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Report to Congressional Requesters: 

United States Government Accountability Office:
GAO: 

September 2010: 

VA Health Care: 

Spending for and Provision of Prosthetic Items: 

GAO-10-935: 

GAO Highlights: 

Highlights of GAO-10-935, a report to congressional requesters. 

Why GAO Did This Study: 

In fiscal year 2009, the Department of Veterans Affairs (VA) provided 
more than 59 million prosthetic items to more than 2 million veterans. 
After VA physicians and other clinicians prescribe prosthetic items, 
VA’s Prosthetic and Sensory Aids Service (PSAS) is responsible for 
processing prescriptions and providing prosthetic items to veterans. 
PSAS is also responsible for managing VA’s spending for prosthetic 
items—more than $1.6 billion in fiscal year 2009. In fiscal year 2008, 
this spending exceeded VA’s budget estimates. Each year, VA makes an 
initial funding allocation for prosthetic items, and may reallocate by 
increasing or decreasing the funding available for prosthetic items 
during the fiscal year. 

GAO was asked to examine (1) how, for fiscal years 2005 through 2009, 
VA’s spending for prosthetic items compared to budget estimates, and 
the extent to which VA reallocated funding for prosthetic items; (2) 
how PSAS monitors its performance in processing and providing 
prosthetic items to veterans; and (3) the efforts VA has undertaken to 
improve PSAS’s performance. GAO reviewed VA’s spending and funding 
allocation data for fiscal years 2005 through 2009. GAO also reviewed 
documents and interviewed VA officials at headquarters, 5 of VA’s 21 
regional health care networks, called VISNs, and 13 VA medical centers 
(VAMC). 

What GAO Found: 

VA spending for prosthetic items for each of fiscal years 2005 through 
2009 differed from budget estimates, varying in amounts—both under and 
over budget estimates—ranging from 6 to 12 percent of VA’s overall 
spending for prosthetic items during the 5 fiscal years. In fiscal 
years 2005, 2008, and 2009, VA spent about $91 million, $83 million, 
and $183 million more, respectively, than VA originally estimated for 
its congressional budget justification. Conversely, in fiscal years 
2006 and 2007, VA spent about $82 million and about $150 million less, 
respectively, for prosthetic items than estimated. VA officials 
reported that they did not perform analysis to determine the specific 
causes of these differences, but that new trends are taken into 
account when allocating funding to be used for prosthetic items. In an 
effort to more closely match funds available for prosthetic items to 
actual spending needs, VA reallocated the funding available to PSAS 
and relied on VISNs and VAMCs to address the need for additional 
funding for prosthetic items at specific VA locations. For example, in 
fiscal year 2008, when an additional $83 million in funding was 
required for prosthetic items, VA reallocated $56 million to PSAS and 
VISNs and VAMCs covered $27 million in spending for prosthetic items. 

PSAS has performance measures that monitor the timeliness of its 
processing of prosthetic prescriptions and a number of veteran 
feedback mechanisms to identify problems in how it provides prosthetic 
items to veterans. In fiscal year 2009, PSAS’s performance measures 
showed that nearly all of its prescriptions for prosthetic items met 
its performance goals. While in many cases, PSAS’s performance 
measures serve as a reasonable proxy for monitoring the timeliness of 
veterans’ receipt of their prosthetic items, they may miss some 
instances in which veterans experience long wait times. Recognizing 
this shortcoming, PSAS officials rely on a number of other mechanisms—
such as telephone calls from veterans and receipt of veteran 
evaluation cards—to obtain information on veteran satisfaction that 
may alert them to timeliness or other problems not reflected in their 
performance measures. 

VA is making a number of efforts at various levels to improve its 
performance in providing prosthetic items to veterans. For example, in 
7 of VA’s 21 VISNs, PSAS personnel at the VISN level centrally manage 
the provision of prosthetic items at all of the VAMCs in their region. 
According to VA officials in several VISNs that have adopted this 
centralized management structure, giving VISN-level PSAS personnel 
more authority has allowed local PSAS personnel at the VAMCs to devote 
more time to meeting veterans’ needs, and in some cases, has enhanced 
management effectiveness and efficiency. At the national level, in 
fiscal year 2009, PSAS had 49 national contracts for prosthetic items, 
which, according to PSAS officials, help ensure that the quality of 
prosthetic items provided to veterans is consistent across the country. 
VA provided technical comments that GAO incorporated as appropriate. 

View [hyperlink, http://www.gao.gov/products/GAO-10-935] or key 
components. For more information, contact Randall B. Williamson at 
(202) 512-7114 or williamsonr@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

In Fiscal Years 2005 through 2009, Actual Spending Needs for 
Prosthetic Items Differed from Estimates, Resulting in the 
Reallocation of Funding Available for Prosthetic Items: 

PSAS Uses Administrative Data and Veteran Feedback Mechanisms to 
Monitor Its Performance in Processing and Providing Prosthetic Items 
to Veterans: 

VA Is Making Local, Regional, and National Efforts to Improve PSAS's 
Performance: 

Agency Comments: 

Appendix I: The Total Costs and Number of Prosthetic Items VA Provided 
to Veterans in Fiscal Years 2005 through 2009: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Examples of VA Prosthetic Items, by Type: 

Table 2: Initial Specific Purpose Funding for Prosthetic and Sensory 
Aids Service (PSAS), Reallocation Amounts, and Final Specific Purpose 
Funding, Fiscal Years 2005 through 2009: 

Table 3: Total Costs and Number of Prosthetic Items VA Provided to 
Veterans by Type of Prosthetic Item, Fiscal Years 2005 through 2009: 

Table 4: Total Costs and Number of Prosthetic Items Provided to 
Veterans by Veterans Integrated Service Network (VISN), Fiscal Years 
2005 through 2009: 

Table 5: Total Costs and the Number of Prosthetic Items Provided to 
Veterans by VA Station, Fiscal Years 2005 through 2009: 

Figures: 

Figure 1: VA Spending for Prosthetic Items, by Type, Fiscal Year 2009: 

Figure 2: Estimated and Actual VA Spending for Prosthetic Items, 
Fiscal Years 2005 through 2009: 

Figure 3: Actual VA Spending for Prosthetic Items by Type of Funding, 
Fiscal Years 2005 through 2009: 

Abbreviations: 

NPPD: National Prosthetics Patient Database: 

PSAS: Prosthetic and Sensory Aids Service: 

VA: Department of Veterans Affairs: 

VAMC: Veterans Affairs medical center: 

VHA: Veterans Health Administration: 

VISN: Veterans Integrated Service Network: 

VPR: VISN prosthetic representative: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

September 30, 2010: 

The Honorable Daniel K. Akaka: 
Chairman: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Bob Filner: 
Chairman: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Department of Veterans Affairs (VA), through its Prosthetic and 
Sensory Aids Service (PSAS), provides prosthetic items to those 
veterans who have experienced the loss or permanent impairment of a 
body part or function. During fiscal year 2009, PSAS procured and 
delivered more than 59 million prosthetic items[Footnote 1] to more 
than 2 million veterans, or nearly 40 percent of the veterans who 
received health care services from VA during the year.[Footnote 2] The 
prosthetic items provided by VA include a variety of medical devices 
and equipment ranging from artificial limbs and surgical implants--
such as pacemakers and hip replacements--to eyeglasses and hearing aid 
batteries. In recent years, the annual number of veterans who have 
received prosthetic items through PSAS and the annual amount that VA 
has spent on those items have increased significantly. Between fiscal 
years 2005 and 2009, the number of veterans to whom PSAS furnished 
prosthetic items grew 50 percent, from about 1.5 million to almost 2.2 
million. During the same period, VA spending for prosthetic items 
increased about 60 percent, from about $1 billion to more than $1.6 
billion. 

As PSAS provides more prosthetic items to more veterans, it is 
increasingly important that PSAS effectively manage the funding VA 
allocates to PSAS for prosthetic items and that it ensure prosthetic 
items are provided to veterans in an economical and timely manner. 
[Footnote 3] Each year, VA develops annual spending estimates for 
prosthetic items, which are included in VA's annual congressional 
budget justification as part of its estimate for health care services. 
VA does not, however, receive a specific appropriation for prosthetic 
items; rather, VA receives an appropriation for all of its health care 
services, including prosthetic items--the Medical Services 
appropriation. As a result, VA has considerable discretion in how it 
allocates its appropriated funding among its health care services, 
including the reallocation of funding throughout a fiscal year as 
required to meet actual spending needs. In 2009, veterans service 
organizations reported that actual spending for prosthetic items 
significantly exceeded estimates for fiscal year 2008. In light of 
this information, these organizations recommended that Congress ensure 
VA's appropriations are sufficient to meet the prosthetic needs of all 
veterans so that any requests for additional funding for prosthetic 
items do not compromise other programs.[Footnote 4] 

You expressed interest in obtaining information in order to better 
understand the operation of PSAS, including its management of VA 
funding allocated for prosthetic items and its performance in 
providing prosthetic items in a timely manner. This report discusses 
(1) how, for fiscal years 2005 through 2009, VA's spending for 
prosthetic items compared to budget estimates, and the extent to which 
VA reallocated the funding available for prosthetic items; (2) how 
PSAS monitors its performance in processing and providing prosthetic 
items to veterans; and (3) the efforts VA has undertaken to improve 
PSAS's performance in providing prosthetic items to veterans. 

To determine how VA's spending for prosthetic items compared to budget 
estimates, we obtained information from VA on its annual spending for 
prosthetic items for each of fiscal years 2005 through 2009.[Footnote 
5] We also reviewed VA's estimates for prosthetic items that the 
department included in its annual congressional budget justifications 
for the same fiscal years. We compared actual spending for prosthetic 
items with the estimates reported in the budget justifications. To 
determine the extent to which VA reallocated funding for prosthetic 
items, we obtained information for each of fiscal years 2005 through 
2009 on the funding VA initially allocated and subsequently 
reallocated for prosthetic items. We interviewed VA officials from 
PSAS's central office and the Veterans Health Administration's (VHA) 
[Footnote 6] Office of Finance on differences between spending and 
estimates for prosthetic items as well as about VA's reallocation of 
funding. We also interviewed officials from a judgmental sample of 13 
VA medical centers (VAMC); these VAMCs were located in Phoenix and 
Tucson, Arizona; Bay Pines, Gainesville, and Tampa, Florida; Atlanta 
and Augusta, Georgia; Albuquerque, New Mexico; Buffalo and Syracuse, 
New York; Portland, Oregon; Columbia, South Carolina; and Seattle, 
Washington. We conducted site visits to 12 of the 13 VAMCs.[Footnote 
7] To select the 13 VAMCs, we obtained data from VA's National 
Prosthetic Patient Database[Footnote 8] on the prosthetic items that 
VA provided veterans during fiscal years 2005 through 2009 and 
identified the number of prosthetic items provided to veterans at each 
VAMC and their reported costs. We used these data and input from VA 
officials to select the VAMCs based on factors such as spending for 
prosthetic items, the number of prosthetic items provided, PSAS 
management structure, geographic location, whether VAMCs operated 
special units that use a large number prosthetic items,[Footnote 9] 
and recent performance in meeting PSAS performance goals. 

To identify how PSAS monitors its performance in processing and 
providing prosthetic items to veterans and to describe the efforts VA 
has undertaken to improve PSAS's performance, we interviewed VA 
officials from PSAS's central office; 5 of VA's 21 regional health 
care networks, called Veterans Integrated Service Networks 
(VISN);[Footnote 10] and the 13 VAMCs in our sample. We also obtained 
and reviewed VA's quarterly performance measure reports used to 
monitor the timeliness of VA's processing of prosthetic items to 
veterans. 

We assessed the reliability of data on VA's spending and allocation of 
funding, data from the National Prosthetic Patient Database, and data 
on PSAS's performance measures for monitoring the timeliness of VA's 
processing of prosthetic items in several ways. These included 
electronic and manual data testing and interviews of VA officials 
knowledgeable about the data. We determined that the data that we used 
in our analyses were sufficiently reliable for the purposes of this 
report. 

We conducted this performance audit from June 2009 through August 2010 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

As part of a uniform set of benefits provided to all veterans who 
enroll in its health care system, VA, through PSAS, provides 
prosthetic items to veterans. PSAS has budget and management 
responsibilities for VA's provision of prosthetic items, including 
allocating funding for prosthetic items to VISNs and VAMCs and 
ensuring veterans receive prescribed prosthetic items in a timely 
manner. According to PSAS officials, several factors--including 
expansions in the types of items VA defines as prosthetic items--
contributed to an increased demand for prosthetic items between fiscal 
years 2005 and 2009. 

Prosthetic Items Provided to Veterans: 

VA, through VHA, operates one of the nation's largest health care 
systems.[Footnote 11] VA provides a range of services to veterans who 
are enrolled in its health care system, such as preventive and primary 
health care, a full range of outpatient and inpatient services, and 
prescription drugs.[Footnote 12] VA's outpatient care includes 
providing prosthetic items to those veterans disabled as a result of 
amputation or permanent impairment of a body part or function. 
[Footnote 13] VA classifies a variety of medical devices and equipment 
as prosthetic items, including artificial arms and legs, eyeglasses, 
hearing aids, hearing aid batteries, home dialysis equipment and 
supplies, home respiratory aids, hospital beds, orthoses (orthotic 
braces, supports, and footwear),[Footnote 14] pacemakers, telehealth 
equipment,[Footnote 15] and wheelchairs. These items range in price, 
including a cane tip that costs about $2 as well as a microprocessor- 
controlled knee which can cost more than $100,000. In addition, while 
the vast majority of prosthetic items are purchased from outside 
vendors, VA fabricated nearly 4 percent of the artificial limbs and 
orthoses provided to veterans in fiscal year 2009. 

Table 1 shows the types of prosthetic items VA provides and specific 
examples of each type. 

Table 1: Examples of VA Prosthetic Items, by Type: 

Type of prosthetic item: Accessibility items[A]; 
Examples of items: 
* scooters and accessories; 
* standard, motorized, and custom-built wheelchairs and accessories. 

Type of prosthetic item: Artificial limbs[A]; 
Examples of items: 
* artificial arms and legs. 

Type of prosthetic item: Medical equipment[A]; 
Examples of items: 
* computer equipment; 
* diabetic socks; 
* hearing aid batteries; 
* hospital beds and accessories; 
* patient lifts; 
* recreational equipment[B]; 
* telehealth equipment[C]; 
* walking aids (e.g., walkers). 

Type of prosthetic item: Orthoses[A]; 
Examples of items: 
* ankle, knee, leg, spinal, and other braces; 
* arch supports, shoe inserts, and shoes. 

Type of prosthetic item: Other[A]; 
Examples of items: 
* home dialysis equipment and supplies; 
* Home Improvement and Structural Alterations grants[D]; 
* home oxygen equipment and supplies; 
* restorations (e.g., breast, eye, and facial). 

Type of prosthetic item: Sensori-neuro aids[A]; 
Examples of items: 
* blind aids; 
* eyeglasses and contact lenses; 
* hearing aids; 
* speech devices. 

Type of prosthetic item: Surgical implants; 
Examples of items: 
* anchors, plates, and screws; 
* biological implants (e.g., bone and tissue grafts); 
* dental implants; 
* implantable cardioverter defibrillators and leads; 
* pacemakers; 
* stents. 

Source: GAO analysis of VA data. 

Note: This table presents data from VA's National Prosthetic Patient 
Database--an internal system used by VA to administer the department's 
provision of prosthetic items--on the types of prosthetic items VA 
provided to veterans in fiscal year 2009. 

[A] Accessibility items, artificial limbs, medical equipment, 
orthoses, other, and sensori-neuro aids also include components used 
for fabrication and repair of those items. 

[B] Recreational equipment includes artificial legs used for swimming, 
artificial arms used for archery, hand-powered cycles, and Braille 
dominos. 

[C] Telehealth is the use of telecommunications technology including 
video, digital pictures, and messaging devices to exchange health care 
information to provide health care services to rural and remote areas. 

[D] Home Improvement and Structural Alterations grants provide for the 
improvements and structural alterations veterans need to access their 
home and essential bathroom facilities. 

[End of table] 

In fiscal year 2009, the type of prosthetic items for which VA spent 
the largest amount was surgical implants, which accounted for 27 
percent of the more than $1.6 billion VA spent for prosthetic items 
that year. (See figure 1.) See appendix I for information on the total 
costs of and number of prosthetic items provided to veterans in fiscal 
years 2005 through 2009. 

