VA Took Action on Veterans' Access to Care, but COVID-19 Highlighted Continued Scheduling Challenges (GAO-21-476)
Summary
A GAO report to congressional addressees, GAO-21-476, dated June 2021, on the Veterans Community Care Program (VCCP), which the Department of Veterans Affairs (VA) implemented in June 2019 so that eligible veterans can receive care from community providers. It describes actions VA took during the COVID-19 pandemic regarding veterans' access to care, such as recommending that facility staff schedule telehealth appointments whenever possible to reduce veterans' risk of exposure. VA also directed staff to prioritize appointment scheduling. Its title states that COVID-19 highlighted continued scheduling challenges.
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United States Government Accountability Office
Report to Congressional Addressees
VETERANS
June 2021
COMMUNITY CARE
PROGRAM
VA Took Action on
Veterans' Access to
Care, but COVID-19
Highlighted Continued
Scheduling
Challenges
GAO-21-476
June 2021
VETERANS COMMUNITY CARE PROGRAM
VA Took Action on Veterans’ Access to Care, but COVID-19
Highlighted Continued Scheduling Challenges
Highlights of GAO-21-476, a report to
congressional addressees
Why GAO Did This Study What GAO Found
In June 2019, VA implemented a new During the COVID-19 pandemic, the Department of Veterans Affairs (VA) took
community care program—the action regarding veterans’ access to care through the Veterans Community Care
VCCP—under which eligible veterans Program (VCCP). For example, VA recommended that VA medical facility staff
can receive care from community schedule telehealth appointments whenever possible in order to reduce veterans’
providers. GAO has previously risk of exposure to COVID-19. VA also directed facility staff to prioritize
reported on challenges VA has faced appointment scheduling and monitor referrals. Nevertheless, for referrals created
regarding oversight of its community between January 2020 and January 2021, GAO’s analysis below shows that
care programs, including the VCCP. about 172,000 referrals (3 percent) remain unscheduled as of March 24, 2021.
VA’s ability to ensure veterans have
timely access to care under the VCCP Status of Veterans Community Care Program Referrals Created Between January 2020 and
is especially important as VA continues January 2021, as of March 24, 2021
to respond to the COVID-19 pandemic.
The CARES Act includes a provision
for GAO to report on its ongoing
monitoring and oversight efforts related
to the COVID-19 pandemic. This report
describes (1) VA’s response to the
COVID-19 pandemic as it relates to the
VCCP and (2) challenges selected VA
medical facilities experienced
scheduling VCCP appointments.
GAO reviewed VA documentation,
such as guidance for VCCP
appointment scheduling, and reviewed
VCCP referral and appointment data.
GAO interviewed officials from VA and
its two third-party administrators, and
community care management and staff
from six VA medical facilities, which Note: A referral is complete after the veteran attends the appointment and VA staff receive medical documentation from the provider. A
were selected, in part, based on canceled referral is returned to the ordering VA provider. A discontinued referral is no longer wanted or needed. Referral data from one
VA facility were not reported after October 2020.
complexity, rurality, and location. aThe number of unscheduled referrals created in January 2020 through May 2020 is too small to display in this figure.
What GAO Recommends Staff at six selected VA medical facilities told GAO they faced both new and
previously identified challenges scheduling VCCP appointments during COVID-
GAO is not making new 19. For example, staff from all six facilities stated that community care wait times
recommendations in this report but increased during the pandemic. However, as VA lacks an overall wait-time
reiterates its past recommendations (1) measure for the VCCP, the effect of COVID-19 on appointment timeliness is
to Congress to require VA to unknown. GAO previously identified, and made recommendations to address,
implement a VCCP wait-time measure
VA’s lack of wait-time measures under its previous community care programs in
and (2) to VA directing medical facility
2013 and 2018. Given that VA had not implemented these recommendations
leadership to assess their community
care staffing needs. VA provided over the prior 7 years, in 2020 GAO recommended congressional action to
general and technical comments, require VA to establish a VCCP wait-time measure.
which GAO incorporated as Staff from all six facilities said they also faced challenges with understaffed
appropriate. community care offices and increased referral volume as veterans returned to
View GAO-21-476. For more information, seek care. GAO previously recommended in 2020 that VA direct its medical
contact Sharon M. Silas at (202) 512-7114 or facilities to assess community care staffing needs. VA has taken some action to
silass@gao.gov. address these concerns but has not yet implemented this recommendation.
United States Government Accountability Office
Contents
Letter 1
Background 5
VA Expanded Telehealth Use and Directed Facility Community
Care Staff to Prioritize Appointment Scheduling and Monitor
Referrals During COVID-19 10
COVID-19 Highlighted New and Previously Identified Challenges
with VCCP Appointment Scheduling at Selected VA Facilities 24
Agency Comments 32
Appendix I Department of Veterans Affairs Community Care Networks Regional
Map and Implementation Time Frames 35
Appendix II Veterans Community Care Program Referral Volume 37
Appendix III Comments from the Department of Veterans Affairs 40
Appendix IV GAO Contact and Staff Acknowledgments 43
GAO Related Products 44
Table
Table 1: GAO Recommendations and Implementation Status for
Addressing Veterans’ Access to Care under the Veterans
Community Care Program (VCCP) 26
Figures
Figure 1: General Appointment Scheduling Steps for the Veterans
Community Care Program (VCCP) 7
Figure 2: Number of Completed Veterans Community Care
Program Telehealth Appointments per Month, June 2019
to February 2021 12
Page i GAO-21-476 Access to VA Community Care
Figure 3: Percent of Completed Veterans Community Care
Program Referrals Created Between April 2020 and
September 2020, as of March 24, 2021 18
Figure 4: Status of Veterans Community Care Program Referrals
Created Between January 2020 and January 2021, as of
March 24, 2021 20
Figure 5: Map of Community Care Networks and Awarded Third-
Party Administrators for the Veterans Community Care
Program, as of June 2021 35
Figure 6. New Veterans Community Care Program (VCCP)
Referrals per Month, June 2019 to February 2021 38
Abbreviations
CCN Community Care Network
COVID-19 Coronavirus Disease 2019
VA Department of Veterans Affairs
VCCP Veterans Community Care Program
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Page ii GAO-21-476 Access to VA Community Care
Letter
441 G St. N.W.
Washington, DC 20548
June 28, 2021
Congressional Addressees
In addition to delivering health care services at its own medical facilities,
the Department of Veterans Affairs (VA) allows eligible veterans to
receive care from community providers through the Veterans Community
Care Program (VCCP). 1 The VCCP, established by the VA MISSION Act
of 2018 (VA MISSION Act) and implemented on June 6, 2019, is the most
recent iteration of VA’s long-standing practice of allowing veterans to
receive care from community providers when they face challenges
accessing care at VA medical facilities. 2 While veterans still receive most
of their care in VA medical facilities, according to VA, the number of
veterans who received community care increased 64 percent from
approximately 1.1 million in 2014 to 1.8 million in 2020.
We and the VA Office of Inspector General have identified challenges VA
faced in implementing and administering its community care programs. 3
For example, in 2020, we reported that under the VCCP, VA lacks an
overall wait-time performance measure for veterans to receive community
care. In addition, we found that few VA medical facilities’ community care
offices had the number of staff VA recommended to administer the
program in the first region to implement the new community provider
networks under the VCCP. 4 In 2018, we found that under VA’s earlier
1Under the VCCP, eligible veterans may choose to obtain health care services from
community providers rather than from a VA provider when the veteran is enrolled in VA’s
health care system, or is not enrolled but otherwise entitled to care under 38 U.S.C. §
1705(c)(2), and receives VA’s approval for community care based on certain criteria. See
Pub. L. No. 115-182, tit. I, § 101, 132 Stat. 1393, 1395-1404 (2018), codified at 38 U.S.C.
§ 1703(d), (e), and implementing regulations at 38 C.F.R. §§ 17.4000 - 17.4040.
2Pub. L. No. 115-182, tit. I, § 101, 132 Stat. 1393, 1395 (2018) (codified as amended at 38
U.S.C. § 1703).
3For example, see GAO, Veterans Community Care Program: Improvements Needed to
Help Ensure Timely Access to Care, GAO-20-643 (Washington, D.C.: Sept. 28, 2020) and
Veterans Choice Program: Improvements Needed to Address Access-Related Challenges
as VA Plans Consolidation of Its Community Care Programs, GAO-18-281 (Washington,
D.C.: June 4, 2018). See also VA Office of Inspector General, Veterans Health
Administration, Review of the Implementation of the Veterans Choice Program, Report
No. 15-04673-333 (Washington, D.C.: Jan. 30, 2017).
4See GAO-20-643. This report reviewed, among other things, community care staffing
data from 40 VA medical centers, one type of VA medical facility.
Page 1 GAO-21-476 Access to VA Community Care
iteration of its community care program, veterans still experienced lengthy
wait times when using community care, and that VA had a limited ability
to monitor the timeliness with which veterans access such care. 5 To
address these issues, we made several recommendations to VA to
improve its oversight of community care, including the VCCP—many of
which remain unimplemented. 6 We describe some of these
recommendations, and a related matter for congressional consideration
regarding wait times, later in this report.
VA’s ability to effectively oversee the VCCP, and ensure that veterans
have timely access to care, is especially important during the Coronavirus
Disease 2019 (COVID-19) pandemic. 7 COVID-19 began quickly
spreading throughout the United States less than a year after VA
implemented the VCCP, taking a severe toll on the health care sector and
causing disruptions to care and services. During this time, many veterans
chose to delay care to reduce unnecessary risks and potential exposure
to COVID-19. 8
The CARES Act includes a provision for GAO to monitor and oversee the
authorities and funding provided to address the COVID-19 pandemic as
5See GAO-18-281.
