But recruiting, retaining doctors is a serious problem
For many years, U.S. military veterans--an estimated 50,000 of them--scattered throughout the Pacific in places like Guam, Saipan and American Samoa, have loudly complained of second rate medical treatment they've received from the U.S. Veterans Administration by comparison with their U.S. mainland counterparts.
But the complaints have been getting back to the U.S. Congress which directed the General Accounting Office to take a fresh look at the situation. The GAO and the VA's Office of Inspector General started out by conceding that "The remote nature of the Pacific Islands creates some unique challenges for [the Veterans Administration], which may affect its ability to provide [vets] with timely access to primary, mental health, and specialty care."
The GAO/IG team traveled around the far-flung region, reviewing medical records and meeting with local clinic staffs to try to get a handle on the problems and come up with solutions.
According to the report, "most veterans received primary and mental health care from the Department of Veterans Affairs Pacific Islands Health Care System within timeliness goals set by the VHA," though many faced delays in program enrollment, scheduling and receiving complete mental health evaluations.
GAO/IG said, "These delays were similar to some GAO had identified in previous work pertaining to veterans' access to care nationwide."
Recommendations in the report include urging local clinics to take a closer look at processes for referring patients and more closely follow existing guidelines for this. The secretary of the VA is urged to ensure that referral information is entered into electronic records systems.
But more important and probably more difficult is to improve how the VA goes about recruiting and retaining physicians as well as nurses, psychologists, and social workers and that's a problem throughout the system.
"Having an adequate physician workforce is key to ensuring veterans’ timely access to health care. Overall, there were at least 17 physician vacancies out of approximately 100 positions across [the VA Pacific Health Care system] as of October 2017, as well as several more vacancies for other types of health care providers, some of which have been unfilled for some time," the report says.
"For example, Guam clinic staff told us that at one point between October 2016 and March 2017, the period of our medical record review, the clinic had 1.8 primary care physician full-time equivalents even though it was authorized for 4."
The recruitment problems don't appear likely to go away even with policy changes, in the face of geographic realities and professional shortages that apply across the region as well as other circumstances that make living and working in the region less attractive.
The GAO makes four recommendations to the Department of Veterans Affairs for executive action:
The Secretary of VA should ensure that VAPIHCS review its referral process for referrals to DOD providers, including referral cancellation, to determine why VHA policy is not being adhered to and make changes as needed.
The Secretary of VA should ensure that VAPIHCS clarify guidance to clearly define and document roles and responsibilities for VAPIHCS staff involved in the referral process with Naval Hospital Guam (NHG).
The Secretary of VA should ensure that VAPIHCS improves the monitoring of referrals and communication with NHG to ensure the timely management of referrals to NHG, including verifying the availability of services for veterans; ensuring referrals are entered into NHG’s electronic medical record system; and obtaining information about the status of scheduling appointments for veterans.
The Secretary of VA should ensure that VAPIHCS evaluates the effectiveness of strategies it currently uses to promote physician recruitment and retention, including how the strategies could be improved. The plan should also include an assessment of whether additional strategies currently offered by VHA would be beneficial.
"Travel options for VA staff and their families are limited. Finding physicians that are willing to relocate to such remote locations is difficult, according to officials. In prior work, we found that other VA clinics experienced challenges recruiting physicians who were reluctant to practice in rural or geographically remote areas.
This challenge is likely more pronounced for VA Pacific Islands Health Care System, given the location of its clinics. Both American Samoa and Guam are thousands of miles from the mainland United States and travel to and from these islands requires significant time and money. For example, American Samoa only has two direct commercial flights a week (on Mondays and Fridays) and Guam has only a daily direct commercial flight to Honolulu. While the Hawaiian Islands are more accessible to the mainland, they are still geographically isolated relative to the rest of the United States, and face some of the same travel challenges as American Samoa and Guam."
Guam Sen. Frank Aguon, a veteran, commented on the report:
“We, veterans here on Guam, understand that the current staff at Guam CBOC are not to blame for the inconsistencies found in the recent GAO report. We know that the Guam CBOC has more patients than medical professionals and their support staff are overworked. We know that the VA and the VAVHA leadership could do more, but chooses to do nothing. What we need now is for the Congresswoman to be firm with the VA and the VAVHA leadership; and press the issue of adequate, accessible, and timely care for all veterans on Guam and in the Pacific Islands,” Aguon said.
“GAO identified weaknesses in VAPIHCS’ management of its referral process for sending veterans for specialty care services at one of the two military treatment facilities. GAO found VAPIHCS did not always manage referrals to the military treatment facility in a timely way and there was inconsistent guidance describing the roles and responsibilities of the VAPIHCS staff involved in the process. These weaknesses may have contributed to the amount of time it took for veterans to receive specialty care services.”
“I will be respectfully requesting a response from Congresswoman Bordallo on how she will be moving forward, and what specific steps she will take to hold the VA Secretary and the Veterans Health Administration (VHA) accountable to the issues addressed in the report,” Aguon said.
In August of 2015, Resolution No. 111-33 (COR), introduced by Senator Aguon, Senator Tom Ada, and Senator Tommy Morrison, was adopted by the members of the 33rd Guam Legislature. Resolution No. 111-33 (COR) requested for the United States Secretary of Veterans Affairs, to conduct a system-wide audit of the scheduling and access management practices at the Guam Community Based Outpatient Clinic (CBOC); and if necessary, provide recommendations to improve services to Guam's Veterans.