Recommendation: The Under Secretary for Benefits should work with State and SSA to identify and implement ways to help ensure that embassy staff and RFBOs are made aware of relevant changes in VA policy and standard operating procedures in a timely and consistent manner and can more readily identify available resources so they can efficiently help veterans living abroad with VA's disability claims process. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Benefits should identify and implement an interim strategy to consistently document the complete contact information for veterans living abroad within VBMS, while OIT and VBA continue to explore a long-term solution. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Benefits should systematically assess the quality of embassy-referred exams and use the results of this review to identify whether there are common problems related to the use of these exams, and, if necessary, take steps to address those problems, such as by developing tailored technical assistance for embassy-referred examiners. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Benefits and Under Secretary for Health—in concert with the General Counsel—should assess and decide whether to reimburse beneficiaries for travel to disability medical exams in foreign countries. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Health, working with the Under Secretary of Benefits, should identify ways to reimburse examiners who conduct disability medical exams via direct deposit in the local currency, assess the cost-effectiveness of these options, and implement the method it selects. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should develop a department-wide succession plan for leadership and mission-critical occupations that incorporates key leading practices for succession planning. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of April 2020, VA reported that it is developing a department-wide succession plan for leadership positions and mission-critical occupations. VA estimated it would complete this plan by September 30, 2020. When VA provides us a copy of the completed plan, we will provide updated information.

Recommendation: The Under Secretary for Health should incorporate key leading practices into VHA's succession planning processes, including monitoring and evaluating VHA's succession planning. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: As of April 2020, VHA reported that it is developing guidance and metrics, developing a process to assess field-based succession planning actions, and incorporating evaluations and updates of implementation strategies into its succession plan. VHA also indicated that it is developing a new VHA Executive Succession Plan. VHA plans to complete these actions by December 2021. When we receive VHA's updated plans and guidance, we will provide updated information.

Recommendation: The Under Secretary for Benefits should develop a succession planning process for all leadership positions and incorporate key leading practices into VBA's succession planning for leadership positions and mission-critical occupations. These practices include aligning the plans with strategic goals, identifying strategies to close workforce gaps, and monitoring and evaluating VBA's succession planning. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Benefits Administration
Status: Open

Comments: As of April 2020, VBA reported that it is developing succession plans that align with VBA's strategic goals and identify succession planning strategies. VBA also indicated that it plans to review, assess, and update the plans annually. According to VBA, its plans will cover mission-critical occupations as well as leadership positions within those mission-critical occupations. However, VBA stated that VA's Corporate Senior Executive Management Office (CSEMO) is responsible for planning related to VBA's senior executives and that VBA will coordinate with CSEMO on succession planning for senior executives. To implement our recommendation, VBA will need to demonstrate that VBA, or CSEMO in coordination with VBA, has developed succession planning processes that cover all leadership positions (including senior executives) and mission-critical occupations. VBA expects to complete its succession plans by September 30, 2020. When we receive VBA's completed plans, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should update VA's 2003 directive on workforce and succession planning to incorporate relevant legal requirements, including Office of Personnel Management strategic human capital management regulation requirements. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of April 2020, VA reported that its updated directive is going through the Department's internal review and concurrence process. VA estimated it would complete the directive by July 31, 2020. When VA provides us a copy of the directive, we will provide updated information.

Recommendation: The Under Secretary for Benefits should systematically solicit and collect information on potential financial exploitation from VA's Pension Management Centers and other relevant VA components, including VA's Office of General Counsel, and assess this information to inform plans to address the potential exploitation of veterans receiving pension benefits. Such plans could also address the broader population of veterans with disabilities. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of July 2020, VA reported taking steps to share data on potential financial exploitation threats, but further opportunities to collect information exist. In February 2020, VA updated its policy manual, instructing Pension Management Centers to send copies of any OIG fraud referrals to VA's Fraud, Waste, and Abuse Incident Team. This team plans to use the information to identify trends in potential fraud, and recommend changes to VA laws, policies, or procedures, as needed. VA also plans to use this data to coordinate with other Government agencies and offices to help prevent financial exploitation. However, VA has not reported taking steps to collect information from its Office of General Counsel, Pension Management Centers, and other components on threats to veterans that do not result in fraud referrals to OIG. VA asserts that collecting additional information on suspicious activities that do not meet the level of fraud that can be referred to OIG would be inappropriate because VA lacks investigative authority. As GAO noted in its report, not all suspicious activity or complaints rise to the level of fraud. Collecting additional information could improve VA's ability to understand threats to veterans and develop responses, such as outreach, and could build on VA efforts already underway with its Fraud, Waste, and Abuse Incident Team.

Recommendation: The Under Secretary for Benefits should place additional warnings on paper and electronic documents, including on benefit applications, regarding fees which veterans cannot be charged. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of July 2020, VA reports that it plans to include warnings on its pension applications to clarify which fees attorneys and others may charge veterans for representing them when applying for pension benefits. According to VA, information collection requests were published in the Federal Register in June 2020, and VA expects its application forms to be revised by the end of calendar year 2020. GAO will close this recommendation once VA's applications are revised.

Recommendation: The Under Secretary for Benefits should explore the costs and benefits of additional steps claims processors could take to verify that the direct deposit information provided by claimants on their applications is for the appropriate party. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: In August 2020 VA reported that it is in the process of updating its application forms to require claimants to submit documentation, such as a voided check or deposit slip, when applying for pension benefits. GAO will close this recommendation once changes to these applications are complete.

