VA Health Care: Actions Needed to Improve Oversight of Graduate Medical Education Reimbursement
Fast Facts
The Department of Veterans Affairs’ Graduate Medical Education program trains more than 45,000 medical and dental residents annually. It reimbursed affiliated medical schools and teaching hospitals about $765 million in 2019—covering residents’ salaries for their work at VA facilities.
After detecting payment errors at one facility, VA added a new oversight process meant to complement an existing requirement that facilities audit reimbursements. But overlap between the two processes, and insufficient tools, guidance, and training for both may prevent VA from detecting payment errors.
Our recommendations are to help improve program oversight.
Doctor and patient
Highlights
What GAO Found
The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides training to more than 45,000 medical and dental residents annually through its Graduate Medical Education (GME) program. VHA has established policy for its GME program that details many roles and responsibilities for overseeing VA medical facilities' reimbursements to affiliated academic institutions for residents' salaries and benefits. However, this policy does not define key roles and responsibilities for VHA's central office components, its regional networks, or its medical facilities. For example, VHA's regional networks do not have defined roles and responsibilities for overseeing GME disbursements—contributing to noninvolvement or inconsistent involvement in disbursement agreement oversight. VHA officials reported that they are in the process of updating disbursement agreement policy, but did not indicate if the updates would address all identified concerns.
While VHA officials said that VHA's two disbursement agreement oversight mechanisms—facility periodic audits and the Resident Disbursement Audit Process (ReDPro) checklist—are meant to have distinct but complementary purposes, GAO found that VHA policy, guidance, and the tools distributed for these oversight mechanisms did not reflect the distinct purposes officials described. VHA officials said that periodic audits are intended to be a first level of defense and to review actual payments to affiliates, whereas the ReDPro checklist is intended to be a second level of defense, aimed at reviewing the process to see if the rules related to disbursement agreements are being followed by VA medical facilities. However, the ReDPro checklist tool and VHA's recommended periodic audit tool have numerous areas of overlap, including duplicative questions. This overlap causes inefficiencies and unnecessary burden on VA medical facility staff.
GAO also found additional weaknesses in the tools, guidance, and training for the two oversight mechanisms. For example, GAO found
- an unclear ReDPro checklist tool, along with insufficient guidance and training related to conducting the ReDPro reviews. Officials from eight of 13 facilities in GAO's review indicated that the ReDPro checklist instructions were unclear regarding appropriate supporting documents for checklist responses. These weaknesses contributed to errors and inconsistencies in ReDPro responses.
- the lack of a standard audit tool, and inadequate guidance and training for periodic audit teams that contributed to problematic inconsistencies in the methodologies used by the audit teams and deficiencies in some of the audits conducted. Officials from 10 of 13 facilities in GAO's review indicated that they would benefit from more tools, guidance, or training related to conducting periodic audits.
These weaknesses limit the effectiveness of VHA's oversight mechanisms, and put VHA at increased risk of both not being able to identify and correct facilities' lack of adherence to disbursement agreement policy and of possible improper payments to GME affiliates.
Why GAO Did This Study
Under VHA's GME program, VA medical facilities use disbursement agreements to reimburse affiliated academic institutions for residents' salaries and benefits. VHA developed policy related to establishing and administering disbursement agreements, but audits have found that facilities have not always adhered to VHA policy—resulting in improper payments to affiliates.
GAO was asked to review VHA policies and procedures related to reimbursements to affiliates for GME. This report examines (1) oversight roles and responsibilities for GME disbursement agreements and (2) VHA's mechanisms for ensuring VA medical facilities adhere to policy.
GAO reviewed relevant VHA documents and federal internal control standards and interviewed VHA officials. GAO also reviewed ReDPro checklist responses and documentation from 13 VA medical facilities—selected based on factors including geographic variation, GME program size, and number of affiliates. GAO also visited four of the 13 facilities and interviewed officials at the other nine facilities.
Recommendations
GAO is making seven recommendations to VA to define key roles in policy, reduce overlap between the ReDPro checklist and facility periodic audits, and improve the oversight mechanisms' tools, guidance, and training. VA concurred with GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Under Secretary for Health should fully define in VHA policy the oversight roles and responsibilities related to ensuring facilities' adherence to disbursement agreement policies, including roles related to ReDPro and the role of VISNs. (Recommendation 1) |
Closed – Implemented
VA agreed with this recommendation. In October 2021, VA reported that the relevant VHA Directive had been revised, approved, and published as of June 2, 2021. This revised Directive now defines the roles and responsibilities for VISNs and key central office components like the Office of Academic Affiliations and the Office of Compliance and Business Integrity--including roles related to ReDPro, as appropriate. As such, we are closing this recommendation as implemented.
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| Department of Veterans Affairs | The Under Secretary for Health should more clearly define in VHA policy the purposes of the periodic independent audits and the ReDPro checklist reviews—including differentiating their purposes from one another and ensuring that they do not unnecessarily overlap. (Recommendation 2) |
Closed – Implemented
VA agreed with this recommendation. In November 2020, VA reported that the agency had revised and streamlined these processes, creating a new ReDPro review process with unique, but complementary roles for facility independent audit teams (now to be called independent review teams) and compliance officers. VA reported that the revised Directive had been submitted for stakeholder and leadership review in VHA's concurrence process, and was expected to be completed by June 2021. The revised Directive was later approved and published on June 2, 2021, and a related standard operating procedures document was issued on January 4, 2022. The revised, streamlined process now consists only of the ReDPro checklist reviews, with three different roles in the review process completed by different staff. As VHA has documented the revised oversight process and its purpose in policy, we are closing this recommendation as implemented.
