GAO Reports: Military and Veterans Health Care and Disability Benefits

This page lists the most recent reports and testimonies related to military and veterans' health care and disability benefits issued since March 2003.

Health Care Benefits

http://gao.gov/docsearch/featured/healthcaredisabilitybenefits.html Sun, 22 Nov 2009 08:26:12 -0500 GAO http://www.gao.gov/images/title_object.jpg GAO logo http://www.gao.gov/ Feed provided by GAO. Click to visit. VA Health Care: Ineffective Medical Center Controls Resulted in Inappropriate Billing and Collection Practices, October 15, 2009 http://www.gao.gov/new.items/d10152t.pdf GAO was asked to testify on billing practices of the Department of Veterans Affairs (VA). GAO previously reported that continuing problems in billing and collection processes at VA impaired its ability to maximize revenue from private insurance companies (third-party insurers). In June 2008, GAO reported on its follow-up review that (1) evaluated VA billing controls, (2) assessed VA-wide controls for collections, and (3) determined the effectiveness of VA oversight over third-party billings and collections. To perform the review, GAO conducted case-study analyses of the third-party billing function at 18 medical centers, statistically tested controls over collections VA-wide, and reviewed current oversight policies and procedures. GAO reported the results of this review in GAO-08-675. In June 2008, GAO reported that its case-study analysis of unbilled patient services at 18 medical centers, including 10 medical centers with low billing performance and 8 medical centers under VA's Consolidated Patient Account Centers (CPAC) initiative considered to be high performers, found documentation, coding, and billing errors and inadequate management oversight that resulted in unbilled amounts. The total amount that VA had categorized as unbillable in fiscal year 2007 for these 18 case-study medical centers was approximately $1.7 billion. Although some medical services are not billable, such as service-connected treatment, management had not validated reasons for related unbilled amounts of about $1.4 billion to assure that all billable costs are charged to third-party insurers. GAO also found excessive time to bill and coding errors. The 10 non-CPAC medical centers reported average days to bill ranging from 109 days to 146 days in fiscal year 2007, compared to VA's goal of 60 days, and significant coding and billing errors and other problems that totaled over $254 million or 21 percent of the total in unbilled medical services costs at those centers. Although GAO determined that CPAC officials performed a more thorough review of billings, GAO's analysis of unbilled amounts for the 8 CPAC centers found problems that accounted for $37.5 million, or about 7 percent, of the total unbilled medical services costs. GAO's June 2008 report identified significant percentages of cases where required follow-up was not done. These are considered to be control failures. VA guidance requires medical center accounts receivable staff to make up to three follow-up contacts, as necessary, on outstanding third-party insurer unpaid bills, which were $600 million as of September 2007. As shown in the table below, GAO's statistical tests of a random sample of fiscal year 2007 third-party bills identified high control-failure rates related to the requirement for initial, second, and third follow-ups with third-party insurers on unpaid amounts. Thu, 15 Oct 2009 00:00:00 -0400 VA Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans, July 16, 2009 http://www.gao.gov/new.items/d09899t.pdf Historically, the vast majority of VA patients have been men, but that is changing. VA provided health care to over 281,000 women veterans in 2008--an increase of about 12 percent since 2006--and the number of women veterans in the United States is projected to increase by 17 percent between 2008 and 2033. Women veterans seeking care at VA medical facilities need access to a full range of health care services, including basic gender-specific services--such as cervical cancer screening--and specialized gender-specific services--such as treatment of reproductive cancers. This testimony, based on ongoing work, discusses GAO's preliminary findings on (1) the on-site availability of health care services for women veterans at VA facilities, (2) the extent to which VA facilities are following VA policies that apply to the delivery of health care services for women veterans, and (3) some key challenges that VA facilities are experiencing in providing health care services for women veterans. GAO reviewed applicable VA policies, interviewed officials, and visited 19 medical facilities--9 VA medical centers (VAMC) and 10 community-based outpatient clinics (CBOC)--and 10 Vet Centers. These facilities were chosen based in part on the number of women using services and whether facilities offered specific programs for women. The results from these site visits cannot be generalized to all VA facilities. GAO shared this statement with VA officials, and they generally agreed with the information presented. The VA facilities GAO visited provided basic gender-specific and outpatient mental health services to women veterans on-site, and some facilities also provided specialized gender-specific or mental health services specifically designed for women on-site. Basic gender-specific services, including pelvic examinations, were available on-site at all nine VAMCs and 8 of the 10 CBOCs GAO visited. Almost all of the medical facilities GAO visited offered women veterans access to one or more female providers for their gender-specific care. The availability of specialized gender-specific services for women, including treatments after abnormal cervical cancer screenings and breast cancer, varied by service and facility. All VA medical facilities refer female patients to non-VA providers for obstetric care. Some of the VAMCs GAO visited offered a broad array of other specialized gender-specific services on site, but all contracted or fee-based at least some services. Among CBOCs, the two largest facilities GAO visited offered an array of specialized gender-specific care on-site; the other eight referred women to other VA or non-VA facilities for most of these services. Outpatient mental health services for women were widely available at the VAMCs and most Vet Centers GAO visited, but were more limited at some CBOCs. While the two larger CBOCs offered group counseling for women and services specifically for women who have experienced sexual trauma in the military, the smaller CBOCs tended to rely on VAMC staff,often through videoconferencing, to provide mental health services. The extent to which the VA medical facilities GAO visited were following VA policies that apply to the delivery of health care services for women veterans varied, but none of the facilities had fully implemented these policies. None of the VAMCs and CBOCs GAO visited were fully compliant with VA policy requirements related to privacy for women veterans in all clinical settings where those requirements applied. For example, many of the medical facilities GAO visited did not have adequate visual and auditory privacy in their check-in areas. Further, the facilities GAO visited were in various stages of implementing VA's new initiative to provide comprehensive primary care for women veterans, but officials at some VAMCs and CBOCs reported that they were unclear about the specific steps they would need to take to meet the goals of the new policy. Officials at facilities that GAO visited identified a number of challenges they face in providing health care services to the increasing numbers of women veterans seeking VA health care. One challenge was that space constraints have raised issues affecting the provision of health care services. For example, the number, size, or configuration of exam rooms or bathrooms sometimes made it difficult for facilities to comply with VA requirements related to privacy for women veterans. Officials also reported challenges hiring providers with specific training and experience in women's health care and in mental health care, such as treatment for women veterans with post-traumatic stress disorder or who had experienced military sexual trauma. Thu, 16 Jul 2009 00:00:00 -0400 VA Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans, July 14, 2009 http://www.gao.gov/new.items/d09884t.pdf Historically, the vast majority of VA patients have been men, but that is changing. VA provided health care to over 281,000 women veterans in 2008--an increase of about 12 percent since 2006--and the number of women veterans in the United States is projected to increase by 17 percent between 2008 and 2033. Women veterans seeking care at VA medical facilities need access to a full range of health care services, including basic gender-specific services--such as cervical cancer screening--and specialized gender-specific services--such as treatment of reproductive cancers. This testimony, based on ongoing work, discusses GAO's preliminary findings on (1) the on-site availability of health care services for women veterans at VA facilities, (2) the extent to which VA facilities are following VA policies that apply to the delivery of health care services for women veterans, and (3) key challenges that VA facilities are experiencing in providing health care services for women veterans. GAO reviewed applicable VA policies, interviewed officials, and visited 19 medical facilities--9 VA medical centers (VAMC) and 10 community-based outpatient clinics (CBOC)--and 8 Vet Centers. These facilities were chosen based in part on the number of women using services and whether facilities offered specific programs for women. The results from these site visits cannot be generalized to all VA facilities. GAO shared this statement with VA officials, and they generally agreed with the information presented. The VA facilities GAO visited provided basic gender-specific and outpatient mental health services to women veterans on site, and some facilities also provided specialized gender-specific or mental health services specifically designed for women on site. Basic gender-specific services, including pelvic examinations, were available on site at all nine VAMCs and 8 of the 10 CBOCs GAO visited. Almost all of the medical facilities GAO visited offered women veterans access to one or more female providers for their gender-specific care. The availability of specialized gender-specific services for women, including treatments after abnormal cervical cancer screenings and breast cancer, varied by service and facility. All VA medical facilities refer female patients to non-VA providers for obstetric care. Some of the VAMCs GAO visited offered a broad array of other specialized gender-specific services on site, but all contracted or fee-based at least some services. Among CBOCs, the two largest facilities GAO visited offered an array of specialized gender-specific care on site; the other eight referred women to other VA or non-VA facilities for most of these services. Outpatient mental health services for women were widely available at the VAMCs and most Vet Centers GAO visited, but were more limited at some CBOCs. While the two larger CBOCs offered group counseling for women and services specifically for women who have experienced sexual trauma in the military, the smaller CBOCs tended to rely on VAMC staff, often through videoconferencing, to provide mental health services. The extent to which the VA medical facilities GAO visited were following VA policies that apply to the delivery of health care services for women veterans varied, but none of the facilities had fully implemented these policies. None of the VAMCs and CBOCs GAO visited were fully compliant with VA policy requirements related to privacy for women veterans in all clinical settings where those requirements applied. For example, many of the medical facilities GAO visited did not have adequate visual and auditory privacy in their check-in areas. Further, the facilities GAO visited were in various stages of implementing VA's new initiative to provide comprehensive primary care for women veterans, but officials at some VAMCs and CBOCs reported that they were unclear about the specific steps they would need to take to meet the goals of the new policy. Officials at facilities that GAO visited identified a number of challenges they face in providing health care services to the increasing numbers of women veterans seeking VA health care. One challenge was that space constraints have raised issues affecting the provision of health care services. For example, the number, size, or configuration of exam rooms or bathrooms sometimes made it difficult for facilities to comply with VA requirements related to privacy for women veterans. Officials also reported challenges hiring providers with specific training and experience in women's health care and in mental health care, such as treatment for women veterans with post-traumatic stress disorder or who had experienced military sexual trauma. Tue, 14 Jul 2009 00:00:00 -0400 Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of Required Policies but Challenges Remain, July 8, 2009 http://www.gao.gov/new.items/d09728.pdf The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) requires the Departments of Defense (DOD) and Veterans Affairs (VA) to jointly develop and implement comprehensive policies on the care, management, and transition of recovering servicemembers. The Wounded, Ill, and Injured Senior Oversight Committee (SOC)--jointly chaired by DOD and VA leadership--has assumed responsibility for these policies. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in jointly developing and implementing the policies. This report focuses on the joint development of the policies. Implementation of the policies will be addressed in future reports. Specifically, this report provides information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required by the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development of these policies. GAO determined the current status of policy development by assessing the status reported by SOC officials and analyzing supporting documentation. To identify challenges, GAO interviewed the Acting Under Secretary of Defense for Personnel and Readiness, the Executive Director and Chief of Staff of the SOC, the departmental co-leads for most of the SOC work groups, the Acting Director of DOD's Office of Transition Policy and Care Coordination, and other knowledgeable officials. DOD and VA have made substantial progress in jointly developing policies required by sections 1611 through 1614 of the NDAA 2008 in the areas of (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) transition of care and services received from DOD to VA. Overall, GAO's analysis showed that as of April 2009, 60 of the 76 policy requirements GAO identified have been completed and the remaining 16 policy requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and physical disability evaluations, including issuing a report on the feasibility and advisability of consolidating the DOD and VA disability evaluation systems, although the pilot for this approach is still ongoing. DOD has also completed establishing standards for returning recovering servicemembers to active duty. More than two-thirds of the policy development requirements have been completed for the remaining two policy areas--care and management and the transition of recovering servicemembers from DOD to VA. Most of these requirements were addressed in a January 2009 DOD memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which is to be issued in August 2009. VA also plans to issue related policy guidance in the fourth quarter of 2009. DOD and VA officials told GAO that they have experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. For example, the SOC must still standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD and VA agreement on key definitions for what constitutes "mental health," for instance, is important for developing policies that define the scope, eligibility, and service levels for recovering servicemembers. Recent changes affecting the SOC may also pose future challenges to policy development. Some officials have expressed concern that DOD's recent changes to staff supporting the SOC have disrupted the unity of command because SOC staff now report to three different officials within DOD and VA. However, it is too soon to determine how well DOD's staffing changes will work. Additionally, according to DOD and VA officials, the SOC's scope of responsibilities appears to be in flux. While the SOC will remain responsible for policy matters for recovering servicemembers, a number of policy issues may now be directed to the DOD and VA Joint Executive Council. Despite this uncertainty, DOD and VA officials told GAO that the SOC's work groups continue to carry out their roles and responsibilities. GAO provided a draft of this report to DOD and VA for comment. VA provided technical comments, which GAO incorporated as appropriate. DOD and VA did not provide other comments. Wed, 08 Jul 2009 00:00:00 -0400 VA Health Care: Overview of VA's Capital Asset Management, June 9, 2009 http://www.gao.gov/new.items/d09686t.pdf Through its Veterans Health Administration (VHA), the Department of Veterans Affairs (VA) operates one of the largest integrated health care systems in the country. In 1999, GAO reported that better management of VA's large inventory of aged capital assets could result in savings that could be used to enhance health care services for veterans. In response, VA initiated a process known as Capital Asset Realignment for Enhanced Services (CARES). Through CARES, VA sought to determine the future resources needed to provide health care to our nation's veterans. This testimony describes (1) how CARES contributes to VHA's capital planning process, (2) the extent to which VA has implemented CARES decisions, and (3) the types of legal authorities that VA has to manage its real property and the extent to which VA has used these authorities. The testimony is based on GAO's body of work on VA's management of its capital assets, including GAO's 2007 report on VA's implementation of CARES (GAO-07-408). The CARES process provides VA with a blueprint that drives VHA's capital planning efforts. As part of the CARES process, VA adapted a model to estimate demand for health care services and to determine the capacity of its current infrastructure to meet this demand. VA continues to use this model in its capital planning process. The CARES process resulted in capital alignment decisions intended to address gaps in services or infrastructure. These decisions serve as the foundation for VA's capital planning process. According to VA officials, all capital projects must be based on demand projections that use the planning model developed through CARES. VA has started implementing some CARES decisions, but does not centrally track their implementation or monitor the impact of their implementation on its mission. VA is in varying stages (e.g., planning or construction) of implementing 34 of the major capital projects that were identified in the CARES process and has completed 8 projects. Our past work found that, while VA had over 100 performance measures to monitor other agency programs and activities, these measures either did not directly link to the CARES goals or VA did not use them to centrally monitor the implementation and impact of CARES decisions. Without this information, VA could not readily assess the implementation status of CARES decisions, determine the impact of such decisions, or be held accountable for achieving the intended results of CARES. VA has recently created the CARES Implementation Working Group, which has identified performance measures for CARES and will monitor the implementation and impact of CARES decisions in the future. VA has a variety of legal authorities available, such as enhanced-use leases, sharing agreements, and others, to help it manage real property. However, legal restrictions and administrative- and budget-related disincentives associated with implementing some authorities affect VA's ability to dispose and reuse property in some locations. For example, legal restrictions limit VA's ability to dispose of and reuse property in West Los Angeles and Sepulveda. Despite these challenges, VA has used these legal authorities to help reduce underutilized space (i.e., space not used to full capacity). In 2008, we reported that VA reduced underutilized space in its buildings by approximately 64 percent from 15.4 million square feet in fiscal year 2005 to 5.6 million square feet in fiscal year 2007. While VA's use of various legal authorities likely contributed to VA's overall reduction of underutilized space since fiscal year 2005, VA does not track the overall effect of using these authorities on space reductions. Not having such information precludes VA from knowing what effect these authorities are having on reducing underutilized or vacant space or knowing which types of authorities have the greatest effect. According to VA officials, VA will institute a system in 2009 that will track square footage reductions at the building level. Tue, 09 Jun 2009 00:00:00 -0400 VA Health Care: Challenges in Budget Formulation and Issues Surrounding the Proposal for Advance Appropriations, April 29, 2009 http://www.gao.gov/new.items/d09664t.pdf The Department of Veterans Affairs (VA) estimates it will provide health care to 5.8 million patients with appropriations of about $41 billion in fiscal year 2009. It provides a range of services, including primary care, outpatient and inpatient services, long-term care, and prescription drugs. VA formulates its health care budget by developing annual estimates of its likely spending for all its health care programs and services, and includes these estimates in its annual congressional budget justification. GAO was asked to discuss budgeting for VA health care. As agreed, this statement addresses (1) challenges VA faces in formulating its health care budget and (2) issues surrounding the possibility of providing advance appropriations for VA health care. This testimony is based on prior GAO work, including VA Health Care: Budget Formulation and Reporting on Budget Execution Need Improvement (GAO-06-958) (Sept. 2006); VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement (GAO-09-145) (Jan. 2009); and VA Health Care: Challenges in Budget Formulation and Execution (GAO-09-459T) (Mar. 2009); and on GAO reviews of budgets, budget resolutions, and related legislative documents. We discussed the contents of this statement with VA officials. GAO's prior work highlights some of the challenges VA faces in formulating its budget: obtaining sufficient data for useful budget projections, making accurate calculations, and making realistic assumptions. For example, GAO's 2006 report on VA's overall health care budget found that VA underestimated the cost of serving veterans returning from military operations in Iraq and Afghanistan. According to VA officials, the agency did not have sufficient data from the Department of Defense, but VA subsequently began receiving the needed data monthly rather than quarterly. In addition, VA made calculation errors when estimating the effect of its proposed fiscal year 2006 nursing home policy, and this contributed to requests for supplemental funding. GAO recommended that VA strengthen its internal controls to better ensure the accuracy of calculations used to prepare budget requests. VA agreed and, for its fiscal year 2009 budget justification, had an independent actuarial firm validate savings estimates from proposals to increase fees for certain types of health care coverage. In January 2009, GAO found that VA's assumptions about the cost of providing long-term care appeared unreliable given that assumed cost increases were lower than VA's recent spending experience and guidance provided by the Office of Management and Budget. GAO recommended that VA use assumptions consistent with recent experience or report the rationale for alternative cost assumptions. In a March 23, 2009, letter to GAO, VA stated that it concurred and would implement this recommendation for future budget submissions. The provision of advance appropriations would "use up" discretionary budget authority for the next year and so limit Congress's flexibility to respond to changing priorities and needs. While providing funds for 2 years in a single appropriations act provides certainty about some funds, the longer projection period increases the uncertainty of the data and projections used. If VA is expected to submit its budget proposal for health care for 2 years, the lead time for the second year would be 30 months. This additional lead time increases the uncertainty of the estimates and could worsen the challenges VA already faces when formulating its health care budget. Given the challenges VA faces in formulating its health care budget and the changing nature of health care, proposals to change the availability of the appropriations it receives deserve careful scrutiny. Providing advance appropriations will not mitigate or solve the problems we have reported regarding data, calculations, or assumptions in developing VA's health care budget. Nor will it address any link between cost growth and program design. Congressional oversight will continue to be critical. Wed, 29 Apr 2009 00:00:00 -0400 Recovering Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Policies but Additional Challenges Remain, April 29, 2009 http://www.gao.gov/new.items/d09540t.pdf The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) requires the Departments of Defense (DOD) and Veterans Affairs (VA) to jointly develop and implement comprehensive policies on the care, management, and transition of recovering servicemembers. The Senior Oversight Committee (SOC)--jointly chaired by DOD and VA leadership--has assumed responsibility for these policies. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in developing and implementing the policies. This statement provides preliminary information on (1) the progress DOD and VA have made in jointly developing the comprehensive policies required in the NDAA 2008 and (2) the challenges DOD and VA are encountering in the joint development and initial implementation of these policies. GAO determined the current status of policy development by assessing the status reported by SOC officials and analyzing supporting documentation. To identify challenges, GAO interviewed the Acting Under Secretary of Defense for Personnel and Readiness, the Executive Director and Chief of Staff of the SOC, the departmental co-leads for most of the SOC work groups, the Acting Director of DOD's Office of Transition Policy and Care Coordination, and other knowledgeable officials. DOD and VA have made substantial progress in jointly developing policies required by sections 1611 through 1614 of the NDAA 2008 in the areas of (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) transition of care and services received from DOD to VA. Overall, GAO's analysis showed that as of March 2009, 60 of the 76 requirements GAO identified have been completed and the remaining 16 requirements are in progress. DOD and VA have completed all of the policy development requirements for medical and disability evaluations, including issuing a report on the feasibility and advisability of consolidating the DOD and VA disability evaluation systems, although the pilot for this approach is still ongoing. DOD has also completed establishing standards for returning recovering servicemembers to active duty. More than two-thirds of the policy development requirements have been completed for the remaining two policy areas--care and management and the transition of recovering servicemembers from DOD to VA. Most of these requirements were addressed in a January 2009 DOD Directive-Type Memorandum that was developed in consultation with VA. DOD officials reported that more information will be provided in a subsequent policy instruction, which will be issued in June 2009. VA also plans to issue related policy guidance in June 2009. DOD and VA officials told GAO that they have experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. For example, the SOC must still standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD and VA agreement on key definitions for what constitutes "mental health," for instance, is important for developing policies that define the scope, eligibility, and service levels for recovering servicemembers. Recent changes affecting the SOC may also pose future challenges to policy development. Some officials have expressed concern that DOD's recent changes to staff supporting the SOC have disrupted the unity of command because SOC staff now report to three different officials within DOD and VA. However, it is too soon to determine how DOD's staffing changes will work. Additionally, according to DOD and VA officials, the SOC's scope of responsibilities appears to be in flux. While the SOC will remain responsible for policy matters for recovering servicemembers, a number of policy issues may now be directed to the DOD and VA Joint Executive Council. Despite this uncertainty, DOD and VA officials told GAO that the SOC's work groups continue to carry out their responsibilities. GAO shared the information contained in this statement with DOD and VA officials, and they agreed with the information GAO presented. Wed, 29 Apr 2009 00:00:00 -0400 Military Disability Retirement: Closer Monitoring Would Improve the Temporary Retirement Process, April 13, 2009 http://www.gao.gov/new.items/d09289.pdf Service members found unfit for duty due to a service-related illness or injury may be eligible for military disability retirement. When their disability is not stable, however, they may be placed on the military's Temporary Disability Retired List (TDRL) and granted temporary benefits for as long as 5 years. GAO was asked to respond to concerns about TDRL caseloads, management, and impact on servicemembers. To address these concerns, we analyzed TDRL data; interviewed military officials; reviewed laws, regulations, and other relevant documents; and conducted 12 focus groups with temporary retirees. This report examines (1) recent trends in the TDRL caseload size, (2) recent trends in the characteristics of those placed on the TDRL, (3) disability retirement outcomes for TDRL placements, (4) the adequacy of TDRL management, and (5) the adequacy of information provided to TDRL retirees. TDRL caseloads within the Department of Defense (DOD) grew by 43 percent, from 9,983 in fiscal year 2003 to 14,285 in fiscal year 2007. Growth in caseloads could be attributable to a combination of increases in the number of cases going through the military's disability evaluation system, higher TDRL placement rates, and low numbers of cases removed from the TDRL relative to new cases added to the list. DOD-wide, servicemembers placed on the TDRL in each calendar year from 2000 through 2007 varied little with respect to their military status, years of service, and disabilities. In each of these years, most TDRL placements had been active duty personnel, although the small proportion who had been reservists grew considerably. Most TDRL placements in each year also had fewer than 20 years of service and, over time, their average years of service declined. The disabilities most prevalent among TDRL placements were musculoskeletal, mental, or neurological in nature. Among those with mental and neurological disabilities, the incidence of post traumatic stress disorder and conditions related to traumatic brain injury increased substantially across the services. Although the experiences of temporary disability retirees varied, some outcomes were more common than others. DOD-wide, very few who were placed on the list between calendar years 2000 and 2003 returned to military service. Further, about half received a final determination within 3 years and, of those who ultimately received permanent disability benefits, 73 percent had final disability ratings that were no different than their initial ratings. Finally, only 7 percent of TDRL placements, DOD-wide, received a final disability rating that qualified them for permanent disability payment amounts higher than their TDRL payments. DOD and the services do not effectively manage key aspects of the TDRL process. The military does not systematically examine physical evaluation board (PEB) stability decisions for accuracy and consistency or routinely compile information on TDRL outcomes to better inform its assessments of stability. According to TDRL administrative staff, ensuring that medical reexaminations are done in TDRL cases at least once every 18 months is often a challenge. However, the military does not monitor the extent to which this requirement is met. Moreover, there is limited use of nonmilitary physicians to perform reexaminations, which could reduce burdens on medical treatment facilities. Finally, military procedures do not ensure consistent enforcement of TDRL rules. Information about the TDRL that the services provide is not always clear or complete and can be difficult to access. PEB findings forms provided to temporary retirees do not fully explain why service members are placed on the list or what is required of them. Temporary retirees reported that counseling related to PEB decisions was inconsistent and lacking in followthrough. Information from military pamphlets, brochures, fact sheets, and Web sites is often incomplete or difficult to find. Temporary retirees participating in our focus groups expressed considerable confusion about and dissatisfaction with their limited access to information and points of contact. Mon, 13 Apr 2009 00:00:00 -0400 VA Health Care: Challenges in Budget Formulation and Execution, March 12, 2009 http://www.gao.gov/new.items/d09459t.pdf The Department of Veterans Affairs (VA) estimates it will provide health care to 5.8 million patients with appropriations of $41.2 billion in fiscal year 2009. The President has proposed an increase in VA's health care budget for fiscal year 2010 to expand services for veterans. VA's patient population includes aging veterans who need services such as long-term care-- including nursing home and noninstitutional care provided in veterans' homes or community-- and veterans returning from Afghanistan and Iraq. Each year, VA formulates its medical care budget, which involves developing estimates of spending for VA's health care services. VA is also responsible for budget execution-- spending appropriations and monitoring their use. GAO was asked to discuss challenges related to VA's health care services budget formulation and execution. This statement focuses on (1) challenges VA faces in formulating its health care budget, and (2) challenges VA faces in executing its health care budget. This testimony is based on three GAO reports: VA Health Care: Budget Formulation and Reporting on Budget Execution Need Improvement (GAO-06-958) (Sept. 2006); VA Heath Care: Spending for Mental Health Strategic Plan Initiatives Was Substantially Less Than Planned (GAO-07-66) (Nov. 2006); and VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement (GAO-09-145) (Jan. 2009). VA faces challenges formulating its health care budget each fiscal year. As noted in GAO's 2006 report on VA's overall health care budget, these include making realistic assumptions about the budgetary impact of policy changes, making accurate calculations, and obtaining sufficient data for useful budget projections. For example, GAO found that VA made unrealistic assumptions about how quickly it would realize savings from proposed changes in nursing home policy. While VA took steps to respond to GAO's 2006 recommendations about VA budgeting, recent GAO work found similar issues. In 2009, GAO reported on VA's long-term care budget--namely, on challenges in projecting the amount and cost of VA long-term care. GAO found that in its fiscal year 2009 budget justification, VA used assumptions about the cost of nursing home and noninstitutional care that appeared unrealistically low given recent VA experience and other indicators. VA said it would complete an action plan responding to GAO's 2009 recommendations by the end of March 2009. VA also faces challenges executing its health care budget. These include spending and tracking funds for specific initiatives and providing timely and useful information to Congress on budget execution progress and problems. GAO's 2006 report on VA funding for new mental health initiatives found VA had difficulty spending and tracking funds for initiatives in VA's mental health strategic plan to expand services to address service gaps. The initiatives were to enhance VA's larger mental health program and were to be funded by $100 million in fiscal year 2005. Some VA medical centers did not spend all the funds they had received for the initiatives by the end of the fiscal year, partly due to the time it took to hire staff and renovate space for mental health programs. Also, VA did not track how funding allocated for the initiatives was spent. GAO's 2006 report on VA's overall health care budget found that VA monitored its health care budget execution and identified execution problems for fiscal years 2005 and 2006, but did not report the problems to Congress in a timely way. GAO also found that VA's reporting on budget execution to Congress could have been more informative. VA has not fully implemented one of GAO's two recommendations for improving VA budget execution. Sound budget formulation, monitoring of budget execution, and the reporting of informative and timely information to Congress for oversight continue to be essential as VA addresses budget challenges GAO has identified. Budgeting involves imperfect information and uncertainty, but VA has the opportunity to improve the credibility of its budgeting by continuing to address identified problems. This is particularly true for long-term care, where for several years GAO work has highlighted concerns about workload assumptions and cost projections. By improving its budget process, VA can increase the credibility and usefulness of information it provides to Congress on its budget plans and progress in spending funds. GAO's prior work on new mental health initiatives may provide a cautionary lesson about expanding VA programs--namely, that funding availability does not always mean that new initiatives will be fully implemented in a given fiscal year or that funds will be adequately tracked. Thu, 12 Mar 2009 00:00:00 -0400 Traumatic Brain Injury: Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent, and Timely Decisions for the Traumatic Injury Insurance Program, January 29, 2009 http://www.gao.gov/new.items/d09108.pdf In 2005, Congress created a traumatic injury insurance benefit program, known as TSGLI, to help servicemembers with traumatic brain injury and other serious injuries with the financial burdens that they and their families face. The Department of Veterans Affairs (VA) administers the program, in collaboration with the Department of Defense (DOD), while the branches of service are responsible for deciding servicemembers' claims. GAO examined (1) the TSGLI approval rate for traumatic brain injury claimants, and whether DOD and VA have assurance that claims are processed accurately, consistently, and in a timely manner and (2) any challenges servicemembers with traumatic brain injury may have faced in accessing TSGLI benefits, and the extent to which DOD and VA have taken steps to address such challenges. GAO analyzed program data and interviewed DOD and VA officials, servicemembers, and medical professionals. Although VA data show that 63 percent of servicemembers with traumatic brain injury were approved for TSGLI, the actual approval rate may be lower, and DOD and VA lack assurance that claim decisions are accurate, consistent, and timely within and across the branches of service. VA's data show that 520 of the 821 servicemembers who filed TSGLI claims for traumatic brain injury received benefits. However, the actual approval rate may be lower because VA does not include all denials for traumatic brain injury in its data. In addition, DOD and VA officials told us there is no systematic quality assurance review process to ensure that claim decisions are accurate and consistent within and across the services. Finally, DOD and VA lack reliable data on how long it takes the services to make decisions on traumatic brain injury claims. We identified three major challenges servicemembers with traumatic brain injury have faced and found that DOD and VA have taken a number of steps to address these challenges and expand access to the program. First, while TSGLI is intended as a quick benefit, servicemembers have had difficulties in starting claims soon after their injuries, in part because of a lack of awareness about the program. In response, DOD placed TSGLI staff in 10 of its largest medical treatment facilities to educate servicemembers and help them file claims. Second, the eligibility criteria for traumatic brain injury in place at the time of our review were subjective and unclear, which created some challenges for servicemembers. The criteria stated that a servicemember with traumatic brain injury must be completely dependent on another person to perform two of six activities of daily living, such as eating or getting dressed. However, medical providers may have differing opinions on whether someone who requires verbal instructions or reminders to perform these activities is considered completely dependent. VA has since clarified that a servicemember who requires verbal assistance is eligible, but acknowledged that subjectivity still exists in assessing functional ability. Third, servicemembers with traumatic brain injury have faced challenges in obtaining medical records to prove that they meet eligibility criteria. VA made a change to the program to allow servicemembers who can document a 15-day hospital stay to be eligible for a minimum benefit. DOD and VA are reviewing all claims that were denied or approved for less than the maximum amount to determine whether servicemembers are now eligible under these changes. Thu, 29 Jan 2009 00:00:00 -0500 VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement, January 23, 2009 http://www.gao.gov/new.items/d09145.pdf In fiscal year 2007, the Department of Veterans Affairs (VA) spent about $4.1 billion on long-term care for veterans. VA provides--through VA or other providers--institutional care in nursing homes and noninstitutional care in veterans' homes or the community. In response to a statute, VA published in 2007 a long-term care strategic plan through fiscal year 2013. VA includes long-term care spending estimates in its annual budget justifications for Congress. These estimates are based on workload projections--the amount of care to be provided--and cost assumptions. VA has discretion in allocating appropriated funds among its medical services, such as long-term care. GAO examined (1) VA's reporting of planned workload in its 2007 long-term care strategic plan and (2) VA's long-term care spending estimates, including its cost assumptions and workload projections, in VA's fiscal year 2009 budget justification. GAO analyzed budget and planning documents and interviewed VA officials. In its 2007 long-term care strategic plan, VA reported planned increases for some long-term care workload, but the workload information VA provided for both nursing home and noninstitutional care was incomplete. With respect to nursing home care, VA reported plans to increase workload for certain veterans for whom VA is required to provide such care. However, VA did not report its nursing home workload plans for most veterans VA currently serves--veterans who receive such care from VA on a discretionary basis and who accounted for over three-fourths of VA's nursing home workload in fiscal year 2007. Although not reported in its strategic plan, VA's intention is to keep its total nursing home workload stable. Doing so while increasing workload for veterans VA is required to serve would reduce care provided on a discretionary basis. For noninstitutional care, VA reported plans to increase workload to close gaps in services--previously identified by GAO--for enrolled veterans, for whom those services are to be available. But VA's plan did not report the magnitude of this planned increase--167 percent between fiscal years 2007 and 2013--or VA's time frame for achieving this planned increase. Currently, VA is developing its next long-term care strategic plan. In its fiscal year 2009 budget justification, VA estimated that it will increase its long-term care spending over its fiscal year 2008 level, but this estimate is based on cost assumptions and a workload projection that appear unrealistic. VA estimated that spending for both nursing home and noninstitutional care will increase in fiscal year 2009 by about $108 million and $165 million, respectively. However, VA may have underestimated its nursing home spending because it assumed nursing home costs would increase about 2.5 percent, an amount that appears unrealistically low compared to VA's recent experience and other indicators. For noninstitutional care, VA proposed a spending increase in order to partially reduce gaps in services. However, VA's estimated noninstitutional spending for fiscal year 2009 appears to be unreliable, because it is based on a cost assumption that appears unrealistically low and a workload projection that appears unrealistically high, given recent VA experience. The net effect of these two factors on VA's fiscal year 2009 noninstitutional spending estimate is unknown. VA's fiscal year 2009 budget justification did not explain the rationale behind its nursing home and noninstitutional cost assumptions or its plans for how it will increase noninstitutional workload. Because the workload information reported in VA's long-term care strategic plan is incomplete, the plan is of limited usefulness to Congress and stakeholders for determining VA's strategic direction, the extent to which VA's priorities are consistent with congressional priorities, and the level of resources VA may need to achieve its strategic plan goals. In addition, in its fiscal year 2009 budget justification, VA's use, without explanation, of cost assumptions and a workload projection that appear to be unrealistic raises questions about both the reliability of VA's spending estimates and the extent to which VA is closing gaps in noninstitutional long-term care services. Fri, 23 Jan 2009 00:00:00 -0500 VA Health Care: Improved Staffing Methods and Greater Availability of Alternate and Flexible Work Schedules Could Enhance the Recruitment and Retention of Inpatient Nurses, October 24, 2008 http://www.gao.gov/new.items/d0917.pdf Registered nurses (RNs) are the largest group of health care providers employed by VA's health care system. RNs are relied on to deliver inpatient care, but VA medical centers (VAMC) face RN recruitment and retention challenges. VAMCs use a patient classification system (PCS) to determine RN staffing on inpatient units by classifying inpatients according to severity of illness to determine the amount of RN care needed. GAO reviewed VAMC inpatient units for (1) the usefulness of information generated by VA's PCS; (2) key factors that affect RN retention; and (3) factors that contribute to delays in hiring RNs. GAO performed a Web-based survey of all VAMC nurse executives; interviewed VA headquarters officials and VAMC nursing officials, and conducted RN focus groups at eight VAMCs visited by GAO. The findings of GAO's survey are generalizable to all nurse executives; however, findings from the focus groups at the eight VAMCs are not generalizable. VAMC nursing officials--nurse executives who are responsible for all nursing care at VAMCs and nurse managers who are responsible for supervising RNs on VAMC inpatient units--GAO interviewed reported that although VA inpatient RNs are required to input patient data into VA's PCS, they do not rely on the information generated by PCS because it is outdated and inaccurate. These nursing officials noted that VA's PCS does not accurately capture the severity of patients' illnesses or account for all the nursing tasks currently performed on inpatient units. Because of the shortcomings of VA's PCS, nurse managers use data from a variety of sources to help set RN staffing levels for their inpatient units. At four of the eight VAMCs GAO visited, nurse managers told GAO that they set RN staffing levels for their inpatient units by adhering to the historical staffing levels that had been established for the units. Three VAMCs GAO visited set their RN staffing levels using data on the RN staffing levels found in inpatient units in other hospitals with similar characteristics. VA reported it is proposing to develop a new RN staffing system. However, VA has not developed a detailed action plan that includes a timetable for building, testing, and implementing the new nurse staffing system. VA nursing officials reported that VA's ability to retain its RNs is adversely affected by two main factors. First, inpatient RNs reported that they spend too much time performing non-nursing duties such as housekeeping and clerical tasks. Second, even though VAMCs were authorized in 2004 to offer RNs two alternate work schedules that are generally desired by nurses--such as working three12-hour shifts within a week that would be considered full-time for pay and benefits purposes--few nurse executives reported offering these schedules; therefore, few RNs work these schedules. Specifically, according to nurse executives GAO surveyed only about 1 percent of many inpatient units offered alternate schedules and less than 1 percent of RNs actually worked these schedules. The availability of flexible work schedules, for example, working eight 10-hour shifts over a 2-week period, are more widely available among VAMCs but are still limited, according to GAO's survey of nurse executives. Nursing officials and RNs noted other factors affecting retention such as reliance on supplemental staffing strategies--for example, RN overtime--and insufficient professional development opportunities. Both VA nurse executives and nursing officials identified limitations in VA's process for hiring RNs and VA-imposed hiring freezes and lags as major contributing factors causing delays in hiring RNs to fill inpatient vacancies at VAMCs. VA nursing officials reported that hiring freezes and lags at VAMCs and delays resulting from limitations in VA's hiring process can discourage prospective candidates from seeking or following through on applications for employment at these facilities. Although VA has recently taken steps to address some of the factors that are reported to contribute to RN hiring delays, it is too early to determine the extent to which these steps have been effective in reducing hiring delays Fri, 24 Oct 2008 00:00:00 -0400 VA National Initiatives and Local Programs that Address Education and Support for Families of Returning Veterans, October 22, 2008 http://www.gao.gov/new.items/d0922r.pdf As the military operations in Afghanistan and Iraq--known as Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively--have progressed, increasing numbers of OEF/OIF servicemembers have transitioned to veteran status and have begun receiving care from the Department of Veterans Affairs (VA). VA data show that as of March 2008, over 868,000 OEF/OIF servicemembers, including National Guard and Reserve members, had left active duty and become eligible for VA health care, and over 340,000-- about 40 percent--had accessed VA health care services. Returning OEF/OIF veterans may have a range of health care needs, such as treatment for mental health conditions like posttraumatic stress disorder (PTSD), treatment for traumatic brain injury (TBI) or other injuries, or counseling to address difficulties readjusting from wartime military service to civilian life. Family members can play an important role in helping and supporting OEF/OIF veterans. For example, family members may notice symptoms the veteran has, such as anxiety or difficulty sleeping, and encourage the veteran to seek care. They may also help the veteran identify health care services and ensure that the veteran receives needed services. Family members may also provide emotional support--such as encouragement and reassurance--to the veteran. For example, they can support the veteran's efforts to reach rehabilitation goals by providing encouragement and helping the veteran stay motivated to participate in rehabilitation therapy. To help the veteran, family members may need a range of education and support from VA. They may need information about symptoms of mental or physical conditions, how those conditions can affect the veteran and the veteran's family, and the health care resources and treatment options that are available. They may also need information on potential readjustment difficulties that the returning veteran may face, as well as ways in which family members can help and support the veteran. At the same time, family members may experience difficulties--such as stress, uncertainty, or strained relationships-- due to the veteran's medical conditions or readjustment difficulties. According to VA officials, educated and supportive family members can help facilitate a veteran's readjustment and recovery. Congress asked GAO to provide information on the education and support available from VA for families of OEF/OIF veterans. In this report, we describe selected national initiatives and local programs VA has in place that address education and support for families of OEF/OIF veterans who are receiving VA health care. In summary, VA has national initiatives and a range of local programs that address education and support for families of OEF/OIF veterans with post-deployment readjustment, mental health, and other health care needs. VA has two national initiatives that address education and support for families of OEF/OIF veterans, but it is too early to tell what impact these initiatives will have on VA's provision of education and support for families of OEF/OIF veterans. In June 2008, VA established an interdisciplinary Caregiver Advisory Board that is to develop a caregiver assistance program that addresses caregiver issues across VA's various health care disciplines and programs. The board's activities are to include the identification of core caregiver needs systemwide, the development of initial recommendations for VA caregiver support services, and the oversight of eight caregiver assistance pilot programs to assess the feasibility and advisability of various mechanisms to expand and improve VA caregiver assistance services. In April 2007, VA established the VA Advisory Committee on OIF/OEF Veterans and Families, which is responsible for reviewing VA services and benefits; providing advice to the Secretary of Veterans Affairs on health care, benefits, and family support issues; and making recommendations for tailoring VA services and benefits to meet the needs of OEF/OIF veterans and their families. Issues affecting families, including dependents and survivors, is one of nine priorities the committee is expected to address. The VA medical centers we reviewed offered a range of local programs for families of OEF/OIF veterans. We identified examples of medical center programs that addressed the following five issues: post-deployment counseling, PTSD, serious mental illness, caregiver assistance, and serious injuries. Post-deployment counseling programs included an education and support program for veterans who have recently returned from a combat theater and their families. The PTSD programs we identified at VA