Recommendation: The Under Secretary for Benefits should develop and implement a plan for how VBA will use data from the new exam management system to oversee contractors, including how it will capture accurate data on the status of exams and use it to (1) assess contractor timeliness, (2) monitor time spent correcting inadequate and insufficient exams, and (3) verify proper exam invoicing. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and outlined improvements in the information collected through VBA's new exam management system. VBA is testing a mechanism to validate exam invoices submitted by contractors. It will be important for VBA to take the next step of developing and implementing a plan for how it will use information from the new system to ensure both accurate timeliness data and proper exam invoicing.

Recommendation: The Under Secretary for Benefits should regularly monitor and assess aggregate performance data and trends over time to identify higher-level trends and program-wide challenges. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. The agency stated that VBA will use improved data in the new exam management system to regularly monitor and assess aggregate performance data, identify error trends, and monitor contractor performance and program-wide challenges.

Recommendation: The Under Secretary for Benefits should document and implement a plan and processes to verify that contracted examiners have completed required training. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. The agency stated that VBA has started developing a training plan for contractors, as well as a new training delivery system, to validate that required training has been completed and to assess the effectiveness of this training through feedback from trainees, contractors, and quality review staff in VBA's contract exam program office. VBA intends to use this information to improve the implementation and content of training. VBA expects to fully implement its new training system before the end of fiscal year 2020. Once implemented, GAO will be able to close both of its recommendations related to training verification and assessment.

Recommendation: The Under Secretary for Benefits should collect information from contractors or examiners on training and use this information to assess training and make improvements as needed. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. The agency stated that VBA has started developing a training plan for contractors, as well as a new training delivery system, to validate that required training has been completed and to assess the effectiveness of this training through feedback from trainees, contractors, and quality review staff in VBA's contract exam program office. VBA intends to use this information to improve the implementation and content of training. VBA expects to fully implement its new training system before the end of fiscal year 2020. Once implemented, GAO will be able to close both of its recommendations related to training verification and assessment.

Recommendation: The Under Secretary for Benefits should develop and implement a new regional office performance measure that allows it to better measure the accuracy of each regional office's work. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Benefits Administration
Status: Open

Comments: VBA is working to develop and implement a new measure to assess the accuracy of each regional office. We will close this recommendation once VA has finalized and implemented the new measure.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should issue an updated Commandant Instruction that establishes policies and procedures to improve the reliability and completeness of TAP data by including when and by whom data should be recorded and updated. (Recommendation 1)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security agreed with our recommendation and reported that a Commandant Instruction had been drafted, which will include a policy on the duties and requirements for recording TAP data. The Commandant Instruction is anticipated to be issued by October 31, 2018. We will consider this recommendation closed when the Commandant Instruction is officially issued.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should establish a formal performance goal with a measurable target for participation rates in VOW Act-mandated portions of TAP. (Recommendation 2)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security (DHS) agreed with our recommendation and reported that the Coast Guard, Department of Defense (DOD), and other partners collaborated to identify measurable and specific performance goals that are compliant with VOW requirements. In addition, the these goals will be measured using the DOD's TAP-IT Enterprise tracking system once it becomes fully functional to the Coast Guard by October 31, 2018. We will close this recommendation when DHS provides documentation of its measures and goals.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should issue an updated Commandant Instruction that defines the roles and responsibilities of the personnel who administer the program and ensure servicemembers' participation. (Recommendation 5)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security agreed with our recommendation and reported that a Commandant Instruction has been drafted, which will identify the duties of personnel who administer TAP. The Commandant Instruction is anticipated to be issued by October 31, 2018. We will consider this recommendation closed when the Commandant Instruction is officially issued.

Recommendation: To ensure that all eligible Coast Guard servicemembers are provided the opportunity to complete the Transition Assistance Program (TAP), the Commandant of the Coast Guard should, once reliable data are available by installation or unit, enable unit commanders and the higher-level commanders to whom they report to access TAP performance information specifically for the units they oversee so that they can monitor compliance with all TAP requirements. (Recommendation 6)

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The Department of Homeland Security agreed with our recommendation and reported the Coast Guard expects to fully transition to DOD's TAP-IT Enterprise System by October 31, 2018, which is expected to facilitate tracking of servicemember attendance within all TAP components. The agency also stated that following the transition and release of the new Commandant Instruction, Commanding Officers will be able to monitor their compliance with TAP performance and requirements. Both these efforts are expected to be completed by October 31, 2018. We will consider this recommendation closed when the Commandant Instruction has been issued and documentation is provided of the ability to track performance information by unit.

Recommendation: The Secretary of Veterans Affairs should clearly articulate in VA's appeals plan how VA will monitor and assess the new appeals process compared to the legacy process, including specifying a balanced set of goals and measures--such as timeliness goals for all VBA appeals options and Board dockets, and measures of accuracy, veteran satisfaction, and cost--and related baseline data. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA concurred with this recommendation and, as of March 2020, addressed some but not all aspects of it. Regarding monitoring, VA has made progress in monitoring and addressing workload changes in its new and legacy appeals processes. For example, VA has developed sensitivity models and other analyses to monitor and forecast future VBA and Board workloads, production, and staffing requirements to help VA manage the new and legacy appeals processes. Further, the Board is aiming to complete non-remanded legacy appeals by December 2022 by first addressing hearing-requested appeals. However, VBA and the Board have yet to specify a complete set of balanced goals for monitoring the new and legacy appeals processes (e.g., timely and accurate processing of appeals while ensuring veteran satisfaction). For example, the Board will not establish timeliness goals for all new Board options until after collecting additional data during implementation of the new appeals process, thus delaying VA's vision for what successful implementation should look like and hindering awareness of resources required to achieve that vision. Regarding comparing the performance of the new and legacy appeals processes, VA officials have previously reported that they intend to use timeliness and productivity metrics from section 5 of the Appeals Modernization Act. Further, VBA and Board officials have articulated steps they are taking to collect, through surveys, comparable information on veterans' satisfaction with the new and legacy appeals processes. However, VA has not fully articulated detailed steps and timeframes for assessing the relative performance of the new and legacy appeals processes. For example, VA has not indicated how it will assess whether or the extent to which the new process, which also allows for multiple appeal opportunities, will achieve final resolution of veterans' appeals sooner, on average, than the legacy process, as we recommended in GAO-17-234. We will consider closing this recommendation when VA provides documentation indicating how it will assess the new appeals process against the legacy process vis a vis balanced measures.