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| Department of Veterans Affairs | The Under Secretary for Health should ensure that OAA and CBI modify the ReDPro checklist and associated guidance, to include ensuring that checklist items are clearly stated, relevant to the updated purpose of the ReDPro checklist, and not unnecessarily duplicative of items to be addressed by the periodic independent audits. The guidance should also include detailed instruction on what the compliance officers should review, and how they should determine the appropriate response for each checklist item. (Recommendation 3) |
Closed – Implemented
VA agreed with this recommendation. In November 2020, VA reported that the agency had revised and streamlined the previous disbursement agreement oversight mechanisms. The ReDPro checklist tool was revised, and a new accompanying standard operating procedure document was created. The updated oversight process should eliminate prior duplication by assigning unique, but complementary roles to facility independent audit teams and compliance officers--lessening the burden on VA facility staff. Further, the updated checklist and accompanying standard operating procedure document contain detailed instructions on what the compliance officers should review, and how they should determine the appropriate response for each checklist item, which should help eliminate errors and inconsistencies in checklist responses. As such, we are closing this recommendation as implemented.
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| Department of Veterans Affairs | The Under Secretary for Health should ensure that OAA and CBI develop and provide additional ReDPro training for compliance officers, consistent with the updated checklist and guidance. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how ReDPro reviews should be conducted. (Recommendation 4) |
Closed – Implemented
VA agreed with this recommendation. In November 2020, VA reported that the previous disbursement agreement oversight mechanisms had been revised, and that the Office of Academic Affiliations had developed training for compliance officers specific to their role in the revised and updated ReDPro review process. VA reported completing initial training related to the new ReDPro process in February 2021. However, in training evaluation results, some compliance officers and independent review team members reported concerns, particularly related to the ease of following the ReDPro checklist process. In response, VHA officials made changes to the ReDPro process, including changes related to who would perform certain key tasks. These changes required new training, which was completed January through May 2022. Training survey results indicated improved satisfaction with the ReDPro training and guidance documents. Further, VHA officials told us in September 2022 that a newly created role within the ReDPro process, with GME subject matter expertise, was helping to close the previous knowledge gap of compliance officers on GME programs and disbursement agreement oversight. This newly designated Educational Activity Record Champion at each facility will serve as a subject matter expert in the Health Professions Education office, and the work is assigned as a collateral duty. VHA officials stated that they will continue to make ReDPro process improvements over time, and that training will be revised accordingly. Given the enhancements to the ReDPro process and training for compliance officers, we are closing this recommendation as implemented.
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| Department of Veterans Affairs | The Under Secretary for Health should ensure that OAA implements a standardized independent audit tool that is consistent with the updated purpose of the periodic independent audits, and does not unnecessarily overlap with the ReDPro checklist. This could include modifying its existing recommended checklist, or developing a new tool. (Recommendation 5) |
Closed – Implemented
VA agreed with this recommendation. In November 2020, VA reported that the agency had revised and streamlined the previous disbursement agreement oversight mechanisms. The ReDPro checklist tool was revised, and is now the standardized audit tool to be used by facility independent audit teams (now to be called independent review teams). The updated oversight process should eliminate prior duplication by assigning unique, but complementary roles to facility independent review teams and compliance officers--lessening the burden on VA facility staff. As such, we are closing this recommendation as implemented.
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| Department of Veterans Affairs | The Under Secretary for Health should ensure that OAA develops guidance for periodic independent audits to assist the audit teams and facility management in understanding how audits are to be conducted. (Recommendation 6) |
Closed – Implemented
VA agreed with this recommendation. In November 2020, VA reported that the agency had revised and streamlined the previous disbursement agreement oversight mechanisms. The ReDPro checklist tool was revised, and is now the standardized audit tool to be used by facility independent audit teams (now to be called independent review teams), and an additional standard operating procedure document was created. The updated ReDPro standard operating procedure document contains detailed instructions on how facility management and independent review team members are to complete their roles in the revised ReDPro process. This new guidance should help reduce the inconsistencies and other deficiencies we identified in facilities' audits. As such, we are closing this recommendation as implemented.
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| Department of Veterans Affairs | The Under Secretary for Health should ensure that OAA develops substantive training for independent audit team members, consistent with the updated audit purpose, guidance, and tools. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how the independent audits should be conducted. (Recommendation 7) |
Closed – Not Implemented
VA agreed with this recommendation. In November 2020, VA reported that the previous disbursement agreement oversight mechanisms had been revised, and that the Office of Academic Affiliations had developed training for independent audit teams (now to be called independent review teams) specific to their role in the revised ReDPro review process. VA reported completing initial training related to the new ReDPro process in February 2021. However, in training evaluation results, some independent review team members and compliance officers reported concerns, particularly related to the ease of following the ReDPro checklist process. In response, VHA officials reported that they were making changes to the ReDPro process, including changes related to who would perform certain key tasks. These changes required new training, which VHA officials reported was completed January through May 2022. Upon reviewing information provided by VA associated with the new training, it became clear that our recommendation was no longer applicable as written given changes to the ReDPro process and who was to perform certain functions previously handled by the independent audit teams. As such, we are closing the recommendation as not implemented.
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