oversight

Veterans' Health Care Budget: Better Labeling of Services and More Detailed Information Could Improve the Congressional Budget Justification

Published by the Government Accountability Office on 2012-09-18.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States Government Accountability Office

GAO              Report to Congressional Committees




September 2012
                 VETERANS’ HEALTH
                 CARE BUDGET
                 Better Labeling of
                 Services and More
                 Detailed Information
                 Could Improve the
                 Congressional Budget
                 Justification




GAO-12-908
                                            September 2012

                                            VETERANS’ HEALTH CARE BUDGET
                                            Better Labeling of Services and More Detailed
                                            Information Could Improve the Congressional
                                            Budget Justification
Highlights of GAO-12-908, a report to
congressional committees




Why GAO Did This Study                      What GAO Found
The VA operates one of the largest          The Department of Veterans Affairs (VA) creates its budget request through its
health care delivery systems in the         Enrollee Health Care Projection Model (EHCPM) using data from systems
nation. Within VA, VHA provides a           designed for the former single-account structure. These systems do not explicitly
range of health care services for           consider the three appropriations accounts: Medical Services, Medical Support
eligible veterans, such as primary care,    and Compliance, and Medical Facilities. According to Veterans Health
inpatient and outpatient surgery, and       Administration (VHA) officials, VHA formulates its budget based on the single
nursing home care. In the past, VHA         appropriations account, in part, because the systems to formulate the request
received medical care funds primarily       were in place prior to 2004, which was when the three-account structure was
through a single appropriations
                                            established. VA then presents the information in the Congressional Budget
account. However, to “provide better
                                            Justification (CBJ) by taking the data developed by the EHCPM and then, based
oversight and receive a more accurate
accounting of funds,” in 2004,
                                            on historical percentages and future projections, assigning the requested
Congress established a new three            amounts to the three appropriations accounts.
appropriations account structure.           The information about VA’s health care accounts in its CBJ can be difficult to
GAO was asked to (1) describe the           follow because information is not displayed consistently across the three medical
relationship between VHA’s                  care appropriations accounts. This is due to inconsistent labeling and varying
appropriations account structure and        levels of detail among the three appropriations accounts throughout the
VA’s development of the budget              justification. VHA officials stated that inconsistent labeling in the CBJ’s tables
request; and (2) examine how VA             was inadvertent. With respect to varying levels of detail among the three
presents information about the three        appropriations accounts, VHA officials said that the administrative and facilities
VHA appropriations accounts in its          costs for some programs are relatively small compared to the Medical Services
CBJ. To conduct this work GAO               costs. Thus they are not displayed for all three accounts. However, in at least
reviewed VA budget policy documents,        one instance, the amount of administrative and facilities costs not shown was
VA’s fiscal year 2009-2013 CBJs, prior      about 31 percent—a total of $1.05 billion—of the program’s cost. Finally, VA
GAO work on budget formulation at           presents several summary tables that highlight program costs; however,
VA, and interviewed VHA budget              information on how most of these costs break down across the three accounts
officials.                                  cannot be found in the CBJ. The lack of such account-level information can make
                                            it more difficult for congressional decision makers to make appropriations
What GAO Recommends                         decisions and to conduct oversight.
GAO recommends that VA label health         VA Medical Care Appropriations Accounts
care services consistently so it is clear
what services are being referred to
across appropriations accounts. GAO
also recommends that VA further
consult with congressional decision
makers when determining what
detailed information related to
appropriations accounts should be
presented—and how— in its CBJ. VA
generally agrees with GAO’s
conclusions and concurs with GAO’s
recommendations. VA stated what
actions it will take to implement the
recommendations.

View GAO-12-908. For more information,
contact Melissa Emrey-Arras at (617) 788-
0534 or emreyarrasm@gao.gov.

