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Mental Health Services Could Be Improved' which was released on May 
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Report to Congressional Requesters: 

United States Government Accountability Office: 
GAO: 

May 2010: 

VA Health Care: 

Reporting of Spending and Workload for Mental Health Services Could Be 
Improved: 

GAO-10-570: 

GAO Highlights: 

Highlights of GAO-10-570, a report to congressional requesters. 

Why GAO Did This Study: 

The Department of Veterans Affairs (VA) provides, or pays for, a range 
of mental health services for veterans. To effectively manage 
resources and ensure access to eligible veterans, VA needs complete 
spending and workload information for mental health services. This 
information is also important for congressional oversight. 

GAO was asked to examine VAs mental health spending and workload. In 
this report, GAO examined for fiscal year 2009 (1) VAs spending for 
mental health services and (2) VAs workload for mental health 
services. GAO examined VAs reporting of mental health spending and 
workload data for fiscal year 2009 in its fiscal year 2011 
congressional budget justification and whether VA reported these data 
in any other publicly available report. GAO analyzed additional mental 
health spending and workload data and interviewed VA officials. 

What GAO Found: 

VA reported in its fiscal year 2011 congressional budget justification 
spending about $4.4 billion on mental health services in fiscal year 
2009 in VA settings primarily used for providing mental health 
services. However, VA had additional spending in fiscal year 2009 for 
mental health services that VA did not report as mental health 
spending in its budget justification or in any other publicly 
available report. Specifically, VA did not report as mental health 
spending the amounts it spent for those mental health services that it 
(1) paid non-VA providers to provide in community settings and (2) 
provided in VA settings not primarily used for providing mental health 
services, such as nursing homes. VA also did not report as mental 
health spending the amount it spent for counseling services to address 
mental health issues provided by VA Vet Centers. Although VA did not 
report this spending information, VA does determine its spending for 
mental health services provided by non-VA providers and for outpatient 
mental health services provided in VA settings not primarily used for 
providing mental health services. According to VA officials, VA spent 
an additional $269 million for these services in fiscal year 2009. VA 
does not have complete spending information for inpatient hospital 
mental health services provided by mental health providers in VA 
settings not primarily used to provide mental health services nor does 
it have spending information for counseling services to address mental 
health issues provided by Vet Centers. 

In fiscal year 2009, VA provided mental health services to about 1.22 
million unique patients in VA settings primarily used for providing 
mental health services. However, VA did not report this information in 
its fiscal year 2011 congressional budget justification or in any 
other publicly available report. VA officials said that the number of 
unique patients is not available until after VAs budget justification 
is published. Additionally, VA did not report other workload 
information that it has on (1) the number of encounters for outpatient 
services and the average daily census for each of its inpatient 
hospital, residential, and domiciliary services provided in VA 
settings primarily used for providing mental health services and (2) 
the workload for mental health services provided in other settings
community settings for which VA paid non-VA providers to provide 
mental health services and VA settings not primarily used for 
providing mental health services. VA also did not report the workload 
for counseling services to address mental health issues provided by 
Vet Centers, but VA is able to estimate its workload for these 
services. 

VAs reporting of mental health spending and workload does not give 
Congress a complete overview of VAs mental health services and limits 
information available for congressional oversight of VAs mental 
health services. Reporting additional mental health spending and 
workload information could enhance information available for 
congressional oversight. 

What GAO Recommends: 

GAO recommends that VA report in its annual congressional budget 
justification or in a separate annual report that is publicly 
available additional workload and spending information for its mental 
health services. VA concurred with three recommendations, but did not 
concur with the recommendations regarding Vet Centers. GAO believes 
the Vet Center recommendations could be implemented while addressing 
VAs concerns. 

View [hyperlink, http://www.gao.gov/products/GAO-10-570] or key 
components. For more information, contact Randall B. Williamson at 
(202) 512-7114 or williamsonr@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

VA Reported Spending about $4.4 Billion for Mental Health Services in 
Fiscal Year 2009, but This Amount Did Not Include All Mental Health 
Services: 

VA Provided Mental Health Services to More Than 1 Million Unique 
Patients in Fiscal Year 2009, but VA Did Not Report Workload for All 
of Its Mental Health Services: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Comments from the Department of Veterans Affairs: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Description of Mental Health Services Provided by VA: 

Table 2: VA Workload for Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by Type 
of Service, Fiscal Year 2009: 

Table 3: Workload for Outpatient Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by VA 
Network, Fiscal Year 2009: 

Table 4: Workload for Inpatient Hospital Mental Health Services 
Provided in VA Settings Primarily Used for Providing Mental Health 
Services, by VA Network, Fiscal Year 2009: 

Table 5: Workload for Residential and Domiciliary Mental Health 
Services Provided in VA Settings Primarily Used for Providing Mental 
Health Services, by VA Network, Fiscal Year 2009: 

Figures: 

Figure 1: VA Spending on Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by Type 
of Service, Fiscal Year 2009: 

Figure 2: VA Spending on Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by VA 
Network, Fiscal Year 2009: 

Abbreviations: 

PTSD: post-traumatic stress disorder: 

VA: Department of Veterans Affairs: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

May 28, 2010: 

The Honorable Michael Michaud: 
Chairman: 
Subcommittee on Health: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable Brian Baird: 
House of Representatives: 

The Department of Veterans Affairs (VA) operates one of the largest 
health care delivery systems in the nation. VA provides, or pays for, 
a range of mental health services throughout its 21 health care 
networks[Footnote 1] for veterans with conditions such as depression, 
post-traumatic stress disorder (PTSD), and substance use disorders. 
With the ongoing military operations in Afghanistan and Iraq--
Operation Enduring Freedom and Operation Iraqi Freedom, respectively--
VA has experienced an increased demand for its mental health services. 
[Footnote 2] This growing demand highlights the importance of VA's 
goal to ensure that all eligible veterans, wherever they obtain care 
in VA, have access to needed mental health services.[Footnote 3] To 
effectively manage its resources and achieve its goal, VA needs 
complete and accurate information on the amount it spends each fiscal 
year to provide mental health services and on its mental health 
workload, which is the amount of mental health care VA provides. 

Complete and accurate information on VA's mental health spending and 
workload is also important for congressional oversight of VA's mental 
health services. Each year, VA develops annual spending and workload 
estimates for all of its medical services, including mental health 
care, and provides these estimates and supporting information in the 
budget justification that VA submits to the subcommittees with 
jurisdiction over its appropriations as part of the annual 
appropriations process. This information is used to conduct 
congressional oversight functions, for example determining the 
adequacy of VA funding and assessing VA's current efforts to address 
the mental health care of veterans. Complete and accurate mental 
health spending and workload information can help Congress effectively 
oversee VA's mental health services and identify VA's intended use of 
resources and workload. 

You expressed interest in obtaining information on VA's spending and 
workload for mental health services. In this report, we examined, for 
fiscal year 2009, (1) VA's spending for mental health services and (2) 
VA's workload for mental health services. As part of this work, we 
also examined VA's reporting of its fiscal year 2009 mental health 
spending and workload in VA's fiscal year 2011 congressional budget 
justification and whether VA reported this information in any other 
publicly available report. 

