oversight

Major Management Challenges and Program Risks: Department of Veterans Affairs

Published by the Government Accountability Office on 1999-01-01.

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

                United States General Accounting Office

GAO             Performance and Accountability
                Series




January 1999
                Major Management
                Challenges and Program
                Risks
                Department of Veterans
                Affairs




GAO/OCG-99-15
GAO   United States
      General Accounting Office
      Washington, D.C. 20548

      Comptroller General
      of the United States



      January 1999
      The President of the Senate
      The Speaker of the House of Representatives

      This report addresses the major performance and
      management challenges that confront the Department of
      Veterans Affairs (VA) in carrying out its mission of service
      to America’s veterans and their families. It also addresses
      corrective actions that VA has taken or initiated on these
      challenges and further actions that are needed. For many
      years, we have reported significant management
      problems at VA. These problems include obsolete
      infrastructure, poor monitoring of the effects of health
      service delivery changes on patient outcomes, inadequate
      data, and ineffective management of non-health-care
      benefits and management information systems.

      VA has made progress in developing a framework for
      managing and evaluating changes in health care service
      delivery; however, much more needs to be done. In its
      restructuring, VA must ensure that it meets its educational
      and medical missions without compromising efforts to
      improve efficiency and effectiveness. VA needs to improve
      the accuracy and reliability of information for measuring
      the extent to which veterans receive appropriate care,
      especially veterans with special needs, and have equitable
      access to care across the country. In managing
      non-health-care benefits challenges, VA must continue to
      set results-oriented goals for compensating disabled
      veterans and develop effective strategies for improving
disability claims processing and vocational rehabilitation.
VA must also implement adequate control and
accountability mechanisms over its direct loan and loan
sales activities as well as institutionalize fundamental
changes to its approach to information systems
management to ensure that benefits are not disrupted in
the year 2000.

This report is part of a special series entitled the
Performance and Accountability Series: Major
Management Challenges and Program Risks. The series
contains separate reports on 20 agencies—one on each of
the cabinet departments and on most major independent
agencies as well as the U.S. Postal Service. The series
also includes a governmentwide report that draws from
the agency-specific reports to identify the performance
and management challenges requiring attention across
the federal government. As a companion volume to this
series, GAO is issuing an update to those government
operations and programs that its work has identified as
“high risk” because of their greater vulnerabilities to
waste, fraud, abuse, and mismanagement. High-risk
government operations are also identified and discussed
in detail in the appropriate performance and
accountability series agency reports.

The performance and accountability series was done at
the request of the Majority Leader of the House of
Representatives, Dick Armey; the Chairman of the House
Government Reform Committee, Dan Burton; the
Chairman of the House Budget Committee, John Kasich;



             Page 2                 GAO/OCG-99-15 VA Challenges
the Chairman of the Senate Committee on Governmental
Affairs, Fred Thompson; the Chairman of the Senate
Budget Committee, Pete Domenici; and Senator Larry
Craig. The series was subsequently cosponsored by the
Ranking Minority Member of the House Government
Reform Committee, Henry A. Waxman; the Ranking
Minority Member, Subcommittee on Government
Management, Information, and Technology, House
Government Reform Committee, Dennis J. Kucinich;
Senator Joseph I. Lieberman; and Senator Carl Levin.

Copies of this report series are being sent to the
President, the congressional leadership, all other
Members of the Congress, the Director of the Office of
Management and Budget, the Secretary of Veterans
Affairs, and the heads of other major departments and
agencies.




David M. Walker
Comptroller General of
the United States




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Contents



Overview                                            6

Major                                              11
Performance and
Management
Issues
Related GAO                                        49
Products
Performance and                                    53
Accountability
Series




                  Page 4   GAO/OCG-99-15 VA Challenges
Page 5   GAO/OCG-99-15 VA Challenges
Overview



                      The Department of Veterans Affairs (VA) is
                      responsible for administering benefits and
                      services that affect the lives of more than
                      25 million veterans and approximately
                      44 million members of their families.
                      Through its budget—approximately
                      $43 billion in fiscal year 1999—VA provides
                      an array of health care benefits;
                      non-health-care benefits, such as
                      compensation and pensions; and other
                      supporting programs. Over 200,000 VA
                      employees deliver these services from more
                      than 1,000 facilities. As it administers this
                      diverse group of programs, VA is confronting
                      a number of serious performance and
                      management challenges.


