oversight

Veterans' Affairs and Military Health Care Issues Issue Area Plan--Fiscal Years 1998-99

Published by the Government Accountability Office on 1997-09-01.

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

                   United   States General   Accounting   Office

GAO                Health, Education, and Human Services
                   Division



September   1997
                   Veterans Affairs and
                   Military Health Care Issues
                   Issue Area Plan for Fiscal
                   Years 1998-99
.

    .
Foreword


               As the investigative arm of the Congress and the nation’s auditor, the
               General Accounting Office is charged with following the federal dollar
               wherever it goes. Reflecting stringent standards of objectivity and
               independence, GAO'S audits, evaluations, and investigations promote a
               more efficient and cost-effective government; expose waste, fraud, abuse,
               and mismanagement in federal programs; help the Congress target budget
               reductions; assessfinancial and information management; and alert the
               Congress to developing trends that may have significant fiscal or
               budgetary consequences-In fuhilhng its responsibilities, GAO performs
               original research and uses hundreds of databases or creates its own when
               information is unavailable elsewhere.

               To ensure that GAO'S resources are directed toward the most important
               issues facing the Congress, each of GAO'S 33 issue areas develops a
               strategic plan that describes the signi6cance of the issues it addresses, its
               objectives, and the focus of its work. Each issue area relies heavily on
               input Tom congressional committees, agency officials, and subjecematter
               experts in developing its strategic plan.

               The Veterans’Affairs and Military Health Care issue area covers health
               care services provided to veterans and military beneficiaries through the
               systems of hospitals and clinics of the Department of Veterans’Affairs (VA)
               and the Department of Defense (DOD). We also examine health care
               provided by the Indian Health Service and Bureau of Prisons. Our work at
               VA also evaluates programs providing certain nonhealth benefits, such as
               disability compensation and pensions, to veterans and their dependents or
               survivors.

               The principal issues covered by this strategic plan are

           . identifying opportunities to improve existing VA and DOD health care
             systems’and VA benefit programs’management and accountability;
           l assessing efforts to structurally reform the VA and DOD health care and VA
             benefits systems to better accomplish their missions;
           l evaluating the implementation of, and lessons learned from, managed
             health care strategies in VA and DOD; and
           l determining whether federal agencies are effectively serving the unique
             health needs of special populations.

               In the pages that follow, we describe our key planned work on these
               issues.




               Page 1                                                            GAO/UP-97-2   1
       Foreword




:r ,
       Because events may significantly affect even the best of plans and because
       periodic measurement of success against any plan is essential, our
       planning process allows for updating and responding quickly to emerging
       issues. If you have any questions or suggestions about this plan, please call
       me at (202) 512-7101.




       Stephen P. Backhus
       Director, Veterans’Affairs and
         Military Health Care Issues




                                                                                 Cl


       Page 2                                                           GAO/UP-97-21
Contents


Foreword
Table I: Key Issues
Table II: Planned
Major Work
Table III: GAO
Contacts




                      Page 3
-‘i’TableI: Key Issues



                                                          Significance
             Improving management and                     VA and DOD operate two of the largest health care systems In the world; in addition, VA
             accountability: How can existrng VA and      delivers a wide array of nonmedrcal benefits to the natron’s veterans VA’s 222,000
             DOD health care systems and VA benefits      workers deliver services in more than 1,000 facrlitres at a cost of over $38 billion annually
             programs be better managed?                  DOD’s health system currently includes some 115 hospitals and 471 clinics operating
                                                          worldwlde and employs about 146,000 civilian and mrlrtary personnel at an annual cost of
                                                          over $15 blllron The VA and DOD health care systems also play important roles rn
                                                          trarning healthcare professionals, conducting medical research, and testing advanced
                                                          medical technologies and services. VA and DOD face many management challenges in
                                                          delivering servrces and benefits and improving performance through a focus on results
                                                          and accountabrlrty

  Reforming VA and DOD:                                   VA and DOD health care systems face increasing challenges and competrtron from a
’ Can VA and DOD health and VA benefit                    changing health care marketplace as well as pressures to reduce health care costs As
  systems be restructured to better                       VA’s inpatient population continues to shrink sharply because of declining numbers of
. accomplish their missions?                              veterans and changes in health care practices, the economtc viability of VA hospitals is
                                                          threatened The military health care system must adjust to substantial reductions in the
                                                          overall size of the nation’s military forces. Pressure to reduce the deficit also increases
                                                          attentron on nonhealth benefits for veterans, and their dependents and survivors, where
                                                          there are significant issues regarding elrgrbility and potential overlap and duplication rn
                                                          delivery systems
             Moving to managed care strategies: How       Nationwide changes In the practice of medicine are having an effect on the VA and DOD
             effectively are the VA and DOD health care   health care systems In partrcular, managed care rnrtratrveshave been widely adopted In
             systems implementing managed care            the private sector and in other government programs and are being Implemented in
             rnltlatlves?                                 DOD’s TRICARE program By September 1997, DOD expects to have implemented
                                                          TRICARE nationwide to serve more than 5 million beneficiaries VA IS changing the way
                                                          physrcrans practice by moving from provrding eplsodrc specialized care to a patient-
                                                          based primary care model, a move long embraced by health maintenance organizations
                                                          The Congress will continue to seek assessments of how these efforts are progressing
                                                          and identify lessons learned


P li
,,--    *
   _    --
             --


       ’ -Serving special populations:                    VA and DOD face challenges as they seek to ensure access and provrde quality care to
          How effectively IS the federal government       indrvrduals with special health care needs Veterans In need of post-traumatic stress
          delrvenng specialized health and related        disorder treatment or long-term psychratnc care, for example, face space and resource
          services?                                       limits in VA programs As a result, some of these veterans have been unable to receive
                                                          the specralrzed care they need Moreover, Persian Gulf veterans have reported an array
                                                          of medical problems which they attribute to their service In the Perstan Gulf, and have
                                                          sought VA medical treatment and compensation In addition, the federal government
                                                          delivers health care through the lndran Health Service and Bureau of Prisons and needs
                                                          to ensure that these services are delivered cost-effectlvelv




