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Report to the Chairman, Subcommittee on VA, HUD, and Independent 
Agencies, Committee on Appropriations, U.S. Senate: 

United States Government Accountability Office: 

GAO: 

March 2005: 

VA Health Care: 

Important Steps Taken to Enhance Veterans' Care by Aligning Inpatient 
Services with Projected Needs: 

GAO-05-160: 

GAO Highlights: 

Highlights of GAO-05-160, a report to the Chairman, Subcommittee on VA, 
HUD, and Independent Agencies, Committee on Appropriations, U.S. 
Senate: 

Why GAO Did This Study: 

he Department of Veterans Affairs (VA) operates one of the nation's 
largest health care systems. In 1999, GAO reported on VA's aged, 
obsolete capital assets, noting that better management of these assets 
could significantly reduce VA's operating costs. GAO further noted that 
VA could reinvest the savings to enhance veterans' health care 
services. 

In response, VA initiated its Capital Asset Realignment for Enhanced 
Services (CARES) process. Through CARES, VA identified what health care 
services it should provide and in which locations through 2022. The 
CARES process included assessing alternative ways to align inpatient 
services by closing or adding services at existing VA medical 
facilities or establishing new facilities.In May 2004, VA published its 
CARES decisions, but did not provide a national comprehensive summary 
of all its decisions about the alignment of inpatient services. 

GAO was asked to provide additional information about the inpatient 
service assessments and decisions made by VA. To provide a national, 
comprehensive summary, GAO summarized the locations where VA (1) 
identified a need to evaluate alternative ways to align inpatient 
health care service to improve quality, efficiency, or access and (2) 
made decisions to realign inpatient services or leave inpatient 
services as aligned, or deferred decisions pending further study. 

What GAO Found: 

Through CARES, VA identified 136 locations for evaluation of 
alternative ways to align inpatient services. These locations included 
VA medical facilities, health care markets (geographic areas 
established by VA for the coordination of care), and health care 
networks (regional organizations of VA health care facilities 
established to facilitate management). Of the 136 locations, 99 were VA 
medical facilities with potential duplication of services at another 
nearby VA medical facility or low acute inpatient workload. In 
addition, VA identified limitations in geographic access to inpatient 
services in 31 markets and 6 networks, for example, when large numbers 
of veterans face lengthy driving times to VA facilities that provide 
acute or tertiary care. 

VA made alignment decisions for inpatient services at 120 locations and 
deferred decisions for 16 locations pending further study. VA decided 
to realign inpatient services at 30 locations and maintain inpatient 
services as currently aligned at 90 locations. VA decided to close all 
inpatient services at 5 facilities and add them at 5 nearby VA 
facilities where they were not already available; close one or more, 
but not all, inpatient services at 12 other facilities; add inpatient 
services to medical facilities in 2 markets and 5 networks; and 
establish 1 new medical facility in a location where VA did not own an 
inpatient facility when it made its CARES decisions. 

VA's decisions on inpatient alignment and planned studies are tangible 
steps forward in improving management of its capital assets and 
enhancing health care. Ultimately, however, accomplishing these goals 
will depend on VA's success in completing its studies and implementing 
its CARES decisions on inpatient and other health care services to 
better ensure that resources now spent on unneeded capital assets are 
redirected to health care. 

VA concurred with GAO's findings. 

VA's Decisions on Alignment of Inpatient Health Care Services at 136 
Locations: 

[See PDF for image]

[End of figure]

www.gao.gov/cgi-bin/getrpt?GAO-05-160. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Cynthia A. Bascetta at 
(202) 512-7101. 

[End of section]

Contents: 

Letter1: 

Results in Brief: 

Background: 

VA Identified 136 Locations for Evaluation of Alternative Alignments of 
Inpatient Services: 

VA Made Decisions on Alignment of Inpatient Services for 120 Locations 
and Deferred Decisions for 16 Pending Completion of Studies: 

Concluding Observations: 

Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: VA Medical Facilities Identified for Potential Duplication 
of Tertiary Care Services: 

Appendix III: VA Medical Facilities Identified for Potential 
Duplication of Acute Inpatient Medicine Services: 

Appendix IV: VA Medical Facilities Identified for Potential Duplication 
of Other Inpatient Services or Support Services: 

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication 
or Low Acute Inpatient Workload, and Alignment Decisions: 

Appendix VI: VA's 77 Markets, Limitations in Geographic Access to 
Inpatient Services, and Alignment Decisions: 

Appendix VII: VA's 21 Networks, Limitations in Geographic Access to 
Specialized Inpatient Services, and Alignment Decisions: 

Appendix VIII: Comments from the Department of Veterans Affairs: 

Appendix IX: GAO Contact and Acknowledgments: 

GAO Contact: 

Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: VA Medical Facilities with Potential Duplication of Tertiary 
Care Services: 

Table 2: VA Medical Facilities with Potential Duplication of Acute 
Inpatient Medicine Services: 

Table 3: VA Medical Facilities with Potential Duplication of Other 
Inpatient Services or Services That Support Inpatient Service Delivery: 

Table 4: VA Medical Facilities with Potential Low Acute Inpatient 
Workload: 

Table 5: VA's Driving Time Standards for Access to Acute Inpatient Care 
and Tertiary Care: 

Table 6: VA Networks Where VA Identified Limitations in Access to 
Specialized Inpatient Treatment for Spinal Cord Injury and Disorder or 
Blind Rehabilitation: 

Table 7: VA's Decisions on the Alignment of Inpatient Services at 120 
Locations: 

Table 8: VA's Decisions to Close All Inpatient Services at a VA Medical 
Facility and Add Those Services to a Nearby VA Medical Facility When 
Not Already Available There: 

Table 9: VA's Decisions to Close One or More, but Not All, Inpatient 
Services at a VA Medical Facility: 

Table 10: VA Health Care Markets Where VA Decided to Add Acute or Long- 
Term Inpatient Services: 

Table 11: VA Health Care Networks Where VA Decided to Add Specialized 
Inpatient Treatment for Spinal Cord Injury and Disorder or Blind 
Rehabilitation: 

Table 12: VA Medical Facilities Where Inpatient Alignment Decisions 
Were Deferred Pending Further Study: 

Figure: 

Figure 1: VA Medical Facilities Identified for Evaluation of Inpatient 
Service Alignment Based on Potential Service Duplication, Low Acute 
Inpatient Workload, or Both: 

Abbreviations: 

CARES: Capital Asset Realignment for Enhanced Services: 

VA: Department of Veterans Affairs: 

United States Government Accountability Office: 

Washington, DC 20548: 

March 2, 2005: 

The Honorable Christopher S. Bond: 
Chairman: 
Subcommittee on VA, HUD, and Independent Agencies:
Committee on Appropriations: 
United States Senate: 

Dear Mr. Chairman: 

The Department of Veterans Affairs (VA) operates one of our nation's 
largest health care systems. VA provided health care to nearly 5 
million veterans in fiscal year 2003 at a cost of about $26 
billion.[Footnote 1] Most of VA's inpatient care is provided in 172 
medical facilities that it owns and maintains.[Footnote 2] Many of VA's 
facilities were built more than 50 years ago and are no longer well 
suited to providing accessible, high-quality, cost-effective health 
care in the 21st century. For example, some facilities are not located 
within reasonable driving times of veterans' residences and others are 
structured to emphasize inpatient health care, as was the practice when 
these facilities were constructed, rather than outpatient health care, 
as is today's practice. Moreover, some facilities do not conform to 
modern standards because, for example, they are not configured to 
accommodate modern technology, lack fire sprinklers, or are not 
seismically sound. 

In 1999, we reported that VA's aged, obsolete inventory of capital 
assets could be the biggest obstacle confronting VA's efforts to meet 
veterans' health care needs efficiently and effectively.[Footnote 3] We 
noted that better management of VA's buildings and land, which include 
more than 4,700 buildings and other structures and thousands of acres 
of land, could significantly reduce funds needed to operate current 
assets and that these funds could instead be used to enhance health 
care services for veterans.[Footnote 4] The challenge of capital asset 
management is not unique to VA, but is part of a larger federal 
government challenge to effectively manage buildings and land, referred 
to as real property. We have designated management of federal real 
property as high risk because long-standing problems in this area have 
multibillion-dollar cost implications and can seriously jeopardize the 
ability of federal agencies to accomplish their missions.[Footnote 5]

In response to our recommendations in 1999 for improving VA's capital 
asset planning and budgeting, VA initiated a process known as Capital 
Asset Realignment for Enhanced Services (CARES). CARES was designed to 
assess VA's buildings and land ownership in light of expected demand 
for VA inpatient and outpatient health care services through fiscal 
year 2022 (the CARES planning horizon). Through CARES, VA sought to 
determine what health care services veterans would need in what 
locations. These locations included VA's 172 medical facilities, 77 
health care markets,[Footnote 6] and 21 health care networks.[Footnote 
7] This process involved an examination of VA's needs for capital 
assets at the locations where it has medical facilities and at possible 
new locations. To do so, VA first identified locations where specific 
factors suggested a need to evaluate options for realigning its 
inpatient services. VA focused on three specific factors to identify 
these locations. Two factors involved VA's existing medical facilities. 
One of these factors was potential duplication of inpatient services 
among two or more medical facilities that are close enough 
geographically to consider whether the services are needed at both 
facilities. A second factor was low acute inpatient workload at 
individual medical facilities. The third factor was geographic access 
limitations, which VA identified differently for different inpatient 
services. For most inpatient services, including acute and tertiary 
inpatient care, CARES addressed geographic access at the market level, 
primarily by identifying markets where a large number of veterans face 
lengthy driving times to access a VA medical facility. For two 
specialized inpatient services, inpatient treatment for spinal cord 
injury and disorder and inpatient blind rehabilitation, VA addressed 
geographic access at the network level based on projected demand and 
referral patterns. The CARES process was not designed to address 
another aspect of veterans' access to health care--the time that 
veterans wait to obtain appointments at VA medical facilities--because 
waiting times are related to multiple operational issues, such as 
staffing and resources, in addition to capital infrastructure. 

On May 7, 2004, VA announced its CARES decisions on the alignment of 
inpatient services at locations it identified for potential service 
duplication, low workload, or limitations in geographic access (along 
with its other CARES decisions, including those regarding outpatient 
services) and published a report on these decisions.[Footnote 8] VA 
announced decisions for 74 of its 77 markets.[Footnote 9]

In the context of the alignment of its inpatient services, VA's report 
focused primarily on decisions involving medical facilities, markets, 
and networks where VA's inpatient health care services are to be 
realigned or studied further. The report did not, however, provide a 
national, comprehensive summary of the medical facilities, markets, and 
networks that VA identified as needing evaluation for potential 
alternative alignments of inpatient services and did not include a 
discussion of all of the locations where it decided to leave inpatient 
services as currently aligned. On the basis of your request that we 
examine VA's inpatient service assessments and decisions, we developed 
(1) a national summary of the medical facilities, markets, and networks 
where VA identified potential service duplication, low workload, or 
geographic access limitations as factors that could indicate a need to 
evaluate alternative ways to align inpatient health care services and 
(2) a national summary of the medical facilities, markets, and networks 
where VA made decisions--to either realign inpatient services or leave 
inpatient services as aligned--or deferred decisions pending further 
study. 

To summarize the number of medical facilities, markets, and networks 
where VA identified potential service duplication, low workload, or 
geographic access limitations as factors that could indicate a need to 
evaluate alternative ways to align inpatient health care services, we 
reviewed major CARES documents for information about locations where VA 
identified these factors. Because no one source includes all the 
information about these factors, we reviewed CARES planning documents, 
VA's Draft National CARES Plan, the report by an independent Commission 
appointed by VA that was charged with making CARES recommendations to 
the Secretary, and the Secretary's report of VA's CARES decisions. When 
identification of a medical facility as one with potential service 
duplication or low workload depended on the availability of acute 
inpatient medicine, we confirmed that the facility provided that 
service during the first half of fiscal year 2004, the time period 
immediately before VA made its CARES decisions, by examining data 
provided by VA. 

To summarize VA's decisions about the alignment of its inpatient 
services, we reviewed major CARES documents to determine if VA made a 
decision to realign inpatient services or leave inpatient services as 
aligned or if VA deferred making a decision pending further study. We 
defined realignment of an inpatient service as (1) eliminating the 
service in its entirety at a facility where VA provided it, (2) adding 
an inpatient service to an existing VA facility where VA did not 
provide the service, or (3) establishing a new VA medical facility 
where VA did not own capital assets. The inpatient services in our 
review included both acute and long-term inpatient services. 
Specifically, these inpatient services included tertiary care;[Footnote 
10] the acute inpatient services of medicine, surgery, and psychiatry; 
and other inpatient services. Other inpatient services included 
subacute and intermediate medicine; the long-term inpatient services of 
nursing home care, long-term psychiatry, domiciliary care,[Footnote 11] 
and residential rehabilitation; and specialized inpatient services of 
blind rehabilitation and treatment for spinal cord injury and disorder. 
To identify VA's decisions on the alignment of inpatient services at 
the locations it identified for evaluation, we reviewed CARES documents 
and information provided by VA about the inpatient services provided at 
current facilities that would be affected if VA's decisions were 
implemented. We classified a decision as pending further study when VA 
determined that additional information or analysis was necessary to 
determine whether to add or close one or more inpatient services at 
that location. We compared data from CARES with other information from 
VA about the inpatient services available at its medical facilities and 
when we identified discrepancies, resolved them through discussions 
with VA officials. We found the data to be adequate for our purposes, 
and VA officials agreed that our methodology was reasonable. We did not 
review VA's other CARES decisions such as those for reconfiguring space 
to meet projected demand for services, modernization needed to provide 
services appropriately, disposal of assets that may no longer be 
needed, or the alignment of outpatient services. We conducted our work 
from October 2003 through March 2005 in accordance with generally 
accepted government auditing standards. See appendix I for a more 
detailed discussion of our methodology. 

Results in Brief: 

Through its CARES process, VA identified 136 locations where potential 
service duplication, low workload, or limitations in geographic access 
to care indicated a need to evaluate alternative alignments of 
inpatient health care services. These locations included 99 of VA's 
existing medical facilities--72 medical facilities that potentially 
duplicated services with nearby VA medical facilities, 19 facilities 
that were expected to have low inpatient workload (primarily for acute 
medicine, surgery, and psychiatry) during the CARES planning horizon, 
and 8 other facilities that both potentially duplicated services and 
were expected to have low workloads. The 136 locations that VA 
identified also included 31 markets where VA identified limitations in 
geographic access to care. VA identified limitations to acute or 
tertiary care in markets where a large number of veterans face lengthy 
driving times to a VA facility. It identified limitations in access to 
long-term care in some locations based on information such as referral 
patterns, for example, when veterans were referred to a distant VA 
medical facility to obtain domiciliary care because that service was 
not available at a VA medical facility nearer to their residences. VA 
determined that it could not evaluate access to long-term care services 
on a systematic, nationwide basis because VA had not developed an 
adequate model for projecting demand for these services at the time 
CARES decisions were made. VA also identified 6 networks where 
projected demand and referral patterns indicated limitations in access 
to specialized inpatient treatment for spinal cord injury and disorder 
or blind rehabilitation. 

VA made decisions on the alignment of inpatient health care services 
for 120 of the 136 locations it identified as needing evaluation of 
alignment alternatives; decisions for 16 locations, primarily medical 
facilities with service duplication or low workload, were deferred 
pending further study of potential realignment options. Regarding the 
120 locations, VA decided to realign inpatient services for 30 
locations and maintain its inpatient services as aligned for 90 
locations. Of the 30 locations, 22 involved realignment of inpatient 
services among medical facilities that had potential service 
duplication or low workload. For 10 facilities, VA decided to realign 
inpatient services, primarily by closing all inpatient services at 5 
facilities and adding services at 5 others. For 12 other medical 
facilities, VA decided to close some, but not all, inpatient services 
and refer patients to VA medical facilities that already provided these 
services or enter into agreements for care from non-VA providers. Of 
the remaining 8 locations, 3 were markets where VA identified 
limitations in access to acute inpatient care or a long-term inpatient 
service and 5 were networks where VA identified limitations in access 
to specialized inpatient treatment for spinal cord injury and disorder 
or blind rehabilitation. To improve access for veterans in these 
locations, VA decided to add such services at 7 existing medical 
facilities that had not previously offered these services and to 
establish a new VA medical facility where VA did not own capital 
assets. In addition to these decisions to realign inpatient services, 
for 27 of the 90 locations where VA decided to maintain its inpatient 
services as aligned, VA decided to enter into agreements with non-VA 
providers to improve access to acute or tertiary inpatient services. 

VA concurred with our findings. 

Background: 

VA dramatically transformed its health care delivery system over the 
last decade. A central goal of this transformation has been to reduce 
the need for, and the length of, inpatient hospital stays by providing 
primary care in outpatient settings and taking advantage of 
technological advances that reduce the need for hospitalization. VA 
developed a continuum of care grounded in outpatient settings, made 
available a broader array of services including preventive care, and 
opened hundreds of community-based outpatient clinics. As a result, VA 
reduced the length of inpatient stays while providing health care to a 
growing number of veterans. From fiscal year 1996 through fiscal year 
2003, VA's national acute inpatient daily census fell by over 40 
percent while the number of veterans who received health care from VA 
increased by about 2 million (69 percent). As these transformations 
occurred, VA was left with increasingly obsolete infrastructure, 
including many hospitals built or acquired more than 50 years ago in 
locations that are sometimes far from where veterans live. 