                                                                                    United States Government Accountability Office
Contents


Letter                                                                                     1
              Background                                                                   2
              VA’s Budget Request Is Based on Data from Systems Designed for
                the Former Single-Account Structure                                        7
              VA Provides Inconsistent Information across VHA’s Three Medical
                Care Appropriations Accounts                                              7
              Conclusions                                                                12
              Recommendations for Executive Action                                       12
              Agency Comments                                                            12

Appendix I    Comments from the Department of Veterans Affairs                           14



Appendix II   GAO Contact and Staff Acknowledgments                                      16



Tables
              Table 1: Excerpts from VA’s CBJ Showing Different Labels for the
                       Same Service                                                        9
              Table 2: Excerpts from VA’s CBJ Showing Similar Labels for
                       Different Services                                                  9
              Table 3: Information from VA’s CBJ Comparing Obligations
                       Provided for Nursing Home Care and Long-Term Care                 10


Figure
              Figure 1: VA Medical Care Appropriations Accounts                            4




              Page i                                  GAO-12-908 Veterans’ Health Care Budget
Abbreviations
CBJ               Congressional Budget Justification
CHAMPVA           Civilian Health and Medical Program of the Department of
                  Veterans Affairs
CWVV              Children of Women Vietnam Veterans
EHCPM             Enrollee Health Care Projection Model
FMP               Foreign Medical Program
OMB               Office of Management and Budget
VA                Department of Veterans Affairs
VA CLC            Veterans Affairs Community Living Centers
VHA               Veterans Health Administration

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Page ii                                           GAO-12-908 Veterans’ Health Care Budget
United States Government Accountability Office
Washington, DC 20548




                                   September 18, 2012

                                   The Honorable Patty Murray
                                   Chairman
                                   The Honorable Richard Burr
                                   Ranking Member
                                   Committee on Veterans’ Affairs
                                   United States Senate

                                   The Honorable Jeff Miller
                                   Chairman
                                   The Honorable Bob Filner
                                   Ranking Member
                                   Committee on Veterans’ Affairs
                                   House of Representatives

                                   The Department of Veterans Affairs (VA) operates one of the largest
                                   health care delivery systems in the nation. Within VA, the Veterans Health
                                   Administration (VHA) provides a range of health care services for eligible
                                   veterans, including primary care, inpatient and outpatient surgery,
                                   prosthetics, mental health services, prescription drugs, and nursing home
                                   care. In the past, VHA received medical care funds primarily through a
                                   single appropriations account. However, in 2004, Congress established a
                                   new account structure to “provide better oversight and receive a more
                                   accurate accounting of funds.” 1 This changed VHA’s medical care
                                   appropriations account structure from one account to three: Medical
                                   Services, Medical Support and Compliance, and Medical Facilities. These
                                   three accounts are considered to comprise VHA’s “medical care”
                                   accounts.

                                   An appropriations account structure broadly reflects how the House and
                                   Senate appropriations committees make resource allocation choices, the
                                   preferences of these appropriations committees, and the types of control
                                   and incentives these committees consider most important. Previously, we
                                   reported that changes to the budget structure and Congressional Budget
                                   Justifications (CBJ)—documents that support agency budget requests—




                                   1
                                    H.R. Rep. No. 108-401, at 1036 (2003).




                                   Page 1                                    GAO-12-908 Veterans’ Health Care Budget
             have the potential to help reframe budget choices. 2 Moreover, in the past,
             we have emphasized the importance of transparency in federal agencies’
             CBJs—that is, they should be clear and easy to understand—in part
             because Congress relies on the information in them to make resource
             allocation decisions and conduct oversight. 3 This report responds to your
             request that we (1) describe the relationship between VHA’s
             appropriations account structure and VA’s development of the budget
             request and (2) examine how VA presents information about the three
             VHA appropriations accounts in its CBJ.

             To complete our work, we reviewed VA budget policy documents, its
             fiscal years 2009 through 2013 CBJs, and our prior work on budget
             formulation at VA, and we interviewed VHA budget officials. We
             conducted this performance audit from June 2011 to September 2012 in
             accordance with generally accepted government auditing standards.
             Those standards require that we plan and perform the audit to obtain
             sufficient, appropriate evidence to provide a reasonable basis for our
             findings and conclusions based on our audit objectives. We believe that
             the evidence obtained provides a reasonable basis for our findings and
             conclusions based on our audit objectives.


