VA Primary Care:
Improved Oversight Needed to Better Ensure Timely Access and Efficient Delivery of Care
GAO-16-83: Published: Oct 8, 2015. Publicly Released: Oct 22, 2015.
What GAO Found
GAO found that the Department of Veterans Affairs' (VA) data on primary care panel sizes—that is, the number of patients VA providers and support staff are assigned as part of their patient portfolio—are unreliable across VA's 150 medical facilities and cannot be used to monitor facilities' management of primary care. Specifically, as part of its review, GAO found missing values and other inaccuracies in VA's data. Officials from VA's Primary Care Operations Office confirmed that facilities sometimes record and self-report these data inaccurately or in a manner that does not follow VA's policy and noted that this could result in the data reliability concerns GAO identified. GAO obtained updated data from six of seven selected facilities, corrected these data for inaccuracies, and then calculated the actual panel sizes for the six facilities. GAO found that for these six facilities the actual panel size varied from 23 percent below to 11 percent above the modeled panel size, which is the number of patients for whom a provider and support staff can reasonably deliver primary care as projected by VA. Such wide variation raises questions about whether veterans are receiving access to timely care and the appropriateness of the size of provider workload at these facilities.
Moreover, GAO found that while VA's primary care panel management policy requires facilities to ensure the reliability of their panel size data, it does not assign responsibility to VA Central Office or networks for verifying the reliability of facilities' data or require them to use the data for monitoring purposes. Federal internal control standards call for agencies to clearly define key areas of authority and responsibility, ensure that reliable information is available, and use this information to assess the quality of performance over time. Because VA's panel management policy is inconsistent with federal internal control standards, VA lacks assurance that its facilities' data are reliable and that the facilities are managing primary care panels in a manner that meets VA's goals of providing efficient, timely, and quality care to veterans.
In contrast to VA's panel data, GAO found that primary care encounter and expenditure data reported by all VA medical facilities are reliable, although the data show wide variations across facilities. For example, in fiscal year 2014, expenditures per primary care encounter—that is, a professional contact between a patient and a primary care provider—ranged from a low of $150 to a high of $396 after adjusting to account for geographic differences in labor costs across facilities. Such wide variations may indicate that services are being delivered inefficiently at some facilities with relatively higher per encounter costs compared to other facilities. However, while VA verifies and uses these data for financial purposes, VA's policies governing primary care do not require the use of the data to monitor facilities' management of primary care. Federal internal control standards state that agencies need both operational and financial data to determine whether they are meeting strategic goals and should use such data to assess the quality of performance over time. Using panel size data in conjunction with encounter and expenditure data would allow VA to assess facilities' capacity to provide primary care services and the efficiency of their care delivery. By not using available encounter and expenditure data in this manner, VA is missing an opportunity to potentially improve the efficiency of primary care service delivery.
Why GAO Did This Study
VA's 150 medical facilities manage primary care services provided to veterans. VA requires facilities to record and report data on primary care panel sizes to help facilities manage their workload and ensure that veterans receive timely and efficient care. VA also requires facilities to record and report data on primary care encounters and expenditures.
GAO was asked to examine these data and VA's oversight of primary care. This report examines (1) VA's panel size data across facilities and how VA uses these data to oversee primary care, and (2) VA's encounter and expenditure data across facilities and how VA uses these data to oversee primary care. GAO analyzed fiscal year 2014 data on primary care panel size, encounters, and expenditures for all VA facilities. GAO also conducted a more in-depth, nongeneralizable analysis of data and interviewed officials from seven facilities, selected based on geographic diversity and differences in facility complexity. GAO also interviewed VA Central Office and network officials to examine their oversight of primary care, including the extent to which they verify the data and use it to monitor the management of primary care.
What GAO Recommends
GAO recommends that VA verify facilities' panel size data, monitor and address panel sizes that are too high or too low, and review and document how to use encounter and expenditure data to help monitor facilities' management of primary care. VA agreed with GAO's recommendations and described its plans to implement them.
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Recommendations for Executive Action
Status: Closed - Implemented
Comments: In October 2016, VA reported that it had completed nationwide deployment of new software for managing panel sizes, called Primary Care Management Module (PCMM) Web, which is designed to enable better management and monitoring of primary care panel sizes. In addition, in September 2015 and December 2016, VA required all facilities to validate their data on primary care panel sizes, as well as the number of support staff and exam rooms. In February 2017, all but one of VA facilities certified that they had validated their data. The remaining facility was still in the process of completing data validation efforts.
Recommendation: To improve the reliability of VA's primary care panel size data and improve VA Central Office and the networks' oversight of facilities' management of primary care, the Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to incorporate in policy an oversight process for primary care panel management that assigns responsibility, as appropriate, to VA Central Office and networks for (1) verifying each facility's reported panel size data currently in PCMM and in web-PCMM, if the software is rolled-out nationally, including such data as the number of primary care patients, providers, support staff, and exam rooms; and (2) monitoring facilities' reported panel sizes in relation to the modeled panel size and assisting facilities in taking steps to address situations where reported panel sizes vary widely from modeled panel sizes.
Agency Affected: Department of Veterans Affairs
Status: Closed - Implemented
Comments: As of August 2016, VA reported that the Offices of Primary Care Services and Primary Care Operations established a workgroup to review and document how to use encounter and expenditure data in conjunction with panel size data to strengthen monitoring and management of primary care data. VA also reported that it has assembled a dashboard of costs by facility which also includes a variety of veteran satisfaction data as well as performance and efficiency data, with the goal of evaluating associations between primary care costs, efficiency, and performance. A committee including subject matter experts and key stakeholders is assisting in providing direction and oversight of this initiative.
Recommendation: To improve the reliability of VA's primary care panel size data and improve VA Central Office and the networks' oversight of facilities' management of primary care, the Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to review and document how to use encounter and expenditure data in conjunction with panel size data to strengthen monitoring of facilities' management of primary care.
Agency Affected: Department of Veterans Affairs