medical centers included marriage and couples therapy on an individual basis or in a group setting, as well as other types of group-oriented programs. Programs to address serious mental illness included family psychoeducation pilot programs for families of veterans with illnesses such as schizophrenia, bipolar disorder, and major depression. With regard to caregiver assistance, VA announced in December 2007 that it would establish eight caregiver assistance pilot programs at selected VA medical centers nationwide, to examine ways to improve education and provide training and resources for caregivers assisting veterans. Among the VA medical center programs focusing on serious injuries was the Family Care Map pilot program at VA's four Polytrauma Rehabilitation Centers (PRC)--regional centers that provide acute comprehensive medical and rehabilitative care for the severely injured. The Vet Centers we reviewed offered a range of programs for families of OEF/OIF veterans, including group-oriented programs and programs offered on an individual basis, such as couples and family counseling.18 Group-oriented programs addressing issues related to veterans' military service included a relationship enrichment group to provide education and skills to couples to address the impact of PTSD on interpersonal relationships; a parenting class to help veterans and their partners learn effective strategies for successfully raising their children; and a spousal support group providing education about PTSD, TBI, or other deployment-related issues affecting spouses of veterans. Wed, 22 Oct 2008 00:00:00 -0400 Information Technology: DOD and VA Have Increased Their Sharing of Health Information, but Further Actions Are Needed, September 24, 2008 http://www.gao.gov/new.items/d081158t.pdf The National Defense Authorization Act for Fiscal Year 2008 required the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for full interoperability (generally, the ability of systems to use data that are exchanged) and that are compliant with federal standards. The act also established an interagency program office to function as a single point of accountability for the effort and whose role is to implement such systems or capabilities by September 30, 2009. Further, the act required that GAO semi-annually report on the progress made in achieving these goals; its first report was issued in July 2008. In that report, GAO described the departments' progress in sharing electronic health information, developing electronic health records that comply with federal standards, and establishing the interagency program office. In this testimony, GAO discusses its July 2008 report and updated information obtained from the departments. DOD and VA are sharing some, but not all, electronic health information. This includes exchanging some information in computable form, which is the highest level of interoperability. In other cases, data can be viewed only--a lower level of interoperability that still provides clinicians with important information. The departments have undertaken a number of initiatives, resulting in varied sharing capabilities. However, information is still being captured in paper records at many DOD medical facilities, and not all electronic health information is being shared. Further enhancing sharing and interoperability depends on adherence to common standards. The two departments have agreed on numerous common standards and are working with federal groups and each other to ensure adherence to such standards and to align their initiatives with emerging standards. These efforts, led by the Office of the National Coordinator for Health Information Technology (within the Department of Health and Human Services), include identifying relevant existing standards, identifying and addressing overlaps and gaps in the standards, and developing interoperability specifications and certification criteria based on these standards. The departments are also in the process of setting up a new interagency program office that will play a crucial role in accelerating their efforts to achieve electronic health records and capabilities that allow for full interoperability. However, the program office is not expected to be fully operational until the end of the year, which will allow the departments only 9 months to meet the deadline for full interoperability between the departments by September 2009. While DOD and VA have produced a plan for achieving interoperability within this time period, many milestones have yet to be determined. In view of the short timeframe and without a fully established program office and a complete plan with fully established milestones, the departments may be challenged in achieving interoperable electronic health records and capabilities that most effectively serve military service members and veterans. Wed, 24 Sep 2008 00:00:00 -0400 Military Disability System: Increased Supports for Servicemembers and Better Pilot Planning Could Improve the Disability Evaluation Process, September 24, 2008 http://www.gao.gov/new.items/d081137.pdf In February 2007, a series of articles in The Washington Post about conditions at Walter Reed Army Medical Center highlighted problems in the military's disability evaluation system. Subsequently, the Department of the Army, Department of Defense (DOD), and Department of Veterans Affairs (VA) undertook initiatives to address concerns with the disability evaluation process. In 2007, the Army took steps to streamline its process, and DOD and VA began piloting a joint evaluation system to address systemic concerns about timeliness and the potential inefficiency of having separate disability evaluation systems. GAO was asked to examine (1) recent actions by the Army to help servicemembers navigate its disability evaluation process and (2) the status, plans, and challenges of DOD and VA's efforts to pilot and implement a joint disability evaluation system. GAO interviewed Army, DOD, and VA officials; visited Army treatment facilities; and reviewed data from these sources. The Army has taken a number of steps to help servicemembers navigate the disability evaluation process through additional support mechanisms and streamlining efforts, but faces challenges in meeting internal goals and demonstrating impact. Most significantly, the Army has begun hiring more staff to facilitate the process for servicemembers, such as legal personnel, and setting staffing goals for key positions, such as for board liaisons and physicians. However, the Army has not met its internal staffing goals for board liaisons and physicians, and continues to face shortages in legal personnel. The Army has also struggled to meet timeliness goals for case processing and has even experienced negative trends over the last year, despite streamlining initiatives. Furthermore, the Army faces particular challenges in meeting timeliness goals for completing reservists' evaluations, due in part to the challenge of obtaining complete personnel and medical documents from nonmilitary sources. Besides staffing initiatives, the Army has also taken steps to help servicemembers better understand and navigate the process. However, we found that these efforts varied by location, and that many servicemembers we spoke with were unaware of the availability of expert legal counsel. To increase transparency of the disability process, one location we visited afforded servicemembers the opportunity to have the written summary of their medical conditions explained to them, but not all Army locations have adopted this practice. In general, the Army faces challenges in demonstrating that its efforts to date have had an overall positive impact on servicemembers' satisfaction, because it has not implemented a survey that adequately targets and queries servicemembers who are undergoing disability evaluations. Under direction from the agencies' joint Senior Oversight Committee, DOD and VA moved quickly to design and pilot a joint disability evaluation process, but gaps remain in their plans to evaluate the pilot and potentially implement a joint process on a larger scale. DOD and VA have established a comprehensive mechanism for measuring key aspects of the pilot. However, they have not yet decided on criteria for determining whether the joint process is worthy of widespread implementation. In addition, although DOD and VA are in the process of developing surveys to measure servicemember and stakeholder satisfaction, sufficient comparative data on servicemember satisfaction may not be available when the pilot is scheduled to end. DOD and VA are also in the process of tracking challenges that have arisen in implementing the pilot, but they have not yet resolved several challenges associated with expanding the joint process if the pilot is deemed successful. Such challenges include determining who will perform the single physical examination when a VA medical center is not nearby. Beyond these concerns, DOD and VA may ultimately need to prepare for challenges that come with implementing large-scale system changes--such as those envisioned by the pilot. These challenges include sustaining management attention to ensure that the changes are implemented well and are producing the intended results. However, the Senior Oversight Committee's planned January 2009 end raises questions about whether management attention will be maintained over the long term. Wed, 24 Sep 2008 00:00:00 -0400 Veterans Health Administration: Improvements Needed in Design of Controls over Miscellaneous Obligations, September 11, 2008 http://www.gao.gov/new.items/d08976.pdf The Veterans Health Administration (VHA) has been using miscellaneous obligations for over 60 years to record estimates of obligations to be incurred at a later time. The large percentage of procurements recorded as miscellaneous obligations in fiscal year 2007 raised questions about whether proper controls were in place over the authorization and use of billions of dollars. GAO was asked to review (1) how VHA used miscellaneous obligations during fiscal year 2007, and (2) whether Department of Veterans Affairs (VA) policies and procedures were designed to provide adequate controls over their authorization and use. GAO obtained and analyzed available VHA data on miscellaneous obligations, reviewed VA policies and procedures, and reviewed a nongeneralizable sample of 42 miscellaneous obligations at three case study locations. VHA recorded over $6.9 billionof miscellaneous obligationsfor the procurement of mission-related goods and services in fiscal year 2007. According to VHA officials, miscellaneous obligations were used to facilitate payment for goods and services when the quantities and delivery dates are not known. According to VHA data, almost $3.8 billion (55.1 percent) of VHA's miscellaneous obligations was for fee-based medical services for veterans and another $1.4 billion (20.4 percent) was for drugs and medicines. The remainder funded, among other things, state homes for the care of disabled veterans, transportation of veterans to and from medical centers for treatment, and logistical support and facility maintenance for VHA medical centers nationwide. GAO's Standards for Internal Control in the Federal Government states that agency management is responsible for developing detailed policies and procedures for internal control suitable for their agency's operations. However, VA policies and procedures were not designed to provide adequate controls over the authorization and use of miscellaneous obligations with respect to oversight by contracting officials, segregation of duties, and supporting documentation for the obligation of funds. Collectively, these control design flaws increase the risk of fraud, waste, and abuse (including employees converting government assets to their own use without detection). These control design flaws were confirmed in our case studies at VHA Medical centers in Pittsburgh, Pennsylvania; Cheyenne, Wyoming; and Kansas City, Missouri. In May 2008, VHA issued revised guidance on required procedures for authorizing and using miscellaneous obligations. GAO reviewed the revised guidance and found that while it offered some improvement, it did not fully address the specific control design flaws GAO identified. Furthermore, according to VA officials, VA's policies governing miscellaneous obligations have not been subject to legal review by VA's Office of General Counsel. Such a review is essential to ensure that policies and procedures comply with applicable federal appropriations law and internal control standards. Thu, 11 Sep 2008 00:00:00 -0400 Military Personnel: Actions Needed to Strengthen Implementation and Oversight of DOD's and the Coast Guard's Sexual Assault Prevention and Response Programs, September 10, 2008 http://www.gao.gov/new.items/d081146t.pdf In 2004, Congress directed the Department of Defense (DOD) to establish a comprehensive policy to prevent and respond to sexual assaults involving servicemembers. Though not required to do so, the Coast Guard has established a similar policy. This statement addresses implementation and oversight of DOD's and the Coast Guard's programs to prevent and respond to sexual assault incidents. Specifically, it addresses the extent to which DOD and the Coast Guard (1) have developed and implemented policies and procedures to prevent, respond to, and resolve reported sexual assault incidents; (2) have visibility over reports of sexual assault in the military; and (3) exercise oversight over reports of sexual assault involving servicemembers. This statement draws on GAO's report on DOD's and the Coast Guard's Sexual Assault Prevention and Response programs issued on August 29, 2008 (GAO-08-924). For this work, GAO reviewed legislative requirements and DOD and Coast Guard guidance, analyzed sexual assault incident data, and obtained through surveys and interviews the perspective of more than 3,900 servicemembers on sexual assault matters. GAO made 11 recommendations to improve implementation of DOD's and the Coast Guard's programs. These include, for example, reviewing and evaluating guidance and training, and improving oversight of the programs. DOD and the Coast Guard concurred with the recommendations. DOD and the Coast Guard have established policies and programs to prevent, respond to, and resolve reported sexual assault incidents involving servicemembers; however, implementation of the programs is hindered by several factors. GAO found that (1) DOD's guidance may not adequately address some important issues, such as how to implement the program in deployed and joint environments; (2) most, but not all commanders support the programs; (3) required sexual assault prevention and response training is not consistently effective; and (4) factors such as a DOD-reported shortage of mental health care providers affect whether servicemembers who are victims of sexual assault can or do access mental health services. Left unchecked, these challenges can discourage or prevent some servicemembers from using the programs when needed. GAO found, based on responses to its nongeneralizable survey administered to 3,750 servicemembers and a 2006 DOD survey, the most recent available, that occurrences of sexual assault may be exceeding the rates being reported, suggesting that DOD and the Coast Guard have only limited visibility over the incidence of these occurrences. At the 14 installations where GAO administered its survey, 103 servicemembers indicated that they had been sexually assaulted within the preceding 12 months. Of these, 52 servicemembers indicated that they did not report the sexual assault. GAO also found that factors that discourage servicemembers from reporting a sexual assault include the belief that nothing would be done; fear of ostracism, harassment, or ridicule; and concern that peers would gossip. There were also concerns that reporting an incident would negatively affect their careers or unit morale and that a report made using the restricted reporting option would not remain confidential. Although DOD and the Coast Guard have established some mechanisms for overseeing reports of sexual assault, neither has developed an oversight framework--including clear objectives, milestones, performance measures, and criteria for measuring progress--to guide their efforts. GAO's prior work has demonstrated the importance of outcome-oriented performance measures to successful program oversight, and that an effective plan for implementing initiatives and measuring progress can help decision makers determine whether initiatives are achieving desired results. DOD provides information on reports of alleged sexual assaults annually to Congress. However, DOD's report does not include some data that would aid congressional oversight, such as why some sexual assaults could not be substantiated following an investigation. Further, the military services have not provided data that would facilitate oversight and enable DOD to conduct trend analyses. While the Coast Guard voluntarily provides data to DOD for inclusion in its report, this information is not provided to Congress because there is no requirement to do so. Without an oversight framework, as well as more complete data, decision makers in DOD, the Coast Guard, and Congress lack information they need to evaluate the effectiveness of the programs. Wed, 10 Sep 2008 00:00:00 -0400 Federal Real Property: Progress Made in Reducing Unneeded Property, but VA Needs Better Information to Make Further Reductions, September 10, 2008 http://www.gao.gov/new.items/d08939.pdf The Department of Veterans Affairs (VA) operates one of the largest healthcare-related real estate portfolios in the nation. However, many VA facilities are older and no longer well suited to providing care, leaving VA with millions of square feet of property it does not use to capacity (underutilized) or at all (vacant). VA has various legal authorities that allow it to dispose of such property. GAO was asked to identify (1) VA's progress in reducing underutilized or vacant property and how much VA spends operating the underutilized or vacant property it retains; (2) VA's use of its various legal authorities to reduce underutilized and vacant property and the extent to which VA tracks how these authorities contribute to reductions; and (3) the challenges VA faces in minimizing underutilized and vacant space and the strategies VA is using to address these challenges. To accomplish these objectives, GAO reviewed VA property data, and visited eight VA locations based on space utilization, use of authorities, and other factors. GAO also interviewed officials from various VA offices and stakeholders. VA has made significant progress in cutting underutilized space in its buildings from 15.4 million square feet in fiscal year 2005 to 5.6 million square feet in fiscal year 2007, and although the number of vacant buildings decreased, the amount of vacant space remained relatively unchanged at approximately 7.5 million square feet. GAO estimated VA spent $175 million in fiscal year 2007 operating underutilized and vacant space at its medical facilities, where 98 percent of such space exists. GAO developed this estimate because VA does not track the cost of operating underutilized and vacant building space at the building level and has not developed a reliable method for doing so. VA's use of various legal authorities such as enhanced-use leases and sharing agreements likely contributed to the overall reduction of underutilized space, but VA does not track the effect of these authorities. Their use provides VA with revenue and services. Revenue comes from such diverse sources as rent for space and money paid for using buildings as film sets, among other things. For example, at Fort Howard, Maryland, in 2006, VA entered into a new enhanced-use lease with a developer to build a retirement community where veterans are given priority for occupancy. However, the lack of building-level information about the extent to which these authorities reduce underutilized or vacant space or provide benefits such as revenue or services means that VA cannot track, monitor, or evaluate their impact or determine which authorities have the greatest effect from year to year. VA faces several challenges to minimizing underutilized and vacant space and is using strategies at some facilities to mitigate them. One challenge is location: VA officials reported difficulty finding entities interested in using underutilized or vacant property in areas with low property values. Another challenge is cost: many of VA's underutilized or vacant buildings are in poor condition and require an estimated $3 billion in repairs before they can be fully utilized. Finally, competing stakeholder interests and legal and budgetary limitations can further impede VA's efforts. To mitigate these challenges, individual VA locations have used strategies such as improving communication with veterans groups and other external stakeholders, obtaining support from internal stakeholders, and entering into public-private partnerships. Wed, 10 Sep 2008 00:00:00 -0400 Defense Health Care: Oversight of Military Services' Post-Deployment Health Reassessment Completion Rates Is Limited, September 4, 2008 http://www.gao.gov/new.items/d081025r.pdf Military servicemembers engaged in combat tours in Afghanistan and Iraq are at risk of developing combat-related mental health conditions, including post-traumatic stress disorder (PTSD). In many cases, signs of potential mental health conditions do not surface until months after servicemembers return from deployment. In 2004, Army researchers published a series of articles that indicated a significant increase in the number of servicemembers reporting mental health concerns 90 to 120 days after returning from deployment, compared with mental health concerns reported before or soon after deployment. These findings led the Department of Defense (DOD) in March 2005 to develop requirements and policies for the post-deployment health reassessment (PDHRA) as part of its continuum of deployment health assessments for servicemembers. PDHRA is a screening tool for military servicemembers; it is designed to identify and address their health concerns--including mental health concerns--90 to 180 days after return from deployment. Servicemembers answer a set of questions about their physical and mental health conditions and concerns, and health care providers review the answers and refer servicemembers for further evaluation and treatment if necessary. A November 2007 study showed that a larger number of servicemembers indicated mental health concerns on their PDHRAs than on assessments earlier in their deployment cycles. Although DOD established PDHRA requirements and policies, it gave the military services discretion to implement them to meet their unique needs as long as the services adhere to the requirements and policies. DOD oversees the military services' compliance with PDHRA requirements through its deployment health assessment quality assurance program and is required to report on the quality assurance program annually to the Armed Services Committees of the House of Representatives and Senate. In June 2007, we reported that DOD's oversight of its deployment health assessments does not provide DOD or Congress with the information needed to evaluate DOD and the military services' compliance with deployment health assessment requirements. That report is part of a body of work in which we identified weaknesses in DOD's quality assurance program. The Senate Committee on Armed Services directed us to review DOD's oversight of PDHRA, and the House Committee on Armed Services and 11 senators also expressed interest in this work. In this report, we focus on how DOD ensures that servicemembers complete the PDHRA. Specifically, we discuss how well DOD's quality assurance program oversees the military services' compliance with the requirement that they ensure that servicemembers complete the PDHRA. DOD's quality assurance program has limitations and does not allow the department to accurately assess whether the military services ensure that servicemembers complete the PDHRA. DOD's quality assurance program relies on quarterly reports from each military service, monthly reports from AFHSC, and site visits to military installations to oversee the military services' compliance with deployment health assessment requirements, including completion of PDHRA. Each of these sources of information has limitations. The military services' quarterly reports and the monthly reports from AFHSC do not provide the information DOD needs to accurately assess the military services' PDHRA completion rates, which would allow DOD to determine if the military services have ensured that servicemembers completed the PDHRA. These reports do not allow DOD to calculate a completion rate because they do not provide essential information, such as the total number of servicemembers who returned from deployment and should have completed the PDHRA in that quarter or month. Furthermore, DOD cannot use information collected from site visits to validate the services' quarterly reports because the small number of site visits constitutes an insufficient sample for validation purposes. In our 2007 report, we recommended that DOD make enhancements to its quality assurance program, which would allow the department to better evaluate compliance with deployment health requirements. Although DOD concurred with the recommendation included in the 2007 report, as of June 2008, the department had not implemented the recommendation. As a result, DOD's quality assurance program cannot provide decision makers with reasonable assurance that servicemembers complete PDHRA. Overall, DOD concurred with our report's findings and conclusions; however, DOD identified several items in the report that it addressed in written comments. DOD suggested that the function of oversight is beyond the scope of the quality assurance program. Additionally, DOD commented that the department is taking steps that it believes will resolve some of the issues we note in this report. However, DOD did not provide us with relevant details or evidence pertaining to these efforts. We believe that oversight is an essential function of the quality assurance program and that the program currently does not receive the information necessary to perform this function. Thu, 04 Sep 2008 00:00:00 -0400 Military Personnel: DOD's and the Coast Guard's Sexual Assault Prevention and Response Programs Face Implementation and Oversight Challenges, August 29, 2008 http://www.gao.gov/new.items/d08924.pdf In 2004, Congress directed the Department of Defense (DOD) to establish a comprehensive policy to prevent and respond to sexual assaults involving servicemembers. Though not required to do so, the Coast Guard has established a similar policy. In response to congressional requests and Senate Report No. 110-77, GAO evaluated the extent to which DOD and the Coast Guard (1) have developed and implemented policies and programs to prevent, respond to, and resolve sexual assault incidents involving servicemembers; (2) have visibility over reports of sexual assault involving servicemembers; and (3) exercise oversight over reports of sexual assault involving servicemembers. To conduct this review, GAO reviewed legislative requirements and DOD and Coast Guard guidance; analyzed sexual assault incident data; and obtained through surveys and interviews the perspective on sexual assault matters of more than 3,900 servicemembers. DOD and the Coast Guard have established polices and programs to prevent, respond to, and resolve reported sexual assault incidents involving servicemembers; however, implementation of the programs is hindered by several factors. GAO found that (1) DOD's guidance may not adequately address some important issues, such as how to implement its program in deployed and joint environments; (2) most, but not all, commanders support the programs; (3) required sexual assault prevention and response training is not consistently effective; and (4) factors such as a DOD-reported shortage of mental health care providers affect whether servicemembers who are victims of sexual assault can or do access mental health services. Left unchecked, these challenges can discourage or prevent some servicemembers from using the programs when needed. GAO found, based on responses to its nongeneralizable survey administered to 3,750 servicemembers stationed at military installations in the United States and overseas and a 2006 DOD survey, the most recent available, that occurrences of sexual assault may be exceeding the rates being reported, suggesting that DOD and the Coast Guard have only limited visibility over the incidence of these occurrences. At the 14 installations where GAO administered its survey, 103 servicemembers indicated that they had been sexually assaulted within the preceding 12 months. Of these, 52 servicemembers indicated that they did not report the sexual assault. GAO also found that factors that discourage servicemembers from reporting a sexual assault include the belief that nothing would be done; fear of ostracism, harassment, or ridicule; and concern that peers would gossip. Although DOD has established some mechanisms for overseeing reports of sexual assault, and the Coast Guard is beginning to do so, neither has developed an oversight framework--including clear objectives, milestones, performance measures, and criteria for measuring progress--to guide its efforts. In compliance with statutory requirements, DOD reports data on sexual assault incidents involving servicemembers to Congress annually. However, DOD's report does not include some data that would aid congressional oversight, such as why some sexual assaults could not be substantiated following an investigation. Further, the military services have not provided data that would facilitate oversight and enable DOD to conduct trend analyses. While the Coast Guard voluntarily provides data to DOD for inclusion in its report, this information is not provided to Congress because there is no requirement to do so. To provide further oversight of DOD's programs, Congress, in 2004, directed the Defense Task Force on Sexual Assault in the Military Services to conduct an examination of matters relating to sexual assault in the Armed Forces. However, as of July 2008, the task force had not yet begun its review. Without an oversight framework, as well as more complete data, decision makers in DOD, the Coast Guard, and Congress lack information they need to evaluate the effectiveness of the programs. Fri, 29 Aug 2008 00:00:00 -0400 Veterans Health Administration: Improvements Needed in Design of Controls over Miscellaneous Obligations, July 31, 2008 http://www.gao.gov/new.items/d081056t.pdf The Veterans Health Administration (VHA) has been using miscellaneous obligations for over 60 years to record estimates of obligations to be incurred at a later time. The large percentage of procurements recorded as miscellaneous obligations in fiscal year 2007 raised questions about whether proper controls were in place over the authorization and use of billions of dollars. GAO's testimony provides preliminary findings related to (1) how VHA used miscellaneous obligations during fiscal year 2007, and (2) whether the Department of Veterans' Affairs (VA) policies and procedures were designed to provide adequate controls over their authorization and use. GAO recently provided its related draft report to the Secretary of Veterans Affairs for review and comment and plans to issue its final report as a follow-up to this testimony. GAO obtained and analyzed available VHA data on miscellaneous obligations, reviewed VA policies and procedures, and reviewed a nongeneralizable sample of 42 miscellaneous obligations at three case study locations. GAO's related draft report includes four recommendations to strengthen internal controls governing the authorization and use of miscellaneous obligations, in compliance with applicable federal appropriations law and internal control standards. VHA recorded over $6.9 billion of miscellaneous obligations for the procurement of mission-related goods and services in fiscal year 2007. According to VHA officials, miscellaneous obligations were used to facilitate the payment for goods and services when the quantities and delivery dates are not known. According to VHA data, almost $3.8 billion (55.1 percent) of VHA's miscellaneous obligations was for fee-based medical services for veterans and another $1.4 billion (20.4 percent) was for drugs and medicines. The remainder funded, among other things, state homes for the care of disabled veterans, transportation of veterans to and from medical centers for treatment, and logistical support and facility maintenance for VHA medical centers nationwide. GAO's Standards for Internal Control in the Federal Government states that agency management is responsible for developing detailed policies and procedures for internal control suitable for their agency's operations. However, based on GAO's preliminary results, VA policies and procedures were not designed to provide adequate controls over the authorization and use of miscellaneous obligations with respect to oversight by contracting officials, segregation of duties, and supporting documentation for the obligation of funds. Collectively, these control design flaws increase the risk of fraud, waste, and abuse (including employees converting government assets to their own use without detection). These control design flaws were confirmed in the case studies at Pittsburgh, Cheyenne, and Kansas City. In May 2008, VA issued revised guidance concerning required procedures for authorizing and using miscellaneous obligations. GAO reviewed the revised guidance and found that while it offered some improvement, it did not fully address the specific control design flaws GAO identified. Furthermore, according to VA officials, VA's policies governing miscellaneous obligations have not been subject to legal review by VA's Office of General Counsel. Such a review is essential in ensuring that the policies and procedures comply with applicable federal appropriations law and internal control standards. Thu, 31 Jul 2008 00:00:00 -0400 Electronic Health Records: DOD and VA Have Increased Their Sharing of Health Information, but More Work Remains, July 28, 2008 http://www.gao.gov/new.items/d08954.pdf Under the National Defense Authorization Act for Fiscal Year 2008, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) are required to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for full interoperability (generally, the ability of systems to use data that are exchanged) and that are compliant with federal standards. The act also established a joint interagency program office to act as a single point of accountability for the effort, whose function is to implement such systems or capabilities by September 30, 2009. Further, the act required that GAO semi-annually report on the progress made in achieving these goals. For this first report, GAO describes the departments' progress to date in sharing electronic health information, developing electronic health records that comply with federal standards, and setting up the joint interagency program office. To do so, GAO reviewed its past work, analyzed agency documentation, and conducted interviews with agency officials. DOD and VA are sharing some, but not all, electronic health information at different levels of interoperability. Specifically, pharmacy and drug allergy data on about 18,300 patients who receive care from both departments are exchanged at the highest level of interoperability--that is, in computable form; at this level, the data are in a standardized format that a computer application can act on (for example, to provide alerts to clinicians of drug allergies). In other cases, data can be viewed only--a lower level of interoperability that still provides clinicians with important information. However, not all electronic health information is yet shared, and information is still captured on paper at many DOD medical facilities. According to the departments, a DOD/VA Information Interoperability Plan (targeted for approval in August 2008) is to address these and other issues and define tasks required to guide the development and implementation of an interoperable electronic health record capability. If properly developed and implemented, the plan could help the departments achieve the goal of seamless sharing of health information. DOD and VA have agreed upon numerous common standards that allow them to share health data, which include standards that are part of current and emerging federal interoperability specifications. This collaboration provided the essential foundation for the departments to begin sharing computable health data. The departments are currently participating in recent initiatives led by the Office of the National Coordinator for Health Information Technology (within the Department of Health and Human Services) that are aimed at promoting the adoption of federal standards and broader use of electronic health records. These initiatives include identifying relevant existing standards, identifying and addressing overlaps and gaps in the standards, and developing interoperability specifications and certification criteria based on these standards. The involvement of the departments in these activities is an important mechanism for aligning their electronic health records with emerging federal standards. In establishing the joint interagency program office, Congress directed the departments to develop an implementation plan for setting up the office and carrying out related activities (such as validating and establishing requirements for interoperable health capabilities). The departments' effort to set up the program office is still in its early stages. Leadership positions in the office are not yet permanently filled, staffing is not complete, and facilities to house the office have not been designated. Further, the implementation plan is currently in draft, and although it includes schedules and milestones, dates for several activities have not yet been determined (such as implementing a capability to share immunization records), even though all capabilities are to be achieved by September 2009. Without a fully established program office and a finalized implementation plan with set milestones, the departments may be challenged in meeting the required date for achieving interoperable electronic health records and capabilities. Mon, 28 Jul 2008 00:00:00 -0400 VA Health Care: Ineffective Controls over Medical Center Billings and Collections Limit Revenue from Third-Party Insurance Companies, June 10, 2008 http://www.gao.gov/new.items/d08675.pdf GAO previously reported that continuing problems in billing and collection processes at the Department of Veterans Affairs (VA) impaired VA's ability to maximize revenue from private (third-party) insurance companies. VA has undertaken several initiatives to address these weaknesses. GAO was asked to perform a follow-up audit to (1) evaluate VA billing controls, (2) assess VA-wide controls for collections, (3) determine the effectiveness of VA-wide oversight, and (4) provide information on the status of key VA improvement initiatives. GAO performed case study analyses of the third-party billing function, statistically tested controls over collections, and reviewed current oversight policies and procedures. GAO also reviewed and summarized VA information on the status of key management initiatives to enhance third-party revenue. GAO's case study analysis of unbilled patient encounters at 18 medical centers, including 10 medical centers with low billing performance and 8 medical centers under VA's Consolidated Patient Account Centers (CPAC) initiative considered to be high performers, found documentation, coding, and billing errors and inadequate management oversight for approximately $1.7 billion deemed unbillable in fiscal year 2007. Although some medical services are unbillable, such as service-connected treatment, management has not validated reasons for related unbilled amounts of about $1.4 billion to assure that all billable costs are charged to third-party insurers. Because insurers will not accept improperly coded bills and they generally will not pay bills received more than 1 year after the date that medical services were provided, it is important that coding for medical services is accurate and timely. The 10 case study medical centers reported average days to bill ranging from 109 days to 146 days in fiscal year 2007 and significant coding and billing errors and other problems that accounted for over $254 million, or 21 percent, of the $1.2 billion in unbilled medical services costs. Although GAO determined that CPAC officials performed a more thorough review of billings, GAO's analysis of unbilled amounts for the 8 CPAC centers found problems that accounted for $37.5 million, or about 7 percent, of the $508.7 million in unbilled medical services costs. In addition, GAO's VA-wide statistical tests of collections follow-up on unpaid third-party bills of $250 or more identified significant control failures related to timely follow-up and documentation of contacts with third-party insurers on outstanding receivables. VA guidance requires medical center accounts receivable staff to make up to three follow-up contacts, as necessary, on outstanding third-party receivables. GAO's tests identified high failure rates VA-wide as well as for CPAC and non-CPAC medical centers related to the requirement for timely follow up with third-party insurers on unpaid amounts. GAO's tests also found high failure rates associated with the lack of documentation of follow-up contacts. VA lacks policies and procedures and a full range of standardized reports for effective management oversight of VA-wide third-party billing and collection operations. Further, although VA management has undertaken several initiatives to enhance third-party revenue, many of these initiatives are open-ended or will not be implemented for several years. Until these shortcomings are addressed, VA will continue to fall short of its goal to maximize third-party revenue, thereby placing a higher burden on taxpayers. Tue, 10 Jun 2008 00:00:00 -0400 DOD Health Care: Mental Health and Traumatic Brain Injury Screening Efforts Implemented, but Consistent Pre-Deployment Medical Record Review Policies Needed, May 30, 2008 http://www.gao.gov/new.items/d08615.pdf The John Warner National Defense Authorization Act for Fiscal Year 2007 included provisions regarding mental health concerns and traumatic brain injury (TBI). GAO addressed these issues as required by the Act. In this report GAO discusses (1) DOD efforts to implement pre-deployment mental health screening; (2) how post-deployment mental health referrals are tracked; and (3) screening requirements for mild TBI. GAO selected the Army, Marine Corps, and Army National Guard for the review. GAO reviewed documents and interviewed DOD officials and conducted site visits to three military installations where the pre-deployment health assessment was being conducted. DOD has taken positive steps to implement mental health standards for deployment and pre-deployment mental health screening. However, DOD's policies for providers to review medical records are inconsistent. DOD issued minimum mental health standards that servicemembers must meet in order to be deployed to a combat theater and identified the pre-deployment health assessment as a mechanism for ensuring their use in making deployment decisions. DOD's November 2006 policy implementing these deployment standards requires a review of servicemember medical records during the pre-deployment health assessment. However, DOD's August 2006 Instruction on Deployment Health, which implements policy and prescribes procedures for conducting pre-deployment health assessments, is silent on whether such a review is required. Because of this inconsistency, providers determining if Operation Enduring Freedom and Operation Iraqi Freedom servicemembers meet DOD's mental health deployment standards may not have complete medical information. Health care providers at the installations GAO visited where the post-deployment health assessment (PDHA) is conducted manually track whether servicemembers who receive mental health referrals from the PDHA make or complete appointments with mental heath providers. Because health care providers conducting the PDHA and making referrals from the PDHA may not have an ongoing relationship with referred servicemembers, health care providers responsible for tracking referrals at these installations have developed manual systems to track servicemembers to ensure that they made or kept their appointments for evaluations. Tracking is more challenging for Guard and Reserve units because their servicemembers generally receive civilian care. Guard and Reserve units do not know if servicemembers used civilian care to complete their PDHA referrals unless disclosed by the servicemembers, which they may be reluctant to do because of stigma concerns. DOD is addressing the TBI requirement through implementing screening for mild TBI in its PDHA and prior to deployment. DOD has also provided guidance and training for health care providers. DOD in January 2008 added TBI screening to the PDHA, and plans to require screening of all servicemembers for mild TBI prior to deployment beginning in July 2008. The TBI screening questions on the PDHA assess the servicemember's exposure to events that may have increased the risk of a TBI and the servicemember's symptoms. The TBI screening questions to be used prior to deployment are similar to those on the PDHA. Prior to DOD's screening efforts, several installations had been screening servicemembers for mild TBI before or after deployment. An official from the Defense and Veterans Brain Injury Center told GAO that these initiatives would probably be replaced by the DOD-wide screening. Fri, 30 May 2008 00:00:00 -0400 VA Health Care: Facilities Have Taken Action to Provide Language Access Services and Culturally Appropriate Care to a Diverse Veteran Population, May 28, 2008 http://www.gao.gov/new.items/d08535.pdf The Department of Veterans Affairs (VA) faces challenges in bridging language and cultural barriers as it seeks to provide quality health care services to an increasingly diverse veteran population in terms of race, ethnicity, sex, and age. To meet the needs of veterans with limited English proficiency (LEP), VA issued an LEP Directive that provides guidance for medical centers in assessing language needs and, if needed, developing language access services designed to ensure effective communication between English-speaking providers and those with LEP. In addition, VA is also challenged to deliver health care services in ways that are culturally appropriate--that is, respectful of and responsive to the cultural values of a diverse veteran population. In light of these challenges, GAO was asked to discuss the (1) actions VA has taken to implement its LEP Directive and the status of veterans' utilization of language access services, and (2) efforts VA has made to provide culturally appropriate health care services. GAO reviewed VA's policies and the LEP Directive, interviewed VA officials and reviewed efforts by 6 VA medical centers and 10 other VA facilities to implement VA's LEP Directive and to provide culturally appropriate health care services. GAO also reviewed documents from 17 other VA medical centers related to implementation of the LEP Directive. VA reported that as of June 2007, all of its medical centers had taken action to implement the guidance in VA's LEP Directive. Specifically, medical center officials told VA that they had assessed the language needs of their veteran service populations, and, if necessary, developed language assistance policies and offered language access services, including providing translated materials and interpretation services. The VA medical centers GAO reviewed provided translated materials to meet the various language needs of their veteran service populations and offered interpretation services as well. For example, VA medical centers maintained a list of bilingual medical center staff who can provide interpretation services during a clinical encounter between a provider and a veteran with LEP. In addition, five of the six VA medical centers GAO reviewed can access telephone interpretation services that are provided through a contract to help ensure that medical staff can communicate with veterans and their families with LEP. According to officials at medical centers GAO reviewed, utilization of language access services is low. However, VA officials told GAO that they expect the demand for language access services to grow as the increasingly diverse military servicemember population transitions to veteran status. VA medical centers are addressing the need for culturally appropriate health care services through staff training and tailoring health care services. Medical centers provide training for medical center staff to facilitate the delivery of culturally appropriate health care services including an annual mandatory training on the health care needs of veterans in various age groups. VA medical centers and other VA facilities GAO reviewed have implemented a variety of measures to meet the needs of their culturally diverse veteran populations. For example, three VA facilities GAO reviewed offer spiritual services, such as the use of medicine men and traditional healing rituals, in order to meet the needs of Native American veterans. Also, VA has minority veterans program coordinators at each medical center to identify barriers to health care for minorities and advise medical center officials in developing services to make health care more accessible and culturally appropriate for minority veteran populations. VA medical centers GAO reviewed have also initiated outreach efforts to promote the availability of culturally appropriate care. In commenting on a draft of this report, VA stated that it agreed with the information presented as it pertained to VA. Wed, 28 May 2008 00:00:00 -0400 VA and DOD Health Care: Progress Made on Implementation of 2003 President's Task Force Recommendations on Collaboration and Coordination, but More Remains to Be Done, April 30, 2008 http://www.gao.gov/new.items/d08495r.pdf Improving collaboration and health resource sharing between the Department of Veterans Affairs (VA) and the Department of Defense (DOD) has been the focus of numerous efforts by Congress and the executive branch for more than two decades. In 1982, Congress passed the Veterans' Administration and Department of Defense Health Resources Sharing and Emergency Operations Act (Sharing Act), which authorized VA and DOD health care facilities to partner and enter into sharing agreements to buy, sell, and barter medical and support services. Since then, Congress has passed additional legislation to continue to promote VA and DOD health resource sharing. However, in previous work we have pointed out continuing barriers to such efforts, including incompatible computer systems that affect the exchange of patient health information, inconsistent reimbursement and budgeting policies, and burdensome processes for approving agreements between the departments. On May 28, 2001, the President established the 15-member President's Task Force to Improve Health Care Delivery for Our Nation's Veterans. The task force's mission was to identify ways to improve coordination and sharing between VA and DOD in order to improve health care for servicemembers and veterans. The task force reviewed barriers and challenges in several areas related to coordination, including leadership, transition to veteran status, and improving quality of health care. In May 2003, it made recommendations to VA and DOD to increase collaboration and coordination between the two departments to improve health care delivery. The task force also recommended that the administration take action through the Department of Health and Human Services (HHS) to help improve VA and DOD collaboration, and that Congress take additional action to improve such collaboration. Other more recent task force and commission reports have voiced similar concerns and identified more areas for improvement. Congress asked us to examine the status of VA and DOD's efforts in implementing the 2003 task force recommendations. Specifically, this report describes the extent to which VA and DOD have implemented the recommendations of the 2003 President's Task Force to Improve Health Care for Our Nation's Veterans related to collaboration and coordination. In summary, we found that VA and DOD have made progress in implementing the task force recommendations, but more remains to be done to fully implement all task force recommendations. Seven of the recommendations have been fully implemented and 11 have been partially implemented. We could not determine the status of 1 because of insufficient information, and 1 does not require VA or DOD action. Wed, 30 Apr 2008 00:00:00 -0400 VA Health Care: Recruitment and Retention Challenges and Efforts to Make Salaries Competitive for Nurse Anesthetists, April 9, 2008 http://www.gao.gov/new.items/d08647t.pdf Certified registered nurse anesthetists (CRNA), registered nurses who have completed a master's degree program in nurse anesthesia, provide the majority of anesthesia care in the Department of Veterans Affairs (VA) medical facilities. There are approximately 500 VA-employed CRNAs (VA CRNA) who provide care to veterans in VA medical facilities. While the demand for CRNAs has increased, many employed by VA are nearing retirement eligibility age. Concerns have been raised about the challenges VA may face in making VA CRNA salaries competitive in order to maintain its VA CRNA workforce, particularly in local markets that can be highly competitive. This testimony is based on GAO work reported in VA Health Care: Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists, (GAO-08-56, Dec. 13, 2007). This testimony (1) identifies workforce challenges that VA medical facilities experience related to VA CRNAs, and (2) identifies a key mechanism that VA medical facilities have to help make VA CRNA salaries competitive and the extent to which VA facilities use this mechanism. For the December 2007 report, GAO analyzed surveys sent to VA chief anesthesiologists, VA human resources officers, and VA CRNAs. GAO also visited eight VA medical facilities and interviewed facility officials about efforts to recruit and retain VA CRNAs. GAO reported in December 2007 that VA medical facilities had challenges recruiting and retaining VA CRNAs. In GAO's report, most surveyed officials said that they had difficulty recruiting VA CRNAs at their facilities. The challenge of recruiting VA CRNAs affected the ability of VA officials to reduce existing VA CRNA vacancy rates--the number of unfilled VA CRNA positions--at their medical facilities. Vacancy rates varied across VA and, according to GAO's survey, impacted the delivery of services at VA medical facilities. On the basis of its survey results, GAO also found that in addition to their current recruiting challenges, VA medical facilities would likely face a challenge retaining VA CRNAs in the next 5 years due to the number of VA CRNAs projected to either retire from or leave VA. VA medical facility officials reported in GAO's survey that the recruitment and retention challenges were caused primarily by the low level of VA CRNA salaries when compared with CRNA salaries in local market areas. GAO also reported that VA's locality pay system (LPS) is a key mechanism VA medical facilities can use to determine whether to adjust VA CRNA salaries to help the facilities remain competitive with CRNA salaries in local market areas. GAO also