Recommendation: The Secretary of Veterans Affairs should augment the master schedule for VA's appeals plan to reflect all activities--such as modifications to information technology (IT) systems--as well as assigned responsibilities, interdependencies, start and end dates for key activities for each workgroup, and resources, to establish accountability and reduce overall risk of implementation failures. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. Since our report was issued, VA took significant action on its project plan and in February 2019, implemented the Veterans Appeals Improvement and Modernization Act of 2017. VA provided increasingly more details in updates to its plan about sub-activities related to processing legacy appeals, monitoring implementation, drafting Board policies, training, and testing of the new process. For example, VA added activities related to the Rapid Appeals Modernization Program (RAMP) test of the VBA-only options as well as the test of the new Board options. In spring and summer 2018, according to VA officials, VA set a baseline schedule for implementing appeals reform in response to the potential February 2019 implementation date established in the Act. In October 2018, VA provided us with lower-level schedules and other related information that allowed us to conduct a more detailed assessment of VA's IMS against applicable best practices criteria. However, as of December 2018, VA's schedule did not fully align with best practices. For example, VA's schedule did not contain a work breakdown structure that defines the work, activities, and resources necessary to accomplish implementation-details that would inform resources and time needed for the project. (For details on this assessment, see GAO-19-272T.) While VA fully implemented appeals reform in February 2019, incorporating such lessons learned into future project planning could help VA improve its project scheduling capabilities. Specifically, in February 2020 VA reported that Caseflow-VA's replacement system intended to support appeals reform-had "minimal functionality," with many functionalities yet to be implemented. We will consider closing this recommendation when VA has produced a more complete plan for-and that establishes accountability and reduces risk of failure related to-developing, implementing, and integrating remaining key functionality envisioned under Caseflow. We will also continue tracking whether the Board addresses long-term Caseflow planning under recommendation 2 in GAO-17-234.

Recommendation: The Secretary of Veterans Affairs should ensure that the appeals plan more fully addresses risk associated with appeals reform--for example, by assessing risks against a balanced set of goals and measures, articulating success criteria and an assessment plan for RAMP, and testing or conducting sensitivity analyses of all appeals options--prior to fully implementing the new appeals process. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation to more fully address risks associated with implementing a new appeals process. As of March 2020, VA has taken many steps to address our recommendation, although key steps are remaining for VA to better assess risks associated with implementing appeals reform and managing appeals workloads in the legacy process. Specifically, since May 2018, VBA and Board officials reported developing and using new sensitivity analyses that would allow the agency to project potential budget needs and staffing requirements. Further, VBA is using these analyses to more accurately predict resolution of legacy appeals given certain assumptions. Furthermore, in addition to testing two appeal options available within VBA through its Rapid Appeals Modernization Program (RAMP), VA conducted small-scale testing of the three new Board appeals options through the Board's Early Applicability of Appeals Modernization (BEAAM) pilot, testing that was missing from VA's original November 2017 plan. VA also reported using lessons learned from testing all appeals options to update the implementation process. However, as designed, RAMP and BEAAM lacked well-defined, measurable criteria for assessing lessons learned from its testing, and the agency did not fully test all aspects of the appeals options before moving to full implementation in February 2019. Even though VA has fully implemented the new disability appeals process without addressing these aspects of our recommendation, many of the other principles of sound planning practices that informed our recommendation remain relevant, even after implementation, to ensure the new process meets veterans' needs. Specifically, VA has not developed mitigation strategies for all identified risks, such as veterans appealing to the Board at higher rates than expected or choosing more resource-intensive Board options, such as those involving new evidence or a hearing. As of January 2020, the more resource-intensive hearing option accounted for over 50 percent of new appeals inventory. At the same time, the Board reported it plans to prioritize resources on reducing the legacy appeals inventory and on the least resource intensive appeal option for which it established a timeliness goal. Although the Board has increased productivity, addressing legacy hearings will take several years as veterans may continue choosing the new hearing option at high rates and the Board prioritizes other workloads. This circumstance could subject veterans to longer wait times and increasing backlogs under the hearing option. As of March 2020, VA also has not established a complete and balanced set of goals and measures for the new appeals options, which are a necessary pre-condition to effectively assessing risk. Lacking a complete set of goals and measures, VA may not have comprehensively identified key risks.

Recommendation: The Under Secretary for Health should specify in VHA policy that reviews of providers' clinical care after concerns have been raised should be documented, including retrospective and comprehensive reviews. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with the recommendation and indicated plans to revise policy to codify requirements to document reviews. As of April 2020, VA estimates completing these and other revisions to the policy in August 2020.

Recommendation: The Under Secretary for Health should specify in VHA policy a timeliness requirement for initiating reviews of providers' clinical care after a concern has been raised. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with the recommendation and indicated plans to revise policy to incorporate timeline expectations for initiating reviews after clinical care concerns have been raised. As of April 2020, VA estimates completing these and other revisions to the policy in August 2020.

Recommendation: The Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: As of January 2020, VHA continues to disagree with the recommendation and has not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.

