Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

Abstract

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Access to quality health care is a central part of the nation's commitment to Veterans. In February 2014, a recently retired U.S. Department of Veterans Affairs (VA) physician alleged that at least 40 Veterans died while waiting for care at the Phoenix VA Health Care System. While the allegations of deaths were not proven, this raised concerns about how effectively the commitment to Veterans was being fulfilled (VA, Office of Inspector General, 2014b). Following the Phoenix allegations, the VA Office of Inspector General investigated the timeliness of VA health care, finding that some VA staff regularly entered false information regarding patients' preferred dates of care to minimize reported wait times between the preferred date and the actual date of appointments. The Inspector General also pointed to systemic issues within VA that may limit Veterans' access to care, including lack of available appointments within certain clinical specialties and problems with care transitions for patients discharged from mental health services.

The accessibility and timeliness of care are longstanding areas of concern within VA. VA has many ongoing programs and initiatives to increase access to care for Veterans, including, most recently, the Veterans Choice Act, passed in 2014. The Veterans Choice Program expanded VA authority to furnish care to Veterans through agreements with non-VA providers, as well as provisions regarding improved access to telemedicine through mobile medical centers; 27 new major medical facility leases; increased transparency of performance data on VA providers, including wait times; new residency and other training and education programs; and recruitment and appointment of personnel in occupations identified by the VA Inspector General as having the greatest shortages. The law includes appropriations for VA to support these activities.

Section 201 of the Veterans Choice Act included a requirement for 12 independent assessments of VA health care. This study addresses Assessment B (identified under Title II – Health Care Administrative Matters, Section 201 of the Veterans Choice Act). The assessment responds to language in the Veterans Choice Act of 2014, Title II – Health Care Administrative Matters, Section 201.A.1.b, which mandates an independent assessment of “current and projected health care capabilities and resources of the Department [VA], including hospital care, medical services, and other health care furnished by non-Department facilities under contract with the Department, to provide timely and accessible care to veterans” (Veterans Choice Act, Section 201).

Study Purpose and Approach

We assessed VA's current and projected resources and capabilities, the level and nature of access to VA care, and barriers and facilitators to access. We also explored how selected policies could affect Veterans' access to high-quality care. Specifically, we addressed the following research questions:

1. What are VA's current resources and capabilities in key domains?

2. What are current levels of access to VA care?

3. What is the quality of care in VA?

4. What are VA's projected resources and capabilities to provide timely and accessible care, and how might different policy options enhance VA's resources and capabilities for treating Veterans in the future?

We answered these questions broadly and also identified seven illustrative clinical populations to provide a more detailed understanding of VA capabilities, resources, and accessibility in selected subpopulations of Veterans.

We used a multipronged approach to address these research questions. We examined VA's resources and capabilities in five domains (fiscal, workforce and human resources, physical infrastructure, interorganizational relationships, and information technology [IT]). To understand access, we examined available data on five dimensions of access to VA health care: geographic, timely, financial, digital, and cultural. We assessed the quality of VA health care in comparison with non-VA care as measured in previous studies and by analyzing more recent VA performance data, using the six dimensions of health care quality identified by the Institute of Medicine: Care should be safe, timely, equitable, effective, efficient, and patient-centered (Institute of Medicine, 2001).

We also developed a method for projecting future resources, which we compared with forecasted changes in patient demand for VA health care identify potential gaps. To support analyses of future options for VA to address identified gaps, we identified and analyzed a reasonable range of feasible policy options to enhance VA's ability to provide timely and accessible care to Veterans. These analyses were informed by data collected through literature reviews, key informant interviews, a 2015 Survey of VA Resources and Capabilities, and other VA and non-VA data sources.

Findings

Assessment of VA Resources and Capabilities

VA operates a unique health care system with broad and deep resources and capabilities for Veterans, including facilities, personnel, and IT infrastructure. However, our assessment identified a number of barriers to the effective planning for and use of these resources and capabilities, which can affect their availability to Veterans.