The Challenges

VA Health Care        Many VA facilities are deteriorating,
Infrastructure Does   inappropriately configured, or no longer
Not Meet Current      needed because of their age and VA’s shift in
and Future Needs      emphasis from providing specialized
                      inpatient services to providing primary care
                      in an outpatient setting. Despite eliminating
                      about one-half of VA’s hospital beds, excess
                      capacity remains.




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                       Overview




VA Lacks Adequate      VA lacks accurate, reliable, and consistent
Information to         information for measuring the extent to
Ensure That            which (1) veterans are receiving equitable
Veterans Have          access to care across the country, (2) all
Access to Needed
                       veterans enrolled in VA’s health care system
Health Care Services
                       are receiving the care they need, and (3) VA is
                       maintaining its capacity to care for special
                       populations.


VA Lacks Outcome       VA does not know how its rapid move toward
Measures and Data      managed care is affecting the health status
to Assess Impact of    of veterans because measures of the effects
Managed Care           of its service delivery changes on patient
Initiatives
                       outcomes have not been established. Other
                       public and private health care providers have
                       recognized the necessity—and the
                       difficulty—of creating such criteria and
                       instruments.


VA Faces Major         In managing non-health-care benefits
Challenges in          programs, VA needs to overcome a variety of
Managing               difficulties. Currently, VA cannot ensure that
Non-Health-Care        its veterans’ disability compensation benefits
Benefits Programs
                       are appropriately and equitably distributed
                       because its disability rating schedule does
                       not accurately reflect veterans’ economic
                       losses resulting from their disabilities. Also,
                       VA is compensating veterans for diseases that
                       are neither caused nor aggravated by


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                     Overview




                     military service. In addition, claims
                     processing in VA’s compensation and pension
                     program continues to be slow, and the
                     vocational rehabilitation program has
                     yielded limited results. Moreover, the data
                     that VA will use to measure compensation
                     and pension program performance are
                     questionable. Furthermore, VA has
                     inadequate control and accountability over
                     the direct loan and loan sales activities
                     within VA’s Housing Credit Assistance
                     program.


VA Needs to Manage   VA has made progress in addressing Year
Its Information      2000 challenges but still has a number of
Systems More         associated issues to address. In addition, VA
Effectively          lacks adequate control and oversight of
                     access to its computer systems and has not
                     yet institutionalized a disciplined process for
                     selecting, controlling, and evaluating
                     information technology investments, as
                     required by the Clinger-Cohen Act.


Progress and         As required by the Government Performance
Next Steps           and Results Act of 1993, commonly known
                     as the Results Act, VA submitted a strategic
                     plan for fiscal years 1998 to 2003. In this
                     plan, VA developed strategic goals covering
                     all its major programs and included


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Overview




objectives, strategies, and performance goals
to support its strategic goals. VA has made
progress in developing a framework for
managing and evaluating changes in service
delivery. However, there is still much more
to do.

In particular, VA must determine whether it
will better serve veterans’ needs for health
care services by repairing, renovating, and
maintaining existing buildings or by
spending resources directly on patient care.
In its restructuring, VA must ensure that it
meets its educational and medical missions
without compromising efforts to improve
efficiency and effectiveness, and it must
consider the impact such changes may have
on its role in national emergencies. VA must
also improve its management information to
help it ensure that veterans have equitable
access to care across the country, that it
maintains its capacity to serve special
populations, and that it can meet enrolled
veterans’ demand for care. Furthermore, VA
needs to have clearly understandable,
reliable, and consistent information available
to its health care managers at all levels to
identify and correct negative trends in health
outcomes in a timely manner.




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Overview




In addressing non-health-care benefits
challenges, VA must continue to set
results-oriented goals, such as whether
disabled veterans are being compensated
appropriately under the existing disability
program. VA must develop effective
strategies for resolving its long-term
disability claims processing and vocational
rehabilitation shortcomings. Also, VA must
implement adequate control and
accountability over its direct loan and loan
sales activities to ensure that the true cost
associated with these activities can be
measured. Furthermore, VA must implement
and institutionalize fundamental changes to
its approach to information systems
management to ensure that benefits
payments and medical care to veterans are
not disrupted in the year 2000, unauthorized
access to and misuse of VA systems do not
occur, and sound information technology
investment practices continue.