To perform our work, we obtained fiscal year 2009 data on VA's 
spending and workload for mental health services. Fiscal year 2009 
data were the most recently available spending and workload data at 
the time of our review. We used the data to examine VA's national 
spending and workload for mental health services as well as VA's 
spending and workload for each of its 21 health care networks. We also 
interviewed VA officials from the Veterans Health Administration's 
Office of Finance, Office of Mental Health Services, Mental Health 
Enhancement Initiative for Primary Care, and Mental Health Workload 
and Data Analysis Workgroup. We also obtained fiscal year 2009 data 
and interviewed officials from Veterans Health Administration's 
Readjustment Counseling Service to examine workload for counseling 
services to address mental health issues that are provided by Vet 
Centers--a nationwide system of community-based centers that VA 
established separately from its medical centers to provide 
readjustment counseling services to combat veterans.[Footnote 4] 
Fiscal year 2009 spending data were not available for Vet Centers' 
counseling services to address mental health issues. Additionally, we 
reviewed VA documents and interviewed VA officials to determine VA's 
reporting of spending and workload information for the services 
discussed in this report in its fiscal year 2011 congressional budget 
justification or whether VA reported this information in any other 
publicly available report. 

For our analysis of VA mental health spending, we used obligations-- 
VA's cost of providing or paying for mental health services for 
eligible veterans, including costs of administering mental health 
services, and national overhead, which includes the operating costs 
for VA headquarters, networks, and national programs. It does not 
include VA's costs of providing medications for the treatment of 
mental health conditions.[Footnote 5] For our analysis of VA mental 
health workload, we used the following four workload measures: (1) 
unique patients--unduplicated count of patients receiving a particular 
type of service, (2) encounters--professional contacts between 
patients and providers for outpatient services, (3) visits--one or 
more professional contacts between a patient and provider during a 
single day, and (4) average daily census--the average number of 
patients receiving inpatient services on any given day during the 
course of the year. We chose these measures because VA officials told 
us that they are key measures that are relevant for measuring mental 
health workload. We assessed the reliability of the information we 
obtained about VA's mental health spending and workload in several 
ways, including interviewing agency officials knowledgeable about VA's 
mental health services and about VA's mental health spending and 
workload data and the processes used to calculate them. We determined 
that the data we used were sufficiently reliable for the purposes of 
this report. 

We conducted this performance audit from April 2009 through May 2010 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. See appendix I 
for a complete description of our scope and methodology. 

Background: 

VA provides mental health services in each of its medical centers, 
which are located throughout VA's 21 health care networks, in settings 
primarily used for providing mental health services. In these 
settings, which include mental health clinics, VA provides outpatient, 
residential, domiciliary, and inpatient hospital mental health 
services. (See table 1 for a description of VA's mental health 
services.) The mental health services provided in these settings focus 
on rehabilitation-and recovery-oriented services to help patients with 
severe and persistent mental illnesses, including substance use 
disorders. 

Table 1: Description of Mental Health Services Provided by VA: 

Mental health service: Outpatient; 
Description: Outpatient services provide evaluation and treatment 
services that include ambulatory services, such as individual or group 
therapy, and telemental health services in which care is provided via 
a video connection between a VA mental health professional and patient 
who are located in different geographical areas. 

Mental health service: Residential; 
Description: Residential services provide rehabilitation, treatment, 
and a range of other services, which may include work therapy and 
social skills training in a structured living arrangement at a VA 
facility. VA provides specialized residential treatment services for 
mental health conditions, including PTSD and substance use disorder. 

Mental health service: Domiciliary; 
Description: Domiciliary services are a type of residential service. 
These services are provided as part of larger residential programs 
with multiple units serving various patient populations. 

Mental health service: Inpatient hospital; 
Description: Inpatient hospital services provide intensive treatment 
for patients admitted to hospitals for mental health conditions. 

Source: VA. 

[End of table] 

VA also provides mental health services in VA settings that are not 
primarily used to provide mental health services, such as nursing 
homes (also referred to by VA as community living centers) and spinal 
cord injury clinics. Additionally, in some situations, VA pays for 
mental health services provided by non-VA providers in community 
settings. When there are no VA facilities near the veteran's home or 
VA facilities are unable to provide certain mental health services on 
site, VA is authorized to enter into agreements with non-VA providers 
to provide these services.[Footnote 6] Specifically, VA facilities can 
make outpatient mental health services available from non-VA providers 
in the community who will accept VA payment--referred to as fee-basis 
care. In addition, VA facilities can contract with non-VA hospitals in 
the local community for inpatient hospital services--referred to as 
contract care. 

VA also provides counseling services that focus on mental health 
issues through VA Vet Centers. The counseling services to address 
mental health issues provided by Vet Centers differ from the mental 
health services provided by VA medical centers in that they focus on 
counseling to assist combat veterans in readjusting from wartime 
military service to civilian life. For example, the Vet Centers do not 
diagnose veterans' mental health conditions. These counseling services 
provided by Vet Centers focus on a range of issues, including PTSD, 
drug and alcohol abuse, sexual trauma, and family issues.[Footnote 7] 
Veterans needing more acute care--for example, veterans with mental 
health co-morbidities such as severe PTSD and depression or those who 
pose a risk of harm to themselves or others--are often referred to VA 
medical centers for further evaluation and treatment. The number of 
Vet Centers has increased from 232 in fiscal year 2008 to 271 in 
fiscal year 2009. VA plans to increase the number of Vet Centers from 
271 to 300 by the end of fiscal year 2011. 

VA Reported Spending about $4.4 Billion for Mental Health Services in 
Fiscal Year 2009, but This Amount Did Not Include All Mental Health 
Services: 

VA reported in its fiscal year 2011 congressional budget justification 
spending about $4.4 billion in fiscal year 2009 on mental health 
services in VA settings primarily used for providing mental health 
services. However, VA had additional spending in fiscal year 2009--for 
mental health services provided in other settings--that VA did not 
report as mental health spending in its congressional budget 
justification or in any other publicly available report. 

VA Reported Spending about $4.4 Billion in Fiscal Year 2009 for Mental 
Health Services in VA Settings Primarily Used for Providing Mental 
Health Services: 

In its fiscal year 2011 congressional budget justification, VA 
reported spending about $4.4 billion in fiscal year 2009 for mental 
health services provided in VA settings primarily used for mental 
health services.[Footnote 8],[Footnote 9] Outpatient services 
accounted for about 55 percent of this spending--about $2.4 billion--
in fiscal year 2009. (See fig. 1.) VA reported spending the remaining 
$2 billion on inpatient hospital services--which provide intensive 
treatment for patients admitted to hospitals for mental health 
conditions--and on residential and domiciliary services, which provide 
rehabilitation, treatment, and a range of other services in a 
structured living arrangement at a VA facility. 

Figure 1: VA Spending on Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by Type 
of Service, Fiscal Year 2009: 

[Refer to PDF for image: pie-chart] 

Outpatient: $2,445,432,000; 55%; 
Inpatient hospital: $1,322,505,000: 30%; 
Domiciliary: $414,587,000; 9%; 
Residential: $263,687,000: 6%. 

Source: GAO analysis of fiscal year 2009 data reported in VA's fiscal 
year 2011 congressional budget justification. 

Note: According to VA officials, this spending included about $60 
million for mental health services provided by mental health 
professionals who have been integrated in primary care clinics. 

[End of figure] 

In fiscal year 2009, VA's spending on mental health services provided 
in VA settings used primarily for mental health services varied across 
VA's 21 networks, ranging from about $123 million in Network 19 
(Denver) to about $297 million in Network 16 (Jackson). (See fig. 2.) 
Across VA's networks, outpatient services accounted for the largest 
percentage of each network's mental health spending in fiscal year 
2009, followed by inpatient hospital services, though specific 
spending amounts varied by each network. According to VA officials, 
this variation may be caused, in part, by the number of inpatient 
mental health beds within a network. Networks with more beds would 
likely have higher utilization of inpatient hospital mental health 
services, resulting in higher spending for mental health services. VA 
officials told us that they do not have data to identify all the 
factors that account for the variations in spending for mental health 
services across networks. 