VA faces a number of challenges in planning for and using its fiscal resources effectively. The total VA budget for fiscal year (FY) 2015 is approximately $60 billion, rising to $63 billion for the advanced FY 2016 appropriation. We were not able to determine whether VA has adequate fiscal resources for health care, because there is no valid benchmark against which to compare VA's budget and spending. We did find, however, a number of issues related to VA's budget process, including concerns about the data used for budget planning, inflexibility in budgeting stemming from the congressional appropriation processes, and challenges in VA's allocation processes. VA develops its health care budget from older data, and there can be problems with the assumptions used in this process. In addition, congressional priorities can affect VA's appropriation, and the impact of increases in purchased care from the Veterans Choice Act on the budget in future years is currently unknown. In interviews, facility directors described problems with the allocation system to the Veterans integrated service networks (VISNs), including the use of past data in calculating the allocation and the fact that some facilities undertake various activities to ensure that their allocation is as high as possible in subsequent years. These challenges can leave facilities that are experiencing change over- or underfunded in the current year, and they create incentives for facilities to see more of certain types of patients in order to increase funding in future years. There are also continued challenges with the separate budgets for medical care, capital construction, and IT that do not move in concert and can limit facilities' ability to improve access.

VA has an extensive health care workforce but faces challenges in workforce planning and assessment. As one of the largest providers of health services in the world, VA employs physicians, nurses, other providers, and a range of support staff to provide care directly to Veterans. VA also contracts with private physicians to deliver some services within VA facilities (U.S. Government Accountability Office, 2013). In FY 2014, VA employed a total of 31,269 physician employees working either full-time or part-time, for a total of 19,900 full-time equivalents (FTEs). On average, these physicians spend close to 80 percent of their FTEs in clinical care, for a total of 15,543 physician clinical FTEs across all specialties. We identified several challenges associated with VA workforce planning and assessment processes. These include a lack of guidance about what methods should be used, a lack of external productivity benchmarks, inaccurate or incomplete data inputs, and the inability of the data system to adequately account for certain types of providers and patient visits.

VA workforce capacity may not be sufficient to provide timely care to Veterans across a number of key specialties, as well as primary care. VA faces shortages of physicians in some geographic areas and of certain physician specialists more generally. These constraints are influenced by a number of key factors, including relatively low salaries, a slow credentialing process, and infrastructure constraints. We found significant variation across facilities and VISNs in terms of productivity. Our estimates must be considered, however, in light of concerns about coding and data quality. In particular, interviewees reported that variations in coding practices, inconsistently entered workload data, and incomplete or poorly detailed physician encounter data make it difficult to consistently measure productivity.

VA operates one of the most extensive systems of health care infrastructure in the country, but the need for additional physical space is a limiting factor in improving access. Of 955 sites, 871 are medical facilities; the remaining sites, considered nonmedical facilities, generally provide outpatient services or residential treatment. On average, the VA system has 18.3 hospital beds per 10,000 enrollees and an inpatient daily census of 11 patients per 10,000 enrollees, for an occupancy rate of 60 percent; however, hospital bed supply varies widely across VISNs. Interviewees in leadership or clinical care positions were generally satisfied with VA medical equipment and supplies, but they noted that physical space was in short supply and that even new facilities can quickly grow out of date. The need for more effective use of existing space was also identified as a key limiting factor in improving access for Veterans.

VA has many outside options for providing care to Veterans, although managing this resource can be challenging. Care is provided to VA enrollees by non-VA entities through several programs and various types of payment or contractual arrangements, including the “traditional program,” partnership agreements, the Access Received Closer to Home (ARCH) program, the Patient Centered Community Care (PC3) program, and the Veterans Choice Program. Spending for purchased care has grown dramatically—reaching around $5.5 billion in 2014—and the Veterans Choice Act provides new funding of $10 billion over three years. However, managing this complex resource has proven challenging. Contracting with non-VA providers has been described as a “long and painful” process, and there are well-documented problems with VA's claims processing system. As VA was attempting to address some of the administrative challenges associated with arranging, coordinating, and reimbursing purchased care through the implementation of the PC3 program, for example, the addition of the Veterans Choice Program further complicated the situation and resulted in confusion among Veterans, VA employees, and non-VA providers. VA and members of Congress have expressed a desire to more effectively utilize this important resource as demand increases. The Assessment C report addresses these topics in greater detail (RAND Health, 2015b).

VA has been and continues to be an innovator and leader in developing health IT capabilities, although there is room for improvement in some areas. VA is on par with or exceeds other organizations' capability to use IT in care delivery in many regards, including telehealth and MyHealtheVet, VA's online patient portal. However, VA's role as an innovator and leader has been challenged by issues related to the management and planning of its IT systems. For every IT capability we studied, we found clear barriers—including inadequate infrastructure, lack of facility leadership and provider buy-in, and administrative burden—to allowing Veterans to take further advantage of what IT can offer.

