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VA Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement

GAO-09-145 Published: Jan 23, 2009. Publicly Released: Jan 23, 2009.
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Highlights

In fiscal year 2007, the Department of Veterans Affairs (VA) spent about $4.1 billion on long-term care for veterans. VA provides--through VA or other providers--institutional care in nursing homes and noninstitutional care in veterans' homes or the community. In response to a statute, VA published in 2007 a long-term care strategic plan through fiscal year 2013. VA includes long-term care spending estimates in its annual budget justifications for Congress. These estimates are based on workload projections--the amount of care to be provided--and cost assumptions. VA has discretion in allocating appropriated funds among its medical services, such as long-term care. GAO examined (1) VA's reporting of planned workload in its 2007 long-term care strategic plan and (2) VA's long-term care spending estimates, including its cost assumptions and workload projections, in VA's fiscal year 2009 budget justification. GAO analyzed budget and planning documents and interviewed VA officials.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs To make available more complete information for congressional oversight and use by stakeholders regarding VA's plans for the provision of long-term care, the Secretary of Veterans Affairs should direct the Under Secretary for Health to include three types of workload information in VA's forthcoming long-term care strategic plan: (1) planned total nursing home workload, including care provided to veterans on a discretionary basis; (2) estimated demand for noninstitutional services and VA's time frame for meeting this demand; and (3) a comparison of planned noninstitutional workload with recent noninstitutional workload to show the magnitude of the expected change in services provided.
Closed – Implemented
In January 2009, GAO recommended that the Department of Veterans Affairs (VA) enhance its forthcoming long-term care strategic plan by including three types of workload information: (1) planned total nursing home workload, including care provided to veterans on a discretionary basis; (2) estimated demand for non-institutional services and VA's time frame for meeting this demand; and (3) a comparison of planned non-institutional workload with recent non-institutional workload, to show the magnitude of the expected change in services provided. In September 2009, VA finalized its new long-term care strategic plan. Its new strategic plan included the three types of workload information that GAO recommended.
Department of Veterans Affairs To strengthen the credibility of VA's estimates of spending for its long-term care services budgeting proposals and increase transparency for Congress and stakeholders, the Secretary of Veterans Affairs should, in future budget justifications, use cost assumptions for estimating nursing home spending that are consistent with VA's recent experience or report the rationale for using cost assumptions that are not.
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with our recommendation. In its response to our recommendation, VA stated that the Veterans Health Administration Budget Office would, in future budget justifications, use cost assumptions consistent with VA's recent experience or report the rationale for using other assumptions. In its fiscal year 2010 budget justification, VA assumed nursing home cost would increase 10 percent--an amount that is in line with VA's recent experience.
Department of Veterans Affairs To strengthen the credibility of VA's estimates of spending for its long-term care services budgeting proposals and increase transparency for Congress and stakeholders, the Secretary of Veterans Affairs should, in future budget justifications, use cost assumptions for estimating noninstitutional long-term care spending that are consistent with VA's recent experience or report the rationale for using cost assumptions that are not.
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with our recommendation. In its response to our recommendation, VA stated that the Veterans Health Administration Budget Office would, in future budget justifications, use cost assumptions consistent with VA's recent experience or report the rationale for using other assumptions. In its fiscal year 2010 budget justification, VA assumed non-institutional long-term care costs would increase about 9.5 percent--an amount that is in line with VA's recent experience.
Department of Veterans Affairs To strengthen the credibility of VA's estimates of spending for its long-term care services budgeting proposals and increase transparency for Congress and stakeholders, the Secretary of Veterans Affairs should, in future budget justifications, use workload projections for estimating noninstitutional long-term care spending that are consistent with VA's recent experience or report the rationale for using projections that are not.
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with our recommendation. In its response to our recommendation, VA stated that the Veterans Health Administration Budget Office would, in future budget justifications, use workload projections for estimating non-institutional long-term care spending consistent with VA's recent experience or report the rationale for using other assumptions. In its fiscal year 2010 budget justification, VA assumed non-institutional long-term care workload would increase 25 percent, an amount that is in line with VA's recent experience.
Department of Veterans Affairs To strengthen the credibility of VA's estimates of spending for its long-term care services budgeting proposals and increase transparency for Congress and stakeholders, if VA uses different measures of workload for noninstitutional long-term care services for estimating spending, the Secretary of Veterans Affairs should, in future budget justifications, report which measures are used for each service and how these measures reflect the volume of services received by veterans.
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with our recommendation. In its response to our recommendation, VA stated that the Veterans Health Administration Budget Office would, in future budget justifications, report which workload measures are used for each non-institutional long-term care service and how these measures reflect the volume of services received by veterans. VA implemented this recommendation in its fiscal year 2012 budget justification by reporting all but one noninstitutional services using the same measure -- average daily census -- and reporting that the one service that did not use this method, spinal cord injury home care, used a monthly census. In addition, VA provided information about the number of days each year that noninstitutional services were available to be provided, which was detail that had not been included in the budget justifications for fiscal years 2009, 2010, or 2011. As a result, this additional information provides greater clarity for congressional oversight and for use by stakeholders interested in VA's projections of noninstitutional care workload.

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Budget functionsBudget obligationsBudget outlaysConfidential communicationsCost analysisFunds managementFuture budget projectionsHealth care facilitiesHealth care planningHealth care programsHealth care reformHealth care servicesHealth resources utilizationHome health care servicesLong-term careNursing homesStrategic planningVeteransVeterans hospitalsVeterans' medical careCost awarenessCost estimates