The VA healthcare system is inefficient due to policies that resulted in veterans dying while waiting for appointments. An investigation found VA employees were falsifying appointment times. The VA's goal of seeing patients within 30 days is unacceptable compared to Medicare patients seeing doctors within 3 days. Two alternative policies are proposed to increase efficiency: 1) A hybrid system using Medicare for non-service related care and the VA for service-related care. 2) Removing priority groups 7 and 8 from VA healthcare to reduce wait times by 50% for service-disabled veterans in groups 1-6.

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Fratricide:
Waiting, Waiting, and Still Waiting
November 30, 2015
Joe Washam
Disclaimer: This paper was written with other students. To respect their privacy, I
removed their names. The objective of the paper was to show our instructor that
we understood concepts learned in class.
Written for the University of North Texas
PADM 4450 - Public Policy Analysis
Policy making, impact of public policy and factors that place specific problems on
the public agenda.

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In 2014, the Department of Veterans Affairs (VA) had identified forty patients that had
died while waiting for appointments within a one year time frame (1). The Veterans Health
Administration (VHA) had a fourteen day scheduling goal that included incentives to employees
for achieving this goal. If in fact employees were meeting the scheduling goals then the question
would be, why were people dying while waiting for appointments? After an investigation by the
VA Office of Inspector General (VAOIG), it was discovered that employees were falsifying
appointment times while pushing back originally scheduled appointments. This caused the VHA
to create a new wait time goal for patients to be seen within thirty days of their requested
appointment (2). The VA healthcare system is inefficient based on these events and policies in
place.
Clearly there is a problem, and we believe these issues are related to the commitment and
coordination aspects of the policy. We are basing our criteria on the fact that VA patients are not
being seen in a timely manner, compared to Medicare patients. According to the VA website on
patient access data, the VA’s goal of completed appointments within thirty days or less is getting
worse than when the 2014 VAOIG report occurred (3). Half of the Medicare patients reported
seeing a doctor within three days, and only twelve percent said that it took longer than nineteen
days for an appointment (4).
Obviously, the VHA has not provided a policy that efficiently provides services to
patients in a timely manner. With that being said, should there be more government intervention
throughout the VHA, or should there be more public participation needed within the VHA? We
believe that both more government intervention and public participation is needed because the
current policy in place is inefficient. The United States Government Accountability Office has
identified the VHA as high risk within the federal government. “Coordination of care between

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VA and non-VA providers is critical. Without it, there is increased risk of unfavorable health
outcomes for veterans” (5).
There are eight priority groups within the VHA that determine access to health care.
“Veterans who seek medical care from the Department of Veterans Affairs (VA) are enrolled in
one of eight priority groups that are defined on the basis of income, disability status, and other
factors” (6). Groups one through six have a service connected disability. A service-connected
disability is determined by the VA to be “an injury or illness that was incurred or aggravated
during active military service” (7). Priority groups seven and eight are required to make
copayments for their healthcare services in the VHA. In the CBO report, the Health Care System
for Veterans: An Interim Report, priority groups seven and eight used the VHA less than all the
other priority groups for their healthcare (8). “In 2012, nearly 90 percent of enrollees in priority
groups 7 and 8 had other health care coverage, most notably Medicare and private health
insurance” (9). With veterans in groups seven and eight being eligible to receive VA healthcare,
Medicare, and private insurance, that allows these groups flexibility when choosing their
healthcare provider in the market. Veterans in groups one to six are more dependent on VA
healthcare, therefore the resources are limited to a point where demand exceeds supply. This is
due to lack of coordination and commitment.
In this case of measuring the efficiency of the current policy in place, we have come to
the conclusion that this policy is inefficient. We have come to this conclusion by using the Pareto
Criterion as a tool for measurement, which is the idea that someone gains at someone else’s
expense. Group seven and eight gain at the expense of groups one to six, because seven and eight
have more resources to access healthcare. We know this to be true because nearly ninety percent
of veterans in group seven and eight have more than one healthcare provider. In fact, group