6In addition, due to concerns we have with VA’s ability to provide timely, cost-effective,
and quality care, VA health care continues to be on our High Risk List. GAO maintains a
high-risk program to focus attention on government operations that it identifies as high risk
due to their greater vulnerabilities to fraud, waste, abuse, and mismanagement or the
need for transformation to address economy, efficiency, or effectiveness challenges. We
added VA health care to the High Risk List in 2015. See GAO, High-Risk Series:
Dedicated Leadership Needed to Address Limited Progress in Most High-Risk Areas,
GAO-21-119SP (Washington, D.C.: Mar. 2, 2021).
7In December 2019, a new strain of coronavirus emerged and quickly spread around the
globe. In response, in January 2020, the Secretary of Health and Human Services
declared a public health emergency for the United States, and in March 2020, the World
Health Organization characterized it as a pandemic. Subsequently, the President of the
United States declared a national emergency in response to COVID-19 under the National
Emergencies Act and a nationwide emergency under section 501(b) of the Robert T.
Stafford Disaster Relief and Emergency Assistance Act.
8A September 2020 study published by the Centers for Disease Control and Prevention
found that an estimated 41 percent of Americans had delayed or avoided medical care by
June 30, 2020, because of concerns about COVID-19. See ME Czeisler, K Marynak, KE
Clark, et al., “Delay or Avoidance of Medical Care Because of COVID-19-Related
Concerns—United States, June 2020,” Morbidity and Mortality Weekly Report (MMWR)
69, no. 36 (Sept. 11, 2020): 1250-1257, accessed Apr. 7, 2021,
https://dx.doi.org/10.15585/mmwr.mm6936a4.
Page 2 GAO-21-476 Access to VA Community Care
well as the effect of the pandemic on the health, economy, and public and
private institutions of the United States. 9 This report is part of our body of
work in response to the CARES Act and focuses on the effects of COVID-
19 on veterans’ access to community care. Specifically, in this report, we
describe
1. VA’s response to the COVID-19 pandemic as it relates to the
VCCP; and
2. challenges selected VA medical facilities experienced with VCCP
appointment scheduling during the COVID-19 pandemic.
To describe VA’s response to the COVID-19 pandemic as it relates to the
VCCP, we reviewed applicable VA guidance for VCCP appointment
scheduling released prior to and during the COVID-19 pandemic. 10 We
also analyzed VA-provided data on VCCP referrals and appointments
from June 2019—the month the VCCP was implemented—through
February 2021—the most recent data at the time of our review. These
data provide information on the number of VCCP referrals created, status
of the referrals, the number of canceled appointments, the number of
appointments conducted via telehealth, and the priority groupings VA
used to schedule veterans’ appointments during the COVID-19
pandemic. 11 We reviewed the data for completeness and to identify any
9Pub. L. No. 116-136, § 19010, 134 Stat. 281, 579-81 (2020). We regularly issue
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021). Our next government-wide report
will be issued in July 2021 and will be available on GAO’s website at
https://www.gao.gov/coronavirus.
10In this report, we use the term “guidance” to refer to VA memorandum and directives,
the VA Office of Community Care Field Guidebook (which establishes facility staff
responsibilities and describes actions staff must take to schedule and coordinate care
through the VCCP), documentation of trainings VA provided to facility staff, and other
written communication from VA to facility staff and community providers (for example,
newsletters or email updates).
11A referral is an electronic request entered into VA’s electronic health record system by a
VA provider who is seeking an opinion, advice, or expertise regarding evaluation or
management of a veteran’s condition.
To aid facility staff in prioritizing appointment scheduling during the pandemic, VA
established numerical priority groupings based on clinical urgency, which facility staff
could assign to VCCP referrals.
We analyzed the number of VCCP appointment cancellations from March 2020 to
February 2021, because VA officials said they did not collect this data in earlier months.
Page 3 GAO-21-476 Access to VA Community Care
obvious errors, and we interviewed VA officials about the data. On this
basis, we determined these data were sufficiently reliable for the purpose
of our objective.
In addition, we interviewed officials from VA’s Office of Community Care
and Office of Veterans Access to Care about VA’s response to COVID-
19, including how VA updated VCCP appointment scheduling and
monitoring processes. We also interviewed community care
management, scheduling, and clinical staff from six VA medical facilities
about these updates to the VCCP scheduling and monitoring process
between November 2020 and February 2021. We selected at least one
facility from each of four regions of the VCCP network of community care
providers and then selected facilities from those regions based on varying
facility complexity, rurality, and number of veteran COVID-19 cases. 12
The facilities we selected were located in Fayetteville, North Carolina; St.
Cloud, Minnesota; Marion, Illinois; Montgomery and Tuskegee, Alabama;
Houston, Texas; and Sheridan, Wyoming. 13 We also interviewed officials
from the two third-party administrators responsible for managing the
VCCP network of community providers about VA’s response to COVID-19
and actions the third-party administrators took to communicate with
community providers during the pandemic. Last, we reviewed written
responses from select Veterans Service Organizations, about their
perspective on VA’s response to COVID-19 as it relates to the VCCP. 14
The information we obtained from the selected VA medical facilities and
Veterans Service Organizations cannot be generalized.
12The community provider network under the VCCP is divided into six regions that, as of
June 2021, VA is in the process of implementing. We selected facilities in the four regions
that were implemented at the time of our review. Specifically, we selected four facilities
across region 1 (one facility), region 2 (two facilities), and region 3 (one facility), which are
managed by the same third-party administrator, and two facilities in region 4, managed by
a second third-party administrator.
13The VA medical facility we selected that is located in Alabama includes two campuses:
one located in Montgomery and one in Tuskegee. VA medical facility community care staff
we spoke with stated that the community care department that covers both campuses is
located primarily on the Tuskegee campus.
14We received a written response from the American Legion and reviewed the response
from the Disabled American Veterans from a related GAO engagement. In addition, we
reviewed two written statements from Veteran Service Organizations for congressional
testimonies: (1) a September 2020 joint statement to the House Committee on Veterans’
Affairs, Subcommittee on Health, regarding community care wait times from the Disabled
American Veterans, Paralyzed Veterans of America, and Veterans of Foreign Wars, and
(2) an October 2020 statement to the Senate Committee on Veterans’ Affairs regarding
VA’s implementation of the VA MISSION Act from the Disabled American Veterans.
Page 4 GAO-21-476 Access to VA Community Care
To describe challenges selected VA medical facilities experienced with
VCCP appointment scheduling during the COVID-19 pandemic, we
interviewed community care management, scheduling, and clinical staff
from the six selected VA medical facilities to understand any challenges
staff faced when scheduling VCCP appointments during the COVID-19
pandemic. We analyzed information from these interviews to identify
common challenges, and identified whether those challenges were
caused by the pandemic, or had existed prior to the onset of the
pandemic. We reviewed open GAO recommendations that aligned with
any identified challenges. We also reviewed written responses from select
Veterans Service Organizations about the effects of COVID-19 on
veterans’ access to community care. Last, we interviewed VA and third-
party administrator officials regarding any actions they’ve taken to
address identified challenges, and actions VA has taken to implement our
recommendations. The information we obtained from the selected VA
medical facilities and Veterans Service Organizations cannot be
generalized.
We conducted this performance audit from August 2020 to June 2021 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
COVID-19 On January 31, 2020, the Secretary of Health and Human Services
declared a public health emergency for the United States due to the
rapidly spreading coronavirus. On March 13, 2020, the President
declared the COVID-19 outbreak to be a national emergency under the
National Emergencies Act and a nationwide emergency under section
501(b) of the Robert T. Stafford Disaster Relief and Emergency
Assistance Act, 2 days after the World Health Organization declared
COVID-19 to be a pandemic. COVID-19 took a severe toll on the nation’s
health care sector, including VA’s health care system, not only in terms of
the sharp rise in demand for services to care for COVID-19 patients, but
also the disruption of care and services for non-COVID-19 patients due to
social distancing guidelines. As a result, many health care entities, such
as physician offices, curtailed their services.
Page 5 GAO-21-476 Access to VA Community Care
In July 2020, the VA Office of Inspector General found that several VA
medical facilities reported difficulties rescheduling VCCP appointments
that had been canceled due to COVID-19 in certain categories of care,
such as gastroenterology and dental, and reported additional challenges
related to the community provider networks. 15 Additionally, in September
2020, the VA Office of Inspector General reported that VA faces a
potentially large volume of VCCP referrals, as veterans return to seek
care at VA facilities and as facility staff work to reschedule previously
canceled appointments. 16
Veterans Community Care On June 6, 2019, VA implemented the VCCP, a permanent community
Program (VCCP) care program that consolidated many of VA’s existing community care
programs, in response to the enactment of the VA MISSION Act. 17 VA
issued regulations to carry out the new program, including defining certain
eligibility criteria. 18 For example, veterans may be eligible to receive care
under the VCCP when services are not available at a VA medical facility
or VA cannot furnish care within its designated access standards. 19
15See VA Office of Inspector General, Veterans Health Administration, Review of
Veterans Health Administration’s COVID-19 Response and Continued Pandemic
Readiness, Report No. 20-03076-217 (Washington, D.C.: July 16, 2020).