Our findings also confirm the results of previous studies concerning strengths and weaknesses in VA's current electronic health record technologies (VistA, that is, Veterans Health Information Systems and Technology Architecture, and VA's Computerized Patient Record System [CPRS]), which suffer from an aging architecture and 10 years of limited development. However, interviews across the spectrum of VA personnel—from management and IT thought leaders to end users—suggest strong support for renewed investment in a modern, homegrown product rather than transitioning to a commercial off-the-shelf alternative. The advantages, disadvantages, and trade-offs between homegrown versus commercial electronic health record software are discussed in the Assessment H report (MITRE, 2015).

Taken together, these barriers present a formidable, though not insurmountable, challenge to ensuring that sufficient VA resources and capabilities are available to all Veterans. Addressing these barriers will require a mix of short- and long-term initiatives, as we describe later in the Recommendations section.

Assessment of Access to VA Care

Ensuring Veterans' access to health care depends not just on the level of resources and capabilities available, but on how well VA's health care system addresses Veterans' needs. While our assessment did not find evidence of a system-wide crisis in access to VA care, we found considerable variability across the different dimensions of access (geographic, timely, financial, digital, and cultural) as well as opportunities to improve access, even at the top-performing VA facilities.

Veterans' geographic access to VA care varies according to the access standard used and by region and type of service. Many Veterans have geographic access to VA care, although it varies when using different access standards (that is, 40-mile straight-line distance, 40-mile driving distance, 60-minute driving time in free-flow traffic or rush hour traffic, 60-minute public transit time) and by region. Enrollees' average driving time to the nearest VA medical center (VAMC) or hospital is less, on average, than enrollees' average reported willingness to travel for routine medical care or Medicare beneficiaries' observed average travel times. Veterans who must rely on public transportation have much less access than other Veterans. Further, our assessment found that substantially lower proportions of enrollees have geographic access to advanced and specialized services in VA medical facilities. For example, only 43 percent of enrollees live within 40 miles of VA interventional cardiology services, and only 55 percent of enrollees live within 40 miles of VA oncology services.

Veterans who live far from a VA medical facility have good geographic access to non-VA community hospitals, emergency care, and primary care physicians, but poor access to hospitals and physicians offering specialized services. Nearly all Veterans (96 percent) who live far from VA medical facilities can drive to community and emergency care at non-VA hospitals within 40 miles, but access to more advanced care at academic and teaching hospitals is much lower: Only 15 percent live within 40 miles of a teaching hospital, and only 3 percent live within 40 miles of an academic hospital. These Veterans are also less likely to have geographic access to a range of highly specialized care at non-VA hospitals, including many cardiology, surgery, and oncology services. The same is true for access to non-VA clinicians in the community. A large share of VA enrollees living far from a VA medical facility are within 40 miles of primary care providers, but far fewer of these enrollees are near providers offering highly specialized care. This finding suggests that expanding access to non-VA providers in these regions can help most Veterans seeking routine and emergency care, but will help far fewer Veterans who need access to advanced and specialized care.

Most VA appointments meet VA timeliness standards; however, there is variation in timeliness across the VA system, with poor performance for some VA facilities. Most Veterans complete their appointments within VA timeliness standards of 30 days of the preferred date—that is, the date recommended by the physician or that the Veteran prefers. However, some Veterans who do not receive care within 30 days may be at risk of poor health outcomes. The average number of days that Veterans wait for appointments varies tremendously across VA facilities, indicating substantial opportunities for improvement in some facilities. At 91 top-performing VA facilities, over 96 percent of new primary care patients receive appointments within 30 days of the preferred date. However, 14 VA facilities were far below this benchmark, with less than 84 percent of patients receiving appointments within 30 days of the preferred date. At the top-performing VA facilities, more than 60 percent of Veterans report that they “always got urgent care appointments as soon as needed.” At the worst-performing VA facility, this rate was closer to 20 percent. Even at the facilities with the shortest wait times, many Veterans report that they do not always get an appointment as soon as needed, suggesting that even these top-performing facilities do not meet many Veterans' expectations for timely appointments.