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seven and eight represent 2.3 million, or twenty six percent of veterans already enrolled in the
VA healthcare system (9). The benefit of using the Pareto Criterion as a tool of measurement
allows us to analyze the coordination inefficiencies of this policy. The drawback of using the
Pareto Criterion as a tool of measurement is that we are not able to measure the level of
commitment from the VHA.
The first alternative solution that we found in order to increase the efficiency of the
commitment and coordination of the policy, was to create a hybrid health care delivery plan
(HHCDP). The HHCDP is measured using the social welfare theorem tool, in this package
groups one through six that have Medicare, will use that to find a private health provider for non-
service connected disability treatments. In the case that medical care is needed for a service
connected disability, then the VHA is responsible for providing medical service to veterans in
groups one through six. Groups seven and eight under the HHCDP, are responsible for finding
their own healthcare provider. Groups seven and eight are excluded from the VHA services
because they have no service connected disabilities. The second alternative that we found
increases efficiency, would be the removal of group seven and eight; while allowing the VHA to
provide all services to veterans in groups one through six. The measurement for this alternative is
the cost benefit analysis tool. One piece of evidence that shows efficiency will increase, with the
adoption of new alternative policies is in the 2001 National Survey of Veterans (10) According
to this document, over thirty nine percent of veterans use Medicare. According to the CBO
reports Comparing Cost, “about half of veterans enrolled in VHA are also enrolled in Medicare”
(11). Knowing that the other half of the veteran patients in VHA have no other source of
healthcare, the VHA acts as their only means for healthcare. Their healthcare appointment wait
times could be reduced by fifty percent, by implementing the HHCDP. This is further validates

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that the HHCDP will increase efficiency in coordination and commitment, in order for veterans
to be seen in a timely manner. Previous evidence shows that group seven and eight represent
twenty six percent of the veterans enrolled in the VHA. The value of twenty six percent
represents 2.3 million veterans assigned to group seven and eight out of the total 8.7 million
VHA enrolled veterans (12).
After identifying the initial problem concerning lack of coordination and commitment we
identified that the current policy was inefficient, because of veterans in group seven and eight
taking appointment slots which causes excessive wait times for patients. Compared to the wait
times of most Medicare patients being able to see a doctor within three days of requesting an
appointment, the VA’s goal of seeing patients by thirty days is unacceptable. Veterans with
service connected disabilities, have sacrificed their minds and bodies on behalf of our Nation,
and deserve the most efficient access to the best health care possible. The HHCDP will ensure
that wait times are reduced, while increasing quicker access to healthcare for service disabled
veterans.

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Works Cited
1. "Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the
Phoenix VA Health Care System." VA.gov. 26 Aug. 2014. Web. 30 Nov. 2015.
http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf
2. "Report to Congress on the Veterans Choice Program Authorized by Section 101 of the
Veterans Access, Choice, and Accountability Act of 2014 (Pub. L. 113-146)." VA.gov. 3
Oct. 2014. Web. 30 Nov. 2015.
http://www.va.gov/HEALTH/docs/VA_Report_Section101-PL_113-146-Final.pdf
3. "Veterans Health Administration." Patient Access Data -. Web. 1 Dec. 2015.
https://www.va.gov/health/access-audit.asp
4. "Medicare Patients' Access to Physicians: A Synthesis of The Evidence." Medicare
Patients' Access to Physicians: A Synthesis of the Evidence. Web. 1 Dec. 2015.
http://kff.org/medicare/issue-brief/medicare-patients-access-to-physicians-a-synthesis-of-
the-evidence/
5. "High Risk: Managing Risks and Improving VA Health Care." U.S. GAO -. Web. 1 Dec.
2015.
http://www.gao.gov/highrisk/managing_risks_improving_va_health_care/why_did_study
- t=0
6. "Health Benefits." Priority Groups -. Web. 1 Dec. 2015.
https://www.va.gov/healthbenefits/resources/priority_groups.asp
7. "Office of Public Affairs." Chapter 2 Service-connected Disabilities. Web. 1 Dec. 2015.
https://www.va.gov/opa/publications/benefits_book/benefits_chap02.asp
8. "The Health Care System for Veterans: An Interim Report." CBO.gov. 1 Dec. 2007. Web.
30 Nov. 2015.
http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/88xx/doc8892/12-21-
va_healthcare.pdf
9. "End Enrollment in VA Medical Care for Veterans in Priority Groups 7 and 8."
Congressional Budget Office. 20 Nov. 2013. Web. 1 Dec. 2015.
https://www.cbo.gov/budget-options/2013/44902
10. "2001 National Survey of Veterans." VA.gov. 1 Mar. 2003. Web. 30 Nov. 2015.
http://www.va.gov/VETDATA/docs/SurveysAndStudies/Table_315_319.pdf

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11. "Comparing the Costs of the Veterans’ Health Care System With Private-Sector
Costs." CBO.gov. 1 Dec. 2014. Web. 30 Nov. 2015.
https://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/49763-
VA_Healthcare_Costs.pdf
12. "The Number of Veterans That Use VA Health Care Services: A Fact Sheet."
www.fas.org. Web. 30 Nov. 2015.
https://fas.org/sgp/crs/misc/R43579.pdf