                                                          Page 4                                                                        GAO/UP-97-21
                                               Table I: Key Issues




Objectives                                                                                   Focus of work
1. Identify more effective management controls to mtnlmrze fraud, waste, and abuse           l Examtne DOD and VA controls over

                                                                                             payments to contractors and benefrcrarres.
2 Identify opportunities for cost savings through legislative or admrnistratrve changes that l Assess DOD and VA efforts to avord
Improve overall operatlonal efficiency                                                       double billing and obtain reimbursements
                                                                                             . Examine DOD health systems’ and VA’s
3 Assess the effectiveness of VA’s and DOD’s strategic plannrng efforts                      budgeting and spending activities
                                                                                             l Monitor VA’ s efforts to modernize Its
                                                                                             information systems and technology
                                                                                             l Examine VA’  s and DOD’s efforts to
                                                                                             develop goals and measures that focus on
                                                                                             program results
1 Identify alternatives available to VA for reforming its benefits programs                  l Examtne VA’  s efforts to restructure its
                                                                                             benefits programs.
2 Identify needed changes in military medicine organizatton and structure rn response to     l Assess DOD’   s plans and progress rn
changes in mrlltary force size, requirements, and threats                                    decentrallzrng functions and consolldatrng    _
                                                                                             and downsizing medical facrlrtles
3 identify alternative ways that VA and DOD could jointly provide health care and benefits. l Identify opportunities for DOD and VA to
                                                                                             consolidate programs and share resources


1 Identify ways to improve DOD’s managed care implementation for beneficiaries and the      l Assess DOD’    s progress in Implementing,
government                                                                                  and the cost-effectiveness of, TRICARE
                                                                                            l Examine TRICARE financing and

2. Monitor VA’s efforts to move from inpatient to outpatient health care                    contractor performance
                                                                                            l Assess DOD efforts to develop

3 Examine VA and DOD efforts to serve veterans and retired military personnel in a          performance goals and measures for
managed care environment                                                                    TRICARE
                                                                                            l Assess VA policies, plans, and progress

                                                                                            in shifting from a hospital-based to a more
                                                                                            ambulatory, primary care system
                                                                                            l Examrne options for meeting long-term

                                                                                            care needs
                                                                                            l Assess VA and DOD Medicare

                                                                                            subvention initiatives
1. Assess VA’s efforts to meet the health needs of special veteran populations              l Assess the adequacy and effectiveness

                                                                                            of VA’s response to veterans’ specialized
                                                                                            health needs
                                                                                            l Examine the effects of VA’  s health
                                                                                            system restructuring on special veteran
                                                                                            populations




                                                Page 5
2,‘
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:$!-’



??‘able II: Planned Major W o rk


:;A :,
     Issue                              Planned maior iob starts
      Improving management and          -Adequacy of DOD medical facilitres’and TRICARE contractors’third-party collections
      accountability                    -VA ‘s quality assurance program for compensation and pension claims
                                        -Extent of duplicate billings under VA’s fee basis and contract hospital and nursing
                                           home programs
                                        -DOD malpractice cost increases
                                        -Examine DOD health budgeting activities
                                        -Merits of postemployment restrictions on former DOD officials
                                        -VA budgeting Issues and activities
                                        -Navy graduate medical education programs
                                        -VA’s Alabama hospital integration plan
                                        -VA information technology and systems modernization
                                        -DOD information technology and systems
                                        -VA’s efforts to develop an integrated departmentwide strategic plan
                                        -DOD’s measures for monitoring medical facilities’ and contractors’performance in
                                           providlnq health care access
.     Reforming VA and DOD              -Examine proposed use of state cemeteries for veteran burials
                                        -DOD’s pharmacy programs
                                        -Mllltary hospital competitiveness
                                        -Potential for consolidating military medical facilities in the national capitol region *
                                        -Assess the merits of VA and DOD Jointventures
                                        -Level of VA participation as TRICARE provider
                                        -Assess the need for seoarate VA and DOD disabilitv comoensatlon oroarams
      Moving to managed care strategies -Overview and status of TRICARE rmplementation
                                        -Cost neutrality of TRICARE
                                        -TRICARE contractor reporting requirements’consistency with GPRA’s focus on results
                                        -Extent of DOD consulting contracts
                                        -VA eligibility reform impiementatlon
                                        -Veterans Equitable Resource Allocation/Veterans Integrated Service Networks impact on
                                           health care access and quality
                                        -VA’s expanded contracting authority for health services
                                        -VA and DOD efforts to train specialists for primary care responslbllitres
                                        -VA role In providing long-term care
                                        -Medicare subvention options
      Serving special populations       -Persian Gulf rllness
                                        -VA’s handling of Persian Gulf War veterans’claims
                                        -Appropnateness of disability ratings for Persian Gulf War veterans
                                        -Impact of VA eliglbllity reform on special emphasis programs
                                        -Health care available to women veterans




                                                 Page 6                                                                  GAomP-97-21
Table III: GAO Contacts
                                                                      , -




Director                    Stephen P. Backhus       (202) 512-7101

Acting Associate Director   Cynthia M. Fagnoni       (202) 512-7202

Assistant Directors         Michael Blair (Atlanta Office)
                            Daniel Brier
                            Irene Chu
                            Bruce Layton
                            James Linz
                            George Poindexter
                            Paul Reynolds




                            Page 7
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