Figure 1: VA Spending for Prosthetic Items, by Type, Fiscal Year 2009: 

[Refer to PDF for image: pie-chart] 

Surgical implants: 27%; 
Sensori-neuro aids: 17%; 
Medical equipment: 14%; 
Accessibility items: 11%; 
Orthoses: 6%; 
Artificial limbs: 6%; 
Other[A]: 19%. 

Source: GAO analysis of VA data. 

Note: This figure presents data from VA’s National Prosthetic Patient 
Database—an internal system used by VA to administer the department’s 
provision of prosthetic items. 

[A] Other includes home dialysis equipment and supplies, Home 
Improvement and Structural Alterations grants, home oxygen equipment 
and supplies, restorations, and other miscellaneous items. 

[End of figure] 

VA's Process for Estimating and Allocating Funding for Prosthetic 
Items: 

The funding VA uses to procure prosthetic items for veterans is made 
available as part of the appropriations process for VA's health care 
services.[Footnote 16] Each year, VA formulates its annual health care 
budget by developing estimates of its likely spending for all of its 
health care services, including prosthetic items.[Footnote 17] We have 
previously noted that the formulation of VA's budget is challenging, 
as it is based on assumptions and imperfect information on the health 
services VA expects to provide.[Footnote 18] For example, VA is 
responsible for anticipating the service needs of very different 
veteran populations--including an aging veteran population and a 
growing number of veterans returning from military operations in 
Afghanistan and Iraq--and for calculating future costs associated with 
providing health care services to these populations. VA uses an 
actuarial model to develop its budget estimates for most of its health 
care services, including estimates for prosthetic items, and 
incorporates these estimates in the department's annual congressional 
budget justification to the appropriations subcommittees.[Footnote 19] 
Rather than receiving an appropriation for each individual health care 
service it provides, VA receives an appropriation for all its health 
care services--the Medical Services appropriation.[Footnote 20] As a 
result, VA has considerable discretion in how it allocates 
appropriated funding among its various health care services. 

VA allocates the Medical Services appropriation either as specific 
purpose funding or general purpose funding. Where specific purpose 
funding is restricted to the purposes of individual health care 
services, such as organ transplant services or readjustment 
counseling, general purpose funding may be used to cover costs related 
to any health care service, including services for which specific 
purpose funding may be insufficient. While most of the funding from 
the Medical Services appropriation is distributed among the VISNs and 
ultimately to the VAMCs, according to VA officials, VA also maintains 
a national reserve to provide additional funding, when needed, to 
VISNs and VAMCs, as well as for those health care services for which 
VA allocates specific purpose funds. In addition, during the course of 
a fiscal year, VA may reallocate funding--that is, adjust how the 
department allocates its funding--to match spending needs, including 
redesignating specific purpose funds as general purpose funds or vice 
versa. 

Citing significant decreases in the level of care and timely delivery 
of prosthetic items, VA designated funding for prosthetic items as 
specific purpose funding in 2001.[Footnote 21] In general, VA 
allocates specific purpose funds to PSAS, which in turn allocates them 
to VISNs; VISNs then allocate funds to VAMCs. These specific purpose 
funds are for the procurement of prosthetic items as well as the 
procurement of various components for VA-fabricated or VA-repaired 
prostheses and orthoses. According to VA officials, these funds do not 
cover administrative and clinical costs, such as the salaries and 
benefits of PSAS personnel or labor costs associated with VA 
fabrication of prosthetic items. Typically, these administrative and 
clinical costs are covered by a VISN's or VAMC's general purpose 
funds. In addition, VISNs and VAMCs may use their general purpose 
funds for prosthetic items if spending needs exceed the amount 
available in specific purpose funds. 

PSAS Roles and Responsibilities: 

After physicians and other clinicians at VA medical facilities 
determine the prosthetic needs of veterans and prescribe specific 
prosthetic items to meet those needs, PSAS is responsible for 
processing the prescriptions and providing the prescribed prosthetic 
items to individual veterans.[Footnote 22] According to PSAS 
officials, purchasing agents, generally located at VAMCs, perform 
administrative actions to process prescriptions for prosthetic items. 
These administrative actions include activities such as requesting and 
obtaining additional information from a prescribing clinician, 
obtaining a price quote from a contractor, and creating a purchase 
order to authorize the procurement and shipment of an over-the-counter 
item or the fabrication of a custom-ordered item. PSAS officials 
stated that the processing of the prescription is considered complete 
when a prosthetic item has been issued to the veteran from PSAS's 
inventory or a purchase order is created for the item.[Footnote 23] 
PSAS also has some clinical staff--prosthetists and orthotists--who 
provide clinical services related to the provision of artificial limbs 
and orthoses, including participating in the evaluations of prosthetic 
needs for amputees and, subsequently, designing, fabricating, fitting, 
and adjusting artificial limbs and custom orthoses. PSAS officials 
reported that they provide varying levels of services related to the 
design, fabrication, fitting, and delivery of artificial limbs and 
orthoses at 77 locations. 

PSAS officials are also responsible for the overall administration of 
VA's provision of prosthetic items. Specifically, PSAS officials in 
VA's central office establish national policies and procedures on VA's 
provision of prosthetic items; allocate VA specific purpose funding 
for prosthetic items among the 21 VISNs; monitor the spending of this 
specific purpose funding and, if appropriate, facilitate the 
reallocation of funding among the VISNs; and establish and monitor 
mechanisms, such as performance measures and goals, to evaluate VA's 
performance in providing prosthetic items. VISN prosthetic 
representatives (VPR), located within each of VA's 21 VISNs, further 
allocate specific purpose funding among their VAMCs and, with the 
assistance of local prosthetics chiefs,[Footnote 24] support central 
office efforts to monitor VA's spending for prosthetic items and VA's 
performance in providing prosthetic items. 

Factors Contributing to the Increased Demand for Prosthetic Items: 

Between fiscal years 2005 and 2009, the annual number of veterans who 
received prosthetic items through PSAS increased about 50 percent and 
the total amount VA spent on those items grew by about 60 percent. 
According to VA officials, a number of factors have contributed to 
this growth and may contribute to expected increases in the future. 
These factors include the following: 

* VA has expanded the medical devices and equipment it classifies as 
prosthetic items. For example, during fiscal year 2008, VA classified 
biological implants, such as bone and tissue grafts, as prosthetic 
items.[Footnote 25] In fiscal year 2009, VA spent about $21 million on 
biological implants. 

* New technologies in prosthetic items available to veterans may 
increase costs. For example, in the fall of 2010, PSAS plans to begin 
providing the X2 microprocessor knee--the latest generation of 
components for prosthetic legs--to some veterans.[Footnote 26] 
According to PSAS officials, this component is expected to add about 
$40,000 to the cost of each prosthesis using this technology. 

* VA guidance clarifying veteran eligibility for certain prosthetic 
items expanded the number of veterans receiving prosthetic items. For 
example, in October 2008, VA released a directive restating the 
department's policy on veteran eligibility for eyeglasses. As result, 
the number of eyeglasses VA provided to veterans increased by nearly 
22 percent, from about 830,000 pairs in fiscal year 2008 to more than 
1 million pairs in fiscal year 2009.[Footnote 27] 

In addition, VA expanded eligibility for enrollment in its health care 
system. In 2009, VA raised the income thresholds that define certain 
veterans' eligibility for VA health care services, resulting in 
approximately 260,000 additional veterans gaining 
eligibility.[Footnote 28] This may also have increased the number of 
prosthetic items provided. 

In Fiscal Years 2005 through 2009, Actual Spending Needs for 
Prosthetic Items Differed from Estimates, Resulting in the 
Reallocation of Funding Available for Prosthetic Items: 

In each of fiscal years 2005 through 2009, VA's actual spending needs 
for prosthetic items differed from the estimates VA reported in its 
congressional budget justifications for those years, on which the 
initial allocation to PSAS for prosthetic items was based. As shown in 
figure 2, VA spent less for prosthetic items than it had estimated in 
its justifications for fiscal years 2006 and 2007. These differences-- 
about $82 million in fiscal year 2006 and about $150 million in fiscal 
year 2007--represented 7 and 12 percent, respectively, of VA's actual 
spending for prosthetic items during those fiscal years. In fiscal 
years 2005, 2008, and 2009, VA spent about $91 million, $83 million, 
and $183 million more, respectively, than originally estimated (9, 6, 
and 11 percent, respectively, of VA's spending for prosthetic items in 
those fiscal years).[Footnote 29] 

Figure 2: Estimated and Actual VA Spending for Prosthetic Items, 
Fiscal Years 2005 through 2009: 

[Refer to PDF for image: vertical bar graph] 

Fiscal year: 2005; 
Estimated spending: $947 million; 	
Actual spending: $1.04 billion. 

Fiscal year: 2006; 
Estimated spending: $1.200 billion; 
Actual spending: $1.12 billion. 

Fiscal year: 2007; 
Estimated spending: $1.39 billion; 
Actual spending: $1.24 billion. 

Fiscal year: 2008; 
Estimated spending: $1.34 billion; 
Actual spending: $1.42 billion. 

Fiscal year: 2009; 
Estimated spending: $1.46 billion; 
Actual spending: $1.64 billion. 

Source: GAO analysis of VA data. 

Notes: Estimated spending represents amounts originally reported in 
VA's annual congressional budget justifications. Actual VA spending 
represents total obligations for prosthetic items reported by VA. 

[End of figure] 

VA officials from the VHA Office of Finance and PSAS central office 
said that they did not perform analysis to determine the specific 
reasons for the differences between VA's budget estimates and its 
actual spending for prosthetic items in a given fiscal year. PSAS 
officials reported that they do perform some analysis to identify new 
trends in VA's spending for prosthetic items, which are taken into 
account when allocating specific purpose funding for prosthetic items. 
According to officials, to develop the budget estimates, VHA's Office 
of Finance uses the most recently available spending and utilization 
data in its actuarial model. They noted, however, that these data are 
3 years old at the time VA begins to develop budget estimates for a 
new fiscal year--for example, the actuarial model in VA's 2010 budget 
estimate used spending and utilization data from fiscal year 2007. 
This, coupled with the increased demand for prosthetic items, makes it 
more difficult to accurately estimate year-to-year PSAS funding needs, 
according to VA officials. 

PSAS central office officials reported that they depend upon staff at 
the VISNs and VAMCs to identify local factors, such as a new surgical 
service, that could increase demand for prosthetic items, in order to 
develop more up-to-date estimates for the purpose of allocating 
specific purpose funding for prosthetic items to VISNs and VAMCs. PSAS 
officials at each of the 13 VAMCs in our sample identified numerous 
local factors that can affect spending for prosthetic items during a 
particular fiscal year. For example, at one VAMC, the prosthetics 
chief said that the hiring of a new surgeon was expected to increase 
local spending for certain surgical implants, such as pacemakers, by 
more than $300,000. This same prosthetics chief also noted that recent 
increases in the diagnosis and treatment of sleep apnea resulted in an 
increase of nearly $380,000 in local spending for prosthetic items. 

In 4 of the 5 fiscal years we reviewed, VA reallocated the funding 
available for prosthetic items--that is, adjusted the amount of the 
specific purpose funding for these items--in an effort to better match 
specific purpose funds for prosthetic items with actual spending 
needs. Specifically, in fiscal years 2006, 2007, and 2009, VA reduced 
the amount of specific purpose funding for prosthetic items.[Footnote 
30] During fiscal year 2008, VA allocated an additional $56 million in 
specific purpose funds from the department's national reserve in order 
to meet a request from PSAS for additional funding. (See table 2.) VA 
based these reallocations on projections of annual spending for 
prosthetic items developed throughout each fiscal year using year-to- 
date information on spending. Each year during the third quarter of 
the fiscal year, for example, VA uses the amount spent on prosthetic 
items through the first two quarters of the fiscal year to project 
spending for the rest of the fiscal year and reallocates funding to 
adjust the amount of specific purpose funding available for prosthetic 
items accordingly. 

Table 2: Initial Specific Purpose Funding for Prosthetic and Sensory 
Aids Service (PSAS), Reallocation Amounts, and Final Specific Purpose 
Funding, Fiscal Years 2005 through 2009: 

Fiscal year: 2005; 
Initial specific purpose funding allocation: $947 million; 
Reallocation amounts: $0; 
Final specific purpose funding allocation: $947 million; 
Percentage that reallocations increased (decreased) funding: 0%. 

Fiscal year: 2006; 
Initial specific purpose funding allocation: $1.20 billion; 
Reallocation amounts: ($72 million); 
Final specific purpose funding allocation: $1.13 billion; 
Percentage that reallocations increased (decreased) funding: (6%). 

Fiscal year: 2007; 
Initial specific purpose funding allocation: $1.39 billion; 
Reallocation amounts: ($158 million); 
Final specific purpose funding allocation: $1.23 billion; 
Percentage that reallocations increased (decreased) funding: (11%). 

Fiscal year: 2008; 
Initial specific purpose funding allocation: $1.34 billion; 
Reallocation amounts: $56 million; 
Final specific purpose funding allocation: $1.40 billion; 
Percentage that reallocations increased (decreased) funding: 4%. 

Fiscal year: 2009; 
Initial specific purpose funding allocation: $1.73 billion; 
Reallocation amounts: ($35 million); 
Final specific purpose funding allocation: $1.69 billion; 
Percentage that reallocations increased (decreased) funding: (2%). 

Source: GAO analysis of VA data. 

Notes: Initial specific purpose funding allocations represent the 
funding VA allocated to PSAS for prosthetic items at the beginning of 
the fiscal year. Final specific purpose funding allocations represent 
the actual amount of funding VA allocated for prosthetic items at the 
end of the fiscal year. Reallocation amounts represent increases or 
decreases in the amount of funding VA allocated as specific purpose 
funds for prosthetic items. 

[End of table] 

In addition to the efforts VA made at the national level to reallocate 
funds to better match specific purpose funding for prosthetic items 
with actual spending needs, for 3 of the 5 fiscal years we reviewed, 
some VISNs and VAMCs used general purpose funds for prosthetic items. 
VA policy requires that VISNs provide additional funding to PSAS, when 
necessary, from general purpose funding to ensure the provision of 
prosthetic items is not delayed for lack of funding. In fiscal years 
2005, 2007, and 2008, VISNs and VAMCs provided $91 million, $5 
million, and $27 million, respectively, from their general purpose 
funds to address the difference between allocated specific purpose 
funding and actual spending needs for prosthetic items. (See figure 
3.) While VHA and PSAS officials acknowledge the use of general 
purpose funds for prosthetic items reduced the funding available for 
other purposes, they emphasized that this use did not compromise any 
veteran's medical care. 

Figure 3: Actual VA Spending for Prosthetic Items by Type of Funding, 
Fiscal Years 2005 through 2009: 

[Refer to PDF for image: stacked vertical bar graph] 

Fiscal year: 2005; 
Specific purpose funding: $947 million; 
General purpose funding: $91 million. 

Fiscal year: 2006; 
Specific purpose funding: $1.12 billion; 
General purpose funding: 0. 

Fiscal year: 2007; 
Specific purpose funding: $1.23 billion; 
General purpose funding: $5 million. 

Fiscal year: 2008; 
Specific purpose funding: $1.40 billion; 
General purpose funding: $27 million. 

Fiscal year: 2009; 
Specific purpose funding: $1.634 billion; 
General purpose funding: 0. 

Source: GAO analysis of VA data. 

Notes: Actual VA spending represents total obligations for prosthetic 
items reported by VA. In this figure, specific purpose funding 
represents VA funding specifically allocated for prosthetic items. 
General purpose funding represents VA funding that can be used for any 
health care service, including covering the costs of services for 
which specific purpose funding is insufficient. 

[End of figure] 

PSAS Uses Administrative Data and Veteran Feedback Mechanisms to 
Monitor Its Performance in Processing and Providing Prosthetic Items 
to Veterans: 

PSAS has performance measures that monitor the timeliness of its 
processing of prosthetic prescriptions and a number of veteran 
feedback mechanisms to identify problems in how it provides prosthetic 
items to veterans. In fiscal year 2009, PSAS's performance measures 
showed that nearly all of its prescriptions for prosthetic items met 
its performance goals. While in many cases, PSAS's performance 
measures serve as a reasonable proxy for monitoring the timeliness of 
veterans' receipt of their prosthetic items, they may miss some 
instances in which veterans experience long wait times. Recognizing 
this shortcoming, PSAS officials rely on a number of other mechanisms--
such as feedback submitted through telephone calls from veterans and 
receipt of veteran evaluation cards--to obtain information on veteran 
satisfaction that may alert them of timeliness or other problems not 
reflected in its performance measures. 