To address its obsolete infrastructure, VA initiated its CARES process-
-the first comprehensive, long-range assessment of its health care 
system's capital asset requirements since 1981. VA completed a pilot 
phase of the CARES process in February 2002, when it announced 
decisions for Network 12, which consists of parts of five states: 
Illinois, Indiana, Michigan, Minnesota, and Wisconsin. VA then assessed 
its other 20 networks. Through CARES, VA compared the sizes, locations, 
and available health care services of VA's existing medical facilities 
to projected demand for health care services through fiscal year 2022. 

In conducting this comparison, VA identified three factors that 
indicated a need to evaluate alternative ways to align inpatient 
services--potential duplication of services, low acute inpatient 
workload, and limitations in geographic access to VA health care 
services. 

* Duplication of inpatient services at VA inpatient medical facilities 
that are close to one another geographically was of concern because 
duplication could needlessly increase operating costs. Excess operating 
costs can also occur when two facilities that are close to one another 
geographically provide different inpatient services that could be 
provided in a single location. In such situations, administrative 
services and services that support inpatient care, such as building 
maintenance, could be unnecessarily duplicated. Consolidation or 
closure of duplicated services in such circumstances could improve cost 
efficiency by eliminating the need to maintain all or part of a medical 
facility and reducing resources spent on inpatient services or services 
that support inpatient care. VA also noted that realigning inpatient 
services could enhance the quality or accessibility of care by placing 
related clinical services in the same location. 

* Low acute inpatient workload was of concern for reasons associated 
with both the quality and cost-effectiveness of care. As VA noted, the 
medical literature and consumer groups have suggested that higher 
workload volume is generally related to better health care outcomes, 
particularly for surgical procedures. Although VA noted that its small 
facilities with lower inpatient workloads have often been leaders in 
the provision of quality health care, it also noted that as medical 
care becomes more technologically advanced, it could become more 
difficult and less cost-effective for such facilities to maintain and 
use the tools and skills necessary to provide high-quality care. In 
light of these concerns, VA identified medical facilities with low 
acute inpatient workload to evaluate the option of closing acute 
inpatient services. 

* Limitations in veterans' geographic access to VA health care services 
were also of concern. VA considered options for improving access to 
acute and tertiary inpatient care in health care markets where large 
numbers of veterans face lengthy driving times to obtain those health 
care services from VA. VA also considered options for improving access 
to a long-term inpatient care service in markets where information such 
as referral patterns indicated limitations to access, for example, when 
veterans were referred to a distant VA medical facility to obtain 
domiciliary care because that service was not available at a VA medical 
facility nearer to their residences. For two specialized inpatient 
services--treatment for spinal cord injury and disorder and blind 
rehabilitation--VA used information about projected demand and referral 
patterns to identify networks where options for improving access to 
these specialized inpatient services were to be evaluated. 

Three major milestones have occurred in the CARES process since August 
2003. First, on August 4, 2003, VA's Under Secretary for Health 
released the Draft National CARES Plan for public review.[Footnote 12] 
In developing this plan, VA officials, including those in the 20 
networks covered by the plan, identified locations where changes to the 
existing health care delivery system could address potential 
duplication of services, low workload, or geographic access 
limitations. Network directors, working with input from local 
stakeholders, studied those locations and proposed plans for the 
alignment of health care services. After reviewing these plans, the 
Under Secretary for Health made recommendations concerning the 
alignment of health care services; these recommendations were presented 
in the Draft National CARES Plan, along with other recommendations, 
such as those concerning resizing of capacity and modernization of 
buildings that are critical to VA's missions and disposal of unneeded 
(excess) buildings and land. 

Second, on February 12, 2004, an independent 16-member commission 
appointed by the Secretary of Veterans Affairs issued recommendations 
to the Secretary based on its review of the Draft National CARES Plan. 
In developing its recommendations, the CARES Commission conducted 38 
public hearings, 81 site visits, and 10 public meetings; analyzed 
212,000 written comments[Footnote 13] from veterans and other 
stakeholders; reviewed VA documents supporting the Draft National CARES 
Plan; and engaged experts to evaluate key issues, such as the model 
used to project demand for VA health care services. The CARES 
Commission documented its recommendations and findings in a 609-page 
report to the Secretary of Veterans Affairs.[Footnote 14]

Third, on May 7, 2004, VA's Secretary announced and published a report 
on VA's CARES decisions concerning the alignment of VA's health care 
services, based on his review of the CARES Commission's findings and 
recommendations. In general, he stated his acceptance of the 
Commission's report, noting that it provided a strategically sound path 
forward for VA's health care system. He noted that when the 
Commission's report provided options, he selected the option that would 
minimize the effect of service realignments on continuity of care for 
those veterans who received those services at the time VA made its 
CARES decisions. Moreover, he stated that implementing these decisions 
will require substantial capital investment--about $1 billion annually 
over at least the next 5 years--and that not implementing the CARES 
decisions would also require funding to maintain or renovate obsolete 
facilities and perpetuate VA's need to manage redundant, outmoded, or 
poorly located facilities. In anticipation of the Secretary's decision, 
Congress passed legislation in December 2003 that requires the 
Secretary to notify Congress of decisions involving reorganization, 
consolidation, and closure of health care services and provide a period 
of at least 60 days during which Congress can consider these CARES 
decisions before they are implemented.[Footnote 15]

VA Identified 136 Locations for Evaluation of Alternative Alignments of 
Inpatient Services: 

Through CARES, VA identified 136 locations where potential service 
duplication, low acute inpatient workload, or geographic access 
limitations indicated that alignment of inpatient health care services 
should be evaluated. These locations included 99 of VA's existing 
medical facilities where VA identified potential service duplication or 
low inpatient workload, 31 markets where VA identified a need to 
evaluate options for improving access to tertiary or acute inpatient 
care or a long-term inpatient service, and 6 networks where VA 
identified a need to evaluate options for improving access to 
specialized inpatient treatment for spinal cord injury and disorder or 
blind rehabilitation. 

VA Identified 99 Medical Facilities with Potential Service Duplication 
or Low Acute Inpatient Workload: 

VA identified 99 of its medical facilities for evaluation of 
alternative ways to align inpatient services because of potential 
service duplication or low acute inpatient workload. Most of these 
facilities were identified for potential service duplication (see fig. 
1). 

Figure 1: VA Medical Facilities Identified for Evaluation of Inpatient 
Service Alignment Based on Potential Service Duplication, Low Acute 
Inpatient Workload, or Both: 

[See PDF for image]

[End of figure]

VA identified potential service duplication when two or more inpatient 
medical facilities were close enough geographically to consider whether 
both should continue providing all the inpatient services that they 
provided. VA identified 80 medical facilities that potentially 
duplicated services. For our review, we classified these facilities as 
potentially duplicating tertiary care services; acute inpatient 
medicine services; or other services, including other types of 
inpatient care (such as long-term psychiatry) or services that support 
inpatient care (such as administration or maintenance). Some of the 
facilities that VA identified potentially duplicated more than one of 
these types of inpatient service. 

For tertiary care services, we determined if the medical facilities 
that VA identified as potentially duplicating services were also 
identified by VA as tertiary care facilities within 120 miles of 
another VA tertiary care facility. VA selected 120 miles as a distance 
that would permit tertiary care facilities to develop cooperative 
arrangements with one another to provide tertiary care. Of the 80 
medical facilities VA identified as potentially duplicating services, 
28 met these criteria for potential duplication of tertiary care 
services (see table 1). Appendix II lists these 28 facilities and the 
VA medical facilities close enough geographically for VA to consider 
whether tertiary care services were needed at both. 

Table 1: VA Medical Facilities with Potential Duplication of Tertiary 
Care Services: 

1. Ann Arbor, Mich. 

2. Augusta, Ga.-Downtown. 

3. Baltimore, Md. 

4. Bay Pines, Fla. 

5. Bronx, N.Y. 

6. Brooklyn, N.Y. 

7. Charleston, S.C. 

8. Cincinnati, Ohio. 

9. Columbia, S.C. 

10. Dayton, Ohio. 

11. Detroit, Mich. 

12. East Orange, N.J. 

13. Indianapolis, Ind. 

14. Lexington, Ky.-Cooper. 

15. Loma Linda, Calif. 

16. Long Beach, Calif. 

17. Louisville, Ky. 

18. Manhattan, N.Y. 

19. Northport, N.Y. 

20. Palo Alto, Calif. 

21. Philadelphia, Pa. 

22. Richmond, Va. 

23. San Diego, Calif. 

24. San Francisco, Calif. 

25. Tampa, Fla. 

26. Washington, D.C. 

27. West Haven, Conn. 

28. West Los Angeles, Calif. 

Source: GAO analysis of VA data. 

Note: These VA medical facilities provide tertiary care services, are 
within 120 miles of another VA medical facility that provides tertiary 
care services, and were identified by VA as potentially duplicating 
inpatient services. 

[End of table]

For acute inpatient medicine services, we determined if the medical 
facilities that VA identified as potentially duplicating services were 
also identified by VA as providing acute inpatient medicine services 
within 60 miles of another VA medical facility that provides acute 
inpatient medicine services.[Footnote 16] VA selected 60 miles as a 
distance that would permit acute inpatient facilities to develop 
cooperative arrangements with one another to provide acute inpatient 
medical, surgical, or psychiatric care. Of the 80 medical facilities VA 
identified as potentially duplicating services, 27 potentially 
duplicated acute medicine services during the first half of fiscal year 
2004, the time period immediately before CARES decisions were made (see 
table 2). Appendix III lists these 27 facilities and the VA medical 
facilities close enough geographically for VA to consider whether acute 
inpatient medicine services were needed at both. About half of these 
medical facilities were also identified as potentially duplicating 
tertiary care services. 

Table 2: VA Medical Facilities with Potential Duplication of Acute 
Inpatient Medicine Services: 

1. Ann Arbor, Mich. 

2. Baltimore, Md. 

3. Bronx, N.Y. 

4. Brooklyn, N.Y. 

5. Castle Point, N.Y. 

6. Cincinnati, Ohio. 

7. Dayton, Ohio. 

8. Detroit, Mich. 

9. East Orange, N.J. 

10. Gainesville, Fla. 

11. Kansas City, Mo. 

12. Lake City, Fla. 

13. Leavenworth, Kans. 

14. Little Rock, Ark. 

15. Long Beach, Calif. 

16. Manhattan, N.Y. 

17. Murfreesboro, Tenn. 

18. Nashville, Tenn. 

19. North Little Rock, Ark. 

20. Northport, N.Y. 

21. Perry Point, Md. 

22. Philadelphia, Pa. 

23. Providence, R.I. 

24. Washington, D.C. 

25. West Los Angeles, Calif. 

26. West Roxbury, Mass. 

27. Wilmington, Del. 

Source: GAO analysis of VA data. 

Note: These VA medical facilities provide acute inpatient medicine 
services, are within 60 miles of another VA medical facility that 
provides acute inpatient medicine services, and were identified by VA 
as potentially duplicating inpatient services. 

[End of table]

For other services, we determined if the medical facilities that VA 
identified as potentially duplicating services were ones where VA 
determined that it should consider whether other inpatient services and 
administrative or maintenance services that support inpatient care were 
needed at both. VA did not specify a distance criterion for identifying 
these facilities as close enough geographically for it to consider 
whether inpatient services were needed at both. The potentially 
duplicated services generally included psychiatric and long-term 
inpatient care, administrative services, and building maintenance and 
groundskeeping. Of the 80 medical facilities VA identified as 
potentially duplicating services, 50 potentially duplicated these other 
inpatient, administrative, or maintenance services (see table 3). For 
example, in some cities VA has two inpatient medical facilities that 
provide different inpatient services, such as a tertiary care facility 
and a nursing home or one facility that provides medical and surgical 
care and another that provides psychiatric care. If it were possible to 
move all services to a single facility, potential benefits include cost 
savings by avoiding duplication of inpatient support services such as 
building maintenance at the two facilities. In addition, VA noted that 
placing related clinical services (such as acute medicine and acute 
psychiatry) in the same location has the potential to enhance the 
quality or accessibility of care. Appendix IV lists these 50 facilities 
and indicates which other VA medical facilities were close enough 
geographically for VA to consider whether inpatient services were 
needed at both. 

Table 3: VA Medical Facilities with Potential Duplication of Other 
Inpatient Services or Services That Support Inpatient Service Delivery: 

1. American Lake, Wash. 

2. Augusta, Ga.--Downtown. 

3. Augusta, Ga.--Uptown. 

4. Batavia, N.Y. 

5. Bedford, Mass. 

6. Biloxi, Miss. 

7. Brockton, Mass. 

8. Brooklyn, N.Y. 

9. Buffalo, N.Y. 

10. Canandaigua, N.Y. 

11. Castle Point, N.Y. 

12. Cleveland, Ohio--Brecksville. 

13. Cleveland, Ohio--Wade Park. 

14. Des Moines, Iowa. 

15. East Orange, N.J. 

16. Fort Meade, S. Dak. 

17. Fort Wayne, Ind. 

1. 18. Gainesville, Fla. 

19. Gulfport, Miss. 

20. Hot Springs, S. Dak. 

21. Jamaica Plain, Mass. 

22. Kansas City, Mo. 

23. Kerrville, Tex. 

24. Knoxville, Iowa. 

25. Lake City, Fla. 

26. Leavenworth, Kans. 

27. Lexington, Ky.--Cooper. 

28. Lexington, Ky.--Leestown. 

29. Livermore, Calif. 

30. Lyons, N.J. 

31. Marion, Ind. 

32. Miami, Fla. 

33. Montgomery, Ala. 

34. Montrose, N.Y. 

35. Palo Alto, Calif. 

36. Pittsburgh, Pa.--Heinz Center. 

37. Pittsburgh, Pa.--Highland Drive. 

38. Pittsburgh, Pa.--University Drive. 

39. Portland, Oreg. 

40. Roseburg, Oreg. 

41. San Antonio, Tex. 

42. St. Albans, N.Y. 

43. Temple, Tex. 

44. Topeka, Kans. 

45. Tuskegee, Ala. 

46. Vancouver, Wash. 

47. Waco, Tex. 

48. West Palm Beach, Fla. 

49. West Roxbury, Mass. 

50. White City, Oreg. 

Source: GAO analysis of VA data. 

Note: These VA medical facilities were identified by VA as close enough 
geographically to another VA medical facility for VA to consider 
whether inpatient services other than tertiary care or acute inpatient 
medicine were needed at both. The potentially duplicated inpatient 
services generally included psychiatric and long-term inpatient care; 
services that support inpatient care generally included administration 
and maintenance. 

[End of table]

VA also evaluated the alignment of its inpatient services at its 
medical facilities with potential low acute inpatient workload. VA 
identified low acute inpatient workload based on projected need for 
acute inpatient beds, viability of specific services, and changes in 
workload at one location that could result from decisions made about 
other locations. VA identified low total projected acute inpatient 
workload when a medical facility that provides acute inpatient medicine 
services was projected to need fewer than 40 acute medicine, surgery, 
and psychiatry beds (combined) in fiscal years 2012 and 2022.[Footnote 
17] In addition, VA identified low acute inpatient workload at some 
other facilities even if the total projected number of acute medicine, 
surgery, and psychiatry beds was expected to exceed 40 in fiscal years 
2012 or 2022. In some of these cases, VA questioned the viability of a 
specific acute inpatient service, for example, when projections 
indicated that few beds would be needed for inpatient surgery. In other 
cases, VA noted that low acute inpatient workload could result from 
decisions it made about inpatient health care at other locations, for 
example, when a decision to enter into an agreement for non-VA care 
could shift acute inpatient workload away from an existing VA medical 
facility. Using these criteria, 27 medical facilities were identified 
as having potentially low acute inpatient workload (see table 4). 

Table 4: VA Medical Facilities with Potential Low Acute Inpatient 
Workload: 

1. Altoona, Pa. 

2. Bath, N.Y. 

3. Beckley, W.Va. 

4. Big Spring, Tex. 

5. Boise, Idaho. 

6. Butler, Pa. 

7. Castle Point, N.Y. 

8. Cheyenne, Wyo. 

9. Chillicothe, Ohio. 

10. Des Moines, Iowa. 

11. Dublin, Ga. 

12. Erie, Pa. 

13. Fort Harrison, Mont. 

14. Fort Wayne, Ind. 

15. Grand Junction, Colo. 

16. Hot Springs, S. Dak. 

17. Huntington, W.Va. 

18. Kerrville, Tex. 

19. Marion, Ind. 

20. Murfreesboro, Tenn. 

21. Muskogee, Okla. 

22. Poplar Bluff, Mo. 

23. Prescott, Ariz. 

24. Roseburg, Oreg. 

25. Saginaw, Mich. 

26. Spokane, Wash. 

27. Walla Walla, Wash. 

Source: GAO analysis of VA data. 

Note: Low total projected acute inpatient workload was identified when 
a VA medical facility that provided acute inpatient medicine services 
during the first half of fiscal year 2004, the time period immediately 
before VA made its CARES decisions, was projected to need fewer than 40 
acute medicine, surgery, and psychiatry beds (combined) in fiscal years 
2012 and 2022. Other low acute inpatient workload was identified (1) 
when VA questioned the viability of a specific acute inpatient service, 
for example, because projections indicated that few beds would be 
needed for inpatient surgery, or (2) when low acute inpatient workload 
at an existing VA medical facility could result from decisions VA made 
about inpatient health care at other locations, even if the total 
projected number of acute medicine, surgery, and psychiatry beds was 
expected to exceed 40 in fiscal years 2012 or 2022. 