Figure 2: VA Spending on Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by VA 
Network, Fiscal Year 2009: 

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

VA network: 19 (Denver); 
Outpatient: $69,073; 
Inpatient hospital: $40,304; 
Residential: $5,667; 
Domiciliary: $8,434; 
Total: $123,481. 

VA network: 2 (Albany); 
Outpatient: $84,132; 
Inpatient hospital: $23,308; 
Residential: $5,854; 
Domiciliary: $17,586; 
Total: $130,882, 

VA network: 18 (Phoenix); 
Outpatient: $82,228; 
Inpatient hospital: $31,843; 
Residential: $6,139; 
Domiciliary: $12,459; 
Total: $132,671. 

VA network: 9 (Nashville); 
Outpatient: $88,962; 
Inpatient hospital: $53,004; 
Residential: $10,799; 
Domiciliary: $13,429; 
Total: $166,196. 

VA network: 5 (Baltimore); 
Outpatient: $76,490; 
Inpatient hospital: $44,239; 
Residential: $14,886; 
Domiciliary: $36,270; 
Total: $171,887. 

VA network: 23 (Minneapolis); 
Outpatient: $118,399; 
Inpatient hospital: $34,497; 
Residential: $10,682; 
Domiciliary: $18,316; 
Total: $181,896. 

VA network: 15 (Kansas City); 
Outpatient: $91,622; 
Inpatient hospital: $64,251; 
Residential: $6,916; 
Domiciliary: $19,838; 
Total: $182,630. 

VA network: 11 (Ann Arbor); 
Outpatient: $95,491; 
Inpatient hospital: $69,999; 
Residential: $15,866; 
Domiciliary: $6,463; 
Total: $187,821. 

VA network: 17 (Dallas); 
Outpatient: $87,792; 
Inpatient hospital: $53,262; 
Residential: $17,329; 
Domiciliary: $36,870; 
Total: $195,255. 

VA network: 10 (Cincinnati); 
Outpatient: $116,628; 
Inpatient hospital: $42,617; 
Residential: $14,794; 
Domiciliary: $24,454; 
Total: $198,495. 

VA network: 20 (Portland); 
Outpatient: $122,943; 
Inpatient hospital: $42,963; 
Residential: $13,150; 
Domiciliary: $26,911; 
Total: $205,969. 

VA network: 12 (Chicago); 
Outpatient: $107,896; 
Inpatient hospital: $58,029; 
Residential: $17,003; 
Domiciliary: $30,843; 
Total: $213,773. 

VA network: 6 (Durham); 
Outpatient: $111,940; 
Inpatient hospital: $84,801; 
Residential: $12,958; 
Domiciliary: $8,523; 
Total: $218,224. 

VA network: 21 (San Francisco); 
Outpatient: $125,742; 
Inpatient hospital: $63,745; 
Residential: $22,271; 
Domiciliary: $11,709; 
Total: $223,469. 

VA network: 7 (Atlanta); 
Outpatient: $150,500; 
Inpatient hospital: $68,912; 
Residential: $8,835; 
Domiciliary: $22,067; 
Total: $252,317. 

VA network: 4 (Pittsburgh); 
Outpatient: $119,197; 
Inpatient hospital: $74,600; 
Residential: $14,156; 
Domiciliary: $44,413; 
Total: $252,369. 

VA network: 3 (Bronx); 
Outpatient: $122,151; 
Inpatient hospital: $92,222; 
Residential: $24,146; 
Domiciliary: $24,362; 
Total: $262,883. 

VA network: 22 (Long Beach); 
Outpatient: $144,772; 
Inpatient hospital: $102,229; 
Residential: $0; 
Domiciliary: $16,568; 
Total: $263,571. 

VA network: 8 (Bay Pines); 
Outpatient: $186,129; 
Inpatient hospital: $64,973; 
Residential: $22,063; 
Domiciliary: $14,007; 
Total: $287,175. 

VA network: 1 (Boston); 
Outpatient: $164,286; 
Inpatient hospital: $104,777; 
Residential: $12,380; 
Domiciliary: $10,677; 
Total: $292,122. 

VA network: 16 (Jackson); 
Outpatient: $170,591; 
Inpatient hospital: $107,970; 
Residential: $7,818; 
Domiciliary: $10,412; 
Total: $296,793. 

Source: GAO analysis of fiscal year 2009 VA data. 

Note: According to VA officials, this spending includes about $60 
million for mental health services provided by mental health 
professionals who have been integrated in primary care clinics. 

[End of figure] 

VA Spent Additional Amounts for Mental Health Services in Fiscal Year 
2009 but Did Not Report These as Mental Health Spending: 

In addition to the $4.4 billion VA reported spending in fiscal year 
2009 for mental health services provided in VA settings primarily used 
for mental health, VA spent additional amounts for mental health 
services. Specifically, VA (1) paid non-VA providers to provide mental 
health services in community settings; (2) provided mental health 
services through VA mental health providers in VA settings not 
primarily used for providing mental health services, such as nursing 
homes and spinal cord injury clinics; and (3) provided counseling 
services to address mental health issues through Vet Centers. However, 
VA did not report this spending as mental health spending in its 
fiscal year 2011 congressional budget justification or in any other 
publicly available report. 

VA determines how much it spends for some of these mental health 
services. According to VA officials, VA spent about $269.4 million in 
fiscal year 2009 for the following mental health services: 

* VA spent about $137.4 million for non-VA providers--such as 
community-based hospitals and mental health professionals--to provide 
mental health services to patients. 

* VA spent about $132 million on outpatient mental health services 
provided by mental health providers in VA settings not primarily used 
for providing mental health services. 

Although VA determines how much it spends for some of its mental 
health services, it did not report fiscal year 2009 spending for these 
mental health services as mental health spending in its fiscal year 
2011 congressional budget justification or in any other publicly 
available report. Instead, according to VA officials, VA includes this 
spending as part of broader categories of spending when reporting 
information in congressional budget justifications. For example, VA's 
reporting of outpatient care in its congressional budget justification 
includes part of VA's spending for outpatient mental health services 
provided by non-VA providers in community settings. VA officials told 
us VA does not report its spending for mental health services provided 
by non-VA providers in community settings in its congressional budget 
justifications because determining this spending requires data that 
are not available at the time the congressional budget justification 
is published. 

In contrast to the mental health services for which VA determines how 
much it spends, there are other mental health services for which VA 
does not have spending information for fiscal year 2009. According to 
VA officials, VA does not have complete spending information for 
inpatient hospital mental health services provided by mental health 
providers in VA settings not primarily used to provide mental health 
services. Additionally, VA does not have spending information for 
counseling services to address mental health issues provided by Vet 
Centers. 

VA officials told us that VA does not determine how much it spends for 
these services for several reasons. For inpatient hospital mental 
health services, VA officials told us that it does not have cost 
information for about 25 percent of the services. According to VA 
officials, determining the costs for inpatient hospital mental health 
services is a new process and VA is currently determining these costs. 
For counseling services to address mental health issues provided by 
Vet Centers, VA officials told us that separating spending for these 
services from total Vet Center spending is difficult because most 
veterans receive multiple services--counseling and social support 
services, such as employment and legal support--from Vet Centers. 