Recommendation: The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. In November 2017, VHA's Executive in Charge chartered the Specialty Care Provider Staffing and Network Model Workgroup to develop a methodology for determining the scope and complexity of specialty care services. The Workgroup also developed an analytical tool to support local decision-making around specialty staffing levels. According to VHA, the Specialty Care Services Staffing model has been validated across some VHA regions. The Workgroup was directed to develop an Executive Decision Memorandum for an official determination as to implementation of the model. As of January 2020, VHA was awaiting the results of the Governing Board's decision on the Executive Decision Memorandum, the guidance documents, and analytical template. VHA reported the target date for completion is March 2020.

Recommendation: The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. VHA is working to develop the necessary capacity to enable a system-wide method for sharing information about physician trainees to help fill vacancies. In April 2019, VHA anticipated having this system in place by the end of fiscal year 2019. However, VHA has not submitted any additional information since April 2019. VHA has also created a VHA-Trainee Recruitment and Hiring Workgroup (the Workgroup). The Workgroup serves as the advisory group on trainee recruitment and hiring, for the purpose of developing a permanent Trainee Recruitment and Hiring Function. The Workgroup is holding Virtual Trainee Recruitment Events for critical occupations. Until GAO sees evidence of a system-wide method for sharing information about physician trainees, this recommendation will remain open.

Recommendation: The Undersecretary for Health should take additional steps to ensure that VA's website reports health care quality measures that cover a broad range of health care services, highlights key differences in the clinical quality of care, and presents this information in an easily accessible and understandable way (Recommendation 1).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA provided information that they had updated information on its website to include more quality measures, particularly as they relate to outpatient care. While VA has made progress in reporting on additional measures, we reviewed VA's website-specifically, their Access and Quality webpage which is the primary webpage for veterans to access information on quality-as of February 2020 and found that VA has still yet to report on a broad range of quality measures that would assist veterans in making health care decisions for inpatient care. For example, VA does not report any quality measures related to readmissions and mortality; length-of-stay; or efficiency. VA also continues to report only one timely and effective care measure for inpatient care. With regards to presentation of its quality measures, VA no longer links its Access and Quality webpage to the homepage of VA's website, making it more difficult to find. Additionally, for the new outpatient measures that VA has added to its website, VA has not presented these measures in an easily understandable way as there is little explanation of what they are measuring and how veterans can use these measures to make healthcare decisions. We will keep this recommendation open until VA has made further updates to its website.

Recommendation: The Undersecretary for Health should direct VA Central Office to conduct a systematic assessment of the completeness and accuracy of patient clinical information across VAMCs that is used to calculate the health care quality measures VA reports and address any deficiencies that affect the accuracy of these measures (Recommendation 2).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA has said they have focused on three main efforts as it relates to documenting information on VA quality of care, including: timeliness of access information (e.g., wait times) to health care within VA facilities; timeliness and accuracy of payments to community care providers; and accuracy of coding and documentation within VA and from community providers. In particular, VA has conducted several efforts to improve education and training on clinical documentation and coding, particularly for providers. VA has also said it has made efforts in requiring programs across regional networks aimed at improving clinical documentation and coding. While these efforts can help with improving documentation of care to veterans, it is unclear how VA Central Office has assessed whether these efforts have actually achieved its goals and improved the accuracy of its quality measures. As we stated in our report, VA Central Office has not conducted a systematic assessment of the completeness and accuracy of the clinical data recorded in VA patient medical records across all VAMCs. The results of such a systematic analysis could help identify the deficiencies, if any, in the recording of patient clinical information and what steps, if any, VA Central Office may need to take to address them. We will keep this recommendation open until VA provides information on a systematic assessment of clinical documentation.

Recommendation: The Under Secretary for Health should further clarify when and for what purposes each national policy and guidance document type should be used, including whether guidance documents, such as program office memos, should be vetted and recertified. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: VA agreed with our recommendation. In October 2019, VHA issued an interim policy on program office memos (also known as "operational memos") that described how these guidance documents should be vetted and recertified. For example, operational memos issued after VHA's new interim policy will expire 2 years after publication if no further action is taken. In November 2019, VHA further clarified in another interim policy the purpose of all national policy and guidance documents, including the purpose and audience for each document type. Because VHA interim policy, by definition, is automatically rescinded after 1 year unless incorporated into a national policy directive, VHA needs to provide us with the finalized version of its recertified national policy directive in order to fully implement this recommendation. The recertified national policy directive should include the framework outlined in its interim policy documents.

Recommendation: The Under Secretary for Health should develop standard processes for consistently maintaining and disseminating guidance documents to each level of the organization. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with our recommendation. VHA reported that it added a program office memo (also known as "operational memo") section to its internal publications website in November 2017. Uploading operational memos to this website allowed VHA to identify 327 outdated documents that it has since rescinded, as well as numerous other documents that may require rescission. In October 2019, VHA issued an interim policy requiring all operational memos to be maintained on its publications website. Because interim policy is automatically rescinded after 1 year, VHA needs to provide us with the finalized version of its recertified national policy directive that includes the process it established to maintain these documents. In addition, VHA has not provided documentation of how it will disseminate operational memos so that VHA program offices, VISNs, and VAMCs are aware of new or rescinded guidance.

Recommendation: The Under Secretary for Health should establish a mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and take the appropriate actions. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with our recommendation. In June 2018, VHA reported that it had formed a Field Advisory Workgroup to provide continuing advice on national policy. VHA reported its findings and recommendations from the first workgroup meeting in December 2017 to senior leadership, and held another series of interviews in Summer 2018 to gain additional feedback about how national policy changes affect local facilities. In November 2019, VHA noted that it is developing a standardized process for collecting feedback from the field on published policies. To fully implement this recommendation, VHA should provide documentation of the mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and how it will take the appropriate actions.