[End of table]

Appendix V provides a complete list of VA's inpatient medical 
facilities and notes those at which VA identified potential service 
duplication, low acute inpatient workload, or both as factors that 
indicated that alternative ways to align inpatient services should be 
assessed. 

VA Identified 31 Markets Where Veterans Face Limitations in Geographic 
Access to Acute, Tertiary, or Long-Term Inpatient Services: 

VA identified 31 markets where veterans face limitations in geographic 
access to acute, tertiary, or long-term inpatient services. VA's 
identification of markets where veterans face limitations in access to 
acute or tertiary care was based primarily on its analysis of the 
number of veterans who face lengthy driving times to obtain VA health 
care, while VA's identification of markets where veterans face 
limitations in access to a long-term inpatient care service was based 
on information such as referral patterns. Limitations in geographic 
access could occur in several types of situations. In some markets 
where a VA facility provided acute or tertiary inpatient care, too many 
veterans had lengthy driving times to access these services. In some 
markets, there were no VA facilities providing acute or tertiary 
inpatient care, and veterans had lengthy driving times to access that 
care at VA facilities in other markets. In other markets, VA had a 
facility, but the facility did not provide the needed service. 

To identify markets where a large number of veterans face lengthy 
driving times from home to access acute or tertiary inpatient care at 
VA facilities, VA used specific standards for driving times for urban, 
rural, and highly rural areas (see table 5).[Footnote 18] VA considered 
a market to have a large number of veterans facing lengthy driving 
times if driving time to the nearest VA facility exceeded VA's standard 
for more than 35 percent of those enrolled for VA health care residing 
in the market and exceeded VA's standard for at least 12,000 enrolled 
veterans. 

Table 5: VA's Driving Time Standards for Access to Acute Inpatient Care 
and Tertiary Care: 

Type of inpatient health care: Acute care (medicine, surgery, and 
psychiatry); 
Type of county: Urban[B]; 
Driving time for veterans to access health care at a VA medical 
facility[A]: 60 minutes. 

Type of inpatient health care: Acute care (medicine, surgery, and 
psychiatry); 
Type of county: Rural[C]; 
Driving time for veterans to access health care at a VA medical 
facility[A]: 90 minutes. 

Type of inpatient health care: Acute care (medicine, surgery, and 
psychiatry); 
Type of county: Highly rural[D]; 
Driving time for veterans to access health care at a VA medical 
facility[A]: 120 minutes. 

Type of inpatient health care: Tertiary care; 
Type of county: Urban[B]; 
Driving time for veterans to access health care at a VA medical 
facility[A]: 240 minutes. 

Type of inpatient health care: Tertiary care; 
Type of county: Rural[C]; 
Driving time for veterans to access health care at a VA medical 
facility[A]: 240 minutes. 

Type of inpatient health care: Tertiary care; 
Type of county: Highly rural[D]; 
Driving time for veterans to access health care at a VA medical 
facility[A]: Community standard. 

Source: VA, Draft National CARES Plan. 

[A] VA used a zip-code-based analysis to calculate driving times from 
veterans' homes to the nearest VA-owned or VA-affiliated medical 
facility that provides acute or tertiary care. VA-affiliated medical 
facilities include hospitals that are owned by non-VA providers where 
VA has arranged for VA staff to provide care to veterans. 

[B] Counties designated as metropolitan by the U.S. Census Bureau and 
counties with a population density of more than 166 people per square 
mile. 

[C] Counties that are not designated as metropolitan by the U.S. Census 
Bureau and have a population density of 26 to 166 people per square 
mile. 

[D] Counties with a population density of less than 26 people per 
square mile and counties designated as highly rural by the VA health 
care network in which the county is located. 

[End of table]

Using these standards, VA identified 28 markets in which a large number 
of veterans face lengthy driving times from home to access acute or 
tertiary inpatient care at VA facilities (see app. VI). VA identified a 
need to evaluate options for improving access to acute inpatient care 
(medicine, surgery, and psychiatry) in 20 markets, tertiary care in 4 
markets, and both acute and tertiary care in 4 markets. 

In addition, VA identified 3 markets where options to improve access to 
a long-term care service needed evaluation by using information such as 
referral patterns. VA determined that it could not evaluate access to 
long-term care services on a systematic, nationwide basis because VA 
had not developed an adequate model for projecting demand for these 
services at the time CARES decisions were made. 

* VA identified a need to assess options to improve access to 
domiciliary care in the Washington, D.C., market of Network 5, a market 
that includes the District of Columbia and parts of Maryland and 
Virginia. The network proposed this evaluation because VA did not 
provide domiciliary care and the market has a large population of 
homeless veterans who were referred to a different market to obtain 
domiciliary care. 

* VA identified a need to assess options to improve access to 
residential rehabilitation for post-traumatic stress disorder and 
substance abuse in the Michigan market of Network 11, a market that 
includes lower Michigan and part of northwest Ohio. The CARES 
Commission proposed this evaluation because many veterans with these 
disorders who live in the Detroit, Michigan, area now travel about 125 
miles to obtain inpatient residential rehabilitation through VA's 
medical facility in Battle Creek, Michigan.[Footnote 19]

* VA identified a need to assess options to improve access to nursing 
home services and to ensure future access to acute inpatient care in 
the Nevada market of Network 22, a market that includes southern 
Nevada. VA did not own an inpatient medical facility in this market at 
the time it made its CARES decisions; instead, it collaborated with the 
Department of Defense to provide acute inpatient services in Las Vegas, 
Nevada, by having VA staff provide services to veterans in the 
Department of Defense hospital at Nellis Air Force Base. The network 
proposed an evaluation of options for improving access to nursing home 
care because VA did not have a nursing home in this market and the 
market has a large proportion of veterans who are aged 65 or older. In 
addition, although VA did not identify a limitation to veterans' access 
to acute inpatient care in this market using its driving time 
standards, VA identified a need to assess options to ensure future 
access to acute inpatient care in this market. It did so in part 
because of questions about whether the rapid growth in demand for 
inpatient services in the Nevada market could be accommodated within 
the existing collaborative relationship with the Department of Defense. 

Appendix VI provides a list of all VA markets and indicates those in 
which VA identified limitations in geographic access to tertiary, 
acute, or long-term inpatient health care services. This appendix also 
summarizes descriptions of the geographic areas that each market 
covers. 

VA Identified Six Networks Where Options to Improve Veterans' Access to 
Specialized Inpatient Treatment for Spinal Cord Injury and Disorder or 
Blind Rehabilitation Needed Evaluation: 

To identify limitations in veterans' access to specialized inpatient 
treatment services for spinal cord injury and disorder or blind 
rehabilitation, VA used information about projected demand for these 
services and referral patterns within and across networks. VA has 
specialized inpatient treatment units for these two types of disability 
that serve veterans in areas that are larger than the markets VA 
defined for its other health care services. VA identified six networks 
where there was a need to evaluate options to improve veterans' access 
to these specialized services (see table 6). 

Table 6: VA Networks Where VA Identified Limitations in Access to 
Specialized Inpatient Treatment for Spinal Cord Injury and Disorder or 
Blind Rehabilitation: 

Network: 1. Network 2 (upstate New York and parts of north central 
Pennsylvania); 
Type of specialized inpatient service: Spinal cord injury and disorder. 

Network: 2. Network 8 (most of Florida, part of southern Georgia, 
Puerto Rico, the U.S. Virgin Islands of St. Thomas and St. Croix, and 
Arecibo); 
Type of specialized inpatient service: Spinal cord injury and disorder. 

Network: 3. Network 16 (Louisiana; most of Arkansas, Mississippi, and 
Oklahoma; eastern Texas; and parts of three other states: Alabama, 
Florida, and Missouri); 
Type of specialized inpatient service: Spinal cord injury and disorder; 
Blind rehabilitation. 

Network: 4. Network 19 (Utah; most of Colorado, Montana, and Wyoming; 
and parts of five other states: Idaho, Kansas, Nebraska, Nevada, and 
North Dakota); 
Type of specialized inpatient service: Spinal cord injury and disorder. 

Network: 5. Network 22 (southern California and southern Nevada); 
Type of specialized inpatient service: Blind rehabilitation. 

Network: 6. Network 23 (Iowa and South Dakota; 
most of Minnesota, Nebraska, and North Dakota; and parts of five other 
states: Illinois, Kansas, Missouri, Wisconsin, and Wyoming); 
Type of specialized inpatient service: Spinal cord injury and disorder. 

Source: GAO analysis of VA data. 

Note: VA health care facilities are organized into 21 regional 
networks, known as Veterans Integrated Service Networks, which are to 
coordinate the activities of and allocate resources to VA health care 
facilities. VA had 22 networks until January 2002, when it merged 
Networks 13 and 14 to form a new network, Network 23. 

[End of table]

Appendix VII provides a list of all VA networks and indicates those 
where VA identified limitations in access to specialized inpatient 
services of treatment for spinal cord injury and disorder or blind 
rehabilitation. This appendix also summarizes descriptions of the 
geographic areas that each network covers. 

VA Made Decisions on Alignment of Inpatient Services for 120 Locations 
and Deferred Decisions for 16 Pending Completion of Studies: 

VA made decisions concerning the alignment of inpatient health care 
services for 120 of the 136 locations that it identified for potential 
service duplication, low acute inpatient workload, or limitations to 
geographic access. For the remaining 16 locations, VA deferred 
decisions pending further study of options that include adding or 
closing inpatient services. For most of its 120 decisions, VA provided 
reasons that were related to the feasibility of alternative ways of 
aligning inpatient services or the effect of possible realignments of 
inpatient services on such considerations as the quality or 
accessibility of care. 

VA Made Decisions on Alignment of Inpatient Health Care Services for 
120 Locations: 

VA made decisions to realign inpatient services for 30 locations and to 
leave services as aligned at 90 locations (see table 7). 

Table 7: VA's Decisions on the Alignment of Inpatient Services at 120 
Locations: 

VA's decision: Realign VA inpatient services; 
Locations: Medical facilities with potential service duplication or low 
acute inpatient workloads: 22; 
Locations: Markets with limitations in geographic access to acute, 
tertiary, or long-term inpatient services: 3; 
Locations: Networks with limitations in geographic access to 
specialized inpatient treatment of spinal cord injury and disorder or 
blind rehabilitation: 5; 
Total: 30. 

VA's decision: Maintain VA inpatient services as aligned; 
Locations: Medical facilities with potential service duplication or low 
acute inpatient workloads: 63; 
Locations: Markets with limitations in geographic access to acute, 
tertiary, or long-term inpatient services: 27; 
Locations: Networks with limitations in geographic access to 
specialized inpatient treatment of spinal cord injury and disorder or 
blind rehabilitation: 0; 
Total: 90. 

VA's decision: Total; 
Locations: Medical facilities with potential service duplication or low 
acute inpatient workloads: 85; 
Locations: Markets with limitations in geographic access to acute, 
tertiary, or long-term inpatient services: 30; 
Locations: Networks with limitations in geographic access to 
specialized inpatient treatment of spinal cord injury and disorder or 
blind rehabilitation: 5; 
Total: 120. 

Source: GAO analysis of VA data. 

[End of table]

VA Made Decisions to Realign Inpatient Services for 30 Locations: 

Of the 22 medical facilities with potential service duplication or low 
acute inpatient workload, VA's decisions for 10 involved realignments 
including the closure of all inpatient services at 5 facilities. In all 
but one of these closures, VA decided to add the closed services at a 
nearby VA medical facility when the services were not already available 
there (see table 8). For this closure, VA will contract for care from 
non-VA providers or refer veterans to a VA medical facility 
approximately 130 miles away. 

Table 8: VA's Decisions to Close All Inpatient Services at a VA Medical 
Facility and Add Those Services to a Nearby VA Medical Facility When 
Not Already Available There: 

Close all inpatient services: VA medical facility: Cleveland, Ohio-- 
Brecksville; 
Close all inpatient services: Services to be closed: 
* Acute psychiatry; 
* Long-term psychiatry; 
* Nursing home care; 
* Domiciliary care; 
Add inpatient services: VA medical facility: Cleveland, Ohio--Wade 
Park, about 20 miles away; 
Add inpatient services: Services to be added[A]: 
* Long-term psychiatry; 
* Nursing home care; 
* Domiciliary care. 

Close all inpatient services: VA medical facility: Fort Wayne, Ind; 
Close all inpatient services: Services to be closed: 
* Acute medicine; 
Add inpatient services: VA medical facility: Not applicable (VA decided 
to contract for care with non-VA providers or refer veterans to its 
Indianapolis, Ind., medical facility, about 130 miles away); 
Add inpatient services: Services to be added[A]: 
* Not applicable. 

Close all inpatient services: VA medical facility: Gulfport, Miss; 
Close all inpatient services: Services to be closed: 
* Acute psychiatry; 
* Long-term psychiatry; 
* Nursing home care; 
Add inpatient services: VA medical facility: Biloxi, Miss., about 8 
miles away; 
Add inpatient services: Services to be added[A]: 
* Acute psychiatry; 
* Long-term psychiatry. 

Close all inpatient services: VA medical facility: Knoxville, Iowa; 
Close all inpatient services: Services to be closed: 
* Acute psychiatry; 
* Intermediate medicine; 
* Nursing home care; 
* Domiciliary care; 
Add inpatient services: VA medical facility: Des Moines, Iowa (about 45 
miles away); 
Add inpatient services: Services to be added[A]: 
* Acute psychiatry; 
* Nursing home care. 

Close all inpatient services: VA medical facility: Pittsburgh, Pa.-- 
Highland Drive; 
Close all inpatient services: Services to be closed: 
* Acute psychiatry; 
* Long-term psychiatry; 
* Domiciliary care; 
* Residential rehabilitation; 
Add inpatient services: VA medical facility: Pittsburgh, Pa.--
University Drive, about 5 miles away; 
Add inpatient services: Services to be added[A]: 
* Acute psychiatry; 
* Long-term psychiatry. 
VA medical facility: Pittsburgh, Pa.--Heinz Center, about 5 miles away; 
Add inpatient services: Services to be added[A]: 
* Domiciliary care; 
* Residential rehabilitation. 

Source: GAO analysis of VA data. 

[A] Inpatient services already provided at the facility are not listed 
as added services. In each case in which VA decided to close all 
inpatient services at a medical facility and to add services to a 
nearby facility, VA decided to add all the inpatient services that it 
decided to close that are not already available at the nearby VA 
medical facility. 

[End of table]

VA's decisions for 12 other medical facilities identified for potential 
service duplication or low acute inpatient workload were to close one 
or more inpatient services at a medical facility, but retain other 
inpatient services provided at that facility (see table 9). In general, 
VA will not add the service that will be closed at another VA facility, 
but instead will enter into agreements for that care from non-VA 
providers or refer veterans to a VA medical facility that already 
provides that service. In one case, VA will add services to a nearby 
medical facility that did not, at the time VA made its CARES decisions, 
provide two inpatient services that VA decided to close. Specifically, 
VA decided to add acute and long-term psychiatry services to its 
medical facility in Castle Point, New York, which is about 30 miles 
from its facility in Montrose, New York. 

Table 9: VA's Decisions to Close One or More, but Not All, Inpatient 
Services at a VA Medical Facility: 

Medical facility: 1. American Lake, Wash; 
Inpatient service or services to be closed: Acute medicine. 

Medical facility: 2. Butler, Pa; 
Inpatient service or services to be closed: Acute medicine. 

Medical facility: 3. Canandaigua, N.Y; 
Inpatient service or services to be closed: Acute psychiatry. 

Medical facility: 4. Castle Point, N.Y; 
Inpatient service or services to be closed: Treatment for spinal cord 
injury and disorder. 

Medical facility: 5. Dublin, Ga; 
Inpatient service or services to be closed: Surgery. 

Medical facility: 6. Kerrville, Tex; 
Inpatient service or services to be closed: Acute medicine. 

Medical facility: 7. Livermore, Calif; 
Inpatient service or services to be closed: Subacute medicine. 

Medical facility: 8. Montrose, N.Y; 
Inpatient service or services to be closed: Acute and long-term 
psychiatry and nursing home care. 

Medical facility: 9. Murfreesboro, Tenn; 
Inpatient service or services to be closed: Surgery. 

Medical facility: 10. Muskogee, Okla; 
Inpatient service or services to be closed: Surgery. 

Medical facility: 11. Roseburg, Oreg; 
Inpatient service or services to be closed: Surgery. 

Medical facility: 12. Saginaw, Mich; 
Inpatient service or services to be closed: Acute medicine. 

Source: GAO analysis of VA data. 

