A year after Americans recoiled at new revelations that sick veterans were getting sicker while languishing on waiting lists — and months after the Department of Veterans Affairs instituted major reforms costing billions of dollars — government data shows that the number of patients facing long waits at VA facilities has not dropped at all.
No one expected that the VA mess could be fixed overnight. But The Associated Press has found that since the summer, the number of vets waiting more than 30 or 60 days for non-emergency care has largely stayed flat. The number of medical appointments that take longer than 90 days to complete has nearly doubled.
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Nearly 894,000 appointments completed at VA medical facilities from Aug. 1 to Feb. 28 failed to meet the health system's timeliness goal, which calls for patients to be seen within 30 days.
That means roughly one in 36 patient visits to a caregiver involved a delay of at least a month. Nearly 232,000 of those appointments involved a delay of longer than 60 days — a figure that doesn't include cancellations, patient no-shows, or instances where veterans gave up and sought care elsewhere.
A closer look reveals deep geographic disparities.
Many delay-prone facilities are clustered within a few hours' drive of each other in a handful of Southern states, often in areas with a strong military presence, a partly rural population and patient growth that has outpaced the VA's sluggish planning process.
Of the 75 clinics and hospitals with the highest percentage of patients waiting more than 30 days for care, 12 are in Tennessee or Kentucky, 11 are in eastern North Carolina and the Hampton Roads area of Virginia, 11 more are in Georgia and southern Alabama, and six are in north Florida.
Seven more were clustered in the region between Albuquerque, New Mexico, and Colorado Springs, Colorado.
Those 47 clinics and hospitals represent just a fraction of the more than 1,000 VA facilities nationwide, but they were responsible for more than one in five of the appointments that took longer than 60 days to complete, even though they accounted for less than 6 percent of patient visits.
That has meant big headaches for veterans like Rosie Noel, a retired Marine gunnery sergeant who was awarded the Purple Heart in Iraq after rocket shrapnel slashed open her cheek and broke her jaw.
Noel, 47, said it took 10 months for the VA to successfully schedule her for a follow-up exam and biopsy after an abnormal cervical cancer screening test in June 2013.
First, she said, her physician failed to mention she needed the exam at all. Then, her first scheduled appointment in February 2014 was postponed due to another medical provider's "family emergency." She said her make up appointment at the VA hospital in Fayetteville, one of the most backed-up facilities in the country, was abruptly canceled when she was nearly two hours into the drive from her home in Sneads Ferry on the coast.
Noel said she was so enraged, she warned the caller that she had post-traumatic stress disorder, she wasn't going to turn around — and they better have security meet her in the lobby.
"I served my country. I'm combat wounded. And to be treated like I'm nothing is unconscionable," she said.
The AP examined wait times at 940 individual VA facilities from Sept. 1 through Feb 28 to gauge any changes since a scandal over delays and attempts to cover them up led to the resignation of VA Secretary Eric Shinseki in May and prompted lawmakers to pass the Veterans Access, Choice and Accountability Act in August. The analysis included all VA hospitals and outpatient clinics for which consistent wait time data was available. It excluded residential treatment centers, homeless dormitories and disability evaluation centers. Data for individual facilities were not available for August.
It is difficult to quantify exactly how things have changed because the VA introduced a new method for measuring wait times at the end of the summer. VA officials say the new methodology is more accurate, but its adoption also meant that about half of all patient appointments previously considered delayed are now being classified as meeting VA timeliness standards. That means published wait times now can't be directly compared with data the VA released last spring.
The trend, however, is clear: Under the VA's old method for calculating delays, the percentage of appointments that took longer than 30 days to complete had been steadily ticking up, from 4.2 percent in May to nearly 5 percent in September. Under the new method — the one that counts half as many appointments as delayed — the percentage went from 2.4 percent in August to 2.9 percent in February.
The number of appointments delayed by more than 90 days abruptly jumped to nearly 13,000 in January and more than 10,000 in February, compared to an average of around 5,900 the previous five months. That's not a change that can simply be blamed on bad winter weather; many of the places reporting the largest gains are warm year-round.