reported that the majority of VA medical facilities that employ VA CRNAs used LPS. However, at the eight VA medical facilities it visited, GAO found that although the facilities used VA's LPS, the majority of them did not fully follow VA's LPS policy correctly in either 2005 or 2006. The problems some VA medical facilities had fully following VA's LPS policy, along with the explanations of facility officials, indicated that VA had not provided adequate training on its LPS policy. As a result, VA medical facility officials cannot ensure that VA CRNA salaries have been adjusted as needed to be competitive in local market areas. Training on the LPS is necessary to help ensure that VA medical facilities are competitive as an employer. In December 2007, GAO recommended that VA expedite the development and implementation of a training course for VA medical facility officials responsible for compliance with the policy. VA agreed with GAO's recommendation and in comments on GAO's draft report stated that it had developed a draft action plan for training staff on its LPS policy. VA anticipated that the online training course would be available by the end of fiscal year 2008. Wed, 09 Apr 2008 00:00:00 -0400 DOD Pharmacy Program: Continued Efforts Needed to Reduce Growth in Spending at Retail Pharmacies, April 4, 2008 http://www.gao.gov/new.items/d08327.pdf Estimated to reach $15 billion by 2015, the Department of Defense's (DOD) prescription drug spending has been a growing concern for the federal government. The John Warner National Defense Authorization Act (NDAA) for Fiscal Year 2007 required GAO to examine DOD's pharmacy benefits program. Specifically, as discussed with the committees of jurisdiction, GAO examined DOD's prescription drug spending trends from fiscal years 2000 through 2006 and DOD's key efforts to limit its prescription drug spending. To conduct this work, GAO analyzed DOD's data on spending trends, including trends in beneficiary pharmacy use. GAO also assessed DOD's cost avoidance data and the agency's efforts to limit spending through its uniform formulary, which is a list of preferred drugs available to all beneficiaries. GAO interviewed DOD officials about these and other efforts to limit spending. Collectively, DOD's drug spending at retail pharmacies, military treatment facilities (MTF), and the TRICARE Mail Order Pharmacy (TMOP) more than tripled from $1.6 billion in fiscal year 2000 to $6.2 billion in fiscal year 2006. Retail pharmacy spending drove most of this increase, rising almost ninefold from $455 million to $3.9 billion and growing from 29 percent of overall drug spending to 63 percent. The growth in retail spending reflects the fact that federal pricing arrangements, which generally result in prices lower than retail prices, were not applied to drugs dispensed at retail pharmacies during this time. In addition, beneficiaries' increased use of retail pharmacies over the less costly options of MTFs or the TMOP exacerbated the effect of these higher prices. For example, 2 million beneficiaries used only retail pharmacies in fiscal year 2006--double the number in fiscal year 2002. However, future growth in retail pharmacy spending may slow as the NDAA for Fiscal Year 2008 now requires that federal pricing arrangements be applied to drugs dispensed at retail pharmacies. DOD's key efforts to limit its prescription drug spending have included its use of the uniform formulary and beneficiary outreach to encourage use of the TMOP. By leveraging its uniform formulary, which was implemented in fiscal year 2005, the agency avoided about $447 million in drug costs in fiscal year 2006 and $916 million in fiscal year 2007, according to DOD's data. In exchange for formulary placement, manufacturers can offer DOD prices below those otherwise available through federal pricing arrangements, which at the time of our review were applied only to drugs dispensed at MTFs and the TMOP. To compensate, in August 2006, DOD began obtaining voluntary manufacturer rebates for formulary drugs dispensed at retail network pharmacies. As of October 1, 2007, DOD collected about $28 million in rebates for fiscal year 2007. Also in 2006, DOD began beneficiary outreach--through quarterly newsletters and other materials--emphasizing the TMOP's convenience and cost savings. To help beneficiaries transfer their prescriptions to the TMOP, DOD launched the Member Choice Center in August 2007 and plans to target related outreach toward beneficiaries who frequently obtain high-cost drugs from retail pharmacies. DOD's ongoing efforts are important to limit future prescription drug spending. In addition, DOD has the recommendations of a congressionally mandated task force to consider--that copayment policies be changed to encourage beneficiaries to purchase preferred drugs from cost-effective sources. The agency is also undertaking a fundamental reform--the NDAA for Fiscal Year 2008 requirement to apply federal pricing arrangements to drugs dispensed at retail pharmacies--that could have an even greater impact on spending. DOD will need to carefully monitor the impact of this new requirement along with its ongoing efforts in order to assess the progress in controlling spending. DOD will also need to determine what types of additional efforts, if any, will be necessary to ensure the fiscal sustainability of its pharmacy benefits program. Fri, 04 Apr 2008 00:00:00 -0400 Military Personnel: Better Debt Management Procedures and Resolution of Stipend Recoupment Issues Are Needed for Improved Collection of Medical Education Debts, April 1, 2008 http://www.gao.gov/new.items/d08612r.pdf Military physicians and other health care professionals are needed to support operational forces during war or other military conflicts and to maintain the well-being of the forces during nonoperational periods. These professionals also provide health care services to military retirees and dependents. The Department of Defense (DOD) acquires its health care professionals primarily through two programs--the Armed Forces Health Professions Scholarship Program and the Financial Assistance Program--with which it recruits and trains military health care providers who fill medical specialty positions. These programs offer participants reimbursement for tuition, books, fees, other education expenses, and a stipend, which is a fixed amount of money given to the participants on a monthly basis, in return for an active duty service obligation. Recruiting and retaining highly qualified health care professionals, however, is becoming more challenging for each of the military services. The added stresses of repeated deployments and the general perceptions of war, along with the potential for health care providers to earn significantly more money outside of DOD, have caused some professionals to choose to separate themselves from military service, even after DOD has paid for all or part of their medical education. Because DOD medical training programs can take years and are a costly investment, DOD is negatively affected both financially and operationally when individuals do not fulfill their active duty obligations. The Conference Report accompanying the National Defense Authorization Act for Fiscal Year 2008 directed the Comptroller General of the United States to report to the congressional defense committees by April 1, 2008, on the number of Health Professions Scholarship Program or Financial Assistance Program participants who do not enter active duty following completion of the program of studies for which they were enrolled, including the extent to which the military services have sought and received reimbursement for stipends or annual grants paid. Accordingly, we examined the extent to which (1) participants in the Health Professions Scholarship Program or Financial Assistance Program fail to enter active duty service, as obligated; (2) DOD has procedures in place to recoup expenditures paid under the Health Professions Scholarship Program or Financial Assistance Program to participants who failed to meet their contractual obligations; and, (3) DOD has specifically sought and received reimbursement for stipends. Only a small percentage of the participants in the Armed Forces Health Professions Scholarship Program and Financial Assistance Program have failed to complete their education or serve their active duty service obligation. Our analyses of service and DFAS data showed that, for fiscal years 2003 through 2007, fewer than 1 percent (171) of the total number of participants (19,921) withdrew from the programs or, alternatively, graduated but did not go on to active duty service. The most common reasons cited by these participants were voluntary withdrawal from the program, medical disqualification, and academic failure. Upon withdrawal or release from the program, participants are obligated to reimburse the government for all or some portion of their medical education expenses unless relieved of that obligation by their respective service secretary. DOD has procedures in place to recoup medical education expenditures from participants who fail to complete their education or serve their active duty obligation, and many cases we reviewed were processed in a timely manner. However, in some cases, it took more than 5 years from the time recoupment actions on individuals' debts were initiated until the time DFAS established an official debt account and began collection efforts. Until DOD takes steps to clarify the roles and responsibilities for initiating debt recoupment actions, follow established debt collection procedures, and improve communications, its collection of medical education debts will be hindered by confusion and inconsistency. DOD's practice of seeking reimbursement for stipends has changed over time, and the department's efforts to recoup money are diminished by conflicting views among the services and DFAS over DOD's legal authority to recoup stipends. Without a clear determination regarding the recoupability of stipends and communication of this determination to all program participants, DOD is not in a position to ensure that it is collecting all of the money to which it is authorized or collecting reimbursements consistently across the services. Further, program participants do not have full and accurate information regarding DOD's recoupment policies. Tue, 01 Apr 2008 00:00:00 -0400 Federal Compensation Programs: Perspectives on Four Programs for Individuals Injured by Exposure to Harmful Substances, April 1, 2008 http://www.gao.gov/new.items/d08628t.pdf The U.S. federal government has played an ever-increasing role in providing benefits to individuals injured as a result of exposure to harmful substances. Over the years, it has established several key compensation programs, including the Black Lung Program, the Vaccine Injury Compensation Program (VICP), the Radiation Exposure Compensation Program (RECP), and the Energy Employees Occupational Illness Compensation Program (EEOICP), which GAO has reviewed in prior work. Most recently, the Congress introduced legislation to expand the benefits provided by the September 11th Victim Compensation Fund of 2001. As these changes are considered, observations about other federal compensation programs may be useful. In that context, GAO's testimony today will focus on four federal compensation programs, including (1) the structure of the programs; (2) the cost of the programs through fiscal year 2004, including initial cost estimates and the actual costs of benefits paid, and administrative costs; and (3) the number of claims filed and factors that affect the length of time it takes to finalize claims and compensate eligible claimants. To address these issues, GAO relied on its 2005 report on four federal compensation programs. As part of that work, GAO did not review the September 11th Victim Compensation Fund of 2001. The four federal compensation programs GAO reviewed in 2005 were designed to compensate individuals injured by exposure to harmful substances. However, the structure of these programs differs significantly in key areas such as the agencies that administer them, their funding, benefits paid, and eligibility. For example, although initially funded through annual appropriations, the Black Lung Program is now funded by a trust fund established in 1978 financed by an excise tax on coal and supplemented with additional funds. In contrast, EEOICP and RECP are completely federally funded. Since the inception of the programs, the federal government's role has increased and all four programs have been expanded to provide eligibility to additional categories of claimants, cover more medical conditions, or provide additional benefits. As the federal role for these four programs has grown and eligibility has expanded, so have the costs. Total benefits paid through fiscal year 2004 for two of the programs--the Black Lung Program and RECP--significantly exceeded their initial estimates for various reasons. The initial estimate of benefits for the Black Lung Program developed in 1969 was about $3 billion. Actual benefits paid through 1976--the date when the program was initially to have ended--totaled over $4.5 billion and, benefits paid through fiscal year 2004 totaled over $41 billion. Actual costs for the Black Lung Program significantly exceeded the initial estimate for several reasons, including (1) the program was initially set up to end in 1976 when state workers' compensation programs were to have provided these benefits to coal miners and their dependents, and (2) the program has been expanded several times to increase benefits and add categories of claimants. For RECP, the costs of benefits paid through fiscal year 2004 exceeded the initial estimate by about $247 million, in part because the original program was expanded to include additional categories of claimants. In addition, the annual administrative costs for the programs varied, from approximately $3.0 million for RECP to about $89.5 million for EEOICP for fiscal year 2004. Finally, the number of claims filed for three of the programs significantly exceeded the initial estimates, and the structure of the programs affected the length of time it took to finalize claims and compensate eligible claimants. For the three programs for which initial estimates were available, the number of claims filed significantly exceeded the initial estimates. In addition, the way the programs were structured, including the approval process and the extent to which the programs allow claimants and payers to appeal claims decisions in the courts, affected how long it took to finalize the claims. Some of the claims have taken years to finalize. For example, it can take years to approve some EEOICP claims because of the lengthy process required for one of the agencies involved in the approval process to determine the levels of radiation to which claimants were exposed. In addition, claims for benefits provided by programs in which the claims can be appealed can take a long time to finalize. Tue, 01 Apr 2008 00:00:00 -0400 VA Health Care: Additional Efforts to Better Assess Joint Ventures Needed, March 28, 2008 http://www.gao.gov/new.items/d08399.pdf The Department of Veterans Affairs (VA) and the Department of Defense (DOD) have a long history of partnering to achieve more cost-effective use of health care resources. Their partnerships have evolved to include joint ventures--joint efforts to construct or share medical facilities. VA has maintained eight joint ventures with DOD across the country. VA has also developed partnerships, or affiliations, with university medical schools to obtain health care services for veterans and provide training to medical residents. VA has not entered into a joint venture with an academic affiliate to date. However, several proposals for such joint ventures have surfaced in the last decade. This congressionally requested report discusses the (1) potential benefits and concerns associated with joint ventures and the extent to which they are documented and measured, (2) lessons learned from existing and proposed VA joint ventures, and (3) steps VA has taken to evaluate proposed joint ventures. To address these issues, GAO conducted site visits to and interviews with officials from all existing and proposed joint venture sites. VA and DOD officials identified a number of potential benefits and concerns associated with joint ventures, but they have not routinely or comprehensively documented and measured them. Among the potential benefits, VA and DOD officials and academic affiliate representatives cited improved access to care, lower or avoided costs, and improved training opportunities. While the identified benefits are many, these officials and representatives also cited a number of concerns associated with joint ventures, such as potential conflicts of missions and cultures, a loss of organizational identity and control, staffing uncertainties, and financial risks. Although able to provide anecdotal information of the benefits and concerns associated with joint ventures, officials at the joint ventures do not use performance measures to routinely or comprehensively document and assess the outcomes of the joint ventures. Without such efforts, it is difficult to know to what extent these benefits and concerns have materialized. VA also does not use performance measures at the department level to determine what is being achieved through the joint ventures--thereby making it difficult to determine the overall outcomes of the joint ventures and to hold joint venture partners accountable for results. Officials from VA and DOD and representatives from academic affiliates identified several lessons they have learned from their experiences with the existing and proposed joint ventures. These lessons include the importance of establishing joint committees to work through issues, communicating frequently with their partners, securing leadership buy-in and support at all levels, developing contingency plans, allowing adequate time to implement change, and establishing clear roles and responsibilities. For example, at most VA-DOD joint venture sites, officials have created jointly staffed committees to tackle specific issues, such as clinical, financial, and information management. Also, in New Orleans, Louisiana, VA and its academic affiliate signed a memorandum of understanding that, among other things, identifies the roles and responsibilities of the parties involved in the proposed joint venture negotiations. VA has taken steps to enhance its process for evaluating proposed joint ventures, but additional efforts are warranted. In response to our previous recommendations, VA developed and issued criteria for evaluating joint venture proposals in November 2007. In addition, VA established working groups in Charleston, South Carolina, and New Orleans to examine joint venture proposals with academic affiliates. However, VA's criteria for evaluating joint venture proposals are not sufficiently specific, in terms of both the definition and the application of the criteria. As a result, VA's evaluations of joint venture proposals could be inconsistent and, therefore, may not serve as a reliable guide for federal investments in joint ventures. In addition, the criteria are not tailored to take into account differences in prospective joint venture partners to ensure that VA applies the appropriate level of review and scrutiny to proposals. Fri, 28 Mar 2008 00:00:00 -0400 DOD and VA: Preliminary Observations on Efforts to Improve Care Management and Disability Evaluations for Servicemembers, February 27, 2008 http://www.gao.gov/new.items/d08514t.pdf In February 2007, a series of Washington Post articles about conditions at Walter Reed Army Medical Center highlighted problems in the Army's case management of injured servicemembers and in the military's disability evaluation system. These deficiencies included a confusing disability evaluation process and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. These reported problems prompted various reviews and commissions to examine the care and services to servicemembers. In response to problems at Walter Reed and subsequent recommendations, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement updates GAO's September 2007 testimony and is based on ongoing work to (1) assess actions taken by the Army to help ill and injured soldiers obtain health care and navigate its disability evaluation process; and to (2) describe the status, plans, and challenges of DOD and VA efforts to implement a joint disability evaluation system. GAO's observations are based largely on documents obtained from and interviews with Army, DOD, and VA officials. The facts contained in this statement were discussed with representatives from the Army, DOD, and VA. Over the past year, the Army significantly increased support for servicemembers undergoing medical treatment and disability evaluations, but challenges remain. To provide a more integrated continuum of care for servicemembers, the Army created a new organizational structure--the Warrior Transition Unit--in which servicemembers are assigned key staff to help manage their recovery. Although the Army has made significant progress in staffing these units, several challenges remain, including hiring medical staff in a competitive market, replacing temporarily borrowed personnel with permanent staff, and getting eligible servicemembers into the units. To help servicemembers navigate the disability evaluation process, the Army is increasing staff in several areas, but gaps and challenges remain. For example, the Army expanded hiring of board liaisons to meet its goal of 30 servicemembers per liaison, but as of February 2008, the Army did not meet this goal at 11 locations that support about half of servicemembers in the process. The Army faces challenges hiring enough liaisons to meet its goals and enough legal personnel to help servicemembers earlier in the process. To address more systemic issues, DOD and VA promptly designed and are now piloting a streamlined disability evaluation process. In August 2007, DOD and VA conducted an intensive 5-day exercise that simulated alternative pilot approaches using previously-decided cases. This exercise yielded data quickly, but there were trade-offs in the nature and extent of data that could be obtained in that time frame. The pilot began with "live" cases at three treatment facilities in the Washington, D.C. area in November 2007, and DOD and VA may consider expanding the pilot to additional sites around July 2008. However, DOD and VA have not finalized their criteria for expanding the pilot beyond the original sites and may have limited pilot results at that time. Significantly, current evaluation plans lack key elements, such as an approach for measuring the performance of the pilot--in terms of timeliness and accuracy of decisions--against the current process, which would help planners manage for success of further expansion. Wed, 27 Feb 2008 00:00:00 -0500 VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain, February 8, 2008 http://www.gao.gov/new.items/d08276.pdf Traumatic brain injury (TBI) has emerged as a leading injury among servicemembers serving in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) combat theaters. The widespread use of improvised explosive devices, such as roadside bombs, in these combat theaters increases the likelihood that servicemembers will be exposed to incidents that can cause a TBI. TBIs can vary from mild to severe, and in general, mild TBI can be difficult to identify. Because mild TBI can have lasting effects if not identified and treated, concerns have been raised about how the Department of Veterans Affairs (VA) identifies and treats OEF/OIF veterans with a mild TBI. In this report GAO describes VA's (1) efforts to screen OEF/OIF veterans for mild TBI, (2) steps taken so that those OEF/OIF veterans at risk for mild TBI are evaluated and treated, and (3) challenges in screening and evaluating OEF/OIF veterans for mild TBI. GAO reviewed VA's policies, interviewed VA officials and TBI experts, and reviewed nine VA medical facilities' efforts to implement TBI screening and evaluation processes. To screen OEF/OIF veterans for mild TBI, VA implemented in its medical facilities in April 2007 a computer-based screening tool to identify OEF/OIF veterans who may have a mild TBI. VA's tool consists of questions that VA must ask all OEF/OIF veterans when they come to a VA medical facility for care. VA issued a policy requiring its medical facilities to use the tool to screen all OEF/OIF veterans who present for care in any clinic in the facility, including primary care and specialty care clinics. The policy has guidance on what types of providers may administer the tool and directs providers that a positive screening result requires a further evaluation by a specialist to determine if the veteran has mild TBI. VA's screening efforts depend on its TBI screening tool and VA recognizes the importance of determining the tool's clinical validity and reliability--that is, how effectively the tool identifies those who are and are not at risk for mild TBI and if the tool would yield consistent results if administered to the same veteran more than once. However, VA is planning to but has not yet begun to determine the tool's validity and reliability. VA's screening tool was based largely on a tool developed and validated by the Defense and Veterans Brain Injury Center (DVBIC)--a medical and educational collaboration among DOD, VA, and two civilian partners--used at selected military bases to screen returning OEF/OIF servicemembers for TBI. However, because VA's tool is a modified version of DVBIC's tool and is used to screen a slightly different population, the results of the validity study of DVBIC's tool are not directly applicable to VA's tool. To help ensure that OEF/OIF veterans identified as at risk for a mild TBI by VA's screening tool are evaluated and treated, VA developed a national protocol for their evaluation and treatment. According to VA's protocol, veterans with a positive screening result should be offered a follow-up evaluation by a specialist to determine if they have a mild TBI. The follow-up evaluation should include a history of the veteran's injury, a physical examination targeted to the veteran's symptoms, and the use of a checklist to assess the presence and severity of symptoms associated with mild TBI. VA has established training for its providers to enhance use of the protocol and help ensure veterans are evaluated and treated for mild TBI. Providers at some VA medical facilities we visited had difficulties fully following the protocol. However, the facilities had taken steps to resolve the difficulties, and VA has put in place measures to help providers follow the protocol. VA faces clinical and cultural challenges in its efforts to screen and evaluate mild TBI in OEF/OIF veterans. Clinical challenges include the lack of existing objective diagnostic tests that can definitively identify mild TBI. Also, many symptoms of mild TBI are similar to those associated with other conditions, such as post-traumatic stress disorder, making a diagnosis of mild TBI harder to reach. Some characteristics of the OEF/OIF veteran population present cultural challenges in that they may affect veterans' willingness to seek care for TBI symptoms. For example, some may believe that being labeled with a TBI could affect their ability to stay in the National Guard or Reserves. Fri, 08 Feb 2008 00:00:00 -0500 VA and DOD Health Care: Administration of DOD's Post-Deployment Health Reassessment to National Guard and Reserve Servicemembers and VA's Interaction with DOD, January 25, 2008 http://www.gao.gov/new.items/d08181r.pdf Congress's long-standing interest in health care services for servicemembers returning from deployment has grown regarding National Guard and Reserve servicemembers because they are being activated in numbers not seen since World War II. For servicemembers who have been deployed overseas--whether National Guard, Reserve, or active duty--the Department of Defense (DOD) has developed a continuum of programs to assess servicemembers' health needs by obtaining information on their health concerns. One health assessment is administered before deployment, another about the time servicemembers return from deployment, and a third 90 to 180 days after deployment, which is called the post-deployment health reassessment (PDHRA). DOD directed the PDHRA to be implemented in June 2005 in response to studies that showed that health concerns were emerging several months after servicemembers' return from deployment. One intent of the PDHRA is to identify servicemembers' health concerns with a specific emphasis on screening for mental health and to assess whether servicemembers need referrals for further evaluation. PDHRAs can result in referrals being made to military treatment facilities, TRICARE providers, chaplains, Military OneSource, or Department of Veterans Affairs (VA) facilities, such as VA medical centers, VA community clinics, and Vet Centers. Congressional interest in health care services for National Guard and Reserve servicemembers returning from deployment has increased because of their large numbers and because they have reported post-deployment mental health concerns at a higher rate than their active duty counterparts, though this varies by military service. Related to this interest, Congress asked us to describe the administration of the PDHRA to National Guard and Reserve servicemembers. This report describes: (1) how DOD administers the PDHRA to National Guard and Reserve servicemembers and what information it obtains and (2) how VA interacts with DOD in the PDHRA process for these servicemembers and the information VA obtains. DOD uses a health care contractor in all but a small number of cases to administer the PDHRA to National Guard and Reserve servicemembers either in person or by telephone through a call center. Specifically, DOD contracts with a company that provides administrative staff and health care providers--physicians, physician's assistants, and nurse practitioners--to administer the assessments. The PDHRA form asks for demographic information--such as the servicemember's date of birth, gender, and marital status--and health information that can lead to referrals for additional evaluation. For example, the PDHRA asks servicemembers questions about the occurrence of nightmares, conflicts with family and friends, and increased alcohol use. Servicemembers who answer affirmatively to these questions may receive a referral for further evaluation for mental health conditions, such as post-traumatic stress disorder or alcohol abuse. These referrals result from in-person or telephone discussions that take place between the servicemember and the health care provider during the PDHRA administration. Of the about 156,000 PDHRAs completed by National Guard and Reserve servicemembers from June 2005 through January 1, 2008, nearly 46 percent resulted in referrals for further evaluation for physical or mental health concerns. According to our discussions with VA and DOD officials, VA officials interact with DOD officials in the PDHRA process in several ways and receive information about servicemembers from DOD. Through coordination with DOD, VA officials are generally present when PDHRAs are administered to National Guard and Reserve servicemembers during drill weekends, whether the PDHRAs are administered in person or by telephone through a call center. VA interaction with DOD also occurs when servicemembers are referred to a VA facility. VA staff provide servicemembers with information about VA benefits and help them make appointments at VA facilities. Information VA receives from DOD includes the location of PDHRA administrations, numbers of servicemembers referred to VA facilities, and the PDHRAs of individual servicemembers who access VA health care. Of the National Guard and Reserve servicemembers referred through the PDHRA process for either physical or mental health concerns from June 2005 through January 1, 2008, 47 percent (almost 34,000) were referred to VA facilities. Fri, 25 Jan 2008 00:00:00 -0500 Military Health Care: Cost Data Indicate That TRICARE Reserve Select Premiums Exceeded the Costs of Providing Program Benefits, December 21, 2007 http://www.gao.gov/new.items/d08104.pdf (DOD) TRICARE Reserve Select (TRS) program allows most reservists to purchase coverage under TRICARE, the military health insurance program, when not on active duty. DOD intends to set premiums at a level equal to the expected costs of providing TRS benefits. The National Defense Authorization Act for 2007 required GAO to review TRS costs. As discussed with the committees of jurisdiction, GAO compared (1) the TRS premiums established by DOD to the reported costs of providing benefits under TRS in 2006 and (2) DOD's projected costs for TRS before implementation to DOD's reported costs for the program in 2005 and 2006. To do this work, GAO examined DOD analyses and interviewed DOD officials and external experts. In 2006, the premium for both individual and family coverage under TRS--which DOD based on Blue Cross and Blue Shield (BCBS) premiums--exceeded the reported average cost per plan of providing TRICARE benefits through the program. TRS currently serves less than 1percent of the overall TRICARE population, and unlike most other TRICARE beneficiaries, TRS enrollees pay a premium to receive health care coverage. At the time of GAO's analysis, TRS consisted of three tiers, established by law, with reservists in each tier paying different portions of the total premium, based on the tier for which they qualified. Over 90 percent of reservists who purchased TRS coverage enrolled in tier 1. The premium for individual coverage under tier 1 was 72 percent higher than the average cost per plan of providing benefits through the program. Similarly, the premium for family coverage under tier 1 was 45 percent higher than the average cost per plan of providing benefits. DOD based TRS premiums on BCBS premiums because, at the time DOD was developing TRS, actual data on the costs of TRS did not exist; however, these data are now available. Had DOD been successful in establishing premiums that were equal to the cost of providing benefits in 2006, the portion of the premium paid by enrollees in tier 1--which is set by law to cover 28 percent of the full premium--would have been lower that year. Reasons that TRS premiums did not align with benefit costs included differences between the TRS and BCBS populations and differences in the way the two programs are designed, which DOD did not consider in its methodology. According to experts, the most successful methods for aligning premiums with actual program costs involve using program cost data when setting premiums. The regulation governing TRS premium adjustments allows DOD to use either BCBS premiums or other means as the basis for TRS premiums. However, DOD officials told GAO that they plan to continue, at least for the near future, to base TRS premiums on BCBS premiums because of limitations associated with using currently available data to predict future TRS costs. However, these limitations should decrease over time as DOD gains more experience with the program and enrollment increases. Nonetheless, due to the uncertainty associated with predicting future health care costs, premiums are unlikely to exactly match program costs, even when they are based on cost data from prior years. Other insurance programs have methods to address differences between premiums and program costs, which are not provided to DOD in the law governing TRS. DOD overestimated the total cost of providing benefits through TRS. While the department projected that its total costs would amount to about $70 million in fiscal year 2005 and about $442 million in fiscal year 2006, DOD's reported costs in those years were about $5 million and about $40 million, respectively. DOD's cost projections were too high largely because it overestimated the number of reservists who would purchase TRS and the associated cost per plan of providing TRS benefits. DOD officials told GAO that they chose not to use TRS cost and enrollment data when projecting future year program costs and enrollment levels because of uncertainty about whether they would provide an accurate indication of future experience. Fri, 21 Dec 2007 00:00:00 -0500 VA Health Care: Many Medical Facilities Have Challenges in Recruiting and Retaining Nurse Anesthetists, December 13, 2007 http://www.gao.gov/new.items/d0856.pdf Certified registered nurse anesthetists (CRNA), registered nurses who have completed a master's degree program in nurse anesthesia, provide the majority of anesthesia care veterans receive in VA medical facilities. While the demand for CRNAs is anticipated to increase, many CRNAs employed by VA--VA CRNAs--are nearing retirement eligibility age. Concerns have been raised about the challenges VA may face in maintaining its VA CRNA workforce. GAO (1) identified VA CRNA workforce challenges that VA medical facilities may experience related to VA CRNAs, (2) identified the key mechanisms that VA medical facilities can use to recruit and retain VA CRNAs, and (3) determined the extent to which facilities use the key mechanisms. To identify VA CRNA workforce challenges, GAO analyzed Web-based surveys it sent to VA chief anesthesiologists, VA human resources officers, and VA CRNAs, with survey response rates of 92, 85, and 76 percent, respectively. GAO also identified the key mechanisms VA medical facilities can use to recruit and retain VA CRNAs and the extent that these mechanisms are used. Department of Veterans Affairs (VA) medical facilities have challenges in recruiting and retaining VA CRNAs for their workforce. About three-fourths of all VA medical facility chief anesthesiologists responding to GAO's survey reported that they had difficulty recruiting VA CRNAs. The challenge recruiting VA CRNAs has made it difficult to fill existing VA CRNA vacancies at VA medical facilities. Overall, 54 percent of VA medical facility chief anesthesiologists reported temporarily closing some operating rooms and 72 percent reported delaying some elective surgeries. VA's retention challenge comes from a projected substantial attrition rate. Based on the results of its survey, GAO projects that 26 percent of VA's CRNAs will either retire from or leave VA in the next 5 years. VA medical facility officials reported in GAO's survey that the recruitment and retention challenges are caused primarily by the low level of VA CRNA salaries when compared with CRNA salaries in local market areas. VA has three key mechanisms its medical facilities can use to recruit and retain VA CRNAs. VA medical facilities can give bonuses to VA CRNAs--recruitment, relocation, and retention bonuses. In addition, VA has education payment programs that provide funding to cover CRNA education costs. Finally, medical facilities can also use VA's locality pay system (LPS) to determine whether to adjust VA CRNA salaries to help the facilities remain competitive with CRNA salaries in local market areas. Each of the three key recruitment and retention mechanisms--bonuses, education payment programs, and VA's LPS--are used by some VA medical facilities. GAO found that in fiscal years 2005 or 2006, just over one-third of VA medical facilities that hired VA CRNAs gave recruitment bonuses. For VA medical facilities that have VA CRNAs, less than one-third gave retention bonuses in fiscal years 2005 or 2006. In addition, all VA CRNAs that applied for funds to attend a CRNA school or to offset their educational debt and were eligible received these funds in fiscal years 2005 and 2006. GAO also found that more than half of VA medical facilities used VA's LPS to determine whether to adjust VA CRNA salaries in 2005 and in 2006. However, in the eight VA medical facilities visited, GAO found that although the facilities used VA's LPS, the majority of them did not fully follow VA's LPS policy correctly in either 2005 or 2006. Officials at these facilities did not always know or were not aware of certain aspects of the LPS policy, and VA has not provided training on the LPS to VA medical facility officials since the policy was changed in 2001. As a result, VA medical facility officials have not received LPS training that reflects VA's current LPS policy, and accordingly, cannot ensure that VA CRNA salaries have been adjusted as needed to be competitive. Although VA is in the process of developing a Web-based training course for the LPS, the department has not established a time frame for finalizing the development and implementation of this training course. Thu, 13 Dec 2007 00:00:00 -0500 Military Base Realignments and Closures: Impact of Terminating, Relocating, or Outsourcing the Services of the Armed Forces Institute of Pathology, November 9, 2007 http://www.gao.gov/new.items/d0820.pdf The 2005 Base Realignment and Closure (BRAC) provision required the Department of Defense (DOD) to close the Armed Forces Institute of Pathology (AFIP). GAO was asked to address the status and potential impact of implementing this BRAC provision. This report discusses (1) key services AFIP provides to the military and civilian communities; (2) DOD's plans to terminate, relocate, or outsource services currently provided by AFIP; and (3) the potential impacts of disestablishing AFIP on military and civilian communities. New legislation requires DOD to consider this GAO report as it develops its plan for the reorganization of AFIP. GAO reviewed DOD's plans, analysis, and other relevant information, and interviewed officials from the public and private sectors. AFIP pathologists perform three key services--diagnostic consultations, education, and research--primarily for physicians from DOD, the Department of Veterans Affairs (VA), and civilian institutions. AFIP provides consultations when physicians cannot make a diagnosis or are unsure of their initial diagnosis. About half of its 40,000 consultations in 2006 were for DOD physicians, and the rest were nearly equally divided between VA and civilian physicians. AFIP's educational services train physicians in diagnosing the most difficult-to-diagnose diseases. Civilian physicians use these services more extensively than military physicians. In addition, AFIP pathologists collaborate with others on research applicable to military operations and general medicine, often using material from AFIP's repository of tissue specimens to gain a better understanding of disease diagnosis and treatment. To implement the 2005 BRAC provision, DOD plans to terminate most services currently provided by AFIP and is developing plans to relocate or outsource others. DOD plans to outsource some diagnostic consultations to the private sector through a newly established office and use its pathologists for consultations when possible. With the exception of two courses, DOD does not plan to retain AFIP's educational program. DOD also plans to halt AFIP's research and realign the repository, which is AFIP's primary research resource. The BRAC provision allows DOD flexibility to retain services that were not specifically addressed in the provision. As a result, DOD will retain four additional AFIP services and is considering whether to retain six others. DOD had planned to begin implementation of the BRAC provision related to AFIP in July 2007 and complete action by September 2011, but statutory requirements prevent DOD from reorganizing or relocating AFIP functions until after DOD submits a detailed plan and timetable for the proposed implementation of these changes to congressional committees no later than December 31, 2007. Once the plan has been submitted, DOD can resume reorganizing and relocating AFIP. Discontinuing, relocating, or outsourcing AFIP services may have minimal impact on DOD, VA, and civilian communities because pathology services are available from alternate sources, but a smooth transition depends on DOD's actions to address the challenges in developing new approaches to obtaining pathology expertise and managing the repository. For consultations, these challenges are to determine how to use existing pathology resources, obtain outside expertise, and ensure coordination and funding of services to avoid disincentives to quality care. While DOD has begun to identify the challenges, it has not developed strategies to address them. Similarly, whether the repository will continue to be a rich resource for military and civilian research depends on how DOD populates, maintains, and provides access to it in the future, but DOD has not developed strategies to address these issues. DOD contracted for a study, due to be completed in October 2008, of the usefulness of the material in the repository. DOD plans to use this study to help make decisions about managing the repository. Fri, 09 Nov 2007 00:00:00 -0500 VA Health Care: Improvements Made in Physician Privileging Policies, but Medical Facility Compliance Has Not Been Assessed, November 6, 2007 http://www.gao.gov/new.items/d08271t.pdf In a report issued in May 2006, GAO examined compliance with the Department of Veterans Affairs' (VA) physician credentialing and privileging requirements at seven VA medical facilities GAO visited. VA's credentialing process is used to determine whether a physician's professional credentials, such as licensure, are valid and meet VA's requirements for employment. VA's privileging process is used to determine which health care services or clinical privileges, such as surgical procedures, a VA physician is qualified to provide to veterans without supervision. Although GAO cannot generalize from its findings, GAO found that the seven facilities were complying with credentialing requirements. However, the facilities were not complying with aspects of certain privileging requirements. To better ensure that VA physicians are qualified to deliver care safely to veterans, GAO made three recommendations to improve VA's privileging of physicians. GAO was asked to testify on (1) how VA credentials and privileges physicians working in its medical facilities and (2) the extent to which VA has implemented the three recommendations made in GAO's May 2006 report that address VA's privileging requirements. To update its issued work, GAO reviewed VA's policies, procedures, and correspondence related to physician privileging and interviewed VA central office officials to determine if the recommendations made in GAO's May 2006 report were implemented. The Department of Veterans' Affairs (VA) has specific requirements that medical facility officials must follow to credential and privilege physicians. VA requires its medical facility officials to credential and privilege facility physicians periodically so that they can continue to work at VA. Facility officials verify the information used in the credentialing process and query certain databases that contain information on disciplinary actions that have been taken against a physician's state medical license and have information about a physician's professional competence. Each physician also must complete a written request for clinical privileges that is reviewed by the physician's supervisor who considers whether the physician has the appropriate professional credentials, training, and work experience. In addition, every 2 years, the supervisor is to consider information on a physician's performance, such as a physician's surgical complication rate, when deciding whether to renew a physician's clinical privileges. In a May 2006, GAO examined compliance with VA's physician credentialing and privileging requirements at seven VA medical facilities it visited and made three recommendations designed to improve aspects of privileging and oversight of the process. The three recommendations were (1) to provide guidance to medical facilities on how to collect individual physician performance information in accordance with VA's credentialing and privileging policy to use in medical facilities' privileging process, (2) to enforce the requirement that medical facilities submit information on paid VA medical malpractice claims to VA within 60 days after being notified that the claim is paid, and (3) to instruct medical facilities to establish internal controls to ensure the accuracy of their privileging information. VA reports that it has implemented all three recommendations by establishing policy and guidance for its medical facilities. However, GAO does not know the extent of compliance with these requirements at VA medical facilities. Tue, 06 Nov 2007 00:00:00 -0500 VA Health Care: Status of Inspector General Recommendations for Health Care Services Contracting, October 31, 2007 http://www.gao.gov/new.items/d0861r.pdf The Department of Veterans Affairs (VA) operates one of the largest health care systems in the nation. For fiscal year 2007, VA estimates that it will provide health care to more than 5 million veterans, either in its own facilities or through other health care providers. During the past decade, the numbers of VA patients and the costs for treating them have increased rapidly, due in part to an expansion in the number of veterans eligible to receive care. The Veterans Health Administration (VHA)--the VA entity responsible for the health care of veterans--spends about $35 billion a year providing health care to veterans, including more than $7 billion to acquire health care services and products. In its own health care facilities, VHA contracts for a broad range of medical services such as anesthesiology, for other services that support the delivery of medical care such as facility maintenance and laundry services, and for products such as medical equipment, food, and hospital linens. It also contracts for medical care for veterans provided in non-VA hospitals and community based clinics. Contracting for services at VHA represents a large and growing proportion of total contract spending. In an effort to improve the operation of VHA's health care system, VA's Inspector General (IG) conducted reviews of individual VHA facilities through structured site visits with teams of IG officials from fiscal year 1999 through fiscal year 2006. These teams included officials from three IG offices--Audit, Health Care Inspections, and Investigations. These reviews, known as the Combined Assessment Program (CAP), focused in part on actions to increase the efficiency and effectiveness of VHA's contracting. The IG issued a summary report in September 2006 on the results of these CAP reviews, including summaries of recommendations made to address systemic, recurring deficiencies in the planning, management, and oversight of service contracts. In addition the IG issued other reports in recent years on weaknesses in VHA health care contracting. Congress requested that GAO review the recommendations made by the VA IG to improve the award and administration of service contracts for veterans' health care, and VA's efforts to implement these recommendations. In this report GAO identifies (1) the recurring themes among the key recommendations from recent reports of the IG concerning VHA's award and administration of service contracts for veterans' health care, and (2) the current status of VHA's implementation of the recommendations, according to VA data. GAO identified five recurring themes among the 214 key recommendations contained in recent VA IG reports concerning service contracts for veterans' health care. Three of these themes track the phases of the procurement process--pre-award, award, and post-award--and account for about 61 percent of the key recommendations identified. For the pre-award phase, the IG recommended that contracting officers request pre-award audits when needed, and that VHA facilities ensure that legal and technical reviews are conducted on large-dollar contracts. In awarding contracts, the IG recommended that contracting officers explain the rationale for the award in price negotiation memoranda and conduct background checks once a contractor is selected prior to contract performance. The post-award recommendations focused mostly on payment issues such as verifying invoices and taking action to identify and recover overpayments. In addition to these themes, GAO also identified two other overarching recurring themes--human capital and management concerns--that account for about 39 percent of the key recommendations identified. About one quarter of the key recommendations involved human capital issues--such as ensuring the timely appointment and ongoing training of contracting officers' technical representatives, the staff who oversee contractor performance--while the remainder focused on the need to ensure compliance with applicable laws and regulations through management oversight of contracting activity. According to VA data, all the key acquisition-related recommendations identified in recent VA IG reports have been implemented. In general, managers of the VHA facilities that were reviewed as part of the IG's Combined Assessment Program had taken at least some action in response to the IG's recommendations before the reviews had been completed or in some cases had prepared plans for taking action, as detailed in the IG reports. Analysis of the key recommendations shows that the IG made the same or similar recommendations at many VA facilities. The VA IG Office of Audit told GAO that the issues that led to the same or similar recommendations being made at many facilities may be evidence of recurring and systemic issues throughout VA, and is therefore changing the way it conducts reviews to take a more agencywide approach to these issues. Wed, 31 Oct 2007 00:00:00 -0400 Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records, October 24, 2007 http://www.gao.gov/new.items/d08207t.pdf The Department of Veterans Affairs (VA) and the Department of Defense (DOD) are engaged in ongoing efforts to share medical information, which is important in helping to ensure high-quality health care for active-duty military personnel and veterans. These efforts include a long-term program to develop modernized health information systems based on computable data: that is, data in a format that a computer application can act on--for example, to provide alerts to clinicians of drug allergies. In addition, the departments are engaged in short-term initiatives involving existing systems. GAO was asked to testify on the history and current status of the departments' efforts to share health information. To develop this testimony, GAO reviewed its previous work, analyzed documents about current status and future plans and interviewed VA and DOD officials. For almost a decade, VA and DOD have been pursuing ways to share health information and to create comprehensive electronic medical records. However, they have faced considerable challenges in these efforts, leading to repeated changes in the focus of their initiatives and target completion dates. Currently, the two departments are pursuing both long- and short-term initiatives to share health information. Under their long-term initiative, the modern health information systems being developed by each department are to share standardized computable data through an interface between data repositories associated with each system. The repositories have now been developed, and the departments have begun to populate them with limited types of health information. In addition, the interface between the repositories has been implemented at seven VA and DOD sites, allowing computable outpatient pharmacy and drug allergy data to be exchanged. Implementing this interface is a milestone toward the departments' long-term goal, but more remains to be done. Besides extending the current capability throughout VA and DOD, the departments must still agree to standards for the remaining categories of medical information, populate the data