Recommendation: The Under Secretary for Health should establish a standard policy exemption waiver process and centrally track and monitor approved waivers. (Recommendation 5)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with our recommendation. In October 2018, VHA reported that it had collected information on the waiver procedures and areas of improvement that exist at both the national and local levels. Based on this information, VHA's Waiver Workgroup was finalizing its recommendations for implementing a formal waiver process. As of November 2019, VHA had not yet reached a decision on how to proceed. To fully implement this recommendation, VHA should provide us with documentation of a process that standardizes policy exemptions waivers, including tracking and monitoring those that are approved.

Recommendation: The Under Secretary for Health should establish a standard process, including designated oversight roles, to periodically monitor that local policies established by VISNs and VAMCs align with national policies. (Recommendation 6)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with our recommendation. In June 2018, VHA reported that it had identified approximately 55,000 local policies and included them in a SharePoint database, which will serve as a baseline for removing redundant or conflicting local policy. In November 2019, VHA issued an interim policy that established business rules for oversight and monitoring local policy development at the VISN and VAMC levels. Specifically, VHA will assess the number of local policies every 6 months as well as identify patterns of non-compliance. In addition, the interim policy includes standardized templates, a recertification requirement of 5 years to mirror the national policy requirement, and restricts VHA program offices from creating requirements for local policy development. VHA also established resources for the new interim policy, such as a list of local policies as required by national policy. Because VHA interim policy, by definition, is automatically rescinded after 1 year unless incorporated into a national policy directive, VHA needs to provide us with the finalized version of its recertified national policy directive in order to fully implement this recommendation.

Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to ensure that the department-level investment review structure is implemented as planned and that guidance on the IT governance process is documented and identifies criteria for selecting new investments, and reselecting investments currently operational at VHA.

Agency: Department of Veterans Affairs
Status: Open

Comments: In its comments on our report, VA concurred with our recommendation and provided meeting minutes for its Portfolio Investment Management Board and documentation describing the proposed alignment and interdependencies between information technology (IT) governance boards. According to VA officials, as of September 2019, the department had continued to further evolve its IT governance framework, reworked the committee structure and related working groups that oversee IT investments, and refined the process for prioritizing investments. A draft IT Governance Policy that describes an updated governance structure intended to implement IT solutions and an agile workforce was to be implemented by March 2020. The department has yet to report on the status and results of this implementation. We will continue to monitor VA's actions to ensure that the implementation is consistent with planned actions.

Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to identify additional performance metrics to align with VHA's core business functions, and then use these metrics to determine the extent to which the department's IT systems support performance of VHA's mission.

Agency: Department of Veterans Affairs
Status: Open

Comments: In its comments on our report, VA concurred with our recommendation. In addition, the department outlined steps it intends to take to address our recommendation, including developing a set of metrics to provide continuous input into investment portfolio decisions and establishing a methodology for ensuring that IT investments are aligned to business needs and that expected outcomes are defined prior to making the investments. According to department officials, VA issues a Joint Business Plan that identifies annual milestones associated with initiatives agreed upon by both VHA and OIT. As of September 2020, we are reviewing additional documentation related to the underlying processes that support the compilation of the plan and any related metrics for the associated investments that are to support VHA's mission. We will continue to monitor progress in this area.

Recommendation: To assist VA in improving key IT management processes to ensure that investments support the delivery of health care services, the Secretary of Veterans Affairs should direct the Under Secretary for Health and the Chief Information Officer to ensure that unmet IT needs identified by key program areas--pharmacy benefits management, scheduling, and community care--are addressed appropriately and that related business functions are supported by IT systems to the extent required.

Agency: Department of Veterans Affairs
Status: Open

Comments: In its comments on our report, VA concurred with our recommendation. The department described its intention to ensure that unmet IT needs for the pharmacy benefits management, scheduling, and community care program areas were addressed appropriately during fiscal year 2018 budget formulation. In March 2020, we met with officials from the Pharmacy Benefits Management program office, the Office of Veterans Access to Care, and the Community Care program to discuss the status of new service requests and the extent to which IT needs have been met since our report. While there was a slight decrease in the total number of new service requests that remained open for 5 years or more, officials from each office did not consistently report improvements in how IT needs were being addressed. For example, Pharmacy Benefits Management officials still waited for improvements that may come with the deployment of the new electronic health record system, but they continued to report that updates to industry standards should be addressed sooner and often IT needs did not make it through the prioritization process at the Veterans Health Administration to be considered by the Office of Information and Technology. Community Care officials reported a general improvement in the IT governance process and a more engaged relationship with the Office of Information Technology; however, the list of open new service requests still included long-term VistA-related enhancements, some of which had not yet been prioritized by the department. The Office of Veterans Care has not yet provided an updated list of open new service requests, but officials were satisfied with a new maintenance contract that allowed them to address a number of IT issues. We will continue to monitor the number of new service requests in each program area and the extent to which the IT needs are being met by the IT governance process.