16The VA Office of Inspector General made three recommendations to VA regarding in-
house appointment management during COVID-19, including that VA monitor VA medical
facilities’ progress with appointment cancellation follow-up. VA agreed with this
recommendation, and stated in June 2020 that it developed a reporting tool and
monitoring mechanism as part of its COVID-19 appointment and referral management
initiative plan, which will track all canceled appointments and referrals, regardless of
whether staff indicated COVID-19 was the reason for the cancellation. See VA Office of
Inspector General, Veterans Health Administration, Appointment Management During the
COVID-19 Pandemic, Report No. 20-02794-218 (Washington, D.C.: Sept. 1, 2020).
17Pub. L. No. 115-182, tit. I, § 101, 132 Stat. 1393, 1395 (2018) (codified as amended at
38 U.S.C. § 1703).
1838 C.F.R. §§ 17.4000 - 17.4040 (2020).
19See 38 C.F.R. § 17.4010 (2020) (veteran’s eligibility). VA’s designated access standards
include when the veteran’s average drive time to a VA provider is more than 30 minutes
for primary care or more than 60 minutes for specialty care, or the next available
appointment with a VA provider is not within 20 days for primary care or 28 days for
specialty care of the date of request of care unless a later date has been agreed upon. 38
C.F.R. § 17.4040 (2020) (designated access standards). See also VA, Veterans Health
Administration Office of Community Care Field Guidebook (May 21, 2020); Veterans
Health Administration: Referral Coordination Initiative Implementation Guidebook (Jan. 10,
2020); and Fact Sheet: Veteran Community Care Eligibility (Aug. 30, 2019).
Page 6 GAO-21-476 Access to VA Community Care
VA’s Office of Community Care manages the VCCP at the national level,
while VA medical facility community care staff coordinate and schedule
veterans’ care with community providers at the local level. As described in
VA guidance, the process for scheduling a VCCP appointment begins
when a VA provider creates a referral for a veteran who needs additional
care. Facility staff are responsible for reviewing the referral to determine
the veteran’s eligibility for community care and contacting the veteran to
discuss available options for care, both at a VA medical facility and
through the VCCP (if the veteran is eligible). If the veteran chooses to
receive community care, the staff are responsible for forwarding the
referral to the facility’s community care office. 20
Once received, facility community care staff are responsible for reviewing
the referral and taking several actions to schedule the appointment. This
includes identifying and contacting community providers to determine
appointment availability; creating and sending the VCCP authorization
and information about the veteran (such as medical documentation) to the
community provider; scheduling the veteran’s appointment with the
community provider; and communicating appointment details to the
veteran. 21 (See fig. 1.)
Figure 1: General Appointment Scheduling Steps for the Veterans Community Care Program (VCCP)
20If the veteran chooses to receive their care at a VA medical facility, facility staff schedule
their appointment with a VA provider and communicates appointment details to the
veteran.
21Some veterans may choose to self-schedule their appointments with community
providers.
Page 7 GAO-21-476 Access to VA Community Care
Note: This figure illustrates general steps in the VCCP scheduling process for eligible veterans who
are referred to the VCCP through routine referrals (non-emergent), and have VA facility staff—referral
coordination staff and community care scheduling staff—schedule the appointments on their behalf.
As a referral moves through the appointment scheduling process, it can
have one of the following statuses, according to VA guidance: 22
• Pending: The referral has been sent to the VA medical facility
community care office, but staff have not yet taken action to receive
and review the referral.
• Active: The referral has been received and reviewed by facility staff
and scheduling efforts are underway.
• Scheduled: Facility staff have scheduled an appointment with a
community provider.
• Completed: The veteran has attended the appointment and medical
documentation of the visit has been received by facility staff, or staff
have documented at least two attempts at obtaining the
documentation. 23
• Canceled: The referral is returned to the ordering VA provider for
review.
• Discontinued: The referral is no longer wanted or needed.
According to VA guidance at the time of our review, at least 90 percent of
referrals should be in a scheduled status within 30 days of referral
creation. 24 However, as we previously reported, VA has not established a
22VA Directive 1232(2) Consult Processes and Procedures (June 28, 2019) and Office of
Community Care Field Guidebook (as of Dec. 30, 2020).
We excluded other referral statuses from our analysis, such as “partial” which indicates a
referral note requires a signature. These referrals accounted for less than 0.01 percent of
VCCP referrals in the data we received from VA.
23According to VA guidance, facility staff must make at least one attempt to collect
medical documents from the community provider before closing the referral. Community
providers are not required to submit medical documentation of the veteran’s appointment
to receive payment for authorized care, based on VA guidance.
24In June 2021, VA officials stated the department now monitors whether appointments
are created within 21 days of referral creation.
Page 8 GAO-21-476 Access to VA Community Care
wait-time performance measure for how long it should take for a veteran
to receive care under the VCCP. 25
VA purchases community care under the VCCP through regional
contracts called Community Care Networks (CCN). 26 VA contracts with
two third-party administrators to develop and administer the CCNs—
specifically, the third-party administrators are responsible for recruiting
and building networks of licensed health care community providers and
paying community provider claims. 27 VA is implementing the CCN
contracts in a phased approach by VA medical facility across six regions.
Implementation began with CCN Region 1 in December 2019, and
implementation of CCN Regions 2 through 5 continued through the
COVID-19 pandemic. As of June 2021, VA has not awarded the contract
for CCN Region 6. VA allowed facilities to continue using the previous
community provider network for a designated time frame during the
transition to the CCN while the third-party administrators worked to grow
each CCN to meet each facilities’ provider network needs. See Appendix
I for more information on the CCN regions and implementation time
frames.
25See GAO-20-643.
26VA also has the option to use direct agreements with community providers for care not
included in those contracts, known as Veterans Care Agreements, and the option to refer
veterans to other federal health care facilities with whom VA has an agreement, such as
Department of Defense military treatment facilities.
27VA awarded the contracts for CCN Regions 1 through 3 to Optum Public Sector
Solutions (Optum) in December 2018, and the contracts for CCN Regions 4 and 5 were
awarded to TriWest Healthcare Alliance (TriWest) in August 2019 and October 2020,
respectively.
Page 9 GAO-21-476 Access to VA Community Care
In its response to the COVID-19 pandemic, VA’s Office of Community
VA Expanded Care took action to expand the use of telehealth in the VCCP. VA also
Telehealth Use and directed VA medical facility staff to prioritize appointment scheduling
based on clinical urgency. Additionally, VA issued guidance for facility
Directed Facility staff to monitor and review referrals during the pandemic.
Community Care Staff
to Prioritize
Appointment
Scheduling and
Monitor Referrals
During COVID-19
VA Expanded Telehealth Beginning in March 2020, VA limited in-person visits at its facilities and
Use in the VCCP During directed facility staff to consider scheduling telehealth appointments, both
at VA facilities and with community providers, in order to reduce the risk
COVID-19 of exposing veterans to COVID-19. 28 According to the VA Office of
Community Care Field Guidebook, facility staff could schedule telehealth
appointments with community providers if the veteran agreed to be seen
via telehealth, and if the type and scope of services needed were
appropriate for telehealth. 29 VA’s Office of Community Care also sent
letter templates to facilities on April 1, 2020, that could be used to
encourage community providers to convert veterans’ appointments from
in-person visits to telehealth whenever possible.
VA also waived certain telehealth requirements at that time in order to
make telehealth more widely available in the VCCP. VA officials stated
28See VA Memorandum, Coronavirus 2019 (COVID-19) – Guidance for Elective
Procedures (Mar. 15, 2020); Guidance on Access Standards in response to Coronavirus
(COVID-19) (Mar. 20, 2020); Guidance on Access Standards in response to Coronavirus
(COVID-19) Updated (Mar. 30, 2020); and Guidance to Avoid All Routine or Non-urgent
Face to Face Visits (Mar. 31, 2020).
29VA officials stated that having a telehealth appointment scheduled with a VA provider
does not remove a veteran’s eligibility for receiving care under the VCCP. However, a
veteran’s eligibility for the VCCP should not be used to determine whether a veteran
should have a telehealth appointment with a VA provider, according to VA guidance.
Rather, facility staff and the veteran should discuss available care options and determine
the appropriate setting.
We recently reported on telehealth use by VA providers, which also increased
substantially during COVID-19. See GAO, COVID-19: Critical Vaccine Distribution, Supply
Chain, Program Integrity, and Other Challenges Require Focused Federal Attention,
GAO-21-265 (Washington, D.C.: Jan. 28, 2021).
Page 10 GAO-21-476 Access to VA Community Care
that, prior to the pandemic, telehealth usage in the VCCP was limited to
follow-up appointments only. VA changed this policy to allow veterans
and community providers to use telehealth for initial visits as well,
according to Office of Community Care officials. Additionally, VA and the
CCN third-party administrators informed community providers that they
could use telehealth under the VCCP following certain Medicare
telehealth waivers and flexibilities implemented by the Secretary of Health
and Human Services in response to COVID-19. Among other things,
these waivers and flexibilities allow Medicare telehealth services to be
provided nationwide (rather than in mostly rural locations), from any
setting (such as the provider’s home), for additional types of services, by
additional types of providers, and including by telephone only.
According to our analysis of VA-provided data, telehealth appointments
with community providers increased from an average of 3,200 telehealth
appointments per month prior to the pandemic to a high of 95,000
telehealth appointments in April 2020. Although the number of telehealth
appointments completed each month is less than April 2020, telehealth
use in the VCCP remains much higher than before the pandemic. VA
officials said that the decrease in telehealth use in the VCCP since April
2020 likely occurred as veterans started to receive some care in-person
again. (See fig. 2.)
Page 11 GAO-21-476 Access to VA Community Care
Figure 2: Number of Completed Veterans Community Care Program Telehealth Appointments per Month, June 2019 to
February 2021
Notes: According to VA officials, these data are based on community providers’ claims, and there
may be a lag in counting appointments between when an appointment takes place and the claim is
paid. Telehealth appointments include live visual and audio visits (including telephone-only visits), as
well as “store and forward” technologies where images or information are sent between a veteran and
a provider in one direction at a time.