Performance Measures Assess Timeliness of Administrative Actions, but 
Do Not Always Reflect Veterans' Actual Receipt of Prosthetic Items: 

During fiscal years 2005 through 2009, PSAS had in place and monitored 
two performance measures that assessed the timeliness of 
administrative actions related to processing prosthetic prescriptions. 

* The first measure, called "delayed orders," assessed the percentage 
of prosthetic prescriptions for which the first administrative action 
related to the prescription, such as researching the cost of the 
prosthetic item from different commercial vendors, occurred more than 
5 business days after the clinical provider submitted it. PSAS's 
performance goal related to this measure was to have no more than 2 
percent of orders categorized as delayed orders. 

* The second measure, called "consults pending,"[Footnote 31] assessed 
the percentage of prosthetic prescriptions that took more than 45 
business days to complete the administrative process associated with 
ordering the prosthetic item; that is, from the time the first 
administrative action was taken to the time PSAS determined that the 
order was complete.[Footnote 32] PSAS's related performance goal was 
to have no consults pending; that is, to administratively process all 
prescriptions within 45 business days. 

For fiscal year 2009, PSAS basically met both of its goals related to 
the delayed orders and consults pending performance measures. PSAS 
calculated its performance relative to these performance measures for 
processing all prosthetic prescriptions submitted at each of its VAMCs 
and VISNs during the year.[Footnote 33] Based on its calculations, 
PSAS met its delayed order goal of no more than 2 percent delayed 
orders, and slightly missed its goal of having no consults pending by 
about 0.3 percent. 

According to VA, the delayed order and consults pending measures in 
many cases accurately reflected the timeliness of processing of 
prosthetic items. However, because of a weakness in PSAS's consults 
pending measure, some prescriptions that took longer than 45 business 
days to process were not detected by the measure. Specifically, PSAS 
officials found that prescriptions could be canceled and reentered, 
effectively resetting the clock on their processing time. In one VAMC 
we visited, for example, the prosthetics chief noted that the VAMC was 
receiving a number of complaints from veterans on the timely receipt 
of their prosthetic items. Upon further investigation, she identified 
more than 3,000 unprocessed prosthetic prescriptions that were not 
reflected in the VAMC's consults pending measure because the computer 
system used to process prescriptions allowed purchasing agents to 
cancel and reenter the prescriptions that were not meeting the 45 
business day goal. According to PSAS officials, there are a number of 
legitimate reasons why processing the prescription for prosthetic 
items can take longer than 45 days to complete.[Footnote 34] However, 
this prosthetics chief told us that, due to high purchasing agent 
workloads, some of the delays she identified most likely represented 
orders for prosthetic items that fell through the cracks, and veterans 
may not have received their prosthetic items until 5 or 6 months after 
their prescriptions were submitted. 

Recognizing the limitation in its consults pending measure, PSAS 
started--at the beginning of fiscal year 2010--to use a new measure, 
called the "timeliness monitor," which according to PSAS officials was 
designed to better assess the timeliness of the complete 
administrative process of providing a prosthetic item to a veteran and 
provide better assurance that a prosthetic item was provided in a 
timely manner. Specifically, PSAS officials said that the timeliness 
monitor assesses whether both the goals for the delayed order and 
consults pending measures were met,[Footnote 35] and whether the 
prescription was completed by either issuing a prosthetic item 
directly to the veteran from PSAS's inventory, or generating a 
purchase order for the item. PSAS's goal related to the new timeliness 
monitor is to have 95 percent of prosthetic prescriptions meet the 
timeliness monitor performance measure, according to PSAS officials. 

In the first quarter of fiscal year 2010, PSAS's timeliness monitor 
showed that less than 83 percent of prescriptions for prosthetic items 
met the time frames in the timeliness monitor performance measure. 
According to PSAS officials at two VISNs, one factor that played a 
significant role in PSAS not meeting its goal for the timeliness 
monitor was that the new measure may recognize some prescriptions as 
incomplete when actually they have been completely processed by PSAS 
staff. For example, if a veteran does not return to the VAMC to pick 
up a custom-fit item, such as a pair of orthopedic shoes, the item 
would not be recorded on the veteran's prosthetic record even though 
PSAS staff had completed the administrative process related to the 
item and it was available for pick up. PSAS officials told us that 
they are updating their system to allow purchasing agents to close 
prescriptions that were processed by PSAS but not recorded in a 
veteran's record for legitimate reasons, effectively excluding these 
prescriptions from being considered in the timeliness monitor. 
According to PSAS officials, once the system is updated, PSAS's 
timeliness monitor scores should improve considerably. 

An additional weakness of VA's performance measures--both with the new 
"timeliness monitor" and the former "consults pending" measure--is 
that these measures do not always identify cases in which a veteran 
waits a long time to receive an item. In many cases, the 
administrative actions related to prosthetic prescriptions do serve as 
a reasonable proxy for monitoring the timeliness of when veterans 
received their prosthetic items. For example, when a veteran receives 
an item out of inventory at a VAMC, the time the prescription is 
recorded as complete reflects the time that the veteran received their 
prosthetic item. However, the completion of processing of a 
prescription does not always correspond with the time at which the 
veteran receives the item. In particular, delays that occur for items 
that must be fabricated for the veteran or are back-ordered by a 
vendor are not reflected in VA's performance measures. For example, 
according to the prosthetics chief at one VAMC we visited, veterans 
routinely waited 10 to 12 weeks to receive eyeglasses because of 
manufacturing delays at the facility that produced the eyeglasses--
even though PSAS processed the eyeglass prescriptions in a timely 
manner. That is, once the purchase order was sent to the facility to 
manufacture the eyeglasses, VA's system considered the processing of 
the prescription to be complete. Officials reported that the VA 
optical laboratory could not meet the unexpected increase in demand 
that followed guidance that VA issued in October 2008. This guidance 
restated the department's policy that veterans whose vision impairment 
interferes with their participation in their own medical treatment are 
eligible to receive eyeglasses. The prosthetics chief at the VAMC 
explained that through feedback from veterans, they became aware of 
these delays. The VA optical laboratory has since taken steps to 
improve wait times, including authorizing overtime and using 
commercial vendors. Further, officials told us that they are planning 
a renovation of the optical laboratory to improve its operations. 
[Footnote 36] 

PSAS officials stated that they recognize their performance measures 
have limitations and that they rely on a number of feedback 
mechanisms--described below--to alert them of timeliness or other 
problems not reflected in PSAS's performance measures. 

PSAS Obtains Information on Veteran Satisfaction from a Number of 
Feedback Mechanisms: 

At a national level, PSAS uses additional mechanisms to identify 
timeliness or other problems which are not captured by its performance 
measures. These include the following: 

* Comments or complaints on VA's Web site. When VA receives comments, 
complaints, or other inquiries related to prosthetics through its Web 
site,[Footnote 37] the department directs the information to PSAS's 
central office, according to PSAS officials. PSAS's central office 
either handles the inquiry directly, or routes it to the relevant 
location or service, such as a VISN or VAMC, to resolve. As of July 
2010, PSAS central office officials reported that they have responded 
to and closed more than 2,085 inquiries received through VA's Web site. 

* Direct contact with PSAS staff. PSAS central office, VISNs, and 
VAMCs receive letters, in-person visits, and telephone calls from 
veterans about complaints or problems with prosthetic items, according 
to VA officials we spoke with. If these complaints come in through 
contacts with PSAS staff at the central office, VISN, or VAMC 
leadership, the complaints or problems are generally passed on to PSAS 
staff at the VAMC level for direct action. PSAS officials told us that 
it is PSAS's policy to handle complaints and problems in the most 
direct manner. For example, in one VAMC we visited, officials said 
that when they receive a complaint, they pass it on to the PSAS 
purchasing agent responsible for ordering the prosthetic item. The 
purchasing agent is then responsible for contacting the patient to 
resolve the complaint or problem. PSAS central office officials 
reported that while individual VISNs and VAMCs may, to varying 
degrees, track patient complaints made in person or by letter or 
telephone, PSAS central office does not systematically track these 
complaints. 

In addition to efforts initiated nationally, some VISNs and VAMCs we 
visited reported that they have developed local mechanisms to further 
monitor veteran satisfaction with VA's processing and providing 
prosthetic items: 

* VISN-sponsored surveys. One VISN we visited conducts patient 
satisfaction surveys of veterans who receive prosthetic items from the 
VAMCs in the VISN. On a quarterly basis, PSAS personnel at the VISN 
send these surveys directly to a sample of veterans who have received 
prosthetic items requesting veterans to rate aspects of PSAS's 
performance such as the quality of the prosthetic items they received, 
the instructions they received, the courtesy and knowledge of the 
prosthetic staff that they came in contact with, and the time it took 
to deliver the prosthetic items. The patients return the surveys to 
the VISN, where PSAS staff summarize the results of the surveys and 
provide quarterly reports to the prosthetics chiefs and leadership in 
each of the VAMCs. The VISN requires prosthetics chiefs at VAMCs with 
a patient satisfaction score below the VISN's established goal to 
develop improvement plans. VISN PSAS staff told us that the surveys 
have enabled them to identify problems and make improvements in how 
PSAS staff at the VAMCs interact with veterans, how PSAS staff process 
prosthetic prescriptions, and in the timeliness and quality of the 
services provided by vendors, such as home oxygen suppliers. 

* Vendor evaluation cards. PSAS officials at one VISN reported that 
their VISN required some of their vendors--such as vendors for home 
oxygen and durable medical equipment--to include a patient comment 
card with the delivery of the prosthetic items. Veterans return these 
comment cards to the VISN where VISN PSAS officials review the 
comments and forward relevant information to VAMC prosthetics offices 
on at least a quarterly basis. 

* VAMC comment cards. Several VAMCs in our sample provided their own 
comment cards. Typically, these cards are or will be made available at 
the PSAS counter and waiting area. PSAS officials at these VAMCs told 
us that they collect and review the comment cards they receive and 
address the comments veterans make concerning VA's processing and 
providing of prosthetic items on a case-by-case basis.[Footnote 38] 

* Letters informing veterans to expect delivery of prosthetic items. 
Officials at two of the five VISNs we visited told us that they use a 
feature in PSAS's system for processing prescriptions to generate and 
send a letter to a veteran each time a prescription is processed. 
These letters provide information such as the date the prosthetic item 
was ordered from a vendor, the date the veteran can expect to receive 
the prosthetic item, and contact information for the PSAS staff 
responsible for monitoring the order. 

PSAS officials expressed confidence that, together, the mechanisms 
they have in place would alert them of serious timeliness and veteran 
satisfaction issues. 

VA Is Making Local, Regional, and National Efforts to Improve PSAS's 
Performance: 

Officials at PSAS's central office, the VISNs, and the VAMCs in our 
sample told us about a number of local, regional, and national efforts 
to enhance management effectiveness and efficiency and improve 
prosthetic services for veterans. 

PSAS Staff at Some VA Medical Facilities Have Made Local Improvements 
to Enhance Performance: 

PSAS staff at the 13 VAMCs in our sample reported that they had 
undertaken local efforts to improve performance. For example, PSAS 
personnel at one VAMC were working to obtain funding from VA's Office 
of Rural Health to place orthotic fitters--technicians who fit 
orthoses--at community-based outpatient clinics. By placing fitters in 
these clinics, PSAS officials hope to improve access for veterans--for 
example, to eliminate the need for veterans to travel for several 
hours to a VAMC to be fitted for and obtain their orthotic shoes--as 
well as to relieve the workload of prosthetists and orthotists at the 
VAMCs in this VISN. In addition, 6 of the 13 VAMCs in our sample had 
recently completed renovations, were in the process of renovating, or 
were planning renovations of their laboratories and clinical space. 
PSAS officials explained that the purpose of these renovations was to 
provide greater patient privacy or increase their capacity to 
fabricate artificial limbs within the VAMCs. Some officials further 
explained that increasing the capacity of their prosthetic 
laboratories would allow more veterans to receive their prosthetic 
limbs directly from the VA rather than from outside vendors, which 
could increase convenience for veterans and reduce costs for VA. 

Some VISNs Have Centralized Management of PSAS at the VISN Level: 

At the regional level, according to PSAS central officials, 7 of VA's 
21 VISNs have chosen to centralize the management of PSAS within the 
VISN. Under a centralized PSAS management structure, the VPR is in 
charge of managing all aspects of the provision of prosthetic items in 
the VAMCs within their VISN, including the hiring and firing of PSAS 
personnel such as prosthetics chiefs and purchasing agents, and 
resolving veterans' complaints.[Footnote 39] PSAS's central office has 
recommended that VISNs adopt this management structure for PSAS for 
more than a decade, but as part of VA's overall decentralized 
management structure, each VISN's leadership has the authority to 
determine how PSAS is managed in its region. 

Although PSAS's central office has not collected performance data 
conclusively showing the benefits of centralized management, officials 
we spoke with identified several potential benefits. PSAS central 
office officials stated that a centralized management structure allows 
for resource sharing within the VISN--for example, PSAS purchasing 
agents at one VAMC performing duties for other VAMCs within the VISN-- 
and helps ensure greater uniformity of supervision and services. PSAS 
and VISN officials at three VISNs we visited that had centralized 
management noted that because centralization shifts costs and 
decisions related to PSAS personnel from the VAMCs to the VISN, PSAS 
avoids competing with other health care services within VAMCs for 
staff resources. Officials in two of these VISNs also stressed that 
centralization not only improved efficiency by facilitating the 
development and implementation of standardized procedures for 
processing prosthetic prescriptions across the VISN, but also enhanced 
veteran care by moving some of the day-to-day administrative tasks up 
to the VISN, thus freeing PSAS staff at the VAMCs to devote more time 
to meeting veterans' needs. 

While in general, the officials we spoke with--both at PSAS's central 
office and at VISNs that had adopted a centralized approach to 
managing PSAS--supported centralization, a few VAMC officials in some 
centralized VISNs expressed some concerns. For example, VAMC officials 
at two VAMCs we visited said that although PSAS was currently meeting 
the needs of veterans at their facilities, they were concerned that 
under a centralized management structure local leadership might not 
have the authority to take appropriate action if the performance of 
local PSAS staff was not satisfactory. In addition, one of these 
officials noted that under a prior director, centralization had 
contributed to a lack of communication between PSAS personnel and VAMC 
leadership. Specifically, it was their understanding that, since PSAS 
staff reported directly to the VISN rather than the leadership at that 
VAMC, the previous VAMC leadership had at times not included PSAS 
staff in management meetings and decisions that affected PSAS. 

National Efforts Undertaken by PSAS Have Focused on Improving 
Consistency of Prosthetic Services across VA: 

PSAS has a number of national efforts to improve the delivery of 
prosthetic items across VA. These efforts include developing national 
contracts, conducting site visits to poorly performing VAMCs, 
providing clinical practice recommendations for physicians who 
prescribe prosthetic items, obtaining accreditation and certification 
for prosthetic laboratories and staff, and training new management 
staff. 

* National contracts. PSAS uses national contracts that, according to 
PSAS officials, provide prosthetic items to veterans across the 
country in a more consistent, timely, and cost-efficient manner. PSAS 
first used national contracts to purchase prosthetic items in fiscal 
year 2002, and in fiscal year 2009, PSAS had 49 national contracts for 
prosthetic items ranging from orthopedic shoes and diabetic socks to 
implantable joints and cardiac pacemakers. According to PSAS 
officials, national contracts can improve efficiency and timeliness 
because the specifications, price, and shipping requirements for 
prosthetic items are determined by the contract rather than by 
individual purchasing agents. These contracts also help ensure that 
the quality of the prosthetic items provided to veterans is consistent 
across the country. According to PSAS officials, PSAS's use of 
national contracts has resulted in substantial cost savings since 
fiscal year 2002. 

* Site visits. Officials from PSAS central office told us that they 
have begun to conduct site visits to review PSAS operations in a 
number of VAMCs. Specifically, PSAS officials told us that they are 
conducting site visits to identify staffing or other problems that 
lead to poor performance and to make recommendations that should lead 
to faster and more consistent prosthetic services for veterans at 
these facilities. For the initial visits, PSAS selected VAMCs and 
VISNs that performed poorly on PSAS's performance measures, such as 
its consults pending measure. As of June 2010, PSAS staff had 
conducted 42 site visits, and PSAS officials said they plan to conduct 
reviews in all 153 VAMCs. 