[End of table]

Appendix V provides a complete list of VA medical facilities and VA's 
decisions about the alignment of inpatient services at each.[Footnote 
20]

Our analysis of major CARES documents that describe VA's decisions to 
realign inpatient services at 22 of its medical facilities indicated 
that VA generally provided reasons for these decisions that involve 
factors such as the quality, accessibility, or costs of care. For 
example, at 5 of its medical facilities VA decided to realign acute 
psychiatry services so that they would be provided in a medical 
facility that also provides acute medicine services, which is 
consistent with VA's goal to improve the quality of care. When 
evaluating options for the alignment of health care services, CARES 
guidelines were consistent with guidelines from the Office of 
Management and Budget[Footnote 21] in calling for attention to the 
costs and benefits of alternatives when evaluating options for the 
alignment of health care services. CARES guidelines are also consistent 
with our previous analysis and, in particular, our view of the 
importance of costs and benefits associated with the quality of care, 
access to care, cost to the government, support for VA's other 
strategic goals (such as medical education of health care providers and 
research), and economic impact on the local community.[Footnote 22]

VA also made decisions to realign inpatient services in three health 
care markets where VA identified limitations in access to acute or long-
term inpatient services (see table 10). VA had several options to 
address these access limitations. VA could realign inpatient services 
by establishing new VA medical facilities or adding services to 
existing VA medical facilities. As an alternative to realigning its 
inpatient services, VA also had the option of entering into agreements 
with non-VA providers. For example, it could improve access by 
purchasing inpatient health care services from non-VA providers, 
leasing space at non-VA medical facilities, or collaborating with the 
Department of Defense. VA decided to add inpatient services at two 
existing VA medical facilities and to establish a new VA medical 
facility to provide inpatient services in Las Vegas, Nevada.[Footnote 
23]

Table 10: VA Health Care Markets Where VA Decided to Add Acute or Long- 
Term Inpatient Services: 

Markets: Washington, D.C., market of Network 5 (the District of 
Columbia and parts of both Maryland and Virginia); 
VA alignment decisions: Add more inpatient services to an existing 
facility: Domiciliary care at VA's Washington, D.C., medical facility; 
VA alignment decisions: Establish a new medical facility: Not 
applicable. 

Markets: Central market of Network 8 (the central part of Florida); 
VA alignment decisions: Add more inpatient services to an existing 
facility: Acute inpatient medicine, surgery, and psychiatry at VA's 
Orlando, Fla., medical facility[A]; 
VA alignment decisions: Establish a new medical facility: Not 
applicable. 

Markets: Nevada market of Network 22 (southern Nevada); 
VA alignment decisions: Add more inpatient services to an existing 
facility: Not applicable; 
VA alignment decisions: Establish a new medical facility: Acute 
inpatient medicine, surgery, psychiatry, and nursing home services at a 
new VA medical facility in Las Vegas, Nev.[B]. 

Source: GAO analysis of VA data. 

[A] VA decided to add an acute care hospital to its medical facility-- 
a nursing home and domiciliary--in Orlando. 

[B] VA did not have an inpatient facility in this market at the time it 
made its CARES decisions. It collaborated with the Department of 
Defense to provide acute inpatient hospital services in Las Vegas, 
Nev., by having VA staff provide services to veterans in a hospital at 
Nellis Air Force Base. 

[End of table]

Appendix VI provides a complete list of VA's health care markets and 
indicates where VA identified limitations in geographic access to 
tertiary, acute, or long-term inpatient health care services and VA's 
decisions for improving veterans' access to these services. 

VA also decided to add specialized centers for the inpatient treatment 
of spinal cord injury and disorder or blind rehabilitation to existing 
VA medical centers in five networks where it had identified limitations 
in veterans' access to these services (see table 11). VA will add 
inpatient centers for the treatment of spinal cord injury and disorder 
in three networks and inpatient centers for blind rehabilitation in two 
networks (see also app. VII). 

Table 11: VA Health Care Networks Where VA Decided to Add Specialized 
Inpatient Treatment for Spinal Cord Injury and Disorder or Blind 
Rehabilitation: 

Network: 1. Network 2 (upstate New York and parts of north central 
Pennsylvania); 
Inpatient services VA decided to add to an existing facility: Inpatient 
Spinal Cord Injury and Disorder Center at VA's Syracuse, N.Y., medical 
facility. 

Network: 2. Network 16 (Louisiana; 
most of Arkansas, Mississippi, and Oklahoma; 
eastern Texas; and parts of three other states: Alabama, Florida, and 
Missouri); 
Inpatient services VA decided to add to an existing facility: Inpatient 
Blind Rehabilitation Center at VA's Biloxi, Miss., medical facility. 

Network: 3. Network 19 (Utah; 
most of Colorado, Montana, and Wyoming; and parts of five other states: 
Idaho, Kansas, Nebraska, Nevada, and North Dakota); 
Inpatient services VA decided to add to an existing facility: Inpatient 
Spinal Cord Injury and Disorder Center at VA's Denver, Colo., medical 
facility. 

Network: 4. Network 22 (southern California and southern Nevada); 
Inpatient services VA decided to add to an existing facility: Inpatient 
Blind Rehabilitation Center at VA's Long Beach, Calif., medical 
facility. 

Network: 5. Network 23 (Iowa and South Dakota; 
most of Minnesota, Nebraska, and North Dakota; and parts of five other 
states: Illinois, Kansas, Missouri, Wisconsin, and Wyoming); 
Inpatient services VA decided to add to an existing facility: Inpatient 
Spinal Cord Injury and Disorder Center at VA's Minneapolis, Minn., 
medical facility. 

Source: GAO analysis of VA data. 

Note: VA health care facilities are organized into 21 regional 
networks, known as Veterans Integrated Service Networks, which are to 
coordinate the activities of and allocate resources to VA health care 
facilities. VA had 22 networks until January 2002, when it merged 
Networks 13 and 14 to form a new network, Network 23. 

[End of table]

Appendix VII provides a complete list of VA's health care networks and 
indicates those where VA identified limitations in veterans' access to 
specialized inpatient treatment programs for spinal cord injury and 
disorder or blindness and VA's decisions about the alignment of these 
inpatient services. 

VA Made Decisions to Maintain Its Inpatient Services as Currently 
Aligned at 90 Locations: 

VA decided to maintain its inpatient services as currently aligned in 
90 locations--63 medical facilities identified as having potential 
service duplication or low acute inpatient workload and 27 markets 
where VA identified limitations in veterans' geographic access to 
tertiary or acute inpatient services. VA provided reasons for its 
decisions to leave services as aligned for most, but not all, of these 
locations. Generally the reasons VA cited in major CARES documents for 
leaving inpatient services as aligned at the 63 medical facilities were 
that realignment was not feasible (for example, because space 
limitations constrain consolidation of potentially duplicative 
services) or would have a negative effect on the quality of care, 
accessibility of care, cost of care, VA's strategic missions, or the 
community's economy. As one example, VA decided to maintain inpatient 
services as aligned at its medical facility in Hot Springs, South 
Dakota, where acute inpatient workload is low, because there are no 
hospitals within 60 miles that have been accredited by the Joint 
Commission on Accreditation of Healthcare Organizations. As another 
example, VA decided to maintain inpatient services as aligned at its 
two medical facilities in Augusta, Georgia, because it concluded that 
space is insufficient to make consolidation practical. 

For the 27 markets where VA decided not to realign the inpatient health 
care services at its existing medical facilities, VA decided instead to 
purchase health care services through contracts with local non-VA 
providers, lease space at non-VA medical facilities, or establish 
collaborative arrangements with the Department of Defense. Each of 
these markets was one where VA identified lengthy driving times to 
access tertiary or acute care. 

VA Deferred Decisions on Alignment of Inpatient Health Care Services 
for 16 Locations Pending Further Study: 

VA deferred decisions about the alignment of inpatient health care 
services for 16 locations,[Footnote 24] including: 

* 14 existing VA medical facilities that have service duplication or 
low acute inpatient workload (see table 12);

* 1 market where VA identified limitations in access to a long-term 
care service, namely, residential rehabilitation for post-traumatic 
stress disorder and substance abuse in the Michigan market of Network 
11 (which includes lower Michigan and part of northwest Ohio); 
and: 

* 1 network where VA identified limitations in access to specialized 
inpatient treatment for spinal cord injury and disorder, namely, 
Network 8 (which includes most of Florida, part of southern Georgia, 
Puerto Rico, the U.S. Virgin Islands of St. Thomas and St. Croix, and 
Arecibo). 

Table 12: VA Medical Facilities Where Inpatient Alignment Decisions 
Were Deferred Pending Further Study: 

1. Bedford, Mass. 

2. Big Spring, Tex. 

3. Brockton, Mass. 

4. Brooklyn, N.Y. 

5. Chillicothe, Ohio. 

6. Jamaica Plain, Mass. 

7. Lake City, Fla. 

8. Manhattan, N.Y. 

9. Montgomery, Ala. 

10. Poplar Bluff, Mo. 

11. Temple, Tex. 

12. Waco, Tex. 

13. Walla Walla, Wash. 

14. West Roxbury, Mass. 

Source: GAO analysis of VA data. 

Note: In addition, VA chose to further study potential alignment 
options at its medical facility at Muskogee, Oklahoma, where it had 
already made one decision about inpatient services. VA decided to close 
inpatient surgery at Muskogee and to study the potential to add 
inpatient psychiatric services or to use non-VA providers to meet 
veterans' inpatient health care needs in the Muskogee/Tulsa region. 

[End of table]

In general, VA indicated that it plans to study ways to align inpatient 
health care services at these locations because it concluded that 
sufficient information was not available to reach a decision by May 7, 
2004. For example, VA concluded that it lacked adequate data about the 
feasibility and cost-effectiveness of building a single new inpatient 
medical facility in Boston, Massachusetts, to replace its inpatient 
medical facilities in Bedford, Brockton, Jamaica Plain, and West 
Roxbury, Massachusetts. As another example, VA concluded that further 
information would be needed to determine whether to add a new inpatient 
center for the treatment of spinal cord injury and disorder or to 
expand an existing center for that treatment in southern Florida. When 
VA announced its CARES decisions, it reported that it planned to 
complete most of these studies by the end of 2004 or the beginning of 
2005; a VA official reported in November 2004 that VA now expects that 
most of the studies will be completed by the end of 2005.[Footnote 25]

In addition, VA plans to develop crosscutting strategic plans for long-
term care and mental health services that could result in decisions to 
realign inpatient services at locations where VA has decided to realign 
other inpatient services and at locations where no realignment 
decisions have been made. Although VA made some decisions about the 
alignment of long-term care services at facilities it had identified 
for potential duplication of services, the CARES process did not 
include a systematic analysis of VA's long-term care services 
(including nursing home care, long-term psychiatric care, domiciliary 
care, and residential rehabilitation) because VA had not developed an 
adequate model to project future need for these services. VA reported 
that it is now working on a strategic plan for long-term care that will 
include nursing home and long-term psychiatric care needs and will be 
adjusted to determine whether access to domiciliary care can be 
improved by realigning such services from rural to urban medical 
facilities. VA also reported that it plans to develop a mental health 
strategic plan that could suggest additional realignments of inpatient 
psychiatry services because it will address the collocation of acute 
inpatient psychiatric services with other acute inpatient services--an 
arrangement that VA noted can enhance the quality of acute psychiatric 
care--and better ensure equitable access to inpatient psychiatric 
services. 

Concluding Observations: 

Through the CARES process, VA has taken important steps in assessing 
and making decisions on the alignment of its future inpatient health 
care services and capital assets in light of projected health care 
needs. Specifically, VA identified 136 locations where potential 
service duplication, low acute inpatient workload, or limitations in 
veterans' geographic access to VA health care indicated the need to 
evaluate alternatives to alignment of inpatient services that could 
enhance health care for veterans. In its evaluation, VA decided to 
realign services at 30 locations, generally citing reasons to maintain 
or enhance the quality of care, improve veterans' access to care, or 
increase the cost efficiency of care and decided to maintain the 
alignment of inpatient services at 90 locations. Among the 90 
locations, VA decided to improve veterans' access to inpatient health 
services by entering into agreements for care from non-VA providers in 
the 27 locations where a large number of veterans face lengthy driving 
times to access VA health care and where VA decided not to add 
inpatient services. 

VA, however, did not complete its assessment of the alignment of 
inpatient services at all locations identified as having potential 
service duplication, low acute inpatient workload, or limitations in 
veterans' geographic access to inpatient care. VA made no decisions on 
the alignment of inpatient services in 16 locations pending completion 
of further studies because VA believed it had insufficient information 
to make a decision. In addition, VA plans other studies concerning 
alignment of other inpatient services, such as nursing home and mental 
health care, that could affect the alignment of these services at other 
medical facilities. 

VA's decisions to realign inpatient services have the potential to 
enhance health care services for veterans. Some veterans who will be 
directly affected by VA's decisions to realign inpatient services may 
benefit from enhanced quality or accessibility of VA health care. 
Moreover, cost savings associated with the closure of VA medical 
facilities and elimination of duplicative services can be redirected to 
better serve the health care needs of veterans. VA's efforts to realign 
its inpatient services and improve management of its capital assets are 
essential to meeting the health care needs of veterans in the 21st 
century. VA's alignment decisions and planned studies of additional 
alternatives for the alignment of inpatient services are tangible steps 
forward in this process. Ultimately, however, accomplishing these goals 
will depend on VA's success in completing its studies and implementing 
its CARES decisions on inpatient and other health care services to 
better ensure that resources now spent on unneeded capital assets are 
redirected to health care. 

Agency Comments: 

In written comments on a draft of this report, VA concurred with our 
findings. VA comments are reprinted in appendix VIII. 

As we agreed with your office, unless you publicly announce the 
contents of this report earlier, we plan no further distribution of it 
until 30 days from its date. We will then send copies of this report to 
the Secretary of Veterans Affairs, appropriate congressional 
committees, and other interested parties. We will also make copies 
available to others upon request. This report will be available at no 
charge on GAO's Web site at http://www.gao.gov. If you or your staff 
have any questions, please call me at (202) 512-7101. Another contact 
and key contributors are listed in appendix IX. 

Sincerely yours,

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care--Veterans' Health and Benefits Issues: 

[End of section]

Appendix I: Scope and Methodology: 

On May 7, 2004, the Secretary of Veterans Affairs published decisions 
the Department of Veterans Affairs (VA) reached through its Capital 
Asset Realignment for Enhanced Services (CARES) process.[Footnote 26] 
The Secretary's report included VA's CARES decisions about the 
alignment of inpatient services at locations it identified for 
potential service duplication, low acute inpatient workload, or 
limitations in geographic access, along with its other CARES decisions. 
These decisions covered 74 of VA's 77 markets in 20 of its 21 
networks.[Footnote 27] In the context of the alignment of its inpatient 
services, VA's report focused primarily on decisions involving medical 
facilities, markets, and networks where VA's inpatient health care 
services are to be realigned or studied further. The report did not, 
however, provide a national, comprehensive summary of the medical 
facilities, markets, and networks that VA identified as needing 
evaluation for potential alternative alignments of inpatient services 
and did not include a discussion of all of the locations where it 
decided to leave inpatient services as currently aligned. 

We examined VA's inpatient service assessments and decisions to develop 
a national summary of the medical facilities, markets, and networks 
where (1) VA identified potential service duplication, low workload, or 
geographic access limitations as factors that could indicate a need to 
evaluate alternative ways to align inpatient health care services and 
(2) VA made decisions to either realign inpatient services or leave 
inpatient services as aligned, or deferred decisions pending further 
study. Our summary of the decisions VA made through CARES focuses on 
inpatient health care services that VA provides in medical facilities 
that it owns in the 20 networks covered by the Secretary's May 7, 2004, 
CARES decisions. Because no one source includes all the information 
about these factors, we reviewed the major CARES documents, namely, 
CARES planning documents such as network market plans, VA's Draft 
National CARES Plan, the report by an independent Commission appointed 
by VA that was charged with making CARES recommendations, and the 
Secretary's report of VA's CARES decisions. 

To summarize the number of medical facilities,[Footnote 28] health care 
markets, and health care networks where VA identified potential service 
duplication, low acute inpatient workload, or geographic access 
limitations as factors that could indicate a need to evaluate 
alternative ways to align inpatient health care services, we reviewed 
major CARES documents for information about these factors. We 
classified the medical facilities that VA identified as potentially 
duplicating inpatient services as potentially duplicating one or more 
of three types of inpatient services, namely, tertiary care services; 
acute inpatient medicine services; or other services, including other 
types of inpatient care (such as long-term psychiatry) or services that 
support inpatient care (such as administration or maintenance). When 
our identification of a medical facility as one with potential service 
duplication or low workload depended on the availability of acute 
inpatient medicine, we confirmed that the facility provided that 
service during the first half of fiscal year 2004, the time period 
immediately before VA made its CARES decisions, by examining data 
provided by VA. We resolved discrepancies in the characterization of 
medical facilities as potentially duplicating inpatient services or 
having low acute inpatient workload through discussions with VA 
officials. 

To summarize VA's decisions about the alignment of inpatient services, 
we reviewed major CARES documents to determine if VA made a decision to 
realign inpatient services or leave inpatient services as aligned or if 
VA deferred making a decision pending further study. We defined 
realignment of an inpatient service as (1) eliminating the service in 
its entirety at a facility where VA provided it, (2) adding an 
inpatient service to an existing VA facility where VA did not provide 
the service, or (3) establishing a new VA medical facility where one 
had not existed. We did not examine the number of beds that VA decided 
to add or close. The inpatient services in our review included both 
acute and long-term inpatient services. Specifically, these inpatient 
services included tertiary care; the acute inpatient services of acute 
medicine, surgery, and psychiatry; and other inpatient services. Other 
inpatient services included subacute and intermediate medicine; the 
long-term inpatient services of nursing home care, long-term 
psychiatry, domiciliary care,[Footnote 29] and residential 
rehabilitation; and specialized inpatient services of treatment for 
spinal cord injury and disorder and blind rehabilitation. In some cases 
in which VA decided to close an inpatient service at one medical 
facility and refer patients to another VA medical facility, CARES 
documents did not indicate whether that inpatient service was already 
available at that medical facility. To determine whether VA had decided 
to add the inpatient service in these cases, we obtained additional 
information from VA. We classified a decision as pending further study 
when VA determined that additional information or analysis was 
necessary to determine whether to add or close one or more inpatient 
services at a location. We compared data from CARES with other 
information from VA about the inpatient services available at its 
medical facilities and when we identified discrepancies, resolved them 
through discussions with VA officials. To identify the reasons VA 
provided for its decisions about the alignment of inpatient services, 
we reviewed major CARES documents. We examined the stated rationale 
associated with each decision for references to feasibility or costs 
and benefits involving the quality of care, access to care, cost to the 
government, support for VA's other strategic goals (such as medical 
education and research), and economic impact on the local community. We 
did not evaluate the stated reasons. 