Page 12 GAO-21-476 Access to VA Community Care
Community care staff from all six VA medical facilities we interviewed
discussed telehealth in the VCCP. They emphasized that its use
depended on community providers’ telehealth capabilities, veterans’
preferences, and the type of care the veteran needed. Facility staff stated
that community providers’ telehealth capabilities varied, and according to
these VA staff, some providers who did not use telehealth prior to the
pandemic developed the capability quickly. Although many veterans
accessed care via telehealth during the pandemic, VA facility staff noted
that some veterans preferred to wait until in-person appointments were
available. 30 Additionally, facility staff noted that some types of care, like
dental services, cannot be provided via telehealth, while officials from VA
and the two CCN third-party administrators, and staff from two facilities,
noted that telehealth was used frequently for mental health care
appointments.
VA Directed Facility Staff Postponing routine care. Beginning in March 2020, VA directed facility
to Prioritize Appointment staff to schedule in-person appointments with community providers on a
case-by-case basis, based on whether the veteran’s clinical need
Scheduling Based on outweighed the risk of exposure to COVID-19. 31 According to VA
Clinical Urgency During guidance, this meant that routine care would likely need to be postponed.
COVID-19 Additionally, if a veteran or community provider canceled or postponed an
appointment due to concerns with COVID-19, VA instructed facility staff to
30Additionally, officials from the American Legion told us some veterans reported issues
accessing telehealth such as dropped calls during appointments, and an overall lack of
internet access and connectivity, particularly in rural locations. We recently described
actions VA took to improve veterans’ access to telehealth provided by VA providers, such
as distributing electronic tablets to veterans. See GAO-21-265.
31See VA Memorandum Guidance on Access Standards in response to Coronavirus
(COVID-19) (Mar. 20, 2020), and Guidance on Access Standards in response to
Coronavirus (COVID-19) Updated (Mar. 30, 2020). In its March 20, 2020, memorandum,
VA indicated that, due to COVID-19, it would temporarily pause VCCP access standards,
such as by providing VA telehealth for routine visits even if wait time or drive time eligibility
for community care exists. In its March 30, 2020, memorandum, VA clarified that referrals
would continue to be sent to facility community care offices and scheduled according to
clinical need for eligible veterans.
According to the VA Office of Community Care Field Guidebook, a clinical review is
performed to determine if the requested service is needed and clinically appropriate based
on the veteran’s diagnosis. The clinical review is completed by facility staff who have been
given a delegation of authority by the facility’s chief of staff to review services for clinical
appropriateness, such as a nurse or physician. See Veterans Health Administration Office
of Community Care Field Guidebook (As of May 21, 2020).
Page 13 GAO-21-476 Access to VA Community Care
not cancel the corresponding referral, and to instead, keep it active. 32
Facility staff were to enter “COVID-19” in the electronic notes for these
referrals, so the referral could be tracked and the appointment could be
scheduled (or rescheduled) at a later date. 33 According to our analysis of
VA-provided data, veterans and community providers canceled
approximately 500,000 VCCP appointments (out of 4.2 million scheduled)
between March 2020 and February 2021. 34
VA officials and facility staff we interviewed noted that community
providers closed or postponed routine care early in the pandemic, and
veterans themselves chose to postpone care due to concerns about
exposure to COVID-19. According to our analysis of VA-provided data,
the number of new VCCP referrals decreased by nearly half (48 percent)
between January 2020 and April 2020 nationwide. 35 See Appendix II for
more information on VCCP referral volume.
Scheduling appointments by priority group. In an effort to prioritize
appointment scheduling during the pandemic, in April 2020, VA updated
its electronic referral management system to allow facility staff to assign a
priority group to referrals. VA encouraged facility staff to prioritize
32See VA Memorandum, Outpatient Clinic Appointment Scheduling Management in
Response to COVID-19 Pandemic (Mar. 22, 2020) and Update to COVID-19 Scheduling
Instructions (Apr. 1, 2020); and Veterans Health Administration Office of Community Care
Field Guidebook (As of May 21, 2020).
According to VA officials, facility staff could continue to cancel and discontinue referrals for
reasons not related to COVID-19 as described in Directive 1232(2) Consult Processes
and Procedures (June 28, 2019).
33VA extended existing VCCP authorizations for most care types to remain valid through
September 30, 2020, to allow more time for appointments to be scheduled and completed.
The extension did not apply to emergency, inpatient, adult day health, home health or in-
home respite care.
34This includes only the first appointment scheduled for a VCCP referral. VA officials
stated the number could be higher because facilities rely on veterans or community
providers to report cancellations to facility staff. Facility staff we interviewed stated they
also contacted community providers to determine if an appointment was cancelled,
including when requesting medical documentation from the community provider after the
appointment date has passed.
35VA officials stated that as some clinics at VA facilities temporarily closed or reduced
services in response to COVID-19, VA providers saw fewer veterans, and in turn, created
fewer referrals to community care.
Page 14 GAO-21-476 Access to VA Community Care
scheduling appointments based on clinical urgency, according to the
following groups: 36
• priority group 1 is care that should be scheduled despite COVID-19;
• priority group 2 is care that should be scheduled after clinical review,
and based on local community provider availability; and
• priority groups 3 and 4 are optional groups that facilities may choose
to define and use, typically for routine care. 37
VA officials stated that they deployed this update to allow facility staff to
use the priority groups to prioritize scheduling (or rescheduling)
appointments, rather than rely on the “COVID-19” comment, because
they felt the pandemic affected all referrals, whether they had a “COVID-
19” comment or not. 38 Additionally, according to VA’s guidance, the
priority groups should help prioritize appointments for veterans with the
most urgent needs. 39 Staff from all six facilities we interviewed discussed
assigning priority groups to referrals, though which groups they used and
which staff assigned the priority varied by facility. For example, staff from
two facilities said they only used priority groups 1 and 2, while staff at the
other four facilities used three or four priority groups. Additionally, staff
said that either VA providers (two facilities), community care nurses (three
36VA Office of Community Care provided this guidance to facility staff via “Office Hours” in
April 2020. VA issued the memorandum detailing this guidance on May 18, 2020. See VA
Memorandum, National Deployment of Consult Toolbox 1.9.0063 and 1.9.0065– COVID-
19 Upgrades (VIEWS# 02748457) (May 18, 2020).
37See VA Memorandum, National Deployment of Consult Toolbox 1.9.0063 and
1.9.0065– COVID-19 Upgrades (VIEWS# 02748457) (May 18, 2020). According to
community care staff we interviewed, some facilities use group 2 for all routine care and
do not use groups 3 and 4. This feature also automatically adds a “COVID-19” comment
to a referral when facility staff assign a priority group, according to VA officials.
38A September 2020 report from the VA Office of Inspector General found that facility staff
were not using the “COVID-19” comment consistently to track canceled appointments for
care delivered at VA facilities, and recommended that facility staff not rely solely on the
comment to reschedule appointments. VA stated the Office of Veterans Access to Care
will provide oversight to ensure medical centers review all appointment cancellations and
provide follow-up. See VA Office of Inspector General, Veterans Health Administration,
Appointment Management During the COVID-19 Pandemic, Report No. 20-02794-218
(Washington, D.C.: Sept. 1, 2020).
39See VA Memorandum, National Deployment of Consult Toolbox 1.9.0063 and
1.9.0065– COVID-19 Upgrades (VIEWS# 02748457) (May 18, 2020).
Page 15 GAO-21-476 Access to VA Community Care
facilities), or both VA providers and community care nurses (one facility)
assign the priority group to a referral.
However, facility staff are not required to assign a priority group to a
referral, according to VA Office of Community Care officials, because the
department wanted the use of the priority groups to be a local facility
decision. VA officials said some facility staff may choose to include
priority information in the electronic referral notes instead of using the
priority groups. 40 According to our analysis of VA data, approximately
953,000 of 2.6 million referrals (37 percent) created between April 2020
and September 2020 were assigned a priority group, but very few
referrals created in October 2020 and later had priority groups assigned.
VA officials told us that as more VA clinics and community providers
reopened, facility staff found the priority group designations less useful,
and instead relied on the veteran’s preferred appointment date. 41 In April
2021, VA officials stated that they have provided additional guidance that
facility staff should continue to use the electronic referral management
system to document priority group 1 and 2 referrals, and are planning on
making updates to the system regarding that guidance. 42
VA Directed Facility Staff VA issued various guidance for VA medical facility staff to monitor and
to Monitor Referrals and review referrals during COVID-19. In May 2020, VA recommended that
facility staff monitor active referrals according to priority group, but as the
Reviewed Referral Data
pandemic continued, VA directed facility staff to attempt to schedule all
active referrals in September 2020, regardless of priority group. In
December 2020, VA required facilities to complete a review of canceled
referrals. VA’s Office of Community Care also monitored referral data at
the national level throughout the pandemic.
40For example, VA officials stated that if the referral volume for a certain specialty is
relatively low, staff may feel they can manage those referrals without using the priority
groups. However, on September 15, 2020, VA notified facilities that staff must use the
priority group feature when designating a referral in priority groups 1 and 2.
41Before VA established priority groups for scheduling appointments during COVID-19, VA
policy stated that facility staff should schedule appointments according to the date an
appointment is deemed clinically appropriate by the referring provider, or in the absence of
a clinically indicated date, the veteran’s preferred date. See VA Directive 1230(2)
Outpatient Scheduling Processes and Procedures (July 15, 2016, amended July 12, 2019
and January 1, 2020.).