Reported wait times for VA care are getting longer. The percentage of appointments completed within 30 days of the preferred date was lower in the first half of FY 2015 than in the first half of FY 2014. Reported declines over this period likely reflect both actual lengthening of wait times—as might be expected, given the increased demand for VA services predicted by VA's Enrollee Health Care Projection Model (EHCPM)—and improvements in the accuracy of the wait-time data.

VA's timeliness standard is much less demanding than alternative standards that have been proposed in the private sector. The standard is also sensitive to the definition of the “preferred date,” which has been subject to gaming. For example, the VA Inspector General found that VA staff regularly entered false information regarding preferred dates of care. Therefore, many have questioned whether the VA data and standard provide a valid reference for timeliness of appointments. While it was outside the scope of this assessment to validate these data, we examined whether alternative standards for timeliness could be applied. Alternative standards, such as those that assess the availability rather than completion of appointments, may be less subject to gaming and more comparable to private-sector standards. It is unclear how many VA facilities or non-VA providers meet these alternative standards. We found limited data available to compare VA and non-VA waits for care, but VA wait times do not seem to be substantially worse than non-VA waits, based on the limited available evidence.

On patient surveys, Veterans are substantially less likely than private-sector patients to report getting appointments, care, and information as soon as needed. The top-performing VA facilities scored comparably or worse than average practices in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Database, which includes a voluntarily participating set of private-sector medical practices and likely overrepresents high-performing practices. VA facilities at the 75th percentile of VA performance scored substantially worse than average CAHPS Database practices.

VA care is considered to be relatively affordable, and demand for VA care may increase if the cost of health care increases. VA is often Veterans' most affordable option for health care coverage. Veterans typically face lower out-of-pocket costs for care in VA than they would if they were privately insured. VA health care workers noted that lack of an affordable private insurance option is a key reason why Veterans enroll in VA. Twenty-eight percent of Veterans responding to the 2014 Survey of Enrollees indicated that their use of VA care would decrease if their financial resources improved. This suggests that, for a substantial minority of Veterans, non-VA care is preferred if available. In interviews, VA administrators and representatives of Veteran Service Organizations noted that Veterans generally like to get their care from VA, but that some Veterans with affordable non-VA care options seek care elsewhere rather than dealing with challenges associated with determining eligibility for services, perceived longer wait times, inconvenience of scheduling processes, and less than state-of-the-art equipment and facilities within VA.

Many Veterans, especially older Veterans, lack Internet access, but the acceptability of digital care is likely to grow as younger Veterans age. Thirty percent of Veterans, especially older Veterans, do not have access to the Internet and therefore cannot access VA's digital services, such as the MyHealtheVet patient portal or telehealth (2013 Survey of Enrollees). As younger Veterans age, Internet access and technological skill are likely to grow more common among Veterans, thereby increasing the acceptability and accessibility of digital health care services.

More could be done to increase VA providers' awareness of the changing demographics among Veterans. For example, increased attention to the needs of female Veterans has enabled broad access to basic reproductive health services; however, access to more advanced services is variable by location, and VA health care workers noted that additional steps could be taken by providers to ensure that female Veterans feel respected while receiving care in VA facilities.

Some variation in performance across regions and VA facilities may be inevitable because of differences in patient characteristics. In addition, some localized strategies for improvement may not scale up well because of contextual factors. However, these findings point to opportunities to improve Veteran access to VA care along several dimensions, as well as the need to consider alternative standards for measuring access to care.

Assessment of Quality of VA Care

Access to care is only beneficial if high-quality care is provided. VA has long played a national leadership role in the quality measurement arena. The assessment showed that VA health care quality was good overall on many measures and domains compared with non-VA comparators. However, as with access to care, quality performance was uneven across VA facilities, with many opportunities for improvement.

The findings of previous studies of quality of care provided in VA settings compared with non-VA settings vary by quality domain. Studies of safety and effectiveness indicated mixed performance, with 22 of 34 studies of safety and 20 of 24 studies of effectiveness showing that quality of care was the same or better in VA facilities. Only five articles assessed patient-centeredness, but all demonstrated better or same VA care quality compared with care in non-VA settings. Four articles assessed equity in VA settings, with one showing better performance, two showing same performance, and one showing worse performance compared with non-VA settings. The nine articles evaluating measures of efficiency, such as hospital length of stay, demonstrated mostly mixed or worse performance in VA facilities compared with non-VA facilities, although two studies showed better performance. Only one study assessed timeliness of care in VA facilities, and it showed worse performance than the non-VA facilities.

