Managing Risks and Improving VA Health Care - High Risk Issue
The Department of Veterans Affairs’ (VA) Veterans Health Administration operates one of the largest health care delivery systems in the nation, with over 160 medical centers and more than 1,000 outpatient facilities. Over the past decade, there have been numerous reports of VA facilities failing to provide timely care.
Demand for VA health services has grown over the past decade due, in part, to servicemembers returning from Afghanistan and Iraq and the aging veteran population. During this period of time, total budgetary resources for VA’s Veterans Health Administration have increased substantially, from $37.8 billion in fiscal year 2006 to $91.2 billion in fiscal year 2016.
VA health care is a high-risk area because of continued concerns about the department’s ability to ensure:
- veterans’ timely access to health care,
- resources are being used cost-effectively and efficiently, and
- the quality and safety of veterans’ health care.
Access to health care
There have been numerous reports for more than a decade of VA facilities failing to provide timely health care. In some cases, the delays in care, or VA’s failure to provide care at all, reportedly resulted in harm to veterans.
In response to serious and longstanding problems with VA health care, the Veterans Access, Choice, and Accountability Act of 2014 (Pub. L. No. 113-146, 128 Stat. 1754) was enacted. It provided temporary authority and $10 billion in funding through August 2017 (or sooner, if those funds are exhausted) for veterans to obtain health care services from community (non-VA) providers to address long wait times, lengthy travel distances, or other challenges accessing VA health care. Under this authority, VA introduced the Veterans Choice Program in November 2014. VA has purchased care from non-VA community providers through its care in the community programs since as early as 1945. VHA has numerous programs, including the Veterans Choice Program, through which it purchases VA care in the community services.
Management of resources for current and future years
VA faces challenges regarding the reliability, transparency, and consistency of its budget estimates for medical services, as well as weaknesses in tracking obligations for medical services and estimating budgetary needs for future years.
These challenges were evident in June 2015, when VA requested additional funds from Congress because of a projected funding gap in fiscal year 2015 of about $3 billion for medical services. The projected funding gap was largely due to administrative weaknesses that resulted in lower-than-expected utilization of the Veterans Choice Program in fiscal year 2015, and higher-than-expected demand for previously-established VA community care programs.
To address the projected funding gap in fiscal year 2015, the VA Budget and Choice Improvement Act provided VA temporary authority to use up to $3.3 billion from the Veterans Choice Program appropriation for obligations incurred for other specified medical services. VA officials anticipated requesting an additional increase in funding for health care services in the budget request for fiscal year 2018.
Coordination of health care services to ensure quality and safety
While timely and cost-effective access to needed health care services is essential, care coordination between VA and community providers, and between VA and the Department of Defense (for transitioning servicemembers), is also critical to ensure the quality and safety of veterans health care.
- Coordination with community providers. With the increased use of community providers, veterans have to navigate multiple complex health care systems to obtain needed health care services. Their quality of care may be adversely affected if VA and community providers do not promptly communicate important clinical information.
- Coordination with the Department of Defense. Servicemembers transitioning from Department of Defense to VA health care may experience a disruption in the continuity of their prescription medication. For example, VA providers may inappropriately discontinue or change mental health medications for transitioning servicemembers because the Department of Defense and VA formularies are different and VA’s related policy is unclear. Specifically, VHA’s policy to ensure the continuation of mental health medications lacks clarity on the types of medications considered mental health medications, and, as a result, VHA providers may be inappropriately changing or discontinuing mental health medications due to formulary differences, potentially increasing the risk for adverse health effects.
GAO-17-408T: Published: Feb 7, 2017. Publicly Released: Feb 7, 2017.
GAO noted in July 2016 that the Department of Veterans Affairs (VA) had moved forward with an effort to modernize its health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—but that the department is uncertain of its long-term plan for addressing its electronic health record system needs beyond fiscal year 2018. Beyond modernizing VistA, GAO repor...
GAO-17-30: Published: Dec 23, 2016. Publicly Released: Jan 23, 2017.
The Veterans Health Administration's (VHA) limited human resources (HR) capacity combined with weak internal control practices has undermined VHA's HR operations and its ability to improve delivery of health care services to veterans.Attrition of medical center HR staff increased between fiscal years 2013 and 2015, due to HR staff transferring to other federal agencies. VHA officials note a lack o...
GAO-17-50: Published: Oct 21, 2016. Publicly Released: Nov 21, 2016.
The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) uses a multi-step strategic planning process to develop its strategic goals and objectives, which includes two key steps—(1) identifying and assessing factors that may affect health care delivery, which is referred to as environmental scanning, and (2) holding the annual National Leadership Council (NLC) Strategic Plan...
GAO-16-803: Published: Sep 27, 2016. Publicly Released: Oct 27, 2016.
Recent internal and external reviews of Veterans Health Administration (VHA) operations have identified deficiencies in its organizational structure and recommended changes that would require significant restructuring to address, including eliminating and consolidating program offices and reducing VHA central office staff. However, VHA does not have a process that ensures recommended organizationa...
GAO-16-584: Published: Jun 3, 2016. Publicly Released: Jun 3, 2016.
GAO found that two areas accounted for the Department of Veterans Affairs' (VA) fiscal year 2015 projected funding gap of $2.75 billion.Higher-than-expected obligations for VA's longstanding care in the community (CIC) programs—which allow veterans to obtain care from non-VA providers—accounted for $2.34 billion or 85 percent of VA's projected funding gap. VA officials expected that the Vetera...
GAO-16-353: Published: May 11, 2016. Publicly Released: May 11, 2016.
To help ensure that veterans are provided timely and accessible health care services, the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) has purchased care from non-VA community providers through its care in the community programs since as early as 1945. VHA's agency-wide data show that in fiscal year 2015, it processed about 66 percent of claims within the agency'...
GAO-16-328: Published: Mar 18, 2016. Publicly Released: Apr 18, 2016.
GAO found that not all newly enrolled veterans were able to access primary care from the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA), and others experienced wide variation in the amount of time they waited for care. Sixty of the 180 newly enrolled veterans in GAO's review had not been seen by providers at the time of the review; nearly half were unable to access prima...