Eighteen months after a scandal broke over waiting periods for Veterans Affairs health care, the department is still struggling to manage patients' schedules, at least in the mental health care arena where some veterans have waited nine months for evaluations, a new government report says.

A review of 100 patient cases by the Government Accountability Office found that while 86 patients seeking an initial mental health evaluation generally were seen within an average four days of scheduling an appointment, they actually waited an average of 26 days from their first request for mental health treatment to get that appointment — and some waited up to 279 days.

GAO also found that at one medical center, schedulers were not using the VA's appointment system and were managing appointments manually — a practice that sidesteps oversight and, in the scandal that exploded last year, drew allegations of scheduling failures and use of "secret wait lists."

"The way in which the Department of Veterans Affairs calculates veteran mental health wait times may not always reflect the overall amount of time a veteran waits for care," Debra Draper, GAO's health care director, said.

Nicholas Karnaze, a former Marine intelligence officer, told the Senate Veterans' Affairs Committee on Wednesday he waited more than a year for care, and when he finally saw a VA psychiatrist, he was prescribed a medication for depression. When he reacted poorly to the prescription, however, he was not able to make a follow-up appointment for another two months.

He stopped taking the drug cold turkey — a decision physicians caution against because withdrawal can cause physical and mental symptoms, including suicidal thoughts.

"I truly believe when we get the right access to care in a timely manner, we are going to see a reduction in suicides and healthier happy families," Karnaze said.

The VA wait time scandal broke in the spring of 2014 after allegations surfaced that veterans died while waiting for care at the VA Phoenix Health Care System. The wait time issues and manipulated appointment scheduling subsequently were found to be a nationwide problem and resulted in the resignation or early retirement of several top officials, including VA Secretary Eric Shinseki.

Congress last fall passed a $15 billion bill to allow more veterans to seek care in the private sector through a program called VA Choice and authorized the VA to hire more doctors.

The GAO report said VA has conflicting policies on allowable wait times, which can cause confusion in assessing whether schedulers are meeting standards. The Veterans Health Administration, for example, sets the standard for mental health appointments at 14 days, while legislation requires VA to refer veterans to private care if they have to wait 30 days or more.

Draper said this has "created confusion among VA medical center officials about which policy they are expected to follow."

The GAO report also noted that some patients still wait as long as 57 days after their first comprehensive mental health appointment to begin treatment.

"I would love to report something differently. We sound like a broken record sometimes but these are the common themes. It's why VA is on the 'high risk' list," of government agencies that warrant extra attention because they are not meeting performance standards, Draper said.

The GAO report recommended that VA clarify its policies on wait times, issue guidance for calculating wait times and reiterate its policies on maintaining schedules, to include using the VA's official system.

Dr. Harold Kudler, chief consultant for mental health services at the Veterans Health Administration, said VA has taken action on the GAO recommendations and is "committed to provided timely access to care."

"GAO found that VA met mental health hiring goals at the national level but individual VAs continue to face hiring challenges and meeting increasing demands for care," Kudler said.

He said VA hired 5,300 mental health clinicians and administrative staff from 2012 to 2013 and increased mental health staffing by a fourth from 2010 to 2014.

VA also has hired more than 900 peer specialists — veterans who are trained to work with veterans seeking counseling and mental health services — and is on track to meet the 30-day requirement for accessing care across the services by March 2016.

He added that veterans in crisis have access to same-day care.

"Although excessive appointment delays do exist at specific locations, a [recent report] required by the Veterans Choice Act found there were no systemwide crises in access to VHA care," Kudler said.

Former Navy sailor Dean Maiers said without VA care, he likely would be dead.

Maiers said it took eight years to seek treatment after he left the military, lost his job and family, tried suicide twice and was homeless for three years.

Even then, he said, he did not find the help he needed until he was admitted to the Ererra Community Care Center administered by the VA Connecticut Healthcare System.

"I have a peer support specialist, my primary care physician, three psychologists. If I can't get one on the phone someone else will call me back," said Maiers, adding that such care should be available nationwide. "Our fellow veterans really need this type of help."

Connecticut Sen. Richard Blumenthal, the committee's ranking member, urged VA to respond swiftly to the GAO report.

"The GAO report documents failures and neglect that needs to be remedied, not in some distant future but literally right away," Blumenthal said.

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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