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Issues


            VA  directly touches the lives of millions of
            veterans and their families every day through
            its health care and non-health-care benefits
            programs. VA serves the medical care needs
            of veterans by providing primary care,
            specialized care, and related medical and
            social support services at hundreds of
            service delivery locations or by purchasing
            that care from other providers. In addition,
            VA supports medical education and research
            and serves as a primary medical backup to
            other federal agencies during national
            emergencies. In the last several years, VA has
            introduced two major initiatives to change
            the way it manages its approximately $18
            billion health care system. In fiscal year
            1996, VA decentralized its management
            structure to form 22 geographically distinct
            Veterans Integrated Service Networks (VISN)
            to coordinate the activities of VA’s hospitals,
            outpatient clinics, nursing homes, and other
            facilities. VA has also been making
            fundamental changes in the way it delivers
            health care services by applying managed
            care practices, such as primary, outpatient,
            and preventive care, and decreasing its
            emphasis on providing inpatient care. In
            addition to providing health care services to
            veterans, VA provides non-health-care
            benefits of over $20 billion each year to
            about 3.3 million veterans, their dependents,
            and their survivors. The non-health-care
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benefits include disability payments,
compensation, pensions, and vocational
rehabilitation assistance programs that are
administered through VA’s 58 regional
benefits offices.

Over the past several years, our reports and
those of VA’s Inspector General and others
have documented problems with VA’s
performance in carrying out its complex
mission and have identified several
management challenges that VA must
address. This report highlights some of the
serious management challenges that VA must
overcome to meet its strategic goals of
efficiently and effectively delivering services
to veterans and their families. These
challenges include an infrastructure that
does not meet current and future needs,
inadequate information for ensuring that
health care services are available to eligible
veterans, poor monitoring of the effects of
health service delivery changes on patient
outcomes, ineffective management of
non-health-care benefits programs, disability
compensation payments that are
inappropriately and inequitably distributed,
and ineffective management of information
systems.




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VA Health Care   Because of their age and recent changes in
Infrastructure   the way VA delivers health care, many VA
Does Not Meet    facilities are deteriorating, unneeded, or
Current and      inappropriately configured. As VA shifts its
Future Needs     emphasis from providing specialized
                 inpatient services to providing primary care
                 in an outpatient setting, less of VA’s existing
                 hospital space is needed. Unneeded vacant
                 space creates a financial drain on VA:
                 maintaining unproductive assets siphons
                 valuable resources away from providing
                 direct medical services. In confronting this
                 challenge, VA needs to make important
                 management decisions about whether and
                 how to maintain, renovate, liquidate, or
                 redirect the use of these buildings and
                 grounds. VA will need to identify services that
                 could be consolidated across its facilities as
                 well as those that could be offered more
                 efficiently by other public and private
                 providers who contract with VA. These
                 decisions must be made in the context of a
                 decreasing population of veterans—one that
                 has a rapidly increasing proportion of
                 members aged 85 and older who will require
                 more intensive services, such as nursing
                 home care. Furthermore, these decisions are
                 likely to affect how VA meets its medical
                 education mission to train physicians and
                 other clinical care providers and will require
                 VA to restructure its affiliation agreements



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                     with medical schools and other institutions.
                     All these decisions will be of critical
                     importance in shaping how VA fulfills its
                     health care role well into the next century.


Many VA Facilities   Many of VA’s facilities—its buildings and
Are Inadequate for   grounds—are no longer adequate for
Delivering Health    efficiently and effectively delivering health
Care                 care to veterans. Many facilities are poorly
                     configured for the way in which VA delivers
                     health care services today and plans to
                     deliver services in the future. For example,
                     most VA facilities were constructed as
                     hospitals with an array of bed sections,
                     treatment rooms, surgical suites, and other
                     accommodations and equipment for treating
                     an inpatient population. The layout of these
                     facilities is often poorly suited for delivering
                     care to an ambulatory population on an
                     outpatient basis. Although changing care
                     practices and efficiency initiatives, such as
                     emphasizing outpatient care and facility
                     integration, have allowed VA to eliminate
                     approximately half of its 52,000 acute-care
                     hospital beds since 1994, excess capacity
                     remains. Furthermore, the veteran
                     population is declining: VA projects that the
                     number of veterans in the country will drop
                     about 21 percent from 1997 to 2010. We have
                     reported that if past efficiency trends and


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demographic projections are realized, VA will
need only about 10,000 of its current 26,000
acute-care beds to meet veterans’ health care
needs in 2010. As a result, VA will likely need
to close some facilities.