We found the data to be adequate for our purposes, and VA officials 
agreed that our methodology was reasonable. We did not review VA's 
other CARES decisions such as those for reconfiguring space to meet 
projected demand for services, modernization needed to provide services 
appropriately, disposal of assets that may no longer be needed, or the 
alignment of outpatient services. We conducted our work from October 
2003 through March 2005 in accordance with generally accepted 
government auditing standards. 

[End of section]

Appendix II: VA Medical Facilities Identified for Potential Duplication 
of Tertiary Care Services: 

VA medical facility[A]: Ann Arbor, Mich; 
Network[B]: 11; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Detroit, 
Mich. 

VA medical facility[A]: Augusta, Ga.--Downtown; 
Network[B]: 7; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Columbia, 
S.C. 

VA medical facility[A]: Baltimore, Md; 
Network[B]: 5; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: 
Philadelphia, Pa., and Washington, D.C. 

VA medical facility[A]: Bay Pines, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Tampa, 
Fla. 

VA medical facility[A]: Bronx, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Brooklyn, 
N.Y; East Orange, N.J; Manhattan, N.Y; Northport, N.Y; Philadelphia, 
Pa; and West Haven, Conn. 

VA medical facility[A]: Brooklyn, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Bronx, 
N.Y; East Orange, N.J; Manhattan, N.Y; Northport, N.Y; Philadelphia, 
Pa; and West Haven, Conn. 

VA medical facility[A]: Charleston, S.C; 
Network[B]: 7; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Columbia, 
S.C. 

VA medical facility[A]: Cincinnati, Ohio; 
Network[B]: 10; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Dayton, 
Ohio; Indianapolis, Ind; Lexington, Ky.--Cooper; and Louisville, Ky. 

VA medical facility[A]: Columbia, S.C; 
Network[B]: 7; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Augusta, 
Ga.--Downtown and Charleston, S.C. 

VA medical facility[A]: Dayton, Ohio; 
Network[B]: 10; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: 
Cincinnati, Ohio, and Indianapolis, Ind. 

VA medical facility[A]: Detroit, Mich; 
Network[B]: 11; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Ann Arbor, 
Mich. 

VA medical facility[A]: East Orange, N.J; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Bronx, 
N.Y; Brooklyn, N.Y; Manhattan, N.Y; Northport, N.Y; Philadelphia, Pa; 
and West Haven, Conn. 

VA medical facility[A]: Indianapolis, Ind; 
Network[B]: 11; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: 
Cincinnati, Ohio; Dayton, Ohio; and Louisville, Ky. 

VA medical facility[A]: Lexington, Ky.--Cooper; 
Network[B]: 9; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: 
Cincinnati, Ohio, and Louisville, Ky. 

VA medical facility[A]: Loma Linda, Calif; 
Network[B]: 22; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Long 
Beach, Calif; San Diego, Calif; and West Los Angeles, Calif. 

VA medical facility[A]: Long Beach, Calif; 
Network[B]: 22; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Loma 
Linda, Calif; San Diego, Calif; and West Los Angeles, Calif. 

VA medical facility[A]: Louisville, Ky; 
Network[B]: 9; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: 
Cincinnati, Ohio; Indianapolis, Ind; and Lexington, Ky.--Cooper. 

VA medical facility[A]: Manhattan, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Bronx, 
N.Y; Brooklyn, N.Y; East Orange, N.J; Northport, N.Y; Philadelphia, Pa; 
and West Haven, Conn. 

VA medical facility[A]: Northport, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Bronx, 
N.Y; Brooklyn, N.Y; East Orange, N.J; Manhattan, N.Y; and West Haven, 
Conn. 

VA medical facility[A]: Palo Alto, Calif; 
Network[B]: 21; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: San 
Francisco, Calif. 

VA medical facility[A]: Philadelphia, Pa; 
Network[B]: 4; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Baltimore, 
Md; Bronx, N.Y; Brooklyn, N.Y; East Orange, N.J; and Manhattan, N.Y. 

VA medical facility[A]: Richmond, Va; 
Network[B]: 6; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: 
Washington, D.C. 

VA medical facility[A]: San Diego, Calif; 
Network[B]: 22; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Loma 
Linda, Calif., and Long Beach, Calif. 

VA medical facility[A]: San Francisco, Calif; 
Network[B]: 21; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Palo Alto, 
Calif. 

VA medical facility[A]: Tampa, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Bay Pines, 
Fla. 

VA medical facility[A]: Washington, D.C; 
Network[B]: 5; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Baltimore, 
Md., and Richmond, Va. 

VA medical facility[A]: West Haven, Conn; 
Network[B]: 1; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Bronx, 
N.Y; Brooklyn, N.Y; East Orange, N.J; Manhattan, N.Y; and Northport, 
N.Y. 

VA medical facility[A]: West Los Angeles, Calif; 
Network[B]: 22; 
VA medical facility or facilities close enough (within 120 miles) to 
consider whether tertiary care services were needed at both: Loma 
Linda, Calif., and Long Beach, Calif. 

Source: GAO analysis of VA data. 

[A] VA medical facilities that provide tertiary care services and are 
within 120 miles of another VA medical facility that provides tertiary 
care services and that VA identified as potentially duplicating 
inpatient services. 

[B] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, which are to coordinate 
the activities of and allocate resources to VA health care facilities. 
VA had 22 networks until January 2002, when it merged Networks 13 and 
14 to form a new network, Network 23. 

[End of table]

[End of section]

Appendix III: VA Medical Facilities Identified for Potential 
Duplication of Acute Inpatient Medicine Services: 

VA medical facility[A]: Ann Arbor, Mich; 
Network[B]: 11; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Detroit, Mich. 

VA medical facility[A]: Baltimore, Md; 
Network[B]: 5; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Perry Point, Md., and Washington, D.C. 

VA medical facility[A]: Bronx, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Brooklyn, N.Y; Castle Point, N.Y; East Orange, N.J; Manhattan, N.Y; and 
Northport, N.Y. 

VA medical facility[A]: Brooklyn, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Bronx, N.Y; East Orange, N.J; Manhattan, N.Y; and Northport, N.Y. 

VA medical facility[A]: Castle Point, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Bronx, N.Y. 

VA medical facility[A]: Cincinnati, Ohio; 
Network[B]: 10; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Dayton, Ohio. 

VA medical facility[A]: Dayton, Ohio; 
Network[B]: 10; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Cincinnati, Ohio. 

VA medical facility[A]: Detroit, Mich; 
Network[B]: 11; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Ann Arbor, Mich. 

VA medical facility[A]: East Orange, N.J; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Bronx, N.Y; Brooklyn, N.Y; Manhattan, N.Y; and Northport, N.Y. 

VA medical facility[A]: Gainesville, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Lake City, Fla. 

VA medical facility[A]: Kansas City, Mo; 
Network[B]: 15; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Leavenworth, Kans. 

VA medical facility[A]: Lake City, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Gainesville, Fla. 

VA medical facility[A]: Leavenworth, Kans; 
Network[B]: 15; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Kansas City, Mo. 

VA medical facility[A]: Little Rock, Ark; 
Network[B]: 16; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
North Little Rock, Ark. 

VA medical facility[A]: Long Beach, Calif; 
Network[B]: 22; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
West Los Angeles, Calif. 

VA medical facility[A]: Manhattan, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Bronx, N.Y; Brooklyn, N.Y; and East Orange, N.J. 

VA medical facility[A]: Murfreesboro, Tenn; 
Network[B]: 9; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Nashville, Tenn. 

VA medical facility[A]: Nashville, Tenn; 
Network[B]: 9; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Murfreesboro, Tenn. 

VA medical facility[A]: North Little Rock, Ark; 
Network[B]: 16; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Little Rock, Ark. 

VA medical facility[A]: Northport, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Bronx, N.Y; Brooklyn, N.Y; and East Orange, N.J. 

VA medical facility[A]: Perry Point, Md; 
Network[B]: 5; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Baltimore, Md., and Wilmington, Del. 

VA medical facility[A]: Philadelphia, Pa; 
Network[B]: 4; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Wilmington, Del. 

VA medical facility[A]: Providence, R.I; 
Network[B]: 1; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
West Roxbury, Mass. 

VA medical facility[A]: Washington, D.C; 
Network[B]: 5; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Baltimore, Md. 

VA medical facility[A]: West Los Angeles, Calif; 
Network[B]: 22; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Long Beach, Calif. 

VA medical facility[A]: West Roxbury, Mass; 
Network[B]: 1; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Providence, R.I. 

VA medical facility[A]: Wilmington, Del; 
Network[B]: 4; 
VA medical facility or facilities close enough (within 60 miles) to 
consider whether acute inpatient medicine services were needed at both: 
Perry Point, Md., and Philadelphia, Pa. 

Source: GAO analysis of VA data. 

[A] VA medical facilities that provide acute inpatient medicine 
services and are within 60 miles of another VA medical facility that 
provides acute inpatient medicine services and that VA identified as 
potentially duplicating inpatient services. 

[B] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, which are to coordinate 
the activities of and allocate resources to VA health care facilities. 
VA had 22 networks until January 2002, when it merged Networks 13 and 
14 to form a new network, Network 23. 

[End of section]

[End of table]

Appendix IV: VA Medical Facilities Identified for Potential Duplication 
of Other Inpatient Services or Support Services: 

VA medical facility[A]: American Lake, Wash; 
Network[B]: 20; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: White City, 
Oreg. 

VA medical facility[A]: Augusta, Ga.--Downtown; 
Network[B]: 7; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Augusta, Ga.-
-Uptown. 

VA medical facility[A]: Augusta, Ga.--Uptown; 
Network[B]: 7; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Augusta, Ga.-
-Downtown. 

VA medical facility[A]: Batavia, N.Y; 
Network[B]: 2; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Buffalo, N.Y., 
and Canandaigua, N.Y. 

VA medical facility[A]: Bedford, Mass; 
Network[B]: 1; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Brockton, 
Mass; Jamaica Plain, Mass; and West Roxbury, Mass. 

VA medical facility[A]: Biloxi, Miss; 
Network[B]: 16; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Gulfport, 
Miss. 

VA medical facility[A]: Brockton, Mass; 
Network[B]: 1; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Bedford, Mass; 
Jamaica Plain, Mass; and West Roxbury, Mass. 

VA medical facility[A]: Brooklyn, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: St. Albans, 
N.Y. 

VA medical facility[A]: Buffalo, N.Y; 
Network[B]: 2; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Batavia, N.Y. 

VA medical facility[A]: Canandaigua, N.Y; 
Network[B]: 2; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Batavia, N.Y. 

VA medical facility[A]: Castle Point, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Montrose, N.Y. 

VA medical facility[A]: Cleveland, Ohio--Brecksville; 
Network[B]: 10; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Cleveland, 
Ohio--Wade Park. 

VA medical facility[A]: Cleveland, Ohio--Wade Park; 
Network[B]: 10; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Cleveland, 
Ohio--Brecksville. 

VA medical facility[A]: Des Moines, Iowa; 
Network[B]: 23; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Knoxville, 
Iowa. 

VA medical facility[A]: East Orange, N.J; 
Network[B]: 3; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Lyons, N.J. 

VA medical facility[A]: Fort Meade, S. Dak; 
Network[B]: 23; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Hot Springs, 
S. Dak. 

VA medical facility[A]: Fort Wayne, Ind; 
Network[B]: 11; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Marion, Ind. 

VA medical facility[A]: Gainesville, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Lake City, 
Fla. 

VA medical facility[A]: Gulfport, Miss; 
Network[B]: 16; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Biloxi, Miss. 

VA medical facility[A]: Hot Springs, S. Dak; 
Network[B]: 23; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Fort Meade, S. 
Dak. 

VA medical facility[A]: Jamaica Plain, Mass; 
Network[B]: 1; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Bedford, Mass; 
Brockton, Mass; and West Roxbury, Mass. 

VA medical facility[A]: Kansas City, Mo; 
Network[B]: 15; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Leavenworth, 
Kans. 

VA medical facility[A]: Kerrville, Tex; 
Network[B]: 17; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: San Antonio, 
Tex. 

VA medical facility[A]: Knoxville, Iowa; 
Network[B]: 23; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Des Moines, 
Iowa. 

VA medical facility[A]: Lake City, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Gainesville, 
Fla. 

VA medical facility[A]: Leavenworth, Kans; 
Network[B]: 15; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Kansas City, 
Mo., and Topeka, Kans. 

VA medical facility[A]: Lexington, Ky.--Cooper; 
Network[B]: 9; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Lexington, 
Ky.--Leestown. 

VA medical facility[A]: Lexington, Ky.--Leestown; 
Network[B]: 9; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Lexington, 
Ky.--Cooper. 

VA medical facility[A]: Livermore, Calif; 
Network[B]: 21; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Palo Alto, 
Calif. 

VA medical facility[A]: Lyons, N.J; 
Network[B]: 3; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: East Orange, 
N.J. 

VA medical facility[A]: Marion, Ind; 
Network[B]: 11; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Fort Wayne, 
Ind. 

VA medical facility[A]: Miami, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: West Palm 
Beach, Fla. 

VA medical facility[A]: Montgomery, Ala; 
Network[B]: 7; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Tuskegee, Ala. 

VA medical facility[A]: Montrose, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Castle Point, 
N.Y. 

VA medical facility[A]: Palo Alto, Calif; 
Network[B]: 21; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Livermore, 
Calif. 

VA medical facility[A]: Pittsburgh, Pa.--Heinz Center; 
Network[B]: 4; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Pittsburgh, 
Pa.--Highland Drive and Pittsburgh, Pa.--University Drive. 

VA medical facility[A]: Pittsburgh, Pa.--Highland Drive; 
Network[B]: 4; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Pittsburgh, 
Pa.--Heinz Center and Pittsburgh, Pa.--University Drive. 

VA medical facility[A]: Pittsburgh, Pa.--University Drive; 
Network[B]: 4; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Pittsburgh, 
Pa.--Heinz Center and Pittsburgh, Pa.--Highland Drive. 

VA medical facility[A]: Portland, Oreg; 
Network[B]: 20; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Vancouver, 
Wash. 

VA medical facility[A]: Roseburg, Oreg; 
Network[B]: 20; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: White City, 
Oreg. 

VA medical facility[A]: San Antonio, Tex; 
Network[B]: 17; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Kerrville, 
Tex. 

VA medical facility[A]: St. Albans, N.Y; 
Network[B]: 3; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Brooklyn, N.Y. 

VA medical facility[A]: Temple, Tex; 
Network[B]: 17; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Waco, Tex. 

VA medical facility[A]: Topeka, Kans; 
Network[B]: 15; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Leavenworth, 
Kans. 

VA medical facility[A]: Tuskegee, Ala; 
Network[B]: 7; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Montgomery, 
Ala. 

VA medical facility[A]: Vancouver, Wash; 
Network[B]: 20; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Portland, 
Oreg. 

VA medical facility[A]: Waco, Tex; 
Network[B]: 17; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Temple, Tex. 

VA medical facility[A]: West Palm Beach, Fla; 
Network[B]: 8; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Miami, Fla. 

VA medical facility[A]: West Roxbury, Mass; 
Network[B]: 1; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: Bedford, Mass; 
Brockton, Mass; and Jamaica Plain, Mass. 

VA medical facility[A]: White City, Oreg; 
Network[B]: 20; 
VA medical facility or facilities close enough geographically to 
consider whether inpatient services were needed at both: American Lake, 
Wash., and Roseburg, Oreg. 

Source: GAO analysis of VA data. 

[A] VA medical facilities that VA identified as close enough 
geographically to another VA medical facility for VA to consider 
whether inpatient services other than tertiary care or acute inpatient 
medicine were needed at both. The potentially duplicated inpatient 
services generally included psychiatric and long-term inpatient care; 
services that support inpatient care generally included administration 
and maintenance. 

[B] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, which are to coordinate 
the activities of and allocate resources to VA health care facilities. 
VA had 22 networks until January 2002, when it merged Networks 13 and 
14 to form a new network, Network 23. 

[End of table]

[End of section]

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication 
or Low Acute Inpatient Workload, and Alignment Decisions: 

VA medical facility[A]: 1. Albany, N. Y; 
Network[B]: 2. 

VA medical facility[A]: 2. Albuquerque, N. Mex; 
Network[B]: 18. 

VA medical facility[A]: 3. Alexandria, La; 
Network[B]: 16. 

VA medical facility[A]: 4. Altoona, Pa; 
Network[B]: 4; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 5. Amarillo, Tex; 
Network[B]: 18. 

VA medical facility[A]: 6. American Lake, Wash; 
Network[B]: 20; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 7. Anchorage, Alaska; 
Network[B]: 20. 