* Clinical practice recommendations. PSAS has developed 40 clinical 
practice recommendations, which are guidance documents to help VA 
clinical staff make appropriate decisions about prosthetic 
prescriptions. These include prescribing recommendations for orthotic 
devices, home oxygen equipment, pacemakers, and hip and knee joint 
replacements. According to PSAS officials, these recommendations help 
ensure that prosthetic items are provided to veterans in a more 
consistent manner across the country.[Footnote 40] 

* Accreditation and certification. PSAS has implemented an initiative 
to provide additional assurance that VA is providing high-quality 
prosthetic services and to develop the technical and management skills 
of PSAS staff. In fiscal year 2007, PSAS established a policy to 
obtain accreditation for its orthotic and prosthetic laboratories, and 
certification for all clinical personnel. According to PSAS officials, 
as of September 2010, PSAS had obtained accreditation, or the 
accreditation was pending, for nearly all of its 77 orthotic and 
prosthetic service locations, and certification for 165 of its 172 
orthotists, prosthetists, and fitters. 

* Management training. PSAS created a technical intern program to 
train prospective managers on the operations of PSAS at the VAMC 
level. According to VA officials, this program is important because a 
large number of the prosthetics chiefs are nearing retirement and in 
many cases there are few experienced staff who could replace them. 

Agency Comments: 

We provided a draft of this report to VA for review. We received 
technical comments from VA, which we incorporated as appropriate. 

We are sending copies of this report to the Secretary of Veterans 
Affairs, appropriate congressional committees, and other interested 
parties. In addition, the report will be available at no charge on 
GAO's Web site at [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix II. 

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

[End of section] 

Appendix I: The Total Costs and Number of Prosthetic Items VA Provided 
to Veterans in Fiscal Years 2005 through 2009: 

This appendix provides the results of our analysis of data from the 
National Prosthetic Patient Database (NPPD)--an internal database used 
by the Department of Veterans Affairs (VA) to administer its provision 
of prosthetic items that contains information on prosthetic items 
furnished to veterans.[Footnote 41] This appendix presents the total 
costs and number of prosthetic items provided to veterans in fiscal 
years 2005 through 2009.[Footnote 42] 

* Table 3 shows the total costs and number of prosthetic items 
provided to veterans by type of prosthetic item. For fiscal year 2009, 
the total cost for various types of prosthetic items ranged from about 
$93 million for orthoses to about $439 million for surgical implants. 

* Table 4 shows the total costs and number of prosthetic items 
provided to veterans by Veterans Integrated Service Network (VISN). 
[Footnote 43] For fiscal year 2009, the total costs for prosthetic 
items for VISNs ranged from about $34 million in VISN 5 (Capitol 
Health Care Network) to about $164 million in VISN 8 (VA Sunshine 
Healthcare Network). 

* Table 5 shows the total costs and number of prosthetic items 
provided to veterans by VA station.[Footnote 44] For fiscal year 2009, 
the total costs of prosthetic items at individual stations that 
provided any prosthetic items ranged from less than $1 million at 
Pittsburgh HCS-Highland Dr., Chattanooga, and several other stations 
to about $39 million at the San Antonio VAMC. 

Table 3: Total Costs and Number of Prosthetic Items VA Provided to 
Veterans by Type of Prosthetic Item, Fiscal Years 2005 through 2009: 

Dollars in millions and items in thousands: 

Prosthetic item type: Accessibility items--scooters and accessories, 
standard, motorized, and custom-built wheelchairs and accessories; 
Dollars spent (number of items provided): 
2005[A]: $125 (311); 
2006[A]: $130 (364); 
2007[A]: $140 (407); 
2008: $163 (482); 
2009: $180 (519); 
Total[B]: $738 (2,083). 

Prosthetic item type: Artificial limbs--artificial arms and legs; 
Dollars spent (number of items provided): 
2005[A]: $67 (161); 
2006[A]: $73 (92); 
2007[A]: $81 (93); 
2008: $96 (100); 
2009: $98 (102); 
Total[B]: $414 (548). 

Prosthetic item type: Medical equipment--computer equipment, hospital 
beds and accessories, patient lifts, recreational equipment, (e.g., 
hand cycles), telehealth equipment, and walking aids; 
Dollars spent (number of items provided): 
2005[A]: $97 (1,148); 
2006[A]: $117 (1,269); 
2007[A]: $148 (1,542); 
2008: $186 (1,852); 
2009: $233 (2,209); 
Total[B]: $781 (8,020). 

Prosthetic item type: Other--home dialysis equipment and supplies, 
Home Improvement and Structural Alteration grants, home oxygen 
equipment and supplies, restorations (e.g., breast, eye, and facial); 
Dollars spent (number of items provided): 
2005[A]: $194 (12,492); 
2006[A]: $205 (12,404); 
2007[A]: $230 (13,000); 
2008: $274 (46,569); 
2009: $302 (51,826); 
Total[B]: $1,205 136,292). 

Prosthetic item type: Orthoses--ankle, knee, leg, spinal, and other 
braces; arch supports; shoe inserts; and shoes; 
Dollars spent (number of items provided): 
2005[A]: $58 (1,059); 
2006[A]: $60 (1,052); 
2007[A]: $66 (1,155); 
2008: $79 (1,320); 
2009: $93 (1,470); 
Total[B]: $355 (6,055). 

Prosthetic item type: Sensori-neuro aids--blind aids, eyeglasses, 
contact lenses, hearing aids, and speech devices; 
Dollars spent (number of items provided): 
2005[A]: $54 (953); 
2006[A]: $56 (1,122); 
2007[A]: $62 (1,050); 
2008: $219 (2,003); 
2009: $278 (2,664); 
Total[B]: $669 (7,792). 

Prosthetic item type: Surgical implants--anchors, plates, and screws; 
biological implants (e.g., bone and tissue grafts); dental implants; 
implantable cardioverter defibrillators and leads; pacemakers; and 
stents; 
Dollars spent (number of items provided): 
2005[A]: $312 (247); 
2006[A]: $341 (229); 
2007[A]: $355 (242); 
2008: $387 (270); 
2009: $439 (313); 
Total[B]: $1,834 (1,300). 

Prosthetic item type: Total[B]; 
Dollars spent (number of items provided): 
2005[A]: $907 (16,371); 
2006[A]: $980 (16,531); 
2007[A]: $1,082 (17,490); 
2008: $1,404 (52,596); 
2009: $1,623 (59,103); 
Total[B]: $5,996 162,090). 

Source: GAO analysis of VA data. 

Notes: Data for this table were obtained from VA's National Prosthetic 
Patient Database (NPPD)--an internal system used by VA to administer 
the department's provision of prosthetic items. Data on total 
obligations for prosthetic items from NPPD are different from the 
obligation data we used to report VA's annual spending for prosthetic 
items in the body of our report. The data on spending represent 
obligations for the procurement of prosthetic items during the course 
of a fiscal year, while NPPD data represent obligations that VA has 
incurred for prosthetic items actually provided to veterans during a 
fiscal year. In some instances, there may be a delay between when VA 
procures a prosthetic item and when the item is provided to the 
veteran. For example, VA may incur an obligation for the procurement 
of prosthetic items for PSAS inventory in one fiscal year, and 
distribute the inventoried prosthetic items to veterans in the next 
fiscal year. 

[A] Prior to fiscal year 2008, VA's NPPD did not contain data related 
to hearing aids, hearing aid batteries, and several other prosthetic 
devices included in the "other" and "sensori-neuro aids" categories. 
As a result, these items are not included for fiscal years 2005 
through 2007. According to a VA official, VA spent $145 million, $140 
million, and $140 million for these items during fiscal years 2005, 
2006, and 2007, respectively. 

[B] Amounts for fiscal years and types may not sum to totals due to 
rounding. 

[End of table] 

Table 4: Total Costs and Number of Prosthetic Items Provided to 
Veterans by Veterans Integrated Service Network (VISN), Fiscal Years 
2005 through 2009: 

Dollars in millions and items in thousands. 

VISN[A]: 1; 
VISN name: New England Healthcare System; 
Dollars spent (number of items provided: 
2005[B]: $39 (2,083); 
2006[B]: $41 (2,028); 
2007[B]: $47 (2,033); 
2008: $58 (3,599); 
2009: $66 (3,857); 
Total [B]: $251 (13,600). 

VISN[A]: 2; 
VISN name: VA Healthcare Network Upstate New York; 
Dollars spent (number of items provided: 
2005[B]: $23 (240); 
2006[B]: $24 (239); 
2007[B]: $26 (254); 
2008: $32 (978); 
2009: $38 (1,110); 
Total [B]: $142 (2,821). 

VISN[A]: 3; 
VISN name: VA New York/New Jersey Veterans Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $28 (410); 
2006[B]: $31 (548); 
2007[B]: $34 (555); 
2008: $43 (1,742); 
2009: $50 (1,946); 
Total [B]: $186 (5,201). 

VISN[A]: 4; 
VISN name: Stars and Stripes Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $44 (1,563); 
2006[B]: $48 (1,687); 
2007[B]: $50 (1,709); 
2008: $69 (4,129); 
2009: $76 (4,490); 
Total [B]: $287 (13,578). 

VISN[A]: 5; 
VISN name: Capitol Health Care Network; 
Dollars spent (number of items provided: 
2005[B]: $20 (633); 
2006[B]: $24 (540); 
2007[B]: $24 (493); 
2008: $29 (1,081); 
2009: $34 (1,182); 
Total [B]: $133 (3,929). 

VISN[A]: 6; 
VISN name: The Mid-Atlantic Network; 
Dollars spent (number of items provided: 
2005[B]: $55 (550); 
2006[B]: $52 (555); 
2007[B]: $63 (688); 
2008: $85 (2,126); 
2009: $102 (2,508); 
Total [B]: $357 (6,426). 

VISN[A]: 7; 
VISN name: The Atlanta Network; 
Dollars spent (number of items provided: 
2005[B]: $59 (811); 
2006[B]: $62 (756); 
2007[B]: $72 (922); 
2008: $97 (2,663); 
2009: $108 (2,931); 
Total [B]: $399 (8,082). 

VISN[A]: 8; 
VISN name: VA Sunshine Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $90 (1,855); 
2006[B]: $100 (1,910); 
2007[B]: $109 (1,784); 
2008: $143 (5,862); 
2009: $164 (6,430); 
Total [B]: $607 (17,840). 

VISN[A]: 9; 
VISN name: Mid South Veterans Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $48 (668); 
2006[B]: $54 (645); 
2007[B]: $59 (673); 
2008: $74 (2,390); 
2009: $83 (2,694); 
Total [B]: $317 (7,071). 

VISN[A]: 10; 
VISN name: VA Healthcare System of Ohio; 
Dollars spent (number of items provided: 
2005[B]: $24 (341); 
2006[B]: $29 (386); 
2007[B]: $34 (404); 
2008: $47 (1,813); 
2009: $60 (2,237); 
Total [B]: $194 (5,180). 

VISN[A]: 11; 
VISN name: Veterans Integrated Service Network; 
Dollars spent (number of items provided: 
2005[B]: $34 (507); 
2006[B]: $38 (452); 
2007[B]: $43 (469); 
2008: $56 (1,823); 
2009: $67 (2,218); 
Total [B]: $239 (5,471). 

VISN[A]: 12; 
VISN name: The Great Lakes Health Care System; 
Dollars spent (number of items provided: 
2005[B]: $36 (893); 
2006[B]: $38 (826); 
2007[B]: $42 (830); 
2008: $52 (1,859); 
2009: $58 (1,998); 
Total [B]: $226 (6,407). 

VISN[A]: 15; 
VISN name: VA Heartland Network; 
Dollars spent (number of items provided: 
2005[B]: $37 (504); 
2006[B]: $42 (465); 
2007[B]: $48 (487); 
2008: $60 (1,760); 
2009: $70 (1,952); 
Total [B]: $257 (5,168). 

VISN[A]: 16; 
VISN name: South Central Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $77 (772); 
2006[B]: $80 (773); 
2007[B]: $88 (848); 
2008: $115 (3,788); 
2009: $131 (4,276); 
Total [B]: $491 (10,457). 

VISN[A]: 17; 
VISN name: VA Heart of Texas Health Care Network; 
Dollars spent (number of items provided: 
2005[B]: $50 (725); 
2006[B]: $58 (763); 
2007[B]: $61 (795); 
2008: $80 (2,036); 
2009: $90 (2,049); 
Total [B]: $339 (6,368). 

VISN[A]: 18; 
VISN name: VA Southwest Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $39 (1,654); 
2006[B]: $45 (1,765); 
2007[B]: $46 (1,912); 
2008: $59 (2,925); 
2009: $70 (3,267); 
Total [B]: $258 (11,523). 

VISN[A]: 19; 
VISN name: Rocky Mountain Network; 
Dollars spent (number of items provided: 
2005[B]: $40 (285); 
2006[B]: $43 (314); 
2007[B]: $47 (348); 
2008: $59 (2,739); 
2009: $67 (3,416); 
Total [B]: $257 (7,102). 

VISN[A]: 20; 
VISN name: Northwest Network; 
Dollars spent (number of items provided: 
2005[B]: $38 (343); 
2006[B]: $41 (338); 
2007[B]: $46 (367); 
2008: $59 (2,189); 
2009: $66 (2,372); 
Total [B]: $250 (5,609). 

VISN[A]: 21; 
VISN name: Sierra Pacific Network; 
Dollars spent (number of items provided: 
2005[B]: $38 (232); 
2006[B]: $40 (283); 
2007[B]: $45 (300); 
2008: $58 (1,520); 
2009: $71 (1,751); 
Total [B]: $253 (4,085). 

VISN[A]: 22; 
VISN name: Desert Pacific Healthcare Network; 
Dollars spent (number of items provided: 
2005[B]: $47 (275); 
2006[B]: $47 (280); 
2007[B]: $50 (648); 
2008: $64 (2,329); 
2009: $71 (2,771); 
Total [B]: $279 (6,303). 

VISN[A]: 23; 
VISN name: Minneapolis & Lincoln Offices; 
Dollars spent (number of items provided: 
2005[B]: $40 (1,027); 
2006[B]: $44 (976); 
2007[B]: $48 (971); 
2008: $66 (3,245); 
2009: $77 (3,649); 
Total [B]: $276 (9,868). 

VISN name: : Total[C]; 
Dollars spent (number of items provided: 
2005[B]: $907 (16,371); 
2006[B]: $980 (16,531); 
2007[B]: $1,082 (17,490); 
2008: $1,404 (52,596); 
2009: $1,623 (59,103); 
Total [B]: $5,996 162,090). 

Source: GAO analysis of VA data. 

Note: Data for this table were obtained from VA's National Prosthetic 
Patient Database (NPPD)--an internal system used by VA to administer 
the department's provision of prosthetic items. Data on total 
obligations for prosthetic items from NPPD are different from the 
obligation data we used to report VA's annual spending for prosthetic 
items in the body of our report. The data on spending represent 
obligations for the procurement of prosthetic items during the course 
of a fiscal year, while NPPD data represent obligations that VA has 
incurred for prosthetic items actually provided to veterans during a 
fiscal year. In some instances, there may be a delay between when VA 
procures a prosthetic item and when the item is provided to the 
veteran. For example, VA may incur an obligation for the procurement 
of prosthetic items for PSAS inventory in one fiscal year, and 
distribute the inventoried prosthetic items to veterans in the next 
fiscal year. 

[A] VISNs 13 and 14 were consolidated and designated as VISN 23 in 
January 2002. 

[B] Prior to fiscal year 2008, VA's NPPD did not contain data related 
to hearing aids, hearing aid batteries, and several other prosthetic 
devices. As a result, these items are not included for fiscal years 
2005 through 2007. According to a VA official, VA spent $145 million, 
$140 million, and $140 million for these items during fiscal years 
2005, 2006, and 2007, respectively. 

[C] Amounts for fiscal years and VISNs may not sum to totals due to 
rounding: 

[End of table] 

Table 5: Total Costs and the Number of Prosthetic Items Provided to 
Veterans by VA Station, Fiscal Years 2005 through 2009: 

Dollars in millions and items in thousands: 

VISN: 1; 
Station[A]: Bedford; 
Dollars spent (number of items provided): 
2005[B]: $1 (90); 
2006[B]: $1 (112); 
2007[B]: $1 (103); 
2008: $1 (127); 
2009: $1 (134); 
Total[C]: $5 (565). 