repositories with this information, complete the development of the two modernized health information systems, and transition from their existing systems. While pursuing their long-term effort to develop modernized systems, the two departments have also been working to share information in their existing systems. Among various short-term initiatives are a completed effort to allow the one-way transfer of health information from DOD to VA when service members leave the military, as well as ongoing demonstration projects to exchange limited data at selected sites. One of these projects, which builds on the one-way transfer capability, developed an interface between certain existing systems that allows a two-way view of current data on patients receiving care from both departments. VA and DOD are now expanding the sharing of additional medical information by using this interface to link other systems and databases. The departments have also established ad hoc processes to meet the immediate need to provide data on severely wounded service members to VA's polytrauma centers, which specialize in treating such patients. These processes include manual workarounds (such as scanning paper records) that are generally feasible only because the number of polytrauma patients is small. While these multiple initiatives and ad hoc processes have facilitated degrees of data sharing, they nonetheless highlight the need for continued efforts to integrate information systems and automate information exchange. At present, it is not clear how all the initiatives are to be incorporated into an overall strategy focused on achieving the departments' goal of comprehensive, seamless exchange of health information. Wed, 24 Oct 2007 00:00:00 -0400 Defense Health Care: DOD Needs to Address the Expected Benefits, Costs, and Risks for Its Newly Approved Medical Command Structure, October 12, 2007 http://www.gao.gov/new.items/d08122.pdf The Department of Defense (DOD) operates one of the largest and most complex health systems in the nation and has a dual health care mission--readiness and benefits. The readiness mission provides medical services and support to the armed forces during military operations. The benefits mission provides health care to over 9 million eligible beneficiaries, including active duty personnel, retirees, and dependents worldwide. Past Government Accountability Office (GAO) and other reports have recommended changes to the military health system (MHS) structure. GAO was asked to (1) describe the options for structuring a unified medical command recommended in recent studies by DOD and other organizations and (2) assess the extent to which DOD has identified the potential impact these options would have on the current MHS. GAO analyzed studies and reports prepared by DOD's Joint/Unified Medical Command Working Group, the Defense Business Board, and the Center for Naval Analyses, and interviewed department officials. DOD considered options to address the department's dual health care mission that differed in their approaches to both command structure and operations. In April 2006, the Joint/Unified Medical Command Working Group identified three options: (1) establishing a unified medical command on par with other functional combatant commands; (2) establishing two separate commands--a Medical Command, which would provide operational/deployable medicine, and a Healthcare Command, which would provide beneficiary health care through the military treatment facilities and civilian providers; and (3) designating one of the military services to provide all health care services across the department. Subsequently, in November 2006, a fourth option was presented that would consolidate key common services and functions, which are currently performed within each of the services, such as finance, information management and technology, human capital management, support and logistics, and force health sustainment. This option would leave the existing structures of the Army, Navy, and Air Force medical departments over all military treatment facilities essentially unchanged. The Deputy Secretary of Defense approved this fourth option in November 2006. Although DOD initiated steps to evaluate the impact that some restructuring options might have on the MHS, it did not perform a comprehensive cost-benefit analysis of all potential options. GAO's Business Process Reengineering Assessment Guide establishes that a comprehensive analysis of alternative processes should include a performance-based, risk-adjusted analysis of benefits and costs for each alternative. The working group used several methods to determine some of the benefits, costs, and risks of implementing its three proposed options. For example, it used the Center for Naval Analyses to determine the cost implications for each option, and it solicited the views of key stakeholders. However, based on the working group's methodology, the group intended to conduct a more detailed cost-benefit analysis of whichever of the three options senior DOD leadership selected, but the group's work ceased once the fourth option was formally approved. While DOD approved the fourth option, DOD has not demonstrated that its decision to move forward with the fourth option was based on a sound business case. Based on GAO's review of DOD's business case, DOD has described only what it believes its chosen option will accomplish. The business case does not demonstrate how DOD determined the fourth option to be better than the other three in terms of its potential impact on medical readiness, quality of care, beneficiaries' access to care, costs, implementation time, and risks because DOD does not provide evidence of any analysis it has performed of the fourth option or a sound business case justifying this choice. Without such analysis and documentation, DOD is not in a sound position to assure the Secretary of Defense and Congress that it made an informed decision when it chose the fourth option over the other three or that its chosen option will have the desired impact on DOD's MHS. Fri, 12 Oct 2007 00:00:00 -0400 DOD and VA: Preliminary Observations on Efforts to Improve Health Care and Disability Evaluations for Returning Servicemembers, September 26, 2007 http://www.gao.gov/new.items/d071256t.pdf In February 2007, a series of Washington Post articles disclosed troublesome deficiencies in the provision of outpatient services at Walter Reed Army Medical Center, raising concerns about the care for returning servicemembers. These deficiencies included a confusing disability evaluation system and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. The reported problems at Walter Reed prompted broader questions about whether the Department of Defense (DOD) as well as the Department of Veterans Affairs (VA) are fully prepared to meet the needs of returning servicemembers. In response to the deficiencies reported at Walter Reed, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement provides information on the near-term actions being taken by the Army and the broader efforts of the Senior Oversight Committee to address longer-term systemic problems that impact health care and disability evaluations for returning servicemembers. Preliminary observations in this testimony are based largely on documents obtained from and interviews with Army officials, and DOD and VA representatives of the Senior Oversight Committee, as well as on GAO's extensive past work. We discussed the facts contained in this statement with DOD and VA. While efforts are under way to respond to both Army-specific and systemic problems, challenges are emerging such as staffing new initiatives. The Army and the Senior Oversight Committee have efforts under way to improve case management--a process intended to assist returning servicemembers with management of their care from initial injury through recovery. Case management is especially important for returning servicemembers who must often visit numerous therapists, providers, and specialists, resulting in differing treatment plans. The Army's approach for improving case management for its servicemembers includes developing a new organizational structure--a Warrior Transition Unit, in which each servicemember would be assigned to a team of three key staff--a physician care manager, a nurse case manager, and a squad leader. As the Army has sought to staff its Warrior Transition Units, challenges to staffing critical positions are emerging. For example, as of mid-September 2007, over half the U.S. Warrior Transition Units had significant shortfalls in one or more of these critical positions. The Senior Oversight Committee's plan to provide a continuum of care focuses on establishing recovery coordinators, which would be the main contact for a returning servicemember and his or her family. This approach is intended to complement the military services' existing case management approaches and place the recovery coordinators at a level above case managers, with emphasis on ensuring a seamless transition between DOD and VA. At the time of GAO's review, the committee was still determining how many recovery coordinators would be necessary and the population of seriously injured servicemembers they would serve. As GAO and others have previously reported, providing timely and consistent disability decisions is a challenge for both DOD and VA. To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks. The Army has also developed and conducted the first certification training for evaluation board liaisons who help servicemembers navigate the system. To address more systemic concerns, the Senior Oversight Committee is planning to pilot a joint disability evaluation system. Pilot options may incorporate variations of three key elements: (1) a single, comprehensive medical examination; (2) a single disability rating done by VA; and (3) a DOD-level evaluation board for adjudicating servicemembers' fitness for duty. DOD and VA officials hoped to begin the pilot in August 2007, but postponed implementation in order to further review options and address open questions, including those related to proposed legislation. Fixing these long-standing and complex problems as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers, and success will ultimately depend on sustained attention, systematic oversight by DOD and VA, and sufficient resources. Wed, 26 Sep 2007 00:00:00 -0400 DOD Civilian Personnel: Medical Policies for Deployed DOD Federal Civilians and Associated Compensation for Those Deployed, September 18, 2007 http://www.gao.gov/new.items/d071235t.pdf As the Department of Defense (DOD) has expanded its involvement in overseas military operations, it has grown increasingly reliant on its federal civilian workforce to support contingency operations. GAO was asked to discuss DOD's (1) force health protection and surveillance policies, (2) medical treatment policies that cover federal civilians while they are deployed to support contingency operations in Afghanistan and Iraq, and (3) differences in special pays and benefits provided to DOD's deployed federal civilian and military personnel. For this statement, GAO primarily drew on its September 2006 report that addressed these objectives. For its report, GAO analyzed over 3,400 deployment-related records at eight component locations for deployed federal civilians and policies related to defense health care, reviewed claims filed under the Federal Employees' Compensation Act (FECA); and examined major provisions of special pays and disability and death benefits provided to DOD's deployed federal civilians and military personnel. In 2006, GAO reported that DOD had established force health protection and surveillance policies to assess and reduce or prevent health risks for its deployed federal civilians, but it lacked procedures to ensure implementation. GAO's review of over 3,400 deployment records found that components lacked documentation that some federal civilians who deployed to Afghanistan and Iraq had received, among other things, required pre- and post-deployment health assessments and immunizations. Also, DOD lacked centralized data to readily identify its deployed civilians and their movement in theater, thus hindering its efforts to assess the overall effectiveness of its force health protection and surveillance capabilities. GAO noted that until DOD establishes a mechanism to strengthen its oversight of this area, it would not be effectively positioned to ensure compliance with its policies, or the health care of deployed federal civilians. GAO also reported that DOD had established medical treatment policies for its deployed federal civilians, which provide those who require treatment for injuries or diseases sustained during overseas hostilities with care under the DOD military health system. GAO reviewed a sample of seven workers' compensation claims (out of a universe of 83) filed under FECA by DOD federal civilians who deployed to Iraq. GAO found in three cases where care was initiated in theater that the affected civilians had received treatment in accordance with DOD's policies. In all seven cases, DOD civilians who requested care after returning to the United States had, in accordance with DOD's policies, received medical examinations and/or treatment for their deployment-related injuries or diseases. GAO reported that DOD provides certain special pays and benefits to its deployed federal civilians, which generally differ in type and/or amount from those provided to deployed military personnel. For example, in cases where injuries are sustained while deployed, both DOD federal civilian and military personnel are eligible to receive government-provided disability benefits; however, the type and amount of the benefits vary, and some are unique to each group. Importantly, continuing challenges with modernizing federal disability programs have been the basis for GAO's designation of this as a high-risk area since 2003. In addition, while the survivors of deceased DOD federal civilian and military personnel generally receive similar types of cash survivor benefits for Social Security, burial expenses, and death gratuity, the comparative amounts of these benefits differ. However, survivors of DOD federal civilians almost always receive lower noncash benefits than military personnel. GAO does not take a position on the adequacy or appropriateness of the special pays and benefits provided to DOD federal civilian and military personnel. Any deliberations on this topic should include an examination of how such changes would affect ensuring adequate and appropriate benefits for those who serve their country, as well as the long-term fiscal well-being of the nation. Tue, 18 Sep 2007 00:00:00 -0400 Military Health: DOD's Vaccine Healthcare Centers Network, June 29, 2007 http://www.gao.gov/new.items/d07787r.pdf Members of the military have long been required to receive immunizations. The Department of Defense (DOD) estimates that over 2.2 million servicemembers receive at least one mandatory immunization annually. Immunizations are provided through the administration of vaccines, which contain "antigens" or parts of a specific virus or bacterium that are used to trigger an immune response to protect the body from disease. DOD's immunization requirements vary depending on several factors, such as a servicemember's branch of military service, location, age, and type of personnel, such as newly enlisted recruits, those conducting high-risk travel, and reserve forces. No immunization is completely safe. Like all individuals, servicemembers may experience side-effects as a result of their immunizations, known as adverse events. Most adverse events consist of relatively mild reactions, such as swelling near the site of the immunization. However, a small number of individuals may experience more severe reactions, such as some servicemembers who received the anthrax and smallpox vaccines. Some servicemembers who received these vaccines experienced severe reactions such as migraines, heart problems, and the onset of diseases including diabetes and multiple sclerosis. Since then, the adverse events associated with these vaccines have caused concern among members of Congress about the safety of some mandatory immunizations. In response to three congressional directives, DOD established the Vaccine Healthcare Centers (VHC) Network in September 2001 with initial funding provided by the Department of Health and Human Services' (HHS) Centers for Disease Control and Prevention (CDC). The purpose of the VHC Network is to meet the health care needs of servicemembers receiving mandatory immunizations. DOD placed the VHC Network under the command of the Army Surgeon General. However, neither DOD nor the Army provided the VHC Network with a mission statement. As a result, VHC Network officials defined their own mission. In addition, since 2001, the VHC Network--which is not included in DOD's long-term budget planning--has relied upon funding provided on an annual basis from a variety of sources. Its lack of both a recognized mission and a specified funding source caused uncertainty among VHC Network officials about its future existence and organizational structure. Two recent laws--the National Defense Authorization Act for Fiscal Year 2006 and the National Defense Authorization Act for Fiscal Year 2007--contained provisions that required us to examine several issues related to the VHC Network. In response, and after consultation with the committees of jurisdiction, this report describes (1) the efforts the VHC Network is undertaking to address the needs of servicemembers arising from mandatory military immunizations and (2) how DOD has supported the mission of the VHC Network. The VHC Network supports the health care needs of servicemembers that may arise from military immunizations in three ways. First, it offers clinical support. For example, it provides clinical care to servicemembers experiencing potential adverse events, and, in cases where the patient is not located near a regional VHC site, it may remotely coordinate the patient's care with the other providers directly involved in the patient's treatment. Second, the VHC Network conducts research to improve the safe administration of vaccines and the prevention, identification, and treatment of adverse events. Third, it educates servicemembers and military health care staff on adverse events. For example, the VHC Network makes information available by conducting briefings and posting training materials on a Web site. In general, DOD and CDC officials said that they consider the VHC Network's contributions important, particularly in the area of clinical care. However, several DOD officials, including DOD medical staff members, added that its educational efforts may not be reaching enough military health care providers who remain unaware, for example, of some adverse events and the role of the VHC Network. DOD's December 2006 decisions, including the plan to place the VHC Network under the command of the Military Vaccine Office (MILVAX), will give the VHC Network recognition as a formal entity within DOD's command structure and an established mission within DOD, and have the potential to provide access to a more stable source of funding, when they are implemented in fiscal year 2008. According to VHC Network officials, the absence of such a mission and a place in DOD's long-range budget has made it difficult to plan strategically, develop and maintain regional VHC sites, and attract and retain staff. Under DOD's new plan, the Army, Air Force, and Navy will each provide funding for the VHC Network. In addition, there will be opportunities for all the services to provide input into decisions regarding the activities of the VHC Network. VHC Network officials stated that they hope that DOD's decisions will provide opportunities for the VHC Network to plan for and accomplish its mission with greater predictability. Fri, 29 Jun 2007 00:00:00 -0400 Military Health Care: TRICARE Cost-Sharing Proposals Would Help Offset Increasing Health Care Spending, but Projected Savings Are Likely Overestimated, May 31, 2007 http://www.gao.gov/new.items/d07647.pdf In light of the fact that Department of Defense (DOD) health care spending more than doubled from 2000 to 2005 and continues to escalate, DOD proposed increasing the share of health care costs paid by TRICARE beneficiaries, under a proposal known as Sustain the Benefit. DOD estimated that if the proposal had been implemented in fiscal year 2007, savings would amount to over $11 billion through fiscal year 2011. As required by the National Defense Authorization Act for 2007, GAO evaluated (1) the likelihood that DOD would achieve its estimated savings from the proposed enrollment fee and deductible increases for retirees and dependents under age 65, (2) the likelihood that DOD would achieve its estimated savings from the proposed pharmacy co-payment increases for all beneficiaries except active duty personnel, and (3) the factors identified by DOD as contributing to increased TRICARE spending from 2000 to 2005. To conduct its work, GAO examined DOD analyses and interviewed DOD officials. GAO also analyzed data on many aspects of health care costs in general and interviewed health economists. Although DOD would likely achieve significant savings if its proposal is implemented, it is unlikely to achieve the $9.8 billion savings that it expects to receive over 5 years as a result of increased TRICARE enrollment fees and deductibles for retirees and dependents under age 65. DOD's savings estimate depends largely on the assumption that the increased fees and deductibles will result in approximately 500,000 retirees and dependents under age 65 either leaving or choosing not to enroll in TRICARE--collectively referred to as avoided users--and on the assumption that each avoided user will save DOD the equivalent of the cost of providing health care to the average TRICARE beneficiary. However, DOD's projected number of avoided users is likely too high. Many beneficiaries in this group, particularly older and sicker individuals, are unlikely to have lower-priced health insurance options available to them and would therefore be likely to continue to use TRICARE. In addition, DOD's estimated savings per avoided user is likely too high because the estimate does not account for older and sicker individuals, who are less likely to leave or not enroll in TRICARE, and who incur greater-than-average medical expenses. Even without any avoided users, GAO estimates that DOD's proposed fee and deductible increases would achieve at least $2.3 billion in savings over 5 years. Neither GAO nor DOD can make a more accurate savings estimate, in part because DOD does not collect and compile certain data, such as the cost of other health insurance options. These data, along with information on beneficiaries' access to other health insurance options, could help DOD estimate beneficiary reaction to changes in TRICARE's cost-sharing structure, such as the number of beneficiaries who would become avoided users. DOD is unlikely to achieve the $1.5 billion it expects to save by increasing retail pharmacy co-payments for all beneficiaries except active duty personnel. DOD based its estimated savings on a study that measured savings from increased pharmacy co-payments in non-DOD employer-sponsored insurance programs. This study was not analogous to DOD's situation, which resulted in DOD overestimating the reduction in the number of prescriptions obtained from retail pharmacies, and thereby overestimating its savings. Therefore, more beneficiaries may continue to use retail pharmacies and pay higher co-payments, generating more revenue for DOD. However, revenues from these beneficiaries would not offset the higher cost of providing these beneficiaries' prescriptions in retail pharmacies. DOD attributed its increase in health care spending, from $17.4 billion in 2000 to $35.4 billion in 2005, to a number of factors. The factors DOD identified as the largest contributors were medical care inflation and benefit enhancements required by law, including TRICARE for Life, which supplements Medicare coverage for TRICARE beneficiaries, generally after age 65. DOD also identified other factors, including an increased number of beneficiaries who have chosen to use TRICARE and health care costs for mobilized reservists and their families due to the Global War on Terrorism. Thu, 31 May 2007 00:00:00 -0400 Military Pay: Processes for Retaining Injured Army National Guard and Reserve Soldiers on Active Duty Have Been Improved, but Some Challenges Remain, May 29, 2007 http://www.gao.gov/new.items/d07608.pdf In February 2005, GAO reported that weaknesses in the Army's Active Duty Medical Extension (ADME) process caused injured and ill Army National Guard and Reserve (reserve component) soldiers to experience gaps in pay and benefits. During the course of GAO's previous work, the Army implemented the Medical Retention Processing (MRP) program in May 2004 and Community-Based Health Care Initiative (CBHCI) in March 2004. CBHCI allows reserve component soldiers on MRP orders to return home and receive medical care through a civilian health care provider. As directed by congressional mandate, GAO determined whether (1) MRP has resolved the pay issues previously identified with ADME and (2) the Army has the metrics it needs to determine whether it is effectively managing CBHCI program risks. GAO's scope did not include the medical, facilities, or disability ratings issues recently reported by the media at Walter Reed Army Medical Center. The Army's MRP program has largely resolved the widespread delays in order processing that were associated with ADME. As a result, injured and ill reserve component soldiers retained on active duty through MRP have not experienced significant gaps in pay and benefits. The Army has addressed 17 of the 22 recommendations GAO made previously, which include developing comprehensive guidance for retaining injured and ill reserve component soldiers on active duty, providing a more effective means of tracking the location of soldiers in the MRP program, addressing problems related to inadequate administrative support for processing active duty retention orders, and developing performance measures to evaluate MRP. Of the five recommendations the Army has not fully implemented, two are related to providing adequate training to reserve component soldiers in the MRP program and Army personnel responsible for managing the program and three deal with improving the Army's order-writing, pay, personnel, and medical eligibility systems. Although the Army has issued a soldiers' handbook for soldiers in the MRP program and developed a biannual training conference for Army personnel responsible for managing these soldiers, the Army lacks consistent, Army-wide training standards for injured reserve component soldiers in the MRP program and Army personnel responsible for managing the program. Because of an Army-wide system integration challenge that affects all soldiers, not just those in the MRP program, information is not always updated in the order-writing, pay, personnel, and medical eligibility systems as it should be. As a result, 7 of the 25 randomly selected soldiers GAO interviewed reported that their families' medical benefits were temporarily disrupted when they transitioned to MRP orders. The lack of integrated systems also caused overpayment problems when soldiers were released from active duty but still had time left on their MRP orders. Over a nearly 3-year period, GAO estimates that the Army overpaid these soldiers by at least $2.2 million. Although, according to the Army, soldiers participating in CBHCI are at greater risk of being retained on active duty longer than medically necessary, the Army currently lacks the data needed to determine whether it is effectively managing this risk. According to the Army's metrics, soldiers treated by civilian providers through CBHCI are, on average, retained on active duty 117 days longer than soldiers treated at military treatment facilities (MTF). According to the Army, the metrics for soldiers treated at MTFs are skewed lower because of the Army's CBHCI selection criteria-- which exclude soldiers whose injuries or illnesses are expected to be treated within 60 days. However, until the Army obtains more comparable information for the patient populations treated through CBHCI and MTFs, the Army cannot reliably determine whether it is effectively managing the program's risk. Tue, 29 May 2007 00:00:00 -0400 VA Health Care: VA Should Better Monitor Implementation and Impact of Capital Asset Alignment Decisions, March 21, 2007 http://www.gao.gov/new.items/d07408.pdf Through its Veterans Health Administration (VHA), the Department of Veterans Affairs (VA) operates one of the largest health care systems in the country. In 1999, GAO reported that better management of VA's large inventory of aged capital assets could result in savings that could be used to enhance health care services for veterans. In response, VA initiated a process known as Capital Asset Realignment for Enhanced Services (CARES). Through CARES, VA sought to enhance veteran care by the appropriate sizing, upgrading, and locating of VA facilities. GAO was asked to examine the CARES process. Specifically, GAO examined (1) how CARES contributes to VHA's capital planning process, (2) the extent to which the CARES process considered capital asset alignment alternatives, and (3) the extent to which VA has implemented CARES decisions and how this implementation has helped VA carry out its mission. To address these issues, we analyzed CARES documents, interviewed VA officials, and conducted six site visits, among other things. The CARES process provided VA with a blueprint that drives VHA's capital planning efforts. As part of the CARES process, VA adapted a model to estimate demand for health care services and to determine the capacity of its current infrastructure to meet this demand. VA continues to use this model in its capital planning process. The CARES process resulted in capital alignment decisions intended to address gaps in services or infrastructure. These decisions serve as the foundation for VA's capital planning process. According to VA officials, all capital projects must be based upon demand projections that use the planning model developed through CARES. A range of capital asset alignment alternatives were considered throughout the CARES process, which adheres to capital planning best practices. There was relatively consistent agreement among the Draft National CARES Plan prepared by VA, the CARES Commission appointed by the VA Secretary to make alignment recommendations, and the Secretary as to which were the best alternatives to pursue. Although the Secretary tended to agree with the CARES Commission's recommendations, the extent to which he agreed varied by alignment alternative. In particular, the Secretary always agreed with the commission's recommendations to build new facilities, enter into enhanced use leases, and collaborate with the Department of Defense and universities, but was less likely to agree to the CARES Commission's recommendations to contract out or close facilities. The decisions that emerged from the CARES process will result in an overall expansion of VA's capital assets. For example, the capital alignment alternatives the Secretary chose to meet future health care demand includes building 3 new medical centers and opening 156 outpatient clinics. In contrast, VA will completely close one facility. A number of factors, including competing stakeholders interests and legal restrictions, shaped and in some cases limited VA's range of alternatives considered during the CARES process. VA has started implementing some CARES decisions, but does not centrally track the implementation of all the CARES decisions or monitor the impact such implementation has had on its mission. VA has begun implementing 32 of the more than 100 capital projects and 32 of the 156 outpatient care centers approved by the Secretary during the CARES process. Although VA has over 100 performance measures to monitor other agency programs and activities, these measures either do not directly link to the CARES goals or VA does not use them to centrally monitor the implementation and impact of CARES decisions. Without this information, VA cannot readily assess the implementation status of CARES decisions, determine the impact such decisions are having on veterans' care, or be held accountable for achieving the intended results of CARES. Wed, 21 Mar 2007 00:00:00 -0400 Military Personnel: Medical, Family Support, and Educational Services Are Available for Exceptional Family Members, March 16, 2007 http://www.gao.gov/new.items/d07317r.pdf The Department of Defense's (DOD) Exceptional Family Member Program (EFMP) is a mandatory enrollment program for active duty servicemembers who have family members with special medical needs. When military servicemembers are considered for assignment to an installation within the United States, EFMP enrollment is used to determine whether needed services, such as specialized pediatric care, are available through the military health system at the proposed location. Due to this consideration, each military service assigns servicemembers with exceptional family members who have significant needs to certain locations because of the resources available through DOD's health care system in these communities. Further, DOD policy allows (but does not require) the military services to provide family support services specifically for exceptional family members. State and local medical, family support, and educational services in these communities may also serve the military's exceptional family members as part of providing services to local residents. The Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005 directed us to evaluate the effect of EFMP on health, support, and education services in selected civilian communities with a high concentration of EFMP enrollees. As discussed with the committees of jurisdiction, this report describes (1) the services provided by the military health and family support systems that are available to meet the needs of exceptional family members within the United States, and (2) state and local services--including medical, family support, and educational services--available for the exceptional family members in select communities. Through TRICARE and its supplementary coverage program, DOD provides exceptional family members located at installations within the United States with basic medical services--including inpatient and outpatient care, drugs, and durable medical equipment--and, when needed, additional medical services such as health care provided in the home and respite care. However, DOD officials with whom we spoke in all four communities said that certain medical services requested by exceptional family members may be difficult to obtain because of a limited number of specialists available in DOD's health care system in these communities. Due to a lack of data on exceptional family members and their medical conditions, we were unable to determine the extent to which medical services are utilized by exceptional family members. Family support services are also available to exceptional family members through military service family centers, which provide information about specialized services--including day care, after-school care, and recreational programs. However, some family support services may not be available to accommodate exceptional family members with certain medical conditions. State and local medical, family support, and educational services are available to exceptional family members. Some of the services available include mental health counseling, respite care, therapies for children with developmental delays, and therapy for autism. However, state and local agency officials in the four communities we visited were unable to provide data that could be used to determine the specific service needs of exceptional family members or their utilization of services. Even though data on EFMP were not collected, local officials said that it may be difficult to obtain some services because of the limited number of specialist providers practicing in the community. The availability of services also may depend on the laws and policies of the state where the exceptional family member resides. In addition, under federal law, exceptional family members attending a U.S. public school may be eligible for special education and related services from age 3 through 21. However, we could not identify the type or amount of special education services used by exceptional family members in the communities that we visited due to the absence of specific data on exceptional family members. Fri, 16 Mar 2007 00:00:00 -0400 DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery Process, March 8, 2007 http://www.gao.gov/new.items/d07606t.pdf As of March 1, 2007, over 24,000 servicemembers have been wounded in action since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), according to the Department of Defense (DOD). GAO work has shown that servicemembers injured in combat face an array of significant medical and financial challenges as they begin their recovery process in the health care systems of DOD and the Department of Veterans Affairs (VA). GAO was asked to discuss concerns regarding DOD and VA efforts to provide medical care and rehabilitative services for servicemembers who have been injured during OEF and OIF. This testimony addresses (1) the transition of care for seriously injured servicemembers who are transferred between DOD and VA medical facilities, (2) DOD's and VA's efforts to provide early intervention for rehabilitation for seriously injured servicemembers, (3) DOD's efforts to screen servicemembers at risk for post-traumatic stress disorder (PTSD) and whether VA can meet the demand for PTSD services, and (4) the impact of problems related to military pay on injured servicemembers and their families. This testimony is based on GAO work issued from 2004 through 2006 on the conditions facing OEF/OIF servicemembers at the time the audit work was completed. Despite coordinated efforts, DOD and VA have had problems sharing medical records for servicemembers transferred from DOD to VA medical facilities. GAO reported in 2006 that two VA facilities lacked real-time access to electronic medical records at DOD facilities. To obtain additional medical information, facilities exchanged information by means of a time-consuming process resulting in multiple faxes and phone calls. In 2005, GAO reported that VA and DOD collaboration is important for providing early intervention for rehabilitation. VA has taken steps to initiate early intervention efforts, which could facilitate servicemembers' return to duty or to a civilian occupation if the servicemembers were unable to remain in the military. However, according to DOD, VA's outreach process may overlap with DOD's process for evaluating servicemembers for a possible return to duty. DOD was also concerned that VA's efforts may conflict with the military's retention goals. In this regard, DOD and VA face both a challenge and an opportunity to collaborate to provide better outcomes for seriously injured servicemembers. DOD screens servicemembers for PTSD but, as GAO reported in 2006, it cannot ensure that further mental health evaluations occur. DOD health care providers review questionnaires, interview servicemembers, and use clinical judgment in determining the need for further mental health evaluations. However, GAO found that 22 percent of the OEF/OIF servicemembers in GAO's review who may have been at risk for developing PTSD were referred by DOD health care providers for further evaluations. According to DOD officials, not all of the servicemembers at risk will need referrals. However, at the time of GAO's review DOD had not identified the factors its health care providers used to determine which OEF/OIF servicemembers needed referrals. Although OEF/OIF servicemembers may obtain mental health evaluations or treatment for PTSD through VA, VA may face a challenge in meeting the demand for PTSD services. VA officials estimated that follow-up appointments for veterans receiving care for PTSD may be delayed up to 90 days. GAO's 2006 testimony pointed out problems related to military pay have resulted in debt and other hardships for hundreds of sick and injured servicemembers. Some servicemembers were pursued for repayment of military debts through no fault of their own. As a result, servicemembers have been reported to credit bureaus and private collections agencies, been prevented from getting loans, gone months without paychecks, and sent into financial crisis. In a 2005 testimony GAO reported that poorly defined requirements and processes for extending the active duty of injured and ill reserve component servicemembers have caused them to be inappropriately dropped from active duty, leading to significant gaps in pay and health insurance for some servicemembers and their families. Thu, 08 Mar 2007 00:00:00 -0500 DOD and VA Health Care: Challenges Encountered by Injured Servicemembers during Their Recovery Process, March 5, 2007 http://www.gao.gov/new.items/d07589t.pdf As of March 1, 2007, over 24,000 servicemembers have been wounded in action since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), according to the Department of Defense (DOD). GAO work has shown that servicemembers injured in combat face an array of significant medical and financial challenges as they begin their recovery process in the health care systems of DOD and the Department of Veterans Affairs (VA). GAO was asked to discuss concerns regarding DOD and VA efforts to provide medical care and rehabilitative services for servicemembers who have been injured during OEF and OIF. This testimony addresses (1) the transition of care for seriously injured servicemembers who are transferred between DOD and VA medical facilities, (2) DOD's and VA's efforts to provide early intervention for rehabilitation for seriously injured servicemembers, (3) DOD's efforts to screen servicemembers at risk for post-traumatic stress disorder (PTSD) and whether VA can meet the demand for PTSD services, and (4) the impact of problems related to military pay on injured servicemembers and their families. This testimony is based on GAO work issued from 2004 through 2006 on the conditions facing OEF/OIF servicemembers at the time the audit work was completed. Despite coordinated efforts, DOD and VA have had problems sharing medical records for servicemembers transferred from DOD to VA medical facilities. GAO reported in 2006 that two VA facilities lacked real-time access to electronic medical records at DOD facilities. To obtain additional medical information, facilities exchanged information by means of a time-consuming process resulting in multiple faxes and phone calls. In 2005, GAO reported that VA and DOD collaboration is important for providing early intervention for rehabilitation. VA has taken steps to initiate early intervention efforts, which could facilitate servicemembers' return to duty or to a civilian occupation if the servicemembers were unable to remain in the military. However, according to DOD, VA's outreach process may overlap with DOD's process for evaluating servicemembers for a possible return to duty. DOD was also concerned that VA's efforts may conflict with the military's retention goals. In this regard, DOD and VA face both a challenge and an opportunity to collaborate to provide better outcomes for seriously injured servicemembers. DOD screens servicemembers for PTSD but, as GAO reported in 2006, it cannot ensure that further mental health evaluations occur. DOD health care providers review questionnaires, interview servicemembers, and use clinical judgment in determining the need for further mental health evaluations. However, GAO found that 22 percent of the OEF/OIF servicemembers in GAO's review who may have been at risk for developing PTSD were referred by DOD health care providers for further evaluations. According to DOD officials, not all of the servicemembers at risk will need referrals. However, at the time of GAO's review DOD had not identified the factors its health care providers used to determine which OEF/OIF servicemembers needed referrals. Although OEF/OIF servicemembers may obtain mental health evaluations or treatment for PTSD through VA, VA may face a challenge in meeting the demand for PTSD services. VA officials estimated that follow-up appointments for veterans receiving care for PTSD may be delayed up to 90 days. GAO's 2006 testimony pointed out problems related to military pay have resulted in debt and other hardships for hundreds of sick and injured servicemembers. Some servicemembers were pursued for repayment of military debts through no fault of their own. As a result, servicemembers have been reported to credit bureaus and private collections agencies, been prevented from getting loans, gone months without paychecks, and sent into financial crisis. In a 2005 testimony GAO reported that poorly defined requirements and processes for extending the active duty of injured and ill reserve component servicemembers have caused them to be inappropriately dropped from active duty, leading to significant gaps in pay and health insurance for some servicemembers and their families. Mon, 05 Mar 2007 00:00:00 -0500 Veterans' Disability Benefits: VA Can Improve Its Procedures for Obtaining Military Service Records, December 12, 2006 http://www.gao.gov/new.items/d0798.pdf The Ranking Democratic Member, House Committee on Veterans' Affairs, asked GAO to determine (1) whether VA's internal assessments indicate its regional offices are complying with the requirements of the Veterans Claims Assistance Act (VCAA) of 2000 for obtaining military service records for veterans' disability compensation claims and (2) whether VBA could improve its procedures for obtaining military service records for claims involving post-traumatic stress disorder (PTSD). The Department of Veterans Affairs' (VA) internal assessments indicate its regional offices generally comply with VCAA's requirements for obtaining military service records for veterans' compensation claims. For example, of the decisions made by regional offices on compensation claims during the first half of fiscal year 2006, Veterans Benefits Administration (VBA) quality reviewers found that less than 4 percent contained errors involving failure to obtain military service records. Similarly, of the appealed compensation cases decided by the Board of Veterans' Appeals during November 2004-January 2006, the board remanded less than 3 percent to VBA for rework due to deficiencies in obtaining military service records. However, VBA does not systematically evaluate the quality of research done on behalf of regional offices by a VBA unit at the National Personnel Records Center, where the service records of many veterans are stored. Regional offices rely on this unit to do thorough and reliable searches and analyses of records and provide accurate reports on the results. Without a systematic program for assessing the quality of this unit's work, VBA does not know the extent to which the information that this unit provides to regional offices is reliable and accurate. VBA potentially could improve its procedures and reduce the time required to process some veterans' claims for PTSD, which may result after a veteran participates in, or is exposed to, stressful events or experiences (stressors). Regional offices sometimes must turn to information contained in the military historical records of the Department of Defense (DOD) to verify the occurrence of claimed stressors. While regional offices are able to directly access and search an electronic library of such records for many Marine Corps veterans, they must rely on DOD's U.S. Army and Joint Services Records Research Center (JSRRC) to research such records for all other service branches. The JSRRC's response time to regional office requests approaches an average of 1 year. However, by building on work already done by several regional offices to establish and use an electronic library of DOD military historical records for the other service branches, VBA may be able to greatly reduce the time required to process many veterans' PTSD claims. Tue, 12 Dec 2006 00:00:00 -0500 VA Health Care: Spending for Mental Health Strategic Plan Initiatives Was Substantially Less Than Planned, November 21, 2006 http://www.gao.gov/new.items/d0766.pdf The Department of Veterans Affairs (VA) provides mental health services to veterans with conditions such as post-traumatic stress disorder (PTSD) and substance abuse disorders. To address gaps in services needed by veterans, VA approved a mental health strategic plan in 2004. VA planned to increase its fiscal year 2005 allocations for plan initiatives by $100 million above fiscal year 2004 levels and its fiscal year 2006 allocations for plan initiatives by $200 million above fiscal year 2004 levels. GAO was asked to provide information on VA's allocation and use of funding for mental health strategic plan initiatives in fiscal years 2005 and 2006, and to examine the adequacy of how VA tracked spending and the extent of spending for plan initiatives. GAO reviewed VA reports and documents on plan initiatives and conducted interviews with VA officials at headquarters, 4 of 21 health care networks, and seven medical centers. VA networks provide oversight of medical center operations and most medical center resources. In fiscal year 2005, VA headquarters allocated about $88 million of the $100 million above fiscal year 2004 levels that VA officials intended for mental health strategic plan initiatives. VA allocated about $53 million directly to medical centers and certain offices based on proposals submitted for funding and other approaches targeted to specific initiatives. VA solicited proposals from networks for initiatives to be carried out at medical centers through requests for proposals (RFP). In addition, VA headquarters officials said that VA allocated $35 million for plan initiatives through VA's general resource allocation system to its 21 health care networks on a retrospective basis, several months after resources had been provided to the networks though the general resource allocation system. VA did not notify network and medical center officials that these funds were to be used for plan initiatives. Network and medical center officials interviewed told GAO that they were not aware these allocations had been made. As a result, it is likely that some of these funds were not used for plan initiatives. VA did not allocate the approximately $12 million remaining of the $100 million for fiscal year 2005 because, according to VA officials, there was not enough time during the fiscal year to do so. Medical center officials said they used funds allocated for plan initiatives for new services and for enhancement of existing services. For example, two medical centers increased the number of mental health providers at community-based outpatient clinics. However, some medical center officials reported they did not use all funds allocated by the end of the fiscal year, due in part to the time it took to hire staff. In fiscal year 2006, VA headquarters allocated about $158 million of the $200 million above fiscal year 2004 levels intended for mental health strategic plan initiatives directly to medical centers and certain offices. VA allocated about $92 million of these funds to support new initiatives, using RFPs and other targeted funding approaches. VA also allocated about $66 million to support recurring costs of continuing initiatives from the prior fiscal year. About $42 million of the $200 million for fiscal year 2006 was not allocated. Officials from seven medical centers GAO interviewed reported they had used funds for plan initiatives, such as the creation of a new case management program. Officials at some medical centers reported they did not anticipate problems using all of the funds allocated within the fiscal year; however, officials at other medical centers were less certain they would be able to do so. VA tracking of spending for plan initiatives was inadequate. In fiscal year 2005, VA did not track such spending. In fiscal year 2006, VA tracked aspects of plan initiatives but not dollars spent. However, available information indicates that VA spending for plan initiatives was substantially less than planned. In fiscal year 2006, VA medical centers returned to headquarters about $46 million of about $158 million allocated for plan initiatives because they could not spend the funds that year. However, VA cannot determine to what extent the approximately $112 million remaining was spent on plan initiatives because it did not track specifically how these funds were spent. Tue, 21 Nov 2006 00:00:00 -0500 DOD Civilian Personnel: Greater Oversight and Quality Assurance Needed to Ensure Force Health Protection and Surveillance for Those Deployed, September 29, 2006 http://www.gao.gov/new.items/d061085.pdf As the Department of Defense (DOD) has expanded its involvement in overseas military operations, it has grown increasingly reliant on its federal civilian workforce to support contingency operations. The Senate Armed Services Committee required GAO to examine DOD's policies concerning the health care for DOD civilians who deploy in support of contingency operations in Afghanistan and Iraq. GAO analyzed over 3,400 deployment-related records for deployed federal civilians and interviewed department officials to determine the extent to which DOD has established and the military services and defense agencies (hereafter referred to as DOD components) have implemented (1) force health protection and surveillance policies and (2) medical treatment policies and procedures for its deployed federal civilians. GAO also examined the differences in special pays and benefits provided to DOD's deployed federal civilians and military personnel. DOD has established force health protection and surveillance policies to assess and reduce or prevent health risks for its deployed federal civilian personnel, but it lacks procedures to ensure implementation. Our review of over 3,400 deployment records at eight component locations found that components lacked documentation that some federal civilian personnel who deployed to Afghanistan and Iraq had received, among other things, required pre- and post-deployment health assessments and immunizations. These deficiencies were most prevalent at Air Force and Navy locations, and one Army location. As a larger issue, DOD lacked complete and centralized data to readily identify its deployed federal civilians and their movement in theater, further hindering its efforts to assess the overall effectiveness of its force health protection and surveillance capabilities. In August 2006, DOD issued a revised policy which outlined procedures that are intended to address these shortcomings. However, these procedures are not comprehensive enough to ensure that DOD will know the extent to which its components are complying with existing health protection requirements. In particular, the procedures do not establish an oversight and quality assurance mechanism for assessing the implementation of its force health protection and surveillance requirements. Until DOD establishes a mechanism to strengthen its force health protection and surveillance oversight, it will not be effectively positioned to ensure compliance with its policies, or the health care and protection of deployed federal civilians. DOD has also established medical treatment policies for its deployed federal civilians which provide those who require treatment for injuries or diseases sustained during overseas hostilities with care that is