VA medical facility[A]: 8. Ann Arbor, Mich; 
Network[B]: 11; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 9. Asheville, N. C; 
Network[B]: 6. 

VA medical facility[A]: 10. Atlanta, Ga; 
Network[B]: 7. 

VA medical facility[A]: 11. Augusta, Ga. --Downtown; 
Network[B]: 7; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 12. Augusta, Ga. --Uptown; 
Network[B]: 7; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 13. Baltimore, Md; 
Network[B]: 5; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]: X. 

VA medical facility[A]: 14. Batavia, N. Y; 
Network[B]: 2; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 15. Bath, N. Y; 
Network[B]: 2; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 16. Battle Creek, Mich; 
Network[B]: 11. 

VA medical facility[A]: 17. Bay Pines, Fla; 
Network[B]: 8; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 18. Beckley, W. Va; 
Network[B]: 6; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 19. Bedford, Mass; 
Network[B]: 1; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 20. Big Spring, Tex; 
Network[B]: 18; 
Low acute inpatient workload: Other basis[G]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 21. Biloxi, Miss; 
Network[B]: 16; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 22. Birmingham, Ala; 
Network[B]: 7. 

VA medical facility[A]: 23. Boise, Idaho; 
Network[B]: 20; 
Low acute inpatient workload: Other basis[G]. 

VA medical facility[A]: 24. Bonham, Tex; 
Network[B]: 17. 

VA medical facility[A]: 25. Brockton, Mass; 
Network[B]: 1; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 26. Bronx, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 27. Brooklyn, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
. 

VA medical facility[A]: 28. Buffalo, N. Y; 
Network[B]: 2; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 29. Butler, Pa; 
Network[B]: 4; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 30. Canandaigua, N. Y; 
Network[B]: 2; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 31. Castle Point, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
. 

VA medical facility[A]: 32. Charleston, S. C; 
Network[B]: 7; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 33. Cheyenne, Wyo; 
Network[B]: 19; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 34. Chicago, Ill. --West Side; 
Network[B]: 12[K]. 

VA medical facility[A]: 35. Chillicothe, Ohio; 
Network[B]: 10; 
Low acute inpatient workload: Other basis[G]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 36. Cincinnati, Ohio; 
Network[B]: 10; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 37. Clarksburg, W. Va; 
Network[B]: 4. 

VA medical facility[A]: 38. Cleveland, Ohio--Brecksville; 
Network[B]: 10; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I][L]. 

VA medical facility[A]: 39. Cleveland, Ohio--Wade Park; 
Network[B]: 10; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 40. Coatesville, Pa; 
Network[B]: 4. 

VA medical facility[A]: 41. Columbia, Mo; 
Network[B]: 15. 

VA medical facility[A]: 42. Columbia, S. C; 
Network[B]: 7; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 43. Dallas, Tex; 
Network[B]: 17. 

VA medical facility[A]: 44. Danville, Ill; 
Network[B]: 11. 

VA medical facility[A]: 45. Dayton, Ohio; 
Network[B]: 10; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 46. Denver, Colo. [M]; 
Network[B]: 19; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 47. Des Moines, Iowa; 
Network[B]: 23; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 48. Detroit, Mich; 
Network[B]: 11; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 49. Dublin, Ga; 
Network[B]: 7; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 50. Durham, N. C; 
Network[B]: 6. 

VA medical facility[A]: 51. East Orange, N. J; 
Network[B]: 3; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 52. Erie, Pa; 
Network[B]: 4; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 53. Fargo, N. Dak; 
Network[B]: 23. 

VA medical facility[A]: 54. Fayetteville, Ark; 
Network[B]: 16. 

VA medical facility[A]: 55. Fayetteville, N. C; 
Network[B]: 6. 

VA medical facility[A]: 56. Fort Harrison, Mont; 
Network[B]: 19; 
Low acute inpatient workload: Other basis[G]. 

VA medical facility[A]: 57. Fort Meade, S. Dak; 
Network[B]: 23; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 58. Fort Thomas, Ky; 
Network[B]: 10. 

VA medical facility[A]: 59. Fort Wayne, Ind; 
Network[B]: 11; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I][L]. 

VA medical facility[A]: 60. Fresno, Calif; 
Network[B]: 21. 

VA medical facility[A]: 61. Gainesville, Fla; 
Network[B]: 8; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 62. Grand Island, Nebr; 
Network[B]: 23. 

VA medical facility[A]: 63. Grand Junction, Colo; 
Network[B]: 19; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 64. Gulfport, Miss; 
Network[B]: 16; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I][L]. 

VA medical facility[A]: 65. Hampton, Va; 
Network[B]: 6. 

VA medical facility[A]: 66. Hines, Ill; 
Network[B]: 12[K]. 

VA medical facility[A]: 67. Honolulu, Hawaii; 
Network[B]: 21. 

VA medical facility[A]: 68. Hot Springs, S. Dak; 
Network[B]: 23; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 69. Houston, Tex; 
Network[B]: 16. 

VA medical facility[A]: 70. Huntington, W. Va; 
Network[B]: 9; 
Low acute inpatient workload: Other basis[G]. 

VA medical facility[A]: 71. Indianapolis, Ind; 
Network[B]: 11; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 72. Iowa City, Iowa; 
Network[B]: 23. 

VA medical facility[A]: 73. Iron Mountain, Mich; 
Network[B]: 12[K]. 

VA medical facility[A]: 74. Jackson, Miss; 
Network[B]: 16. 

VA medical facility[A]: 75. Jamaica Plain, Mass; 
Network[B]: 1; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 76. Kansas City, Mo; 
Network[B]: 15; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 77. Kerrville, Tex; 
Network[B]: 17; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 78. Knoxville, Iowa; 
Network[B]: 23; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I][L]. 

VA medical facility[A]: 79. Lake City, Fla; 
Network[B]: 8; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 80. Leavenworth, Kans; 
Network[B]: 15; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 81. Lebanon, Pa; 
Network[B]: 4. 

VA medical facility[A]: 82. Lexington, Ky. --Cooper; 
Network[B]: 9; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 83. Lexington, Ky. --Leestown; 
Network[B]: 9; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 84. Little Rock, Ark; 
Network[B]: 16; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 85. Livermore, Calif; 
Network[B]: 21; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 86. Loch Raven, Md; 
Network[B]: 5. 

VA medical facility[A]: 87. Loma Linda, Calif; 
Network[B]: 22; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 88. Long Beach, Calif; 
Network[B]: 22; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 89. Louisville, Ky; 
Network[B]: 9; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 90. Lyons, N. J; 
Network[B]: 3; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 91. Madison, Wis; 
Network[B]: 12[K]. 

VA medical facility[A]: 92. Manchester, N. H; 
Network[B]: 1. 

VA medical facility[A]: 93. Manhattan, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 94. Marion, Ill; 
Network[B]: 15. 

VA medical facility[A]: 95. Marion, Ind; 
Network[B]: 11; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 96. Martinez, Calif; 
Network[B]: 21. 

VA medical facility[A]: 97. Martinsburg, W. Va; 
Network[B]: 5. 

VA medical facility[A]: 98. Memphis, Tenn; 
Network[B]: 9. 

VA medical facility[A]: 99. Menlo Park, Calif; 
Network[B]: 21. 

VA medical facility[A]: 100. Miami, Fla; 
Network[B]: 8; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 101. Miles City, Mont; 
Network[B]: 19. 

VA medical facility[A]: 102. Milwaukee, Wis; 
Network[B]: 12[K]. 

VA medical facility[A]: 103. Minneapolis, Minn; 
Network[B]: 23; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 104. Montgomery, Ala; 
Network[B]: 7; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 105. Montrose, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 106. Mountain Home, Tenn; 
Network[B]: 9. 

VA medical facility[A]: 107. Murfreesboro, Tenn; 
Network[B]: 9; 
Potential inpatient service duplication: Acute medicine care[D]; 
Low acute inpatient workload: Other basis[G]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 108. Muskogee, Okla; 
Network[B]: 16; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 109. Nashville, Tenn; 
Network[B]: 9; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 110. New Orleans, La; 
Network[B]: 16. 

VA medical facility[A]: 111. North Chicago, Ill; 
Network[B]: 12[K]. 

VA medical facility[A]: 112. North Little Rock, Ark; 
Network[B]: 16; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 113. Northampton, Mass; 
Network[B]: 1. 

VA medical facility[A]: 114. Northport, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 115. Oklahoma City, Okla; 
Network[B]: 16. 

VA medical facility[A]: 116. Omaha, Nebr; 
Network[B]: 23. 

VA medical facility[A]: 117. Orlando, Fla; 
Network[B]: 8; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 118. Palo Alto, Calif; 
Network[B]: 21; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 119. Perry Point, Md; 
Network[B]: 5; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 120. Philadelphia, Pa; 
Network[B]: 4; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 121. Phoenix, Ariz; 
Network[B]: 18. 

VA medical facility[A]: 122. Pittsburgh, Pa. --Heinz Center; 
Network[B]: 4; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 123. Pittsburgh, Pa. --Highland Drive; 
Network[B]: 4; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I][L]. 

VA medical facility[A]: 124. Pittsburgh, Pa. --University Drive; 
Network[B]: 4; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 125. Poplar Bluff, Mo; 
Network[B]: 15; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 126. Portland, Oreg; 
Network[B]: 20; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 127. Prescott, Ariz; 
Network[B]: 18; 
Low acute inpatient workload: Total projected demand[F]. 

VA medical facility[A]: 128. Providence, R. I; 
Network[B]: 1; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 129. Reno, Nev; 
Network[B]: 21. 

VA medical facility[A]: 130. Richmond, Va; 
Network[B]: 6; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 131. Roseburg, Oreg; 
Network[B]: 20; 
Potential inpatient service duplication: Other care[E]; 
Low acute inpatient workload: Other basis[G]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 132. Sacramento, Calif; 
Network[B]: 21. 

VA medical facility[A]: 133. Saginaw, Mich; 
Network[B]: 11; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Close one or more inpatient service(s)[I]. 

VA medical facility[A]: 134. Salem, Va; 
Network[B]: 6. 

VA medical facility[A]: 135. Salisbury, N. C; 
Network[B]: 6. 

VA medical facility[A]: 136. Salt Lake City, Utah; 
Network[B]: 19. 

VA medical facility[A]: 137. San Antonio, Tex; 
Network[B]: 17; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 138. San Diego, Calif; 
Network[B]: 22; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 139. San Francisco, Calif; 
Network[B]: 21; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 140. San Juan, P. R; 
Network[B]: 8. 

VA medical facility[A]: 141. Seattle, Wash; 
Network[B]: 20. 

VA medical facility[A]: 142. Sepulveda, Calif; 
Network[B]: 22. 

VA medical facility[A]: 143. Sheridan, Wyo; 
Network[B]: 19. 

VA medical facility[A]: 144. Shreveport, La; 
Network[B]: 16. 

VA medical facility[A]: 145. Sioux Falls, S. Dak; 
Network[B]: 23. 

VA medical facility[A]: 146. Spokane, Wash; 
Network[B]: 20; 
Low acute inpatient workload: Other basis[G]. 

VA medical facility[A]: 147. St. Albans, N. Y; 
Network[B]: 3; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 148. St. Cloud, Minn; 
Network[B]: 23. 

VA medical facility[A]: 149. St. Louis, Mo. --Jefferson Barracks; 
Network[B]: 15. 

VA medical facility[A]: 150. St. Louis, Mo. --John Cochran; 
Network[B]: 15. 

VA medical facility[A]: 151. Syracuse, N. Y; 
Network[B]: 2; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 152. Tampa, Fla; 
Network[B]: 8; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 153. Temple, Tex; 
Network[B]: 17; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 154. Togus, Maine; 
Network[B]: 1. 

VA medical facility[A]: 155. Tomah, Wis; 
Network[B]: 12[K]. 

VA medical facility[A]: 156. Topeka, Kans; 
Network[B]: 15; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 157. Tucson, Ariz; 
Network[B]: 18. 

VA medical facility[A]: 158. Tuscaloosa, Ala; 
Network[B]: 7. 

VA medical facility[A]: 159. Tuskegee, Ala; 
Network[B]: 7; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 160. Vancouver, Wash; 
Network[B]: 20; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 161. Waco, Tex; 
Network[B]: 17; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 162. Walla Walla, Wash; 
Network[B]: 20; 
Low acute inpatient workload: Total projected demand[F]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 163. Washington, D. C; 
Network[B]: 5; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Add one or more inpatient service(s)[H]. 

VA medical facility[A]: 164. West Haven, Conn; 
Network[B]: 1; 
Potential inpatient service duplication: Tertiary care[C]. 

VA medical facility[A]: 165. West Los Angeles, Calif; 
Network[B]: 22; 
Potential inpatient service duplication: Tertiary care[C]; 
Potential inpatient service duplication: Acute medicine care[D]. 

VA medical facility[A]: 166. West Palm Beach, Fla; 
Network[B]: 8; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 167. West Roxbury, Mass; 
Network[B]: 1; 
Potential inpatient service duplication: Acute medicine care[D]; 
Potential inpatient service duplication: Other care[E]; 
VA's May 7, 2004, decisions to add, close, or study inpatient services: 
Study ways to align inpatient services[J]. 

VA medical facility[A]: 168. White City, Oreg; 
Network[B]: 20; 
Potential inpatient service duplication: Other care[E]. 

VA medical facility[A]: 169. White River Junction, Vt; 
Network[B]: 1. 

VA medical facility[A]: 170. Wichita, Kans; 
Network[B]: 15. 

VA medical facility[A]: 171. Wilkes-Barre, Pa; 
Network[B]: 4. 

VA medical facility[A]: 172. Wilmington, Del; 
Network[B]: 4; 
Potential inpatient service duplication: Acute medicine care[D]. 

Source: GAO analysis of VA data. 

[A] VA medical facilities where VA owns capital assets that are used, 
at least in part, for inpatient health care services. 

[B] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, which are to coordinate 
the activities of and allocate resources to VA health care facilities. 
VA had 22 networks until January 2002, when it merged Networks 13 and 
14 to form a new network, Network 23. 

[C] VA medical facilities that provide tertiary care services and are 
within 120 miles of another VA medical facility that provides tertiary 
care services and that VA identified as potentially duplicating 
inpatient services. 

[D] VA medical facilities that provide acute inpatient medicine 
services and are within 60 miles of another VA medical facility that 
provides acute inpatient medicine services and that VA identified as 
potentially duplicating inpatient services. 

[E] VA medical facilities that VA identified as close enough 
geographically to another VA medical facility for VA to consider 
whether inpatient services other than tertiary care or acute inpatient 
medicine were needed at both. The potentially duplicated inpatient 
services generally included psychiatric and long-term inpatient care; 
services that support inpatient care generally included administration 
and maintenance. 

[F] We identified low total projected acute inpatient demand when a VA 
medical facility that provided acute inpatient medicine services during 
the first half of fiscal year 2004, the time period immediately before 
VA made its CARES decisions, was projected to need fewer than 40 acute 
medicine, surgery, and psychiatry beds (combined) in fiscal years 2012 
and 2022. 

[G] VA identified other low acute inpatient workload, even if the total 
projected number of acute medicine, surgery, and psychiatry beds was 
expected to exceed 40 in fiscal years 2012 or 2022, when (1) it 
questioned the viability of a specific acute inpatient service, for 
example, because projections indicated that few beds would be needed 
for inpatient surgery or (2) low acute inpatient workload at an 
existing VA medical facility could result from decisions VA made about 
inpatient health care at other locations. 

[H] VA's decision to add an inpatient service means that one or more 
inpatient services will be added to an existing VA medical facility 
that did not provide the service. 

[I] VA's decision to close an inpatient service means that one or more 
inpatient services will be eliminated at a VA medical facility that 
provided the service. 

[J] We defined a study as one that could result in a decision to add or 
close an inpatient service at a VA medical facility. 

[K] VA studied its facilities in Network 12 during a pilot phase of 
CARES that was completed in February 2002. 

[L] VA decided to close all inpatient services at this medical 
facility. 

[M] In addition to its decision to add inpatient treatment for spinal 
cord injury and disorder to its medical facility in Denver, Colorado, 
VA also decided to build a replacement for this facility. Once the new 
medical facility is complete, VA will close the existing facility and 
transfer all inpatient care to the new facility. 

[End of table]

[End of section]

Appendix VI: VA's 77 Markets, Limitations in Geographic Access to 
Inpatient Services, and Alignment Decisions: 

Network and market[A]: 1--East; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Rhode Island and eastern 
Massachusetts. VA owns five inpatient medical facilities in this 
market, located in Bedford, Brockton, Jamaica Plain, and West Roxbury, 
Mass., and Providence, R.I. 

Network and market[A]: 1--Far North; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Maine. VA owns one inpatient 
medical facility in this market, located in Togus, Maine; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 1--North; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes New Hampshire and Vermont. 
VA owns two inpatient medical facilities in this market, located in 
Manchester, N.H., and White River Junction, Vt; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 1--West; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Connecticut and western 
Massachusetts. VA owns two inpatient medical facilities in this market, 
located in Northampton, Mass., and West Haven, Conn. 

Network and market[A]: 2--Central; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes east central upstate New 
York. VA owns one inpatient medical facility in this market, located in 
Syracuse, N.Y. 

Network and market[A]: 2--Eastern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern upstate New York. VA 
owns one inpatient medical facility in this market, located in Albany, 
N.Y. 