VISN: 1; 
Station[A]: Manchester; 
Dollars spent (number of items provided): 
2005[B]: $2 (88); 
2006[B]: $2 (143); 
2007[B]: $3 (165); 
2008: $3 (312); 
2009: $5 (359); 
Total[C]: $15 (1,067). 

VISN: 1; 
Station[A]: Newington Campus; 
Dollars spent (number of items provided): 
2005[B]: $1 (14); 
2006[B]: $2 (16); 
2007[B]: $2 (17); 
2008: $2 (15); 
2009: $2 (15); 
Total[C]: $9 (77). 

VISN: 1; 
Station[A]: Northampton; 
Dollars spent (number of items provided): 
2005[B]: $1 (119); 
2006[B]: $1 (114); 
2007[B]: $1 (110); 
2008: $2 (155); 
2009: $3 (193); 
Total[C]: $9 (691). 

VISN: 1; 
Station[A]: Providence; 
Dollars spent (number of items provided): 
2005[B]: $3 (177); 
2006[B]: $3 (177); 
2007[B]: $4 (180); 
2008: $5 (205); 
2009: $7 (278); 
Total[C]: $23 (1,018). 

VISN: 1; 
Station[A]: Togus; 
Dollars spent (number of items provided): 
2005[B]: $6 (203); 
2006[B]: $6 (271); 
2007[B]: $7 (295); 
2008: $9 (596); 
2009: $10 (625); 
Total[C]: $38 (1,991). 

VISN: 1; 
Station[A]: VA Boston HCS-Boston Div.; 
Dollars spent (number of items provided): 
2005[B]: $6 (968); 
2006[B]: $6 (674); 
2007[B]: $7 (662); 
2008: $10 (1,139); 
2009: $10 (1,052); 
Total[C]: $40 (4,495). 

VISN: 1; 
Station[A]: VA Boston HCS-West Roxbury Div.; 
Dollars spent (number of items provided): 
2005[B]: $8 (8); 
2006[B]: $8 (9); 
2007[B]: $9 (11); 
2008: $8 (13); 
2009: 8 (21); 
Total[C]: $41 (62). 

VISN: 1; 
Station[A]: West Haven Campus; 
Dollars spent (number of items provided): 
2005[B]: $7 (371); 
2006[B]: $9 (468); 
2007[B]: $10 (439); 
2008: $11 (813); 
2009: $13 (893); 
Total[C]: $50 (2,984). 

VISN: 1; 
Station[A]: White River Jct.; 
Dollars spent (number of items provided): 
2005[B]: $3 (44); 
2006[B]: $3 (44); 
2007[B]: $3 (50); 
2008: $5 (224); 
2009: $6 (287); 
Total[C]: $20 (650). 

VISN: 2; 
Station[A]: Albany; 
Dollars spent (number of items provided): 
2005[B]: $4 (49); 
2006[B]: $4 (43); 
2007[B]: $4 (44); 
2008: $5 (46); 
2009: $6 (53); 
Total[C]: $23 (235). 

VISN: 2; 
Station[A]: Bath; 
Dollars spent (number of items provided): 
2005[B]: $1 (19); 
2006[B]: $1 (19); 
2007[B]: $1 (21); 
2008: $2 (25); 
2009: $2 (30); 
Total[C]: $8 (115). 

VISN: 2; 
Station[A]: Canandaigua; 
Dollars spent (number of items provided): 
2005[B]: $1 (11); 
2006[B]: $1 (11); 
2007[B]: $1 (13); 
2008: $1 (13); 
2009: $1 (15); 
Total[C]: $5 (63). 

VISN: 2; 
Station[A]: Rochester; 
Dollars spent (number of items provided): 
2005[B]: $1 (13); 
2006[B]: $1 (13); 
2007[B]: $1 (15); 
2008: $2 (15); 
2009: $2 (18); 
Total[C]: $7 (75). 

VISN: 2; 
Station[A]: Syracuse; 
Dollars spent (number of items provided): 
2005[B]: $7 (79); 
2006[B]: $8 (83); 
2007[B]: $10 (90); 
2008: $11 (97); 
2009: $12 (113); 
Total[C]: $47 (462). 

VISN: 2; 
Station[A]: Upstate New York HCS; 
Dollars spent (number of items provided): 
2005[B]: $9 (68); 
2006[B]: $9 (70); 
2007[B]: $8 (71); 
2008: $13 (781); 
2009: $15 (881); 
Total[C]: $54 (1,871). 

VISN: 3; 
Station[A]: Bronx; 
Dollars spent (number of items provided): 
2005[B]: $4 (34); 
2006[B]: $5 (156); 
2007[B]: $5 (52); 
2008: $6 (59); 
2009: $7 (66); 
Total[C]: $27 (367). 

VISN: 3; 
Station[A]: Castle Point Division-Hudson Valley HCS-; 
Dollars spent (number of items provided): 
2005[B]: $2 (37); 
2006[B]: $2 (42); 
2007[B]: $2 (41); 
2008: $2 (41); 
2009: $2 (52); 
Total[C]: $10 (214). 

VISN: 3; 
Station[A]: Hudson Valley HCS; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (6); 
2006[B]: Less than $1 (7); 
2007[B]: $1 (12); 
2008: $1 (12); 
2009: $1 (12); 
Total[C]: $3 (48). 

VISN: 3; 
Station[A]: Lyons; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (7); 
2006[B]: Less than $1 (5); 
2007[B]: Less than $1 (10); 
2008: Less than $1 (7); 
2009: $0 (0); 
Total[C]: $1 (29). 

VISN: 3; 
Station[A]: New Jersey HCS; 
Dollars spent (number of items provided): 
2005[B]: $5 (78); 
2006[B]: $5 (105); 
2007[B]: $6 (155); 
2008: $7 (186); 
2009: $8 (217); 
Total[C]: $30 (743). 

VISN: 3; 
Station[A]: New York Harbor HCS-NY Div.; 
Dollars spent (number of items provided): 
2005[B]: $9 (63); 
2006[B]: $9 (67); 
2007[B]: $10 (71); 
2008: $15 (1,218); 
2009: $17 (1,348); 
Total[C]: $59 (2,767). 

VISN: 3; 
Station[A]: New York Harbor HCS-Brooklyn-Poly Pl. Campus; 
Dollars spent (number of items provided): 
2005[B]: $4 (67); 
2006[B]: $4 (78); 
2007[B]: $4 (107); 
2008: $6 (117); 
2009: $7 (126); 
Total[C]: $26 (496). 

VISN: 3; 
Station[A]: Northport; 
Dollars spent (number of items provided): 
2005[B]: $5 (117); 
2006[B]: $5 (88); 
2007[B]: $6 (105); 
2008: $6 (102); 
2009: $8 (126); 
Total[C]: $30 (538). 

VISN: 4; 
Station[A]: Butler; 
Dollars spent (number of items provided): 
2005[B]: $1 (15); 
2006[B]: $2 (16); 
2007[B]: $2 (18); 
2008: $3 (205); 
2009: $3 (212); 
Total[C]: $11 (466). 

VISN: 4; 
Station[A]: Clarksburg; 
Dollars spent (number of items provided): 
2005[B]: $2 (23); 
2006[B]: $3 (59); 
2007[B]: $3 (75); 
2008: $4 (244); 
2009: $5 (249); 
Total[C]: $18 (650). 

VISN: 4; 
Station[A]: Coatesville; 
Dollars spent (number of items provided): 
2005[B]: $1 (12); 
2006[B]: $1 (53); 
2007[B]: $1 (58); 
2008: $3 (322); 
2009: $3 (316); 
Total[C]: $9 (760). 

VISN: 4; 
Station[A]: Erie; 
Dollars spent (number of items provided): 
2005[B]: $2 (34); 
2006[B]: $2 (42); 
2007[B]: $3 (55); 
2008: $4 (274); 
2009: $4 (303); 
Total[C]: $16 (708). 

VISN: 4; 
Station[A]: James E. Van Zandt VA (Altoona); 
Dollars spent (number of items provided): 
2005[B]: $2 (223); 
2006[B]: $2 (221); 
2007[B]: $2 (189); 
2008: $3 (353); 
2009: $4 (377); 
Total[C]: $12 (1,364). 

VISN: 4; 
Station[A]: Lebanon; 
Dollars spent (number of items provided): 
2005[B]: $4 (453); 
2006[B]: $5 (463); 
2007[B]: $5 (414); 
2008: $7 (868); 
2009: $9 (909); 
Total[C]: $30 (3,108). 

VISN: 4; 
Station[A]: Philadelphia; 
Dollars spent (number of items provided): 
2005[B]: $10 (42); 
2006[B]: $10 (47); 
2007[B]: $10 (107); 
2008: $12 (349); 
2009: $13 (400); 
Total[C]: $55 (946). 

VISN: 4; 
Station[A]: Pittsburgh HCS-Highland Dr.; 
Dollars spent (number of items provided): 
2005[B]: $0 (0); 
2006[B]: Less than $1 (2); 
2007[B]: Less than $1 (1); 
2008: $0 (0); 
2009: Less than $1 (1); 
Total[C]: $1 (4). 

VISN: 4; 
Station[A]: Pittsburgh HCS-University Dr.; 
Dollars spent (number of items provided): 
2005[B]: $15 (702); 
2006[B]: $15 (721); 
2007[B]: $16 (727); 
2008: $21 (1,121); 
2009: $23 (1,313); 
Total[C]: $88 (4,584). 

VISN: 4; 
Station[A]: Wilkes Barre; 
Dollars spent (number of items provided): 
2005[B]: $5 (37); 
2006[B]: $5 (41); 
2007[B]: $5 (42); 
2008: $7 (278); 
2009: $8 (279); 
Total[C]: $29 (677). 

VISN: 4; 
Station[A]: Wilmington; 
Dollars spent (number of items provided): 
2005[B]: $2 (21); 
2006[B]: $3 (21); 
2007[B]: $3 (22); 
2008: $4 (115); 
2009: $5 (131); 
Total[C]: $16 (310). 

VISN: 5; 
Station[A]: Baltimore; 
Dollars spent (number of items provided): 
2005[B]: $7 (377); 
2006[B]: $7 (259); 
2007[B]: $7 (225); 
2008: $8 (348); 
2009: $11 (418); 
Total[C]: $40 (1,626). 

VISN: 5; 
Station[A]: Fort Howard; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (6); 
2006[B]: Less than $1 (6); 
2007[B]: Less than $1 (6); 
2008: Less than $1 (5); 
2009: $1 (12); 
Total[C]: $3 (34). 

VISN: 5; 
Station[A]: Martinsburg; 
Dollars spent (number of items provided): 
2005[B]: $4 (104); 
2006[B]: $5 (105); 
2007[B]: $5 (111); 
2008: $6 (332); 
2009: $7 (338); 
Total[C]: $26 (990). 

VISN: 5; 
Station[A]: Perry Point; 
Dollars spent (number of items provided): 
2005[B]: $1 (5); 
2006[B]: $1 (6); 
2007[B]: $2 (9); 
2008: $3 (12); 
2009: $2 (14); 
Total[C]: $8 (46). 

VISN: 5; 
Station[A]: Washington; 
Dollars spent (number of items provided): 
2005[B]: $8 (141); 
2006[B]: $11 (165); 
2007[B]: $9 (143); 
2008: $13 (384); 
2009: $14 (399); 
Total[C]: $56 (1,232). 

VISN: 6; 
Station[A]: Asheville-Oteen; 
Dollars spent (number of items provided): 
2005[B]: $5 (83); 
2006[B]: $6 (95); 
2007[B]: $8 (109); 
2008: $11 (278); 
2009: $14 (300); 
Total[C]: $45 (865). 

VISN: 6; 
Station[A]: Beckley; 
Dollars spent (number of items provided): 
2005[B]: $2 (53); 
2006[B]: $3 (49); 
2007[B]: $3 (58); 
2008: $5 (251); 
2009: $5 (262); 
Total[C]: $17 (673). 

VISN: 6; 
Station[A]: Durham; 
Dollars spent (number of items provided): 
2005[B]: $17 (83); 
2006[B]: $13 (63); 
2007[B]: $15 (91); 
2008: $20 (276); 
2009: $25 (359); 
Total[C]: $90 (872). 

VISN: 6; 
Station[A]: Fayetteville NC; 
Dollars spent (number of items provided): 
2005[B]: $3 (66); 
2006[B]: $3 (66); 
2007[B]: $4 (74); 
2008: $7 (233); 
2009: $8 (272); 
Total[C]: $26 (712). 

VISN: 6; 
Station[A]: Hampton; 
Dollars spent (number of items provided): 
2005[B]: $4 (51); 
2006[B]: $4 (60); 
2007[B]: $5 (79); 
2008: $5 (181); 
2009: $7 (214); 
Total[C]: $24 (585). 

VISN: 6; 
Station[A]: Richmond; 
Dollars spent (number of items provided): 
2005[B]: $13 (88); 
2006[B]: $12 (78); 
2007[B]: $14 (81); 
2008: $17 (254); 
2009: $19 (296); 
Total[C]: $74 (796). 

VISN: 6; 
Station[A]: Salem; 
Dollars spent (number of items provided): 
2005[B]: $5 (61); 
2006[B]: $5 (63); 
2007[B]: $7 (86); 
2008: $9 (197); 
2009: $10 (240); 
Total[C]: $35 (648). 

VISN: 6; 
Station[A]: W.G. (Bill) Hefner Salisbury VAMC; 
Dollars spent (number of items provided): 
2005[B]: $6 (66); 
2006[B]: $6 (80); 
2007[B]: $8 (109); 
2008: $11 (456); 
2009: $14 (565); 
Total[C]: $44 (1,276). 

VISN: 7; 
Station[A]: Augusta; 
Dollars spent (number of items provided): 
2005[B]: $10 (82); 
2006[B]: $11 (97); 
2007[B]: $13 (122); 
2008: $18 (409); 
2009: $19 (444); 
Total[C]: $71 (1,153). 

VISN: 7; 
Station[A]: Birmingham; 
Dollars spent (number of items provided): 
2005[B]: $11 (161); 
2006[B]: $11 (108); 
2007[B]: $12 (181); 
2008: $16 (475); 
2009: $18 (537); 
Total[C]: $69 (1,462). 

VISN: 7; 
Station[A]: Charleston; 
Dollars spent (number of items provided): 
2005[B]: $7 (55); 
2006[B]: $8 (61); 
2007[B]: $9 (69); 
2008: $12 (177); 
2009: $13 (193); 
Total[C]: $49 (555). 

VISN: 7; 
Station[A]: Columbia; 
Dollars spent (number of items provided): 
2005[B]: $8 (98); 
2006[B]: $8 (92); 
2007[B]: $11 (108); 
2008: $14 (314); 
2009: $17 (361); 
Total[C]: $59 (972). 

VISN: 7; 
Station[A]: Decatur; 
Dollars spent (number of items provided): 
2005[B]: $13 (253); 
2006[B]: $13 (235); 
2007[B]: $15 (288); 
2008: $22 (738); 
2009: $23 (793); 
Total[C]: $86 (2,307). 

VISN: 7; 
Station[A]: Dublin; 
Dollars spent (number of items provided): 
2005[B]: $3 (39); 
2006[B]: $3 (47); 
2007[B]: $5 (56); 
2008: $6 (62); 
2009: $7 (77); 
Total[C]: $24 (281). 

VISN: 7; 
Station[A]: Montgomery; 
Dollars spent (number of items provided): 
2005[B]: $5 (86); 
2006[B]: $5 (79); 
2007[B]: $5 (59); 
2008: $7 (343); 
2009: $7 (376); 
Total[C]: $28 (942). 

VISN: 7; 
Station[A]: Tuscaloosa; 
Dollars spent (number of items provided): 
2005[B]: $2 (37); 
2006[B]: $2 (37); 
2007[B]: $2 (40); 
2008: $3 (146); 
2009: $4 (150); 
Total[C]: $13 (411). 

VISN: 8; 
Station[A]: Bay Pines; 
Dollars spent (number of items provided): 
2005[B]: $9 (155); 
2006[B]: $11 (163); 
2007[B]: $12 (177); 
2008: $16 (902); 
2009: $19 (973); 
Total[C]: $67 (2,370). 

VISN: 8; 
Station[A]: Broward County; 
Dollars spent (number of items provided): 
2005[B]: $0 (0); 
2006[B]: $0 (0); 
2007[B]: $0 (0); 
2008: $1 (18); 
2009: $1 (12); 
Total[C]: $2 (30). 