equivalent in scope to that provided to active duty military personnel under the DOD military health system. GAO reviewed a sample of seven workers' compensation claims (out of a universe of 83) filed under the Federal Employees' Compensation Act by DOD federal civilians who deployed to Iraq. GAO found in three cases where care was initiated in theater, that the affected civilians had received treatment in accordance with DOD's policies. In all seven cases, DOD federal civilians who requested care after returning to the United States had, in accordance with DOD's policies, received medical examinations and/or treatment for their deployment-related injuries or diseases through either military or civilian treatment facilities. DOD provides certain special pays and benefits to its deployed federal civilians, which generally differ in type and/or amount from those provided to deployed military personnel. For example, both civilian and military personnel are eligible to receive disability benefits for deployment-related injuries; however, the type and amount of these benefits vary, and some are unique to each group. Further, while the survivors of deceased federal civilian and military personnel generally receive similar types of cash survivor benefits, the comparative amounts of these benefits differ. Fri, 29 Sep 2006 00:00:00 -0400 VA Health Care: Preliminary Information on Resources Allocated for Mental Health Strategic Plan Initiatives, September 28, 2006 http://www.gao.gov/new.items/d061119t.pdf The Department of Veterans Affairs (VA) provides mental health services to veterans with conditions such as post-traumatic stress disorder (PTSD) and substance abuse disorders. To address gaps in services needed by veterans, VA approved a mental health strategic plan in 2004. VA planned to increase its fiscal year 2005 allocations for plan initiatives by $100 million above fiscal year 2004 levels. VA also planned to increase its fiscal year 2006 allocations for plan initiatives by $200 million above fiscal year 2004 levels--composed of $100 million for continuation of fiscal year 2005 initiatives and an additional $100 million identified in the President's fiscal year 2006 budget request. GAO was asked to provide preliminary information on VA's allocation and use of funding for mental health strategic plan initiatives in fiscal years 2005 and 2006. A report on this work will be issued later in the fall of 2006. GAO reviewed VA reports and documents on mental health strategic plan initiatives and conducted interviews with VA officials from headquarters, 4 of 21 health care networks, and 7 medical centers. VA delegates decision making to its health care networks for most budget and management responsibilities regarding medical center operations, and medical centers receive most of their resources from the networks. In fiscal year 2005, VA headquarters allocated $88 million of the $100 million VA officials intended for mental health strategic plan initiatives. VA allocated about $53 million directly to medical centers and certain offices based on proposals submitted for funding and other approaches targeted to specific initiatives. VA solicited submissions from networks for specific initiatives to be carried out at their individual medical centers through requests for proposals (RFPs). In addition, VA headquarters officials said that VA allocated $35 million for this purpose through VA's general resource allocation system to its 21 health care networks on a retrospective basis. VA made this decision several months after resources had been provided to the networks through the general allocation system. Moreover, VA did not notify network and medical center officials that these funds were to be used for plan initiatives. Health care network and medical center officials interviewed told GAO that they were not aware these allocations had been made. As a result, it is likely that some of these funds were not used for plan initiatives. Moreover, VA did not allocate the approximately $12 million remaining of the $100 million for fiscal year 2005 because, according to VA officials, there was not enough time during the fiscal year to do so. Medical center officials said they used the funds allocated directly to their medical centers for plan initiatives that included new mental health services and more of the services they already provided. For example, two medical centers used funds allocated to them through RFPs or other targeted approaches to increase the number of mental health providers at community based outpatient clinics. One of those medical centers also started a new 6-week PTSD day treatment program. However, some medical center officials reported that they did not use all funds allocated for plan initiatives by the end of fiscal year 2005, due in part to the length of time it took to hire new staff. In fiscal year 2006, as of September 20, 2006, VA headquarters had allocated $158 million of the $200 million planned for mental health strategic plan initiatives. VA allocated about $92 million of these funds directly to medical centers and certain offices to support new initiatives, using RFPs and other targeted funding approaches. VA also allocated about $66 million to support recurring costs of the continuing initiatives from the prior fiscal year. As of September 20, 2006, about $42 million of the $200 million for fiscal year 2006 had not been allocated. Officials from seven medical centers we interviewed reported that they had used funds for plan initiatives, such as the creation of a new intensive mental health case management program. Officials at some medical centers reported that they did not anticipate problems using all of the funds allocated to them through RFPs and other targeted approaches in fiscal year 2006. However, officials at other medical centers were less certain that they would use all of these funds for plan initiatives by the end of fiscal year 2006. GAO discussed the information in this statement with VA officials who agreed that the data are accurate, and provided updated data which are incorporated as appropriate. Thu, 28 Sep 2006 00:00:00 -0400 VA Health Care: Budget Formulation and Reporting on Budget Execution Need Improvement, September 20, 2006 http://www.gao.gov/new.items/d06958.pdf The Department of Veterans Affairs (VA) estimates it will serve 5.4 million patients in fiscal year 2006. Medical services for these patients are funded with appropriations, after consideration by Congress of the President's budget request. VA formulates the medical programs portion of that request. VA is also responsible for budget execution--using appropriations and monitoring their use for providing care. For fiscal years 2005 and 2006, the President requested additional funding for VA medical programs, beyond what had been originally requested. GAO was asked to examine for fiscal years 2005 and 2006 (1) how the President's budget requests for VA medical programs were formulated, (2) how VA monitored and reported to Congress on its budget execution, and (3) which key factors in the budget formulation process contributed to requests for additional funding. To do this, GAO analyzed budget documents and interviewed VA and Office of Management and Budget (OMB) officials. The formulation of the President's budget requests for VA medical programs for fiscal years 2005 and 2006 was informed by VA's comparison of its cost estimate of projected demand for medical services to its anticipated resources. VA projected about 86 percent of its costs using an actuarial model that estimated veterans' demand for health care. To project the costs of long-term care (about 10 percent of the funds for VA medical programs in each of these years) and the remaining medical care costs (about 4 percent), separate estimation approaches were used that did not rely upon an actuarial model but used other methods instead. The agency anticipated resources based on prior year appropriations, guidance from OMB, and other factors. For both fiscal years, VA officials told GAO that projected costs--calculated from the actuarial model and other approaches--exceeded anticipated resources and that they addressed the difference in budget requests for those years with cost-saving policy proposals and management efficiencies. Although VA staff closely monitored budget execution and identified problems for fiscal years 2005 and 2006, VA did not report this information to Congress in a sufficiently informative manner. VA closely monitored the fiscal year 2005 budget as early as October 2004, anticipating challenges managing within its resources. However, Congress did not learn of these challenges until April 2005. VA initially planned to manage within its budget for fiscal year 2005 by delaying some spending on equipment and nonrecurring maintenance and drawing on funds it had planned to carry over into 2006. Instead, the President requested additional funds from Congress for both fiscal years 2005 (a $975 million supplemental appropriation in June 2005) and 2006 (a budget amendment of $1.977 billion in July 2005). Congress included in the 2006 appropriations act a requirement for VA to submit quarterly reports regarding the medical programs budget status during this fiscal year. These reports have not included some of the measures that would be useful for congressional oversight, such as patient workload measures to capture costs and the time required for new patients to be scheduled for their first primary care appointment. Unrealistic assumptions, errors in estimation, and insufficient data were key factors in VA's budget formulation process that contributed to the requests for additional funding for fiscal years 2005 and 2006. Unrealistic assumptions about how quickly cost savings could be realized from proposed nursing home policy changes contributed to the additional requests, as did computation errors measuring the estimated effect of one of these changes. Insufficient data in VA's initial budget projections also contributed to the additional funding requests. For example, VA underestimated the cost of serving veterans returning from Iraq and Afghanistan, in part because estimates for fiscal year 2005 were based on data that largely predated the Iraq conflict and because according to VA, the agency had challenges for fiscal year 2006 in obtaining data from the Department of Defense. Wed, 20 Sep 2006 00:00:00 -0400 VA and DOD Health Care: Efforts to Provide Seamless Transition of Care for OEF and OIF Servicemembers and Veterans, June 30, 2006 http://www.gao.gov/new.items/d06794r.pdf As of the end of March 2006, over 1.3 million U.S. military servicemembers had served or were serving in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). These servicemembers, including members of the reserves and National Guard, may be eligible to receive health care from the Department of Veterans Affairs (VA) while serving on active duty or upon separating from active duty. Although the Department of Defense (DOD) provides health care services to servicemembers under TRICARE, legislation passed by the Congress in May 1982 authorized VA to provide health care services to servicemembers in time of war or national emergency, when DOD may have insufficient resources to care for casualties. Through December 16, 2005, DOD had arranged for 193 active duty servicemembers with serious injuries--traumatic brain injuries and other complex trauma, such as missing limbs--to receive medical and rehabilitative care at VA polytrauma rehabilitation centers (PRC). In addition, about 30 percent (over 144,000) of the servicemembers who had separated from active duty following service in OEF or OIF have sought VA health care, including over 4,000 who received inpatient care at VA medical facilities. In September 2005, we testified on VA's collaboration with DOD to provide seamless transition of care for servicemembers between DOD and VA health care systems--that is, no interruption of care as the person moves from being a DOD patient to being a VA patient. We reported that VA has developed policies and procedures that direct its medical facilities to provide OEF and OIF servicemembers with timely access to care but that the sharing of health information between DOD and VA was limited. Congress asked us to update the information we provided in our testimony by reviewing the efforts VA is making to inform servicemembers and veterans about VA health care services and to help ensure that there is a seamless transition of care for servicemembers from DOD's to VA's health care system. We addressed the following questions: (1) What outreach efforts has VA made to inform OEF and OIF servicemembers and veterans about the VA health care services that may be available to them? (2) What actions has VA taken to facilitate the seamless transition of medical and rehabilitation care for seriously injured OEF and OIF servicemembers who are transferred between DOD medical treatment facilities (MTF) and PRCs? (3) What special educational activities or clinical tools is VA using to help ensure its medical providers are aware of and recognize the needs of eligible OEF and OIF servicemembers and veterans? VA has made a variety of outreach efforts to provide OEF and OIF servicemembers and veterans and their families with information on VA health care services. VA reported that from October 1, 2000, through May 31, 2006, it provided about 36,000 briefings to almost 1.4 million active duty, reserve, and National Guard servicemembers about VA health care services that may be available to them. In some cases, family members also attended these briefings, which were provided at over 200 sites, including 70 sites outside the United States. VA also maintains a Web site containing health information focused on OEF and OIF servicemembers and veterans, distributes brochures and pamphlets to provide information about topics of interest to OEF and OIF servicemembers and veterans and their families, and sends letters and newsletters to veterans about VA health care services and health issues specific to veterans. VA has taken several actions to facilitate the transition of medical and rehabilitative care for seriously injured servicemembers who are being transferred from MTFs to PRCs. In April 2003, the Secretary of VA authorized VA medical facilities to give priority to OEF and OIF servicemembers over veterans, except those with service-connected disabilities. In April 2004, VA signed a memorandum of agreement (MOA) with DOD that established the referral procedures for transferring injured servicemembers from DOD to VA medical facilities. VA and DOD also established joint programs to ease the transfer of injured servicemembers to VA medical facilities, including a program that assigned VA social workers to selected MTFs to coordinate patient transfers to VA medical facilities. Nevertheless, problems remain in the process for electronically sharing the medical records VA needs to determine whether servicemembers are medically stable enough to participate in vigorous rehabilitation activities. VA has developed a number of educational activities and online clinical tools to help ensure that VA medical providers and other staff are aware of and recognize the health care needs of OEF and OIF servicemembers and veterans. Examples of VA's educational efforts include developing online courses on infectious diseases of Southwest Asia; holding conferences on brain injuries; conducting conference calls, each of which provided more than 100 VA staff with information on transferring servicemembers from DOD to VA health care services; and developing publications on the long-term effects of using an antimalarial drug. VA has also provided educational activities at two East Coast centers targeting medical professionals (such as physicians, nurses, and social workers), including conferences on topics such as physical and mental health issues, infectious disease issues, and health care services provided by VA. Furthermore, VA has developed clinical tools to help its staff be aware of and responsive to the needs of OEF and OIF servicemembers and veterans. VA and DOD have also developed guidelines to assist clinicians in providing medical care to OEF and OIF veterans. Fri, 30 Jun 2006 00:00:00 -0400 VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement, May 25, 2006 http://www.gao.gov/new.items/d06648.pdf The Department of Veterans Affairs (VA) is responsible for determining that over 36,000 physicians working in its facilities have the appropriate professional credentials and qualifications to deliver health care to veterans. To do this, VA credentials and privileges physicians providing care at its medical facilities. In this report, GAO determined the extent to which selected VA facilities complied with (1) four VA credentialing requirements and five VA privileging requirements and (2) a requirement to submit information on paid malpractice claims. GAO also determined (3) whether VA has internal controls to help ensure the accuracy of information used to renew clinical privileges. GAO reviewed VA's policies, interviewed VA officials, and randomly sampled 17 physician files at each of seven VA medical facilities. GAO found that the files reviewed at seven VA medical facilities complied with four of VA's credentialing requirements selected for review, and all but one of five privileging requirements. Credentialing is the process of verifying that a physician's professional credentials, such as state medical licenses, are valid and meet VA's requirements for employment. Privileging is the process for determining which health care services a physician is allowed to provide to veterans. For the files GAO reviewed, compliance with the fifth privileging requirement was problematic at six facilities because officials used performance information when renewing clinical privileges but collected all or most of this information through their facility's quality assurance program. This is prohibited under VA policy. In general, VA quality assurance information is confidential, according to federal law and VA policy. According to VA officials, if quality assurance information is used outside of a facility's quality assurance program, it could be used for other purposes, including litigation. The information is protected to encourage physicians to participate in quality assurance programs by reporting and discussing adverse events to help prevent such events from occurring in the future. VA has not provided guidance to help medical facilities find ways to efficiently collect performance information outside of a facility's quality assurance program. At the seventh medical facility, officials did not use performance information to renew clinical privileges, as required. Three of the seven medical facilities did not meet VA's requirement to submit, within 60 days after being notified that the claim was paid, any information on paid VA medical malpractice claims involving facility practitioners, including physicians, to VA's Office of Medical-Legal Affairs. This office reviews the information and determines whether practitioners involved in the claims delivered substandard care, displayed professional incompetence, or engaged in professional misconduct. The office informs facilities of its determinations. When facilities do not submit all relevant VA malpractice information in a timely manner, VA medical facility officials lack complete information that would allow them to make informed decisions about the clinical privileges that their physicians should be granted. VA has not required its medical facilities to establish internal controls to help ensure that privileging information managed by medical staff specialists--who are responsible for obtaining and verifying the information used in the credentialing and privileging processes--is accurate. One facility GAO visited did not identify 106 physicians whose privileging process had not been completed by facility officials for at least 2 years because of inaccurate information provided by the facility's medical staff specialist. As a result, these physicians were practicing at the facility without current clinical privileges. Without accurate information on the privileges that have been granted to physicians and the dates for renewing those privileges, VA medical facility officials will not know if they have failed to renew clinical privileges for any of their physicians in accordance with VA policy. Thu, 25 May 2006 00:00:00 -0400 Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers, May 11, 2006 http://www.gao.gov/new.items/d06397.pdf Many servicemembers supporting Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have engaged in intense and prolonged combat, which research has shown to be strongly associated with the risk of developing post-traumatic stress disorder (PTSD). GAO, in response to the Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005, (1) describes DOD's extended health care benefit and VA's health care services for OEF/OIF veterans; (2) analyzes DOD data to determine the number of OEF/OIF servicemembers who may be at risk for PTSD and the number referred for further mental health evaluations; and (3) examines whether DOD can provide reasonable assurance that OEF/OIF servicemembers who need further mental health evaluations receive referrals. DOD offers an extended health care benefit to some OEF/OIF veterans for a specified time period, and VA offers health care services that include specialized PTSD services. DOD's benefit provides health care services, including mental health services, to some OEF/OIF veterans for 180 days following discharge or release from active duty. Additionally, some veterans may purchase extended benefits for up to 18 months. VA also offers health care services to OEF/OIF veterans following their discharge or release from active duty. VA offers health benefits for OEF/OIF veterans at no cost for 2 years following discharge or release from active duty. After their 2-year benefit expires, some OEF/OIF veterans may continue to receive care under VA's eligibility rules. Using data provided by DOD, GAO found that 9,145 or 5 percent of the 178,664 OEF/OIF servicemembers in its review may have been at risk for developing PTSD. DOD uses a questionnaire to identify those who may be at risk for developing PTSD after deployment. DOD providers interview servicemembers after they complete the questionnaire. A joint VA/DOD guideline states that servicemembers who respond positively to three or four of the questions may be at risk for PTSD. Further, we reviewed a retrospective study that found that those individuals who provided three or four positive responses to the four PTSD screening questions were highly likely to have been previously given a diagnosis of PTSD prior to the screening. Of the 5 percent who may have been at risk, GAO found that DOD providers referred 22 percent or 2,029 for further mental health evaluations. DOD cannot provide reasonable assurance that OEF/OIF servicemembers who need referrals receive them. According to DOD officials, not all of the servicemembers with three or four positive responses to the PTSD screening questions will need referrals for further mental health evaluations. DOD relies on providers' clinical judgment to decide who needs a referral. GAO found that DOD health care providers varied in the frequency with which they issued referrals to OEF/OIF servicemembers with three or more positive responses; the Army referred 23 percent, the Marines about 15 percent, the Navy 18 percent, and the Air Force about 23 percent. However, DOD did not identify the factors its providers used in determining which OEF/OIF servicemembers needed referrals. Knowing the factors upon which DOD health care providers based their clinical judgments in issuing referrals could help explain variation in the referral rates and allow DOD to provide reasonable assurance that such judgments are being exercised appropriately. Thu, 11 May 2006 00:00:00 -0400 Military Personnel: Military Departments Need to Ensure That Full Costs of Converting Military Health Care Positions to Civilian Positions Are Reported to Congress, May 1, 2006 http://www.gao.gov/new.items/d06642.pdf Based on studies showing that many military members are performing tasks that are not considered military essential, the Air Force, Army, and Navy have plans to convert certain numbers of military health care positions to civilian positions. Questions have surfaced regarding the potential effects of these conversions on the Defense Health Program. The National Defense Authorization Act for Fiscal Year 2006 prohibits the military departments from performing any further conversions until the secretary of each department certifies to Congress that the conversions will not increase costs or decrease quality or access to care. The act also requires GAO to study the military departments' conversions and their potential effects. Specifically, GAO examined (1) the military departments' plans for and actions to date in converting military health care positions to civilian positions and the departments' experiences in filling the converted positions with civilians and (2) the potential effects of converting military health care positions to civilian positions on the Defense Health Program. The Air Force, Army, and Navy have converted or have plans to convert several thousand military health care positions to civilian positions and have made progress in hiring civilian replacement personnel. From fiscal years 2005 through 2007, the Air Force, Army, and Navy collectively have converted or plan to convert a total of 5,507 military health care positions to civilian positions. Of the 5,507 military health care positions, the departments plan to convert 152 physician positions, 349 nurse positions, and 208 dental positions to civilian positions. In fiscal year 2006, there were a total of 10,352 military physicians, 9,138 nurses, and 3,020 dentists in the Air Force, Army, and Navy. The Navy is the most significantly affected of the three military departments, having converted or planning to convert a total of 2,676 military health care positions, representing 49 percent of the total 5,507 positions converted or planned for conversion. While the departments have been recruiting for about 4 to 7 months to hire civilian replacements for converted positions, to date, they have not experienced significant difficulties filling the civilian positions. The military departments do not expect the conversions to affect medical readiness, quality of care, recruitment and retention of military health care personnel, or decrease beneficiaries' access to care. However, it is unknown whether the conversions will increase or decrease costs to DOD. At present, the military departments may not prepare their congressional certifications using cost data prepared by DOD's Office of Program Analysis and Evaluation, which is identifying the full costs for military health care positions. Instead, the military departments may use cost data that do not contain all the costs, like training, necessary to support a military medical position. Without accounting for the full costs in their methodologies, the military departments will not be able to make a true comparison of the total costs required to support military positions versus civilian positions. Moreover, Congress will be unable to judge the extent to which the departments' certifications are based on actual and anticipated compensation costs for civilian hires unless they include such delineations in their certifications. Mon, 01 May 2006 00:00:00 -0400 VA Health Care: Experiences in Denver and Charleston Offer Lessons for Future Partnerships with Medical Affiliates, April 28, 2006 http://www.gao.gov/new.items/d06472.pdf The Department of Veterans Affairs (VA) maintains affiliations with medical schools, including the Medical University of South Carolina (MUSC) and the University of Colorado at Denver and Health Services Center and University of Colorado Hospital (UCH), to obtain enhanced medical care for veterans. As part of their plans for new medical campuses, both UCH and MUSC proposed jointly constructing and operating new medical facilities with VA in Denver and Charleston, respectively. This report discusses (1) how VA evaluated the joint venture proposals for Denver and Charleston and the status of these proposals, (2) the challenges these proposals pose for VA, and (3) the lessons VA can learn from its experiences in Charleston and Denver for future partnerships. VA evaluated the joint venture proposals for its medical facilities in Denver and Charleston using criteria developed specifically for each location, and while VA opted to build a stand-alone facility in Denver, it is still considering a joint venture in Charleston. Because the proposals involved joint construction and service sharing on a scale beyond anything VA had experienced with its medical affiliates in the past, VA did not have criteria at the departmental level to evaluate the proposals on a consistent basis in both locations. In both locations, negotiations between VA and its medical affiliates stretched over a number of years, in part because they were hampered by limited collaboration and communication, among other things. While VA decided against a joint venture in Denver, it has made no decision on Charleston. A VA-MUSC steering group, formed last summer to study the joint venture proposal in Charleston, issued a report in December 2005 that outlined the advantages and disadvantages of different options. The joint ventures proposed in Denver and Charleston present a number of challenges to VA, including addressing institutional differences between VA and its medical affiliates, identifying legal issues and seeking legislative remedies, and balancing funding priorities. For example, capital expenditures for a joint venture would have to be considered in the context of other VA capital priorities. Although addressing these issues will be difficult, the VA-MUSC steering group's efforts could provide insight into how to tackle them. VA's experiences with joint venture proposals in Denver and Charleston offer several lessons for VA as it considers similar opportunities in the future. One of the most important lessons is that having criteria at the departmental level to evaluate joint venture proposals helps to improve the transparency of decisions concerning joint ventures and VA's ability to ensure that the decisions are made in a consistent manner across the country. Another key lesson is that having a strategy for communicating with stakeholders, such as employees and veterans, helps VA build understanding and trust among stakeholders. The following table identifies these and other lessons from VA's experiences in Denver and Charleston. Fri, 28 Apr 2006 00:00:00 -0400 Military Pay: Hundreds of Battle-Injured GWOT Soldiers Have Struggled to Resolve Military Debts, April 27, 2006 http://www.gao.gov/new.items/d06494.pdf As part of the Committee on Government Reform's continuing focus on pay and financial issues affecting Army soldiers deployed in the Global War on Terrorism (GWOT), the requesters were concerned that battle-injured soldiers were not only battling the broken military pay system, but faced blemishes on their credit reports and pursuit by collection agencies from referrals of their Army debts. GAO was asked to determine (1) the extent of debt of separated battle-injured soldiers and deceased Army soldiers who served in the GWOT, (2) the impact of DOD debt collection action on separated battle-injured and deceased soldiers and their families, and (3) ways that Congress could make the process for collecting these debts more soldier friendly. Pay problems rooted in the complex, cumbersome processes used to pay Army soldiers from their initial mobilization through active duty deployment to demobilization have generated military debts. As of September 30, 2005, nearly 1,300 separated Army GWOT soldiers who were injured or killed during combat in Iraq and Afghanistan had incurred over $1.5 million in military debt, including almost 900 battle-injured soldiers with debts of $1.2 million and about 400 soldiers who died in combat with debts of $300,000. As a policy, DOD does not pursue collection of debts of soldiers who were killed in combat. However, hundreds of battle-injured soldiers experienced collection action on their debts. The extent of these debts may be greater due to incomplete reporting. GAO's case studies of 19 battle-injured soldiers showed that collection action on military debts resulted in significant hardships to these soldiers and their families. For example, 16 of the 19 soldiers were unable to pay their basic household expenses; 4 soldiers were unable to obtain loans to purchase a car or house or meet other needs; and 8 soldiers' debts were offset against their income tax refunds. In addition, 16 of the 19 case study soldiers had their debts reported to credit bureaus and 9 soldiers were contacted by private collection agencies. Due to concerns about soldier indebtedness resulting from pay-related problems during deployments, Congress recently gave the Service Secretaries authority to cancel some GWOT soldier debts. Because of restrictions in the law, debts of injured soldiers who separated at different times can be treated differently. For example, soldiers who separated more than 1 year ago are not eligible for debt relief and soldiers who paid their debts are not eligible for refunds. Further, because this authority expires in December 2007, injured soldiers and their families could face bad credit reports, visits from collection agents, and tax refund offsets in the future. Thu, 27 Apr 2006 00:00:00 -0400 Military Pay: Military Debts Present Significant Hardships to Hundreds of Sick and Injured GWOT Soldiers, April 27, 2006 http://www.gao.gov/new.items/d06657t.pdf In light of GAO's past four reports and testimonies on Army military pay and travel pay for soldiers who have served in the Global War on Terrorism (GWOT), GAO was asked to determine if weaknesses in Army processes for initiating and terminating active duty pay might result in erroneous payments and debt, including (1) overpayments to soldiers in the Fort Brag Medical Retention Processing Unit (MRPU)--1 of 23 MRPUs--and (2) overpayments and other errors that resulted in debt collection action against battle-injured soldiers who were released from active duty. GAO also was asked to develop case studies to illustrate the effects of these problems on soldiers and their families and to determine ways that Congress could make the debt collection process more soldier friendly. Continuing pay problems resulted in overpayments and debt for sick and injured Army soldiers serving in GWOT. As with GAO's prior work, these pay problems resulted in significant frustration and financial problems for the soldiers and their families. Our audit of separated Army GWOT soldier debt identified nearly 1,300 separated battle-injured soldiers and soldiers who were killed in combat during the first 4 years of GWOT deployment who had incurred a total of $1.5 million in debt as of September 30, 2005. DOD has authority to write off debts of deceased soldiers and generally does not pursue collection action on the debts of soldiers who were killed in action. However, we found that hundreds of battle-injured soldiers were pursued for repayment of military debts through no fault of their own, including at least 74 soldiers whose debts had been reported to credit bureaus and private collection agencies at the time we initiated our audit in June 2005. Although the Debt Collection Act gives DOD authority to use these debt collection tools, in response to our audit, the Army temporarily suspended collection action on debts of battle-injured soldiers until a determination could be made about whether these soldiers' debts were eligible for relief. In addition our investigation of pay problems related to Army National Guard and Reserve soldiers assigned to the Fort Bragg MRPU identified overpayments of approximately $218,000 related to 232 sick and injured soldiers. Many sick and injured Fort Bragg soldiers faced garnishment of wages and other debt collection action resulting from their pay errors. Congress recently gave the Department of Defense (DOD) authority to cancel some GWOT soldier debts. Because of restrictions in the law, debts of injured soldiers who separated at different times can be treated differently, and soldiers who paid their debts are not eligible for refunds. Also, because this authority expires in December 2007, soldiers and their families could face bad credit reports and visits from collection agencies in the future. Thu, 27 Apr 2006 00:00:00 -0400 Military Pay: Inadequate Controls for Stopping Overpayments of Hostile Fire and Hardship Duty Pay to Over 200 Sick or Injured Army National Guard and Army Reserve Soldiers Assigned to Fort Bragg, April 27, 2006 http://www.gao.gov/new.items/d06384r.pdf Over the past several years, we have reported on significant pay problems experienced by mobilized Army National Guard and Army Reserve (Army Guard and Reserve) soldiers in the wake of the September 11, 2001, terrorist attack. These reports included examples of hundreds of soldiers receiving inaccurate and untimely payroll payments due to a paper-intensive, error-prone pay process and the lack of integrated pay and personnel systems. In response to our reports, the Department of Defense (DOD) has taken some action to improve controls designed to pay Army Guard and Reserve soldiers accurately and on time, especially those who had become sick or injured in the line of duty. This report responds to a Congressional request that we investigate the allegation that 37 Army Guard and Reserve soldiers assigned to the Medical Retention Processing Unit (MRPU) at Fort Bragg, North Carolina, were overpaid for hostile fire and hardship duty pay while in an outpatient status. Our objectives were to determine (1) whether the allegations were true, and if so, whether the pay issues were more widespread at Fort Bragg and (2) the key causes of the overpayments and the resulting impact on soldiers and their families. Our investigation confirmed that 28 of the 37 Army Guard and Reserve soldiers assigned to the MRPU in an outpatient status at Fort Bragg with alleged pay problems were in fact overpaid for hostile fire and hardship duty pay. We also identified at least 204 additional cases of sick or injured soldiers assigned to the MRPU who were overpaid for the same entitlements. An estimated $218,000 in hostile fire and/or hardship duty overpayments were made to a total of about 232 Army Guard and Reserve soldiers in an outpatient status at Fort Bragg during the period April 2003 through June 2005. As we have previously reported, internal control weaknesses in Army processes, human capital, and the lack of integrated systems caused the overpayments of hostile fire and hardship duty pay. Our investigation disclosed that the Fort Bragg Finance Battalion and MRPU controls often failed to detect the overpayments in a timely manner. A Fort Bragg Finance official acknowledged that the Finance Battalion "dropped the ball" by failing to promptly detect and stop the overpayments to sick or injured Army Guard and Reserve soldiers upon their arrival to the Fort Bragg MRPU. Further, in October 2005, DFAS completed an annual performance inspection of the Fort Bragg Finance Battalion that confirmed our conclusion about the problems soldiers were having with hostile fire and hardship duty pay. Our case studies showed that as a result of these overpayments, some soldiers and their families had to expend significant time and effort dealing with pay and resulting debt problems while recovering from their injuries. Several soldiers experienced large, unexpected deductions--as much as $1,172 from a single paycheck--for repaying the debt resulting from the Army's failure to stop the overpayments. On the other hand, the Fort Bragg Finance Battalion did not consistently take action to recover overpayments from other MRPU soldiers during the time of our investigation. Thu, 27 Apr 2006 00:00:00 -0400 VA Long-Term Care: Data Gaps Impede Strategic Planning for and Oversight of State Veterans' Nursing Homes, March 31, 2006 http://www.gao.gov/new.items/d06264.pdf The Department of Veterans Affairs (VA) provides or pays for veterans' nursing home care in three settings: VA-operated nursing homes, privately owned nursing homes in the community from which VA purchases services, and state veterans' nursing homes. VA supports state veterans' nursing homes in a number of ways, including reimbursement for a portion of the cost of providing nursing home services to veterans, issuance of policy guidance, and oversight of their nursing home operations. GAO was asked to determine the extent to which VA collects information on veterans in state veterans' nursing homes and the type of care they receive, to assess whether VA's reimbursement policy has been applied consistently, and to identify revenue sources such homes use. VA does not compile information on key characteristics of veterans receiving care in state veterans' nursing homes: veterans' length of stay, priority group status for VA hospital and outpatient services, age, and gender. VA needs such information for strategic planning, in order to develop baseline data of characteristics of veterans in state veterans' nursing homes and the care provided to them, which can help VA estimate the proportion of nursing home need it currently meets and the need it may be asked to meet as the number of older veterans changes over time. Based on visits to four states--Florida, Maine, Oklahoma, and Pennsylvania--GAO obtained information on key characteristics of state veterans' nursing home populations, which showed that these populations differed to varying degrees across the states. For example, state veterans' nursing homes in three of the four states generally were providing long-stay care (90 days or more), but 60 percent of stays in state veterans' nursing homes in Maine were short (less than 90 days). GAO also found that certain aspects of VA's per diem reimbursement policy had not been applied consistently. For example, a VA medical center in one of the four states GAO visited approved reimbursement only for care provided to veterans admitted to state veterans' nursing homes who have had wartime military service. VA's policy does not limit reimbursement on this basis. GAO also found that VA headquarters officials have not been consistent in explaining to VA medical centers whether they could approve reimbursement to state veterans' nursing homes for care provided to veterans determined to have lowest priority for VA hospital and outpatient services. In the states that GAO visited, state veterans' nursing homes rely on VA and non-VA revenue sources to varying degrees. In fiscal year 2004, per diem reimbursement from VA accounted for about one-fourth to one-third of revenues used for veterans' care. In addition to revenue from VA, state veterans' nursing homes in two of the four states GAO visited received reimbursement from Medicare and Medicaid for inpatient nursing home care provided to veterans. State veterans' nursing homes in three of the four states received funding directly from their states, ranging from 54 percent to 10 percent of revenues used for veterans' care in fiscal year 2004. In all the states GAO examined, the remainder of revenues comes from veterans' resources, such as Social Security and private pensions. Fri, 31 Mar 2006 00:00:00 -0500 VA and DOD Health Care: Opportunities to Maximize Resource Sharing Remain, March 20, 2006 http://www.gao.gov/new.items/d06315.pdf The National Defense Authorization Act for Fiscal Year 2003 required that the Departments of Veterans Affairs (VA) and Defense (DOD) implement programs referred to as the Joint Incentive Fund (JIF) and the Demonstration Site Selection (DSS) to increase health care resource sharing between the departments. The act requires GAO to report on (1) VA's and DOD's progress in implementing the programs. GAO also agreed with the committees of jurisdiction to report on (2) the actions taken by VA and DOD to strengthen resource sharing and opportunities to improve upon those actions and (3) whether VA and DOD performance measures are useful for evaluating progress toward achieving health care resource-sharing goals. VA and DOD are making progress in implementing two programs required by legislation in December 2002 to encourage health care resource sharing and collaboration--JIF and DSS. While JIF projects experienced challenges because of delays resulting from the initial absence of funding mechanisms and, in some cases, the need for additional acquisition and construction approvals, as of December 2005, 7 of 11 selected 2004 projects were operational. The DSS program also experienced challenges as some sites reported difficulty putting together project submission packages, noting confusion over the timelines and approval process as well as frustration with the amount of paperwork and rework required. Nonetheless, as of December 2005, 7 of the 8 DSS projects were operational. However, the Joint Executive Council (JEC) and Health Executive Council (HEC), VA and DOD entities established to facilitate collaboration and health care resource sharing between the departments, have not established a plan to measure and evaluate the advantages and disadvantages of DSS projects--information that will be useful for determining if projects that produce cost savings or enhance health care delivery efficiencies can be replicated systemwide. VA and DOD are creating mechanisms that support the potential to increase collaboration, sharing, and coordination of management and oversight of health care resources and services. The departments have taken steps to create interagency councils and workgroups to facilitate collaboration and sharing of information, establish working relationships among their leaders, and develop communication channels to further health care resource sharing. In addition, the departments developed a Joint Strategic Plan outlining six goals. However, JEC and HEC have not seized upon a number of opportunities to further collaboration and coordination. For example, JEC and HEC have not developed a system for collecting and monitoring information on the health care services that each department contracts for from the private sector--such as individual VA medical center or military treatment facility contracts for dialysis, laboratory services, or magnetic resonance imaging. If such a system were in place, the departments could use it to identify services that could be exchanged from one another or possibly obtain better contract pricing through joint purchasing of services, thus promoting systemwide cost savings and efficiencies. Furthermore, JEC and HEC have not directed that a joint nationwide market analysis be conducted to obtain information on what their combined future workloads will be in the areas of services, facilities, and patient needs. VA and DOD lack performance measures that would be useful for evaluating how well they are achieving their health care resource-sharing goals. For example, of the 30 measures contained in the departments' joint strategic plan, 5 were not developed at the time the plan was issued and 11 lacked longitudinal information. For the remaining 14 that require periodic measurement, there was variation in the rigor or specificity in the types of data to be collected or the analysis to be performed. Mon, 20 Mar 2006 00:00:00 -0500 VA Health Care: Preliminary Findings on the Department of Veterans Affairs Health Care Budget Formulation for Fiscal Years 2005 and 2006, February 6, 2006 http://www.gao.gov/new.items/d06430r.pdf This report documents the information we provided to Congress in a briefing on February 2, 2006, in response to a request concerning the Department of Veterans Affairs (VA) internal budget formulation process. This includes information that VA develops for its budget submission to the Office of Management and Budget (OMB), but it does not include information on subsequent interactions that occur between VA and OMB. We will do additional work to incorporate information from OMB and complete our analysis in a report to be issued at a later date. Congress requested information on VA's budget formulation process because of its interest in ensuring that VA's budget forecasts are accurate and based on valid patient estimates. In response to the request for information on VA's internal budget formulation process, this report provides the following for fiscal years 2005 and 2006: (1) a description of VA's process for developing its budget submission to OMB for its medical programs, and the role of VA's actuarial model; (2) a description of the medical program activities cited by VA as needing additional funding, and how VA identified these activities; and (3) key factors in VA's budget formulation process that contributed to the requests for additional funding. VA's internal process for formulating the medical programs funding requests was informed by, but not driven by, projected demand. VA projected costs based on projected demand for medical care under current policy. Throughout the process, VA compared projected costs to its anticipated request level for the OMB submission and made adjustments to address the difference. VA officials stated that this was done in two ways: through cost-saving policy proposals, such as assessing an annual health care enrollment fee, and management efficiencies. After making adjustments to address the difference between projected costs and its anticipated request level, VA developed its budget submission for OMB. VA later cited a number of activities as needing additional funding based on programmatic priorities and an analysis of expenditure data. Among the activities that were cited for fiscal year 2005 was $273 million for veterans returning from Iraq and Afghanistan; $226 million for long-term care; and almost $400 million for increases in the number of patients, as well as increases in both utilization and intensity of care. For the fiscal year 2006 budget, VA cited $677 million to cover a 2 percent increase in the number of patients, $600 million to correct VA's estimate for long-term care costs, $400 million for an unexpected 1.2 percent increase in average cost per patient, and $300 million to replace funds VA planned to carry over from fiscal year 2005 to fiscal year 2006. VA officials said that they chose to highlight activities that were of high programmatic priority and could be supported by workload and expenditure data (e.g. veterans returning from Iraq and Afghanistan). They also reviewed spending and workload trends to determine whether spending trends were on target or whether adjustments were needed. An unrealistic assumption, errors in estimation, and insufficient data were key factors in VA's budget formulation process that contributed to the requests for additional funding. According to VA, an unrealistic assumption about the speed with which VA could implement a policy to reduce nursing home patient workload in VA-operated nursing homes for fiscal year 2005 led to a need for additional funds. VA officials told us that errors in estimating the effect of a nursing home policy to reduce workload in all three of its nursing home settings--VA-operated nursing homes, community nursing homes, and state veterans' nursing homes--accounted for a request for additional funding for fiscal year 2006. VA officials said that the error resulted from calculations being made in haste during the OMB appeal process. Finally, VA officials told us that insufficient data on certain activities contributed to the requests for additional funds for both years. For example, inadequate data on veterans returning from Iraq and Afghanistan resulted in an underestimate in the initial funding request. Mon, 06 Feb 2006 00:00:00 -0500 Veterans Affairs: Limited Support for Reported Health Care Management Efficiency Savings, February 1, 2006 http://www.gao.gov/new.items/d06359r.pdf The Department of Veterans Affairs (VA) provides a uniform set of health care services to eligible veterans who enroll to receive such care and seek it from VA. These services include preventive and primary health care, a full range of outpatient and inpatient services, and prescription drugs. VA provides additional services, such as nursing home and dental care and other services, as required by law for some veterans and makes these services available to other veterans on a discretionary basis as resources permit. Most of the nation's 24 million veterans are eligible for some aspect of VA's health care services if they choose to enroll. In fiscal year 2005, about 7 million veterans were enrolled to receive VA health care services. In that year, VA planned to provide health care services to about 5 million veterans based on its initial budget request of $ 30.2 billion. Funding for VA's health care program has increased substantially in recent years. Congress appropriates funds annually for VA to provide health care services to eligible veterans. Congressional budget deliberations start when the President submits his annual budget request to Congress as the Budget of the United States Government. This is soon followed by VA providing the Congress with a more detailed budget justification of the President's policy and funding proposals for its programs. In each of the President's budget requests for fiscal years 2003 through 2006, the proposals assumed implementation of management efficiency initiatives that would save money without reducing the quality of service. Indeed, over these 4 fiscal years, the President's budget proposals assumed that these initiatives reduced funding requests by billions of dollars. Since savings from management efficiencies were expected to help reduce the level of annual appropriations, Congress asked us to examine (1) VA's methodology for projecting the health care management efficiency savings that were assumed in the President's budget requests for fiscal years 2003 through 2006 and (2) VA's support for reported actual savings achieved through management efficiency initiatives during fiscal years 2003 and 2004--including the methodology and documentation used to track and report achieved savings. We also summarized prior GAO and VA Office of the Inspector General (OIG) reports that have identified management inefficiencies at VA. VA lacked a methodology for making the health care management efficiency savings assumptions reflected in the President's budget requests for fiscal years 2003 through 2006 and, therefore, was unable to provide us with any support for those estimates. VA officials told us that the management efficiency savings assumed in these requests were savings goals used to reduce requests for a higher level of annual appropriations in order to fill the gap between the cost associated with VA's projected demand for health care services and the amount the President was willing to request. Further, VA lacks adequate support for the $1.3 billion it reported as actual management efficiency savings achieved for fiscal years 2003 and 2004 because it lacked a sound methodology and adequate documentation for calculating and reporting management efficiency savings. Specifically, there was little consistency with respect to what VA's regional networks reported as management efficiency savings, how savings were calculated, and what type of documentation was available to support the savings figures reported. In addition, VA's regional networks sometimes reported savings resulting from cost-cutting measures as management efficiency savings. Although both can achieve savings, cost-cutting measures, unlike management efficiency initiatives, are not consistent with VA's objective of providing the