Key Issues > High Risk > Managing Risks and Improving VA Health Care
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Managing Risks and Improving VA Health Care

This information appears as published in the 2017 High Risk Report.

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Since designating Department of Veterans Affairs (VA) health care as a high-risk area in 2015, we continue to be concerned about VA’s ability to ensure its resources are being used cost-effectively and efficiently to improve veterans’ timely access to health care, and to ensure the quality and safety of that care. VA’s Veterans Health Administration (VHA) operates one of the largest health care delivery systems in the nation, with 168 medical centers and more than 1,000 outpatient facilities organized into regional networks. VA has faced a growing demand by veterans for its health care services—due, in part, to servicemembers returning from the United States’ military operations in Afghanistan and Iraq and the needs of an aging veteran population—and that trend is expected to continue. For example, the total number of veteran enrollees in VA’s health care system rose from 7.9 million to almost 9 million from fiscal year 2006 through fiscal year 2016. Over that same period, VHA’s total budgetary resources have increased substantially, from $37.8 billion in fiscal year 2006 to $91.2 billion in fiscal year 2016.

Although VA’s budget and the total number of medical appointments provided have substantially increased for at least a decade, there have been numerous reports in this same period of time—by us, VA’s Office of the Inspector General, and others—of VA facilities failing to provide timely health care. In some cases, the delays in care or VA’s failure to provide care at all reportedly have resulted in harm to veterans. In response to these serious and longstanding problems with VA health care, the Veterans Access, Choice, and Accountability Act of 2014 (Pub. L. No. 113-146, 128 Stat. 1754) was enacted, which provided temporary authority and $10 billion in funding through August 7, 2017 (or sooner, if those funds are exhausted) for veterans to obtain health care services from community (non-VA) providers to address long wait times, lengthy travel distances, or other challenges accessing VA health care. Under this authority, VA introduced the Veterans Choice Program in November 2014. The $10 billion is meant to supplement VA’s medical services budget and is funded through a separate appropriations account, the Veterans Choice Fund. The 2014 law also appropriated $5 billion to expand VA’s capacity to deliver care to veterans by hiring additional clinicians and improving the physical infrastructure of VA’s medical facilities.

VA faces challenges regarding the reliability, transparency, and consistency of its budget estimates for medical services, as well as weaknesses in tracking obligations for medical services and estimating budgetary needs for future years. These challenges were evident in June 2015, when VA requested additional funds from Congress because agency officials projected a fiscal year 2015 funding gap of about $3 billion in its medical services appropriation account.[1] The projected funding gap was largely due to administrative weaknesses that slowed the utilization of the Veterans Choice Program in fiscal year 2015 and resulted in higher-than-expected demand for VA’s previously established VA community care programs. In particular, VA officials expected that the Veterans Choice Program would absorb much of the increased demand from veterans for health care services delivered by non-VA providers, but instead the slow utilization resulted in veterans continuing to receive care through previously established VA community care programs that drew funds from VA’s medical services appropriation account. To avoid a projected funding gap in VA’s medical services appropriation account, the VA Budget and Choice Improvement Act provided VA temporary authority to use up to $3.3 billion from the Veterans Choice Program appropriation for obligations incurred for other specified medical services, starting May 1, 2015, until October 1, 2015.[2]

While timely and cost-effective access to needed health care services is essential, care coordination between VA and community providers, and between VA and the Department of Defense (DOD) (for transitioning servicemembers), is also critical to preventing unfavorable health outcomes for veterans. With the increased utilization of community providers that has occurred as a result of the Veterans Access, Choice, and Accountability Act, veterans are required to navigate multiple complex health care systems—the VA health care system and those of community providers—to obtain needed health care services. The quality of veterans’ care may be adversely affected if VA and community providers do not promptly communicate important clinical information. In addition, servicemembers transitioning from DOD to VA health care may experience problems if, for example, VA inappropriately discontinues medications, such as those for mental health conditions, because of a lack of clarity in VA’s medication continuation policy, potentially increasing the risk for adverse health effects.


[1] In this report, the projected funding gap refers to the period in fiscal year 2015 when VA’s obligations for medical services were projected to exceed its available budget authority for that purpose for that year. The Antideficiency Act prohibits agencies from incurring obligations in excess of available budget authority. 31 U.S.C. § 1341(a). An evaluation of whether an Antideficiency Act violation occurred in fiscal year 2015 was outside the scope of our work.

[2] Pub. L. No. 114-41, Tit. IV, § 4004, 129 Stat. 443, 463-464 (2015)

Managing Risks and Improving VA Health Care

Overall, VA has partially met the criteria for leadership commitment and an action plan to address the five areas of concern we identified when we placed VA health care on our High-Risk List in 2015. These five areas of concern are: (1) ambiguous policies and inconsistent processes; (2) inadequate oversight and accountability; (3) information technology (IT) challenges; (4) inadequate training for VA staff; and (5) unclear resource needs and allocation priorities. VA has not met the other criteria for removal: capacity to address the areas of concern, monitoring implementation of corrective actions, and demonstrating progress.

