Taking advantage of a new program, Army veteran Mike Peacock decided to see a chiropractor outside the Department of Veterans Affairs medical system, where he gets his regular care, to deal with a back problem.

His VA physician initiated the referral last summer.

But the Kapolei resident’s experience with the nearly 3-year-old national program that allows vets to seek outside care left him wondering why the system still seems so uneven.

Peacock said he missed the first of a series of chiropractic appointments in September because no one told him about it. When he went to his VA physician a month later to follow up on his back problem, the complete set of recommendations from the chiropractor was not relayed to his doctor. Peacock had to retrieve the full report later and deliver it himself.

“It was frustrating, it was disheartening,” said Peacock, co-founder of the advocacy group Hawaii Vet 2 Vet. “The program is good, but it’s not efficient.”

Other vets have come to the same conclusion.

“Overall, it has helped a lot of veterans,” said Army veteran Ray Welch, commander of the Disabled American Veterans in Hawaii. “It’s more positive than negative. But (the problems) need to be fixed.”

Veterans Choice, which was created in 2014 to address a national controversy over long wait times for VA appointments, still is marred by a convoluted bureaucracy — so much so that the department’s new secretary said a top priority is to simplify the system.

The problems have been magnified in Hawaii, partly because Veterans Choice is open to all veterans eligible for VA care. On the mainland, only veterans who have to wait more than 30 days for an appointment or live more than 40 miles from a VA facility have the Choice option.

The wide availability has contributed to a more than 40 percent increase in outside appointments the past few years, according to data from the Honolulu-based VA Pacific Islands Health Care System, which cares for about 50,000 veterans throughout the Pacific. Most live in Hawaii.

A September report from the VA’s Office of Inspector General found that many of the administrative and access-to-care challenges found nationally afflict the Hawaii system and are compounded by a shortage of providers, the complexities of dealing with patients over a huge swath of the Pacific, and the diversity of the population served.

Employees told the report’s authors that the initial launch and subsequent changes to the Choice program in the islands were disjointed, confusing and not clearly communicated to veterans or staff.

The rise in outside care has come at a time when overall patient growth in the Pacific system has averaged about 6 percent annually the past few years.

The impact has meant delayed appointments and bureaucratic runarounds, according to veterans, some of whom derisively refer to the care program as “No Choice” or “Bad Choice.”

“You just keep getting put off and put off and put off,” said Edith Hall, an Air Force veteran from Hawaii island.

Unprepared for demand

Officials acknowledged that the system initially was not prepared to handle the dramatic surge in demand, though improvements have been made.

“The Choice program is pretty choppy,” VA executive David Stockwell told the Honolulu Star-Advertiser in an interview earlier this month. “It’s pretty confusing. So the ability for the VA to get it right, for the vendors in the community to get it right and for the veterans to get it right, (department officials) really need to simplify it.”

Despite the choppiness of the program, which partly reflects the choppiness of the U.S. health care system, the VA still provides high-quality care to veterans, according to Stockwell, who was acting director of the Hawaii system at the time he spoke to the newspaper.

Stockwell referred to a Rand Corp. study released in July 2016 that showed the VA system, according to Rand, “generally performs better than or similar to other health care systems on providing safe and effective care.”

Citing the VA’s focus on the holistic needs of veterans, Stockwell said, “Our attention to the whole patient is superior to the private sector.”

But as the VA has increasingly turned to outside providers in Hawaii, problems have persisted, according to interviews with about a dozen veterans.

One prime example has been getting documentation from outside consults to VA physicians on a timely basis.

Veterans say they have gone for follow-up appointments only to learn their VA doctor has yet to receive the documentation, often requiring the physician to spend time tracking down information while the patient waits. Sometimes, the veterans say, the information is not immediately available.

Backlog an ‘urgent concern’

The backlog in scanning and transmitting consult records became so serious last summer that it was described as an “urgent concern” in VA documents.