             In fiscal year 2011, approximately 6.2 million patients received health
Background   care from VA. 4 In providing that care, VA operates 152 hospitals, 133
             nursing homes, 824 community-based outpatient clinics, and other
             facilities through 21 regional health care networks.



             2
              GAO, Performance Budgeting: Efforts to Restructure Budgets to Better Align Resources
             with Performance, GAO-05-117SP (Washington, D.C.: February 2005).
             3
              GAO, Internal Revenue Service: Assessment of Budget Justification for Fiscal Year 2011
             Identified Opportunities to Enhance Transparency, GAO-10-687R (Washington, D.C.: May
             26, 2010).
             4
              Eligibility is determined on the basis of service-connected disability, income, and other
             special statuses, such as former prisoners of war, and is used to determine priority for VA
             services. VA is required to provide a specified set of health care services, including
             hospital care, to eligible veterans. 38 U.S.C. §§ 1710(a)(1), (2), 1701(5), (6). VA is
             authorized to provide these health care services to other veterans not identified in these
             groups. 38 U.S.C.§ 1710(a)(3). The population of veterans to whom VA is required to
             provide nursing home care is more limited than the population to whom VA is required to
             provide other health care services, although VA also makes nursing home care available
             to other veterans on a discretionary basis as resources permit. See 38 U.S.C. § 1710A.




             Page 2                                            GAO-12-908 Veterans’ Health Care Budget
A variety of activities are funded through VHA’s three appropriations
accounts for medical care:

•   The Medical Services account includes funds for health care services
    provided to eligible veterans and beneficiaries in VA’s medical
    centers, outpatient clinic facilities, contract hospitals, state homes,
    and outpatient programs on a fee basis. 5 For fiscal year 2012, VA
    received more than $39.6 billion in the Medical Services account. 6

•   The Medical Support and Compliance account includes funds for the
    management and administration of the VA health care system,
    including financial management, human resources, and logistics. For
    fiscal year 2012, VA received more than $5.5 billion in the Medical
    Support and Compliance account. 7

•   The Medical Facilities account includes funds for the operation and
    maintenance of the VA health care system’s capital infrastructure,
    such as costs associated with nonrecurring maintenance, utilities,
    facility repair, laundry services, and grounds keeping. 8 For fiscal year
    2012, VA received more than $5.4 billion in the Medical Facilities
    account. 9




5
 Beneficiaries may include nonveterans, such as family members receiving Civilian Health
and Medical Program of the Department of Veterans Affairs benefits.
6
  Pub. L. No. 112-10, div. B, title X, § 2015, 125 Stat. 38, 175 (Apr. 15, 2011). In addition to
new appropriations that VA receives during the annual appropriations process, funding
may also be available from unobligated balances of multiyear appropriations, which
remain available for a fixed period of time in excess of 1 fiscal year. For example, VA’s
fiscal year 2011 appropriations provided that $1.2 billion be available for 2 fiscal years.
Pub. L. No. 112-10, § 2014. VA’s other sources of funding include collections and
reimbursements. VA’s collections include third-party payments from veterans’ private
health care insurance for the treatment of non-service-connected conditions and veterans’
copayments for outpatient medications. VA’s reimbursements include amounts VA
receives for services provided under service agreements with the Department of Defense.
See GAO, Veterans’ Health Care Budget: Transparency and Reliability of Some Estimates
Supporting President’s Request Could Be Improved, GAO-12-689 (Washington, D.C.:
June 11, 2012).
7
 Pub. L. No. 112-10, § 2015.
8
 This account does not include funding for major or minor construction or for information
technology because separate appropriations provide funds for these purposes.
9
 Pub. L. No. 112-10, § 2015.