Recommendation: To further align efforts to address appeals workload and improve timeliness of decisions, and reduce the risk that efforts will not go as planned, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits; the Chairman, Board of Veterans' Appeals; and the Chief Information Officer, as appropriate, to develop a schedule for IT updates that explicitly addresses when and how any process reform will be integrated into new systems and when Caseflow will be ready to support a potential streamlined appeals process at its onset.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred in principle with this recommendation. Moreover, since our March 2017 report, Congress passed the Veterans Appeals Improvement and Modernization Act of 2017, which required VA to develop a comprehensive appeals plan that included, among other things, descriptions of modifications to, cost estimates of and timelines for information technology that the agency needs to carry out appeals reform. However, more than a year after implementation of appeals reform, VA's February 2020 updated plan and FY 2021 budget request indicate that Caseflow has "minimal functionality", with many functionalities yet to be implemented. Further, VA's February 2020 updated plan and its FY 2021 budget request do not include specific steps or goals related to achieving overall functionality, integrated testing, or IT training for staff on new functionality still to be implemented in 2020 or beyond. While the VA's use of the agile process for IT development can help mitigate risks and avoid cost overruns and delays, VA's plans do not signal when Caseflow will support all of the Board's workflow needs for processing appeals under the new process. Such longer-term planning also could help ensure that all potential changes are anticipated in the plans of various VA components. For example, VA's February 2020 updated plan states that VHA cannot use Caseflow to efficiently and effectively manage its appeals workload. Longer-term planning could also ensure more transparency around additional resources needed to fully implement Caseflow versus other appeals-related technologies enterprise wide. We will consider closing this recommendation when VA has produced a longer-term plan for developing, implementing and integrating Caseflow functionality in support of a streamlined appeals process, including clear definitions of initial/minimal operating capability and full operational capability.

Recommendation: To better understand whether appeals process reform, in conjunction with other efforts, has improved timeliness, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits; the Chairman, Board of Veterans' Appeals; and the Chief Information Officer, as appropriate to develop a strategy for assessing process reform--relative to the current process--that ensures transparency in reporting to Congress and the public on the extent to which VA is improving veterans' experiences with its disability appeals process.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred in principle with this recommendation. Moreover, since our March 2017 report, Congress passed the Veterans Appeals Improvement and Modernization Act of 2017, which required VA to produce a comprehensive appeals plan that required VA, among other things, to periodically publish a range of metrics, including timeliness, related to the processing of appeals under the new and legacy system. As of February 2019, VA implemented appeals reform; however VA has not indicated how it will assess whether or the extent to which the new process, which also allows for multiple appeal opportunities, will achieve final resolution of veterans' appeals sooner, on average, than the legacy process. We will consider closing this recommendation when the Board establishes timeliness goals for all new appeals options and VA has produced a plan for analyzing whether the new process is an improvement. Closure of this recommendation is related to recommendation 2 in GAO-18-352.

Recommendation: To improve the management of DOD's credentialing program and better determine whether the program is achieving its desired results, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to develop and implement program performance measures that include key attributes, such as a baseline and goals, that can be used to assess performance.

Agency: Department of Defense
Status: Open

Comments: DOD did not concur with our recommendation to develop and implement performance measures for its credentialing program. In its response to the recommendation, DOD stated that servicemembers are not required to earn credentials and more than half of the credentials earned by servicemembers are voluntary. Therefore, establishing criteria that might create an incentive to force servicemembers into earning voluntary credentials would be counterproductive. DOD also stated that a basic reporting system is in place that captures credential attainment and associated costs that provides basic information to gauge the program's performance. As of April 2020, the department still does not plan to develop performance measures for the program.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of CMS to assess the feasibility of updating the agency's study on the effect of VA-provided Medicare-covered services on per capita county Medicare FFS spending rates by obtaining VA utilization and diagnosis data for veterans enrolled in Medicare FFS under its existing data use agreement or by other means as necessary.

Agency: Department of Health and Human Services
Status: Open

Comments: In December 2017, the U.S. Department of Health and Human Services (HHS) indicated that it had further reviewed our recommendation and determined that updating the agency's study on the effect of VA-provided Medicare-covered services on per capita county Medicare fee-for-service (FFS) spending rates using the Department of Veterans Affairs' (VA) utilization and diagnosis data was not feasible. Challenges cited by HHS included (1) pricing each VA encounter using Medicare payment rules; (2) determining which Medicare provider would have treated each beneficiary; and (3) the resources required to have an ongoing data feed with VA and to protect VA utilization and diagnosis data. While we acknowledge that there may be challenges associated with incorporating VA utilization and diagnosis data into HHS's analysis, we believe that HHS needs to do additional work before it can determine whether such an approach is feasible. For example, while HHS noted resource concerns related to sharing and storing sensitive VA data, the agency already receives and stores some VA data. It remains unclear whether HHS has assessed what additional resources would be needed to store VA utilization and diagnosis data and whether such data would need to be shared via an ongoing data feed-another challenge mentioned by HHS. As of June 2020, HHS has not provided us with any additional information about actions it has taken to address this recommendation. We continue to believe that HHS should assess the feasibility of implementing a methodology for estimating the effect of VA-provided Medicare-covered services on per capita county Medicare FFS spending rates that incorporates VA data.

Recommendation: If CMS makes an adjustment to the benchmark to account for VA spending on Medicare-covered services, the Secretary of Health and Human Services should direct the Administrator of CMS to assess whether an additional adjustment to MA payments is needed to ensure that payments to MA plans are equitable for veterans and nonveterans.

Agency: Department of Health and Human Services
Status: Open

Comments: In December 2017, the U.S. Department of Health and Human Services (HHS) indicated that there are a number of limitations that would impede the Centers for Medicare & Medicaid Services' (CMS) ability to conduct an analysis of veteran versus nonveteran payments to MA plans. HHS indicated that in order to conduct a thorough assessment, CMS would need utilization and diagnosis data from the Department of Veterans Affairs (VA), which would take several years to collect and analyze. In addition, HHS indicated that if CMS determined an adjustment was needed, the agency would have to overcome other data, operational, and financial challenges related to making the adjustment. As a result, HHS indicated that implementing such an adjustment would be infeasible. However, CMS currently adjusts the benchmark to account for VA spending on Medicare-covered services without VA utilization and diagnosis data. While we agree that VA utilization and diagnosis data may improve the accuracy of an adjustment to MA payments to ensure that payments to MA plans are equitable for veterans and nonveterans, it is unclear why CMS could not make an adjustment without VA utilization and diagnosis data. As of June 2020, HHS has not provided us with any additional information about actions it has taken to address this recommendation. In order for us to close this recommendation, CMS would need to assess whether an additional adjustment to MA payments is needed.

Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. This could be accomplished, for example, by building on the data collection efforts currently being implemented under the "Welcome to VA" program.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: In March 2016, GAO recommended that VA monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. VA concurred with this recommendation, and in June 2017, reported to GAO that it had taken actions to address it. Specifically, VA indicated that it revised an internal report to help identify and document all newly enrolled veterans and monitor their appointment request status. The report is intended to enable VHA and its medical centers to oversee the enrollment and appointment process by tracking the following timeframes: (1) application to enrollment, (2) enrollment to initial contact, (3) initial contact to primary care appointment, and (4) total time from application to primary care appointment. However, VA also indicated in its response that it did not have data that captures application dates for all newly enrolled veterans. As such, the report could not be used to consistently monitor the full amount of time these veterans wait to be seen by primary care providers. In January 2018, VA reported developing and implementing technical enhancements to its electronic systems that will enable it to capture the application date for all newly enrolled veterans. In April 2018 and December 2018, VA reported making continued efforts to implement technical enhancements to its electronic system. In its February 2020 update, VA identified several steps that the agency was completing to fully implement the revised internal report and noted that following a successful piloting of the report, the agency would implement it system-wide. VA reported that it expects to fully address this recommendation by October 2020.

Recommendation: The Secretary of Defense should direct the Secretary of the Army to implement processes to review and monitor the Army military treatment facility prescribing practices for medications discouraged under the PTSD guideline and address identified deviations.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and stated that any policy that it may issue related to the monitoring of prescribing practices would be directed toward all of the military services. In May 2018 DOD stated that it planned to (1) conduct a comprehensive review of existing prescribing practices for the treatment of PTSD; (2) develop policy guidance for addressing prescribing practices for the management of PTSD that deviate from the clinical practice guideline; and (3) implement an automated dashboard that will flag medications that the PTSD guideline discourages from use. In its February 26, 2020 response, DOD stated that July 30, 2020 is the estimated completion date for these planned actions. To close this recommendation, DOD needs to implement its planned actions and provide documentation showing that the Department is monitoring medications discouraged from use under the PTSD guideline and addressing identified deviations.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should address overpayments resulting from enrollment changes by identifying and implementing a cost-effective way to allow Post-9/11 GI Bill beneficiaries to verify their enrollment status each month, and require monthly reporting.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency was in the latter stages of developing a pilot program to verify beneficiaries' attendance using text messaging. This pilot, scheduled for release in November 2020, will initially be limited to beneficiaries receiving the Rogers STEM Scholarship to extend their Post-9/11 GI Bill benefits, but would eventually be expanded to all Post-9/11 GI Bill beneficiaries if it is successful. VA expects to complete these efforts by December 2021.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should improve efforts to notify veterans and schools about overpayment debts by identifying and implementing other methods of notifying veterans and schools about debts to supplement the agency's mailed notices (e.g., email, eBenefits).

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency has taken action to move away from a reliance on mailed letters, including the eventual use of email notifications for debt letters and other GI Bill correspondence. The agency plans to implement these changes December by 2020.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should revise policy for calculating overpayments to increase collections by prorating tuition overpayments when veterans reduce their enrollment during the term based on the actual date of the enrollment change rather than paying additional benefits through the end of the month during which the reduction occurred.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency is revising its tuition overpayment regulations to address the recommendation in GAO's 2015 report. VA officials said that these revisions are part of its broader regulatory proposal that has experienced delays due to 2017 legislative changes and other legal developments. They expect these proposed regulations to be published by December 2020.

Recommendation: To improve the administration of the Post-9/11 GI Bill, reduce the occurrence of overpayments, and increase debt collections, the Secretary of Veterans Affairs should ensure it is recovering the full amount of tuition and fee payments if a school does not charge a veteran for any tuition or fees after dropping a class or withdrawing from school. For example, VA could adjust its overpayment calculation to account for these situations or provide schools with guidance on how to account for school refund policies when reporting enrollment and tuition changes.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA officials reported in August 2020 that the agency plans to amend its procedures to account for school refund policies when calculating veterans' overpayment debts, as we recommended. VA plans to incorporate this change in its information technology (IT) upgrades by December 2021. Earlier plans to implement this recommendation were put on hold so the department could prioritize other IT updates that it said are necessary to implement certain legislative changes to the GI Bill program.

Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to develop an updated plan for VBMS that includes (1) a schedule for when VBA intends to complete development and implementation of the system, including capabilities that fully support disability claims, pension claims, and appeals processing and (2) the estimated cost to complete development and implementation of the system.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation and as of January 2020, is continuing to develop requirements for VBMS in order to develop functionality to replace legacy information systems. In addition, the department subsequently provided us with expected completion dates for implementation of claims and appeals processing, but has not provided a schedule for the implementation of pension claims processing. To fully implement this recommendation, the department needs to provide the expected completion date for pension claims processing and an estimate of the cost to complete remaining development and implementation of VBMS.

Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to reduce the incidence of high- and medium-priority level defects that are present at the time of future VBMS releases.

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) concurred with this recommendation and reiterated its plans and procedures for decreasing the incidences of defects in each system release. However, while the most recent VBMS release (i.e., May 2019) showed a decrease in the number of high- and medium-priority level defects, the release in February 2019 showed an increase in the number of high- and medium-priority defects. In addition, both the February 2019 and May 2019 releases showed the presence of the highest severity defects--critical--which have extensive user impact and workarounds do not exist. We will continue to monitor VA's actions and progress in response to this recommendation.