Network and market[A]: 2--Finger Lakes/ Southern Tier; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes west central upstate New 
York and parts of north central Pennsylvania. VA owns two inpatient 
medical facilities in this market, located in Bath and Canandaigua, 
N.Y. 

Network and market[A]: 2--Western; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes western upstate New York. VA 
owns two inpatient medical facilities in this market, located in 
Batavia and Buffalo, N.Y. 

Network and market[A]: 3--Long Island; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Long Island, New York. VA 
owns one inpatient medical facility in this market, located in 
Northport, N.Y. 

Network and market[A]: 3--Metro New York; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes New York City and the Hudson 
Valley area of New York. VA owns six inpatient medical facilities in 
this market, located in Brooklyn, the Bronx, Castle Point, Manhattan, 
Montrose, and St. Albans, N.Y. 

Network and market[A]: 3--New Jersey; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes northern New Jersey. VA owns 
two inpatient medical facilities in this market, located in East Orange 
and Lyons, N.J. 

Network and market[A]: 4--Eastern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Delaware, southern New 
Jersey, eastern Pennsylvania, and part of New York. VA owns five 
inpatient medical facilities in this market, located in Coatesville, 
Lebanon, Philadelphia, and Wilkes-Barre, Pa., and Wilmington, Del. 

Network and market[A]: 4--Western; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes western Pennsylvania and 
parts of three other states: New York, Ohio, and West Virginia. VA owns 
seven inpatient medical facilities in this market, located in Altoona, 
Butler, Erie, and Pittsburgh, Pa. (Heinz Center, Highland Drive, and 
University Drive), and Clarksburg, W.Va. 

Network and market[A]: 5--Baltimore; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Maryland. VA owns 
three inpatient medical facilities in this market, located in 
Baltimore, Loch Raven, and Perry Point, Md. 

Network and market[A]: 5--Martinsburg; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes western Maryland, 
northwestern Virginia, eastern West Virginia, and part of Pennsylvania. 
VA owns one inpatient medical facility in this market, located in 
Martinsburg, W.Va. 

Network and market[A]: 5--Washington, D.C; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes the District of Columbia and 
parts of both Maryland and Virginia. VA owns one inpatient medical 
facility in this market, located in Washington, D.C; 
VA identification of limitations in geographic access to inpatient 
care: Long-term care[F]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Add one or more VA inpatient service(s)[F]. 

Network and market[A]: 6--Northeast; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes parts of eastern Virginia 
and northeastern North Carolina. VA owns two inpatient medical 
facilities in this market, located in Hampton and Richmond, Va. 

Network and market[A]: 6--Northwest; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes parts of western Virginia 
and southeastern West Virginia. VA owns two inpatient medical 
facilities in this market, located in Beckley, W.Va., and Salem, Va. 

Network and market[A]: 6--Southeast; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of eastern North 
Carolina and part of South Carolina. VA owns two inpatient medical 
facilities in this market, located in Durham and Fayetteville, N.C; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 6--Southwest; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of western North 
Carolina. VA owns two inpatient medical facilities in this market, 
located in Asheville and Salisbury, N.C. 

Network and market[A]: 7--Alabama; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Alabama and part of 
western Georgia. VA owns four inpatient medical facilities in this 
market, located in Birmingham, Montgomery, Tuscaloosa, and Tuskegee, 
Ala; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 7--Georgia; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Georgia and part of 
South Carolina. VA owns four inpatient medical facilities in this 
market, located in Atlanta, Augusta (Downtown and Uptown), and Dublin, 
Ga. 

Network and market[A]: 7--South Carolina; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of South Carolina and 
part of Georgia. VA owns two inpatient medical facilities in this 
market, located in Charleston and Columbia, S.C; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 8--Atlantic; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes southeast Florida. VA owns 
two inpatient medical facilities in this market, located in Miami and 
West Palm Beach, Fla. 

Network and market[A]: 8--Central; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes the central part of Florida. 
VA owns two inpatient medical facilities in this market, located in 
Orlando and Tampa, Fla; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Add one or more VA inpatient service(s)[G]. 

Network and market[A]: 8--Gulf; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes part of southwestern 
Florida. VA owns one inpatient medical facility in this market, located 
in Bay Pines, Fla; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 8--North; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of northern Florida and 
part of southern Georgia. VA owns two inpatient medical facilities in 
this market, located in Gainesville and Lake City, Fla; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 8--Puerto Rico; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Puerto Rico, the U.S. Virgin 
Islands of St. Thomas and St. Croix, and Arecibo. VA owns one inpatient 
medical facility in this market, located in San Juan, P.R. 

Network and market[A]: 9--Central; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes central Tennessee and parts 
of both Georgia and Kentucky. VA owns two inpatient medical facilities 
in this market, located in Murfreesboro and Nashville, Tenn. 

Network and market[A]: 9--Eastern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Tennessee and parts 
of three other states: Kentucky, North Carolina, and Virginia. VA owns 
one inpatient medical facility in this market, located in Mountain 
Home, Tenn. 

Network and market[A]: 9--Northern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Kentucky and parts 
of three other states: Indiana, Ohio, and West Virginia. VA owns four 
inpatient medical facilities in this market, located in Huntington, 
W.Va., and Lexington (Cooper and Leestown) and Louisville, Ky. 

Network and market[A]: 9--Western; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Arkansas, northern 
Mississippi, and western Tennessee. VA owns one inpatient medical 
facility in this market, located in Memphis, Tenn. 

Network and market[A]: 10--Central; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes the southern central portion 
of Ohio. VA owns one inpatient medical facility in this market, located 
in Chillicothe, Ohio; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 10--Eastern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes northeastern Ohio. VA owns 
two inpatient medical facilities in this market, located in Cleveland, 
Ohio (Brecksville and Wade Park); 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 10--Western; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes southwestern Ohio and parts 
of both Indiana and Kentucky. VA owns three inpatient medical 
facilities in this market, located in Cincinnati and Dayton, Ohio, and 
Fort Thomas, Ky. 

Network and market[A]: 11--Central Illinois; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes the eastern central portion 
of Illinois and part of western Indiana. VA owns one inpatient medical 
facility in this market, located in Danville, Ill; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 11--Indiana; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Indiana and part of 
Ohio. VA owns three inpatient medical facilities in this market, 
located in Fort Wayne, Indianapolis, and Marion, Ind. 

Network and market[A]: 11--Michigan; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes lower Michigan and part of 
northwest Ohio. VA owns four inpatient medical facilities in this 
market, located in Ann Arbor, Battle Creek, Detroit, and Saginaw, Mich; 
VA identification of limitations in geographic access to inpatient 
care: Long-term care[H]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Study options for care[H]. 

Network and market[A]: 12--Central[I]; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Wisconsin and parts 
of both Illinois and Minnesota. VA owns three inpatient medical 
facilities in this market, located in Madison, Milwaukee, and Tomah, 
Wis. 

Network and market[A]: 12--Northern[I]; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Michigan's Upper Peninsula 
and northeastern Wisconsin. VA owns one inpatient medical facility in 
this market, located in Iron Mountain, Mich. 

Network and market[A]: 12--Southern[I]; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes parts of northeastern 
Illinois and northwestern Indiana. VA owns three inpatient medical 
facilities in this market, located in Chicago--West Side, Hines, and 
North Chicago, Ill. 

Network and market[A]: 15--Central; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Kansas, most of 
western Missouri, and part of Illinois. VA owns four inpatient medical 
facilities in this market, located in Columbia and Kansas City, Mo., 
and Leavenworth and Topeka, Kans. 

Network and market[A]: 15--Eastern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes southern Illinois, western 
Kentucky, eastern Missouri, and parts of both Arkansas and Indiana. VA 
owns four inpatient medical facilities in this market, located in 
Marion, Ill., and Poplar Bluff and St. Louis (Jefferson Barracks and 
John Cochran), Mo. 

Network and market[A]: 15--Western; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of western Kansas. VA 
owns one inpatient medical facility in this market, located in Wichita, 
Kans. 

Network and market[A]: 16--Central Lower; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes western Louisiana, eastern 
Texas, and part of Arkansas. VA owns three inpatient medical facilities 
in this market, located in Alexandria and Shreveport, La., and Houston, 
Tex. 

Network and market[A]: 16--Central Southern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Louisiana and most 
of Mississippi. VA owns four inpatient medical facilities in this 
market, located in Biloxi, Gulfport, and Jackson, Miss., and New 
Orleans, La. 

Network and market[A]: 16--Eastern Southern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes parts of southern Alabama 
and western Florida. VA does not own any inpatient medical facilities 
in this market; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 16--Upper Western; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Arkansas and 
Oklahoma and parts of both Missouri and Texas. VA owns five inpatient 
medical facilities in this market, located in Fayetteville, Little 
Rock, and North Little Rock, Ark., and Muskogee and Oklahoma City, 
Okla. 

Network and market[A]: 17--Central; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes the central portion of 
Texas. VA owns two inpatient medical facilities in this market, located 
in Temple and Waco, Tex; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 17--North; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes part of north Texas and part 
of Oklahoma. VA owns two inpatient medical facilities in this market, 
located in Bonham and Dallas, Tex. 

Network and market[A]: 17--Southern; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes south central Texas. VA owns 
two inpatient medical facilities in this market, located in Kerrville 
and San Antonio, Tex. 

Network and market[A]: 17--Valley - Coastal Bend; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes southern Texas. VA does not 
own any inpatient medical facilities in this market; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 18--Arizona; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Arizona. VA owns three 
inpatient medical facilities in this market, located in Phoenix, 
Prescott, and Tucson, Ariz. 

Network and market[A]: 18--New Mexico - West Texas; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes New Mexico, western Texas, 
and parts of southern Colorado and western Oklahoma. VA owns three 
inpatient medical facilities in this market, located in Albuquerque, N. 
Mex., and Amarillo and Big Spring, Tex; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA 
providers[D][E,J]. 

Network and market[A]: 19--Eastern Rockies; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Colorado, 
southeastern Wyoming, and parts of both Kansas and Nebraska. VA owns 
two inpatient medical facilities in this market, located in Denver, 
Colo., and Cheyenne, Wyo; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 19--Grand Junction; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes western Colorado and 
southeastern Utah. VA owns one inpatient medical facility in this 
market, located in Grand Junction, Colo. 

Network and market[A]: 19--Montana; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Montana and part of 
western North Dakota. VA owns two inpatient medical facilities in this 
market, located in Fort Harrison and Miles City, Mont; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA 
providers[D][E,J]. 

Network and market[A]: 19--Western Rockies; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Utah and parts of 
three other states: Idaho, Nevada, and Wyoming. VA owns one inpatient 
medical facility in this market, located in Salt Lake City, Utah. 

Network and market[A]: 19--Wyoming; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of northern Wyoming. VA 
owns one inpatient medical facility in Sheridan, Wyo. 

Network and market[A]: 20--Alaska; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Alaska. VA owns one 
inpatient medical facility in this market, located in Anchorage, 
Alaska; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][J]. 

Network and market[A]: 20--Inland North; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes eastern Washington, northern 
Idaho, northeastern Oregon, and part of northwest Montana. VA owns two 
inpatient medical facilities in this market, located in Spokane and 
Walla Walla, Wash; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA 
providers[D][E,J]. 

Network and market[A]: 20--Inland South; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes parts of eastern Oregon and 
southern Idaho. VA owns one inpatient medical facility in this market, 
located in Boise, Idaho; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][J]. 

Network and market[A]: 20--South Cascades; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes western Oregon, southwestern 
Washington, and part of northwestern California. VA owns four inpatient 
medical facilities in this market, located in Portland, Roseburg, and 
White City, Oreg., and Vancouver, Wash; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 20--Western Washington; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of western Washington. 
VA owns two inpatient medical facilities in this market, located in 
American Lake and Seattle, Wash. 

Network and market[A]: 21--North Coast; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes northern coastal California. 
VA owns two inpatient medical facilities in this market, located in 
Martinez and San Francisco, Calif. 

Network and market[A]: 21--North Valley; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes north central California. VA 
owns one inpatient medical facility in this market, located in 
Sacramento, Calif. 

Network and market[A]: 21--Pacific Islands; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes Hawaii and other Pacific 
Islands such as Guam, the Philippines, and American Samoa. VA owns one 
inpatient medical facility in this market, located in Honolulu, Hawaii; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][J]. 

Network and market[A]: 21--Sierra Nevada; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes northeastern California and 
western Nevada. VA owns one inpatient medical facility in this market, 
located in Reno, Nev; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][J]. 

Network and market[A]: 21--South Coast; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes part of central California. 
VA owns three inpatient medical facilities in this market, located in 
Livermore, Menlo Park, and Palo Alto, Calif; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 21--South Valley; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes part of central California. 
VA owns one inpatient medical facility in this market, located in 
Fresno, Calif. 

Network and market[A]: 22--California; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes southern California. VA owns 
five inpatient medical facilities in this market, located in Loma 
Linda, Long Beach, San Diego, Sepulveda, and West Los Angeles, Calif. 

Network and market[A]: 22--Nevada; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes southern Nevada. VA does not 
own any inpatient medical facilities in this market; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C][K]; 
VA identification of limitations in geographic access to inpatient 
care: Long-term care[L]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Add one or more VA inpatient service(s)[G,L]. 

Network and market[A]: 23--Iowa; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Iowa and parts of 
both Illinois and Missouri. VA owns three inpatient medical facilities 
in this market, located in Des Moines, Iowa City, and Knoxville, Iowa; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 23--Minnesota; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Minnesota and part 
of northwestern Wisconsin. VA owns two inpatient medical facilities in 
this market, located in Minneapolis and St. Cloud, Minn; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Network and market[A]: 23--Nebraska; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of Nebraska and parts 
of three other states: Iowa, Kansas, and Missouri. VA owns two 
inpatient medical facilities in this market, located in Grand Island 
and Omaha, Nebr. 

Network and market[A]: 23--North Dakota; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of North Dakota and 
parts of both Minnesota and South Dakota. VA owns one inpatient medical 
facility in this market, located in Fargo, N. Dak; 
VA identification of limitations in geographic access to inpatient 
care: Tertiary care[B]; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA 
providers[D][E,J]. 

Network and market[A]: 23--South Dakota; 
Geographic area covered by market and the VA inpatient medical 
facilities within it: This market includes most of South Dakota and 
parts of five other states: Iowa, Minnesota, Nebraska, North Dakota, 
and Wyoming. VA owns three inpatient medical facilities in this market, 
located in Fort Meade, Hot Springs, and Sioux Falls, S. Dak; 
VA identification of limitations in geographic access to inpatient 
care: Acute care[C]; 
VA's May 7, 2004, decisions for improving access to tertiary, acute, or 
long-term inpatient care: Enter agreement with non-VA providers[D][E]. 

Source: GAO analysis of VA data. 

Notes: Markets with three blank cells under the heading "VA 
identification of limitations in geographic access to inpatient care" 
were not identified by VA as having limitations in geographic access to 
tertiary, acute, or long-term care and will therefore have blank 
entries in the cells under the heading "VA's May 7, 2004, decisions for 
improving access to tertiary, acute, or long-term inpatient care." VA's 
May 7, 2004, decisions did not address another aspect of veterans' 
access to health care--the time that veterans wait to obtain 
appointments at VA medical facilities--because waiting times are 
related to multiple operational issues, such as staffing and resources, 
in addition to capital infrastructure. 

[A] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, which are to coordinate 
the activities of and allocate resources to VA health care facilities. 
VA had 22 networks until January 2002, when it merged Networks 13 and 
14 to form a new network, Network 23. VA defines a health care market 
as a geographic area having a sufficient population and geographic size 
to benefit from the coordination and planning of health care services 
and to support a full health care delivery system. Each VA network 
includes from 2 to 6 markets; 
nationwide, VA has 77 markets. 

[B] VA identified limitations in geographic access to tertiary care in 
a market when more than 35 percent and at least 12,000 of the veterans 
enrolled for VA health care who reside in that market exceeded VA's 
driving time standards for reaching a VA health care facility of 240 
minutes for urban and rural areas or the community standard for highly 
rural areas. Urban areas included counties designated as metropolitan 
by the U.S. Census Bureau and counties with a population density of 
more than 166 people per square mile. Rural areas included counties 
that are not designated as metropolitan and have a population density 
of 26 to 166 people per square mile. Highly rural counties included 
counties with a population density of less than 26 people per square 
mile and counties designated as highly rural by the VA health care 
network in which the county is located. 

[C] VA identified limitations in geographic access to acute inpatient 
care in a market when more than 35 percent, and at least 12,000, of the 
veterans enrolled for VA health care who reside in that market exceeded 
VA's driving time standards for reaching a VA health care facility of 
60 minutes for urban areas, 90 minutes for rural areas, and 120 minutes 
for highly rural areas. Urban areas included counties designated as 
metropolitan by the U.S. Census Bureau and counties with a population 
density of more than 166 people per square mile. Rural areas included 
counties that are not designated as metropolitan and have a population 
density of 26 to 166 people per square mile. Highly rural counties 
included counties with a population density of less than 26 people per 
square mile and counties designated as highly rural by the VA health 
care network in which the county is located. 

[D] Options for VA to enter into an agreement with non-VA providers 
include contracting with non-VA providers, leasing space at non-VA 
medical facilities, or collaborating with the Department of Defense. 

[E] Acute inpatient care. 

[F] Domiciliary care. 

[G] Inpatient medicine, surgery, and psychiatry to be provided in a new 
VA-owned hospital. 