42VA’s September 15, 2020, guidance stated that facility staff must use the priority group
feature when designating a referral in priority groups 1 and 2. See VA Memorandum
Changes to Consult/Referral Management during COVID-19 (Sep. 15, 2020).
Page 16 GAO-21-476 Access to VA Community Care
Reporting Tools to Monitor Referrals Monitoring active referrals by priority group. In May 2020, VA
VA’s Office of Community Care also established recommended time frames within which facility staff should
developed reporting tools that facilities can monitor active referrals according to the referral’s priority group.
use to track Veterans Community Care
Program referrals, and staff from all six
According to VA guidance, this would help ensure that veterans with the
facilities we interviewed stated that they use most urgent needs are prioritized for appointment scheduling during the
the reporting tools to monitor active referrals. pandemic. 43 Specifically, the guidance stated that
Specifically, VA developed reports that allow
facilities to track referrals with a COVID-19
comment or canceled appointment, and to • referrals in priority group 1 should be reviewed daily,
monitor referrals based on priority group and
how long the referral has been active. For • referrals in priority group 2 should be reviewed at least every 14 days,
example, facility staff said they use these
reports to generate lists of active referrals by and
priority group to target scheduling efforts and
to monitor whether staff are following time • all other referrals should be reviewed at least every 30 days (including
frames. those without a priority group assigned, according to VA officials). 44
Source: GAO analysis of Department of Veterans Affairs (VA)
documentation and interviews with VA officials and VA facility
staff. | GAO-21-476
Staff from five of the six facilities we interviewed stated that they were
following these or similar time frames to monitor referrals and follow up
with veterans to schedule appointments.
According to our analysis of VA-provided data of VCCP referrals created
between April 2020 and September 2020, a larger percent of priority 1
referrals were completed as of March 24, 2021—meaning the veteran
had attended the appointment—as compared to other priority groups and
referrals without a priority group. 45 Facility staff we interviewed noted that
the type of care that that facilities designate as priority group 1 continued
43See VA Memorandum, National Deployment of Consult Toolbox 1.9.0063 and
1.9.0065– COVID-19 Upgrades (VIEWS# 02748457) (May 18, 2020).
44See VA Memorandum, National Deployment of Consult Toolbox 1.9.0063 and
1.9.0065– COVID-19 Upgrades (VIEWS# 02748457) (May 18, 2020). While the
memorandum specifies priority groups 3 and 4 for review every 30 days, VA officials said
that all referrals, including those without a priority group, should also be reviewed. Officials
said they provided this guidance to facility staff through regular calls regarding referral
management.
Prior to the release of this guidance, the VA Office of Community Care Field Guidebook
stated that facility community care staff should schedule an appointment within 30 days,
for at least 90 percent of the facility’s VCCP referrals. Although VA’s March 2020 guidance
did not change these targets, it stated that referrals should be left active due to COVID-19
in order to schedule the appointment later. In June 2021, VA officials stated the
department now monitors whether appointments are created within 21 days of referral
creation.
45According to our analysis of VA data, 37 percent of referrals created between April 2020
and September 2020 had a priority group designation. The remainder of the referrals
created in this time frame are counted in the no priority group category. According to VA
guidance, facility staff are required to use the electronic referral management system to
document referrals in priority groups 1 and 2.
Page 17 GAO-21-476 Access to VA Community Care
to be provided during the pandemic given its clinical urgency, while the
other priority groups were generally routine care that could be postponed
or that veterans or community providers chose to postpone. (See fig. 3.)
Figure 3: Percent of Completed Veterans Community Care Program Referrals Created Between April 2020 and September
2020, as of March 24, 2021
Notes: Priority group 1 is used for care that should be scheduled despite COVID-19, while priority
groups 2 through 4 are generally routine care that can be scheduled after clinical review and based
on local conditions. A referral is complete after the veteran attends the appointment. This figure
includes all Veterans Community Care Program referrals created between April 2020 and September
2020. Approximately 953,000 referrals created during this time frame were assigned a priority group,
while the remaining 1.6 million referrals are counted in the “none” category.
Page 18 GAO-21-476 Access to VA Community Care
Addressing active referrals. On September 15, 2020, VA directed
facility staff to review and address all active referrals. 46 VA Office of
Community Care officials said they issued this guidance because they did
not want referrals to remain active indefinitely, and opportunities for
veterans to receive care in a safe manner were available again. 47 Facility
staff were to contact veterans that previously declined care due to
concerns about COVID-19, and offer to schedule an appointment, either
via telehealth or in-person at a community provider or at a VA facility.
Additionally, VA officials stated this effort would include addressing
referrals with canceled appointments—because when an appointment is
canceled, its status changes from a scheduled appointment to an active
referral—as well as referrals without a priority group. VA reminded facility
staff to review and address active referrals again in December 2020,
because, according to VA officials, there were still many active referrals at
that time. 48
Our analysis of VA-provided referral data shows the majority of referrals
created between January 2020 and January 2021 (67 percent) have been
completed as of March 24, 2021, meaning the veteran received care.
However, approximately 172,000 (3 percent) of the 6.1 million referrals
created between January 2020 and January 2021 were unscheduled as
of March 24, 2021. 49 (See fig. 4.)
46See VA Memorandum Changes to Consult/Referral Management during COVID-19
(Sep. 15, 2020).
47VA officials also said that facilities received feedback from some veterans who felt that
facility staff were contacting them too often when the veteran did not want to attend an
appointment at the time. Additionally, VA officials said that as VA clinics and community
providers reopened, facility staff found the priority groups less useful.
48VA Memorandum, Department of Veterans Affairs (VA) Internal and Community Care
Consult and Appointment Cancellation Management Initiatives (VIEWS 04061560) (Dec.
14, 2020).
49Referrals from the Spokane VA facility were not included in the data we analyzed after
October 2020.
Page 19 GAO-21-476 Access to VA Community Care
Figure 4: Status of Veterans Community Care Program Referrals Created Between January 2020 and January 2021, as of
March 24, 2021
Notes: A referral is “complete” after the veteran attends the appointment and VA staff receive medical
documentation from the community provider or have made at least two attempts to obtain the
documentation. A referral is “canceled” to return it to the ordering VA provider for review. A referral is
“discontinued” when care is no longer wanted or needed. Referrals from the Spokane VA facility are
not included after October 2020.
a
The number of unscheduled referrals created in January 2020 through May 2020 is too small to
display in this figure.
Page 20 GAO-21-476 Access to VA Community Care
Of those 172,000 unscheduled referrals, approximately 33,000 (19
percent) were more than 6 months old as of March 24, 2021, while the
remaining unscheduled referrals were 6 months old or less at that time.
Approximately 59,000 (34 percent) of the unscheduled referrals were
created in January 2021, and thus were 2 to 3 months old. VA’s
December 2020 guidance stated that facility staff should prioritize
scheduling older referrals, in addition to those that are more clinically
urgent, and staff from five of the six facilities we interviewed said they
were prioritizing scheduling older referrals. At the time of our interviews,
between November 2020 and February 2021, staff from all six facilities
said that the age of their oldest unscheduled referrals ranged, with some
staff still working to schedule referrals from the beginning of the pandemic
and others scheduling referrals from the previous month. However, staff
from three facilities also noted that some veterans still did not want to be
seen due to concerns about COVID-19. In April 2021, VA officials told us
they began holding weekly meetings with Veterans Integrated Service
Network officials and facility leadership in February 2021 to discuss
referral scheduling and timeliness, which they say contributed to
increased completion of referrals, among other efforts. 50
VA’s September 2020 guidance also stated that facility staff could begin
to cancel referrals if the veteran declines an appointment, changing the
March 2020 guidance to leave these referrals active, though facility staff
can leave a referral open if they or the VA provider think the care is still
needed. 51 At the six selected facilities in our review, facility staff we
interviewed had varying opinions on this update to the referral
management process. For example, staff from one facility we interviewed
expressed concern about the volume of referrals VA providers may have
to review, while staff at another facility said they thought the VA provider
50VA’s health care system is divided into areas called Veterans Integrated Service
Networks, each responsible for managing and overseeing the VA medical facilities within
a defined geographic area.
51If the veteran declines, VA facility staff are to remind the veteran to follow up at a later
date when they are ready to receive care. According to VA officials, when a referral is
canceled, the ordering VA provider can review it and work with the veteran to potentially
schedule an appointment within the VA, or resubmit the referral to community care, if the
care is still needed.
Page 21 GAO-21-476 Access to VA Community Care
review would help ensure a plan for care was in place for the veteran. 52
According to our analysis of VA-provided referral data, approximately 22
percent of referrals created between January 2020 and January 2021
were canceled or discontinued as of March 24, 2021.
Facility review of canceled and discontinued referrals. On December
14, 2020, VA directed VA medical facilities to review selected VCCP
referrals that were canceled or discontinued earlier in the pandemic and
determine whether any were canceled or discontinued in error or without
proper documentation, in order to ensure veterans did not miss needed
care. 53 Specifically, VA required facility community care offices to
complete a documented review by March 12, 2021, of referrals that were
• canceled or discontinued between January 1, 2020, and July 21,
2020;
• assigned to priority groups 1 and 2, or that had no priority assigned;
and
• high-volume or high-risk categories of care, such as mental health
and oncology. 54
52In March 2021, the VA Office of Inspector General reported that VA providers had not
reviewed electronic alerts regarding patient test results at the Central Alabama Health
Care System in 2019, which compromised patients and put others at risk of delayed
diagnoses. Facility staff told the VA Office of Inspector General that the volume of alerts
providers received was unmanageable. Additionally, the VA Office of Inspector General
found that ordering providers did not consistently take appropriate actions to edit and
resubmit canceled referrals as required. The VA Office of Inspector General made 11
recommendations, including that the director assess the alert management process and
modify as needed, and conduct a review of discontinued community care referrals to
ensure patients received follow-up care. See VA Office of Inspector General, Veterans
Health Administration: View Alert Process Failures and the Impact on Patient Care at the
Central Alabama Veterans Health Care System in Montgomery Office. Report #20-00427-
92. (Washington, D.C: Mar. 11, 2021).