Page 3                                              GAO-12-908 Veterans’ Health Care Budget
Figure 1 depicts the current appropriations account structure for VA
medical care.

Figure 1: VA Medical Care Appropriations Accounts




The amount of funding Congress gives VA to provide its health care
services is determined by the annual appropriations process. The
development of VA’s annual budget estimate is inherently complex, as
assumptions and imperfect information are used to project the likely
quantity and cost of the health care services VHA expects it will be
required to provide. 10 Unlike most other agencies, VA receives advance
appropriations for health care in addition to annual appropriations. 11
Accordingly, in preparation for the appropriations process, VA begins
developing an annual estimate of the resources needed to provide its




10
  GAO, VA Health Care: Challenges in Budget Formulation and Execution, GAO-09-459T
(Washington, D.C.: Mar. 12, 2009).
11
  The Veterans Health Care Budget Reform and Transparency Act of 2009 provided that
VA’s annual appropriations for health care also include advance appropriations that
become available 1 fiscal year after the fiscal year for which the appropriations act was
enacted. Pub. L. No. 111-81, § 3, 123 Stat. 2137, 2137–38 (2009), codified at 38 U.S.C.
§ 117. The act provided for advance appropriations for VA’s Medical Services, Medical
Support and Compliance, and Medical Facilities appropriations accounts. The act also
required VA to include additional information in its annual CBJ. Specifically, the VA
Secretary must include detailed estimates of the funds necessary to provide VA health
care services for the fiscal year for which advance appropriations will be provided.




Page 4                                           GAO-12-908 Veterans’ Health Care Budget
health care services for 2 fiscal years well in advance. 12 This budget
estimate is reviewed through successively higher levels within the agency
and revised until consolidated into a department-wide annual budget
estimate that is submitted to the Office of Management and Budget
(OMB) for review and consideration. OMB subsequently includes both an
appropriations request for VA health care services for 1 fiscal year and an
advance appropriations request for the next fiscal year in the President’s
annual budget request. 13 This estimate must include assumptions about
future economic conditions, presidential policies, and congressional
actions that may affect the funding needs in the year for which the
request is made. Because VA is required to provide services to eligible
veterans, VA’s budget estimates must also accommodate the future
demand for the total cost of providing health care services, including
direct patient costs as well as costs associated with management,
administration, and maintenance of facilities.

VA develops more than 80 percent of its budget estimates for health care
services using the Enrollee Health Care Projection Model (EHCPM). 14
The EHCPM’s estimates, which are largely based on the historical costs
of health care services, include three basic components: the projected
number of veterans who will be enrolled in VA health care, the projected
demand for health care services by these enrollees, and the projected
unit cost of providing these services. VHA uses the EHCPM to estimate
the resources needed to meet expected demand for over 70 health care
services such as surgery, pharmacy, and prosthetics. Other methods are
used to develop the remaining parts of its budget request; that is, the




12
  VA begins formulating a budget request approximately 10 months before the President
submits the budget to Congress in early February. This is approximately 18 months before
the start of the fiscal year to which the request relates and about 30 months prior to the
start of the fiscal year to which the advance appropriations request relates.
13
   For example, in the spring of 2011, VA began formulating the President’s VA health care
request for fiscal year 2013 and an advance appropriations request for fiscal year 2014. In
the spring of 2012, VA began updating the request for fiscal year 2014. Before or during
fiscal year 2013, Congress and the President may enact advance appropriations for the
needs of fiscal year 2014. If Congress and the President later enact different
appropriations for fiscal year 2014, those appropriations would then supersede any
previously enacted advance appropriations.
14
 GAO-11-205.




Page 5                                           GAO-12-908 Veterans’ Health Care Budget
costs of long-term care and other health care programs. 15 According to
VA, starting in the President’s fiscal year 2014 budget request, long-term
care estimates will be developed using a new model similar to and
grounded in the EHCPM, but specific to the nature of long-term care
costs.