VA Provided Mental Health Services to More Than 1 Million Unique 
Patients in Fiscal Year 2009, but VA Did Not Report Workload for All 
of Its Mental Health Services: 

In fiscal year 2009, VA provided mental health services to about 1.22 
million unique patients in VA settings primarily used for providing 
mental health services. VA also provided mental health services 
through VA mental health providers in other VA settings, such as 
community settings for which VA paid non-VA providers to provide 
mental health services. However, VA did not report workload for all of 
its mental health services in its fiscal year 2011 congressional 
budget justification or in any other publicly available report. 

VA Provided Mental Health Services to about 1.22 Million Unique 
Patients in Fiscal Year 2009 in VA Settings Primarily Used for 
Providing Mental Health Services: 

VA provided mental health services to about 1.22 million unique 
patients in fiscal year 2009 in VA settings primarily used for mental 
health services.[Footnote 10] (See table 2.) Almost all of these 
patients received outpatient services. VA officials said that this is 
primarily because patients receiving mental health services generally 
only need outpatient services and do not need the more intensive 
inpatient hospital and residential services. Inpatient hospital, 
residential, and domiciliary mental health services accounted for 
significantly smaller proportions of the total number of unique 
patients receiving mental health services in fiscal year 2009. 

Table 2: VA Workload for Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by Type 
of Service, Fiscal Year 2009: 

Type of service: Inpatient hospital; 
Unique patients[A]: 65,299; 
Average daily census[B]: 3,011; 
Encounters[C]: N/A. 

Type of service: Residential; 
Unique patients[A]: 15,888; 
Average daily census[B]: 1,852; 
Encounters[C]: N/A. 

Type of service: Domiciliary; 
Unique patients[A]: 20,740; 
Average daily census[B]: 4,773; 
Encounters[C]: N/A. 

Type of service: Outpatient; 
Unique patients[A]: 1,218,661; 
Average daily census[B]: N/A; 
Encounters[C]: 13,812,175. 

Type of service: Total; 
Unique patients[A]: 1,222,485; 
Average daily census[B]: 9,636; 
Encounters[C]: 13,812,175. 

Source: GAO analysis of fiscal year 2009 VA data. 

Notes: According to VA officials, this workload includes patients who 
received mental health services from mental health professionals who 
have been integrated in primary care clinics. 

VA also pays non-VA providers to provide inpatient hospital and 
outpatient mental health services. The workload for these services is 
not included in this table. 

[A] Unique patients are determined for each type of service. The 
number of unique patients for each type of service cannot be summed 
because patients can receive multiple types of services. Total unique 
patients are measured as the number of patients receiving at least one 
type of service during the year. 

[B] Average daily census is the average number of patients receiving 
inpatient hospital, residential, or domiciliary services on any given 
day during the course of the year. VA does not use average daily 
census to measure the workload of outpatient services provided in 
these settings. 

[C] Encounters are professional contacts between patients and 
providers for outpatient services. VA does not use encounters to 
measure the workload of inpatient hospital, residential, and 
domiciliary services provided in these settings. 

[End of table] 

In each of VA's 21 networks, outpatient mental health services 
accounted for the largest percentage--more than 98 percent--of each 
network's total number of unique patients receiving mental health 
services in fiscal year 2009. At the same time, the number of unique 
patients receiving outpatient services varied widely across the 
networks, from about 31,000 in Network 2 (Albany) to about 110,000 in 
Network 8 (Bay Pines). (See table 3.) There was also wide variation 
across the networks in fiscal year 2009 in the number of outpatient 
encounters. In addition, VA's networks varied considerably in the 
number of unique patients receiving inpatient hospital services, with 
Networks 2 (Albany) and 8 (Bay Pines) being among the lowest and 
highest, respectively. (See table 4.) According to VA officials, 
network variations in the number of unique patients receiving mental 
health services may be due to enrollee population as well as other 
factors. For example, in fiscal year 2009, Network 2 (Albany) had the 
second lowest enrollee population, while Network 8 (Bay Pines) had the 
highest enrollee population among all networks.[Footnote 11] VA 
officials told us that they do not have data to identify all the 
factors that account for variations in workload for mental health 
services across the networks. 

Table 3: Workload for Outpatient Mental Health Services Provided in VA 
Settings Primarily Used for Providing Mental Health Services, by VA 
Network, Fiscal Year 2009: 

(Continued From Previous Page) 

VA network: 2 (Albany); 
Unique patients: 30,556; 
Encounters: 392,871. 

VA network: 5 (Baltimore); 
Unique patients: 30,674; 
Encounters: 509,828. 

VA network: 19 (Denver); 
Unique patients: 39,462; 
Encounters: 388,675. 

VA network: 3 (Bronx); 
Unique patients: 42,525; 
Encounters: 691,900. 

VA network: 12 (Chicago); 
Unique patients: 48,407; 
Encounters: 722,227. 

VA network: 15 (Kansas City); 
Unique patients: 49,712; 
Encounters: 564,007. 

VA network: 11 (Ann Arbor); 
Unique patients: 51,847; 
Encounters: 580,527. 

VA network: 1 (Boston); 
Unique patients: 52,438; 
Encounters: 743,976. 

VA network: 10 (Cincinnati); 
Unique patients: 54,079; 
Encounters: 711,397. 

VA network: 23 (Minneapolis); 
Unique patients: 54,390; 
Encounters: 686,451. 

VA network: 18 (Phoenix); 
Unique patients: 54,936; 
Encounters: 482,766. 

VA network: 20 (Portland); 
Unique patients: 55,026; 
Encounters: 622,085. 

VA network: 21 (San Francisco); 
Unique patients: 56,643; 
Encounters: 532,142. 

VA network: 4 (Pittsburgh); 
Unique patients: 59,043; 
Encounters: 598,509. 

VA network: 9 (Nashville); 
Unique patients: 63,005; 
Encounters: 505,334. 

VA network: 17 (Dallas); 
Unique patients: 66,026; 
Encounters: 649,996. 

VA network: 6 (Durham); 
Unique patients: 67,058; 
Encounters: 581,047. 

VA network: 22 (Long Beach); 
Unique patients: 69,284; 
Encounters: 839,818. 

VA network: 7 (Atlanta); 
Unique patients: 81,971; 
Encounters: 913,197. 

VA network: 16 (Jackson); 
Unique patients: 109,405; 
Encounters: 1,086,658. 

VA network: 8 (Bay Pines); 
Unique patients: 110,027; 
Encounters: 1,008,764. 

Source: GAO analysis of fiscal year 2009 VA data. 

Notes: According to VA officials, the workload for these services 
includes patients who received mental health services from mental 
health professionals who have been integrated in primary care clinics. 

[End of table] 

VA also pays non-VA providers to provide outpatient mental health 
services. The workload for these services is not included in this 
table. 

Table 4: Workload for Inpatient Hospital Mental Health Services 
Provided in VA Settings Primarily Used for Providing Mental Health 
Services, by VA Network, Fiscal Year 2009: 

VA network: 2 (Albany); 
Unique patients: 1,204; 
Average daily census: 47. 

VA network: 19 (Denver); 
Unique patients: 1,744; 
Average daily census: 100. 

VA network: 5 (Baltimore); 
Unique patients: 1,969; 
Average daily census: 124. 

VA network: 18 (Phoenix); 
Unique patients: 2,245; 
Average daily census: 71. 

VA network: 21 (San Francisco); 
Unique patients: 2,248; 
Average daily census: 107. 

VA network: 23 (Minneapolis); 
Unique patients: 2,440; 
Average daily census: 52. 

VA network: 20 (Portland); 
Unique patients: 2,676; 
Average daily census: 88. 