Meanwhile, VA continues to serve some
veterans in aged and deteriorating buildings
that will require billions of dollars to
renovate or replace in order to meet current
industry standards and accommodate
changing health care practices. As it
considers priorities for renovating or
redirecting the use of these buildings, VA
should also be planning for the needs of the
increasingly older veteran population. As the
nation’s World War II and Korean War
veteran populations age, their health care
needs are shifting from acute hospital care
to nursing home and other long-term care
services. For example, the number of
veterans aged 85 and older is projected to
increase to about 1.3 million in 2010, a
fourfold increase from 1995.

VA’s major initiative to integrate various
clinical and support operations across some
of its facilities recognizes that some facilities
cannot meet VA’s current and future needs
without extensive renovations. For example,
we have reported that consolidating services


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from four to three locations in the Chicago
area could save $6 million to $27 million in
future renovation costs. Integrations are also
intended to enhance the efficiency and
effectiveness of VA’s health care delivery
system by reducing unnecessary duplication
of services. We have reported that the 23
facility integrations involving 48 health care
facilities that have been completed or are
under way will produce millions of dollars in
savings that can be used to enhance
veterans’ health care. We believe VA needs to
identify additional opportunities for
integrating facilities. For example, we have
reported that if VA closed one of its four
hospitals in the Chicago area, it could save
$20 million annually and enhance veterans’
access to services.

We have also reported, however, that VA’s
planning and implementation efforts for the
integrations it has undertaken have been
inadequate. First, in planning integrations VA
generally did not conduct comprehensive
evaluations thoroughly assessing all
potential resources needed to meet the
expected workload in a given location over
the next 5 to 10 years. As a result of
inadequate planning, VA has spent hundreds
of millions of dollars over the last decade
constructing and renovating inpatient


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capacity that is no longer needed. Second, VA
has implemented some changes before
completing the planning phases and
providing detailed integration plans to
stakeholders. Third, VA has not used
independent planners—that is, planners
without vested interests in the geographic
area. Consequently, VA has encountered
opposition from stakeholders such as
veterans, facility personnel, affiliated
medical school personnel, and Members of
the Congress who represent these groups
when it proposed facility integrations.
However, VA has recently developed a
guidebook for planners to use in developing,
implementing, and evaluating potential
facility integrations. While this is a step
forward, VA needs to apply this framework
and evaluate its effectiveness in saving
resources for both the short and the long
term.

One additional factor that may affect the
need for continued use of some VA facilities
is the expanded authority to contract for
health care services that the Congress
provided VA in 1996. Under this authority, VA
can contract with public or private
providers, who can provide care at lower
cost or care that VA does not offer in a
particular geographic location. To the extent


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                       that VA uses this authority, it may create
                       additional excess capacity in existing
                       facilities. VA needs to determine whether it
                       will better serve veterans by repairing,
                       renovating, and maintaining existing
                       buildings or by spending resources directly
                       on patient care—for example, by contracting
                       for that care with other providers. In making
                       its decisions and in planning future
                       construction and integrations, VA has the
                       opportunity to dramatically reshape its
                       delivery system to meet the changing
                       medical and long-term-care needs of its
                       veteran population. VA generally agrees that
                       it must take a comprehensive, long-range
                       approach to planning to help ensure that it
                       efficiently and effectively meets the needs of
                       veterans in the future.


Infrastructure         VA’s restructuring efforts, particularly
Changes Are            integrating administrative and clinical
Complicated by VA’s    services across two or more medical centers,
Medical School         are complicated by affiliation agreements
Affiliations,
                       that VA facilities have with medical schools
Research Activities,
and Emergency          and agreements with federal agencies
Backup Role            regarding VA’s role in national emergencies.
                       VA has met its education mission by forging
                       close relationships with medical schools.
                       Since VA’s medical education program began
                       in 1946, 130 VA medical centers have


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affiliated with 105 medical schools to
provide training opportunities for medical
students and residents. Today, about
70 percent of all physicians employed by VA
hold faculty appointments at these schools.
In addition, over 100,000 health
professionals from more than 1,000
educational institutions receive clinical
experience in VA medical centers each year.
VA management decisions about
infrastructure affect not only affiliation
agreements with medical schools but also
VA’s responsibility to support the nation’s
medical needs during national emergencies.