There is substantial variation in quality measure performance across VA facilities, indicating that Veterans in some areas are not receiving the same high-quality care that other VA facilities are able to provide. For example, there was a 21-percentage-point difference in FY 2014 performance between the lowest- and highest-performing VA facilities on the rate of eye exams in the outpatient setting for patients with diabetes. Although this variation is lower than that observed in private-sector health plans, a high-priority goal for VA leadership should be narrowing these gaps to ensure that quality of care is more uniform across VA facilities so that Veterans can count on high-quality care no matter which facility they access.

VA outpatient care outperformed non-VA outpatient care on almost all quality measures. VA hospitals performed the same or better than non-VA hospitals on most inpatient quality measures, but worse on others. VA performed significantly better, on average, on almost all 16 outpatient measures when compared with commercial, Medicare, and Medicaid health maintenance organizations (HMOs). On average, VA hospitals performed the same or significantly better than non-VA hospitals on 12 inpatient effectiveness measures, all six measures of inpatient safety, and three inpatient mortality measures, but significantly worse than non-VA hospitals on two effectiveness measures and three readmission measures.

On most measures, Veteran-reported experiences of care in VA hospitals were worse than patient-reported experiences in non-VA hospitals. Average VA facility-level performance was significantly worse than non-VA facilities for six of 10 patient experience measures, including communication with nurses and doctors.

VA uses many systems for monitoring quality. VA currently uses multiple quality monitoring systems—tailored for different care settings and audiences—to collect and report information about the health of Veterans and the care provided to them. Among these systems is ASPIRE, which is part of the VA Transparency Program, which offers publicly available information on the VA Hospital Compare website about how VA is performing relative to other health care organizations across the country. ASPIRE presents information about all aspects of quality, including preventive care, care recommended for acute and chronic conditions, complications and outcomes of care, and patient-reported measures of health care experiences at the national, regional, and local levels of the VA system. In addition to ASPIRE, VA has more than 500 other quality measures that can be used to monitor quality of care regionally and locally and to inform quality improvement projects.

There were mixed opinions on the impact of VA's many quality measures. In interviews, VA administrators and several health care workers noted that attention to quality measurement has led to positive changes in care delivery, for example, by using quality data to identify high-risk patients for more-intensive case management or to initiate patient education in response to high readmission rates. However, several respondents felt that measuring quality did not always have a positive effect on how facilities deliver care. Some noted that the current list of access and quality measures is “just too long” and the measurement process is a burden for VA providers and other staff members.

This level of variation in performance across VA facilities suggests that significant opportunities exist to improve access to care in VA through systematic performance improvement. These findings suggest that a systematic effort is needed to identify and eliminate unwarranted variation, and to develop and encourage the use of best practices to improve performance across the VA system.

Improving Access for Veterans

Looking to the future, the size, demographics, and health care needs of the Veteran population, as described by Assessment A (RAND Health, 2015a), will change. VA will need to adjust its resources and capabilities to meet the changing demand for services among Veterans. VA combines its resources and capabilities to generate the supply of health care services available to enrollees. Access to care, particularly the timeliness of care, is determined in large part by whether the overall level and geographic distribution of supply is well aligned with Veterans' needs. To provide insight into potential challenges to ensuring timely access, we compared projected supply with projected demand in FY 2019 under several scenarios, including (1) an increase in the number of VA providers but no change in productivity, (2) an increase in productivity with no change in the amount of resources, and (3) changes in both resources and productivity.

VA forecasts an increase in demand for VA care by FY 2019. VA's EHCPM forecasts a 19-percent increase in demand for VA health care services nationally from FY 2014 to FY 2019, due to a projected 5.1-percent increase in enrollment and the aging of enrollees. Although the forecast assumes that the number of Veterans will decrease, a growing proportion of Veterans are enrolling in VA health care (Milliman Inc., 2014), and the EHCPM model includes an assumption that this trend will continue through FY 2019. While the EHCPM is used by VA for planning purposes, it is possible that its predictions of increased demand for VA health care services will be inaccurate. Estimates from Assessment A suggest that the number of patients using VA health care services is expected to increase through 2019, then decrease thereafter (RAND Health, 2015a).