VA network: 3 (Bronx); 
Unique patients: 2,710; 
Average daily census: 202. 

VA network: 17 (Dallas); 
Unique patients: 2,779; 
Average daily census: 99. 

VA network: 10 (Cincinnati); 
Unique patients: 2,907; 
Average daily census: 94. 

VA network: 4 (Pittsburgh); 
Unique patients: 3,025; 
Average daily census: 200. 

VA network: 15 (Kansas City); 
Unique patients: 3,187; 
Average daily census: 155. 

VA network: 11 (Ann Arbor); 
Unique patients: 3,207; 
Average daily census: 188. 

VA network: 22 (Long Beach); 
Unique patients: 3,446; 
Average daily census: 167. 

VA network: 7 (Atlanta); 
Unique patients: 3,518; 
Average daily census: 205. 

VA network: 12 (Chicago); 
Unique patients: 3,722; 
Average daily census: 112. 

VA network: 1 (Boston); 
Unique patients: 3,937; 
Average daily census: 293. 

VA network: 9 (Nashville); 
Unique patients: 3,959; 
Average daily census: 127. 

VA network: 6 (Durham); 
Unique patients: 4,466; 
Average daily census: 224. 

VA network: 8 (Bay Pines); 
Unique patients: 5,293; 
Average daily census: 150. 

VA network: 16 (Jackson); 
Unique patients: 5,963; 
Average daily census: 206. 

Source: GAO analysis of fiscal year 2009 VA data. 

Note: VA also pays non-VA providers to provide inpatient hospital 
mental health services. The workload for these services is not 
included in this table. 

[End of table] 

VA's 21 networks also varied widely in terms of the number of unique 
patients receiving residential and domiciliary mental health services 
in fiscal year 2009. For example, the number of unique patients 
receiving residential mental health services ranged from 0 in Network 
22 (Long Beach) to about 1,400 in Network 12 (Chicago). (See table 5.) 
Network and other VA officials told us that these variations are in 
part due to the number of operating beds in each network. For example, 
VA officials told us that Network 22 (Long Beach) does not have any 
residential beds and that the network provides all of its residential 
services through agreements with non-VA providers and through its 
domiciliary services. 

Table 5: Workload for Residential and Domiciliary Mental Health 
Services Provided in VA Settings Primarily Used for Providing Mental 
Health Services, by VA Network, Fiscal Year 2009: 

VA network: 22 (Long Beach); 
Residential: Unique patients: 0[A]; 
Residential: Average daily census: 0[A]; 
Domiciliary: Unique patients: 698; 
Domiciliary: Average daily census: 163. 

VA network: 19 (Denver); 
Residential: Unique patients: 309; 
Residential: Average daily census: 26; 
Domiciliary: Unique patients: 387; 
Domiciliary: Average daily census: 74. 

VA network: 7 (Atlanta); 
Residential: Unique patients: 438; 
Residential: Average daily census: 89; 
Domiciliary: Unique patients: 1,213; 
Domiciliary: Average daily census: 246. 

VA network: 18 (Phoenix); 
Residential: Unique patients: 459; 
Residential: Average daily census: 73; 
Domiciliary: Unique patients: 607; 
Domiciliary: Average daily census: 145. 

VA network: 9 (Nashville); 
Residential: Unique patients: 545; 
Residential: Average daily census: 43; 
Domiciliary: Unique patients: 759; 
Domiciliary: Average daily census: 243. 

VA network: 15 (Kansas City); 
Residential: Unique patients: 560; 
Residential: Average daily census: 74; 
Domiciliary: Unique patients: 1,247; 
Domiciliary: Average daily census: 222. 

VA network: 21 (San Francisco); 
Residential: Unique patients: 563; 
Residential: Average daily census: 72; 
Domiciliary: Unique patients: 372; 
Domiciliary: Average daily census: 94. 

VA network: 16 (Jackson); 
Residential: Unique patients: 598; 
Residential: Average daily census: 68; 
Domiciliary: Unique patients: 822; 
Domiciliary: Average daily census: 127. 

VA network: 20 (Portland); 
Residential: Unique patients: 670; 
Residential: Average daily census: 72; 
Domiciliary: Unique patients: 1,476; 
Domiciliary: Average daily census: 551. 

VA network: 5 (Baltimore); 
Residential: Unique patients: 720; 
Residential: Average daily census: 162; 
Domiciliary: Unique patients: 1,074; 
Domiciliary: Average daily census: 330. 

VA network: 11 (Ann Arbor); 
Residential: Unique patients: 773; 
Residential: Average daily census: 96; 
Domiciliary: Unique patients: 269; 
Domiciliary: Average daily census: 76. 

VA network: 1 (Boston); 
Residential: Unique patients: 833; 
Residential: Average daily census: 143; 
Domiciliary: Unique patients: 399; 
Domiciliary: Average daily census: 91. 

VA network: 4 (Pittsburgh); 
Residential: Unique patients: 869; 
Residential: Average daily census: 112; 
Domiciliary: Unique patients: 2,100; 
Domiciliary: Average daily census: 305. 

VA network: 2 (Albany); 
Residential: Unique patients: 871; 
Residential: Average daily census: 60; 
Domiciliary: Unique patients: 1,060; 
Domiciliary: Average daily census: 237. 

VA network: 8 (Bay Pines); 
Residential: Unique patients: 877; 
Residential: Average daily census: 110; 
Domiciliary: Unique patients: 598; 
Domiciliary: Average daily census: 127. 

VA network: 6 (Durham); 
Residential: Unique patients: 925; 
Residential: Average daily census: 86; 
Domiciliary: Unique patients: 567; 
Domiciliary: Average daily census: 96. 

VA network: 23 (Minneapolis); 
Residential: Unique patients: 963; 
Residential: Average daily census: 88; 
Domiciliary: Unique patients: 1,398; 
Domiciliary: Average daily census: 181. 

VA network: 3 (Bronx); 
Residential: Unique patients: 1,010; 
Residential: Average daily census: 105; 
Domiciliary: Unique patients: 963; 
Domiciliary: Average daily census: 222. 

VA network: 17 (Dallas); 
Residential: Unique patients: 1,286; 
Residential: Average daily census: 134; 
Domiciliary: Unique patients: 1,920; 
Domiciliary: Average daily census: 584. 

VA network: 10 (Cincinnati); 
Residential: Unique patients: 1,330; 
Residential: Average daily census: 97; 
Domiciliary: Unique patients: 1,643; 
Domiciliary: Average daily census: 301. 

VA network: 12 (Chicago); 
Residential: Unique patients: 1,397; 
Residential: Average daily census: 142; 
Domiciliary: Unique patients: 1,462; 
Domiciliary: Average daily census: 357. 

Source: GAO analysis of fiscal year 2009 VA data. 

[A] VA officials told us that Network 22 (Long Beach) does not have 
any residential beds and that the network provides residential 
services through agreements with non-VA providers and through its 
domiciliary services. 