Currently, most VA medical centers are
affiliated with a single, nearby medical
school, making it easy for students,
residents, faculty, and researchers to fulfill
their obligations. Transforming VA’s health
care delivery system from an inpatient to an
outpatient focus, increasing reliance on
primary care, and integrating services in
fewer hospitals are all causing VA and
medical schools to rethink their affiliation
arrangements. As medical services are
eliminated or transferred from one VA facility
to another to improve program efficiencies,
educational opportunities available in VA
facilities will change, which is likely to affect
VA medical center affiliation agreements with



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medical schools. For example, instead of
continuing inpatient surgery and intensive
care at both the Montgomery and Tuskegee
medical centers, VA removed these services
from Tuskegee and consolidated them at
Montgomery, which is 35 miles away. In
addition, because VA is shifting its emphasis
from specialized care to primary care, it has
begun to change the mix of training
opportunities for medical residents. VA’s goal
is to offer 48 percent of its medical resident
training slots to primary care physicians by
the year 2000—an increase of 20 percent
from fiscal year 1997. Furthermore, between
fiscal years 1996 and 2000, VA plans to reduce
the number of medical residents in specialist
training by 1,000 (18 percent) by reallocating
750 specialty slots to primary care and
eliminating 250 others. Although some
medical schools, such as those in the
Chicago area, have raised numerous
concerns about potential VA integrations, it
seems inevitable that more than one medical
school will need to share inpatient
educational and research opportunities at a
single VA facility. VA must work with the
medical schools to ensure it meets its
educational and medical missions without
compromising efforts to improve its
efficiency and effectiveness.



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              Since 1982, VA has served as the primary
              medical system backup to the Department of
              Defense (DOD). VA also works with the
              Federal Emergency Management Agency and
              the National Disaster Medical System during
              national emergencies. For example, as DOD’s
              backup, VA has agreed to make beds
              available in case of war or other military
              need. The integration of facilities’
              administrative functions, the consolidation
              of medical services in fewer VA locations,
              and VA’s reduced reliance on providing
              specialized care may alter the way VA is able
              to support DOD and the federal emergency
              and disaster systems. VA has identified DOD
              and others as stakeholders that are to be
              involved in its planning process but has not
              specified the steps it will take to ensure that
              its plans for restructuring health care
              delivery consider the impact such changes
              may have on its role in national emergencies.


Key Contact   Stephen P. Backhus, Director
              Veterans’ Affairs and Military Health Care
                Issues
              Health, Education, and Human Services
                Division
              (202) 512-7101
              backhuss.hehs@gao.gov



              Page 21                   GAO/OCG-99-15 VA Challenges
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VA Lacks           Because VA lacks accurate, reliable, and
Adequate           consistent information on how resources are
Information to     being allocated, it cannot ensure that
Ensure That        veterans are receiving equitable access to
Veterans Have      care across the country. VA has also been
                   unable to ensure that veterans in need of
Access to Needed
                   costly specialized treatment and
Health Care        rehabilitative services have access to such
Services           care. Finally, VA has not developed
                   information that would enable it to ensure
                   that it meets the increased demand for care
                   generated by its new enrollment process.


VA Does Not Know   VA cannot ensure that veterans who have
Whether Veterans   similar economic status and eligibility
Have Equitable     priority and who are eligible for medical care
Access to Care     have similar access to care regardless of the
                   region of the country in which they live, as
                   required by the Congress. The Congress was
                   concerned that the dramatic shift in the
                   veteran population from the Northeast and
                   Midwest to the South and West had occurred
                   without a corresponding shift in VA health
                   care resources. In fiscal year 1997, therefore,
                   VA introduced a new resource allocation
                   system to begin to correct historical
                   inequities in allocating resources, with the
                   intent of improving the equity of veterans’
                   access to care. Instead of allocating
                   resources directly to medical centers on the


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basis of their budget for the previous year, VA
now allocates funds to its 22 VISNs. A key
factor in these allocations is the number of
veterans each VISN has served. VISNs, in turn,
allocate resources to the facilities in their
geographic area.