same or higher quality and quantity of service at a lower cost. Finally, VA does not have a reliable basis for determining whether it has realized the management efficiency savings that were reflected in the President's budget requests for fiscal years 2003 and 2004. Specifically, VA's use of its savings calculation for its national procurement initiatives is misleading because VA calculates actual savings for these initiatives on a cumulative basis and compares these savings figures with savings goals that are reflected on an incremental basis. In recent years, the VA OIG and we identified management inefficiencies that, if unaddressed, could contribute to requests for higher amounts of appropriations that could otherwise have been avoided. For example, although VA has instituted a number of procurement reform initiatives aimed at leveraging its purchasing power and improving the overall effectiveness of its procurement actions, the VA OIG and we continue to identify problems with VA's procurement processes. Moreover, the VA OIG identified deficiencies in VA's procurement practices as one of the agency's most serious management challenges. For instance, recent GAO and VA OIG reports disclosed significant problems with VA's acquisitions involving Federal Supply Schedule (FSS) contracts; procurement of health care services; VA construction; acquisition support weaknesses; and inadequate management and oversight of major system initiatives. In addition, recent GAO and VA OIG reports have identified both serious control weaknesses in the agency's inventory management and shortfalls in the agency's efforts to provide reliable cost data to accurately assess the efficiency and effectiveness of VA's programs and initiatives. Wed, 01 Feb 2006 00:00:00 -0500 VA Long-Term Care: Trends and Planning Challenges in Providing Nursing Home Care to Veterans, January 9, 2006 http://www.gao.gov/new.items/d06333t.pdf The Department of Veterans Affairs (VA) operates a nursing home program that provides or pays for veterans' care in three nursing home settings: VA-operated nursing homes, community nursing homes, and state veterans' nursing homes. In addition, veterans needing nursing home care may also receive it from non-VA providers that are not funded by VA. VA is faced with a large elderly veteran population, many of whom may be in need of nursing home care. In 2004, 38 percent of the nation's veteran population was over the age of 65, compared with 12 percent of the general population. The Veterans Millennium Health Care and Benefits Act (Millennium Act) of 1999 and VA policy require that VA provide nursing home care to certain veterans. This statement focuses on VA's nursing home program and trends in nursing home expenditures, trends in the number of patients served, or "patient workload," and key challenges VA faces in planning for nursing home care for veterans. To examine these trends, GAO updated information from prior work with spending and patient workload data for fiscal year 2005 that VA provided. In a November 2004 report, GAO presented spending and patient workload data through fiscal year 2003. GAO discussed the updated information with VA and incorporated comments as appropriate. VA's reported overall nursing home care expenditures in its three settings increased from $2.3 billion to almost $3.2 billion from fiscal year 2003 through fiscal year 2005. VA officials attributed the expenditure increase from fiscal year 2003 to fiscal year 2005, in part, to a change in the cost accounting system used to develop expenditure totals for each nursing home setting. Based on VA's reported expenditures, VA-operated nursing homes continued to account for about three-quarters of VA's overall nursing home care expenditures in fiscal year 2005, as they did in fiscal year 2003. In fiscal year 2005, 77 percent of nursing home care expenditures were accounted for by VA-operated nursing homes, compared to 73 percent in 2003. VA spent the remainder on state veterans' nursing homes and community nursing homes. From fiscal year 2003 through fiscal year 2005, the percentage of overall expenditures for state veterans' nursing homes declined from 15 to 12 percent and the percentage of overall expenditures for community nursing homes declined from 12 to 11 percent. VA's overall patient workload in nursing homes increased to an average of 34,375 patients per day by fiscal year 2005, 3.5 percent above the fiscal year 2003 workload. State veterans' nursing homes accounted for over half of VA's patient workload in fiscal year 2005. The workload percent is higher than the 12 percent expenditure in state veterans' nursing homes partly because VA pays on average about one-third of the costs for care veterans receive in state veterans' nursing homes, compared to the full cost in other settings. From fiscal year 2003 through fiscal year 2005, the percentage of workload provided in state veterans' nursing homes increased from 50 to 52 percent. In contrast, the percentage of patient workload provided in VA-operated nursing homes declined from 37 to 35 percent. The percentage of workload in community nursing homes stayed the same at 13 percent. VA faces two key challenges in planning for the provision of nursing home care. The first challenge is estimating who will seek care from VA and what their nursing home care needs will be. This includes estimating the number of veterans that will be eligible for nursing home care, based on law and VA policy, and the extent to which these veterans will be seeking care for short-stay postacute needs or long-stay chronic needs. A second key challenge VA faces is determining whether it will maintain or increase the proportion of nursing home care demand it meets in each of the three nursing home settings or whether veterans will need to rely more on other non-VA nursing home care providers that are funded by other programs, such as Medicaid and Medicare. Mon, 09 Jan 2006 00:00:00 -0500 Purpose Statute Violation: Veterans Affairs Improperly Funded Certain Cost Comparison Studies with VHA Appropriations, November 30, 2005 http://www.gao.gov/new.items/d06124r.pdf The Department of Veterans Affairs (VA) provides health care to about 4.7 million veterans primarily through its medical facilities--which include hospitals, nursing homes, outpatient clinics, and other health care facilities--and by contracting for care with other healthcare providers. To lower costs, increase access, and improve the quality of care provided to eligible veterans, VA evaluates the efficiency of its medical facilities, which includes performing studies to determine whether increased savings and efficiencies can be obtained from outsourcing certain segments of its operations. We have previously reported that VA would benefit from examining certain aspects of its operations, including its medical and laundry facilities, to determine if operational efficiencies could be achieved through consolidations, competitive sourcing, or both. While VA has the authority to conduct cost comparison studies and, when beneficial, to enter into contracts with commercial providers, VA may only finance cost comparison studies with funds that are legally available for this purpose. Under a provision in Title 38 of the U.S. Code, VA is prohibited by law from using any one of its Veterans Health Administration (VHA) appropriations for medical care, medical and prosthetic research, and medical administration and miscellaneous operating expenses--which fund VHA's operations--to conduct cost comparison studies unless the Congress specifically makes these appropriations available to conduct such studies. The Title 38 cost comparison funding prohibition also provides that no employee compensated from these VHA appropriations may carry out any activity in connection with such studies unless the Congress makes these appropriations specifically available for that purpose. In light of this, Congress asked us in April 2004 whether the limitations imposed by the Title 38 cost comparison funding prohibition applied solely to those studies conducted pursuant to the Office of Management and Budget (OMB) Circular No. A-76, Performance of Commercial Activities, which provides policies and procedures for determining whether commercial activities should be performed in-house using government resources or under contract with private contractor resources. If not, the request further asked whether the prohibition applied to such studies conducted as part of VA's Capital Asset Realignment for Enhanced Services (CARES) process. In our October 2004 legal opinion, we concluded that the Title 38 cost comparison funding prohibition was not limited to standard A-76 cost comparison studies in particular, or A-76 studies in general, and that the prohibition applies to CARES cost comparison studies. We further concluded that if VA had in fact obligated the VHA appropriations for the unavailable purpose of conducting cost comparison studies, then it would have violated the purpose statute. However, we noted in the opinion that we had not simultaneously undertaken an audit to determine if VHA had used these appropriations for this purpose. We met with VA headquarters officials and obtained information and documentation regarding cost comparison studies performed as part of CARES and other cost comparison studies performed during fiscal years 2001 to 2004. The information and documentation VA provided in response to our audit inquiry, however, were limited because VA does not maintain comprehensive, centralized data on the number and type of activities related to cost comparison studies conducted in the past or currently underway. Because of this, we limited the scope of our evaluation to determine whether VA improperly used VHA medical care appropriations in the three areas in which VA reported that cost comparison activities were performed: (1) VA's CARES process, (2) VA's evaluation of its medical center laundry facilities, and (3) the 1,626 cost comparison studies referenced in VA's fiscal year 2002 Performance and Accountability Report (PAR). VA employees compensated from the VHA medical care appropriation accounts performed activities in support of cost comparison studies in connection with the CARES process, VA's evaluation of its medical center laundry facilities, and for some of the 1,626 studies referenced in VA's fiscal year 2002 PAR. Because the Congress did not specifically make VHA's medical care appropriations available for cost comparison studies, VA violated the Title 38 cost comparison funding prohibition and, consequently, the purpose statute. Although funds were specifically appropriated for performing such cost comparison studies for fiscal years 1983 through 2000, no similar specific appropriations were made available in subsequent fiscal years. For fiscal years 2001 to 2004, VA requested from the Congress but did not receive specific appropriations--ranging from $16 million to $50 million--to conduct cost comparisons studies. To successfully continue its competitive sourcing activities while complying with the Title 38 cost comparison funding prohibition, VA could have used other available VA appropriations to fund these activities, such as those for major projects construction, minor projects construction, or departmental administration. According to VA, the cost comparison activities we reviewed were not subject to the Title 38 cost comparison funding prohibition because VA interprets the prohibition as applying only to "formal" (i.e., standard) A-76 studies. This is the same position VA asserted to GAO in 2004 in response to our inquiry related to our October 2004 legal opinion. We continue to disagree with VA's interpretation. In our October 2004 legal opinion, we concluded that the Title 38 cost comparison funding prohibition applies to any VA studies comparing the costs of commercial services and products provided by private contractors with those provided by VA personnel whether or not they are "formal" studies under OMB Circular No. A-76. According to VA's fiscal year 2003 PAR, it halted the bulk of its competitive sourcing studies in August 2003 because the VA General Counsel had concluded that the Title 38 cost comparison funding prohibition prevents VA from conducting cost comparisons studies using the VHA medical appropriations unless the Congress provides specific funding for that purpose. According to VA, it is seeking legislative relief so that it can restart its planned competitive sourcing program. VA can correct its purpose statute violations through account adjustment by deobligating the amounts that were improperly charged to the VHA medical appropriations and charging these amounts to otherwise available appropriation accounts. This requires that VA know the amount of VHA medical appropriations used in connection with cost comparison studies. However, VA did not track the time and expense associated with performing cost comparison studies in-house and was thus unable to provide us with a reliable estimate of this amount. Therefore, we were unable to determine whether VA would have sufficient budget authority available in other appropriations to correct the amount of each purpose statute violation. As such, we were also unable to determine if VA could avoid violations of the Antideficiency Act by making account adjustments. Nonetheless, based on documentation provided by VA, the amount of time and effort spent in support of cost comparison studies likely was substantial. For example, according to VA's Draft National CARES Plan, issued on August 4, 2003, hundreds of staff across VA devoted a great deal of time and energy to the CARES implementation process, which lasted 14 months. Wed, 30 Nov 2005 00:00:00 -0500 VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth Transition from DOD Health Care, but Sharing of Health Information Remains Limited, September 28, 2005 http://www.gao.gov/new.items/d051052t.pdf Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) servicemembers and those who are discharged from military service may receive health care from the Department of Veterans Affairs (VA). Since the onset of OIF and OEF, the Department of Defense (DOD) has reported that more than 15,000 servicemembers have been wounded in combat. Those who are seriously injured require comprehensive health care services and may be treated at either DOD or VA medical facilities. Because VA is expected to provide health care to many of the injured OIF and OEF servicemembers, concerns have been raised about the ease with which these individuals and their health care information transition from DOD's to VA's health care system. This statement is based on GAO's preliminary work on "seamless transition" and focuses on (1) the policies and outreach efforts that VA has instituted to provide timely access to health care to OIF and OEF servicemembers and (2) the extent to which individually identifiable health information is shared systematically between DOD and VA. Since GAO's work is still in the early stages of review, the statement is limited to information gathered to date. Since 2002, VA has developed policies and procedures that direct its medical facilities to provide OIF and OEF servicemembers timely access to care. Most notably, VA assigned VA social workers to selected military treatment facilities in August 2003, directed VA facilities to designate combat case managers in October 2003, and directed the establishment of four VA polytrauma centers for OIF and OEF servicemembers in June 2005. In January 2005, VA established the Seamless Transition Office to further improve coordination within the Veterans Benefits Administration and the Veterans Health Administration as well as between DOD and VA. In addition, VA has increased outreach efforts by providing OIF and OEF servicemembers who have been discharged with personal letters and newsletters, a Web site for health information tailored to OIF and OEF servicemembers, counseling services, and briefings on available VA health care services. GAO is in the beginning stages of reviewing VA's efforts to provide a smooth transition from DOD health care and has not yet evaluated the effectiveness of VA's related policies, procedures, and outreach initiatives. An important issue associated with transitioning servicemembers to VA health care is the sharing of health care information between DOD and VA. The two departments have signed a memorandum of understanding for sharing individually identifiable health information, but the memorandum does not specify the particular types of individually identifiable health information that will be exchanged and when the information will be shared. The absence of specific procedures continues to hinder VA's efforts to obtain needed health information from DOD. Recently, DOD has begun to share certain health assessment information with VA on individuals who have been discharged from the military, and the transmitting of this information to VA on a routine basis is expected to occur in October 2005. However, according to VA officials, DOD is not providing health assessment information to VA for Reserve and National Guard members, who comprise 35 percent of the OIF and OEF forces. Wed, 28 Sep 2005 00:00:00 -0400 Computer-Based Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information, September 28, 2005 http://www.gao.gov/new.items/d051051t.pdf For the past 7 years, the Departments of Veterans Affairs (VA) and Defense (DOD) have been working to exchange patient health information electronically and ultimately to have interoperable electronic medical records. Sharing medical information helps (1) promote the seamless transition of active duty personnel to veteran status and (2) ensure that active duty military personnel and veterans receive high-quality health care and assistance in adjudicating their disability claims. This is especially critical in the face of current military responses to national and foreign crises. In testimony before the Veterans' Affairs Subcommittee on Oversight and Investigations in March and May 2004, GAO discussed the progress being made by the departments in this endeavor. In June 2004, at the Subcommittee's request, GAO reported on its review of the departments' progress toward the goal of an electronic two-way exchange of patient health records. GAO is providing an update on the departments' efforts, focusing on (1) the status of ongoing, near-term initiatives to exchange data between the agencies' existing systems and (2) progress in achieving the longer term goal of exchanging data between the departments' new systems. In the past year, VA and DOD have begun to implement applications that exchange limited electronic medical information between the departments' existing health information systems. These applications are (1) Bidirectional Health Information Exchange, a project to achieve the two-way exchange of health information on patients who receive care from both VA and DOD, and (2) Laboratory Data Sharing Interface, an application used to electronically transfer laboratory work orders and results between the departments. The Bidirectional Health Information Exchange application has been implemented at five sites, at which it is being used to rapidly exchange information such as pharmacy and allergy data. Also, the Laboratory Data Sharing Interface application has been implemented at six sites, at which it is being used for real-time entry of laboratory orders and retrieval of results. According to the departments, these systems enable lower costs and improved service to patients by saving time and avoiding errors. VA and DOD are continuing with activities to support their longer term goal of sharing health information between their systems, but the goal of two-way electronic exchange of patient records remains far from being realized. Each department is developing its own modern health information system--VA's HealtheVet VistA and DOD's Composite Health Care System II--and they have taken steps to respond to GAO's June 2004 recommendations regarding the program to develop an electronic interface that will enable these systems to share information. That is, they have developed an architecture for the interface, established project accountability, and implemented a joint project management structure. However, they have not yet developed a clearly defined project management plan to guide their efforts, as GAO previously recommended. Further, they have not yet fully populated the repositories that will store the data for their future health systems, and they have experienced delays in their efforts to begin a limited data exchange. Lacking a detailed project management plan increases the risk that the departments will encounter further delays and be unable to deliver the planned capabilities on time and at the cost expected. Wed, 28 Sep 2005 00:00:00 -0400 VA Health Care: Preliminary Information on the Joint Venture Proposal for VA's Charleston Facility, September 26, 2005 http://www.gao.gov/new.items/d051041t.pdf The Department of Veterans Affairs (VA) maintains partnerships, or affiliations, with university medical schools to obtain medical services for veterans and provide training for medical residents. In 2002, the Medical University of South Carolina (MUSC)--which is affiliated with VA's medical facility in Charleston--proposed that VA and MUSC enter into a joint venture for a new VA facility as part of MUSC's plan to expand its medical campus. Under the proposal, MUSC and VA would jointly construct and operate a new medical center in Charleston. In 2004, the Capital Asset Realignment for Enhanced Services (CARES) Commission, an independent body charged with assessing VA's capital asset requirements, issued its recommendations on the realignment and modernization of VA's capital assets. Although the Commission did not recommend a replacement facility for Charleston, it did recommend, among other things, that VA promptly evaluate MUSC's proposal. This testimony discusses GAO's preliminary findings on the (1) current condition of the Charleston facility, (2) extent to which VA and MUSC collaborated on the joint venture proposal, and (3) issues for VA to consider when exploring the opportunity to participate in the joint venture. VA concurred with GAO's preliminary findings. The most recent VA facility assessment and the CARES Commission concluded that the Charleston medical facility is in overall good condition and, with some renovations, can continue to meet veterans' health care needs in the future. VA officials attribute this to VA's continued capital investments in the facility. For example, over the last 5 years, VA has invested approximately $11.6 million in nonrecurring maintenance projects, such as replacing the fire alarm system and roofing. To maintain the facility's condition over the next 10 years, VA officials from the Charleston facility have identified a number of planned capital maintenance and improvement projects, totaling approximately $62 million. VA and MUSC have collaborated and communicated to a limited extent over the past 3 years on a proposal for a joint venture medical center. For example, before this summer, VA and MUSC had not exchanged critical information that would help facilitate negotiations, such as cost analyses of the proposal. As a result of the limited collaboration, negotiations over the proposal stalled. However, after a congressional delegation visit in August 2005, VA and MUSC took steps to move the negotiations forward. Specifically, VA and MUSC established four workgroups to examine critical issues related to the proposal. The MUSC proposal for a new joint venture medical center presents an opportunity for exploring new ways of providing health care to Charleston's veterans, but it also raises a variety of complex issues for VA. These include the benefits and costs of investing in a joint facility compared with other alternatives, legal issues associated with the new facility such as leasing or transferring property, and potential concerns of stakeholders, including VA patients and employees. The workgroups established by VA and MUSC are expected to examine some, but not all, of these issues. Additionally, some issues can be addressed through collaboration between VA and MUSC, but others may require VA to seek legislative remedies. Mon, 26 Sep 2005 00:00:00 -0400 Defense Health Care: DOD has Established a Chiropractic Benefit for Active Duty Personnel, September 6, 2005 http://www.gao.gov/new.items/d05890r.pdf The Floyd D. Spence National Defense Authorization Act for Fiscal Year 2001 (NDAA 2001) directed the Department of Defense (DOD) to develop and implement a plan to make a chiropractic benefit available to all active duty personnel in the U.S. armed forces. The practice of chiropractic focuses on the relationship between structure (primarily, the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In August 2001, DOD submitted to Congress an implementation plan that described how it planned to develop a chiropractic benefit within the military health system. The plan addressed patient eligibility, access to care, the location of chiropractic clinics, projected costs, staffing, and the marketing and monitoring of the benefit. The NDAA 2001 directed DOD to develop the implementation plan in consultation with the Oversight Advisory Committee (OAC), which was established by the National Defense Authorization Act for Fiscal Year 1995 (NDAA 1995). The OAC was directed by the NDAA 1995 to oversee a 3-year DOD chiropractic demonstration project at no fewer than 10 military treatment facilities (MTF). The NDAA 1995 directed that the OAC include the Assistant Secretary of Defense for Health Affairs; the Surgeons General of the Army, the Air Force, and the Navy; and at least four representatives of the chiropractic profession; and also directed that we serve as a member of the OAC. As a member of the OAC, we attended meetings of the OAC and provided technical input and advice. The NDAA 2001 also mandated that we monitor the development and implementation of DOD's chiropractic health care plan. As agreed with the committees of jurisdiction, we reviewed the implementation of DOD's chiropractic benefit. To implement its chiropractic benefit, DOD has opened chiropractic clinics at 42 of its 238 MTFs, worldwide, and does not plan to add any additional clinics at this time. All of DOD's 1.8 million active-duty personnel are eligible for the benefit. The 42 chiropractic clinics are located in the United States in areas with a high number of active-duty personnel. Approximately 969,000, or 54 percent, of active-duty personnel reside in the areas served by the MTFs with chiropractic clinics. To support the benefit, DOD provides annual allotments from its health care budget. In fiscal year 2004, the allotment increased to $11 million. An additional $203,000 was provided by the MTFs with chiropractic clinics in fiscal year 2004. DOD generally adhered to the priorities specified in its implementation plan in selecting the sites for the 42 clinics and in determining the clinics' staffing levels. DOD has not completed other actions described in the implementation plan. For example, DOD's implementation plan stated that a marketing and promotion program, which would include pamphlets and other materials, would be necessary to make active-duty personnel aware of the benefit. However, DOD did not provide active-duty personnel with such materials as specified in the plan. Instead, DOD relied on each MTF to determine whether and how to promote the benefit. The implementation plan also called for close monitoring of the benefit to determine whether the benefit meets current needs, but DOD officials said that they had not monitored whether the benefit meets current or future demand from active-duty personnel. Tue, 06 Sep 2005 00:00:00 -0400 VA Health Care: Key Challenges to Aligning Capital Assets and Enhancing Veterans' Care, August 5, 2005 http://www.gao.gov/new.items/d05429.pdf The Department of Veterans Affairs (VA) operates one of the nation's largest health care systems. In 1999, GAO reported on VA's aged, obsolete capital assets, noting that better management of these assets could significantly reduce VA's operating costs. GAO also noted that VA could reinvest the savings to enhance veterans' health care. In response, VA initiated its Capital Asset Realignment for Enhanced Services (CARES) process to identify what health care services it should provide in which locations through fiscal year 2022. CARES resulted in decisions to realign inpatient services at some VA facilities and to leave services as currently aligned at others. VA did not complete inpatient alignment decisions across VA for long-term care and mental health services and for inpatient services at some facilities because VA lacked sufficient information on demand for such care and other factors. GAO was asked to examine key challenges VA will face in completing and implementing CARES. This report discusses three key challenges: (1) developing information to complete inpatient alignment decisions, (2) improving management of excess property, and (3) determining priorities for purchasing care to improve access. GAO's analysis is based on its prior CARES work, review of CARES documents, and interviews with VA officials. VA faces a key challenge in developing sufficient information to complete inpatient service alignment decisions. VA concluded that it did not have sufficient information to complete such decisions across VA for long-term care (including nursing home care) and mental health services (including acute psychiatric care). VA also concluded that it did not have sufficient information to complete alignment decisions for inpatient services at 12 facilities. VA faces this challenge for several reasons. For example, it is unclear whether VA has adequate information on the number of veterans who will seek nursing home care and inpatient mental health services from VA on a daily basis because it concluded that its models were inadequate to forecast demand and it has not finalized revised models. VA has taken steps to address the challenge of developing the information needed such as working to develop improved models of demand for these services. Improving the management of VA's large inventory of excess property--including 8.5 million square feet of vacant space--poses another key challenge. This challenge results from disincentives associated with administrative complexity and costs of the disposal of federal property. Like all federal agencies, VA must comply with federal requirements governing property disposal that are intended, for example, to protect subsequent users of the property from environmental hazards. Some VA managers have retained excess property because the complexity and costs of complying with these requirements were disincentives to disposal. Congress has given VA authority to use disposal proceeds for construction and renovation of VA patient facilities and disposal activities, to the extent specified in appropriations acts. VA is taking steps to address this challenge, including hiring network-level capital asset managers to facilitate disposal. VA faces another key challenge in determining priorities for the purchase of inpatient services to improve access to care. While VA determined that purchasing inpatient services from non-VA health care providers in 25 health care markets would be a reasonable option for providing care closer to where veterans live, VA's network managers have to balance the costs and benefits of purchasing care against competing priorities. VA has taken steps to facilitate managers' development of information they need to decide among priorities, including information on the cost effectiveness of proposed contracts and their impact on other health care priorities. To improve its management of capital assets and enhance veterans' health care by reinvesting resources now spent on excess property, VA must overcome challenges in completing and implementing decisions reached through CARES. Furthermore, institutionalizing the CARES process into its ongoing strategic planning will be crucial to VA's effectiveness as a steward of national resources and a health care provider for the nation's veterans. VA concurred with GAO's findings and conclusions. Fri, 05 Aug 2005 00:00:00 -0400 DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers' Transition to VA Services, May 19, 2005 http://www.gao.gov/new.items/d05722t.pdf Since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), the Department of Defense (DOD) reported that more than 12,000 servicemembers have been injured in combat. While many return to active duty, others with more serious injuries are likely to be discharged from the military. To ensure the continuity of medical care and access to all other Department of Veterans Affairs' (VA) benefits, such as vocational rehabilitation, VA formed its Seamless Transition Task Force. In January 2005, GAO reported that VA had given high priority to OEF/OIF servicemembers, but faced challenges in identifying, locating, and following up with seriously injured servicemembers. GAO recommended that VA and DOD reach an agreement for VA to obtain systematic data from DOD, and the departments concurred. However, DOD raised privacy concerns. GAO was asked to review VA's efforts to expedite vocational rehabilitation services to seriously injured servicemembers and to determine the status of an agreement between DOD and VA to share health data. GAO relied on its prior work; interviewed VA and DOD officials; and reviewed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule, which govern the sharing of individually identifiable health data. While VA has taken steps to expedite services to seriously injured servicemembers, VA does not have systematic data from DOD on seriously injured servicemembers who may need VA vocational rehabilitation and other benefits. As a result, VA has had to rely on its regional offices to develop informal data sharing arrangements with local military treatment facility (MTF) staff to identify servicemembers who may need vocational rehabilitation services. However, VA staff have no official data source from DOD from which to confirm the completeness and reliability of the data they obtain. Furthermore, they cannot provide reasonable assurance that some seriously injured servicemembers who may have benefited from vocational rehabilitation services have not been overlooked. Although several VA headquarters officials and regional office staff GAO interviewed said that systematic data from DOD would provide them with a way to reliably identify and follow up with seriously injured servicemembers, DOD and VA have not developed a data sharing agreement. Additionally, VA officials said these data would help VA plan for projected increases in the need for services for newly returning OEF/OIF servicemembers. VA has requested that DOD provide systematic data on seriously injured servicemembers who may need vocational rehabilitation. DOD and VA have been working on a data sharing agreement for over 2 years, but have not reached an agreement. DOD and VA differ in their understanding of HIPAA Privacy Rule provisions that govern the sharing of individually identifiable health data for servicemembers currently receiving treatment at MTFs, and the extent to which the Privacy Rule would permit that exchange. DOD's and VA's inability to resolve these differences has impeded coming to an agreement on exchanging seriously injured servicemembers' individually identifiable health data. Despite being unable to agree on an exchange of individually identifiable health data, DOD and VA are reviewing a draft memorandum of understanding, which the departments believe will move them closer to a data sharing agreement. However, GAO found that the draft memorandum restates many of the legal authorities contained in the Privacy Rule for the use and disclosure of individually identifiable health data. As a result, even if the memorandum of understanding is finalized, DOD and VA will still have to agree on what types of individually identifiable health data can be exchanged and when the data can be shared. DOD and VA generally agreed with GAO's findings. Thu, 19 May 2005 00:00:00 -0400 Veterans Health Care: VA's Medical Support Role in Emergency Preparedness, March 23, 2005 http://www.gao.gov/new.items/d05387r.pdf Since the terrorist attacks on September 11, 2001, the Department of Veterans Affairs (VA) has increased its efforts to plan for and respond to national emergencies, including acts of terrorism and natural disasters. Additionally, in August 2004, the Federal Bureau of Investigation and the Department of Homeland Security announced that military and VA medical facilities were potential terrorist targets. In light of military casualties from conflicts in Afghanistan and Iraq and continued threats of terrorist incidents, Congress asked us to review VA's medical support role in emergency preparedness. Specifically, we agreed to provide information on the following questions: (1) What is VA's role in providing medical support within the U.S. to military personnel in wartime and during national emergencies? (2) What actions has VA taken to improve its internal emergency preparedness to ensure that it is ready to maintain continuity of operations and provision of medical services to veterans? (3) What is VA's role in participating in emergency medical response measures with other federal, state, and local agencies? GAO found that Public Law 97-174 authorizes VA to provide inpatient medical care to active duty members of the armed services during or immediately following their involvement in armed conflicts during wartime and national emergencies. According to VA, while the Department of Defense (DOD) has never requested priority care from VA based on this law, VA has routinely reported to the Congress and DOD the number of inpatient beds available for military personnel. We also found that VA has taken numerous actions to improve emergency preparedness, such as developing educational and training materials for its staff, training staff at 134 VA medical centers, and increasing security at its facilities by requiring a minimum of two patrolling VA police officers on duty at all times. Other activities, such as developing a systemwide strategy for protecting its facilities and acquiring decontamination equipment, are still in progress. Finally, VA participates in emergency medical response measures with other federal, state, and local agencies by providing assistance in seven support functions outlined in the Department of Homeland Security's National Response Plan. For example, if requested, the types of support VA would provide include public health and medical services, emergency management, and public safety and security. Wed, 23 Mar 2005 00:00:00 -0500 VA Disability Benefits and Health Care: Providing Certain Services to the Seriously Injured Poses Challenges, March 17, 2005 http://www.gao.gov/new.items/d05444t.pdf More than 10,000 U.S. military servicemembers, including members of the National Guard and Reserve, have been injured in the conflicts in Afghanistan and Iraq. Those with serious physical and psychological injuries are initially treated at the Department of Defense's (DOD) major military treatment facilities (MTF). The Department of Veterans Affairs (VA) has made provision of services to these servicemembers a high priority. This testimony focuses on the steps VA has taken and the challenges it faces in providing services to the seriously injured and highlights findings from three recent GAO reports that addressed VA's efforts to provide services to the seriously injured. These services include vocational rehabilitation and employment (VR&E) and health care for those with post-traumatic stress disorder (PTSD). VA has taken steps to provide services as a high priority to seriously injured servicemembers returning from Afghanistan and Iraq. To identify and monitor those who may require VA's services, VA and DOD are working on a formal agreement to share data about servicemembers with serious injuries. Meanwhile, VA has relied on its regional offices to coordinate with staff at MTFs and VA medical centers to learn the identities, medical conditions, and military status of seriously injured servicemembers. For servicemembers with PTSD, VA has taken steps to improve care including developing with DOD a clinical practice guideline for identifying and treating individuals with PTSD. The guideline contains a four-question screening tool, which both VA and DOD use to identify those who may be at risk for PTSD. VA faces significant challenges in providing services to seriously injured servicemembers. For example, the individualized nature of recovery makes it difficult to determine when a seriously injured servicemember will be ready for vocational rehabilitation, and DOD has expressed concern that VA's outreach to servicemembers could affect retention for those whose discharge from military service is uncertain. VA is also challenged by the lack of access to DOD data; although VA staff have developed ad hoc arrangements, such informal agreements can break down. Regarding PTSD, inaccurate data limit VA's ability to estimate its capacity for treating additional veterans and to plan for an increased demand for these services. Thu, 17 Mar 2005 00:00:00 -0500 VA Health Care: Important Steps Taken to Enhance Veterans' Care by Aligning Inpatient Services with Projected Needs, March 2, 2005 http://www.gao.gov/new.items/d05160.pdf The Department of Veterans Affairs (VA) operates one of the nation's largest health care systems. In 1999, GAO reported on VA's aged, obsolete capital assets, noting that better management of these assets could significantly reduce VA's operating costs. GAO further noted that VA could reinvest the savings to enhance veterans' health care services. In response, VA initiated its Capital Asset Realignment for Enhanced Services (CARES) process. Through CARES, VA identified what health care services it should provide and in which locations through 2022. The CARES process included assessing alternative ways to align inpatient services by closing or adding services at existing VA medical facilities or establishing new facilities. In May 2004, VA published its CARES decisions, but did not provide a national comprehensive summary of all its decisions about the alignment of inpatient services. GAO was asked to provide additional information about the inpatient service assessments and decisions made by VA. To provide a national, comprehensive summary, GAO summarized the locations where VA (1) identified a need to evaluate alternative ways to align inpatient health care service to improve quality, efficiency, or access and (2) made decisions to realign inpatient services or leave inpatient services as aligned, or deferred decisions pending further study. Through CARES, VA identified 136 locations for evaluation of alternative ways to align inpatient services. These locations included VA medical facilities, health care markets (geographic areas established by VA for the coordination of care), and health care networks (regional organizations of VA health care facilities established to facilitate management). Of the 136 locations, 99 were VA medical facilities with potential duplication of services at another nearby VA medical facility or low acute inpatient workload. In addition, VA identified limitations in geographic access to inpatient services in 31 markets and 6 networks, for example, when large numbers of veterans face lengthy driving times to VA facilities that provide acute or tertiary care. VA made alignment decisions for inpatient services at 120 locations and deferred decisions for 16 locations pending further study. VA decided to realign inpatient services at 30 locations and maintain inpatient services as currently aligned at 90 locations. VA decided to close all inpatient services at 5 facilities and add them at 5 nearby VA facilities where they were not already available; close one or more, but not all, inpatient services at 12 other facilities; add inpatient services to medical facilities in 2 markets and 5 networks; and establish 1 new medical facility in a location where VA did not own an inpatient facility when it made its CARES decisions. VA's decisions on inpatient alignment and planned studies are tangible steps forward in improving management of its capital assets and enhancing health care. Ultimately, however, accomplishing these goals will depend on VA's success in completing its studies and implementing its CARES decisions on inpatient and other health care services to better ensure that resources now spent on unneeded capital assets are redirected to health care. VA concurred with GAO's findings. Wed, 02 Mar 2005 00:00:00 -0500 DOD and VA Health Care: Incentives Program for Sharing Health Resources, February 28, 2005 http://www.gao.gov/new.items/d05310r.pdf Combined, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) provide health care services to about 16.8 million beneficiaries at an estimated cost of $58 billion for fiscal year 2005--$30.4 billion for DOD and $27.7 billion for VA. In 1982, the Congress passed the Veterans' Administration and Department of Defense Health Resources Sharing and Emergency Operations Act (Sharing Act) to promote more cost-effective use of health care resources and more efficient delivery of care. Specifically, the Congress authorized DOD and VA to enter into sharing agreements with each other to buy, sell, and barter medical and support services. To further encourage ongoing collaboration, the Congress passed the Bob Stump National Defense Authorization Act (NDAA) for Fiscal Year 2003, which directed the Secretary of Defense and the Secretary of Veterans Affairs to establish a joint incentives program to identify and provide incentives to implement, fund, and evaluate creative health care coordination and sharing initiatives between DOD and VA. Under the program, DOD and VA are to solicit proposals from their program offices, DOD military treatment facilities, or VA medical facilities for project initiatives at least annually. DOD and VA health care officials are to develop program guidelines and establish project evaluation and selection criteria. To facilitate the program, each secretary is required to contribute a minimum of $15 million from each department's appropriation into an account established in the U.S. Treasury for each fiscal year from 2004 through 2007. The Financial Management Workgroup (FMWG) under the Health Executive Council (HEC) administers the Incentive Fund program. The NDAA also requires that we submit a report on the implementation of the program by February 28 of each fiscal year the program is in effect. We reviewed DOD's and VA's plans for implementing the DOD-VA Health Care Sharing Incentive Fund--including proposal submission guidelines and evaluation and selection criteria--and interviewed department officials from DOD and VA involved in the oversight of the program and those facility or program office officials responsible for the projects that were selected for funding during fiscal year 2004. From December 2002 through January 2005, DOD and VA developed program guidelines and solicited, reviewed, selected, and funded projects. During that time DOD and VA officials completed their review of 58 concept proposals that were submitted, selected 12 projects for implementation, and funded 9 of them. Three projects were awaiting funds as of February 3, 2005. Project selection took place in August 2004, and the departments began funding projects in November 2004. According to the departments, funding could not be provided until project officials and the Surgeons General for DOD's Departments of the Army, Navy, and Air Force completed certain administrative actions. These actions included project officials ensuring that the project would be self-sustaining within 2 years and the Surgeons General ensuring that service-specific department protocols for disbursing funds were followed. DOD and VA officials generally concurred with the information presented in this report. Mon, 28 Feb 2005 00:00:00 -0500 Military Pay: Gaps in Pay and Benefits Create Financial Hardships for Injured Army National Guard and Reserve Soldiers, February 17, 2005 http://www.gao.gov/new.items/d05322t.pdf In light of the recent mobilizations associated with the Global War on Terrorism, GAO was asked to determine if the Army's overall environment and controls provided reasonable assurance that soldiers who were injured or became ill in the line of duty were receiving the pay and other benefits to which they were entitled in an accurate and timely manner. This testimony outlines pay deficiencies in the key areas of (1) overall environment and management controls, (2) processes, and (3) systems. It also focuses on whether recent actions the Army has taken to address these problems will offer effective and lasting solutions. Injured and ill reserve component soldiers--who are entitled to extend their active duty service to receive medical treatment--have been inappropriately removed from active duty status in the automated systems that control pay and access to medical care. The Army acknowledges the problem but does not know how many injured soldiers have been affected by it. GAO identified 38 reserve component soldiers who said they had experienced problems with the active duty medical extension order process and subsequently fell off their active duty orders. Of those, 24 experienced gaps in their pay and benefits due to delays in processing extended active duty orders. Many of the case study soldiers incurred severe, permanent injuries fighting for their country including loss of limb, hearing loss, and back injuries. Nonetheless, these soldiers had to navigate the convoluted and poorly defined process for extending active duty service. The Army's process for extending active duty orders for injured soldiers lacks an adequate control environment and management controls--including (1) clear and comprehensive guidance, (2) a system to provide visibility over injured soldiers, and (3) adequate training and education programs. The Army has also not established user-friendly processes--including clear approval criteria and adequate infrastructure and support services. Many Army locations have used ad hoc procedures to keep soldiers in pay status; however, these procedures often circumvent key internal controls and put the Army at risk of making improper and potentially fraudulent payments. Finally, the Army's nonintegrated systems, which require extensive errorprone manual data entry, further delay access to pay and benefits. The Army recently implemented the Medical Retention Processing (MRP) program, which takes the place of the previously existing process in most cases. MRP, which authorizes an automatic 179 days of pay and benefits, may resolve the timeliness of the front-end approval process. However, MRP has some of the same issues and may also result in overpayments to soldiers who are released early from their MRP orders. Out of 132 soldiers the Army identified as being released from active duty, 15 improperly received pay past their release date--totaling approximately $62,000. Thu, 17 Feb 2005 00:00:00 -0500 Military Pay: Gaps in Pay and Benefits Create Financial Hardships for Injured Army National Guard and Reserve Soldiers, February 17, 2005 http://www.gao.gov/new.items/d05125.pdf In light of the recent mobilizations associated with the Global War on Terrorism, GAO was asked to determine if the Army's overall environment and controls provided reasonable assurance that soldiers who were injured or became ill in the line of duty were receiving the pay and other benefits to which they were entitled in an accurate and timely manner. GAO's audit used a case study approach to provide perspective on the nature of these pay deficiencies in the key areas of (1) overall environment and management controls, (2) processes, and (3) systems. GAO also assessed whether recent actions the Army has taken to address these problems will offer effective and lasting solutions. Injured and ill reserve component soldiers--who are entitled to extend their active duty service to receive medical treatment--have been inappropriately removed from active duty status in the automated systems that control pay and access to medical care. The Army acknowledges the problem but does not know how many injured soldiers have been affected by it. GAO identified 38 reserve component soldiers who said they had experienced problems with the active duty medical extension order process and subsequently fell off their active duty orders. Of those, 24 experienced gaps in their pay and benefits due to delays in processing extended active duty orders. Many of the case study soldiers incurred severe, permanent injuries fighting for their country including loss of limb, hearing loss, and back injuries. Nonetheless, these soldiers had to navigate the convoluted and poorly defined process for extending active duty service. The Army's process for extending active duty orders for injured soldiers lacks an adequate control environment and management controls--including (1) clear and comprehensive guidance, (2) a system to provide visibility over injured soldiers, and (3) adequate training and education programs. The Army has also not established user-friendly processes--including clear approval criteria and adequate infrastructure and support services. Many Army locations have used ad hoc procedures to keep soldiers in pay status; however, these procedures often circumvent key internal controls and put the Army at risk of making improper and potentially fraudulent payments. Finally, the Army's nonintegrated systems, which require extensive errorprone manual data entry, further delay access to pay and benefits. The Army recently implemented the Medical Retention Processing (MRP) program, which takes the place of the previous process in most cases. MRP, which authorizes an automatic 179 days of pay and benefits, may have resolved many of the processing delays experienced by soldiers. However, MRP has some of the same issues and may also result in overpayments to soldiers who are released early from their MRP orders. Out of 132 soldiers the Army identified as being released from active duty, 15 received pay past their release date--totaling approximately $62,000. Thu, 17 Feb 2005 00:00:00 -0500 VA Health Care: VA Should Expedite the Implementation of Recommendations Needed to Improve Post-Traumatic Stress Disorder Services, February 14, 2005 http://www.gao.gov/new.items/d05287.pdf Post-traumatic stress disorder (PTSD), which is caused by an extremely stressful event, can develop after military combat and exposure to the threat of death or serious injury. Mental health experts estimate that the intensity of warfare in Iraq and Afghanistan could cause more than 15 percent of servicemembers returning from these conflicts to develop PTSD. Symptoms of PTSD can be debilitating and include insomnia; intense anxiety; and difficulty coping with work, social, and family relationships. Left untreated, PTSD can lead to substance abuse, severe depression, and suicide. Symptoms may appear within months of the traumatic event or be delayed for years. While there is no cure for PTSD, experts believe early identification and treatment of PTSD symptoms may lessen their severity and improve the overall quality of life for individuals with this disorder. The Department of Veterans Affairs (VA) is a world leader in PTSD treatment and offers PTSD services to eligible veterans. To inform new veterans about the health care services it offers, VA has increased outreach efforts to servicemembers returning from the Iraq and Afghanistan conflicts. Outreach efforts, coupled with expanded access to VA health care for these new veterans, are likely to result