VISN: 8; 
Station[A]: Daytona Beach; 
Dollars spent (number of items provided): 
2005[B]: $1 (10); 
2006[B]: $1 (51); 
2007[B]: $1 (71); 
2008: $1 (68); 
2009: $1 (84); 
Total[C]: $5 (284). 

VISN: 8; 
Station[A]: Ft. Myers; 
Dollars spent (number of items provided): 
2005[B]: $2 (14); 
2006[B]: $1 (12); 
2007[B]: $2 (14); 
2008: $2 (16); 
2009: $2 (21); 
Total[C]: $8 (78). 

VISN: 8; 
Station[A]: Jacksonville; 
Dollars spent (number of items provided): 
2005[B]: $1 (11); 
2006[B]: $1 (16); 
2007[B]: $2 (17); 
2008: $2 (19); 
2009: $3 (24); 
Total[C]: $9 (88). 

VISN: 8; 
Station[A]: Leesburg (Lake County); 
Dollars spent (number of items provided): 
2005[B]: $0 (0); 
2006[B]: Less than $1 (1); 
2007[B]: Less than $1 (1); 
2008: Less than $1 (1); 
2009: Less than $1 (1); 
Total[C]: Less than $1 (3). 

VISN: 8; 
Station[A]: Mayaguez; 
Dollars spent (number of items provided): 
2005[B]: $0 (0); 
2006[B]: $0 (0); 
2007[B]: $0 (0); 
2008: Less than $1 (7); 
2009: Less than $1 (8); 
Total[C]: Less than $1 (15). 

VISN: 8; 
Station[A]: Miami; 
Dollars spent (number of items provided): 
2005[B]: $10 (179); 
2006[B]: $11 (216); 
2007[B]: $11 (182); 
2008: $14 (685); 
2009: $16 (743); 
Total[C]: $63 (2,006). 

VISN: 8; 
Station[A]: North Florida/South Georgia HCS-Gainesville; 
Dollars spent (number of items provided): 
2005[B]: $17 (525); 
2006[B]: $20 (503); 
2007[B]: $22 (427); 
2008: $27 (1,150); 
2009: $31 (1,316); 
Total[C]: $117 (3,921). 

VISN: 8; 
Station[A]: North Florida/South Georgia HCS-Lake City; 
Dollars spent (number of items provided): 
2005[B]: $4 (183); 
2006[B]: $4 (158); 
2007[B]: $4 (158); 
2008: $6 (210); 
2009: $6 (274); 
Total[C]: $24 (982). 

VISN: 8; 
Station[A]: Oakland Park; 
Dollars spent (number of items provided): 
2005[B]: $1 (18); 
2006[B]: $1 (14); 
2007[B]: $1 (16); 
2008: $0 (0); 
2009: $0 (0); 
Total[C]: $3 (48). 

VISN: 8; 
Station[A]: Orlando; 
Dollars spent (number of items provided): 
2005[B]: $4 (109); 
2006[B]: $4 (99); 
2007[B]: $5 (79); 
2008: $5 (115); 
2009: $6 (133); 
Total[C]: $25 (534). 

VISN: 8; 
Station[A]: Ponce; 
Dollars spent (number of items provided): 
2005[B]: $0 (0); 
2006[B]: $0 (0); 
2007[B]: $0 (0); 
2008: Less than $1 (11); 
2009: Less than $1 (13); 
Total[C]: $1 (24). 

VISN: 8; 
Station[A]: San Juan; 
Dollars spent (number of items provided): 
2005[B]: $11 (145); 
2006[B]: $12 (147); 
2007[B]: $13 (172); 
2008: $17 (418); 
2009: $18 (464); 
Total[C]: $71 (1,345). 

VISN: 8; 
Station[A]: Tallahassee; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (7); 
2006[B]: Less than $1 (9); 
2007[B]: Less than $1 (10); 
2008: $1 (17); 
2009: $1 (16); 
Total[C]: $3 (58). 

VISN: 8; 
Station[A]: Tampa; 
Dollars spent (number of items provided): 
2005[B]: $20 (244); 
2006[B]: $22 (260); 
2007[B]: $23 (192); 
2008: $33 (1,353); 
2009: $38 (1,416); 
Total[C]: $138 (3,465). 

VISN: 8; 
Station[A]: Viera; 
Dollars spent (number of items provided): 
2005[B]: $1 (45); 
2006[B]: $2 (38); 
2007[B]: $2 (29); 
2008: $2 (30); 
2009: $2 (31); 
Total[C]: $10 (173). 

VISN: 8; 
Station[A]: W Palm Beach; 
Dollars spent (number of items provided): 
2005[B]: $8 (198); 
2006[B]: $9 (213); 
2007[B]: $10 (229); 
2008: $15 (830); 
2009: $18 (890); 
Total[C]: $60 (2,360). 

VISN: 8; 
Station[A]: Zephyrhills; 
Dollars spent (number of items provided): 
2005[B]: $1 (10); 
2006[B]: $1 (10); 
2007[B]: $1 (11); 
2008: $1 (13); 
2009: $1 (12); 
Total[C]: $4 (55). 

VISN: 9; 
Station[A]: Chattanooga; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (3); 
2006[B]: Less than $1 (4); 
2007[B]: Less than $1 (4); 
2008: Less than $1 (3); 
2009: Less than $1 (4); 
Total[C]: $1 (19). 

VISN: 9; 
Station[A]: Huntington; 
Dollars spent (number of items provided): 
2005[B]: $4 (85); 
2006[B]: $5 (52); 
2007[B]: $6 (60); 
2008: $8 (227); 
2009: $9 (265); 
Total[C]: $32 (689). 

VISN: 9; 
Station[A]: Knoxville; 
Dollars spent (number of items provided): 
2005[B]: $1 (10); 
2006[B]: $2 (9); 
2007[B]: $2 (10); 
2008: Less than $1 (5); 
2009: Less than $1 (9); 
Total[C]: $6 (42). 

VISN: 9; 
Station[A]: Lexington-Cooper Dr.; 
Dollars spent (number of items provided): 
2005[B]: $0 (0); 
2006[B]: $0 (0); 
2007[B]: $0 (0); 
2008: $0 (0); 
2009: $11 (74); 
Total[C]: $11 (74). 

VISN: 9; 
Station[A]: Lexington-Leestown; 
Dollars spent (number of items provided): 
2005[B]: $8 (50); 
2006[B]: $8 (48); 
2007[B]: $9 (59); 
2008: $12 (280); 
2009: $2 (248); 
Total[C]: $39 (684). 

VISN: 9; 
Station[A]: Louisville; 
Dollars spent (number of items provided): 
2005[B]: $7 (72); 
2006[B]: $8 (59); 
2007[B]: $9 (53); 
2008: $12 (389); 
2009: $12 (410); 
Total[C]: $48 (983). 

VISN: 9; 
Station[A]: Memphis; 
Dollars spent (number of items provided): 
2005[B]: $8 (87); 
2006[B]: $9 (96); 
2007[B]: $10 (89); 
2008: $12 (343); 
2009: $13 (375); 
Total[C]: $52 (991). 

VISN: 9; 
Station[A]: Middle Tennessee HCS; 
Dollars spent (number of items provided): 
2005[B]: $14 (198); 
2006[B]: $16 (196); 
2007[B]: $16 (205); 
2008: $21 (662); 
2009: $25 (743); 
Total[C]: $91 (2,005). 

VISN: 9; 
Station[A]: Mountain Home; 
Dollars spent (number of items provided): 
2005[B]: $5 (163); 
2006[B]: $6 (182); 
2007[B]: $7 (193); 
2008: $9 (481); 
2009: $11 (566); 
Total[C]: $38 (1,584). 

VISN: 10; 
Station[A]: Chillicothe; 
Dollars spent (number of items provided): 
2005[B]: $1 (30); 
2006[B]: $1 (31); 
2007[B]: $2 (33); 
2008: $3 (150); 
2009: $3 (183); 
Total[C]: $10 (427). 

VISN: 10; 
Station[A]: Cincinnati; 
Dollars spent (number of items provided): 
2005[B]: $5 (80); 
2006[B]: $6 (132); 
2007[B]: $6 (129); 
2008: $10 (333); 
2009: $13 (397); 
Total[C]: $41 (1,071). 

VISN: 10; 
Station[A]: Cleveland-Wade Park; 
Dollars spent (number of items provided): 
2005[B]: $11 (119); 
2006[B]: $14 (134); 
2007[B]: $17 (149); 
2008: $21 (725); 
2009: $26 (953); 
Total[C]: $90 (2,079). 

VISN: 10; 
Station[A]: Columbus; 
Dollars spent (number of items provided): 
2005[B]: $2 (35); 
2006[B]: $2 (38); 
2007[B]: $3 (48); 
2008: $5 (231); 
2009: $7 (275); 
Total[C]: $20 (626). 

VISN: 10; 
Station[A]: Dayton; 
Dollars spent (number of items provided): 
2005[B]: $4 (78); 
2006[B]: $5 (50); 
2007[B]: $5 (45); 
2008: $8 (375); 
2009: $11 (430); 
Total[C]: $32 (977). 

VISN: 11; 
Station[A]: Ann Arbor HCS; 
Dollars spent (number of items provided): 
2005[B]: $7 (48); 
2006[B]: $9 (51); 
2007[B]: $10 (60); 
2008: $12 (309); 
2009: $16 (369); 
Total[C]: $53 (837). 

VISN: 11; 
Station[A]: Battle Creek; 
Dollars spent (number of items provided): 
2005[B]: $2 (37); 
2006[B]: $2 (40); 
2007[B]: $3 (45); 
2008: $4 (201); 
2009: $6 (235); 
Total[C]: $17 (559). 

VISN: 11; 
Station[A]: Detroit (John D. Dingell); 
Dollars spent (number of items provided): 
2005[B]: $5 (68); 
2006[B]: $6 (65); 
2007[B]: $6 (78); 
2008: $6 (248); 
2009: $7 (287); 
Total[C]: $30 (745). 

VISN: 11; 
Station[A]: Illiana HCS (Danville); 
Dollars spent (number of items provided): 
2005[B]: $3 (150); 
2006[B]: $3 (108); 
2007[B]: $4 (67); 
2008: $5 (212); 
2009: $6 (234); 
Total[C]: $22 (771). 

VISN: 11; 
Station[A]: Indianapolis; 
Dollars spent (number of items provided): 
2005[B]: $11 (103); 
2006[B]: $13 (98); 
2007[B]: $14 (117); 
2008: $17 (331); 
2009: $18 (387); 
Total[C]: $73 (1,036). 

VISN: 11; 
Station[A]: N. Indiana HCS-Ft. Wayne; 
Dollars spent (number of items provided): 
2005[B]: $2 (39); 
2006[B]: $2 (32); 
2007[B]: $3 (37); 
2008: $4 (52); 
2009: $4 (60); 
Total[C]: $15 (220). 

VISN: 11; 
Station[A]: N. Indiana HCS-Marion; 
Dollars spent (number of items provided): 
2005[B]: $1 (14); 
2006[B]: $1 (14); 
2007[B]: $1 (16); 
2008: $3 (338); 
2009: $4 (445); 
Total[C]: $10 (827). 

VISN: 11; 
Station[A]: Saginaw; 
Dollars spent (number of items provided): 
2005[B]: $2 (42); 
2006[B]: $2 (43); 
2007[B]: $3 (49); 
2008: $5 (131); 
2009: $7 (201); 
Total[C]: $18 (466). 

VISN: 11; 
Station[A]: Toledo; 
Dollars spent (number of items provided): 
2005[B]: $1 (7); 
2006[B]: $Less than $1 (2); 
2007[B]: $0 (0); 
2008: $0 (0); 
2009: $0 (0); 
Total[C]: $1 (9). 

VISN: 12; 
Station[A]: Adams Benjamin Jr. (Crown Point IN); 
Dollars spent (number of items provided): 
2005[B]: $Less than $1 (6); 
2006[B]: $1 (6); 
2007[B]: $1 (8); 
2008: $1 (8); 
2009: $1 (9); 
Total[C]: $4 (36). 

VISN: 12; 
Station[A]: Hines; 
Dollars spent (number of items provided): 
2005[B]: $10 (289); 
2006[B]: $9 (348); 
2007[B]: $10 (383); 
2008: $12 (583); 
2009: $13 (541); 
Total[C]: $54 (2,144). 

VISN: 12; 
Station[A]: Iron Mountain MI; 
Dollars spent (number of items provided): 
2005[B]: $1 (29); 
2006[B]: $1 (28); 
2007[B]: $1 (29); 
2008: $2 (102); 
2009: $2 (137); 
Total[C]: $7 (326). 

VISN: 12; 
Station[A]: Jesse Brown VAMC-Chicago HCS; 
Dollars spent (number of items provided): 
2005[B]: $6 (302); 
2006[B]: $5 (220); 
2007[B]: $6 (185); 
2008: $8 (326); 
2009: $10 (325); 
Total[C]: $35 (1,359). 

VISN: 12; 
Station[A]: Madison WI; 
Dollars spent (number of items provided): 
2005[B]: $6 (126); 
2006[B]: $6 (91); 
2007[B]: $6 (81); 
2008: $7 (175); 
2009: $8 (182); 
Total[C]: $33 (656). 

VISN: 12; 
Station[A]: Milwaukee WI; 
Dollars spent (number of items provided): 
2005[B]: $11 (63); 
2006[B]: $12 (57); 
2007[B]: $13 (63); 
2008: $15 (221); 
2009: $16 (258); 
Total[C]: $67 (661). 

VISN: 12; 
Station[A]: North Chicago IL; 
Dollars spent (number of items provided): 
2005[B]: $2 (44); 
2006[B]: $2 (40); 
2007[B]: $2 (46); 
2008: $4 (271); 
2009: $5 (318); 
Total[C]: $14 (719). 

VISN: 12; 
Station[A]: Tomah; 
Dollars spent (number of items provided): 
2005[B]: $1 (33); 
2006[B]: $2 (35); 
2007[B]: $2 (34); 
2008: $3 (173); 
2009: $3 (229); 
Total[C]: $11 (504). 

VISN: 15; 
Station[A]: Columbia MO; 
Dollars spent (number of items provided): 
2005[B]: $6 (61); 
2006[B]: $6 (68); 
2007[B]: $7 (80); 
2008: $8 (79); 
2009: $9 (88); 
Total[C]: $37 (375). 

VISN: 15; 
Station[A]: Kansas City; 
Dollars spent (number of items provided): 
2005[B]: $8 (71); 
2006[B]: $9 (78); 
2007[B]: $10 (76); 
2008: $16 (830); 
2009: $19 (923); 
Total[C]: $61 (1,979). 

VISN: 15; 
Station[A]: Leavenworth; 
Dollars spent (number of items provided): 
2005[B]: $2 (30); 
2006[B]: $1 (24); 
2007[B]: $2 (26); 
2008: $2 (29); 
2009: $2 (31); 
Total[C]: $10 (141). 

VISN: 15; 
Station[A]: Marion IL; 
Dollars spent (number of items provided): 
2005[B]: $4 (58); 
2006[B]: $6 (52); 
2007[B]: $7 (58); 
2008: $6 (65); 
2009: $7 (73); 
Total[C]: $31 (306). 

VISN: 15; 
Station[A]: Poplar Bluff; 
Dollars spent (number of items provided): 
2005[B]: $1 (14); 
2006[B]: $1 (17); 
2007[B]: $1 (19); 
2008: $1 (23); 
2009: $2 (37); 
Total[C]: $6 (110). 

VISN: 15; 
Station[A]: Robert J. Dole VAM&ROC (Wichita); 
Dollars spent (number of items provided): 
2005[B]: $4 (47); 
2006[B]: $3 (41); 
2007[B]: $4 (45); 
2008: $5 (51); 
2009: $6 (56); 
Total[C]: $23 (239). 

VISN: 15; 
Station[A]: St Louis-Jeff Bks.; 
Dollars spent (number of items provided): 
2005[B]: $5 (150); 
2006[B]: $6 (127); 
2007[B]: $7 (123); 
2008: $8 (126); 
2009: $10 (133); 
Total[C]: $37 (659). 

VISN: 15; 
Station[A]: St Louis-John Cochran; 
Dollars spent (number of items provided): 
2005[B]: $6 (27); 
2006[B]: $6 (25); 
2007[B]: $6 (26); 
2008: $10 (519); 
2009: $12 (574); 
Total[C]: $40 (1,171). 