Assuming that the EHCPM demand forecast is accurate, VA will face challenges in meeting demand under current provider growth trends. Given the caveats noted above, our projections under our first supply scenario (increase in the number of providers) indicate that, if the supply of VA providers continues to increase at historical growth rates, and other resources grow in proportion so that providers continue to deliver a similar amount of health care (that is, no increase in productivity), it will be more difficult for VA to meet the demand for services and provide adequate access to Veterans in FY 2019. These challenges will be more acute in some regions and at some VA facilities than others, so considerations of distribution will be as important as consideration of levels.

Substantial increases in the productivity of existing resources will be needed to meet projected demand. Our second supply projection considers the effect of increasing productivity of each specialty in each administrative parent to benchmark levels—25th, 50th, or 75th percentile of the FY 2014 productivity distribution. Our projections indicate that, if productivity were increased to at least the 75th percentile for each specialty at each administrative parent, VA would be able to produce enough health care services to meet projected demand. However, such a large increase in productivity would likely be very difficult to achieve.

If both the number and productivity of resources are increased, VA can produce enough supply to meet projected demand. The third supply projection considers the effect of combining increases in the number of providers and the productivity of resources. We found that, if historical hiring trends were to continue and productivity were raised to the 25th percentile of the FY 2014 distribution, the supply produced in FY 2019 would exceed the projected demand. While the overall level of supply is sufficient to provide timely access to care, there are some VISNs in which demand is expected to exceed supply. As such, Veterans in some regions could experience access problems, indicating a need to redistribute supply across geographic areas to meet all enrollees' health care needs.

Changes in policy can help ensure Veterans' continued access to VA care. Comparing options with a policy objective of increasing Veterans' access to care within the VA system, we found that, of the options we considered, the three with the highest estimated impact on access are formalizing full nursing practice authority, increasing the number of VA physicians, and expanding virtual access to care. None of these options are mutually exclusive; they could be combined in a number of different ways. Each of these options has different potential barriers that present trade-offs. The primary barrier to formalizing full nursing practice authority is political (key stakeholder opposition); the barriers to hiring physicians are related to cost and administrative challenges associated with the hiring process; and the primary barrier to expanding virtual access to care is cost.

Options with a policy objective of increasing access outside the VA system have considerable uncertainty related to potential impact on access. Greater collaboration with and reliance on private-sector health care organizations to enhance VA capacity to provide timely access to care will be crucial to the success of these options. One option—consolidating existing purchased care programs—has the most certain impact. The current system of overlapping programs was widely cited as problematic and does not have any clear benefits. This option is discussed in greater detail in Assessment C (RAND Health, 2015b).

The impact and feasibility of increasing non-VA resources available for Veterans' health care would be highly dependent on the scope of the change. Shifting certain types of services from VA to purchased care could potentially improve both access and quality of care, but doing so could also increase challenges in care coordination. Shifting a greater share of services from VA to purchased care would require more fundamental changes to VA. The TRICARE program could serve as a model for an option to restructure VA as a purchaser rather than provider of health care, and, indeed, its relative success within DoD highlights the potential of such an option. However, our analyses indicate that many Veterans without access to VA health care also face significant barriers to accessing purchased care, including distance and cultural barriers. Thus, the option to transform VA from a provider to a purchaser of health care would not necessarily have a significant positive impact on access.

Conclusions

This study highlights many opportunities to improve VA capabilities to provide timely and accessible care. We identified a large number of barriers to effective use of VA resources. We also found widespread variation in performance across VA facilities. We did not find evidence of a system-wide crisis in current access to VA care. However, our projections indicate that, without changes, it will be increasingly difficult for VA to provide good access to care for the nation's Veterans.

This assessment had several important limitations, a number of which stemmed from the fact that the assessment was conducted over a very short time frame. The lack of direct input from Veterans was a key limitation. To address this challenge, we conducted analyses of secondary data sources that included Veterans' perspectives, as well as interviews with representatives of Veterans Service Organizations. Another limitation was that the projections of future resources relied solely on provider and productivity data and did not directly account for changes in other key resources, such as physical space, equipment, and IT. Moreover, our projection analysis did not account for changes in demand that might occur if supply, and thus access, increased. A projection model that included all resources and the interactions between them (for example, system dynamics) was beyond the scope of this assessment. Differences between VA and other health care organizations, in terms of both the organization of the delivery system and the patient population, limit the value of comparisons between VA and non-VA health care organizations. Therefore, in most cases, we used qualitative data from interviews and literature reviews to assess the adequacy of VA's resources and capabilities.