VA officials say they are aware of the trouble spots in the system. They cite numerous efforts to ramp up capacity by building new health centers and hiring more staff; between April and December, the system added a net 8,000 employees, including 800 physicians and nearly 2,000 nurses.
And they say that in at least one statistical category, the VA has improved: The number of appointments handled by VA facilities between May and February was up about 4.5 percent compared to the same period a year earlier.
But they also readily acknowledge that in some parts of the country, the VA is perpetually a step behind rising demand.
"I think what we are seeing is that as we improve access, more veterans are coming," Deputy Secretary of Veterans Affairs Sloan Gibson told the AP.
He also acknowledged that the VA has historically been "not very adroit as a bureaucracy" in responding to those changes. It takes too long to plan and build new clinics when they are needed, he said, and the VA isn't flexible in its ability to reallocate resources to places that need them most.
"We are doing a whole series of things — the right things, I believe — to deal with the immediate issue," Gibson said. "But we need an intermediate term plan that moves us ahead a quantum leap, so that we don't continue over the next three or four years just trying to stay up. We've got to get ahead of demand."
He also asked for patience. President Barack Obama signed legislation in August giving the VA an additional $16.3 billion to hire doctors, open more clinics and build the new Choice program that allows vets facing long delays or long drives to get care from a private-sector doctor.
It will take time to get some of those initiatives expanded to the point where they "move the needle," Gibson said.
Between Nov. 5 and March 17, according to VA officials, only about 46,000 patients had made appointments for private-sector care through Choice — a drop in the bucket for a system that averages about 4.7 million appointments per month.
In many parts of the country, the VA can boast of being able to deliver care that is just as fast, or even faster, than patients would get in the private sector. Relatively few VA facilities in the Northeast, Midwest and Pacific Coast states reported having significant numbers of patients waiting extended periods for care.
Of the 940 hospitals and outpatient centers included in the AP analysis, 376 met the VA's timeliness standard better than 99 percent of the time. A little less than half of all VA hospitals and clinics reported averaging fewer than two appointments per month that involved a wait of more than 60 days.
The difference between the haves and have-nots can be stark.
The Minneapolis VA, one of the system's busiest medical centers, completed 276,094 medical appointments between Sept. 1 and Feb. 28. Only 424 of them involved a wait of more than 60 days.
At the VA's outpatient clinic in Jacksonville, Florida, a facility handling a third of the volume, 7,117 appointments involved a wait of more than 60 days.
That means there were more vets experiencing extended delays at that one clinic than in the entire states of New York, New Jersey and Connecticut combined.
Equally surprising: The Jacksonville clinic is practically brand new. It opened in 2013 with the express intent of improving access to care in a fast-growing city with a lot of military retirees and a close relationship with three U.S. Navy bases: Naval Air Station Jacksonville, Naval Station Mayport and the Kings Bay Naval Base.
But like other VA facilities built recently in spots now struggling with long waits, the clinic took so long to plan and build — 12 years — that it was too small the day it opened, despite late design changes that added significantly more space.
"Even our best demographic models didn't anticipate the rate at which the growth would occur," said Nick Ross, the assistant director for outpatient clinics at the VA's North Florida/South Georgia Veterans Health System.
In recent months, the clinic has been enrolling another 25 new patients per day — a growth rate that would require the VA to hire another doctor, nurse and medical support assistant every 10 weeks to keep up with demand, said Thomas Wisnieski, the health system's director.
Officials are hoping to lease 20,000 square feet of additional clinic space while they begin the planning process for yet another new building.
Clinic construction is also underway in an attempt to ease chronic delays in care on the Florida panhandle. A new outpatient VA clinic is scheduled to open in Tallahassee in 2016, and a groundbreaking ceremony was held in August for a new clinic in Panama City.
A SLOW PACE OF CHANGE
The Fayetteville VA hopes to celebrate its 75th anniversary this fall with the opening of a huge new outpatient health care center that could ease the types of chronic delays that caused Rosie Noel so much anxiety. (After her canceled exam, the VA paid for Noel to get care at a private-sector clinic; she doesn't have cervical cancer.)