VISN: 15; 
Station[A]: Topeka - Colmery-O'Neil; 
Dollars spent (number of items provided): 
2005[B]: $2 (46); 
2006[B]: $2 (32); 
2007[B]: $2 (34); 
2008: $3 (38); 
2009: $3 (38); 
Total[C]: $11 (189). 

VISN: 16; 
Station[A]: Alexandria; 
Dollars spent (number of items provided): 
2005[B]: $2 (35); 
2006[B]: $2 (39); 
2007[B]: $2 (45); 
2008: $3 (224); 
2009: $4 (246); 
Total[C]: $14 (588). 

VISN: 16; 
Station[A]: Baton Rouge; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (2); 
2006[B]: Less than $1 (4); 
2007[B]: Less than $1 (8); 
2008: $1 (10); 
2009: Less than $1 (6); 
Total[C]: $2 (29). 

VISN: 16; 
Station[A]: Central AR Veterans HCS LR; 
Dollars spent (number of items provided): 
2005[B]: $15 (116); 
2006[B]: $17 (127); 
2007[B]: $17 (121); 
2008: $20 (616); 
2009: $22 (656); 
Total[C]: $91 (1,635). 

VISN: 16; 
Station[A]: Fayetteville AR; 
Dollars spent (number of items provided): 
2005[B]: $3 (70); 
2006[B]: $4 (81); 
2007[B]: $4 (87); 
2008: $7 (395); 
2009: $10 (501); 
Total[C]: $28 (1,134). 

VISN: 16; 
Station[A]: G. V. (Sonny) Montgomery VAMC; 
Dollars spent (number of items provided): 
2005[B]: $6 (55); 
2006[B]: $6 (49); 
2007[B]: $7 (59); 
2008: $10 (303); 
2009: $11 (307); 
Total[C]: $41 (772). 

VISN: 16; 
Station[A]: Gulf Coast HCS; 
Dollars spent (number of items provided): 
2005[B]: $6 (78); 
2006[B]: $6 (70); 
2007[B]: $6 (85); 
2008: $10 (649); 
2009: $11 (699); 
Total[C]: $39 (1,581). 

VISN: 16; 
Station[A]: Houston; 
Dollars spent (number of items provided): 
2005[B]: $17 (138); 
2006[B]: $20 (138); 
2007[B]: $23 (157); 
2008: $27 (394); 
2009: $33 (518); 
Total[C]: $119 (1,345). 

VISN: 16; 
Station[A]: Muskogee; 
Dollars spent (number of items provided): 
2005[B]: $2 (55); 
2006[B]: $2 (58); 
2007[B]: $3 (79); 
2008: $5 (322); 
2009: $5 (353); 
Total[C]: $17 (868). 

VISN: 16; 
Station[A]: New Orleans; 
Dollars spent (number of items provided): 
2005[B]: $6 (45); 
2006[B]: $2 (36); 
2007[B]: $3 (42); 
2008: $5 (155); 
2009: $5 (206); 
Total[C]: $22 (484). 

VISN: 16; 
Station[A]: Oklahoma City; 
Dollars spent (number of items provided): 
2005[B]: $12 (97); 
2006[B]: $12 (89); 
2007[B]: $15 (111); 
2008: $18 (483); 
2009: $18 (518); 
Total[C]: $76 (1,298). 

VISN: 16; 
Station[A]: Overton Brooks VAMC; 
Dollars spent (number of items provided): 
2005[B]: $6 (43); 
2006[B]: $7 (49); 
2007[B]: $6 (45); 
2008: $7 (230); 
2009: $8 (258); 
Total[C]: $33 (625). 

VISN: 16; 
Station[A]: Tulsa; 
Dollars spent (number of items provided): 
2005[B]: $2 (39); 
2006[B]: $1 (35); 
2007[B]: $1 (9); 
2008: $2 (8); 
2009: $2 (8); 
Total[C]: $8 (98). 

VISN: 17; 
Station[A]: Austin Satellite; 
Dollars spent (number of items provided): 
2005[B]: $Less than $1 (3); 
2006[B]: $1 (7); 
2007[B]: $1 (8); 
2008: $1 (12); 
2009: $1 (13); 
Total[C]: $4 (43). 

VISN: 17; 
Station[A]: Bonham VAMC; 
Dollars spent (number of items provided): 
2005[B]: $1 (27); 
2006[B]: $7 (31); 
2007[B]: $Less than $1 (8); 
2008: $0 (0); 
2009: $0 (0); 
Total[C]: $8 (66). 

VISN: 17; 
Station[A]: Dallas VAMC; 
Dollars spent (number of items provided): 
2005[B]: $21 (447); 
2006[B]: $20 (471); 
2007[B]: $25 (491); 
2008: $29 (839); 
2009: $33 (684); 
Total[C]: $128 (2,932). 

VISN: 17; 
Station[A]: Kerrville VAMC; 
Dollars spent (number of items provided): 
2005[B]: $Less than $1 (10); 
2006[B]: $Less than $1 (9); 
2007[B]: $Less than $1 (10); 
2008: $1 (12); 
2009: Less than $1 (7); 
Total[C]: $2 (48). 

VISN: 17; 
Station[A]: San Antonio VAMC; 
Dollars spent (number of items provided): 
2005[B]: $19 (146); 
2006[B]: $22 (149); 
2007[B]: $25 (172); 
2008: $36 (659); 
2009: $39 (758); 
Total[C]: $140 (1,884). 

VISN: 17; 
Station[A]: Temple VAMC; 
Dollars spent (number of items provided): 
2005[B]: $7 (72); 
2006[B]: $6 (76); 
2007[B]: $7 (81); 
2008: $11 (483); 
2009: $15 (567); 
Total[C]: $46 (1,278). 

VISN: 17; 
Station[A]: Waco VAMC; 
Dollars spent (number of items provided): 
2005[B]: $2 (20); 
2006[B]: $2 (22); 
2007[B]: $2 (25); 
2008: $3 (31); 
2009: $2 (20); 
Total[C]: $11 (117). 

VISN: 18; 
Station[A]: Amarillo HCS; 
Dollars spent (number of items provided): 
2005[B]: $3 (79); 
2006[B]: $4 (80); 
2007[B]: $4 (87); 
2008: $5 (174); 
2009: $6 (192); 
Total[C]: $22 (613). 

VISN: 18; 
Station[A]: El Paso HCS; 
Dollars spent (number of items provided): 
2005[B]: $2 (185); 
2006[B]: $3 (249); 
2007[B]: $3 (250); 
2008: $4 (422); 
2009: $5 (475); 
Total[C]: $17 (1,582). 

VISN: 18; 
Station[A]: New Mexico HCS; 
Dollars spent (number of items provided): 
2005[B]: $9 (514); 
2006[B]: $11 (549); 
2007[B]: $12 (674); 
2008: $15 (896); 
2009: $18 (1,027); 
Total[C]: $65 (3,660). 

VISN: 18; 
Station[A]: Northern Arizona HCS; 
Dollars spent (number of items provided): 
2005[B]: $2 (166); 
2006[B]: $2 (146); 
2007[B]: $2 (98); 
2008: $4 (157); 
2009: $4 (186); 
Total[C]: $15 (753). 

VISN: 18; 
Station[A]: Phoenix; 
Dollars spent (number of items provided): 
2005[B]: $7 (447); 
2006[B]: $9 (455); 
2007[B]: $10 (561); 
2008: $12 (746); 
2009: $15 (777); 
Total[C]: $54 (2,985). 

VISN: 18; 
Station[A]: S. Arizona HCS; 
Dollars spent (number of items provided): 
2005[B]: $13 (227); 
2006[B]: $13 (255); 
2007[B]: $12 (210); 
2008: $15 (418); 
2009: $19 (467); 
Total[C]: $72 (1,577). 

VISN: 18; 
Station[A]: West Texas HCS; 
Dollars spent (number of items provided): 
2005[B]: $2 (35); 
2006[B]: $2 (32); 
2007[B]: $2 (32); 
2008: $3 (111); 
2009: $4 (143); 
Total[C]: $13 (352). 

VISN: 19; 
Station[A]: Cheyenne; 
Dollars spent (number of items provided): 
2005[B]: $3 (33); 
2006[B]: $3 (32); 
2007[B]: $4 (33); 
2008: $5 (385); 
2009: $6 (472); 
Total[C]: $21 (956). 

VISN: 19; 
Station[A]: Eastern Colorado HCS; 
Dollars spent (number of items provided): 
2005[B]: $11 (76); 
2006[B]: $13 (79); 
2007[B]: $14 (84); 
2008: $19 (1,191); 
2009: $21 (1,426); 
Total[C]: $77 (2,858). 

VISN: 19; 
Station[A]: Grand Junction; 
Dollars spent (number of items provided): 
2005[B]: $2 (16); 
2006[B]: $2 (16); 
2007[B]: $2 (20); 
2008: $3 (251); 
2009: $4 (367); 
Total[C]: $13 (670). 

VISN: 19; 
Station[A]: Montana HCS; 
Dollars spent (number of items provided): 
2005[B]: $6 (55); 
2006[B]: $7 (56); 
2007[B]: $6 (62); 
2008: $8 (307); 
2009: $11 (384); 
Total[C]: $38 (864). 

VISN: 19; 
Station[A]: Pueblo; 
Dollars spent (number of items provided): 
2005[B]: $Less than $1 (9); 
2006[B]: $1 (12); 
2007[B]: $1 (15); 
2008: $1 (14); 
2009: $1 (16); 
Total[C]: $3 (66). 

VISN: 19; 
Station[A]: Salt Lake City HCS - George E. Wahlen VAMC; 
Dollars spent (number of items provided): 
2005[B]: $16 (80); 
2006[B]: $17 (101); 
2007[B]: $18 (111); 
2008: $21 (516); 
2009: $22 (658); 
Total[C]: $95 (1,466). 

VISN: 19; 
Station[A]: Sheridan; 
Dollars spent (number of items provided): 
2005[B]: $2 (16); 
2006[B]: $2 (17); 
2007[B]: $2 (21); 
2008: $2 (75); 
2009: $2 (93); 
Total[C]: $10 (223). 

VISN: 20; 
Station[A]: Alaska HCS; 
Dollars spent (number of items provided): 
2005[B]: $1 (13); 
2006[B]: $1 (14); 
2007[B]: $2 (17); 
2008: $2 (99); 
2009: $3 (113); 
Total[C]: $10 (256). 

VISN: 20; 
Station[A]: American Lake; 
Dollars spent (number of items provided): 
2005[B]: $4 (54); 
2006[B]: $5 (60); 
2007[B]: $6 (70); 
2008: $5 (502); 
2009: $5 (440); 
Total[C]: $26 (1,126). 

VISN: 20; 
Station[A]: Boise; 
Dollars spent (number of items provided): 
2005[B]: $4 (29); 
2006[B]: $4 (28); 
2007[B]: $4 (29); 
2008: $6 (147); 
2009: $7 (185); 
Total[C]: $25 (419). 

VISN: 20; 
Station[A]: Portland; 
Dollars spent (number of items provided): 
2005[B]: $12 (82); 
2006[B]: $13 (71); 
2007[B]: $14 (89); 
2008: $17 (392); 
2009: $20 (442); 
Total[C]: $75 (1,075). 

VISN: 20; 
Station[A]: Roseburg HCS; 
Dollars spent (number of items provided): 
2005[B]: $3 (29); 
2006[B]: $3 (28); 
2007[B]: $3 (30); 
2008: $4 (198); 
2009: $5 (255); 
Total[C]: $18 (540). 

VISN: 20; 
Station[A]: Seattle; 
Dollars spent (number of items provided): 
2005[B]: $10 (46); 
2006[B]: $10 (44); 
2007[B]: $11 (51); 
2008: $15 (378); 
2009: $16 (412); 
Total[C]: $63 (931). 

VISN: 20; 
Station[A]: Southern Oregon Rehabilitation Ctr & Clinics; 
Dollars spent (number of items provided): 
2005[B]: $1 (9); 
2006[B]: $1 (11); 
2007[B]: $1 (12); 
2008: $2 (87); 
2009: $2 (100); 
Total[C]: $8 (220). 

VISN: 20; 
Station[A]: Spokane; 
Dollars spent (number of items provided): 
2005[B]: $2 (23); 
2006[B]: $2 (24); 
2007[B]: $3 (27); 
2008: $4 (235); 
2009: $4 (247); 
Total[C]: $16 (557). 

VISN: 20; 
Station[A]: Walla Walla; 
Dollars spent (number of items provided): 
2005[B]: $1 (57); 
2006[B]: $1 (58); 
2007[B]: $2 (42); 
2008: $3 (151); 
2009: $4 (178); 
Total[C]: $10 (486). 

VISN: 21; 
Station[A]: Fresno; 
Dollars spent (number of items provided): 
2005[B]: $3 (25); 
2006[B]: $3 (24); 
2007[B]: $3 (28); 
2008: $4 (164); 
2009: $5 (186); 
Total[C]: $18 (428). 

VISN: 21; 
Station[A]: Livermore; 
Dollars spent (number of items provided): 
2005[B]: $1 (8); 
2006[B]: $1 (8); 
2007[B]: $1 (7); 
2008: $2 (9); 
2009: $2 (11); 
Total[C]: $6 (43).
VISN: 
21; 
Station[A]: Manila; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (5); 
2006[B]: Less than $1 (4); 
2007[B]: Less than $1 (6); 
2008: Less than $1 (4); 
2009: Less than $1 (4); 
Total[C]: $1 (22). 

VISN: 21; 
Station[A]: N. California HCS-Martinez; 
Dollars spent (number of items provided): 
2005[B]: $5 (39); 
2006[B]: $6 (48); 
2007[B]: $7 (56); 
2008: $11 (496); 
2009: $14 (566); 
Total[C]: $44 (1,204). 

VISN: 21; 
Station[A]: N. California HCS-Sacramento; 
Dollars spent (number of items provided): 
2005[B]: $Less than $1 (4); 
2006[B]: $0 (0); 
2007[B]: $0 (0); 
2008: $0 (0); 
2009: $0 (0); 
Total[C]: $Less than $1 (4). 

VISN: 21; 
Station[A]: Pacific Islands HCS (Honolulu); 
Dollars spent (number of items provided): 
2005[B]: $3 (30); 
2006[B]: $3 (40); 
2007[B]: $3 (55); 
2008: $4 (123); 
2009: $5 (132); 
Total[C]: $19 (379). 

VISN: 21; 
Station[A]: Palo Alto; 
Dollars spent (number of items provided): 
2005[B]: $9 (42); 
2006[B]: $10 (80); 
2007[B]: $13 (65); 
2008: $15 (329); 
2009: $17 (389); 
Total[C]: $65 (906). 

VISN: 21; 
Station[A]: San Francisco; 
Dollars spent (number of items provided): 
2005[B]: $11 (39); 
2006[B]: $11 (41); 
2007[B]: $12 (44); 
2008: $15 (270); 
2009: $18 (328); 
Total[C]: $66 (723). 

VISN: 21; 
Station[A]: San Jose; 
Dollars spent (number of items provided): 
2005[B]: Less than $1 (4); 
2006[B]: $1 (4); 
2007[B]: Less than $1 (3); 
2008: Less than $1 (4); 
2009: $1 (5); 
Total[C]: $3 (21). 

VISN: 21; 
Station[A]: Sierra Nevada HCS; 
Dollars spent (number of items provided): 
2005[B]: $5 (35); 
2006[B]: $5 (34); 
2007[B]: $5 (36); 
2008: $7 (121); 
2009: $8 (129); 
Total[C]: $30 (355). 

VISN: 22; 
Station[A]: Greater Los Angeles HCS; 
Dollars spent (number of items provided): 
2005[B]: $11 (53); 
2006[B]: $11 (53); 
2007[B]: $11 (371); 
2008: $14 (639); 
2009: $13 (822); 
Total[C]: $60 (1,938). 

VISN: 22; 
Station[A]: Loma Linda VAMC; 
Dollars spent (number of items provided): 
2005[B]: $10 (66); 
2006[B]: $10 (62); 
2007[B]: $12 (74); 
2008: $16 (553); 
2009: $19 (686); 
Total[C]: $65 (1,441). 

VISN: 22; 
Station[A]: Long Beach HCS; 
Dollars spent (number of items provided): 
2005[B]: $6 (32); 
2006[B]: $7 (33); 
2007[B]: $7 (40); 
2008: $9 (304); 
2009: $10 (366); 
Total[C]: $39 (776). 