By October, nearly 60,000 pages were stuck in a queue waiting to be transmitted, including some that had been sitting for as long as nine months, according to VA records. “Providers are not receiving results of consults in a timely manner to render proper care,” one VA document said.

Although the medical industry nationally has had difficulties with transmitting patient information electronically, delays of up to nine months are unusual, according to Dr. Thomas Payne, medical director for information technology services at the University of Washington’s Department of Medicine.

Stockwell said the document backlog in Hawaii has not resulted in any delayed care or patient harm. For cases requiring immediate attention, results are promptly relayed verbally, and in other cases the VA physicians often know the results before the documentation arrives because they’ve spoken to the outside providers, he added.

“The idea that we’re delaying medical care while we’re waiting to get a report back from the community — although technically we have an open consult — that’s a little overstated,” Stockwell said. “It doesn’t really work that way.”

The VA has cut the backlog for roughly 9,000 consult appointments in half since October, and any documents sent to the department over the past six months have been put into the system immediately, according to Stockwell.

He acknowledged that a backlog still exists for documents that have been in the queue more than six months and probably as long as a year.

The problem arose because not all physicians are part of an electronic records exchange system in which results quickly can be accessed digitally. And even when the information is sent, it sometimes arrives on “a chicken-scratched note (sent from) a really old fax machine,” presenting legibility problems, Stockwell said.

Payment issues

To add to the challenges, some physicians aren’t accustomed to sending medical documentation to get paid, so the VA has to chase down those records, which can prolong the process.

The department eventually realized it had to restructure its staff to deal with the documentation issue, and “now the VA is judiciously working down that backlog,” Stockwell said.

Another problem involves the timely payment of outside providers.

Veterans in Hawaii can get outside care two ways. They can bypass the VA altogether and contact the Choice contractor, TriWest Healthcare Alliance, which arranges the appointments and pays the community providers. Or the veterans can be referred by their VA physician. A national VA office pays for that care.

Both systems have had challenges.

Stockwell said about half the bills coming to the VA are paid within 30 days. That 50 percent rate is an improvement from the Pacific system’s old rate of 30 percent, he said. But it still lags the VA national average of 70 percent.

Stockwell said the local number should improve as the national payment office revises its system.

In an email to the Star-Advertiser, TriWest’s Dr. Frank Maguire acknowledged that paying claims on a timely basis was complicated last year because of growing demand. But that was resolved and claims are now paid within 30 to 34 days, he said.

The payment issue and other problems have prompted some Hawaii doctors to stop seeing VA patients or to bill them directly, according to veterans.

Dr. Chris Flanders, executive director of the Hawaii Medical Association, said his organization launched a campaign in 2014 to encourage local providers to participate in Choice, but a “fair number” have since dropped out because of frustrations with the system.

“It just didn’t run real smoothly from the start,” Flanders said, adding that the system seems to have improved lately.

Getting timely appointments also has been an issue. Some veterans say they have waited months to see a doctor, including up to a year for audiologists.

Stockwell said veterans face the same wait times in the private sector as other patients. “We don’t get to move to the front of the line,” he added.

TriWest said the majority of the nearly 7,000 appointments it has made this year were within five days.

The problems with Choice have not helped the VA’s tarnished image in the islands.

Improving wait times

In 2014 the Hawaii system had the dubious distinction of having the longest average wait times in the country for new patients seeking primary care appointments. Back then, they waited an average of 145 days.

But through a variety of initiatives, including hiring new providers, extending clinic hours, boosting use of telemedicine and the launch of Choice, the department has cut the average to 10 days, said Stockwell, who lauded the dedication and pride of the VA workforce.

For primary care and mental health issues, veterans already enrolled in the system can get same-day care, he noted.

Still, Stockwell acknowledged that the choppiness of the VA and U.S. health care systems needs to be addressed.

“Could it be better? Absolutely,” he said. “Could it be more integrated and seamless? Absolutely. Could the queuing not be as long as it is? I think most staff would agree that there is still work to do to improve the veteran experience in health care.”