Recommendations for Consideration

Based on the findings of Assessment B, we make several recommendations to improve access to care for Veterans.

VA should use a systematic, continuous performance improvement process to improve access to care. Although many VA facilities achieve very high levels of performance on key access and quality measures, there is also a great deal of variation across the system. A systematic effort is needed to identify unwarranted variation, identify and develop best practices to improve performance, and embed these practices into routine use across the VA system. Some of the best solutions may be developed locally to reflect local needs and contexts. Solutions should be designed to be responsive to Veterans' preferences, needs, and values.

VA should consider alternative standards of timely access to care. Timeliness standards should be reexamined. VA should examine the utility of existing alternative benchmarks, such as same-day availability of the third next available appointment. Access standards for other dimensions, such as cultural access, should also be developed and used in performance monitoring and improvement. VA should develop methods to routinely compare the timeliness of VA care with non-VA benchmarks and publish these comparisons for transparency.

VA and Congress should develop and implement more sensitive standards of geographic access to care. VA should compare the “one-size-fits-all” approach of driving distance to alternative standards that are more sensitive to differences between Veteran subgroups, clinical populations, geographic regions, and individual facilities. This study highlighted the importance of time spent driving, mode of transportation, traffic, and availability of needed services as key considerations in assessing geographic access to care.

VA should increase its use of data analytics to focus implementation efforts for purchased care. VA has access to data that could be used in geographic assessments that consider locations of VA facilities relative to enrollee populations, access to specialized service offerings in VA facilities, and access to similar services by non-VA providers. VA could use these assessments to identify places where enrollees face barriers to access to VA facilities, but have relatively better access to non-VA providers.

VA should continue moving toward using a smaller number of quality metrics in quality measurement and improvement activities. VA maintains an extensive set of quality measures. Although use of these measures has led to improvements in care, the proliferation of measures creates burdens on staff and resources and can lead to emphasis on the measures rather than improvement in areas of care that are more likely to improve patient outcomes. VA has already moved toward reporting systems that rely on a smaller number of measures, such as Strategic Analytics for Improvement and Learning (SAIL).^[1]

VA should take significant steps to improve access to VA care. Our projections indicate that increases in both resources and the productivity of resources will be necessary to meet increases in demand for health care over the next five years. The options we considered that have the highest estimated potential impact are formalizing full nursing practice authority, increasing physician hiring, and increasing the use of virtual care. These are commonly proposed options for increasing access to VA care. In addition, new models of health care delivery are emerging rapidly in the U.S. health care system that could improve access to care. VA should seek to be an early adopter of these new models and should build a strategy that enables and supports such innovation.

VA should establish itself as a leader and innovator in health care redesign. We found that VA has historically been on the leading edge in several important areas, such as development and use of health IT. It is also on the forefront on many other innovative delivery methods, such as team-based primary care. As a large integrated delivery system, VA is well placed to innovate in comparison with many other U.S. health care delivery systems. It should endeavor to maximize this opportunity, given the constraints associated with being a public entity (for example, hiring processes, salaries, budgeting). VA should also endeavor to learn from current leaders in areas where its leadership position has eroded, particularly in health IT, and seek to reestablish its leading position.

VA should streamline its programs for providing access to purchased care and use them strategically to maximize access. Currently available programs are overlapping and confusing to Veterans and VA employees as well as non-VA providers. VA should clearly identify the objectives of purchased care access and streamline programs to meet those objectives.

VA should systematically identify opportunities to improve access to high-quality care through use of purchased care. Some types of care may be more effectively and efficiently delivered by non-VA providers. Identification of these types of care and the impact of shifting care to non-VA providers requires an in-depth systematic analysis that was beyond the scope of this assessment.

These recommendations would help VA improve Veterans' access to care across the VA system and ensure that future demand for VA care can be met. Although we did not find a system-wide crisis in access to VA care, we did identify a high degree of variability in performance across VA facilities, a number of barriers to effective use of VA resources and capabilities, and likely future challenges. These recommendations should be implemented and progress regularly evaluated to ensure continuous improvement in performance. Such improvement will be needed to ensure that the nation fulfills its commitment to care for Veterans.