[End of table] 

VA Did Not Report Workload for All Mental Health Services Provided in 
Fiscal Year 2009: 

VA did not report workload information for all of the mental health 
services it provided in fiscal year 2009 in its fiscal year 2011 
congressional budget justification or in any other publicly available 
report. Specifically, VA did not report the total number of unique 
patients--1.22 million--receiving mental health services in fiscal 
year 2009 in the VA settings primarily used for providing mental 
health services. VA also did not report the number of unique patients 
receiving each type of service--inpatient hospital, residential, 
domiciliary, or outpatient--in these settings. Additionally, VA did 
not report the number of encounters for outpatient services in fiscal 
year 2009 in these settings. Instead, VA reported in its fiscal year 
2011 congressional budget justification the total number of patients 
treated--the number of patients discharged during the year plus the 
number of patients remaining at the end of the year--for its inpatient 
hospital, residential, and domiciliary mental health services. 
[Footnote 12] VA officials told us that this measure--patients 
treated--would count a person with multiple admissions or discharges 
during the fiscal year multiple times. VA reports the total number of 
patients treated in its congressional budget justifications because 
this information is available at the time VA's budget justification is 
published. The number of unique patients is not available until after 
VA's budget justification is published. 

While VA reported the combined average daily census for inpatient 
hospital, residential, and domiciliary mental health services, it did 
not report the average daily census for each of these services. 
[Footnote 13] Further, VA did not report the average daily census for 
these services with the spending for these services in its budget 
justification, which VA does for some of its services. For example, 
for long-term care services, VA reported average daily census and 
spending in the same table and reported average daily census for both 
institutional and noninstitutional care in its fiscal year 2011 
congressional budget justification.[Footnote 14] VA officials said 
that VA reported the combined average daily census for mental health 
services in its fiscal year 2011 congressional budget justification to 
be consistent with its reporting of this information in previous 
budget justifications. 

Although VA did not report the number of encounters for outpatient 
mental health services provided in VA settings primarily used for 
providing mental health services, VA determines its workload for these 
mental health services using this measure. VA officials told us that 
this workload measure is a key measure that is relevant for measuring 
the workload for mental health services. 

In addition, VA did not report workload for the mental health services 
that it provided in other settings--community settings for which VA 
paid non-VA providers to provide mental health services and VA 
settings not primarily used for providing mental health services, such 
as nursing homes, in which VA mental health providers provided 
services. VA also did not report workload for counseling services to 
address mental health issues provided by Vet Centers. According to 
VA's Mental Health Workload and Data Analysis Workgroup,[Footnote 15] 
any comprehensive review of mental health in VA should include the 
services delivered in these settings. According to the workgroup, VA's 
ability to document the breadth and extent of its mental health 
services is key for ensuring that the resources for these services are 
used in the most productive and effective manner possible. 

Although VA did not report its total workload for mental health 
services provided in other settings in fiscal year 2009, VA determines 
its workload for some of these mental health services and was able to 
provide us with workload information for these services. According to 
VA officials, for fiscal year 2009: 

* VA paid non-VA providers to deliver inpatient hospital mental health 
services in community settings to about 10,400 unique patients and 
outpatient mental health services to about 11,600 unique patients. The 
average daily census for the inpatient hospital services was about 
250. The outpatient services accounted for about 130,000 encounters. 

* VA provided mental health services in VA settings not primarily used 
for providing mental health services that accounted for about 485,000 
encounters with mental health providers. 

According to VA's mental health workload workgroup, the workload for 
mental health services provided in community settings by non-VA 
providers and in VA settings not primarily used for providing mental 
health services should be reported. The workgroup stated that the 
workload should not be reported with the workload for mental health 
services provided in settings that primarily provide mental health, 
but they should exist as a separate segment of any report. VA 
officials told us that while this workload information is not 
discretely identified as mental health in VA's congressional budget 
justification, it is included as part of VA's reporting of its 
workload for other services. VA officials said that VA has 
consistently focused its reporting of mental health services on those 
services provided in established mental health clinics. 

In contrast with the mental health services for which VA determines 
its workload, VA does not determine its workload for the counseling 
services to address mental health issues provided by Vet Centers. 
Similar to Vet Centers' spending for these counseling services, 
according to VA officials, VA does not determine Vet Centers' workload 
for counseling services to address mental health issues separately 
from Vet Centers' total workload because of the difficulty associated 
in separating these counseling services from other services that 
veterans receive through Vet Centers. Nevertheless, VA officials 
estimated for us that Vet Centers provided counseling services to 
address mental health issues to about 70,000 veterans in fiscal year 
2009, and these veterans accounted for about 989,000 visits for 
counseling services to address issues such as PTSD, drug and alcohol 
abuse, and family issues. According to VA's mental health workload 
workgroup, Vet Centers' workload for these services should be reported 
within the context of the mental health services they provide. 

Conclusions: 

VA uses its annual congressional budget justifications to provide its 
appropriations subcommittees and others with information on the 
department's spending and workload for the medical services--such as 
mental health services--provided to eligible veterans in connection 
with appropriation requests. However, the information VA reported in 
its fiscal year 2011 congressional budget justification on its mental 
health services does not reflect VA's total mental health spending and 
workload. In particular, VA did not report key workload information 
for mental health services provided in VA settings primarily used for 
providing mental health services. Specifically, VA did not report the 
number of encounters for outpatient services or the average daily 
census for each of its inpatient hospital, residential, and 
domiciliary services. Additionally, VA did not report the spending and 
workload for mental health services provided in other settings that 
are key to VA's efforts to meet the mental health needs of veterans: 
VA settings not primarily used for providing mental health services 
and community settings where VA pays non-VA providers to provide 
mental health services. Although VA determines the amount it spends 
for some of these services, it did not report this information as 
mental health information in its fiscal year 2011 congressional budget 
justification or in any other publicly available report. Furthermore, 
VA does not determine and did not report spending and workload for the 
counseling services to address mental health issues provided by Vet 
Centers in its congressional budget justification or in any other 
publicly available report. 

VA's reporting of mental health spending and workload does not give 
Congress a complete overview of VA's mental health services and limits 
information available for congressional oversight. Reporting 
additional mental health spending and workload information could 
enhance information available for congressional oversight. 

Recommendations for Executive Action: 

To enhance information available for congressional oversight and use 
by stakeholders on VA's spending and workload for mental health 
services, we recommend that the Secretary of Veterans Affairs take the 
following four actions: 

* include workload information, including number of encounters and 
average daily census, by type of service, for mental health services 
provided in VA settings primarily used for providing mental health 
services with its presentation of mental health spending in its annual 
congressional budget justification; 

* include spending and workload information, including number of 
encounters and average daily census, for mental health services that 
VA pays non-VA providers to deliver in community settings in its 
annual congressional budget justification, or in a separate, annual, 
publicly available report soon after the information becomes available; 

* include spending and workload information, including number of 
encounters and average daily census, for mental health services 
provided in VA settings not primarily used for providing mental health 
services in its annual congressional budget justification, or in a 
separate, annual, publicly available report soon after the information 
becomes available; and: 

* include workload information, including number of visits, for 
counseling services to address mental health issues provided by Vet 
Centers in its annual congressional budget justification, or in a 
separate, annual, publicly available report soon after the information 
becomes available. 

We also recommend that the Secretary of Veterans Affairs direct the 
Under Secretary for Health to identify ways of incorporating spending 
information for Vet Center counseling services that address mental 
health issues in VA's annual congressional budget justification or in 
a separate, annual, publicly available report soon after the 
information becomes available. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to VA for comment. In its written 
comments, reproduced in appendix II, VA concurred with three of our 
recommendations but did not concur with our recommendations related to 
Vet Center counseling services to address mental health issues. 
Specifically, VA concurred with our first recommendation to include 
workload information for mental health services provided in VA 
settings primarily used for providing mental health services with its 
presentation of mental health spending in its annual congressional 
budget justification. VA noted that it plans to provide this 
information in its fiscal year 2012 congressional budget 
justification. VA also concurred with our second and third 
recommendations to include spending and workload information for 
mental health services that (a) VA pays non-VA providers to deliver in 
community settings and (b) VA provides in settings not primarily used 
for providing mental health services in its annual congressional 
budget justification, or in a separate, annual, publicly available 
report soon after the information becomes available. VA noted that it 
would provide the spending and workload information publicly in a 
separate, annual, report by April 2011. 