Although we concluded in our overall assessment that VA’s actions partially met two of our five criteria for removal from the High-Risk List, it is worth noting that the department made significantly less progress in addressing the action plan criterion than it has in demonstrating leadership commitment. Specifically, VA partially met the action plan criterion for only one of the five areas of concern—ambiguous policies and inconsistent processes—whereas VA partially met the leadership commitment criterion for four out of five areas of concern (VA did not meet the leadership commitment criterion for inadequate training for VA staff). The department must make significant progress on the action plan criterion for all five areas of concern we identified in order to meet this criterion for removal from our High-Risk List.

VA officials have expressed their commitment to addressing the department’s High-Risk List designation, and have taken actions such as establishing a task force, working groups, and a governance structure for addressing the issues contributing to the designation. For example, in July 2016, VA chartered the GAO High-Risk List Area Task Force for Managing Risk and Improving VA Health Care (task force) to develop and oversee implementation of VA’s plan to address the root causes of the five areas of concern we identified. VHA’s Deputy Under Secretary for Health (USH) for Organizational Excellence serves as the executive agent for the task force, with support from a combination of permanent and temporary staff. This senior VHA position was created in 2015 and is responsible for overseeing offices focused on assessing and improving health care quality and safety, providing VA leadership with analytics to assess VHA’s performance, and addressing issues related to public trust and integrity. For each of the five areas of concern we identified, VA has established a working group with two senior-level VA officials as leaders. These workgroups and officials are responsible for developing and executing VA’s high-risk mitigation plan for each of our five areas of concern.

VA has also contracted with two entities to support VA’s actions to address the high-risk designation. The first contract—with a Federally Funded Research and Development Center operated by the MITRE Corporation—is focused on (1) developing and executing an action plan, (2) creating a plan to enhance VA’s capacity to manage High-Risk List areas, and (3) recommending changes to the organizational structure VA set up to address the high-risk designation. The total contract value is $5.2 million, with an 8-month performance period that began on June 20, 2016 and 1 option year. The second contract—with Atlas Research, LLC—is for project management staff who will help establish a program executive office within the office of the VHA Deputy USH for Organizational Excellence, and assist with establishing the management functions necessary to oversee the five high-risk area working groups. The total contract value is $2.6 million, with a 1-year performance period that began on September 9, 2016 and the option to extend services for up to 6 additional months.

Since we added VA health care to our High-Risk List in 2015, VA’s leadership has increased its focus on implementing our recommendations. Between January 2010 and February 2015 (when we designated VA health care as a high-risk area), we issued products containing 178 recommendations related to VA health care. When we made our designation in 2015, the department had only implemented about 22 percent of them—39 of the 178 recommendations. In the last 2 years, VA has made good progress, but additional work is needed. Since we designated VA health care as a high-risk area, we have made 66 new recommendations related to VA health care, for a total of 244 recommendations from January 1, 2010 through December 31, 2016. VA has implemented about 50 percent of the recommendations we have made since 2010—122 of the 244 recommendations. (See table 9.) It is critical that VA implement our recommendations not only to remedy the specific weaknesses identified, but because they may be symptomatic of larger underlying problems that also need to be addressed.

Table 9: Status of GAO Recommendations Related to Department of Veterans Affairs (VA) Health Care from Calendar Year 2010 through Calendar Year 2016

Status of recommendations

Number of recommendations when VA health care was added to GAO’s High-Risk List (February 11, 2015)

Number of recommendations as of December 31, 2016

Open because VA has not yet implemented them

134

109a

Closed because VA implemented them

39

122

Closed without VA implementing themb

5

13

Total

178

244

Source: GAO. | GAO-17-317.

aOf these 109 recommendations, 27 have been open for 3 or more years.
bWe close recommendations without agencies having implemented them primarily if the recommendation is no longer valid because circumstances have changed.

On August 18, 2016, VA provided us with an action plan for addressing the High-Risk List designation that acknowledged the deep-rooted nature of the areas of concern we identified, and stated that these concerns would require substantial time and work to address. Although the action plan outlined some steps VA plans to take over the next several years to address its high-risk designation, the overall document did not satisfy the action plan criterion for removal. Specifically, several sections were missing actions that support our criteria for removal, such as analyzing the root causes of the issues and measuring progress with clear metrics. In our feedback to VHA on drafts of their action plan, we highlighted these missing actions and also stressed the need for specific timelines and an assessment of needed resources for implementation. For example, VA plans to use staff from various sources, including contractors and temporarily detailed employees, to support their high-risk area working groups, so it will be important for VA to ensure that these efforts are sufficiently resourced.

While VA has demonstrated partial leadership commitment in most of the five areas of concern, significant gaps remain between VA’s stated plans and its actual progress. This lack of progress is evidenced by findings from our recent work, which have led us to make new recommendations that relate to each of the five areas of concern we highlighted in 2015. (See table 10.)