53See VA Memorandum Department of Veterans Affairs (VA) Internal and Community
Care Consult and Appointment Cancellation Management Initiatives (VIEWS 04061560)
(Dec. 14, 2020). A canceled referral is returned to the ordering VA provider for review. A
discontinued referral is no longer wanted or needed. Facility staff were not to cancel or
discontinue a referral due to COVID-19, but could cancel or discontinue referrals for other
reasons, according to VA officials.
54Facilities reviewed VCCP referrals for oncology, mental health, cardiology,
gastroenterology, and pulmonology. Office of Community Care officials said in April 2021
that they do not plan to expand the review to include more referrals because they want
facility staff to focus on scheduling active referrals.
Page 22 GAO-21-476 Access to VA Community Care
VA officials said they provided facilities with a list of referrals to review
that met these criteria and did not have a cancelation or discontinuation
reason documented in the referral. As of April 2021, all VA facilities had
completed the requested review and documented in VA’s referral system
the reason why each referral had been canceled or discontinued. 55
According to VA data, staff could not determine a cancelation or
discontinuation reason for approximately 13,000 (12 percent) of the
111,000 referrals reviewed. VA officials said they directed Veterans
Integrated Service Network managers in April 2021 to work with facilities
to review those approximately 13,000 referrals and determine the reason
they were canceled or discontinued. Officials said they are developing a
spreadsheet and shared website for facility staff to use to submit
documentation of these subsequent reviews to the Office of Community
Care, and said they are requesting that facilities complete these reviews
within 2 months. 56
VA Office of Community Care oversight. VA Office of Community Care
officials said that, although facility staff are primarily responsible for
monitoring active referrals, they do monitor at a national level how many
referrals are in an active status every 15 days. Additionally, officials said
they can work with facilities as needed to provide guidance and training,
best practices, or reports to monitor progress.
In addition to overseeing national-level data on active referrals, VA Office
of Community Care officials said they reviewed historical, national-level
data on canceled and discontinued referrals in April and May 2020 to
determine whether staff were following the March guidance to leave
referrals active when appointments were canceled or postponed due to
COVID-19. According to VA-provided data, the number of canceled and
discontinued referrals dropped nationwide by 34 percent from March
2020 to May 2020. VA officials said this drop suggests that facility staff
were correctly following guidance. VA officials said they also examined
the results of a review conducted by Veterans Integrated Service Network
55According to VA data, the largest share of referrals that were canceled or discontinued
was because facility staff were unable to contact the veteran (approximately 28 percent).
VA officials said they have begun efforts to improve communication with veterans based
on these findings, such as through using text messaging. Other reasons staff indicated for
canceling or discontinuing a referral included veterans declining appointments or duplicate
referrals.
56VA officials added that they plan to update the referral scheduling system to require
facility staff to enter a reason when canceling or discontinuing a referral.
Page 23 GAO-21-476 Access to VA Community Care
8 (Florida and South Georgia) on VCCP referrals that were canceled or
discontinued between January 1, 2020, and July 31, 2020, at one facility
in that network. According to VA officials, this review found that staff were
generally following guidance in that network. 57
Community care staff we interviewed from six VA medical facilities
COVID-19 identified certain challenges they faced scheduling VCCP appointments
Highlighted New and that stemmed from the COVID-19 pandemic. 58 First, while VA
encouraged facility staff to schedule appointments via telehealth when
Previously Identified possible during the pandemic, staff from all six facilities we interviewed
Challenges with noted limitations in the provider telehealth data in the systems that facility
staff use to manage and schedule VCCP referrals. This included that the
VCCP Appointment Provider Profile Management System—VA’s master database of
Scheduling at community providers, including CCN providers—did not always indicate
whether community providers offered telehealth appointments as an
Selected VA Facilities option for care. 59 Instead of being able to use the system to understand
community provider telehealth capabilities, staff from four facilities stated
that during the appointment scheduling process, they generally had to
contact community providers directly to understand if they were able to
provide telehealth appointments to a veteran.
VA officials stated that the department updated the Provider Profile
Management System in September 2020 to include a data field to display
57According to VA officials, less than 1 percent of the referrals from that facility were
canceled or discontinued without documentation that care was no longer needed. For
those referrals, VA officials said that facility staff contacted veterans and created new
referrals if care was still needed.
58We conducted interviews with community care management, scheduling, and clinical
staff at VA medical facilities located in central Alabama (Montgomery and Tuskegee);
Marion, Illinois; St. Cloud, Minnesota; Fayetteville, North Carolina; Houston, Texas; and
Sheridan, Wyoming between November 2020 and February 2021.
59The Provider Profile Management System was deployed at the end of fiscal year 2018
and receives and stores information from multiple sources about each provider such as
demographic information and the types of services the provider is authorized to deliver.
Staff from three facilities also expressed other concerns about the accuracy of community
provider information in the Provider Profile Management System, including incorrect
demographic information like a provider being misnamed. VA officials acknowledged
facility concerns about data quality, and stated that the provider information that populates
the Provider Profile Management System is provided by the CCN third-party
administrators, and that VA has a process to report any errors to them. In addition, VA
officials stated there can be user errors when searching for providers in the system, and
VA conducted additional trainings for facility staff on using the Provider Profile
Management System. GAO has ongoing work reviewing the accuracy of the data in VA’s
Provider Profile Management System.
Page 24 GAO-21-476 Access to VA Community Care
whether a community provider is able to provide care via telehealth.
Although the submission of data on telehealth capabilities is not a
required field in the data they submit to VA, according to VA officials,
officials from one of the two third-party administrators stated in December
2020 that they report this information to VA for inclusion in the Provider
Profile Management System. 60 In April 2021, officials from the other third-
party administrator stated that they began working to incorporate this
information where available into the data they submit to VA in January
2021 after learning of VA’s update to the system.
Second, staff from all six facilities noted other scheduling challenges
stemming from the pandemic, including community providers requiring
veterans to have COVID-19 testing completed prior to being seen, and
community providers temporarily closing. VA has taken steps to address
these issues.
• Regarding COVID-19 testing requirements, VA announced in July
2020 the primary ways in which testing could be conducted in the
community, either under the veteran’s current referral, at a VA
medical facility, as part of an urgent care visit, or through a new VCCP
referral.
• In regards to community provider closures, although VA officials
stated they were unable to track provider closures nationally, VA
created a section in its referral system for facility staff to document
scheduling and network issues related to COVID-19. 61 Specifically, in
September 2020, VA required facility staff to begin documenting if (1)
no CCN providers were available, (2) CCN providers were identified
but not scheduling routine care or were currently closed, or (3) CCN
60The third-party administrators provide VA with the community provider data reported in
the system. Required fields include data such as the provider’s name, address, and
medical license number. According to VA officials, the CCN third-party administrators are
not required to report whether CCN providers are capable of conducting telehealth
appointments to VA for inclusion in the Provider Profile Management System as this data
field was not included in the original data reporting requirements in the CCN contracts, but
the department worked with the third-party administrators to submit this information when
known.
61We identified the need for this type of reporting in June 2018, and recommended that
VA establish mechanisms to ensure the agency is collecting reliable data on the reasons
that both VA medical facility and third-party administrator staff are unsuccessful in
scheduling veterans’ appointments through the VCCP, and demonstrate that it has
corrected any identified deficiencies. In May 2021, VA confirmed it had also established a
mechanism for the third-party administrators to document scheduling challenges. Based
on these actions, we closed this recommendation in June 2021. See GAO-18-281.
Page 25 GAO-21-476 Access to VA Community Care
providers were available and open, but had a greater than 90-day wait
for an available appointment. 62 VA officials stated that once
scheduling challenges are identified, there is a process in place to
work with the facility and the CCN third-party administrator to resolve
the challenges on a case-by-case basis.
In addition to new challenges, facility staff at the six selected facilities in
our review also discussed ongoing appointment scheduling concerns that
existed prior to COVID-19 but were highlighted, or in some cases,
worsened by the pandemic. These included challenges with (1)
increasing wait times for appointments with community providers, (2)
inadequacies with the CCN community provider networks, and (3) facility
community care workload and staffing. We have previously reported on
these scheduling concerns and made recommendations to VA to address
some of these issues in 2018 and 2020 (see table 1). VA agreed with our
recommendations, but as of June 2021, has not implemented them.
Table 1: GAO Recommendations and Implementation Status for Addressing Veterans’ Access to Care under the Veterans
Community Care Program (VCCP)
GAO recommendation Implementation status as of June 2021
The Under Secretary for Health should establish an achievable Not yet implemented. VA agreed with our recommendation, but as
wait-time goal for the VCCP that will permit VA to monitor of June 2021, does not have an overall wait-time performance
whether veterans are receiving VA community care within time measure for the VCCP. GAO continues to believe the development
frames that are comparable to the amount of time they would of an overall wait-time performance measure for the VCCP is
otherwise wait to receive care at VA medical facilities. important to allow VA to evaluate timely access and to identify any
deficiencies in its appointment scheduling process or networks of
community providers.