Recommendation: To inform decisions on any potential future iterations of the veterans' employment workshop, the Secretary of Labor should assess and report to Congress the extent to which further delivery of employment workshops to veterans and their spouses could fill a niche not fully served by existing federal programs. Such an assessment could involve collaboration with VA and other stakeholder organizations.

Agency: Department of Labor
Status: Open

Comments: In April 2019, DOL restated its assertion that the employment services most needed by veterans and spouses were already available to them through the state workforce system and should not be offered through another mechanism. DOL pointed to changes in the employment workshops under its Transition Assistance Program, though those changes do not inform the need for any additional services such as Off Base Transition Training workshops. Additionally, DOL noted that Section 502 of the Veterans Health Care and Benefits Improvement Act of 2016 called for a 5-year longitudinal study of veteran workforce services. DOL concluded a feasibility study in December 2018 and said it will produce a plan to conduct the 5-year longitudinal study, which will inform the extent to which further delivery of employment workshops to veterans and their spouses could fill a niche not fully served by existing federal programs. While completing the feasibility study and planning to conduct the longitudinal study are important steps, DOL has not yet completed that study, nor has it reported to Congress on the extent to which employment workshops might fill a niche not currently served by existing federal programs.

Recommendation: To ensure the reliability of OEHS data, the Secretary of Defense should establish clear policies and procedures for performing quality assurance reviews of the OEHS data collected during deployment, to include verifying the completeness and the reasonableness of these data, and require that all other related military-service-specific policies be amended and implemented to ensure consistency.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with our recommendation. In August 2016, DOD officials told us that a new DOEHRS version was released that contained several system enhancements and defect corrections to improve overall data quality in the system. However, as of July 2020, DOD had not provided specific information on these system enhancements, which would allow us to determine whether our recommendation has been fully addressed.

Recommendation: To ensure that the Family Caregiver Program is able to meet caregivers' demand for its services, the Secretary of the Department of Veterans Affairs should expedite the process for identifying and implementing an IT system that fully supports the program and will enable VHA program officials to comprehensively monitor the program's workload, including data on the status of applications, appeals, home visits, and the use of other support services, such as respite care.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and the Veterans Health Administration (VHA) and the Office of Information and Technology (OIT) have been working jointly on projects since 2015 to improve and replace the IT system for the Family Caregiver Program. However, two of these projects were terminated without delivering viable software improvements or a replacement system. According to two independent assessments, these prior efforts lacked both effective leadership and implementation of the processes needed for requirements management. In March 2019, VA began a third project, the Caregiver Record Management Application (CARMA), in which OIT and VHA began to acquire and implement a commercial product to replace the program's existing IT system. In February 2020, VA reported that to support the administrative needs of the Family Caregiver Program it had transitioned from its previous IT system to CARMA, its new IT system, in two stages: 1) In October 2019, VA deployed an initial release of CARMA for data entry of veterans and caregivers newly participating in the program, and 2) On December 2, 2019 the transition of existing veterans and caregivers to CARMA occurred. VA also reported in February 2020 that further enhancements and improvements to CARMA would be released over the coming months. However, the department has not yet fully committed to a date by which it will certify that CARMA fully supports the program. As of July 2020, this recommendation remains open pending further updates.

Recommendation: The Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to use data from the IT system, once implemented, as well as other relevant data to formally reassess how key aspects of the program are structured and to identify and implement modifications as needed to ensure that the program is functioning as envisioned so that caregivers can receive the services they need in a timely manner.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. VA transitioned in late 2019 to a new IT system, the Caregiver Record Management Application (CARMA). However, the Department has not yet certified the readiness of CARMA to fully support the needs of the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program). Prior to the transition to CARMA, VA had developed manual processes to obtain and monitor key data points, allowing it to reassess policies and procedures for the Family Caregiver Program. In its September 2019 update, VA reported that it anticipates being able to certify the IT system when proposed regulatory changes to enable the expansion of the Family Caregiver Program are finalized and the necessary changes which have an impact on IT are implemented. VA also reported that following certification, IT development will continue on IT requirements that do not directly impact VA's ability to expand the program, such as improving the program's ability to track and report on clinical appeals. As of July 2020, this recommendation remains open pending further updates on how VA plans to use data from the IT system to monitor and assess the program's performance.

Recommendation: To better enable NCA to meet its mission of providing reasonable access to burial options at veterans cemeteries, the Secretary of Veterans Affairs should direct the Under Secretary for Memorial Affairs to use the capability of NCA's existing software to estimate the served and unserved veteran populations using census tract data.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA disagreed with our recommendation. Although VA agreed that census tract data was more precise than the county-level data NCA was using, the department disagreed that using this more precise data to make decisions would lead to different outcomes. Instead, VA believed that NCA's methodology of using county-level data was sufficient for estimating the number of served and unserved veterans. We disagree with VA's assertion that using more precise data to identify served and unserved veterans would have no effect on the outcome of VA's decisions about cemetery locations or prioritization. In 2019, VA officials provided new information that they make decisions on cemetery locations based in part on the projected, county-level veteran population 30 years in the future. VA officials expressed concern that there would be too much uncertainty trying to perform such long-term population projections at the census tract level. We believe VA's position has some basis, and therefore have removed the priority designation from our 2014 recommendation. However, as we reported in 2019 (GAO-19-121), we continue to maintain the validity of our recommendation and believe that comparing estimates of unserved veterans based on current census tract data with estimates based on current county-level data would provide a useful supplement to the VA's use of long-term projected county-level population data.