In support of the President’s budget request, VA prepares a CBJ. This
CBJ provides Congress with estimates and other information that support
the policies and spending decisions represented in the President’s budget
request, including information on what VA plans to achieve with the
resources requested. In particular, the CBJ reflects detailed information
on estimates of funding needed for ongoing health care services and
health care-related initiatives proposed by the Secretary of VA and the
President and provides information about agency priorities, as well as the
implications of the requested amounts for VHA’s provision of health care
services to veterans. While VA must present the budget using the three-
account structure, as mentioned previously, it also presents the three
accounts in aggregate under the name “medical care.” Instead of
breaking down obligations by account, the medical care table breaks
down obligations using other broad health care categories such as
rehabilitative care, mental health, and institutional long-term care.

The CBJ is a key document that helps Congress make appropriations
decisions, conduct oversight, and provide control over VA’s funds. The
structure of the CBJ reflects OMB guidance and the interests of the
House and Senate appropriations committees. This allows agencies the
flexibility to tailor the contents of the CBJ to the various needs of the
primary users of this information; that is, the appropriations committees of
jurisdiction. Over time, the content and structure of CBJs have evolved to
accommodate changing circumstances and priorities. According to VA
officials, the CBJ was developed by VHA along with OMB in response to
the appropriations committee’s questions about specific areas of medical
care.




15
  The estimates for these services are based on factors, such as recent data on the costs
and the amount of care VHA provided to veterans, VHA’s policy goals for providing such
services, and projections of the number of users.




Page 6                                           GAO-12-908 Veterans’ Health Care Budget
                        VA creates its budget request through the EHCPM using data from
VA’s Budget Request     systems designed for the former single-account structure. 16 These
Is Based on Data from   systems do not explicitly consider the three appropriations accounts. 17
Systems Designed for    According to VHA officials, VHA formulates its budget based on the single
                        appropriations account, in part, because the systems to formulate the
the Former Single-      request were in place prior to 2004, which was when the three-account
Account Structure       structure was established.

                        VA presents the budget request in the CBJ using the three-account
                        structure created by Congress. According to VHA officials, this is done by
                        taking the data about the costs of the over 70 health care services
                        developed by the EHCPM and then based on historical percentages and
                        future projections, assigning the requested amounts to the three
                        appropriations accounts.


                        VA’s CBJ can be difficult to follow because information is not displayed
VA Provides             consistently across the three medical care appropriations accounts. There
Inconsistent            are three key reasons for this:
Information across      1) health care service labels are inconsistent across the three
VHA’s Three Medical        appropriations accounts,
Care Appropriations     2) health care services are described in varying levels of detail across
Accounts                   the three appropriations accounts, and

                        3) summary tables lack detailed account-level information.

                        Consistent information across the three accounts is important to
                        achieving the stated purposes of changing to the three-account structure;
                        that is, to provide better oversight and a more accurate accounting of
                        funds. Moreover, our past work states that in order to facilitate decision
                        making, information needs to be clear and organized in a way that is



                        16
                          The Decision Support System is VHA’s cost accounting system, which aggregates cost
                        information from VA’s workload and financial systems. This system provides EHCPM with
                        data to develop future year budget estimates.
                        17
                          Although the systems used to formulate VA’s budget request in the CBJ do not explicitly
                        consider the three appropriations accounts, VHA officials told us that they manage their
                        resources within the appropriation limits.




                        Page 7                                           GAO-12-908 Veterans’ Health Care Budget
                              meaningful to its users. 18 While the House and Senate appropriations
                              committees are the primary users of the CBJ, other committees also use
                              the information presented in the CBJ. For instance, the House and
                              Senate Committees on Veterans’ Affairs—the authorizing committees—
                              use the CBJ as one tool in conducting oversight.