VA did not concur with our recommendations related to Vet Centers' 
reporting of spending and workload information for counseling services 
to address mental health issues. VA noted that Vet Centers provide a 
unique type of readjustment counseling that differs from the mental 
health services provided at VA medical centers, and that it is 
important not to report these activities as if they were traditional 
mental health activities. VA said that reporting Vet Center activities 
this way will detract from the structure that brings in many combat 
veterans and military sexual trauma clients and underreports the full 
scope of Vet Center activities. VA also said that because Vet Center 
workload and spending are intricately interwoven and directly aligned 
to the Vet Center, VA is unable to report one or the other 
independently within the traditional mental health services. We agree 
that Vet Centers provide a unique type of counseling that differs from 
the mental health services provided at VA medical centers, and have 
described differences between the two in this report. We have pointed 
out, for example, that Vet Centers do not diagnose mental health 
conditions, but instead provide counseling services to address mental 
health issues--such as PTSD and drug and alcohol abuse--as one of the 
services they provide. 

We believe that our recommendations related to Vet Centers could be 
implemented while addressing VA's concerns. In this report, we are 
recommending that VA report Vet Center workload for counseling 
services to address mental health issues and identify ways of 
incorporating spending information for these services; not that Vet 
Center activities be reported as traditional mental health services. 
We believe that VA could report this information in a way that is 
consistent with the unique services Vet Centers provide and does not 
limit VA's reporting of Vet Centers' activities. Moreover, we believe 
that VA can provide workload data for Vet Center counseling services 
to address mental health issues separately from Vet Centers' total 
workload. VA provided estimates included in this report for Vet Center 
workload, measured by visits, for counseling services to address 
mental health issues. Therefore, we believe that such information 
could be reported. Finally, we believe that reporting information on 
Vet Center spending and workload could enhance information available 
for congressional oversight and that this reporting could be done in a 
manner that maintains the distinction between services provided by Vet 
Centers and VA medical centers. 

We are sending copies of this report to the Secretary of Veterans 
Affairs. In addition, the report is available at no charge on the GAO 
Web site at [hyperlink, http://www.gao.gov]. 

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

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

To examine the Department of Veterans Affairs' (VA) spending and 
workload for mental health services, we examined, for fiscal year 
2009, (1) VA's spending for mental health services and (2) VA's 
workload for mental health services. As part of this work, we examined 
VA's reporting of its fiscal year 2009 spending and workload 
information in VA's fiscal year 2011 congressional budget 
justification and whether VA reported this information in any other 
publicly available report. To examine VA's spending and workload for 
mental health services that VA provided in VA medical centers and that 
VA paid non-VA providers to provide in community settings, we analyzed 
national-and network-level data for fiscal year 2009 obtained from the 
Veterans Health Administration Office of Finance.[Footnote 16] To 
examine VA's workload for counseling services to address mental health 
issues that are provided by VA Vet Centers, we analyzed data obtained 
for fiscal year 2009 from the Veterans Health Administration's 
Readjustment Counseling Service.[Footnote 17] Fiscal year 2009 
spending data were not available for Vet Centers' counseling services 
to address mental health issues. Fiscal year 2009 data were the most 
recently available spending and workload data at the time of our 
review. To help us understand how VA approaches mental health spending 
and workload, we also reviewed VA's fiscal year 2008 spending and 
workload data, but we did not include these data in the report. 

For our analysis of VA mental health spending, we used obligations-- 
VA's cost of providing or paying for mental health services, including 
costs of administering mental health services, and national overhead, 
which includes the operating costs for VA headquarters, networks, and 
national programs. We used obligations because VA reports obligations 
for mental health services in its annual congressional budget 
submissions and VA officials told us they routinely determine VA's 
spending for mental health services using obligations data. Our 
analysis of VA mental health spending does not include VA's costs of 
providing medications for the treatment of mental health conditions. 
[Footnote 18] For our analysis of VA's mental health workload in its 
medical centers, in community settings where VA pays non-VA providers 
to provide mental health services, and in Vet Centers, we used the 
following four workload measures: (1) unique patients--unduplicated 
count of patients receiving a particular type of service, (2) 
encounters--professional contacts between patients and providers for 
outpatient services, (3) visits--one or more professional contacts 
between a patient and a provider on a single day, and (4) average 
daily census--the average number of patients receiving inpatient 
hospital, residential, or domiciliary services on any given day during 
the course of the year. We chose these measures because VA officials 
told us that they are key measures that are relevant for measuring 
mental health workload. 

To examine variation in spending and workload we identified across 
VA's networks, we conducted phone interviews with officials from a 
judgmental sample of four VA networks--Network 3 (Bronx), Network 8 
(Bay Pines), Network 17 (Dallas), and Network 22 (Long Beach). We 
selected these networks based on variation in geographic location, 
mental health spending and workload, and the number of veterans 
enrolled in the network. We also visited VA's Perry Point, Maryland, 
medical center to better understand how VA provides and pays for 
mental health services. We selected this medical center based on the 
range of mental health services it provides and the medical center's 
proximity to Washington, D.C. 

We also interviewed officials from VA's Veterans Health Administration 
Office of Finance, Readjustment Counseling Service, Office of Mental 
Health Services, Mental Health Enhancement Initiative for Primary 
Care, and Mental Health Workload and Data Analysis Workgroup. We 
interviewed these officials to obtain information on VA's efforts to 
determine and report complete and accurate information on its spending 
and workload for mental health services. We also examined VA's 
reporting of mental health spending and workload in its congressional 
budget justifications for fiscal years 2006 through 2011 and whether 
VA reported this information in any other publicly available report. 

We assessed the reliability of the national-and network-level data on 
VA's spending and workload for mental health services in several ways. 
First, we checked for internal consistency of VA documents detailing 
VA's spending and workload for mental health services for fiscal year 
2009. Second, we compared the fiscal year 2009 spending and workload 
data we obtained from VA with the fiscal year 2009 mental health data 
VA reported in its fiscal year 2011 congressional budget 
justification. We also compared fiscal year 2009 spending and workload 
data with VA's fiscal year 2008 spending and workload data. Third, we 
interviewed agency officials knowledgeable about VA's mental health 
services and about VA's mental health spending and workload data and 
the processes used to calculate them. We determined that the data we 
used in our analyses were sufficiently reliable for the purposes of 
this report. 

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

[End of section] 

Appendix II: Comments from the Department of Veterans Affairs: 

Department of Veterans Affairs: 
Office of the Secretary: 

May 14, 2010: 

Mr. Randall B. Williamson: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Williamson: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, VA HEALTH CARE: Reporting 
of Spending and Workload for Mental Health Services Could Be Improved 
GAO-10-570) and concurs with three of the findings and recommendations 
to the Department and nonconcurs with one. 

The enclosure addresses GAO's recommendations. VA appreciates the 
opportunity to comment on your draft report. 

Sincerely, 

Signed by: 

John R. Gingrich: 
Chief of Staff: 

Enclosure: 

[End of letter] 

Enclosure: 

Department of Veterans Affairs (VA) Comments to Government 
Accountability Office (GAO) Draft Report: VA Health Care: Reporting of 
Spending and Workload for Mental Health Services Could Be Improved 
(GA0-10-570): 

GAO Recommendation: To enhance information available for congressional 
oversight and use by stakeholders regarding VA's spending and workload 
for mental health services, we recommend that the Secretary of 
Veterans Affairs take the following four actions: 

Recommendation 1: Include workload information, including number of 
encounters and average daily census, by type of service, for mental 
health services provided in VA settings primarily used for providing 
mental health services with its presentation of mental health spending 
in its annual congressional budget justification. 