The Under Secretary of Health should direct VA medical center Not yet implemented. VA agreed with our recommendation, and in
leadership to assess their community care staffing and resource April 2021, stated that facility community care offices are utilizing a
needs, and develop a plan to address any identified risks to staffing tool to capture recommended administrative and clinical
their ability to schedule appointments in a timely manner, staffing levels. In addition, VA is in the process of implementing its
including strategies to adjust staff levels and address Referral Coordination Initiative, collaborating across offices to
recruitment and retention challenges as needed. develop robust staffing models for its Referral Coordination Teams,
and expanding recruitment and retention efforts of facility scheduling
staff. VA expects to implement this recommendation by June 2021.
Source: GAO-18-281 and GAO-20-643 and GAO analysis of Department of Veterans Affairs (VA) information. | GAO-21-476
62See VA Memorandum Changes to Consult/Referral Management during COVID-19
(Sep. 15, 2020). According to VA officials, less than 1 percent of referrals in November
and December 2020 had a scheduling challenge noted. In addition to documenting
scheduling challenges on the tab in VA’s referral system, officials stated that facility staff
can also enter in comments in the Provider Profile Management System regarding
provider operating statuses that other staff can see—for example, if a provider is
temporarily closed.
Page 26 GAO-21-476 Access to VA Community Care
Community care wait times. Staff from all six facilities stated concerns
with increased wait times for appointments as some community providers
temporarily closed or operated at reduced capacities due to COVID-19
infection control procedures. 63 For example, in November 2020, staff from
one facility stated that due to community providers’ limited capacity,
appointments that were usually accommodated within 2 to 3 weeks were
instead being scheduled for 2 to 3 months out. VA officials stated that
community care wait times have varied by geographic area and by
specialty during the COVID-19 pandemic, but noted challenges in rural
areas of the country. 64
In addition to collecting data on scheduling challenges, VA officials stated
they are working with the CCN third-party administrators on a monthly
basis to address scheduling challenges at the facility level. VA officials
also stated that at the time of scheduling an appointment, facility staff can
use a software tool to review the average wait times for VA-based care as
well as community care (when appointment data are available) in order to
inform their discussion with the veteran on where needed care should be
scheduled. 65
However, as we previously reported in September 2020, VA has not
established an overall wait-time performance measure specifying the
maximum amount of time it should take veterans to receive care from
community providers under the VCCP. 66 Without a performance measure
63Officials from the American Legion also noted longer wait times for appointments as a
concern for veterans.
64VA officials stated in April 2021 that urgent referrals (those referrals that need to be
scheduled and care provided within 24 hours) have been completed in less than 2 days
during the pandemic.
65According to VA’s Office of Community Care Field Guidebook, the community care wait
times that schedulers review are not reflective of available appointments at any single
community provider, but a 90-day rolling average of all community providers who offer the
requested service to which that the VA medical facility can refer a veteran. VA officials
explained that wait times are calculated based on appointments that have been scheduled
with those providers, and wait times are not available for categories of care that have no
appointments scheduled with community providers.
In addition, due to the reduced number of face-to-face appointments at VA facilities during
the pandemic, wait times that staff review for appointments at VA facilities include pending
or completed appointment information dating back to January 1, 2020. VA officials
confirmed that the department does not publicly report community care wait times.
66See GAO-20-643.
Page 27 GAO-21-476 Access to VA Community Care
in place, VA is unable to determine the extent to which COVID-19 has
impacted the timeliness of veterans’ access to community care. Based on
our findings in 2013 and 2018 that VA lacked an overall wait-time
measure and faced challenges measuring how long it takes for veterans
to receive care under prior community care programs, we recommended
in June 2018 that VA implement a wait-time goal as it developed and
implemented what became the VCCP. 67 VA agreed with our
recommendation for the new community care program, but never
implemented it.
In September 2020, more than one year after the implementation of the
VCCP, we reiterated our concerns with VA’s lack of action over the prior 7
years in implementing achievable wait-time goals for its prior community
care programs, and recommended Congress consider requiring VA to
establish a wait-time performance measure for the VCCP. 68 Legislation
was enacted in January 2021 requiring VA to establish a process for
scheduling VCCP appointments that includes the maximum number of
days allowed to complete each step of the process. 69 VA officials told us
the department submitted a report to Congress that defines the maximum
number of days in each step of the scheduling process, from the time a
veteran requests care through the time the request is completed. 70
However, as of June 2021, VA does not have an overall wait-time
performance measure for the VCCP. We continue to believe the
development of an overall wait-time performance measure for the VCCP
is important to allow VA to evaluate timely access and to identify any
67See GAO, VA Health Care: Management and Oversight of Fee Basis Care Need
Improvement, GAO-13-441 (Washington, D.C.: May 31, 2013) and GAO-18-281.
68See GAO-20-643. In addition, in May 2021 we reiterated the importance of this
recommendation in our Priority Open Recommendations Letter for the Department of
Veterans Affairs. See GAO Priority Open Recommendations: Department of Veterans
Affairs, GAO-21-469PR (Washington, D.C.: May 10, 2021).
69Specifically, on January 5, 2021, the President signed into law the Johnny Isakson and
David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020, which
required, within 60 days of enactment, VA to establish a process and requirements for
scheduling VCCP appointments that includes the maximum number of days allowed to
complete each step of the process but does not require VA to establish an overall wait-
time performance measure for veterans to receive care. Pub. L. No. 116-315, § 3101(a),
134 Stat. 4932, 4999-5000.
70VA officials also stated the department can track community care wait times through
newly developed software and compare those wait times to the length of time it takes
veterans to receive care at VA medical facilities.
Page 28 GAO-21-476 Access to VA Community Care
deficiencies in its appointment scheduling process or networks of
community providers.
Community provider network adequacy. Staff from all six selected
facilities in our review expressed concerns with the CCN provider
networks, including staff from some facilities noting that providers closed
or reduced their operating capacity during the pandemic. These concerns
varied by facility, and included gaps in the network for certain types of
specialty care, community providers not knowing they were enrolled in the
CCN, delays in adding providers to the CCN, and continuity of care
concerns if a veteran’s former community provider chose not to enroll in
the CCN. However, in contrast with what facility staff told us about their
challenges with the provider networks, officials from both CCN third-party
administrators stated that community provider closures (both temporary
and permanent) during the pandemic have not affected their ability to
meet CCN network adequacy requirements. 71 We previously reported on
concerns around the provider networks in September 2020, including
facility staff believing that the CCN provider network was not adequate,
and education issues with community providers not knowing they were
enrolled in the CCN. 72
VA officials described actions they have taken in response to concerns
over CCN network inadequacy issues. These steps include extending
access to the network of community providers from the previous
community care program and expanding telehealth to increase care
options with community providers. 73 In addition, VA officials said they will
71Network adequacy for the CCN is determined by specific categories of care utilizing two
primary factors: (1) geographic accessibility to a provider based on drive times, and (2)
appointment availability. The appointment availability standard reflects a 30-day maximum
for routine care in urban, rural, and highly rural locations. In January 2021, VA officials
stated when they reviewed the appointment availability data reported by the CCN third-
party administrators during this time, in most case, appointments were being scheduled at
most 10-15 days longer than the 30-day standard, and did not feel this was sufficient
information to allow a deviation from the standard to relax the measures.
72See GAO-20-643. In that report, we spoke with VA facilities (specifically VA medical
centers) located in White River Junction, Vermont; Philadelphia, Pennsylvania; Bronx,
New York; Bath, New York; and Washington, D.C. between September 2019 and
February 2020.
73According to VA documentation and officials, the extension for the use of the previous
community provider network for new referrals ended on October 23, 2020, for CCN
Regions 1 through 4. VA officials stated that CCN Regions 5 and 6 are still using the
previous network until the CCN is fully deployed in those regions.
Page 29 GAO-21-476 Access to VA Community Care
use the scheduling challenges data they started collecting in September
2020 to better monitor the networks at a local level.
Workload and staffing. Staff we interviewed at the six selected facilities
also identified referral workload and facility community care staffing
challenges. According to staff from three facilities, as of November and
December 2020, referral workload—the number of referrals—has
increased as veterans started to seek care again. Staff from one facility
discussed canceling a majority of appointments in March 2020, then
having three times the amount of referrals to schedule a few months later
that included both new referrals as well as the older referrals with
canceled appointments that had to be rescheduled.
Staff from all six facilities discussed staffing challenges that resulted from
COVID-19. Examples of these included challenges associated with VA
adding additional steps to the referral process (such as continually
following up on referrals to check if the veteran or community provider
was ready to schedule an appointment), and challenges created when
community care staff are reassigned to work in different parts of the
facility. For example, staff from one facility stated that when the pandemic
began, some nurses in the community care office were reassigned to
assist with inpatient needs at the facility, which left the community care
office with less staff available to handle the community care referral
workload.
In addition, staff from all six facilities discussed a staffing challenge that
we have previously reported. Specifically, staff stated that they believed
their facility community care offices were understaffed, with some noting
specific vacancies in scheduler and clinical positions. Understaffed
community care offices may affect a facility’s ability to handle veteran’s
community care referrals in a timely manner. We previously reported on
VCCP referral workload and facility community care staffing concerns in
September 2020. Specifically, in that report we noted that while VA
developed a staffing tool to help facilities determine the number of staff
they needed to manage community care, most facilities in CCN Region 1,
as of February 2020, did not have the number of staff recommended by
the tool and were not meeting timeliness metrics for appointment
scheduling. 74 We recommended that VA direct VA medical facility
leadership to assess their community care staffing and resource needs,
74See GAO-20-643. There are 40 VA medical centers in CCN Region 1. We did not
review staffing in the other CCN regions in this report.