Health Care Service Labels    Inconsistent service labels in the CBJ contribute to a confusing
Are Inconsistent across the   presentation. Service labels are inconsistent in that different labels may
Three Appropriations          refer to the same services. For example, as shown in table 1, what is
                              referred to as “psychiatric care” in the detailed presentation of the Medical
Accounts                      Support and Compliance and Medical Facilities accounts is referred to as
                              “mental health” in the detailed presentation for the Medical Services
                              account. 19 We determined that mental health and psychiatric care refer to
                              the same services by comparing the totals and confirming this with VHA
                              officials. The situation is the same as with the Civilian Health and Medical
                              Program of the Department of Veterans Affairs (CHAMPVA) in the
                              Medical Support and Compliance and Medical Facilities accounts. As
                              seen in table 1, this service is labeled as CHAMPVA, Spina Bifida,
                              Foreign Medical Program (FMP), and Children of Women Vietnam
                              Veterans (CWVV) in the displays of the Medical Services account. The
                              smaller programs of Spina Bifida, FMP, and CWVV are included in the
                              Medical Support and Compliance and Medical Facilities accounts, but not
                              listed by name. According to VHA officials, the inconsistent labeling was
                              inadvertent.




                              18
                               GAO-10-687R and GAO-05-117SP.
                              19
                                The CBJ presents two levels of detail for the Medical Services account. Although the
                              detailed presentation uses different labels than what is shown for the other two accounts,
                              the less detailed presentation provides the same labels across all three accounts.




                              Page 8                                            GAO-12-908 Veterans’ Health Care Budget
Table 1: Excerpts from VA’s CBJ Showing Different Labels for the Same Service

Dollars in millions
                                         VHA medical care accounts
       Medical Support and                                                                                                            Total
          Compliance                         Medical Facilities                                    Medical Services                medical care
Description                  2011   Description                          2011          Description                         2011             2011
                      obligations                                 obligations                                       obligations      obligations
Psychiatric care             $708   Psychiatric care                        $827       Mental health                     $3,984          $5,519
CHAMPVA                        78   CHAMPVA                                      5     CHAMPVA, Spina Bifida,              1,138           1,221
                                                                                       FMP, and CWVV
                                          Source: GAO presentation of VA’s 2013 CBJ data.

                                          Note: We created this table using data provided in the Department of Veterans Affairs Congressional
                                          Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request, Vol. 2, Medical
                                          Programs and Information Technology Programs, 1A-5,1C-3, 1D-8, and 1E-12.


                                          In addition to the inconsistencies in labeling among the same services,
                                          similar labeling may refer to entirely different services. For example, as
                                          shown in table 2, a user might think that the “acute hospital care” and
                                          “subacute care” services listed under the Medical Support and
                                          Compliance and Medical Facilities accounts are subcomponents of the
                                          “acute care” services shown under the Medical Services account.
                                          However, they are not subcomponents of acute care. The terminology
                                          and presentation are not consistent with terminology and presentation
                                          used elsewhere. According to VHA officials, the tables represent several
                                          ways of breaking down the subcomponents of the total appropriation and
                                          are a response to requests for different ways to display the information
                                          that have been requested over time.

Table 2: Excerpts from VA’s CBJ Showing Similar Labels for Different Services
Dollars in millions
                                        VHA medical care accounts
       Medical Support and                                                                                                         Total medical
          Compliance                          Medical Facilities                                    Medical Services                       care
                             2011                                           2011                                          2011              2011
Description           obligations   Description                      obligations            Description            obligations       obligations
                                                                                            Acute care                 $27,049          $34,933
Acute hospital care       $1,130    Acute hospital care                     $1,296
Subacute care                 10    Subacute care                                 12
                                          Source: GAO presentation of VA’s 2013 CBJ data.

                                          Note: We created this table using data provided in the Department of Veterans Affairs Congressional
                                          Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request, Vol.2, Medical
                                          Programs and Information Technology Programs, 1A-5, 1C-3, 1D-8, and 1E-12.




