Fast Facts

Racial and ethnic minority veterans made up about 22% of the total veteran population of 18.6 million in 2016, according to VA.

Mirroring trends seen across the United States, VA has identified worse health care outcomes for some diseases among racial and ethnic minority veterans. For example, VA reported lower survival rates for African American veterans with cancer and cardiovascular-related illnesses than for other minority and white veterans.

We reviewed VA efforts to address these disparities. Among other things, we recommended VA ensure that any plans to address the issue include measures of progress and clear lines of accountability.

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Highlights

What GAO Found

The Department of Veterans Affairs (VA) has taken steps to reduce disparities in health care outcomes linked to race and ethnicity, but lacks mechanisms to measure progress and ensure accountability for results. In 2012, VA established the Office of Health Equity to identify and address health care outcome disparities and to develop an action plan to achieve health equity. This office issued an action plan in 2014 that identified activities to make improvements in five focus areas, such as increasing awareness of the significance of disparities and strengthening leadership for addressing them. However, GAO found that the extent of VA's progress in implementing the action plan and advancing health equity is unknown because the action plan lacked performance measures and clear lines of accountability for specific offices. For example, although VA's action plan included a list of “success criteria” for each of the five focus areas, these criteria were not measurable, and were not linked to specific activities or to offices responsible for implementation.

VA funds research efforts that have identified disparities in health care outcomes involving minority veterans, but rely on data that VA officials and researchers noted have weaknesses in completeness and accuracy. One concern is that race and ethnicity information can be labeled incorrectly in VA patients' electronic health records as ”self-reported”, a highly reliable method of collection, when data were actually collected based on the less reliable method of VA staff observation. Other reported concerns include missing values on patients' race and conflicting race and ethnicity information. VA researchers told GAO they account for some of these concerns by using data from other sources, such as Medicare, but such work-arounds are time intensive. Further, VA officials reported that data weaknesses limit their ability to identify and address disparities in health care outcomes in their medical centers. Despite recognizing weaknesses related to the quality of race and ethnicity data, VA has not implemented corrective actions to address them. Without doing so, VA medical center officials cannot readily identify and address disparities in health care outcomes by race and ethnicity.

Concerns Raised by Department of Veterans Affairs (VA) Officials about the Completeness and Accuracy of VA Race and Ethnicity Data

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Note: Concerns about the completeness and accuracy of race and ethnicity information were raised by officials from VA's Office of Health Equity, Veterans Experience Office, and Health Services Research & Development.

Why GAO Did This Study

According to VA, in 2016, racial and ethnic minority veterans represented about 22 percent of the total veteran population of 18.6 million. VA projects racial and ethnic minority veterans will make up 36 percent of its total veteran population by 2040. VA has identified racial and ethnic disparities in its health care outcomes, mirroring trends seen across the United States.

House Report 115-188 included a provision for GAO to review whether VHA provides quality, equitable care for minority veterans. GAO's report examines, among other issues, (1) the extent to which VA has taken steps to advance health equity for racial and ethnic minority veterans, and (2) VA's efforts to use race and ethnicity data to identify and address disparities in health care outcomes involving minority veterans. GAO reviewed relevant documents, such as strategic and operational plans and peer-reviewed research studies; assessed VA's health equity action plan against criteria identified in GAO's body of work on effectively managing performance; and interviewed VA officials familiar with VA's health equity efforts, as well as race and ethnicity data.

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Recommendations

GAO is making two recommendations to VA to (1) ensure that any health equity action plan includes performance measures to assess progress, and clear lines of accountability designating responsibility to specific offices, and (2) conduct an assessment to determine how to address weaknesses identified with the completeness and accuracy of race and ethnicity data in the electronic health record, and implement corrective actions as necessary. VA agreed with GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Office of the Under Secretary for Health The Under Secretary for Health should ensure that any action plan for achieving health equity includes key elements for successful implementation by consistently applying criteria identified in GAO's past work on effectively managing performance, including developing performance measures to assess progress and creating clear lines of accountability by designating specific offices or officials with responsibility for coordinating efforts to implement actions and committing resources necessary for achieving its goals and objectives. (Recommendation 1)
Open
VA concurred with our recommendation. In November 2019, VA reported that it planned to develop annual health equity operational plans that include performance measures, clear lines of accountability, and commitment of necessary resources for achieving VHA's health equity goals. In October 2020, VA reported that it had included this additional information in its FY2020 Operational Plan and achieved all of its performance goals. GAO reviewed the updated 5-year Health Equity Action Plan and corresponding FY2020 and FY 2021 Operational Plans and found that while VHA has made progress in some areas, the Operational Plans do not fully capture the key elements necessary to support their successful implementation. Such elements include developing performance measures to assess progress, creating clear lines of accountability by designating specific offices or officials with responsibility for coordinating efforts to implement actions, and committing resources necessary for achieving outlined goals and objectives. For example, the Operational Plans do not identify specific performance measures that demonstrate how well the organization is meeting goals through its planned objectives throughout the year; nor do they include specific information on the necessary resources and budgets committed to achieving such goals and objectives. To close this recommendation, VHA should further develop the key elements for successful implementation-performance measures, lines of accountability, and commitment of resources-included in its Health Equity Action Plan and related annual Operational Plans by consistently applying criteria described in GAO's body of work on effectively managing performance under the Government Performance and Results Act.
Office of the Secretary To ensure the availability of information on health care outcomes by race and ethnicity throughout the VA health care system, the Secretary of Veterans Affairs should conduct an assessment to determine the completeness and accuracy of race and ethnicity data captured in VA's electronic health record, and implement corrective actions as necessary to resolve any identified deficiencies. (Recommendation 2)
Open
VA concurred with our recommendation. In June 2021, VA provided documentation of its November 2020 study assessing the completeness and accuracy of the race and ethnicity data in VA's electronic health records. The report noted that that the completeness of race and ethnicity data has improved over time and is currently complete for 93 percent of veterans receiving care at VA. VA also reported that the accuracy of the race and ethnicity data is high for White, Black, Asian, Hispanic, and Non-Hispanic Veterans but low for other groups. Further, according to VA's June 2021 response, OHE is developing a summary of best practices for ensuring accuracy and completeness of race and ethnicity data, which OHE will share with all VA medical facilities. VA also reported that technical assistance will be provided to low performing sites to implemented needed actions to improve data quality. GAO has reviewed the assessment and agrees that VA has successfully implemented the first part of the recommendation. However, VA has not provided sufficient evidence of addressing the second part of the recommendation (implement any corrective actions to resolve any identified deficiencies.) In GAO's view, the dissemination of best practices does not meet the threshold of implementing corrective actions set by the recommendation. In order to close this recommendation, VA will need to use its authority to implement any corrective actions across all VA medical centers and clinics to resolve the deficiencies in the completeness and accuracy of VA race and ethnicity data identified in its assessment.

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