in greater numbers of veterans with PTSD seeking VA services. Congress highlighted the importance of VA PTSD services more than 20 years ago when it required the establishment of the Special Committee on Post-Traumatic Stress Disorder (Special Committee) within VA, primarily to aid Vietnam-era veterans diagnosed with PTSD. A key charge of the Special Committee is to make recommendations for improving VA's PTSD services. The Special Committee issued its first report on ways to improve VA's PTSD services in 1985 and its latest report, which includes 37 recommendations for VA, in 2004. The Special Committee reports also include evaluations of whether VA has met or not met the recommendations made by the Special Committee in prior reports. The Department of Veterans Affairs (VA) is a world leader in PTSD treatment and offers PTSD services to eligible veterans. To inform new veterans about the health care services it offers, VA has increased outreach efforts to servicemembers returning from the Iraq and Afghanistan conflicts. Outreach efforts, coupled with expanded access to VA health care for these new veterans, are likely to result in greater numbers of veterans with PTSD seeking VA services. Congress asked us to determine whether VA has addressed the Special Committee's recommendations to improve VA's PTSD services. We focused our review on 24 recommendations related to clinical care and education made by VA's Special Committee on PTSD in its 2004 report to determine (1) the extent to which VA has met each recommendation related to clinical care and education and (2) VA's time frame for implementing each of these recommendations. GAO determined that VA has not fully met any of 24 Special Committee recommendations in our review related to clinical care and education. Specifically, we determined that VA has not met 10 recommendations and has partially met 14 of these 24 recommendations. For example, the Special Committee recommended that VA develop, disseminate, and implement a best practice treatment guideline for PTSD. The Special Committee designated the recommendation as met because VA had developed and disseminated the guideline. However, because we found that VA does not have documentation to show that the treatment part of the guideline is being implemented at its medical facilities and community-based clinics, we designated the recommendation as partially met. We also determined that VA does not plan to fully implement 23 of 24 recommendations until fiscal year 2007 or later. Ten of these are long-standing recommendations that were first made in the Special Committee report issued in 1985. VA's delay in fully implementing the recommendations raises questions about VA's capacity to identify and treat veterans returning from military combat who may be at risk for developing PTSD, while maintaining PTSD services for veterans currently receiving them. This is particularly important because we reported in September 2004 that officials at six of seven VA medical facilities stated that they may not be able to meet an increase in demand for PTSD services. In addition, the Special Committee reported in its 2004 report that VA does not have sufficient capacity to meet the needs of new combat veterans while still providing for veterans of past wars. If servicemembers returning from military combat do not have access to PTSD services, many mental health experts believe that the chance may be missed, through early identification and treatment of PTSD, to lessen the severity of the symptoms and improve the overall quality of life for these combat veterans with PTSD. Moreover, VA has identified geographic areas of the country where large numbers of servicemembers are returning from the current conflicts in Iraq and Afghanistan. VA could consider focusing first on ensuring service availability at facilities in areas that are likely to experience the most demand for PTSD services. Mon, 14 Feb 2005 00:00:00 -0500 Vocational Rehabilitation: More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers, January 14, 2005 http://www.gao.gov/new.items/d05167.pdf More than 10,000 U.S. military servicemembers, including National Guard and Reserve members, have been injured in the conflicts in Afghanistan and Iraq. Those with serious injuries are likely to be discharged from the military and return to civilian life with disabilities. The Department of Veterans Affairs (VA) offers vocational rehabilitation and employment (VR&E) services to help these injured servicemembers in their transition to civilian employment. GAO has noted that early intervention--the provision of rehabilitation services as soon as possible after the onset of a disability--is a practice that significantly facilitates the return to work. GAO examined how VA expedites VR&E services to seriously injured servicemembers and the challenges VA faces in its efforts to do so. VA has taken steps to expedite vocational rehabilitation and employment services for servicemembers returning from Afghanistan and Iraq with serious injuries. The agency has instructed its regional offices to make seriously injured servicemembers a high priority for all VA assistance, including VR&E services, and has asked DOD to provide data that would help VA identify and monitor this population. It has also deployed additional staff to five major Army military treatment facilities where the majority of the seriously injured are treated. Pending an agreement with DOD for sharing data, VA has relied on its regional offices to learn who the seriously injured are and where they are located. We found that the regional offices we reviewed had developed information that varied in completeness and reliability. We also found that VA does not have a policy for maintaining contact with those with serious injuries who may later be ready for VR&E services but did not initially apply for VR&E. Nevertheless, some regional offices did attempt to maintain contact while other regional offices did not. VA faces significant challenges in expediting VR&E services to seriously injured servicemembers. These include: the inherent challenge that individual differences and uncertainties in the recovery process make it difficult to determine when a servicemember will be ready to consider VR&E services; DOD's concerns that VA's outreach, including early intervention with VR&E, could work at cross purposes to military retention goals for servicemembers whose discharge from military service is not yet certain; and the lack of access to data from DOD that would allow VA to readily know which servicemembers are seriously injured and where they are located. VA and DOD generally concurred with our findings and recommendations. Fri, 14 Jan 2005 00:00:00 -0500 VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving the Military, November 12, 2004 http://www.gao.gov/new.items/d0564.pdf Servicemembers who leave the military and file disability claims with the Department of Veterans Affairs (VA) may be subject to potentially duplicative physical exams in order to meet requirements of both the Department of Defense's (DOD) military services and VA. To streamline the process for these servicemembers, the military services and VA have attempted to coordinate their physical exam requirements by developing a single separation exam program. In 1998, VA and DOD signed a memorandum of understanding (MOU) instructing local units to establish single separation exam programs. This report examines (1) VA's and the military services' efforts to establish single separation exam programs, and (2) the challenges to establishing single separation exam programs. To obtain this information, GAO interviewed VA and military service officials about establishing the program; evaluated existing programs at selected military installations; and visited selected installations that did not have programs. Since 1998, VA and the military services have collaborated to establish single separation exam programs. However, while we were able to verify that the program was being delivered at some military installations, DOD, its military services, and VA either could not provide information on program locations or provided us with inaccurate information. As of May 2004, VA reported that 28 military installations had single separation exam programs that used one of five basic approaches to deliver an exam that met both VA's and the military services' requirements. However, when we evaluated 8 of the 28 installations, we found that 4 of the installations did not actually have programs in place. Nonetheless, VA and DOD leadership continue to encourage the establishment of single separation exam programs and have recently drafted a new memorandum of agreement (MOA) that is intended to replace the 1998 MOU. Like the original MOU, the draft MOA delegates responsibility for establishing single separation exam programs to local VA and military installations, depending on available resources. However, the draft MOA also contains a specific implementation goal that selected military installations should have single separation exam programs in place by December 31, 2004. This would require implementation at 139 installations--an ambitious plan given the seemingly low rate of program implementation since 1998 and the lack of accurate information on existing programs. Several challenges impede the establishment of single separation exam programs. The predominant challenge is that the military services may not benefit from a program designed to eliminate the need for two separate physical exams because they usually do not require that servicemembers receive a separation exam. As of August 2004, only the Army had a general separation exam requirement for retiring servicemembers. The other military services primarily require separation exams when the servicemember's last physical exam or medical assessment received during active duty is no longer considered current. In fiscal year 2003, only an estimated 13 percent of servicemembers who left the military received a separation exam. Consequently, the military services may not realize resource savings by eliminating or sharing responsibility for this exam. According to some military officials, another challenge to establishing single separation exam programs is that resources, such as facility space and medical personnel, are needed for other priorities, such as ensuring that active duty servicemembers are healthy enough to perform their duties. Additionally, because single separation exam programs require coordination between personnel from both VA and the military services, military staff changes, including those due to routine rotations, can make it difficult to maintain existing programs. Fri, 12 Nov 2004 00:00:00 -0500 VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data Gaps, November 10, 2004 http://www.gao.gov/new.items/d0565.pdf The Department of Veterans Affairs (VA) operates a $2.3 billion nursing home program that provides or pays for veterans' care in three settings: VA nursing homes, community nursing homes, and state veterans' nursing homes. The Veterans Millennium Health Care and Benefits Act (Millennium Act) of 1999 and VA policy require that VA provide nursing home care to veterans with a certain eligibility. Congress has expressed a need for additional data to conduct oversight of VA's nursing home program. Specifically, for all VA nursing home settings in fiscal year 2003, GAO was asked to report on (1) VA spending to provide or pay for nursing home care, (2) VA workload provided or paid for, (3) the percentage of nursing home care that is long and short stay, and (4) the percentage of veterans receiving care required by the Millennium Act or VA policy. In fiscal year 2003, VA spent 73 percent of its nursing home resources on VA nursing homes--almost $1.7 billion of about $2.3 billion--and the remaining 27 percent on community and state veterans' nursing homes. Half of VA's average daily nursing home workload of 33,214 in fiscal year 2003 was for state veterans' nursing homes, even though this setting accounted for 15 percent of VA's overall nursing home expenditures. In large part, this is because VA pays about one-third of the cost of care in state veterans' nursing homes. Community nursing homes and VA nursing homes accounted for 13 and 37 percent of the workload, respectively. About one-third of nursing home care in VA nursing homes in fiscal year 2003 was long-stay care (90 days or more). Long-stay services include those needed by veterans who cannot be cared for at home because of severe, chronic physical or mental impairments such as the inability to independently eat or the need for supervision because of dementia. The other two-thirds was short-stay care (less than 90 days), which includes services such as postacute care needed for recuperation from a stroke. VA lacks similar data for community and state veterans' nursing homes. About one-fourth of veterans who received care in VA nursing homes in fiscal year 2003 were served because the Millennium Act or VA policy requires that VA provide or pay for nursing home care of veterans with a certain eligibility. All other veterans received care at VA's discretion. VA lacks data on comparable eligibility status for community and state veterans' nursing homes even though these settings combined accounted for 63 percent of VA's overall workload. Gaps in data on length of stay and eligibility in these two settings impede program oversight. Wed, 10 Nov 2004 00:00:00 -0500 VA and Defense Health Care: More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services, September 20, 2004 http://www.gao.gov/new.items/d041069.pdf Post-traumatic stress disorder (PTSD) is caused by an extremely stressful event and can develop after the threat of death or serious injury as in military combat. Experts predict that about 15 percent of servicemembers serving in Iraq and Afghanistan will develop PTSD. Efforts by VA to inform new veterans, including Reserve and National Guard members, about the expanded availability of VA health care services could result in an increased demand for VA PTSD services. GAO identified the approaches DOD uses to identify servicemembers at risk for PTSD and examined if VA has the information it needs to determine whether it can meet an increase in demand for PTSD services. GAO visited military bases and VA facilities, reviewed relevant documents, and interviewed DOD and VA officials to determine how DOD identifies servicemembers at risk for PTSD, and what information VA has to estimate demand for VA PTSD services. DOD uses two approaches to identify servicemembers at risk for PTSD: the combat stress control program and the post-deployment health assessment questionnaire. The combat stress control program trains servicemembers to recognize the early onset of combat stress, which can lead to PTSD. Symptoms of combat stress and PTSD include insomnia, nightmares, and difficulties coping with relationships. To assist servicemembers in the combat theater, teams of DOD mental health professionals travel to units to reinforce the servicemembers' knowledge of combat stress symptoms and to help identify those who may be at risk for combat stress and PTSD. DOD also uses the post-deployment health assessment questionnaire to identify physical ailments and mental health issues commonly associated with deployments, including PTSD. The questionnaire includes the following four screening questions that VA and DOD mental health experts developed to identify servicemembers at risk for PTSD: Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you (1) have had any nightmares about it or thought about it when you did not want to; (2) tried hard not to think about it or went out of your way to avoid situations that remind you of it; (3) were constantly on guard, watchful, or easily startled; and/or (4) felt numb or detached from others, activities, or your surroundings? VA lacks the information it needs to determine whether it can meet an increase in demand for VA PTSD services. VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers--community-based VA facilities that offer trauma and readjustment counseling. Without this information, VA cannot estimate the number of new veterans its medical facilities and Vet Centers could treat for PTSD. VA has two reports on the number of veterans it currently treats, with each report counting different subsets of veterans receiving PTSD services. Veterans who are receiving VA PTSD services may be counted in both reports, one of the reports, or not included in either report. VA does receive demographic information from DOD, which includes home addresses of servicemembers that could help VA predict which medical facilities or Vet Centers servicemembers may access for health care. By assuming that 15 percent or more of servicemembers who have left active duty status will develop PTSD, VA could use the home zip codes of servicemembers to broadly estimate the number of servicemembers who may need VA PTSD services and identify the VA facilities located closest to their homes. However, predicting which veterans will seek VA care and at which facilities is inherently uncertain, particularly given that the symptoms of PTSD may not appear for years. Mon, 20 Sep 2004 00:00:00 -0400 VA Long-Term Care: More Accurate Measure of Home-Based Primary Care Workload Is Needed, September 8, 2004 http://www.gao.gov/new.items/d04913.pdf The Department of Veterans Affairs (VA) provides a variety of long-term care services that includes nursing home care and noninstitutional care provided in community-based settings or in the homes of veterans. One important noninstitutional service is home-based primary care, which uses a multidisciplinary team approach involving VA health care providers and others such as social workers to treat veterans who are homebound. As part of GAO's work for the Committee on Veterans' Affairs, House of Representatives, to assess how VA meets veterans' long-term care needs, GAO reviewed how VA measures workload for home-based primary care and five other noninstitutional services. The amount of home-based primary care veterans receive is not accurately reflected in VA's workload measurement for that service. VA measures home-based primary care workload using the number of days a veteran is enrolled in the program rather than the number of visits the veteran received. For example, if a veteran was enrolled in VA's home-based primary care program for 1 week, and received two visits from VA providers that week, VA would calculate the workload using 7 days, rather than two visits. As a result, using enrolled days as the workload unit of measure overstates the amount of home-based primary care actually received by veterans. In fiscal year 2003, VA reported an average daily workload for home-based primary care of 8,370 using enrolled days; in contrast, GAO determined that using the number of visits results in a workload of 944. In addition, VA's measurement of home-based primary care using enrolled days is inconsistent with the way it measures workload for the other noninstitutional long-term care services GAO reviewed. VA measures workload for these other services using the number of visits a veteran received. As a result, VA's workload total for home-based primary care overstates that service's use compared to other noninstitutional services VA provides. Wed, 08 Sep 2004 00:00:00 -0400 VA Health Care: VA Needs to Improve Accuracy of Reported Wait Times for Blind Rehabilitation Services, July 22, 2004 http://www.gao.gov/new.items/d04949.pdf The Department of Veterans Affairs (VA) provides rehabilitation services to legally blind veterans. These services are intended to help them acquire the skills necessary to become more independent. Almost all of VA's rehabilitation services for legally blind veterans are provided at Blind Rehabilitation Centers (BRC), an inpatient program. VA reported that the average length of time a veteran waited to be admitted to a BRC increased from 168 to 210 days from fiscal years 1999 through 2003. GAO was asked to examine the accuracy of veterans' wait times for admission to BRCs. GAO's objective was to determine whether the average wait times for veterans seeking admission to BRCs reported by VA were accurate. GAO reviewed VA policies and procedures for determining the average length of time veterans wait to be admitted to a BRC. GAO also visited 5 of VA's 10 BRCs to evaluate the reliability of the data used to calculate wait times. GAO found that the average length of time VA reported that veterans wait for admission to BRCs was inaccurate. Some data used to calculate wait times were incomplete or incorrect. For example, at one BRC GAO found that one or more of the data elements used to calculate the wait times--the date the BRC received the application, the earliest admission date offered to the veteran, and the date the veteran was admitted to the BRC--were missing from 31 percent of the records and incorrect in 13 percent of the records. GAO also found missing or inaccurate data at two other BRCs. In addition, GAO found that BRCs used different procedures for their calculations, which also contributed to the inaccurate average wait times. For example, two BRCs correctly ended the wait times calculations on the earliest admission date offered to the veteran, while the other three BRCs ended the wait times calculations on the date the veteran was admitted to the BRC. To enable VA to accurately assess wait times, it is essential for VA to develop more comprehensive instructions to calculate average wait times and for BRCs to adhere to them. Thu, 22 Jul 2004 00:00:00 -0400 VA Health Care: More Outpatient Rehabilitation Services for Blind Veterans Could Better Meet Their Needs, July 22, 2004 http://www.gao.gov/new.items/d04996t.pdf In fiscal year 2003, the Department of Veterans Affairs (VA) estimated that about 157,000 veterans were legally blind, and about 44,000 of these veterans were enrolled in VA health care. The Chairman of the Subcommittee on Health, House Veterans' Affairs Committee, and the Ranking Minority Member, Senate Veterans' Affairs Committee expressed concerns about VA's rehabilitation services for blind veterans. GAO reviewed (1) the availability of VA outpatient blind rehabilitation services, (2) whether legally blind veterans benefit from VA and non-VA outpatient services, and (3) what factors affect VA's ability to increase veterans' access to blind rehabilitation outpatient services. GAO reviewed VA's blind rehabilitation policies; interviewed officials from VA, the Blinded Veterans Association, state and private nonprofit agencies, and visited five Blind Rehabilitation Centers (BRC). VA provides three types of blind rehabilitation outpatient training services. These services, which are available at a small number of VA locations, range from short-term programs provided in VA facilities to services provided in the veteran's own home. They are Visual Impairment Services Outpatient Rehabilitation, Visual Impairment Center to Optimize Remaining Sight, and Blind Rehabilitation Outpatient Specialists. VA reported to GAO that some legally blind veterans could benefit from increased access to outpatient blind rehabilitation services. When VA reviewed all of the veterans who, as of March 31, 2004, were on the waiting list for admission to the five BRCs GAO visited, VA officials reported that 315 out of 1,501 of them, or 21 percent, could potentially be better served through access to outpatient blind rehabilitation services, if such services were available. GAO also identified two factors that may affect the expansion of VA's outpatient blind rehabilitation services. The first involves VA's longstanding position that training for legally blind veterans is best provided in a comprehensive inpatient setting. The second reported factor is VA's method of allocating funds for medical care. VA is currently working to develop an allocation amount that would better reflect the cost of providing blind rehabilitation services on an outpatient basis. Thu, 22 Jul 2004 00:00:00 -0400 VA and DOD Health Care: Resource Sharing At Selected Sites, July 21, 2004 http://www.gao.gov/new.items/d04792.pdf Congress has long encouraged the Department of Veterans Affairs (VA) and the Department of Defense (DOD) to share health resources to promote cost-effective use of health resources and efficient delivery of care. In February 2002, the House Committee on Veterans' Affairs described VA and DOD health care resource sharing activities at nine locations. GAO was asked to describe the health resource sharing activities that are occurring at these sites. GAO also examined seven other sites that actively participate in sharing activities. Specifically, GAO is reporting on (1) the types of benefits that have been realized from health resource sharing activities and (2) VA- and DOD-identified obstacles that impede health resource sharing. GAO analyzed agency documents and interviewed officials at DOD and VA to obtain information on the benefits achieved through sharing activities. The nine sites reviewed by the Committee and reexamined by GAO are: 1) Los Angeles, CA; 2) San Diego, CA; 3) North Chicago, IL; 4) Albuquerque, NM; 5) Las Vegas, NV; 6) Fayetteville, NC; 7) Charleston, SC; 8) El Paso, TX; and 9) San Antonio, TX. The seven additional sites GAO examined are: 1) Anchorage, AK; 2) Fairfield, CA; 3) Key West, FL; 4) Pensacola, FL; 5) Honolulu, HI; 6) Louisville, KY; and 7) Puget Sound, WA. In commenting on a draft of this report, the departments generally agreed with our findings. At the 16 sites GAO reviewed, VA and DOD are realizing benefits from sharing activities, specifically better facility utilization, greater access to care, and reduced federal costs. While all 16 sites are engaged in health resource sharing activities, some sites share significantly more resources than others. For example, at one site VA was able to utilize Navy facilities to provide additional sources of care and reduce its reliance on civilian providers, thus lowering its purchased care cost by about $385,000 annually. Also, because of the sharing activity taking place at this site, VA has modified its plans to build a new $100 million hospital and instead plans to build a clinic that will cost about $45 million. However, at another site the sharing activity was limited to the use of a nurse practitioner to assist with primary care and the sharing of a psychiatrist and a psychologist. GAO found that the primary obstacle cited by almost all of the agency officials interviewed was the inability of VA and DOD computer systems to communicate and exchange patient health information between departments. VA and DOD medical facilities involved in treating both agencies' patient populations must expend staff resources to enter information on the health care provided into the patient records in both systems. Local VA officials also expressed a concern that security screening procedures have increased the time it takes for VA beneficiaries and their families to gain entry to facilities located on Air Force, Army, and Navy installations during periods of heightened security. Wed, 21 Jul 2004 00:00:00 -0400 VA Medical Centers: Internal Control Weaknesses Impair Third-Party Collections, July 21, 2004 http://www.gao.gov/new.items/d04967t.pdf In the face of growing demand for veterans' health care, GAO and the Department of Veterans Affairs Office of Inspector General (OIG) have raised concerns about the Veterans Health Administration's (VHA) ability to maximize its third-party collections to supplement its medical care appropriation. GAO has testified that inadequate patient intake procedures, insufficient documentation by physicians, a shortage of qualified billing coders, and insufficient automation diminished VA's collections. In turn, the OIG reported that VA missed opportunities to bill, had billing backlogs, and did inadequate follow-up on bills. While VA has made improvements in these areas, GAO was asked to review internal control activities over third-party billings and collections at selected medical centers to assess whether they were designed and implemented effectively. VA has continued to take actions to reduce billing times and increase third-party collections. VA reported that its collections of third-party payments increased from $540 million in fiscal year 2001 to $804 million in fiscal year 2003. However, at the three medical centers visited, GAO found continuing weaknesses in the billings and collections processes that impair VA's ability to maximize the amount of dollars paid by third-party insurance companies. For example, the three medical centers did not always bill insurance companies in a timely manner. Medical center officials stated that inability to verify and update patients' third-party insurance, inadequate documentation to support billings, manual processes and workload continued to affect billing timeliness. The detailed audit work at the three facilities GAO visited also revealed inconsistent compliance with follow-up procedures for collections. For example, collections were not always pursued in a timely manner and partial payments were accepted as payments in full, particularly for Medicare secondary insurance companies, rather than pursuing additional collections. VA's current Revenue Action Plan (Plan) includes 16 actions designed to increase collections by improving and standardizing collections processes. Several of these actions are aimed at reducing billing times and backlogs. Specifically, medical centers are updating and verifying patients' insurance information and improving health care provider documentation. Further, hiring contractors to code and bill old cases is reducing backlogs. In addition to actions taken, VA has several other initiatives underway. For example, VA is taking action to enable Medicare secondary insurance companies to determine the correct reimbursement amount, which will strengthen VA's position to follow up on partial payments that it deems incorrect. Although implementation of the Plan could improve VA's operations and increase collections, many of its actions will not be completed until at least fiscal year 2005. As a result, it is too early to determine the extent to which actions in the Plan will address operational problems and increase collections. Wed, 21 Jul 2004 00:00:00 -0400 VA Medical Centers: Internal Control over Selected Operating Functions Needs Improvement, July 21, 2004 http://www.gao.gov/new.items/d04755.pdf The Department of Veterans Affairs (VA) provides health care to veterans through the $27 billion Veterans Health Administration (VHA) medical programs. VHA administers and operates VA's medical system, providing care to nearly 5 million patients in 2003. As of September 2003, VHA operated 160 hospitals, 847 outpatient clinics, 134 nursing homes, 42 domiciliaries, and 73 comprehensive home care programs, including facilities in every state, Puerto Rico, the Philippines, and Guam. VHA is responsible for effective stewardship of the resources provided to it by Congress, which asked GAO to review internal controls in three areas of operation at selected VHA medical centers. GAO conducted a review to assess the effectiveness of control activities over (1) personal property, (2) drugs returned for credit, and (3) part-time physician time and attendance. GAO's review found that six selected VA medical centers lacked a reliable property control database. The property databases for the six medical centers contained incomplete information. As a result, GAO could not select a statistical sample of test items so that results could be projected to each location's entire property universe. Key policies and procedures established by VA to control personal property provided facilities with substantial latitude in conducting physical inventories and maintaining their property management systems, which resulted in reduced property accountability. For example, VA's Materiel Management Procedures handbook allowed the person responsible for custody of VA property to attest to the existence of that property rather than requiring independent verification. Also, personnel at some locations interpreted a policy that established a $5,000 threshold for property that must be inventoried as a license to ignore VA requirements to account for lower cost items that are susceptible to theft or loss, such as personal computers and peripheral equipment. These weak practices, combined with lax implementation, resulted in low levels of accountability and heightened risk of loss. VHA personnel located fewer than half of the 100 items GAO selected at each of five medical centers and 62 of 100 items at the sixth medical center. The process for obtaining credit for recalled, expired, or deteriorated drugs was, in essence, an honor system. Each of the six pharmacies GAO visited used a contractor to return drugs to the manufacturer for credit, but only one of the pharmacies inventoried non-narcotic drugs before they were turned over to the contractor. None of the pharmacies had enough information about which drugs qualified for credit to be able to reconcile the credits they received with the drugs they had turned over to the contractor. There was no agency-level oversight of returned drug information to help identify improvements that might increase the credits that VA receives. At four of the six facilities, non-narcotic drugs held for return were stored in unsecured open bins accessible to anyone in the pharmacy. The combined lack of record keeping and physical controls over non-narcotic drugs held for return exposed them to potential loss, theft, or unauthorized use. Scheduled and actual hours worked by part-time physicians at the six locations GAO visited were not always documented in accordance with a January 2003 VHA directive. Five of the six locations had not prepared written work schedules for all part-time physicians as required. GAO found that latitude provided in the directive resulted in wide variation in procedures used by the six medical centers to verify physician compliance with work schedules. While some timekeepers used informal notes to record daily attendance, one facility required physicians to sign in. However, on the day of GAO's review, only two of 15 scheduled physicians had signed in. Attendance monitoring procedures at the six locations varied in frequency and included monitoring all part-time physicians once per quarter at one location and 5 percent of part-time physicians each month at another. Wed, 21 Jul 2004 00:00:00 -0400 VA Medical Centers: Further Operational Improvements Could Enhance Third-Party Collections, July 19, 2004 http://www.gao.gov/new.items/d04739.pdf In the face of growing demand for veterans' health care, GAO and the Department of Veterans Affairs Office of Inspector General (OIG) have raised concerns about the Veterans Health Administration's (VHA) ability to maximize its third-party collections to supplement its medical care appropriation. GAO has testified that inadequate patient intake procedures, insufficient documentation by physicians, a shortage of qualified billing coders, and insufficient automation diminished VA's collections. In turn, the OIG reported that VA missed opportunities to bill, had billing backlogs, and did inadequate follow-up on bills. While VA has made improvements in these areas, GAO was asked to review internal control activities over third-party billings and collections at selected medical centers to assess whether they were designed and implemented effectively. VA has continued to take actions to reduce billing times and increase third-party collections. Collections of third-party payments have increased from $540 million in fiscal year 2001 to $804 million in fiscal year 2003. However, at the three medical centers visited, GAO found continuing weaknesses in the billings and collections processes that impair VA's ability to maximize the amount of dollars paid by third-party insurance companies. For example, the three medical centers did not always bill insurance companies in a timely manner. Medical center officials stated that inability to verify and update patients' third-party insurance, inadequate documentation to support billings, manual processes and workload continued to affect billing timeliness. The detailed audit work at the three facilities GAO visited also revealed inconsistent compliance with follow-up procedures for collections. For example, collections were not always pursued in a timely manner and partial payments were accepted as payments in full, particularly for Medicare secondary insurance companies, rather than pursuing additional collections. VA's current Revenue Action Plan (Plan) includes 16 actions designed to increase collections by improving and standardizing collections processes. Several of these actions are aimed at reducing billing times and backlogs. Specifically, medical centers are updating and verifying patients' insurance information and improving health care provider documentation. Further, hiring contractors to code and bill old cases is reducing backlogs. In addition to actions taken, VA has several other initiatives underway. For example, VA is taking action to enable Medicare secondary insurance companies to determine the correct reimbursement amount, which will strengthen VA's position to follow up on partial payments that it deems incorrect. Although implementation of the Plan could improve VA's operations and increase collections, many of its actions will not be completed until at least fiscal year 2005. As a result, it is too early to determine the extent to which actions in the Plan will address operational problems and increase collections. Mon, 19 Jul 2004 00:00:00 -0400 Contract Management: Further Efforts Needed to Sustain VA's Progress in Purchasing Medical Products and Services, June 22, 2004 http://www.gao.gov/new.items/d04718.pdf The Department of Veterans Affairs (VA) provides healthcare to millions of veterans at VA's medical centers and healthcare facilities across the country. To support veterans, VA manages a Federal Supply Schedule (FSS) program and a national contract program. Both use VA's sizeable buying power to provide VA and other federal agencies discounts on medical products and services. To cover its costs in running the FSS program, VA charges its customers a user fee. Although sales through VA's FSS and national contracts totaled almost $7 billion in fiscal year 2003, concerns have been raised about the efficiency of these contract programs. GAO was asked to determine whether the FSS and national contracts have provided medical products at favorable prices and to identify opportunities to improve purchasing practices and increase savings. GAO was also asked to determine if VA's user fee is sufficient to cover program cost. The more than 1,200 FSS and 330 national contracts that VA has awarded have resulted in more competitive prices and have yielded substantial savings. VA has achieved these favorable prices and savings, in part, by exercising its audit rights and access to contractor data to pursue best prices aggressively for medical supplies and services. For example, pre-award audits of vendors' contract proposals and post-award audits of vendors' contract actions resulted in savings of about $240 million during fiscal years 1999 to 2003. VA has also taken steps to further leverage its buying power on widely used healthcare items--such as pharmaceuticals and high-tech medical equipment--through its national contracts. According to VA, its national pharmaceutical contracts have led to a cost avoidance of $394 million in fiscal year 2003. However, VA has not taken the same aggressive approach to negotiate more competitive prices for healthcare services, such as radiology. In fiscal year 2003, healthcare services totaled about $1.7 billion, yet VA facilities only purchased about $66 million through VA FSS contracts. Instead, most medical healthcare services are purchased through contracts that individual VA medical centers have negotiated, a process that may not provide the most favorable prices. VA could also realize additional savings through improved medical center purchasing practices. Despite increases in medical centers' FSS purchases--which more than doubled between fiscal years 1999 and 2003--medical centers have not always taken advantage of the best prices available through VA's contracts. For example, in fiscal year 2001, a VA Inspector General (IG) report stated that VA medical centers frequently purchased healthcare products from local sources, instead of from available FSS contracts. Although VA has since implemented policies and procedures that generally require its medical centers to purchase medical products and services through VA's contract programs, a more recent VA IG report found that medical centers continued to make purchases from local suppliers. The VA IG estimated that, with improved procurement practices at medical centers, VA could save about $1.4 billion over 5 years. However, ensuring VA medical centers comply with VA's purchasing policies and procedures will be a challenge for VA, in part, because its monitoring of purchases lacks adequate rigor. The user fee that VA collects on FSS purchases--0.5 percent of sales--is expected to approximate the program costs. VA, however, does not have complete information on the costs to administer the FSS program. Without this cost data, VA is unable to know whether it is charging an appropriate user fee. Tue, 22 Jun 2004 00:00:00 -0400 Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management, June 7, 2004 http://www.gao.gov/new.items/d04687.pdf A critical element of the Department of Veterans Affairs' (VA) information technology program is its continuing work with the Department of Defense (DOD) to achieve the ability to exchange patient health care information and create electronic medical records for use by veterans, active-duty military personnel, and their health care providers. While VA and DOD continue to move forward in agreeing to and adopting standards for clinical data, they have made little progress since last winter toward defining how they intend to achieve an electronic medical record based on the two-way exchange of patient health data. The departments continue to face significant challenges in achieving this capability. VA and DOD lack an explicit architecture--a blueprint--that provides details on what specific technologies will be used to achieve the electronic medical record by the end of 2005. The departments have not fully implemented a project management structure that establishes lead decision-making authority and ensures the necessary day-to-day guidance of and accountability for their investment in and implementation of this project. They are operating without a project management plan describing the specific responsibilities of each department in developing, testing, and deploying the electronic interface. In seeking to provide a two-way exchange of health information between their separate health information systems, VA and DOD have chosen a complex and challenging approach--one that necessitates the highest levels of project discipline. Yet critical project components are currently lacking. As such, the departments risk investing in a capability that could fall short of what is expected and what is needed. Until a clear approach and sound planning are made integral parts of this initiative, concerns about exactly what capabilities VA and DOD will achieve--and when--will remain. Mon, 07 Jun 2004 00:00:00 -0400 VA Health Care: Resource Allocations to Medical Centers in the Mid South Healthcare Network, April 21, 2004 http://www.gao.gov/new.items/d04444.pdf Since fiscal year 1997, the Department of Veterans Affairs (VA) has relied primarily on its 21 health care networks to allocate resources to its medical centers. VA headquarters also directly allocates some resources to the medical centers. In addition, medical centers collect resources from third-party insurance payments and other sources. VA provides general guidance to\ networks for resource allocation to medical centers, but permits variation in networks' allocation methodologies. Representatives from veterans groups and others have expressed concerns regarding resource allocations to medical centers in Network 9 (Nashville) known as the Mid South Healthcare Network. GAO was asked to report for fiscal year 2002 (1) the amount of resources medical centers in the network received and the source of those resources and (2) the basis on which medical centers in the network received these resources. GAO was also asked to supplement findings for fiscal year 2002 with information for fiscal years 1997 through 2003. The six medical centers in Network 9 (Nashville), known as the Mid South Healthcare Network, received a total of about $1 billion in resources in fiscal year 2002. The network allocated 83 percent of the total, or $825 million, to its medical centers. The medical centers received smaller amounts from VA headquarters (9 percent of the total or about $93 million) and resources from collections (7 percent of the total or about $73 million). As in fiscal year 2002, the network allocated more than 80 percent of medical center resources each year from fiscal years 1997 through fiscal year 2003. Medical centers in Network 9 (Nashville) received about 77 percent of their resources, or $760 million, in fiscal year 2002 based on fixed-per-patient amounts, referred to as fixed-capitation amounts, for patient workload and case mix. Patient workload is the number of patients treated, and case mix is a classification of patients into categories based on health care needs and related costs. The largest portion of these resources allocated on this basis came from the network while a smaller portion came from VA headquarters. Medical centers in the network received about 23 percent of their total resources, or $232 million, in fiscal year 2002 based on a variety of other factors such as network managers' determination of the financial needs of medical centers during the course of the year. These resources came from the network, VA headquarters, and collections. Since VA changed its resource allocation system in fiscal year 1997, the medical centers in the network received about the same portions of their resources based on fixed capitation amounts and on a variety of other factors each year from fiscal years 1997 through 2003. VA agreed with GAO's findings. Wed, 21 Apr 2004 00:00:00 -0400 DOD and VA Health Care: Incentives Program for Sharing Resources, February 27, 2004 http://www.gao.gov/new.items/d04495r.pdf Combined, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) provide health care services to about 12 million beneficiaries at an estimated cost of about $53 billion for fiscal year 2004--$26.7 billion for DOD and $26.5 billion for VA. In 1982 the Congress passed the VA and DOD Health Resources Sharing and Emergency Operations Act (Sharing Act) to promote more cost-effective use of health care resources and more efficient delivery of care. Specifically, the Congress authorized military treatment facilities and VA medical centers to enter into sharing agreements to buy, sell, and barter medical and support services. To further encourage on-going collaboration, the Congress, in section 721 of the Bob Stump National Defense Authorization Act (NDAA) for Fiscal Year 2003, directed the Secretary of Defense and the Secretary of Veterans Affairs to establish a joint incentives program to identify and provide incentives to implement, fund, and evaluate creative health care coordination and sharing initiatives between DOD and VA. To facilitate the program, each Secretary is required to contribute a minimum of $15 million from each department's appropriation into an account established in the U. S. Treasury for each fiscal year from 2004 through 2007. DOD's TRICARE Management Activity and VA's Medical Sharing Office administer the incentive fund program. The offices have jointly issued a request for proposals from DOD and VA medical facilities around the country. During the first five months of the program DOD and VA have established criteria for evaluating proposals. As of February 25, 2004, the departments are reviewing 57 proposals that have been submitted. DOD and VA program officials have not established a firm date for final selection but anticipate it will take place during the summer of 2004. While the agencies have made progress in implementing the program, they have not made contributions to the fund; they anticipate doing so by March 31, 2004. VA has raised a concern whether services provided to veterans will have to be commensurate with its contributions to the sharing incentive fund. DOD and VA officials are discussing how the fund contributions will be used. DOD and VA officials agreed the information in this report is accurate. Fri, 27 Feb 2004 00:00:00 -0500 Military Treatment Facilities: Improvements Needed to Increase DOD Third-Party Collections, February 20, 2004 http://www.gao.gov/new.items/d04322r.pdf Like the private health care industry, the cost of providing health care services to the Department of Defense's (DOD) active duty personnel, their dependents, retirees, and survivors and their dependents has increased dramatically over the past decade. In fiscal year 2003, DOD reported that more than 8.7 million Military Health System beneficiaries were eligible to receive health care at a cost of about $27.2 billion per year--up from a reported 8.2 million eligible beneficiaries at a cost of $15.6 billion in fiscal year 1997. To the extent that DOD beneficiaries have private health insurance coverage, DOD is authorized to bill insurance companies under the Third Party Collections Program. As such, DOD has the opportunity to defray the rising cost of providing health care to an increasing number of eligible beneficiaries. In October 2002, we reported that the three military treatment facilities (MTFs) we visited did not always bill and collect from private insurers for care that was reimbursable to the government. At all three facilities, we identified control weaknesses that resulted in instances where these MTFs had not identified all patients with third-party insurance and sometimes did not bill those insurers even when they were aware such coverage existed. Consequently, opportunities to collect millions of dollars of reimbursements from insurers for medical services provided were forgone. Concerned that there were additional MTFs that also did not effectively bill and collect for reimbursable services, Congress requested that we expand our audit to provide some perspective on the amount of such services that were not billed and collected across all of DOD's MTFs. However, after determining that it was not feasible to develop a DOD-wide estimate of missed collection opportunities, as agreed and explained in more detail later, we are providing a perspective on the amount of services not billed and collected across all of DOD's MTFs based on work performed by DOD's service auditors at 35 of the largest MTFs reporting collections. This report also provides information on (1) specific control weaknesses and other issues that impair DOD's ability to increase collections, (2) the department's ongoing efforts to improve the third-party billings and collection function, and (3) our assessment of DOD's use of performance metrics to manage third-party collections at its MTFs. Based on our previous audit work and our analysis of reports issued by the military service auditors, conservatively, tens of millions of dollars are not being collected each year because key information required to effectively bill and collect from third-party insurers is often not properly collected, recorded, or used by the MTFs. DOD's failure to effectively bill and collect from third-party insurers, in effect, reduces the amount third-party private sector insurance companies must pay out in benefits and unnecessarily adds to DOD's increasing health care budget--financed by taxpayers. While DOD has limited control over the burgeoning cost of providing health care benefits to DOD retirees and their dependents and active duty dependents, DOD has an opportunity to offset the impact of its rising health care costs by collecting amounts due from its Third Party Collections Program. However, because DOD does not maintain a reliable central database containing patient insurance information, which would facilitate sampling and thus the development of a statistically based projection across the entire universe of care provided by MTFs, neither the service auditors nor we could feasibly provide a comprehensive estimate of the total third-party collections shortfall across all MTFs. Further, DOD's current transition to a new billing methodology made it impractical for us to perform even limited sampling and testing at this time. Weaknesses throughout DOD's third-party billing and collection process, such as incomplete medical documentation and coding of care provided, insufficient monitoring of accounts receivable, and ineffective follow-up to collect accounts receivable, have all contributed to collection shortfalls. The single biggest obstacle to increasing collections, however, is inadequate identification of patients with third-party insurance. DOD does not have effective systems or processes for obtaining and updating insurance information for patients that have other health insurance coverage. This weakness dramatically reduces the possibility of collecting from third-party insurers and recouping the cost of providing reimbursable care. According to DOD officials, they have several process and system improvement initiatives planned or underway that are intended to address the weaknesses identified. Central to DOD's effort to improve the Third Party Collections Program overall and conform to industry best practices, DOD recently initiated a new itemized billing methodology for outpatient care. However, the new billing system resulted in significant start-up issues that, according to DOD officials, seriously affected third-party outpatient billings and collections in the short term. Consequently, total collections, including inpatient, outpatient, and ancillary reimbursements, in fiscal year 2003 were only about $92 million--down from previous years by about $30 million or 25 percent. DOD officials said that this is a temporary decline due to implementation issues with outpatient itemized billing and the impact of the Iraq mobilization on MTF operations. Officials expect collections to increase and exceed earlier levels as problems are resolved and new system enhancements are implemented. However, according to DOD officials, many of the system enhancements will not be fully operational until fiscal year 2005 and beyond. Although DOD monitors certain performance information related to MTF workload and third-party collections, little is done with this information in terms of managing DOD's Third Party Collections Program. Presently, the department lacks key information needed to establish performance goals for billings and collections functions to assess individual MTFs. Fri, 20 Feb 2004 00:00:00 -0500 VA Health Care: Access for Chattanooga-Area Veterans Needs Improvement, January 30, 2004 http://www.gao.gov/new.items/d04162.pdf Veterans residing in Chattanooga, Tennessee, have had difficulty accessing Department of Veterans Affairs (VA) health care. In response, VA has acted to reduce travel times to medical facilities and waiting times for appointments with primary and specialty care physicians. Recently, VA released a draft national plan for restructuring its health care system as part of a planning initiative known as Capital Asset Realignment for Enhanced Services (CARES). GAO was asked to assess Chattanooga-area veterans' access to inpatient hospital and outpatient primary and specialty care against VA's guidelines for travel