With 250,000 square feet of usable space, the center will be almost as large as the main hospital building itself. The new campus will have 1,800 parking spots, a women's clinic and scores of new treatment rooms. It is sorely needed for a region that is home to two of America's largest military bases, the Army's Fort Bragg and the Marines' Camp Lejeune, and one of the highest concentrations of vets in the country. In two core counties, one in five adults is a veteran.
Yet the new building is also emblematic of the slow pace of change at the VA.
Planning for the facility began in 2008, and Congress approved funding the next year. Construction hadn't even begun when the first target completion date came and went in June 2012. The VA's Office of Inspector General said in a 2013 report that the VA's management of the "timeliness and costs" of seven planned health care centers, including the one in Fayetteville, had "not been effective."
The hospital's director since 2010, Elizabeth Goolsby, cited the VA's failure to expand quickly as a primary reason for why eastern North Carolina now has some of the longest waits for care in the country.
"The contracting and building time in the Department of Veterans Affairs is a lengthy process," she said.
During her tenure in Fayetteville, Goolsby has opened new outpatient clinics in Wilmington, Goldsboro, Pembroke and Hamlet. All now rank among the VA locations with the highest percentage of appointments that fail to meet timeliness standards.
At the VA's clinic in Jacksonville — a small medical office built in a shopping plaza near Camp Lejeune's main gate in 2008 — nearly one in nine appointments completed between Sept. 1 and Feb. 28 involved a wait of longer than 60 days.
"It's not big enough to accommodate the number of veterans we are seeing or the number of providers we need," Goolsby acknowledged.
One solution, she said, has been to keep building.
A new 15,000-square-foot clinic is under construction to serve the area around Camp Lejeune. The VA also is trying to develop a clinic in Sanford, north of Fort Bragg. And there have been stopgap measures, like the construction of modular buildings at the Fayetteville hospital this winter to host mental health clinics, and an emergency lease for a temporary medical office that allowed it to bolster staff in Jacksonville.
Some vets whose doctors were moved over to the new Jacksonville space said things improved immediately, even if that has not yet been reflected in the statistics.
"It used to take me six months to a year to get a doctor's appointment," Jim Davis, a retired Marine who fought in the first Gulf War and now has Lou Gehrig's Disease. Since he transferred to the temporary clinic, he said, "I've called, and within three or four days I can get in to see the doctor."
He called the change a relief, because he preferred to stay within the VA system for care if he could.
"There's not a pharmacist at Wal-Mart calling me at home and asking me if the latest change in medicine made me feel sick. But that is happening in the VA," Davis said. "They are so much more respectful, because they know you served."
RURAL RECRUITING CHALLENGES
After years of planning, a large, new outpatient center also is scheduled to open this fall to expand care offered at the VA medical center in Montgomery, Alabama.
That expansion also is long overdue. Among the VA's full-service medical centers, the Montgomery VA had the highest percentage of appointments that took longer than 30 days to complete. More than one in 11 appointments completed between September and February failed to meet timeliness standards. A sister hospital, a short drive to the east in Tuskegee, was No. 2.
There's no guarantee, though, that a new building will help the Central Alabama Veterans Health Care System solve one of its other longstanding problems — a difficulty recruiting enough doctors and specialists needed to handle demand.
Both hospitals are surrounded by largely poor, rural counties designated by the government as having severe physician shortages.
"They are on the frontier of some of the most medically underserved areas of the country," said Dr. William Curry, associate dean for primary care and rural health at University of Alabama School of Medicine.
That could mean that veterans who might otherwise get care in the private sector are more reliant on the VA. It also has historically meant big challenges recruiting physicians, who can make more money in metropolitan areas.
"Not a lot of medical students want to go work for the VA in a rural community medical clinic," said Dr. Kevin Dellsperger, chief medical officer at the Georgia Regents Medical Center and former chief of staff at the VA medical center in Iowa City, Iowa.