VA Response: Concur. VA will include the number of encounters and 
average daily census by type of service for Mental Health services 
provided in VA settings primarily used for providing mental health 
services in its fiscal year 2012 budget submission. This action will 
be complete by February 2011. 

Recommendation 2: Include spending and workload information including 
number of encounters and average daily census, for mental health 
services that VA pays non-VA providers to deliver in community 
settings in its annual congressional budget justification, or in a 
separate annual publicly available report soon after the information 
becomes available. 

VA Response: Concur. VA will provide the information publicly in a 
separate annual report soon after the information becomes available. 
We anticipate completion of this action by April 2011. 

Recommendation 3: Include spending and workload information including 
number of encounters and average daily census, for mental health 
services provided in VA settings not primarily used for providing 
mental health services in its annual congressional budget 
justification, or in a separate annual publicly available report soon 
after the information becomes available. 

VA Response: Concur. VA will provide the information publicly in a 
separate annual report soon after the information becomes available. 
We anticipate completion of this action by April 2011. 

Recommendation 4: Include workload information, including number of 
visits, for counseling services to address mental health issues 
provided by Vet Centers in its annual congressional budget 
justification, or in a separate annual publicly available report soon 
after the information becomes available. 

We also recommend that the Secretary of Veterans Affairs direct the 
Under Secretary for Health to identify ways of incorporating spending 
information for Vet Center counseling services that address mental 
health issues in VA's annual congressional budget. 

VA response: Non-Concur on both components. The Vet Centers currently 
report data (number of visits and Veterans seen) in an annual report 
to the Secretary of Veterans Affairs and Congress. The Veterans Health 
Administration is planning to publish this information on the VA Web 
site and other venues as the Secretary and Under Secretary for Health 
designate so that it is publicly available. However, providing 
separate reporting about specific mental health problems fails to 
capture and underreports the full scope of activities in the Vet 
Center mission. 

Because Vet Centers are Veteran-centric and provide a unique type of 
readjustment counseling, it is important not to report these 
activities as if they were traditional mental health care services. 
The impetus to identify "mental health" services provided by the Vet 
Center program will detract from the structure that brings in many 
combat Veterans and military sexual trauma clients to receive 
services. These services are provided in community-based locations 
emphasizing a Veteran-centric culture that goes a long way to overcome 
any stigma associated with seeking mental health services by combat 
Veterans and Veterans who have experienced military sexual trauma. 
Many of these Veterans would otherwise not access VA care. While VA 
qualified mental health professionals provide counseling services in 
Vet Centers, the context and manner in which this is done differs from 
traditional mental health services. The concern is that by requiring 
that Vet Center services be characterized into a traditional mental 
health model as this recommendation suggests, the community based, non-
bureaucratic, Veteran-centered value to the Veteran and their families 
would be significantly diminished. When necessary for the treatment of 
more complex and co-morbid mental health conditions, Vet Centers will 
continue to refer Veterans to medical facilities for mental health 
services. These Vet Center to VA medical center referrals provide the 
needed enhanced clinician and pharmaceutical access for Veterans with 
serious mental illness. 

It is important to note that readjustment counseling services and 
mental health services are authorized by separate authorities and 
employ different eligibility criteria. This is consistent with House 
Committee Report 96-100 and Senate Committee Report 98-117, conveying 
the intent of Congress for the implementation of the Vet Center 
program. Because Vet Center services are distinct and add value to the 
holistic care Veterans receive, it is important that the services 
provided by the Vet Centers are not confused with or subsumed into 
traditional mental health care. 

Because workload and spending are intricately interwoven and directly 
aligned to the Vet Center, VA is unable to separate either component 
and report one or the other independently within the traditional 
mental health services. 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

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

Acknowledgments: 

In addition to the contact named above, James Musselwhite, Assistant 
Director; Janina Austin; Romuladus Azuine; Krister Friday; and Sarah 
Harvey made key contributions to this report. 

[End of section] 

Footnotes: 

[1] VA's health care system consists of 21 regional health care 
networks. These networks have budget and management responsibilities 
that include allocating budgetary resources for health care services, 
including mental health services, to their medical centers that 
typically include one or more hospitals and other types of health care 
facilities, such as outpatient clinics. 

[2] The majority of veterans receiving mental health services from VA 
served in prior conflicts. 

[3] Veterans who served in active military and who were discharged or 
released under conditions other than dishonorable are generally 
eligible for VA health care and may receive care upon enrollment. 
Reservists and National Guard members may also be eligible for VA 
health care if they were called to active duty by a federal order and 
completed the full period for which they were called to active duty. 
Veterans can also receive health care, including mental health 
services, financed by sources other than VA, including private 
insurance, Medicare, and Medicaid. 

[4] VA's Readjustment Counseling Service manages the Vet Centers and 
the provision of readjustment counseling. 

[5] VA officials told us that it is difficult to identify which 
medications are used to treat mental health conditions because the 
types of medications used may change rapidly and some medications may 
be used to treat conditions other than mental health. 

[6] 38 U.S.C.  1703. 

[7] Vet Centers also provide social support services, such as 
assistance with employment, and outreach services. 

[8] According to VA officials, this spending includes about $60 
million for mental health services provided by mental health 
professionals who have been integrated in primary care clinics. As of 
September 2009, VA had integrated mental health and primary care in 
131 sites across the country. 

[9] For fiscal year 2009, Congress specified that VA spend a minimum 
of $3.8 billion on specialty mental health care--mental health 
services provided in VA settings primarily used for providing mental 
health services. Pub. L. No. 110-329, 122 Stat. 3574, 3704-05 (2008). 

[10] According to VA officials, this workload includes about 101,000 
unique patients who received mental health services from mental health 
professionals who have been integrated in VA primary care clinics. 

[11] In general, veterans must enroll in VA's health care system in 
order to receive VA's medical benefits package, which covers most of 
VA's medical services. 38 U.S.C.  1705; 38 C.F.R.  17.36 (2009). 

[12] In its fiscal year 2011 congressional budget justification, VA 
refers to the combination of inpatient hospital, residential, and 
domiciliary mental health services as inpatient psychiatric care 
services. 

[13] For these services, VA also reported length of stay--average 
length of time from admission to discharge. 

[14] Department of Veterans Affairs, FY 2011 Budget Submission, 
Medical Programs and Information Technology Programs, Volume 2 of 4 
(Washington D.C.: February 2010) p. 1K-15. 

[15] VA established the Mental Health Workload and Data Analysis 
Workgroup in March 2007. Its major efforts were related to 
standardizing data elements and establishing processes that would 
allow VA to more fully capture mental health workload. 

[16] VA's health care system consists of 21 regional health care 
networks. These networks have budget and management responsibilities 
that include allocating budgetary resources for health care services, 
including mental health services, to their medical centers that 
typically include one or more hospitals and other types of health care 
facilities, such as outpatient clinics. 

[17] VA's Readjustment Counseling Service manages the Vet Centers and 
the provision of readjustment counseling. 

[18] VA officials told us that it is difficult to identify which 
medications are used to treat mental health conditions because the 
types of medications used may change rapidly and some medications may 
be used to treat conditions other than mental health. 

[End of section] 

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