times and appointment waiting times and to determine how the draft CARES plan would affect Chattanooga-area veterans' access to such care. Almost all (99 percent) of the 16,379 enrolled veterans in the 18-county Chattanooga area, as of September 2001, faced travel times that exceeded VA's guidelines for accessing inpatient hospital care. During fiscal year 2002, only a few Chattanooga-area veterans were admitted to non-VA hospitals in Chattanooga--constituting about 5 percent of inpatient workload. In addition, over half (8,400) of Chattanooga-area enrolled veterans faced travel times that exceeded VA's 30-minute guideline for outpatient primary care. Also, waiting times for scheduling initial outpatient primary and specialty care appointments frequently exceeded VA's 30-day guideline. VA's draft CARES plan would shorten travel times for some Chattanooga-area veterans but lengthen travel times for others. Under the plan, the amount of inpatient care VA purchases from non-VA hospitals in Chattanooga would increase from 5 percent to 29 percent, thereby reducing those veterans' travel times to within VA's guidelines. The plan also proposes to shift some inpatient workload from VA's Murfreesboro hospital to its Nashville hospital. As a result, an estimated 54 percent of inpatient workload for Chattanooga-area enrolled veterans will be provided in Nashville compared to 40 percent in fiscal year 2002, thereby lengthening some veterans' travel times by about 20 minutes. The plan also proposes opening four new community-based clinics, which would bring about 2,700 more Chattanooga-area enrolled veterans within VA's 30-minute travel guideline for primary care, leaving about 5,700 enrolled veterans with travel times for such care that exceed VA's guideline. These clinics likely would not open before fiscal year 2011, given priorities specified in the plan. Fri, 30 Jan 2004 00:00:00 -0500 VA Health Care: Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans, December 12, 2003 http://www.gao.gov/new.items/d04106.pdf Hepatitis C is a chronic disease caused by a blood-borne virus that can lead to potentially fatal liverrelated conditions. In 2001, GAO reported that the VA missed opportunities to test about 50 percent of veterans identified as at risk for hepatitis C. GAO was asked to (1) review VA's fiscal year 2002 performance measurement results in testing veterans at risk for hepatitis C, (2) identify factors that impede VA's efforts to test veterans for hepatitis C, and (3) identify actions taken by VA networks and medical facilities to improve the testing rate of veterans at risk for hepatitis C. GAO reviewed VA's fiscal year 2002 hepatitis C performance results and compared them against VA's national performance goals, interviewed headquarters and field officials in three networks, and conducted a case study in one network. VA's performance measurement result shows that it tested, in fiscal year 2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at risk for hepatitis C in VA's performance measurement sample, exceeding its fiscal year 2002 national goal of 55 percent. Thousands of veterans (about one-third) of those identified as at risk for hepatitis C infection in VA's performance measurement sample were not tested. VA's hepatitis C testing result is a cumulative measure of performance over time and does not only reflect current fiscal year performance. GAO found Network 5 (Baltimore) tested 38 percent of veterans in fiscal year 2002 as compared to Network 5's cumulative performance result of 60 percent. In its case study of Network 5, which was one of the networks to exceed VA's fiscal year 2002 performance goal, GAO identified several factors that impeded the hepatitis C testing process. These factors were tests not being ordered by the provider, ordered tests not being completed, and providers being unaware that needed tests had not been ordered or completed. For more than two-thirds of the veterans identified as at risk but not tested for hepatitis C, the testing process failed because hepatitis C tests were not ordered, mostly due to poor communication between clinicians. For the remaining veterans, the testing process was not completed because orders had expired by the time veterans visited the laboratory or test orders were overlooked because laboratory staff had to scroll back and forth through daily lists, a cumbersome process, to identify active orders. Moreover, during subsequent primary care visits by these untested veterans, providers often did not recognize that hepatitis C tests had not been ordered nor had their results been obtained. Consequently, undiagnosed veterans risk unknowingly transmitting the disease as well as potential complications resulting from delayed treatment. The three networks GAO looked at--5 (Baltimore), 2 (Albany), and 9 (Nashville)--have taken steps intended to improve the testing rate of veterans identified as at risk for hepatitis C. To do this, in two networks officials modified clinical reminders in the computerized medical record to alert providers that for ordered hepatitis C tests, results were unavailable. Officials at two facilities developed a "look back" method to search computerized medical records to identify all at-risk veterans who had not yet been tested and identified approximately 3,500 untested veterans. The look back serves as a safety net for veterans identified as at risk for hepatitis C who have not been tested. The modified clinical reminder and look back method of searching medical records appear promising, but neither the networks nor VA has evaluated their effectiveness. Fri, 12 Dec 2003 00:00:00 -0500 Smallpox Vaccination: Review of the Implementation of the Military Program, December 1, 2003 http://www.gao.gov/new.items/d04215r.pdf On December 13, 2002, in response to growing concern that a terrorist or hostile regime might have access to the smallpox virus and attempt to use it against the American people, the President announced the formation of the National Smallpox Vaccination Program. The program has two components--one responsible for vaccinating civilians and another responsible for vaccinating military personnel. The Centers for Disease Control and Prevention (CDC) is responsible for implementing the civilian component of the National Smallpox Vaccination Program. The Department of Defense (DOD) is responsible for implementing the military component of the program. Because the National Smallpox Vaccination Program is the nation's first large-scale bioterrorism defense program, Congress asked us to assess the implementation of the program in order to aid the development of future programs. In April 2003, we reported on the implementation of the civilian component of the National Smallpox Vaccination Program. In this report, we describe (1) how DOD implemented its smallpox vaccination program and (2) the steps DOD took to facilitate the implementation of the program. DOD implemented its smallpox vaccination program in stages and took steps to prevent and monitor adverse health events following the vaccinations. The first stage of the smallpox vaccination program consisted of a pilot program that began in December 2002, during which DOD vaccinated and monitored the health of military personnel at four sites. According to DOD officials, the intent of the pilot program was to assess DOD's procedures for administering the vaccine and monitor the frequency of adverse health reactions. After completion of the pilot program, DOD began full implementation of the smallpox vaccination program in mid-January 2003. DOD vaccinated its personnel in stages--prioritizing its personnel according to which groups would be most likely to respond first to a smallpox outbreak. As of October 2003, DOD had vaccinated more than 500,000 military personnel. In order to minimize the number of people who might have adverse reactions to the vaccine, DOD followed CDC guidelines by screening personnel for health conditions that precluded them from receiving smallpox vaccinations. To monitor adverse health events following the vaccinations, DOD used two health information tracking systems, CDC's Vaccine Adverse Event Reporting System (VAERS) and DOD's Defense Medical Surveillance System (DMSS). To facilitate its vaccination program, DOD took steps to ensure the availability of the vaccine and educate its personnel. Specifically, DOD established practices to limit the amount of vaccine that could be wasted or contaminated. For example, to ensure the vaccine was not wasted due to a loss of potency, its temperature was monitored with a computer chip to ensure that the vaccine was maintained at the proper temperature during shipment. DOD also facilitated the implementation of its vaccination program by educating its personnel--both those who administered the vaccine and those who received it--on related issues, such as vaccination procedures and potential adverse health reactions. Mon, 01 Dec 2003 00:00:00 -0500 Veterans Affairs: Post-hearing Questions Regarding the Departments of Defense and Veterans Affairs Providing Seamless Health Care Coverage to Transitioning Veterans, November 25, 2003 http://www.gao.gov/new.items/d04294r.pdf The Ranking Minority Member of the House Committee on Veterans Affairs requested that GAO respond to follow-up questions on its testimony on its report "Hand-off or Fumble: Are DOD and VA Providing Seamless Health Care Coverage to Transitioning Veterans?" GAO believes that strong leadership and appropriate follow-through are key to improving compliance with force protections and surveillance policies for Operation Iraqi Freedom. It is encouraged that the compliance problems it found for Operation Enduring Freedom and Operation Joint Guardian prompted the Assistant Secretary of Defense for Health Affairs and the military services' Surgeons General to promptly take a number of actions to help ensure compliance with the Department of Defense's (DOD) force health protection and surveillance policies. Operation Iraqi Freedom is an ongoing operation with deployments of servicemembers who presumably are covered by the new quality assurance programs. On the basis these actions, GAO is optimistic that progress is occurring. However, the extent of compliance can be determined only from an examination of servicemembers' medical records. Knowing which servicemembers were at certain locations at specific times in the theater of operations is important for determining their possible exposures to chemical, biological, or environmental health hazards that DOD may know about currently or later discover. Without this exposure information, it would likely be more problematic for the Department of Veterans Affairs to determine a presumption of service-connection and to ascertain whether treatments are appropriate. When GAO issued its May 1997 report, DOD had not finalized its draft joint medical surveillance policy. DOD subsequently finalized its joint medical surveillance policy in August 1997. Although there are some methodological differences between the May 1997 and September 2003 reports, it is clear that force health protection and surveillance compliance problems continue in several areas. However, there appears to be some improvement in DOD's collection of predeployment blood serum samples from deploying servicemembers. Tue, 25 Nov 2003 00:00:00 -0500 Computer-Based Patient Records: Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health Systems, November 19, 2003 http://www.gao.gov/new.items/d04271t.pdf For the past 5 years, the Departments of Veterans Affairs and Defense have been working to exchange health care data and create electronic records for veterans and active duty personnel. Such exchange is seen as a means of reducing the billions of dollars that the departments spend annually on health care services and making such data more readily accessible to those treating our country's approximately 13 million veterans, military personnel, and dependents. This is especially critical when military personnel are engaged in conflicts all over the world, and their health records can reside at multiple locations. GAO has reported on these efforts several times, most recently in September 2002. At the request of the Subcommittee, GAO is updating its observations on the departments' efforts, focusing on (1) the reported status of the ongoing, one-way exchange of data, the Federal Health Information Exchange, and (2) progress toward achieving the longer term two-way exchange under the HealthePeople (Federal) initiative. Access to medical data that includes information on the entire lives of veterans and active duty military personnel represents an enormous step toward enhanced and more effective medical care. VA and DOD are pursuing this goal in two stages. Federal Health Information Exchange: This current, one-way transfer of health care data from DOD to VA is already allowing clinicians in VA medical centers to make faster, more informed decisions through ready access to information on almost 2 million patients, thereby improving their level of health care delivery. The program's fiscal year 2003 cost was just over $11 million. HealthePeople (Federal): The realization of this longer term strategy to enable electronic, two-way information sharing is farther out on the horizon. The departments are proceeding with projects that are expected to result in a limited two-way exchange of health data by the end of 2005. However, VA and DOD face significant challenges in implementing a full data exchange capability. Although a high-level strategy exists, the departments have not yet clearly articulated a common health information infrastructure and architecture to show how they intend to achieve the data exchange capability or what they will be able to exchange by the end of 2005. In addition, critical to achieving the twoway exchange will be completing the standardization of the clinical data that these departments plan to share. Without standardization, the task of sharing meaningful data could be more complex and may not prove successful. Wed, 19 Nov 2003 00:00:00 -0500 Defense Health Care: DOD Needs to Improve Force Health Protection and Surveillance Processes, October 16, 2003 http://www.gao.gov/new.items/d04158t.pdf Following the 1990-91 Persian Gulf War, many servicemembers experienced health problems that they attributed to their military service in the Persian Gulf. However, a lack of servicemember health and deployment data hampered subsequent investigations into the nature and causes of these illnesses. Public Law 105-85, enacted in November 1997, required the Department of Defense (DOD) to establish a system to assess the medical condition of service members before and after deployments. GAO reported on (1) the Army's and Air Force's compliance with DOD's force health protection and surveillance requirements for servicemembers deploying in support of Operation Enduring Freedom (OEF) in Central Asia and Operation Joint Guardian (OJG) in Kosovo and (2) the status of DOD efforts to correct problems related to the accuracy and completeness of databases reflecting which servicemembers were deployed to certain locations. (Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance (GAO-03-1041, Sept. 19, 2003)) GAO was asked to testify on its findings regarding the Army's and Air Force's compliance with DOD's force health protection and surveillance policies. For its report, GAO reviewed records for statistical samples of active duty servicemembers at four military installations. The Army and Air Force--the focus of GAO's review--did not comply with DOD's force health protection and surveillance policies for many active duty servicemembers, including the policies that they be assessed before and after deploying overseas, that they receive certain immunizations, and that health-related documentation be maintained in a centralized location. GAO's review of 1,071 servicemembers' medical records from a universe of 8,742 at selected Army and Air Force installations participating in overseas operations disclosed that 38 to 98 percent of servicemembers were missing one or both of their health assessments and as many as 36 percent were missing two or more of the required immunizations. GAO found that many servicemembers' medical records did not include health assessments found in DOD's centralized database. Similarly, DOD also did not maintain a complete, centralized database of servicemembers' health assessments and immunizations. Health-related documentation missing from the centralized database ranged from 0 to 63 percent for predeployment assessments, 11 to 75 percent for post-deployment assessments, and 8 to 93 percent for immunizations. There was no effective quality assurance program at the Office of the Assistant Secretary of Defense for Health Affairs or at the Army or Air Force that helped ensure compliance with policies. GAO believes that the lack of such a program was a major cause of the high rate of noncompliance. Continued noncompliance with these policies may result in servicemembers deploying with health problems or delays in obtaining care when they return. Finally, DOD's centralized deployment database is still missing the information needed to track servicemembers' movements in the theater of operations. By July 2003, the department's data center had begun receiving location-specific deployment information from the services and is currently reviewing its accuracy and completeness. GAO's report recommended that DOD establish an effective quality assurance program that will ensure that the military services comply with the force health protection and surveillance policies for all servicemembers. DOD agreed with the recommendation and outlined a number of actions the military services are already taking to implement their quality assurance programs. While we view these actions as responsive to our recommendation, the effectiveness of these actions to ensure compliance will depend on follow-through by DOD and the services. Thu, 16 Oct 2003 00:00:00 -0400 Military Personnel: DOD Needs More Data to Address Financial and Health Care Issues Affecting Reservists, September 10, 2003 http://www.gao.gov/new.items/d031004.pdf Since the 1991 Persian Gulf War, National Guard and Reserve personnel have been deployed to a number of contingency operations. Since September 2001, about 300,000 reservists have been called to active duty, and the pace of reserve operations is expected to remain high for the foreseeable future. House Report 107-436 accompanying the Fiscal Year 2003 National Defense Authorization Act (P.L. 107-314) directed GAO to review compensation programs for reservists serving on active duty. GAO evaluated information on income change reported by reservists when activated; reserve families' readiness for call-ups and their awareness and use of family support programs, focusing on personal financial management; and a legislative proposal for the Department of Defense (DOD) to offer TRICARE, the military's health care program, to reservists and their families when members are not on active duty. DOD lacks sufficient information on the magnitude, the causes, and the effects of income change to determine the need for compensation programs targeting reservists who (1) fill critical wartime specialties, (2) experience high degrees of income loss when on extended periods of active duty, and (3) demonstrate that income loss is a significant factor in their retention decisions. Such data are critical for assessing the full nature and scope of income change problems and in developing cost-effective solutions. DOD self-reported survey data from past and current military operations indicate that activated reservists have experienced widely varying degrees of income change. While many reservists lost income, more than half of reservists had either no change or a gain in income. However, survey data are questionable primarily because it is unclear what survey respondents considered as income loss or gain in determining their financial status. DOD has placed greater emphasis on preparing reservists' families for potential call-ups, yet survey data show that one-third of spouses do not feel prepared, over half of reservists are not aware of family support programs, and more than 90 percent of spouses do not use these programs. Personal financial management, one of DOD's core family support programs, illustrates the continuing challenges DOD faces in providing outreach to reservists. The 2000 survey data showed that 61 percent of reservists did not know whether personal financial management services were available. The survey also showed that reservists have financial problems similar to their active duty counterparts. DOD is taking steps to improve personal financial management, but it has not assessed the financial well-being of reserve families, assessed the impact of reservists' financial problems on mission readiness, or determined how to tailor its programs to reservists. Available DOD data do not identify a need to offer TRICARE to reservists and their families when members are not on active duty. Estimates from DOD's 2000 survey showed that nearly 80 percent of reservists had health care coverage when they were not on active duty. This rate is similar to that of comparable groups within the overall U.S. population. DOD has expressed concern over the estimated costs of this proposal. Cost estimates range up to $5.1 billion a year. However, DOD has not fully assessed the ramifications of this proposed legislation, including the impact on recruiting and retention, the effects on active duty personnel, the extent reservists and their families might participate in such a program, or the impact on the TRICARE system. In addition, a high percentage of reservists' civilian employers who currently pay some or all of health care premiums for reservists during activations could discontinue providing such assistance. A number of recent improvements have been made to reservists and their families' health care when members are activated. However, DOD lacks data on problems reservists and their families have experienced with health care since the mobilizations following September 11, 2001; the causes of these problems; and their effects on readiness, recruiting, and retention. Wed, 10 Sep 2003 00:00:00 -0400 VA Health Care: Framework for Analyzing Capital Asset Realignment for Enhanced Services Decisions, August 18, 2003 http://www.gao.gov/new.items/d031103r.pdf On May 14, 2003, as requested, we briefed Congress on our preliminary views on the Capital Asset Realignment for Enhanced Services (CARES) process initiated by the Department of Veterans Affairs (VA). On July 29, 2003, we shared our additional perspectives, which Congressional Staff indicated would be helpful to the Commission as it considers the draft National CARES Plan that VA presented on August 4, 2003. For this reason, we are providing an overview of the approach that we plan to use during our continuing review of CARES. In summary, our approach for analyzing CARES decisions will focus on a series of fundamental questions regarding whether appropriate alternatives were considered and key impacts of competing alternatives were appropriately evaluated. Our framework examines whether choices about the development of capital asset realignment alternatives ensure consideration of alternatives that potentially provide the greatest payoffs, particularly in comparison to the status quo, that is, maintaining VA's existing real property infrastructure for the delivery of health care. It also examines the impacts of such alternatives, focusing on comparisons of their key costs and benefits in a manner consistent with OMB and CARES guidelines. In our view, the success of CARES depends on ensuring that the best alternatives for meeting veterans' needs within a market are recommended and a transparent public record is developed that sufficiently documents the justification supporting CARES decisions. A complete, fact-based public record can facilitate political consensus by allowing the Congress and other stakeholders to focus their deliberations on tradeoffs among the benefits and costs of alternatives for realigning health care assets and enhancing care. Mon, 18 Aug 2003 00:00:00 -0400 VA Health Care: Contract Labor Cost Analysis in RAND Study, June 30, 2003 http://www.gao.gov/new.items/d03579r.pdf The Department of Veterans Affairs (VA) spent about $23 billion to provide health care to over 4 million veterans in fiscal year 2002. To provide this care, VA relied primarily on its own employees, totaling about 190,000. VA also used contract employees, sometimes referred to as contract labor, to provide these services. In response to the requirements of the Federal Activities Inventory Reform Act of 1998 (the FAIR Act), VA compiled an inventory of more than 180,000 full-time equivalent (FTE) positions that it determined to be "health care commercial" in nature. This means that the work carried out in these positions is also done in the private sector and could potentially be done by contract labor. As part of its management initiatives, the Office of Management and Budget (OMB) has emphasized that competition should be used to determine the most effective and efficient way to provide commercial services. The process used to make this determination--referred to as competitive sourcing--is established in OMB Circular A-76. This process generally provides for competition between the government and the private sector on the basis of costs or costs and other factors. OMB has established competitive sourcing FTE targets for federal agencies to achieve as part of OMB's management initiatives. In response to OMB's FTE target for VA, VA established a plan to complete studies of competitive sourcing of 55,000 positions by 2008. RAND addressed limited aspects of the use of VA contract labor in a report that examined another subject. In that report, RAND found that increased use of contract labor appeared to decrease the overall costs at VA health care facilities. However, the report's finding differed from the interim finding that RAND briefed Congressional staff on earlier. In that briefing, RAND stated that contracting for labor could result in higher, rather than lower, VA health care facility costs. Because of this difference in RAND's findings and ongoing concerns about the impact of using contract labor at VA, Congress asked us to (1) determine what data RAND used in its contract labor analysis, (2) explain why RAND's final and interim findings differed regarding the effect of using contract labor on facility costs, and (3) assess whether RAND's report finding provides an adequate basis for making competitive sourcing decisions. RAND used contract labor data provided by VA from its financial accounting system. These data were for contract labor costs, such as for laundry and dry cleaning, for each VA health care facility in fiscal year 2000. According to VA officials, the costs in these accounts are predominately for contract labor costs. However, an undetermined proportion of these costs could also be for costs other than contract labor. Data refinements that RAND made explain most of the difference between RAND's report finding and interim finding on the effect of contract labor on VA facility costs, according to the study authors. In its report, RAND found that increasing contract labor was associated with decreasing VA health care facility costs. In its interim finding, RAND reported the opposite, namely that contract labor was associated with higher, not lower, VA health care facility costs. RAND study authors told us that the difference between their interim finding and their report finding resulted from certain data and analytical refinements that they made during the course of their research and data validation work after the briefing. The most important refinement was to exclude the costs of medical resident stipends and benefits from the contract labor analysis in the report. RAND excluded these costs for the report because they are not funded through the VA health care resource allocation system that RAND was examining. RAND's finding on contract labor does not provide an adequate basis for making competitive sourcing decisions. First, RAND's purpose was not to address this issue but instead to evaluate ways to improve VA's health care resource allocation system, according to the RAND study authors. For example, RAND did not examine the effect of using contract labor for each contract service even though the association with facility costs may vary by type of service. Second, VA contract labor data have limitations that may affect their usefulness for analysis of the relationship between use of contract labor and facility health care costs. One of these is that the data may include some nonlabor costs. In addition, the small proportion of VA labor costs that are for contract labor and the small variation across VA in the use of contract labor limit the usefulness of these data for examining the relationship between contract labor and facility costs, according to the RAND study authors. Mon, 30 Jun 2003 00:00:00 -0400 DOD and VA Health Care: Access for Dual Eligible Beneficiaries, June 13, 2003 http://www.gao.gov/new.items/d03904r.pdf The Department of Defense (DOD) reported that under its current policy, beneficiaries eligible for both TRICARE and the Department of Veterans Affairs' (VA) health care (dual eligible beneficiaries) are not allowed to utilize the services offered by both health care systems for treatment for the same episode of care. For example, if a beneficiary experiences back pain and seeks treatment from VA, the beneficiary must then receive all care related to that back pain from VA. Should the beneficiary then decide to seek treatment for the back pain from TRICARE, any claims related to that care would be denied. According to DOD, this policy was established to ensure continuity of care for beneficiaries and to ensure that there was no duplication of care or of payments from TRICARE or VA. Under the policy, if beneficiaries are dissatisfied with the care provided by VA, they are unable to switch to TRICARE to receive services for the same episode of care. On April 16, 2003, DOD reported to the Congress on a proposal to change its policy and promulgate regulations for coordinating care between DOD and VA. As agreed, we focused our review on the reasonableness of DOD's process. To do so, we reviewed the report submitted to the Congress and TRICARE policies, and interviewed agency officials from DOD and VA. Our work was conducted in June 2003 in accordance with generally accepted government auditing standards. DOD proposes to change its basic policy to enable dual eligible beneficiaries to access both systems for the same episode of care, thus ensuring full freedom of choice. DOD also proposes to pay for medically necessary care to the extent that such care would be covered by TRICARE. DOD's proposal appears reasonable, and it is in the process of developing regulations to implement it. Fri, 13 Jun 2003 00:00:00 -0400 Military Retiree Health Benefits: Enrollment Low in Federal Employee Health Plans under DOD Demonstration, June 6, 2003 http://www.gao.gov/new.items/d03547.pdf Prior to 2001, military retirees who turned age 65 and became eligible for Medicare lost most of their Department of Defense (DOD) health benefits. The DOD-Federal Employees Health Benefits Program (FEHBP) demonstration was one of several demonstrations established to examine alternatives for addressing retirees' lack of Medicare supplemental coverage. The demonstration was mandated by the Strom Thurmond National Defense Authorization Act for Fiscal Year 1999 (NDAA 1999), which also required GAO to evaluate the demonstration. GAO assessed enrollment in the demonstration and the premiums set by demonstration plans. To do this, GAO, in collaboration with the Office of Personnel Management (OPM) and DOD, conducted a survey of enrollees and eligible nonenrollees. GAO also examined DOD enrollment data, Medicare and OPM claims data, and OPM premiums data. Enrollment in the DOD-FEHBP demonstration was low, peaking at 5.5 percent of eligible beneficiaries in 2001 (7,521 enrollees) and then falling to 3.2 percent in 2002, after the introduction of comprehensive health coverage for all Medicare-eligible military retirees. Enrollment was considerably greater in Puerto Rico, where it reached 30 percent in 2002. Most retirees who knew about the demonstration and did not enroll said they were satisfied with their current coverage, which had better benefits and lower costs than the coverage they could obtain from FEHBP. Some of these retirees cited, for example, not being able to continue getting prescriptions filled at military treatment facilities if they enrolled in the demonstration. For those who enrolled, the factors that encouraged them to do so included the view that FEHBP offered retirees better benefits, particularly prescription drugs, than were available from their current coverage, as well as the lack of any existing coverage. Monthly premiums charged to enrollees for individual policies in the demonstration varied widely--from $65 to $208 in 2000--with those plans that had lower premiums and were better known to eligible beneficiaries, capturing the most enrollees. In setting premiums initially, plans had little information about the health and probable cost of care for eligible beneficiaries. Demonstration enrollees proved to have lower average health care costs than either their counterparts in the civilian FEHBP or those eligible for the demonstration who did not enroll. Plans enrolled similar proportions of beneficiaries in poor health, regardless of whether they charged higher, lower, or the same premiums for the demonstration as for the civilian FEHBP. In commenting on a draft of the report, DOD concurred with the overall findings but disagreed with the description of the demonstration's impact on DOD's budget as small. As noted in the draft report, DOD's costs for the demonstration relative to its total health care budget were less than 0.1 percent of that budget. OPM declined to comment. Fri, 06 Jun 2003 00:00:00 -0400 VA Long-Term Care: Veterans' Access to Noninstitutional Care Is Limited by Service Gaps and Facility Restrictions, May 22, 2003 http://www.gao.gov/new.items/d03815t.pdf With the aging of the veteran population, the Department of Veterans Affairs (VA) is likely to see a significant increase in long-term care need. VA uses noninstitutional long-term care services, such as home health care and adult day health care, and institutional care to meet this need. GAO identified limits in veterans' access to six noninstitutional long-term care services and factors that contribute to these limitations in its report VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans' Access to Noninstitutional Care (GAO-03-487, May 9, 2003). The report is based, in part, on a survey of all 139 VA facilities. Today's testimony discusses conclusions and highlights recommendations GAO made in the report to improve access to VA noninstitutional long-term care services. Veterans' access to the six noninstitutional services GAO reviewed is limited by service gaps and facility restrictions. Of VA's 139 facilities, 126 do not offer all six of these services--adult day health care, geriatric evaluation, respite care, home-based primary care, homemaker/home health aide, and skilled home health care. Veterans have the least access to respite care, which is not offered at 106 facilities. By contrast, skilled home health care is not offered at 7 facilities. Veterans' access is more limited than these numbers suggest, however, because even when facilities offer these services they often do so in only part of the geographic area they serve. In fact, for four of the six services the majority of facilities either do not offer the service or do not provide access to all veterans living in their geographic service area. Veterans' access may be further limited by restrictions that individual facilities set for use of services they offer. For example, at least 9 facilities limit veterans' eligibility to receive noninstitutional services based on their level of disability related to military service, which conflicts with VA's eligibility standards. Many facilities restrict the number of veterans who receive services resulting in veterans at 57 of VA's 139 facilities being placed on waiting lists for noninstitutional services. VA's lack of emphasis on increasing access to noninstitutional long-term care services has contributed to service gaps and individual facility restrictions that limit access to care. Faced with competing priorities and little guidance from headquarters, field officials have chosen to use available resources to address other priorities. While VA has implemented a performance measure for fiscal year 2003 that encourages networks to increase veterans' use of five of the six noninstitutional services, it does not require networks to ensure that all facilities provide veterans access to noninstitutional services. Thu, 22 May 2003 00:00:00 -0400 VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans' Access to Noninstitutional Care, May 9, 2003 http://www.gao.gov/new.items/d03487.pdf In April 2002, at the request of the Senate Committee on Veterans' Affairs, we testified on variation in the availability of VA's noninstitutional long-term care services. Congress expressed concern that this variation could mean that some veterans did not have access to noninstitutional services because of gaps in service availability and because of the restrictions that some facilities might place on veterans' use of these services, such as limiting the amount of service a veteran may receive. To address these concerns, we updated and expanded our previous work to determine (1) whether veterans' access to six noninstitutional services is limited by service availability and restrictions on use and (2) if access is limited, what factors, contribute to limited access. Veterans' access to the six noninstitutional long-term care services in our study is limited by the lack of service availability and restrictions on their use. Of VA's 139 facilities, 126 do not offer all six of the services. Veterans have the least access to noninstitutional respite care, which is not offered by 106 VA facilities. By contrast, skilled home health care is not offered at 7 facilities. Furthermore, veterans' access to care is more limited than these numbers suggest, because even when facilities offer these services they often do so in only parts of the geographic area they serve. In fact, for four of the six services--noninstitutional respite care, home-based primary care, adult day health care, and noninstitutional geriatric evaluation--the majority of facilities either do not offer the service or do not offer the service in the entire geographic area they serve. Veterans' access may be further limited by restrictions that individual facilities set for use of services they offer. For example, 9 facilities, in conflict with VA's eligibility standards, limited veterans' access to noninstitutional services based on their level of disability related to military service. Further, restrictions placed by many facilities on the number of veterans who can receive noninstitutional services have resulted in veterans at 57 of VA's 139 facilities being placed on waiting lists for noninstitutional services. VA's lack of emphasis on increasing access to noninstitutional long-term care services and a lack of guidance on the provision of these services have contributed to service gaps and individual facility restrictions. VA headquarters has not emphasized increasing access to these services by establishing measurable performance goals as it has for other priorities such as maintaining workloads in VA nursing homes. Without such performance measures, field officials faced with competing priorities have chosen to use available resources to address other priorities. VA has implemented a performance measure for fiscal year 2003 that encourages networks to increase veterans' use of five of the six noninstitutional services, but it does not require networks to ensure that all network facilities provide veterans access to noninstitutional services. Moreover, VA has not provided facilities with adequate guidance on the provision of noninstitutional respite care, even though most have had little experience in providing the service. Some networks and facilities are confused about how to provide the service and as a result some are not providing the service. VA has also not provided adequate guidance on which noninstitutional services are required. In particular, VA has not specified whether the home health services requirement includes one, all, or some combination of home-based primary care, homemaker/home health aide, and skilled home health care. In the absence of VA headquarters guidance on what home health services are required, VA facilities vary in their interpretations of what services they must provide. Fri, 09 May 2003 00:00:00 -0400 Department of Veterans Affairs: Key Management Challenges in Health and Disability Programs, May 8, 2003 http://www.gao.gov/new.items/d03756t.pdf In previous GAO reports and testimonies on the Department of Veterans Affairs (VA), and in its ongoing reviews, GAO identified major management challenges related to enhancing access to health care, improving the efficiency of health care delivery, and improving the effectiveness of disability programs. This testimony underscores the importance of continuing to make progress in addressing these challenges and ultimately overcoming them. VA has taken actions to address key challenges in its health care and disability programs. However, growing demand for health care and a potentially larger and more complex disability workload may make VA's challenges in these areas more complex. Enhancing access to health care: VA is challenged to deliver timely, convenient health care to its enrolled veteran population. Too many veterans continue to travel too far and wait too long for care. However, shifting care closer to where veterans live is complicated by stakeholder interests. In addition, VA's efforts to reduce waiting times may be complicated by an anticipated short-term surge in demand for specialty outpatient care. VA also faces difficult challenges in providing equitable access to nursing home care services to a growing elderly veteran population. Improving the efficiency of health care delivery: VA is challenged to find more efficient ways to meet veterans' demand for health care. VA operates a large portfolio of aged buildings that is not well aligned to efficiently meet veterans' needs. As a result, VA faces difficult realignment decisions involving capital investments, consolidations, closures, and contracting with local providers. VA also faces challenges in implementing management changes to improve the efficiency of patient support services, such as food and laundry services. Improving the effectiveness of disability programs: VA is challenged to find more effective ways to compensate veterans with disabilities. VA's outdated disability determination process does not reflect a current view of the relationship between impairments and work capacity. Advances in medicine and technology have allowed some individuals with disabilities to live more independently and work more effectively. VA also faces continuing challenges to improve the timeliness, quality and consistency of claims processing. Major improvements may require fundamental program changes. GAO designated federal real property, including VA health care infrastructure, and federal disability programs, including VA disability benefits, as high-risk areas in January 2003. GAO did this to draw attention to the need for broad-based transformation in these areas, which is critical to improving the government's performance and ensuring accountability within expected resource limits. Thu, 08 May 2003 00:00:00 -0400 VA Health Care: VA Increases Third-Party Collections as It Addresses Problems in Its Collections Operations, May 7, 2003 http://www.gao.gov/new.items/d03740t.pdf The Department of Veterans Affairs (VA) collects health insurance payments, known as third-party collections, for veterans' health care conditions it treats that are not a result of injuries or illnesses incurred or aggravated during military service. In September 1999, VA adopted a new fee schedule, called "reasonable charges," that it anticipated would increase revenues from third-party collections. In January 2003, GAO reported on VA's third-party collection efforts and problems in collections operations for fiscal year 2002 as well as VA's initiatives to improve collections (VA Health Care: Third-Party Collections Rising as VA Continues to Address Problems in Its Collections Operations, (GAO-03-145, Jan. 31, 2003)). GAO was asked to discuss its findings and update third-party collection amounts and agency plans to improve collections. VA's fiscal year 2002 third-party collections rose by 32 percent over fiscal year 2001 collections, to $687 million, and available data for the first half of fiscal year 2003 show that $386 million has been collected so far. The increase in collections reflects VA's improved ability to manage the larger billing volume and more itemized bills required under its new fee schedule. VA managers in three regional health care networks attributed billings increases to a reduction of billing backlogs and improved collections processes, such as better medical documentation prepared by physicians, more complete identification of billable care by coders, and more bills prepared per biller. Although collections are increasing, operational problems, such as missed billing opportunities, persist and continue to limit the amount VA collects. VA has been implementing the action items in its Revenue Cycle Improvement Plan of September 2001 that are designed to address operational problems, such as unidentified insurance for some patients, insufficient documentation of services for billing, shortages of billing staff, and insufficient pursuit of accounts receivable. VA reported in April 2003 that 10 of 24 action items are complete; 7 are scheduled for implementation by the end of 2003; and the remaining actions will begin in 2004 with full implementation expected in 2005 or 2006. These dates are behind VA's original schedule. In addition, the Chief Business Office, established in May 2002, has developed a new approach that combines the action items with additional initiatives. Given the growing demand for care, especially from higher-income veterans, it is important that VA resolve its operational problems and sustain its commitment to maximizing third-party collections. It is also important for VA to develop a reliable estimate of uncollected dollars and a complete measure of its collections costs. Without this information, VA cannot evaluate its effectiveness in supplementing its medical care appropriation with third-party dollars. Wed, 07 May 2003 00:00:00 -0400 Military Treatment Facilities: Eligibility Follow-up at Wilford Hall Air Force Medical Center, April 4, 2003 http://www.gao.gov/new.items/d03402r.pdf In October 2002, we reported the results of our audit of selected internal control activities at three military treatment facilities: Eisenhower Army Medical Center, Augusta, Georgia; Naval Medical Center-Portsmouth, Portsmouth, Virginia; and Wilford Hall Air Force Medical Center, San Antonio, Texas. As part of our work for that report, we requested data files of all patients who had been admitted, treated as outpatients, or received pharmaceutical benefits during fiscal year 2001. Despite considerable effort by the three facilities, only Wilford Hall Air Force Medical Center was able to provide a file of beneficiaries who received pharmaceuticals during the year. We compared this file to data in the Social Security Administration's (SSA) Death Master File as a technique to identify instances of potential fraud or abuse. For Wilford Hall, we identified 41 cases in which a prescription was ordered for an individual after the date of his or her death as recorded in the SSA Death Master File. Congress requested that we determine whether individuals fraudulently obtained pharmaceuticals or other health benefits by assuming the identity of a dead person, and, if so, to identify the specific breakdowns in internal controls that allowed such fraud to occur. We confined our investigation to the 41 cases described above. We did not find indications of individuals fraudulently obtaining health care benefits in our examination of the 41 cases we identified of people receiving treatment after they were listed in SSA's Death Master File. In 40 of the 41 cases, data entry errors and/or internal control weaknesses at either SSA or at the military treatment facilities created the impression that a deceased person had received prescriptions. Of the 40 cases, 10 were instances in which SSA's Death Master File had incorrectly listed as deceased the individual on whom a prescription was dispensed and 30 resulted from Department of Defense (DOD) data entry errors. Fri, 04 Apr 2003 00:00:00 -0500 Military Personnel: Preliminary Observations Related to Income, Benefits, and Employer Support for Reservist During Mobilizations, March 19, 2003 http://www.gao.gov/new.items/d03573t.pdf Since the end of the Cold War, there has been a shift in the way reserve forces have been used. Previously, reservists were viewed primarily as an expansion force that would supplement active forces during a major war. Today, reservists not only supplement but also replace active forces in military operations worldwide. Citing the increased use of the reserves to support military operations, House Report 107-436 accompanying the Fiscal Year 2003 National Defense Authorization Act directed GAO to review compensation and benefits for reservists. In response, GAO is reviewing (1) income protection for reservists called to active duty, (2) family support programs, and (3) health care access. For this statement, GAO was asked to discuss its preliminary observations. GAO also was asked to discuss the results of its recently completed review concerning employer support for reservists. The preliminary results of our review indicate that reservists experience widely varying degrees of income loss or gain when they are called up for a contingency operation. While income loss data for current operations Noble Eagle and Enduring Freedom were not available, data for past military operations show that 41 percent of drilling unit members reported income loss, while 30 percent reported no change and 29 percent reported an increase in income. This information is based on self-reported survey data for mobilizations or deployments of varying lengths of time. As would be expected, the data indicate that certain groups, such as medical professionals in private practice, tend to report much greater income loss than the average estimated for all reservists. Although reservists called up to support a contingency operation are generally eligible for the same family support and health care benefits as active component personnel, reservists and their families face challenges in understanding and accessing their benefits. Among the challenges, reservists typically live farther from military installations than their active duty counterparts, are not part of the day-to-day military culture, and may change benefit eligibility status many times throughout their career. Some of these challenges are unique to reservists; others are also experienced by active component members but may be magnified for reservists. Outreach to reservists and their families is likely to remain a continuing challenge for DOD in the areas of family support and health care, and we expect to look at DOD's outreach efforts in more detail as we continue our study. Outreach is also a critical component of maintaining and enhancing employers' support for reservists. Although DOD has numerous outreach efforts, we found that a sizeable number of reservists and employers were unsure about their rights and responsibilities. For example, a 1999 DOD survey found that 31 percent of employers were not aware of laws protecting reservists. Several factors have hampered DOD's outreach efforts to both employers and reservists. However, DOD is taking positive actions in this area, such as moving ahead with plans to collect employer data from all reserve personnel. Wed, 19 Mar 2003 00:00:00 -0500 Military Personnel: Preliminary Observations Related to Income, Benefits, and Employer Support for Reservists During Mobilizations, March 19, 2003 http://www.gao.gov/new.items/d03549t.pdf Since the end of the Cold War, there has been a shift in the way reserve forces have been used. Previously, reservists were viewed primarily as an expansion force that would supplement active forces during a major war. Today, reservists not only supplement but also replace active forces in military operations worldwide. Citing the increased use of the reserves to support military operations, House Report 107-436 accompanying the Fiscal Year 2003 National Defense Authorization Act directed GAO to review compensation and benefits for reservists. In response, GAO is reviewing (1) income protection for reservists called to active duty, (2) family support programs, and (3) health care access. For this testimony, GAO was asked to discuss its preliminary observations. GAO also was asked to discuss the results of its recently completed review concerning employer support for reservists. The preliminary results of our review indicate that reservists experience widely varying degrees of income loss or gain when they are called up for a contingency operation. While income loss data for current operations Noble Eagle and Enduring Freedom were not available, data for past military operations show that 41 percent of drilling unit members reported income loss, while 30 percent reported no change and 29 percent reported an increase in income. This information is based on self-reported survey data for mobilizations or deployments of varying lengths of time. As would be expected, the data indicate that certain groups, such as medical professionals in private practice, tend to report much greater income loss than the average estimated for all reservists. Although reservists called up to support a contingency operation are generally eligible for the same family support and health care benefits as active component personnel, reservists and their families face challenges in understanding and accessing their benefits. Among the challenges, reservists typically live farther from military installations than their active duty counterparts, are not part of the day-to-day military culture, and may change benefit eligibility status many times throughout their career. Some of these challenges are unique to reservists; others are also experienced by active component members but may be magnified for reservists. Outreach to reservists and their families is likely to remain a continuing challenge for DOD in the areas of family support and health care, and we expect to look at DOD's outreach efforts in more detail as we continue our study. Outreach is also a critical component of maintaining and enhancing employers' support for reservists. Although DOD has numerous outreach efforts, we found that a sizeable number of reservists and employers were unsure about their rights and responsibilities. For example, a 1999 DOD survey found that 31 percent of employers were not aware of laws protecting reservists. Several factors have hampered DOD's outreach efforts to both employers and reservists. However, DOD is taking positive actions in this area, such as moving ahead with plans to collect employer data from all reserve personnel. Wed, 19 Mar 2003 00:00:00 -0500