment. As of fiscal year 2018, we were down to 21.2 days. In mental health in 2014, we were up to 11.4 days average for new patient wait time from the date that the patient requests the appointment. Then in 2015, it went up to 12.5 days. Since then, we have seen improvements. We are now down in 2018 to an average of 11.2 days. Then in specialty care in 2014, we were at 23.5 days. In fiscal year of 2018, we were down to an average of 22.1 days. 

You may be wondering, “How do specialty care visits, as well as geographic areas, impact wait times?” We in VA are no different than the private sector. There are specialties where there are known shortages of providers. A common one that we’re aware of is gastroenterology. We are competing with the private sector for these same providers.

We certainly have a special mission in VA, to help encourage specialists to come here. We also provide special incentives in a lot of ways, and there was the Mission Act that was passed in 2018. That also provides us with extra tools for recruiting hard-to-recruit specialties.

In the Office of Veterans Access to Care, they work closely with specialties, primary care, and mental health, where there are significant access challenges to look at what opportunities there are, even when there is a staffing shortage of what we can do to shorten those wait times. We look at different options to optimize our specialty care: what could a nurse do, or what could LPN do, or what could we do with telehealth?

We certainly know that in rural areas, we, like the private sector, can struggle with recruiting providers. One of the things that we do there is telehealth. We find parts of the country where it is relatively easy to hire providers, and they in turn provide telehealth to parts of the country, including rural parts of the country and other places where there are hard-to-recruit areas. Additionally, the Mission Act has given us some tools for how to optimize access in these underserved parts of the country.

Next, you may be wondering, “What do the findings of the study mean for both VA health care workers as well as for patients?” For staff, the best part of this study is that we’ve been on this access journey since 2014. I think this helps support that our improvement efforts are working and that their hard work is paying off.

It also helps us get the word out that it’s not true that VA has the worst access. This helps veterans to understand that VA truly provides timely health care; there are challenges in the health care world, but VA is working hard to improve them, and our improvements are paying off.

Recently in 2018, the RAND Corporation and Dartmouth University both did studies on care quality. Both of them concluded very strongly that VA care quality exceeds or sometimes equals the private sector but often exceeds the private sector. This access study on top of those results continues to get the words to veterans that if you’re not coming here for your care, you really should consider us because we believe we provide the best care anywhere, the highest quality, and the most accessible care.

One limitation of the study was that there were different methodologies used for measuring wait times by Merritt Hawkins vs the way we measured wait times in the VA. The way Merritt Hawkins collected their data is they randomly looked in databases and called up provider offices. The way that they measured that appointment was from the date the employee called and asked for an appointment, how many days that they would have to wait.

What’s different in VA in the way that we measure wait times is we measure from the creation date of the appointment, not taking into account when the veteran wanted their appointment. We measure it this way because we think it better approximates the veteran experience. 

Next, they had relatively small sample sizes. They only reached out to 10 to 20 physician offices in large metropolitan areas asking questions about availability. Their sample size could have been as small as 10, whereas in VA, when we look at all the appointments in these different areas seen over a year, it was  much larger. Certainly, the distributions from the different sample sizes may have skewed results from our analysis, including by region and by specialty. In this case, it would have ideally been better. When you have this kind of a skewed distribution issue, it would have been preferential to use median values instead of the mean values. However, Merritt Hawkins only reported means.

Another limitation of the study was that Merritt Hawkins did not include mental health patients in their study, nor look at rural parts of the country. That is something that would have been useful for us to do a comparison to.

Also, now that they’ve done large metropolitan areas and then medium-sized metropolitan areas, it would be nice if they could move out to smaller or more rural parts of the country. That would be helpful for us to look at those results.

We are not resting with the results of this study. We are continuing to work to do better and better with our wait times and our access in a variety of arenas. Certainly in orthopedics, we had access challenges. That’s an area that we continue to need to focus on.

We, for the past two years, have been publishing our wait time data on the website, www.accesstocare.va.gov. This provides a variety of information on wait times, on patient’s satisfaction scores related to access, and on quality. This is setting the standard for the health care community. We hope someday to see the private sector releasing this kind of information and being transparent in this way.

To hear the full version of this podcast, click here.