VISN: 22; 
Station[A]: San Diego HCS; 
Dollars spent (number of items provided): 
2005[B]: $13 (59); 
2006[B]: $13 (66); 
2007[B]: $14 (89); 
2008: $17 (494); 
2009: $18 (502); 
Total[C]: $75 (1,210). 

VISN: 22; 
Station[A]: Sepulveda; 
Dollars spent (number of items provided): 
2005[B]: $2 (18); 
2006[B]: $2 (20); 
2007[B]: $2 (25); 
2008: $2 (30); 
2009: $3 (39); 
Total[C]: $10 (132). 

VISN: 22; 
Station[A]: Southern Nevada HCS; 
Dollars spent (number of items provided): 
2005[B]: $5 (46); 
2006[B]: $5 (45); 
2007[B]: $5 (49); 
2008: $6 (310); 
2009: $8 (356); 
Total[C]: $28 (807). 

VISN: 23; 
Station[A]: Des Moines; 
Dollars spent (number of items provided): 
2005[B]: $3 (59); 
2006[B]: $3 (59); 
2007[B]: $4 (63); 
2008: $5 (81); 
2009: $5 (83); 
Total[C]: $19 (346). 

VISN: 23; 
Station[A]: Fargo; 
Dollars spent (number of items provided): 
2005[B]: $2 (71); 
2006[B]: $2 (100); 
2007[B]: $2 (116); 
2008: $3 (317); 
2009: $4 (354); 
Total[C]: $14 (958). 

VISN: 23; 
Station[A]: Fort Meade; 
Dollars spent (number of items provided): 
2005[B]: $2 (36); 
2006[B]: $2 (36); 
2007[B]: $2 (40); 
2008: $2 (136); 
2009: $3 (149); 
Total[C]: $10 (397). 

VISN: 23; 
Station[A]: Grand Island; 
Dollars spent (number of items provided): 
2005[B]: $1 (30); 
2006[B]: $1 (32); 
2007[B]: $1 (32); 
2008: $2 (30); 
2009: $2 (35); 
Total[C]: $7 (159). 

VISN: 23; 
Station[A]: Hot Springs; 
Dollars spent (number of items provided): 
2005[B]: $1 (22); 
2006[B]: $1 (25); 
2007[B]: $1 (28); 
2008: $1 (29); 
2009: $1 (29); 
Total[C]: $7 (133). 

VISN: 23; 
Station[A]: Iowa City; 
Dollars spent (number of items provided): 
2005[B]: $5 (50); 
2006[B]: $6 (51); 
2007[B]: $6 (58); 
2008: $7 (57); 
2009: $8 (64); 
Total[C]: $32 (280). 

VISN: 23; 
Station[A]: Knoxville; 
Dollars spent (number of items provided): 
2005[B]: $1 (5); 
2006[B]: $1 (4); 
2007[B]: Less than $1 (2); 
2008: Less than $1 (1); 
2009: Less than $1 (1); 
Total[C]: $2 (13). 

VISN: 23; 
Station[A]: Lincoln; 
Dollars spent (number of items provided): 
2005[B]: $1 (48); 
2006[B]: $1 (19); 
2007[B]: $1 (19); 
2008: $1 (22); 
2009: $1 (22); 
Total[C]: $5 (131). 

VISN: 23; 
Station[A]: Minneapolis; 
Dollars spent (number of items provided): 
2005[B]: $16 (445); 
2006[B]: $17 (378); 
2007[B]: $18 (347); 
2008: $21 (912); 
2009: $25 (972); 
Total[C]: $97 (3,054). 

VISN: 23; 
Station[A]: Omaha; 
Dollars spent (number of items provided): 
2005[B]: $6 (58); 
2006[B]: $7 (50); 
2007[B]: $7 (56); 
2008: $14 (997); 
2009: $17 (1,168); 
Total[C]: $51 (2,328). 

VISN: 23; 
Station[A]: Sioux Falls; 
Dollars spent (number of items provided): 
2005[B]: $2 (69); 
2006[B]: $3 (74); 
2007[B]: $3 (73); 
2008: $5 (223); 
2009: $6 (250); 
Total[C]: $20 (690). 

VISN: 23; 
Station[A]: St. Cloud; 
Dollars spent (number of items provided): 
2005[B]: $1 (133); 
2006[B]: $1 (149); 
2007[B]: $2 (137); 
2008: $4 (440); 
2009: $5 (522); 
Total[C]: $13 (1,380). 

Station[A]: Total[C]; 
Dollars spent (number of items provided): 
2005[B]: $907 (16,371); 
2006[B]: $980 (16,531); 
2007[B]: $1,082 (17,490); 
2008: $1,404 (52,596); 
2009: $1,623 (59,103); 
Total[C]: $5,996 (162,090). 

Source: GAO analysis of VA data. 

Note: Data for this table were obtained from VA's National Prosthetic 
Patient Database (NPPD)--an internal system used by VA to administer 
the department's provision of prosthetic items. Data on total costs 
for prosthetic items from NPPD are different from the obligation data 
we used to report VA's annual spending for prosthetic items in the 
body of the report. The data on spending represent obligations for the 
procurement of prosthetic items during the course of a fiscal year, 
while NPPD data represent obligations that VA has incurred for 
prosthetic items actually provided to veterans during a fiscal year. 
In some instances, there may be a delay between when VA procures a 
prosthetic item and when the item is provided to the veteran. For 
example, VA may incur an obligation for the procurement of prosthetic 
items for PSAS inventory in one fiscal year, and distribute the 
inventoried prosthetic items to veterans in the next fiscal year. 

[A] A station is a medical facility or group of medical facilities 
under a single director. A station may include more than one VA 
medical center. 

[B] Prior to fiscal year 2008, VA's NPPD did not contain data related 
to hearing aids, hearing aid batteries, and several other prosthetic 
devices. As a result, these items are not included for fiscal years 
2005 through 2007. According to a VA official, VA spent $145 million, 
$140 million, and $140 million for these items during fiscal years 
2005, 2006, and 2007, respectively. 

[C] Amounts for fiscal years and stations may not sum to totals due to 
rounding. 

[End of table] 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Kim Yamane, Assistant 
Director; Susannah Bloch; Matthew Byer; Aaron Holling; Lisa Motley; 
Daniel Ries; and Said Sariolghalam made key contributions to this 
report. 

[End of section] 

Footnotes: 

[1] The more than 59 million prosthetic items provided to veterans 
include about 35 million batteries and more than 15 million components 
related to the repair of prosthetic items, such as parts to repair 
wheelchairs and artificial limbs. 

[2] According to VA, the vast majority (96 percent) of veterans 
receiving prosthetic items from the department did not serve in the 
current conflicts in Afghanistan and Iraq. In fiscal year 2009, the 
prosthetic items provided to the veterans from these current conflicts 
accounted for about $38.4 million (2 percent) of the $1.6 billion VA 
spent for prosthetic items. 

[3] In general, the funding VA allocates to PSAS for prosthetic items 
covers the procurement of prosthetic items and components necessary to 
fabricate prosthetic items. According to VA officials, these funds do 
not cover administrative and clinical costs, such as the salaries and 
benefits of PSAS personnel or labor costs associated with VA 
fabrication of prosthetic items. 

[4] Veterans for Veterans, Independent Budget for the Department of 
Veterans Affairs, Fiscal Year 2010, [hyperlink, 
http://www.independentbudget.org/] (accessed Jul 10, 2010), p. 92. 

[5] For purposes of this report, we used data on VA's obligations for 
prosthetic items to report its annual spending for prosthetic items. 
Obligations refer to a definite commitment creating a legal liability 
to make payments immediately or in the future. An obligation is 
incurred, for example, when an agency awards a contract to a private 
entity. 

[6] VHA is the organization within VA that administers the 
department's health care system. 

[7] We interviewed VAMC and PSAS officials from the VAMC in Portland, 
Oregon, by telephone. 

[8] The National Prosthetic Patient Database is an internal system 
used by VA to administer the department's provision of prosthetic 
items. 

[9] For example, VA polytrauma rehabilitation centers provide 
intensive rehabilitative care to veterans and servicemembers who have 
experienced severe injuries to more than one organ system. 

[10] VISNs oversee the operations of the various medical facilities 
within their assigned geographic areas. In general, each of the 21 
VISNs has budget and management responsibilities, such as allocating 
funding for health care services to facilities, clinics, and programs 
within their region and ensuring access to appropriate health care 
services. 

[11] According to VA, in fiscal year 2009, this system treated 5.7 
million patients with appropriations of about $41.2 billion. In that 
same fiscal year, VA operated more than 1,300 sites of care, including 
153 VAMCs and 783 ambulatory care and community-based outpatient 
clinics. 

[12] In general, veterans must enroll in VA's health care system in 
order to receive VA's medical benefits package, which covers most of 
VA's medical services. VA's enrollment system includes eight 
categories for enrollment, with priority generally based on service-
connected disability, low income, and other recognized statuses such 
as former prisoners of war. 38 U.S.C. § 1705; 38 C.F.R. § 17.36 (2010). 

[13] Certain veterans, such as veterans needing prosthetic items for a 
service-connected condition, are eligible for prosthetic items even if 
they are not enrolled in VA's health care system. 38 C.F.R. § 17.37 
(2010). 

[14] An orthosis is a device, such as a brace, that supports and 
strengthens an impaired limb. 

[15] Telehealth is the use of telecommunications technology including 
video, digital pictures, and messaging devices to exchange health care 
information in order to provide health care services to rural and 
remote areas. 

[16] The Veterans Health Care Reform and Transparency Act of 2009 
provided for VA to receive advance appropriations for its Medical 
Services, Medical Support and Compliance, and Medical Facilities 
appropriation accounts beginning with fiscal year 2011. Pub. L. No. 
111-81, § 3, 123 Stat. 2137, 3137-38 (codified at 38 U.S.C. § 117). 
The Military Construction and Veterans Affairs and Related Agencies 
Appropriations Act, 2010 provided appropriations for fiscal year 2010 
and advance appropriations for fiscal year 2011 for those accounts. 
Pub. L. No. 111-117, div. E, tit. II, 123 Stat. 3034, 3298-3300 
(2009). Advance appropriations represent budget authority that becomes 
available one or more fiscal years after the fiscal year covered by 
the appropriations act in which they are made. 

[17] VA begins to formulate its budget approximately 18 months before 
the start of the fiscal year to which the request relates and about 10 
months before the transmission of the President's budget request to 
Congress, which usually occurs in early February. Due to the timing of 
budget preparation, VA's spending estimates for one fiscal year are 
not based on VA's actual spending from the prior year since these data 
are not yet available when VA prepares its estimates. 

[18] See GAO, VA Health Care: Challenges in Budget Formulation and 
Issues Surrounding the Proposals for Advance Appropriations, 
[hyperlink, http://www.gao.gov/products/GAO-09-664T] (Washington, 
D.C.: Apr. 29, 2009). 

[19] This model estimates future VA health care costs by using 
projections of veterans' demand for VA's health care services as well 
as cost estimates associated with particular health care services. 

[20] For fiscal year 2009, VA's Medical Services appropriation totaled 
about $31.0 billion plus reimbursements. 

[21] This reversed a 1998 decision that had designated funding for 
prosthetic items as general purpose funding. According to officials, 
delays in the procurement of prosthetic items were common between 
fiscal years 1998 and 2000. Prior to 1998, funding for prosthetic 
items had been designated as specific purpose funding. 

[22] PSAS also processes benefits for several programs funded under 
the Veterans Benefits Administration--the organization within VA 
responsible for administering the department's programs that provide 
financial and other forms of assistance to veterans, their dependents, 
and their survivors. Specifically, PSAS processes clothing allowance 
benefits and furnishes automobile adaptive equipment to eligible 
veterans. These programs are not considered part of the PSAS budget. 

[23] At the 12 VAMCs we visited, PSAS maintained an inventory of 
certain over-the-counter items, such as raised toilet seats, 
compression socks, knee braces, manual wheelchairs, and walkers. 
According to PSAS officials, most VAMCs maintain similar inventory. 

[24] According to PSAS officials, prosthetics chiefs are officials who 
are responsible for managing the day-to-day operations of PSAS, such 
as overseeing the procurement of prosthetic items, at individual VAMCs. 

[25] Biological implants include all nonsynthetic material, such as 
human bone and tissue, surgically inserted into the body. 

[26] As part of the medical evaluation of a veteran's prosthetic 
needs, VA clinicians assess whether new technology may be appropriate. 

[27] In the previous 4 fiscal years, the annual increase in the number 
of eyeglasses VA provided ranged from 2 percent to 7 percent. 

[28] See 38 C.F.R. § 17.36 (2010); 74 Fed. Reg. 22,832 (May 15, 2009). 

[29] VA received a $1.5 billion supplemental Medical Services 
appropriation in fiscal year 2005. Department of the Interior, 
Environment, and Related Agencies Appropriation Act, 2006, Pub. L. No. 
109-54, 119 Stat. 499, 563-64 (2005). For fiscal years 2008 and 2009, 
VA received appropriations for its Medical Services account that 
exceeded the amounts requested by about $1.9 billion and about $1.2 
billion, respectively. 

[30] The amount by which VA reduced the specific purpose funding was 
reallocated to general purpose funds available for other health care 
services, according to VA officials. 

[31] A consult is VA's term for a prescription for a prosthetic item 
entered into VA's medical record system by a physician. 

[32] PSAS considers the processing of the prescription complete when a 
prosthetic item has been issued to the veteran from PSAS's inventory 
or a purchase order is created for the item. 

[33] PSAS summarizes this information in a quarterly report it calls 
the Prosthetic and Sensory Aids Budget and Management Scorecard. 

[34] For example, the item may require another visit to the VAMC by 
the veteran (for example, for fitting or pick up) before the 
prescription for the prosthetic item can be completed. 

[35] PSAS also changed how the goals for delayed orders and pending 
consults are measured. Through fiscal year 2009, these performance 
measures used 5 business days and 45 business days respectively. 
Beginning in fiscal year 2010, VA assesses these measures using 8 
calendar days and 60 calendar days. 

[36] According to the supervisor of this optical laboratory, wait 
times have been reduced to 3 or 4 weeks using overtime and commercial 
vendors. In addition, he said the renovations and improvements should 
be complete by the end of fiscal year 2011 and at that time, the 
optical laboratory should be able to better meet the increased demand. 

[37] See VA's Inquiry Routing & Information System, [hyperlink, 
https://iris.va.gov/scripts/iris.cfg/php.exe/enduser/home.php] 
(accessed Aug. 9, 2010). 

[38] PSAS at one VAMC recently began using comment cards, and 
according to the prosthetics chief, she had not yet received the 
initial results at the time of our visit. 

[39] VISNs with centralized management for PSAS generally use VISN- 
level general purpose funds for PSAS staff, whereas in noncentralized 
VISNs, each VAMC usually funds PSAS staff using VAMC-level general 
purpose funds. 

[40] See [hyperlink, http://www.prosthetics.va.gov/cpr.asp] (accessed 
on Aug. 8, 2010) for PSAS's clinical practice recommendations. 

[41] Prior to fiscal year 2008, NPPD did not contain data related to 
hearing aids, batteries, and several other prosthetic items. As a 
result, these items are not included in the tables in this appendix 
for fiscal years 2005 through 2007. According to a VA official, VA 
spent about $145 million, $140 million, and $140 million for these 
items during fiscal years 2005, 2006, and 2007, respectively. 

[42] Data on total obligations for prosthetic items from NPPD are 
different from the obligation data we used to report VA's annual 
spending for prosthetic items in the body of our report. The data on 
spending represent obligations for the procurement of prosthetic items 
during the course of a fiscal year, while NPPD data represent 
obligations that VA has incurred for prosthetic items actually 
provided to veterans during a fiscal year. In some instances, there 
may be a delay between when VA procures a prosthetic item and when the 
item is provided to the veteran. For example, VA may incur an 
obligation for the procurement of prosthetic items for PSAS inventory 
in one fiscal year, and distribute the inventoried prosthetic items to 
veterans in the next fiscal year. 

[43] VA has organized its health care system under 21 VISNs, which 
oversee the operations of the various medical facilities within their 
assigned geographic areas. Each of the 21 VISNs has budget and 
management responsibilities, such as allocating resources, including 
funding, for health care services to facilities, clinics, and programs 
within their network and ensuring access to appropriate health care 
services. 

[44] A station is a medical facility or group of medical facilities 
under a single director. A station may include more than one VA 
medical center. 

[End of section] 

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