[H] Residential rehabilitation for post-traumatic stress disorder and 
substance abuse in the Detroit area. 

[I] VA studied its markets in Network 12 during a pilot phase of CARES 
that was completed in February 2002. 

[J] Tertiary care. 

[K] At the time VA made its CARES decisions, VA collaborated with the 
Department of Defense to provide acute inpatient health care services 
in Las Vegas, Nev., by having VA staff provide services to veterans in 
a hospital at a local Air Force base. Through CARES, VA identified the 
Nevada market as needing evaluation of options for improving access to 
acute inpatient services based on its concern that this collaborative 
arrangement would not provide sufficient capacity to meet veterans' 
needs throughout the CARES planning horizon. 

[L] Nursing home care. 

[End of table]

[End of section]

Appendix VII: VA's 21 Networks, Limitations in Geographic Access to 
Specialized Inpatient Services, and Alignment Decisions: 

Network[A]: 1; 
Description of geographic area: This network includes Connecticut, 
Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. 

Network[A]: 2; 
Description of geographic area: This network includes upstate New York 
and parts of north central Pennsylvania; 
Type of specialized inpatient care: Spinal cord injury and disorder; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Add inpatient VA service[B]. 

Network[A]: 3; 
Description of geographic area: This network includes parts of New York 
(the Hudson Valley, Long Island, and New York City) and northern New 
Jersey. 

Network[A]: 4; 
Description of geographic area: This network includes Delaware; 
most of Pennsylvania; 
southern New Jersey; and parts of three other states: New York, Ohio, 
and West Virginia. 

Network[A]: 5; 
Description of geographic area: This network includes the District of 
Columbia, Maryland, northern Virginia, eastern West Virginia, and part 
of Pennsylvania. 

Network[A]: 6; 
Description of geographic area: This network includes most of North 
Carolina and Virginia, southeastern West Virginia, and part of South 
Carolina. 

Network[A]: 7; 
Description of geographic area: This network includes most of Alabama, 
Georgia, and South Carolina. 

Network[A]: 8; 
Description of geographic area: This network includes most of Florida, 
part of southern Georgia, Puerto Rico, the U.S. Virgin Islands of St. 
Thomas and St. Croix, and Arecibo; 
Type of specialized inpatient care: Spinal cord injury and disorder; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Study options for care. 

Network[A]: 9; 
Description of geographic area: This network includes Tennessee; most 
of Kentucky; eastern Arkansas; northern Mississippi; and parts of six 
other states: Georgia, Indiana, North Carolina, Ohio, Virginia, and 
West Virginia. 

Network[A]: 10; 
Description of geographic area: This network includes most of Ohio and 
parts of both Indiana and Kentucky. 

Network[A]: 11; 
Description of geographic area: This network includes the eastern 
central portion of Illinois, most of Indiana, lower Michigan, and part 
of Ohio. 

Network[A]: 12; 
Description of geographic area: This network includes Michigan's Upper 
Peninsula, most of Wisconsin, northern Illinois, and parts of both 
Indiana and Minnesota. 

Network[A]: 15; 
Description of geographic area: This network includes most of Kansas 
and Missouri; southern Illinois; and parts of three other states: 
Arkansas, Indiana, and Kentucky. 

Network[A]: 16; 
Description of geographic area: This network includes Louisiana; 
most of Arkansas, Mississippi, and Oklahoma; eastern Texas; and parts 
of three other states: Alabama, Florida, and Missouri; 
Type of specialized inpatient care: Spinal cord injury and disorder; 
Type of specialized inpatient care: Blind rehabilitation; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Add inpatient VA service[C]; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Study options for care. 

Network[A]: 17; 
Description of geographic area: This network includes central Texas and 
part of Oklahoma. 

Network[A]: 18; 
Description of geographic area: This network includes Arizona, New 
Mexico, western Texas, and parts of southern Colorado and western 
Oklahoma. 

Network[A]: 19; 
Description of geographic area: This network includes Utah; most of 
Colorado, Montana, and Wyoming; and parts of five other states: Idaho, 
Kansas, Nebraska, Nevada, and North Dakota; 
Type of specialized inpatient care: Spinal cord injury and disorder; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Add inpatient VA service[B]. 

Network[A]: 20; 
Description of geographic area: This network includes Alaska, Oregon, 
and Washington; most of Idaho; and parts of both California and 
Montana. 

Network[A]: 21; 
Description of geographic area: This network includes Hawaii; 
northern California; western Nevada; and Pacific Islands such as Guam, 
the Philippines, and American Samoa. 

Network[A]: 22; 
Description of geographic area: This network includes southern 
California and southern Nevada; 
Type of specialized inpatient care: Blind rehabilitation; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Add inpatient VA service[C]. 

Network[A]: 23; 
Description of geographic area: This network includes Iowa and South 
Dakota; most of Minnesota, Nebraska, and North Dakota; and parts of 
five other states: Illinois, Kansas, Missouri, Wisconsin, and Wyoming; 
Type of specialized inpatient care: Spinal cord injury and disorder; 
VA's May 7, 2004, decisions for improving access to specialized 
inpatient treatment of spinal cord injury and disorder or blind 
rehabilitation: Add inpatient VA service[B]. 

Source: GAO analysis of VA data. 

[A] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, which are to coordinate 
the activities of and allocate resources to VA health care facilities. 
VA had 22 networks until January 2002, when it merged Networks 13 and 
14 to form a new network, Network 23. 

[B] Inpatient treatment for spinal cord injury and disorder. 

[C] Inpatient blind rehabilitation. 

[End of table]

[End of section]

Appendix VIII: Comments from the Department of Veterans Affairs: 

THE SECRETARY OF VETERANS AFFAIRS: 
WASHINGTON:

February 28, 2005:

Ms. Cynthia A. Bascetta: 
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:

Dear Ms. Bascetta:

The Department of Veterans Affairs (VA) has reviewed your draft report, 
VA HEALTH CARE: Important Steps Taken to Enhance Veterans' Care by 
Aligning Inpatient Services With Projected Needs (GAO-05-160) and 
concurs with the information as presented. It is consistent with the 
information VA and GAO discussed and shared during the course of your 
review.

Neither medical science nor the veteran population is static and 
unchanging, and VA needs to modernize its facilities to provide quality 
care. To honor our Nation's commitment to veterans, our medical system 
must evolve with the times. While the practice of VA medicine has 
evolved, VA's medical infrastructure has not kept up.

VA's Capital Asset Realignment for Enhanced Services (CARES) process 
was initiated in 1999 to provide VA, veterans, the Congress, and the 
American people with a 20-year plan to provide the infrastructure VA 
will need to provide 21st Century veterans with 21ST Century medical 
care. VA is currently in the process of implementing CARES decisions 
and has initiated 28 major construction projects utilizing funds 
provided in FY 2004 and 2005. CARES is not a simple one-time solution, 
but the creation of a set of tools and a process for annual capital and 
strategic planning.

VA looks forward to working with its stakeholders to include the 
Congress and the United States Government Accountability Office as we 
partner to fulfill this commonly held vision. I appreciate the 
opportunity to comment on your draft report.

Sincerely yours,

Signed for: 

R. James Nicholson: 

[End of section]

Appendix IX: GAO Contact and Acknowledgments: 

GAO Contact: 

James C. Musselwhite, (202) 512-7259: 

Acknowledgments: 

In addition to the person named above, key contributors to this report 
were Kristen Joan Anderson, Frederick Caison, Steven R. Gregory, Janet 
Overton, and Paul Reynolds. 

[End of section]

Related GAO Products: 

Budget Issues: Agency Implementation of Capital Planning Principles Is 
Mixed. GAO-04-138. Washington, D.C.: January 16, 2004. 

Federal Real Property: Vacant and Underutilized Properties at GSA, VA, 
and USPS. GAO-03-747. Washington, D.C.: August 19, 2003. 

VA Health Care: Framework for Analyzing Capital Asset Realignment for 
Enhanced Services Decisions. GAO-03-1103R. Washington, D.C.: August 18, 
2003. 

Department of Veterans Affairs: Key Management Challenges in Health and 
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003. 

VA Health Care: Improved Planning Needed for Management of Excess Real 
Property. GAO-03-326. Washington, D.C.: January 29, 2003. 

High-Risk Series: Federal Real Property. GAO-03-122. Washington, D.C.: 
January 2003. 

Major Management Challenges and Program Risks: Department of Veterans 
Affairs. GAO-03-110. Washington, D.C.: January 2003. 

VA Health Care: More National Action Needed to Reduce Waiting Times, 
but Some Clinics Have Made Progress. GAO-01-953. Washington, D.C.: 
August 31, 2001. 

VA Health Care: Community-Based Clinics Improve Primary Care Access. 
GAO-01-678T. Washington, D.C.: May 2, 2001. 

VA Health Care: VA Is Struggling to Address Asset Realignment 
Challenges. GAO/T-HEHS-00-88. Washington, D.C.: April 5, 2000. 

VA Health Care: Improvements Needed in Capital Asset Planning and 
Budgeting. GAO/HEHS-99-145. Washington, D.C.: August 13, 1999. 

VA Health Care: Challenges Facing VA in Developing an Asset Realignment 
Process. GAO/T-HEHS-99-173. Washington, D.C.: July 22, 1999. 

VA Health Care: Capital Asset Planning and Budgeting Need Improvement. 
GAO/T-HEHS-99-83. Washington, D.C.: March 10, 1999. 

FOOTNOTES

[1] These costs include the resources for operating VA's health care 
system, education and training of health care providers, administrative 
support, and capital investments necessary to support health care 
delivery. 

[2] In this report, we consider medical facilities to be the capital 
assets owned by VA at which it provides inpatient health care services 
to veterans. Medical facilities include tertiary and acute hospitals, 
nursing homes, and other extended care assets. VA also provides 
outpatient care at most of these facilities and owns health care assets 
at other locations where it provides only outpatient care. In addition, 
VA has arrangements with other health care providers to provide 
inpatient or outpatient care to veterans in certain locations where VA 
does not own assets. 

[3] See GAO, Veterans' Affairs: Progress and Challenges in Transforming 
Health Care, GAO/T-HEHS-99-109 (Washington D.C.: Apr. 15, 1999). 

[4] See GAO, VA Health Care: Capital Asset Planning and Budgeting Need 
Improvement, GAO/T-HEHS-99-83 (Washington, D.C.: Mar. 10, 1999); VA 
Health Care: Improvements Needed in Capital Asset Planning and 
Budgeting, GAO/HEHS-99-145 (Washington D.C.: Aug. 13, 1999); and Budget 
Issues: Agency Implementation of Capital Planning Principles Is Mixed, 
GAO-04-138 (Washington, D.C.: Jan. 1, 2004). 

[5] In January 2003, we reported that over 30 federal agencies control 
a valuable portfolio of facilities and land and that federal real 
property is a high-risk area because of such long-standing problems as 
excess and underutilized real property and deteriorating facilities. 
GAO's designation of high-risk areas is intended to help Congress focus 
attention on the most important issues and challenges facing the 
federal government. See GAO, High-Risk Series: Federal Real Property, 
GAO-03-122 (Washington D.C.: January 2003). Also see GAO, Federal Real 
Property: Vacant and Underutilized Properties at GSA, VA, and USPS, GAO-
03-747 (Washington, D.C.: Aug. 19, 2003). 

[6] A health care market is a geographic area having sufficient 
population and geographic size to (1) benefit from the coordination and 
planning of health care services delivered by either VA facilities or 
non-VA facilities and (2) support a continuum of care, including 
inpatient and outpatient care. 

[7] VA health care facilities are organized into 21 regional networks, 
known as Veterans Integrated Service Networks, that are structured to 
manage and allocate resources to VA health care facilities. Each VA 
network includes from two to six markets. VA had 22 networks until 
January 2002, when it merged Networks 13 and 14 to form a new network, 
Network 23. 

[8] Department of Veterans Affairs, Secretary of Veterans Affairs: 
CARES Decision (Washington, D.C.: May 7, 2004). 

[9] In February 2002, VA completed a CARES pilot project that assessed 
current and future use of health care assets in the three markets of 
Network 12, which includes parts of five states: Illinois, Indiana, 
Michigan, Minnesota, and Wisconsin. At that time, VA announced its 
decision to, among other things, discontinue inpatient health care 
services at its Lakeside medical facility in Chicago, Illinois, one of 
eight inpatient medical facilities that VA had in these markets. 

[10] Tertiary care includes specialized diagnostic and treatment 
procedures, such as open heart surgery or neurosurgery, that are not 
necessarily available at all medical facilities that provide acute 
inpatient care. We defined realignment of tertiary care services as 
either eliminating all tertiary care at a facility that provided some 
tertiary care or adding tertiary care to an existing or new VA facility 
where VA did not provide any tertiary care. 

[11] Domiciliary care involves coordinated rehabilitative and 
restorative clinical care in an inpatient setting, with the goal of 
helping veterans achieve and maintain the highest level of functioning 
and independence possible. Domiciliary care differs from other types of 
inpatient care in that bedside nursing is not required. 

[12] Department of Veterans Affairs, Draft National CARES Plan 
(Washington, D.C.: Aug. 4, 2003). 

[13] A large number of these comments addressed a small set of VA 
medical facilities. For example, more than half of the comments were 
about a single facility in upstate New York. 

[14] CARES Commission, Capital Asset Realignment for Enhanced Services: 
Report to the Secretary of Veterans Affairs (Washington, D.C.: Feb. 12, 
2004). 

[15] Veterans Health Care, Capital Asset, and Business Improvement Act 
of 2003, Pub. L. No. 108-170,  222, 117 Stat. 2042, 2050-2051. 

[16] Some of these facilities also potentially duplicated acute 
inpatient surgery or psychiatry services. 

[17] Of the medical facilities that VA identified using these criteria, 
we included those that provided acute inpatient medicine services 
during the first half of fiscal year 2004, the time period immediately 
before VA made its CARES decisions. 

[18] VA used a zip-code-based analysis to calculate driving times from 
veterans' homes to the nearest VA-owned or VA-affiliated medical 
facility that provides acute or tertiary care. VA-affiliated medical 
facilities include hospitals that are owned by non-VA providers where 
VA has arranged for VA staff to provide care to veterans. 

[19] The Commission recommended that residential rehabilitation and 
domiciliary services be provided close to the towns or cities where 
veterans who receive those services typically live. The Secretary 
stated that VA's long-term care strategic plan would incorporate this 
consideration. 

[20] Through CARES, VA also decided to build a replacement for its 
hospital in Denver, Colorado. Once the new medical facility is 
complete, VA will close the existing facility and transfer all 
inpatient care to the new facility. 

[21] Office of Management and Budget, Capital Programming Guide, 
Version 1.0 (Washington, D.C.: July 1997). 

[22] See GAO, VA Health Care: Framework for Analyzing Capital Asset 
Realignment for Enhanced Services Decisions, GAO-03-1103R (Washington, 
D.C.: Aug. 18, 2003). 

[23] At the time VA made its CARES decisions, VA collaborated with the 
Department of Defense to provide inpatient hospital services in Las 
Vegas, Nevada, by having VA staff provide services to veterans in a 
hospital at Nellis Air Force Base. 

[24] VA also deferred, pending further study, some decisions about 
potential alignment options at one medical facility and one network 
where it had already made some decisions on inpatient services. These 
locations are VA's medical facility at Muskogee, Oklahoma, and Network 
16, which includes Louisiana; most of Arkansas, Mississippi, and 
Oklahoma; eastern Texas; and parts of Alabama, Florida, and Missouri. 
In addition to its decision to close inpatient surgery at the facility 
in Muskogee, Oklahoma, VA will study further whether to add inpatient 
psychiatry services to that facility and whether to contract with non- 
VA providers to meet veterans' inpatient health care needs in the 
Muskogee/Tulsa region. In addition to VA's decision to add an inpatient 
blind rehabilitation center in Network 16, VA will study further which 
of its medical facilities in Network 16 would be the best location for 
a new inpatient center for the treatment of spinal cord injury and 
disorder. 

[25] VA has decided to use a contractor to complete most of these 
studies. It expects the contractor to begin the studies by spring of 
2005. VA expects that most of the studies will require from 4 to 9 
months to complete. VA also reported that one study has already been 
completed and that one other study will not begin for approximately 5 
years because options for realignment of inpatient workload at the 
medical facility to be studied depend on major construction at a nearby 
VA medical facility. 

[26] Department of Veterans Affairs, Secretary of Veterans Affairs: 
CARES Decision (Washington, D.C.: May 7, 2004). 

[27] In February 2002, VA completed a CARES pilot project that assessed 
current and future use of health care assets in the three markets of 
Network 12, which includes parts of five states: Illinois, Indiana, 
Michigan, Minnesota, and Wisconsin. At that time, VA announced its 
decision to, among other things, discontinue inpatient health care 
services at its Lakeside medical facility in Chicago, Illinois, one of 
eight inpatient medical facilities that VA had in these markets. 

[28] In this report, we consider medical facilities to be the capital 
assets owned by VA at which it provides inpatient health care services 
to veterans. Medical facilities include tertiary and acute hospitals, 
nursing homes, and other extended care assets. 

[29] Domiciliary care involves coordinated rehabilitative and 
restorative clinical care in an inpatient setting, with the goal of 
helping veterans achieve and maintain the highest level of functioning 
and independence possible. Domiciliary care differs from other types of 
inpatient care in that bedside nursing is not required. 

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