Dr. Srinivas Ginjupalli, acting chief of staff for the Central Alabama Veterans Health Care System, confirmed that recruiting is a challenge, but he said the VA has been boosting salaries since the summer in an attempt to be more competitive in attracting staff.
Goolsby cited similar rural recruiting problems in her enterprise, which serves a sprawling region of hog farms and tobacco fields. Other VA officials said difficulty attracting health care providers to remote or poor parts of the country was an issue throughout the system.
NO EASY FIX
A few places struggling the most with long waits did report improvements.
At the VA in Montgomery, Alabama, the percentage of appointments that take longer than 30 days to complete has fallen from 12.6 percent in September to 6.4 percent in February. That's still a bad number compared to other VA hospitals but, looking at performance only in February, it would be enough improvement to take the hospital from worst to third in terms of the percentage of delays.
The VA's most chronically delayed outpatient clinic throughout the summer and fall, located in Virginia Beach, Virginia, reported improvement, too. In September, 24 percent of its patient visits were delayed by at least 30 days. By February, that had fallen to 11 percent — still terrible, but much better.
The VA site that had the most trouble meeting the VA's timeliness standard during the whole six-month period reviewed by the AP was a small clinic near Fort Campbell in Hopkinsville, Kentucky. One in five appointments took longer than 30 days to complete, and the rate has gotten steadily worse over time.
The centerpiece of the legislation signed over the summer was a plan to expand the number of veterans who are approved to get care outside of VA facilities. Yet the Choice program has barely gotten off the ground.
ID cards for the program were mailed starting in November, but many vets still don't understand how it works. It theoretically is open to patients who can't been seen within 30 days, or who have to drive longer distances for care, but enrollees still have to get VA approval to see a private-sector doctor and only some physicians participate in the payment system.
"It's not working the way it needs to work," said Gibson, the deputy VA secretary, though he added that he was enthusiastic about its potential. He said some consultants advising the VA said it might take 18 months to build the program.
In a meeting with congressional aides and state veterans service officials in March, Goolsby gave some figures to illustrate how the program was working in southeastern North Carolina: Of the 640 patients offered an opportunity for outside care through mid-March, only four were ultimately seen a private-sector doctor.
"We're finding that a lot don't want an outside appointment," she said.
Reasons vary, she said, but one factor is that switching to a new doctor can be disruptive for someone with an ongoing medical issue.
In March, officials loosened the eligibility rules for the program slightly so it would cover more vets who have to drive longer distances for care.
The VA also has been trying to tackle long wait times in other ways.
The Central Alabama Veterans Health Care System, Ginjupalli said, has been promoting the use of "telehealth" systems that allow patients in rural or backed-up areas to see doctors elsewhere via video conferencing.
It also has reached an agreement with the Defense Department to help reduce long delays for care at its clinic in Columbus, Georgia, by moving some staff to a 19,000-square-foot building at the military's medical center at Fort Benning.
Dr. Daniel Dahl, psychiatrist and associate chief of staff for mental health at the Central Alabama VA, said the new space will triple the VA's capacity for mental health care in the area. In February, the average delay for a mental health appointment at the Columbus clinic was 25 days — seven times the national average.
Obama's secretary of Veterans Affairs, Robert McDonald, has cautioned that it will take time for reforms to make a difference.
He also warned in recent testimony to Congress that the system may still be decades away from seeing peak usage by the generation of servicemen and servicewomen who fought in Iraq and Afghanistan.
Total enrollees in the VA system have ballooned from 6.8 million in 2002 to 8.9 million in 2013. During that same period, outpatient visits have soared from 46.5 million to 86.4 million annually; patient spending has grown from $19.9 billion to $44.8 billion; the number of patients served annually has grown from 4.5 million to 6 million.
McDonald told Congress the number of mental health outpatient visits alone is up 72 percent from 2005.
"Today, we serve a population that is older, with more chronic conditions, and less able to afford private sector care," McDonald said.
That could mean that without further change, waits will only grow.
The AP National Investigative Team can be reached at firstname.lastname@example.org