Table 10: GAO Recommendations Related to Department of Veterans Affairs (VA) Health Care from Calendar Year (CY) 2010 through CY 2016, by Area of Concern

VA health care area of concern

Number of recommendations prior to GAO high-risk designation
(Jan. 1, 2010 through Feb. 11, 2015)a

Number of recommendations added since GAO high-risk designation
(Feb. 11, 2015 through Dec. 31, 2016)a

Cumulative percentage of GAO recommendations VA has implemented, CY 2010 through CY 2016

Ambiguous policies and inconsistent processes

42

20

52%

Inadequate oversight and accountability

63

31

50

Information technology challenges

11

2

44

Inadequate training for VA staff

6

7

46

Unclear resource needs and allocation priorities

48

5

65

Not assigned to an area of concern

8

1

44

Total

178

66

50%

Source: GAO. | GAO-17-317.

aRecommendation counts listed include both implemented and not implemented recommendations as of the dates indicated.

Additional Details on What GAO Found are in the full report.

Since we added VA health care to our High-Risk List in 2015, VA has acknowledged the significant scope of the work that lies ahead. VA took an important step toward addressing our criteria for removal by establishing the leadership structure necessary to ensure that actions related to the High-Risk List are prioritized within the department. It is imperative, however, that VA maintain strong leadership support as it completes its transition into a new presidential administration.

In its action plan, VA separated its discussion of department-wide initiatives from its description of High-Risk List mitigation strategies. These department-wide initiatives include MyVA, which intends to make changes to VA’s systems and structures to (1) improve the veteran experience, (2) improve the employee experience, (3) achieve support services excellence, (4) establish a culture of continuous performance improvement, and (5) enhance strategic partnerships. We do not view high-risk mitigation strategies as separate from other department initiatives; actions to address the High-Risk List can and should be integrated in VA’s existing activities. As a new administration sets its priorities, VA will need to integrate those priorities with its high-risk related actions, and facilitate their implementation at the local level through strategies that link strategic goals to actions and guidance. In addition, VA will need to demonstrate that it has the capacity to sustain efforts by devoting appropriate resources—including people, training, and funds—to address the high-risk challenges we identified.

VA’s action plan for addressing its high-risk designation describes many planned outcomes with overly ambitious deadlines for completion. We are concerned about the lack of root cause analyses for most areas of concern, and the lack of clear metrics and needed resources for achieving stated outcomes. This is especially evident in VA’s plans to address the IT and training areas of concern. In addition, with the increased use of community care programs, it is imperative that VA’s action plan include a discussion of the role of community care in decisions related to policies, oversight, IT, training, and resource needs. We will continue to monitor VA’s institutional capacity to fully implement and sustain needed changes, including those related to its IT transformation, comprehensive training management plan, and resourcing decisions.

Finally, to help address our high-risk designation, VA should continue to implement our recommendations and recommendations from other reviews such as the Commission on Care. The Veterans Access, Choice, and Accountability Act of 2014 established the Commission on Care to examine, assess, and report on veterans’ access to VA health care and to strategically examine how best to organize VHA, locate health resources, and deliver health care to veterans during the next 20 years.[1]  The Commission’s June 2016 report to the President included 18 recommendations to improve veterans’ access to care and, more broadly, to improve the quality and comprehensiveness of that care. For example, the Commission recommended that VHA create local, networked systems of care that integrate VA-based care and community care and remove restrictions to veterans seeking care from community providers. On September 1, 2016, the President concurred with 15 of the 18 recommendations and directed VA to implement them.

We will continue to monitor VA’s efforts to address our high-risk areas of concern, including the department’s efforts to implement the 15 Commission on Care recommendations for which the President directed VA action. We also have ongoing work focusing on VA health care, including its policy development and dissemination process; controls and oversight for controlled substances; Veterans Choice Program implementation; physician recruitment and retention; the process for enrolling veterans in VA health care. In particular, the following selected recommendations require VA’s immediate attention:

  • improving oversight of access to timely medical appointments, including the development of wait-time measures that are more reliable and not prone to user error or manipulation, as well as ensuring that medical centers consistently and accurately implement VHA’s scheduling policy.
  • improved oversight of VA community care to ensure—among other things—timely payment to community providers.
  • improved planning, deployment and oversight of VA/VHA IT systems, including identifying outcome-oriented metrics and defining goals for interoperability with DOD.
  • ensuring that recommendations resulting from internal and external reviews of VHA’s organizational structure are evaluated for implementation. This process should include the documentation of decisions and assigning officials or offices responsibility for ensuring that approved recommendations are implemented.

It is critical that Congress maintain its focus on oversight of VA health care to help address this high-risk area. Congressional committees responsible for authorizing and overseeing VA health care programs held more than 70 hearings in 2015 and 2016 to examine and address VA health care challenges. In addition, as VA continues to change its health care service delivery in the coming years, some changes may require congressional action—such as VA’s planned consolidation of community care programs after the Veterans Choice Program expires. Sustained congressional attention to these issues will help ensure that VA continues to improve its management and delivery of health care services to veterans.


[1] Pub. L. No. 113-146, § 202(a)(1), 128 Stat. 1754, 1773 (2014).

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