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VA official to clinics: Stop gaming the system

Jul. 12, 2010 - 01:38PM   |   Last Updated: Jul. 12, 2010 - 01:38PM  |  
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After years of complaints from veterans who say they aren't getting VA medical appointments within 30 days even if Veterans Affairs Department records show they are, a top VA official sent out a memo asking employees to quit "gaming" the system.

"It has come to my attention that, in order to improve scores on assorted access measures, certain facilities have adopted use of inappropriate scheduling practices sometimes referred to as ‘gaming strategies,' " wrote William Schoenhard, VA's deputy undersecretary for health for operations and management, in the April 26 memo.

The "gaming" came after VA required its employees to ensure patients were given initial appointments within 30 days of entering the VA system. Instead, several clinics came up with ways to make it look as if the veterans had canceled their appointments or hadn't asked for one until within 30 days of when the appointment was made.

"As we strive to improve access to our veterans, we must ensure in fact that improvement does not focus or rely on workarounds," Schoenhard wrote. "Workarounds may mask the symptoms of poor access and, although they may aid in meeting performance measures, they do not serve our veterans."

The memo, first reported by Larry Scott of, comes in the wake of exceptional gains in reducing appointment waiting times announced by VA officials.

"In April 2006, there were over 250,000 unique patients waiting more than 30 days for their desired appointment date for health-care services," then-VA Secretary James Peake told the House Veterans' Affairs Committee in early 2008.

"As of Jan. 1, 2008, we had reduced the waiting list to just over 69,000," Peake said. "Our budget request for 2009 provides the resources necessary … to virtually eliminate the waiting list by the end of the year."

Though Schoenhard's memo shows a high-ranking VA official taking clinic-level administrators to task, Paul Sullivan, executive director of Veterans for Common Sense, said this is exactly the reason why his organization sued VA in 2008: Veterans in VA care were attempting suicide at a rate of 1,000 a month, with 17 killing themselves often because they couldn't get access to care.

(Page 2 of 2)

Though the judge in that case stated VA may need a "complete overhaul," he ruled that VA did not fall within his jurisdiction.

Veterans for Common Sense appealed the case, and it is now pending before the Ninth Circuit Court of Appeals.

"There are two reasons VA facilities rushed to cook the books: They are overwhelmed and under-resourced," Sullivan said.

Schoenhard offers advice for VA employees to sniff out the gaming practices, but his memo does not outline any specific actions VA will take to address the problem.

Sullivan said staff training needs to be improved, more oversight is needed, and more accountability must be placed on anyone who tries to impede veterans' access to care.

"This is serious," he said.

Appointment ‘workarounds'

According to the memo, when a medical appointment was not available within VA's standard of 30 days:

Veterans were asked to call back some other month.

Appointment makers wrote the information on a piece of paper and waited to enter it into the computer system until within 30 days of an available appointment.

Appointments were noted in a log book, and then entered into the computer system when they were within 30 days.

Clinics would schedule a fake appointment, then say the patient canceled it, then reschedule it from the canceled date so it would meet the 30-day mandate.

Clinics would create appointments without telling veterans. "This creates a very high likelihood that the patient will no-show," the memo states.

Clinics would use auto-scheduling software that removed scheduling data, so VA officials could not see if appointments met the 30-day limit.

Clinics would schedule several patients from 8 a.m. to 12 p.m. and require them to wait for an open slot.

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