                                          Page 9                                                          GAO-12-908 Veterans’ Health Care Budget
Levels of Detail Vary                           Another area of inconsistency in the CBJ is that levels of detail vary
Across the Three                                across the three appropriations accounts. Specifically, the level of detail
Appropriations Accounts                         provided for the Medical Services account is significantly greater than
                                                what is provided for the Medical Support and Compliance and Medical
                                                Facilities accounts. For example, as shown in table 3, resources
                                                requested for VA community living centers (VA CLC), community nursing
                                                homes, and state nursing homes are provided for the Medical Services
                                                account but not for the Medical Support and Compliance or Medical
                                                Facilities accounts. While the state nursing home, community nursing
                                                homes, and VA CLC programs do consume resources from the Medical
                                                Support and Compliance and Medical Facilities accounts, the amounts
                                                from those accounts are not shown.

Table 3: Information from VA’s CBJ Comparing Obligations Provided for Nursing Home Care and Long-Term Care

Dollars in millions
                                    VHA medical care accounts
    Medical Support and
       Compliance                       Medical Facilities                             Medical Services                 Total medical care
                             2011                             2011                                       2011              2011   Difference–(not
Description           obligations   Description        obligations            Description         obligations       obligations   Shown in CBJ)b
Nursing                     $481    Nursing                      $578         Nursing                 $3,756             $4,815             $1,059
                                                                                       a
home care                           home care                                 home care
                                                                              VA CLC                      2,374           3,425              1,051
                                                                              Community                    607              614                    7
                                                                              nursing
                                                                              homes
                                                                              State nursing                775              775                    0
                                                                              homes
                                                Source: GAO presentation of VA’s 2013 CBJ data.

                                                Note: We created this table using data provided in the Department of Veterans Affairs Congressional
                                                Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request, Vol. 2, Medical
                                                Programs and Information Technology Programs, 1A-5,1C-3, 1C-24, 1D-8, and 1E-12.
                                                a
                                                 While nursing home care does not appear in aggregate alongside its subcomponents in the CBJ, for
                                                the sake of clarity, we present this information together in this table.
                                                b
                                                 This represents the difference between the dollar amounts provided in the medical care detailed
                                                table and the medical services detailed table.


                                                VHA officials explained that they do not produce separate estimates or
                                                display obligations for the Medical Support and Compliance and Medical
                                                Facilities costs because the costs for those accounts are relatively small
                                                compared to the Medical Services account. However, in at least one
                                                instance, the amount not shown was considerable. For example, about 31
                                                percent—a total of $1.05 billion—was obligated for administrative and



                                                Page 10                                                     GAO-12-908 Veterans’ Health Care Budget
                           facilities costs combined for VA CLC, but the CBJ does not show this
                           number or the specific breakdown between the Medical Support and
                           Compliance and Medical Facilities accounts. Congress may consider the
                           administrative and facilities costs for VA CLC to be significant and
                           important to decision making.


Summary Tables Detail      VA presents several summary tables that highlight program costs;
Costs by Program but Not   however, information on how most of these costs break down across the
by Appropriations          three accounts cannot be found in the CBJ. For example, in the table of
                           “selected program highlights,” which VA officials informed us is one of the
Accounts                   key tables of interest to Congress, most program costs are not also
                           broken out across the three accounts. 20 The lack of such account-level
                           information can make it more difficult for Congressional decision makers
                           to conduct oversight.

                           Congressional committees have recently requested more information
                           about VA’s spending and voiced concerns about VA’s CBJ. Specifically,
                           the House Committee on Appropriations recently requested that VA
                           provide additional detail on, for example, administrative costs by
                           headquarters, regional network, and medical center, in order to help
                           inform congressional decisions. 21 The Senate Committee on
                           Appropriations also recently expressed concern that the “justifications
                           continue to lack specificity and the degree of detail needed to ensure
                           informed and timely evaluation of requested funds and proper oversight of
                           a Department the size of the VA.” 22 In addition, according to some
                           authorizing committee staff, the CBJ is confusing and after the switch to
                           the three-account structure, information in the CBJ has not become more
                           detailed or transparent. According to VHA officials, the CBJ reflects the
                           information Congress has asked VA to provide. They added that both the
                           House and Senate appropriations committees have expressed an interest
                           in more detailed information in the CBJ to increase oversight, but have
                           not asked VA to change the structure or content of the CBJ as a whole.