Page 30 GAO-21-476 Access to VA Community Care
and develop a plan to address any identified risks to their ability to
schedule appointments in a timely manner. VA agreed with the
recommendation, but as of June 2021, has not implemented it.
VA officials acknowledged facility staffs’ challenges with increasing VCCP
referral workloads and understaffed facility community care offices. While
officials stated that the initial drop in referrals in March and April 2020
allowed some facilities to work on referral backlogs from before the
pandemic, they also noted that facility staff may require more time to
schedule referrals during the pandemic. For example, officials stated that
it may take facility staff longer to review and schedule older, active
referrals with canceled appointments from earlier in the pandemic as that
process can be time consuming.
In addition, VA officials stated that they updated the staffing tool to reflect
current referral volume and scheduling tasks, and recently requested
facilities update data in the staffing tool in March 2021. Officials found that
a deficit of community care staff continues to exist for both administrative
and clinical positions at VA medical facilities, and the department is now
requiring facilities to update the staffing tool every 90 days to monitor
progress toward addressing staffing deficits. VA officials stated the
department is also using the optional task in the CCN contracts to have
both third-party administrators provide scheduling assistance to select VA
medical facilities. 75
The COVID-19 pandemic hit the United States less than 1 year after VA
implemented the VCCP and began its phased implementation of the
program’s new community provider networks. While the pandemic has
presented unique challenges, VA medical facility staff continued to face
several longstanding appointment scheduling problems that predated
COVID-19, but were highlighted or even worsened by the pandemic. We
made recommendations to VA to address concerns about community
care wait times and staffing in 2018 and 2020, and recommended in 2020
that Congress consider requiring VA to take action regarding wait times.
However, the recommendations we made to VA remain unimplemented.
75According to VA officials, at the time of the CCN contract awards, the agency anticipated
VCCP appointment scheduling responsibilities would be completed by VA medical facility
staff. However, officials said that COVID-19 escalated the need to use the two CCN third-
party administrators for scheduling assistance. As of June 2021, 42 VA medical facilities
are using third-party administrator support for VCCP appointment scheduling, according to
VA officials. In April 2021, VA officials stated that the use of the third-party administrators
for scheduling assistance has helped increase the number of VCCP referrals that have
been scheduled and completed.
Page 31 GAO-21-476 Access to VA Community Care
VA’s ability to effectively administer the VCCP is vital to ensuring
veterans receive timely access to health care through community
providers. While some scheduling challenges that are specific to COVID-
19 may subside when the pandemic is over, others will continue until VA
takes action. Therefore, GAO reiterates the importance of its past
recommendations related to the VCCP and urges VA to take swift action
on them.
We provided a draft of this product to VA for comment. In its comments,
Agency Comments reproduced in appendix III, VA noted actions it took during the COVID-19
pandemic regarding veterans’ access to care through VA’s community
provider networks, which were highlighted in this report. VA also provided
technical comments, which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Veterans Affairs,
appropriate congressional committees, and other interested parties. This
report is also available at no charge on the GAO Web site at
http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or silass@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs are on the last page of this
report. GAO staff who made major contributions to this report are listed in
appendix IV.
Sharon M. Silas
Director, Health Care
Page 32 GAO-21-476 Access to VA Community Care
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chair
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chairwoman
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chair
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
Page 33 GAO-21-476 Access to VA Community Care
The Honorable Bennie G. Thompson
Chair
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Mark Takano
Chairman
Committee on Veterans’ Affairs
House of Representatives
The Honorable Richard Neal
Chair
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Julia Brownley
Chairwoman
Subcommittee on Health
Committee on Veterans’ Affairs
House of Representatives
Page 34 GAO-21-476 Access to VA Community Care
Appendix I: Department of Veterans Affairs
Appendix I: Department of Veterans Affairs
Community Care Networks Regional Map and
Community Care Networks Regional Map
Implementation Time Frames
and Implementation Time Frames
The Department of Veterans Affairs (VA) purchases community care
under its Veterans Community Care Program (VCCP) through regional
contracts called Community Care Networks (CCN). VA has divided the
United States and territories into six regions. VA awarded the contracts
for CCN Regions 1 through 3 to Optum Public Sector Solutions (Optum)
in December 2018, and the contracts for CCN Regions 4 and 5 were
awarded to TriWest Healthcare Alliance (TriWest) in August 2019 and
October 2020, respectively. As of June 2021, VA has not awarded a
contract for CCN Region 6 and is using one of VA’s previous community
provider networks to provide VCCP care in the interim. (See fig. 5.)
Figure 5: Map of Community Care Networks and Awarded Third-Party Administrators for the Veterans Community Care
Program, as of June 2021
Note: The awarded third-party administrators include Optum Public Sector Solutions (Optum) and
TriWest Healthcare Alliance (TriWest).
Page 35 GAO-21-476 Access to VA Community Care
Appendix I: Department of Veterans Affairs
Community Care Networks Regional Map and
Implementation Time Frames
The two third-party administrators are responsible for recruiting and
building networks of licensed health care community providers and paying
community provider claims. VA implemented the CCN contracts region-
by-region in a phased approach by VA medical facility, beginning with VA
medical facilities in CCN Region 1. Specifically:
• CCN Region 1 implementation began in July 2019 and was completed
in December 2019;
• CCN Region 2 implementation began in October 2019 and was
completed in March 2020;
• CCN Region 3 implementation began in January 2020 and was
completed in June 2020;
• CCN Region 4 implementation began in June 2020 and was
completed in August 2020; and
• CCN Region 5 implementation began in April 2021 and is scheduled
to be completed in June 2021.
Page 36 GAO-21-476 Access to VA Community Care
Appendix II: Veterans Community Care
Appendix II: Veterans Community Care
Program Referral Volume
Program Referral Volume
The Veterans Community Care Program (VCCP) allows veterans to
receive care from community providers when they face certain challenges
accessing care at Department of Veterans Affairs (VA) medical facilities,
such as when VA cannot furnish care within its designated access
standards, or a VA provider deems it is in the veteran’s best medical
interest. VA purchases community care through regional contracts called
Community Care Networks (CCN). See Appendix I for more information
on the CCN regions.
According to our analysis of VA-provided data, the number of new VCCP
referrals decreased by nearly half (48 percent) between January 2020
and April 2020 across all CCN regions in light of the COVID-19 pandemic.
However, VCCP referral volume has been increasing since May 2020,
and returned to pre-pandemic levels by September 2020. (See fig. 6)
Page 37 GAO-21-476 Access to VA Community Care
Appendix II: Veterans Community Care
Program Referral Volume
Figure 6. New Veterans Community Care Program (VCCP) Referrals per Month, June 2019 to February 2021
Notes: Veterans Community Care Program (VCCP) referral data for Community Care Network (CCN)
Regions 4, 5, and 6 are reported together. Region 5 (Alaska) has too few referrals (average of 6,955
Page 38 GAO-21-476 Access to VA Community Care
Appendix II: Veterans Community Care
Program Referral Volume
per month) compared to other CCN Regions to display separately on this graph. VA reports Region 6
(Pacific Islands) referral data with Region 4.
Page 39 GAO-21-476 Access to VA Community Care
Appendix III: Comments from the
Appendix III: Comments from the Department
of Veterans Affairs
Department of Veterans Affairs
Page 40 GAO-21-476 Access to VA Community Care
Appendix III: Comments from the Department
of Veterans Affairs
Page 41 GAO-21-476 Access to VA Community Care
Appendix III: Comments from the Department
of Veterans Affairs
Page 42 GAO-21-476 Access to VA Community Care
Appendix IV: GAO Contact and Staff
Appendix IV: GAO Contact and Staff
Acknowledgments
Acknowledgments
Sharon M. Silas, (202) 512-7114 or silass@gao.gov
GAO Contact
In addition to the contact named above, Marcia A. Mann (Assistant
Staff Director), Erika Huber (Analyst-in-Charge), Keith Haddock, and Kate
Acknowledgments Tussey made key contributions to this report. Also contributing were Sam
Amrhein, Vikki Porter, Jennifer Rudisill, and Jeffrey Tamburello.
Page 43 GAO-21-476 Access to VA Community Care
GAO Related Products
GAO Related Products
Veterans Community Care Program: Immediate Actions Needed to
Ensure Health Providers Associated with Poor Quality Care Are
Excluded. GAO-21-71. Washington, D.C.: February 1, 2021.
Veterans Community Care Program: Improvements Needed to Help
Ensure Timely Access to Care. GAO-20-721T. Washington, D.C.:
September 30, 2020.
Veterans Community Care Program: Improvements Needed to Help
Ensure Timely Access to Care. GAO-20-643. Washington, D.C.:
September 28, 2020.
Veterans Health Care: Opportunities Remain to Improve Appointment
Scheduling within VA and through Community Care. GAO-19-687T.
Washington, D.C.: July 24, 2019.
Veterans Health Care: VA Needs to Address Challenges as It Implements
the Veterans Community Care Program. GAO-19-507T. Washington,
D.C.: April 10, 2019.
Veterans Choice Program: Further Improvements Needed to Help Ensure
Timely Payments to Community Providers. GAO-18-671. Washington,
D.C.: September 28, 2018.
Veterans Choice Program: Improvements Needed to Address Access-
Related Challenges as VA Plans Consolidation of Its Community Care
Programs. GAO-18-281. Washington, D.C.: June 4, 2018.
VA Health Care: Management and Oversight of Fee Basis Care Need
Improvement. GAO-13-441. Washington, D.C.: May 31, 2013.
(104473)
Page 44 GAO-21-476 Access to VA Community Care
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