                           20
                             One exception to this is information on CHAMPVA/FMP/Spina Bifida/CWVV. Account-
                           level information on this program is found in CBJ Vol. 2, Medical Programs and
                           Information Technology Programs, 1A-5,1C-3, 1D-8, and 1E-12.
                           21
                            H.R. Rep. No. 112-491, at 47 (2012).
                           22
                            S. Rep. No. 112-168, at 32 (2012).




                           Page 11                                      GAO-12-908 Veterans’ Health Care Budget
                      VA’s CBJ is intended to provide congressional committees with
Conclusions           information they need to make decisions. To facilitate decision making,
                      information needs to be clear and organized in a way that is meaningful to
                      its users. Our work has demonstrated that there are concerns with the
                      clarity and usefulness of the information presented in the CBJ. Users of
                      the CBJ should be able to rely on consistency in labeling to help them
                      understand the information being presented.

                      Increasing congressional oversight was one of the motivations to
                      establish the current account structure. Our work has identified areas
                      where the information as presented across the three accounts does not
                      provide the level of detail desired to improve oversight. Various
                      congressional committees have also stated that the information is not
                      meeting their needs.


                      To improve the clarity and usefulness of information presented in VA’s
Recommendations for   congressional budget justifications that support the President’s budget
Executive Action      request for VA health care, we recommend the Secretary of Veterans
                      Affairs take the following two actions:

                         Label health care services consistently so it is clear what services, such
                          as mental health, are being referred to across appropriations accounts.

                         Further consult with congressional decision makers to determine what
                          detailed information related to the three appropriations accounts
                          should be presented, and how, in its congressional budget
                          justification.


                      We provided a draft of this report to the Secretary of Veterans Affairs for
Agency Comments       comment. In its written comments, reproduced in appendix I, his Chief of
                      Staff generally agrees with our conclusions and concurs with our
                      recommendations. In response to our first recommendation, VA stated
                      they will undertake a review of the programmatic reference in the CBJ
                      volume for the medical programs and standardize throughout. In addition,
                      VA will initiate discussions with the Office of Management and Budget to
                      determine whether the references in the President’s Budget Appendix can
                      also be made consistent. In response to our second recommendation, VA
                      also stated it would consult with Congress to identify any additional
                      information to include in the budget justification document. Finally, VA
                      provided technical comments that were incorporated, as appropriate.




                      Page 12                                   GAO-12-908 Veterans’ Health Care Budget
We are sending copies of this report to the Secretary of Veterans Affairs
and appropriate congressional committees. In addition, the report is
available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact
Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who made
key contributions to this report are listed in appendix II.




Melissa Emrey-Arras
Acting Director
Strategic Issues




Page 13                                  GAO-12-908 Veterans’ Health Care Budget
Appendix I: Comments from the Department
             Appendix I: Comments from the Department of
             Veterans Affairs



of Veterans Affairs




             Page 14                                       GAO-12-908 Veterans’ Health Care Budget
Appendix I: Comments from the Department of
Veterans Affairs




Page 15                                       GAO-12-908 Veterans’ Health Care Budget
Appendix II: GAO Contact and Staff
                  Appendix II: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Melissa Emrey-Arras, (617) 788-0534, emreyarrasm@gao.gov
GAO Contact
                  In addition to the contact named above, Denise Fantone (Director), Carol
Staff             Henn (Assistant Director), Melissa Wolf (Assistant Director), Amber
Acknowledgments   Edwards, Katherine Wulff, Tara Jayant, Lauren Grossman, James
                  Musselwhite, Melanie Papasian, Leah Probst, and Cindy Saunders made
                  key contributions to this report.




(450932)
                  Page 16                                GAO-12-908 Veterans’ Health Care Budget
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