We have reported that while the new method
has indeed improved the equity of resource
distribution among VISNs, VA does not know if
it is making progress in providing similar
services to similarly situated veterans. VA’s
strategic plan does not include a goal for
achieving equitable access, and VA does not
monitor the extent to which equitable access
is being achieved among or within VISNs.
Instead, VA has focused its efforts on
increasing access generally—apparently
expecting this to lead to more equitable
access sometime in the future. Furthermore,
we have reported that VA headquarters
neither provides criteria for VISNs to use to
equitably allocate resources nor reviews
VISNs’ allocations for equity. Although VA has
made progress in improving the equity of
resource allocations nationwide among the
networks, it has done little to ensure that
when networks allocate funds to their
facilities, the promise of the new system is
fulfilled. Although VA told us that having
national indicators to monitor improvements


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in equitable access was contrary to its
philosophy of decentralizing authority and
accountability, we have reported that VA
could use such indicators without being so
prescriptive that local authority and
accountability were compromised. For
example, VA has already used performance
measures based on national criteria to hold
VISN directors accountable for achieving
national goals.

We have also reported that VA’s data for
measuring changes in access are seriously
flawed because different measures are used
for the same indicator, users do not clearly
understand the measures, and obtaining the
same measure over time for comparison
purposes can be difficult. As a result, VA does
not know whether changes in resource
distribution from its new allocation method
and other initiatives to improve access (for
example, emphasizing primary care in
existing medical centers and expanding the
number of community-based outpatient
clinics throughout the country) are
equalizing access nationwide. VA does not
know whether additional changes in
resource allocation, strategic planning, or
management decisionmaking are needed to
ensure more equitable access. Without
accurate, reliable, and consistent


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                      information on changes in the equity of
                      access, VA does not know whether the
                      number of veterans it has served has
                      increased at the expense of reduced access
                      to services for veterans who have been
                      historically underserved.


VA Cannot Ensure It   VA has not been able to adequately address
Has Maintained the    congressional concern that VA maintain its
Capacity to Serve     level of certain high-cost specialized services
Special Populations   in the face of the many initiatives to become
                      a more efficient provider of care. The
                      Congress required VA to ensure that its
                      capacity for specialized treatment and
                      rehabilitative services for certain conditions
                      was not reduced below October 1996 levels
                      and that veterans with these conditions had
                      reasonable access to care. The Congress
                      identified four disabling conditions requiring
                      specialized care: spinal cord dysfunction,
                      blindness, amputation, and mental illness. VA
                      identified two additional conditions:
                      traumatic brain injury and post-traumatic
                      stress disorder.

                      We have reported that much more
                      information and analyses are needed to
                      support VA’s conclusion that it is maintaining
                      its national capacity to treat special
                      disability groups. For example, VA’s data


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indicate that from fiscal year 1996 to fiscal
year 1997, the number of veterans served
increased by 6,000 (or 2 percent), but
spending for specialized disability programs
decreased by $52 million (or 2 percent). VA
attributes the decreased spending to
reducing unnecessarily duplicative services
and replacing more expensive hospital
inpatient treatment with outpatient care.
Such aggregate data and assertions may,
however, mask potential adverse effects on
specific programs and locations. For
example, VA data also show that
expenditures were reduced for veterans with
serious mental illness and post-traumatic
stress disorder. In addition, VA data show
that about 3,000 fewer substance abuse
patients with serious mental illness were
served, and $112 million less was spent.

Consistent with the Results Act, VA plans to
develop outcome measures to track, among
other things, whether the care provided to
disabled veterans is effective as a result of
VA’s shift from inpatient to outpatient care.
While this is a step in the right direction, we
and two of VA’s advisory committees have
questioned the accuracy of VA’s data for
these populations. We have reported
difficulties arising from changing definitions
for data that make it difficult to establish


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                     baselines for comparison purposes;
                     inaccurate reporting at the local level; and
                     irreconcilable differences among medical
                     center, VISN, and national data. For example,
                     we reported that in its 1997 and 1998 reports
                     to the Congress, VA used different 1996
                     baseline expenditure capacity data for each
                     of the six special disability programs. VA
                     needs to develop more comprehensive,
                     uniform, accurate, and reliable information
                     on these programs.


VA May Not Be Able   VA has not developed information to help
to Meet Enrolled     ensure that it meets the increased demand
Veterans’ Demand     for care generated by its new process for
for Care             enrolling veterans in its health care system.
                     As a result, VA’s success in enrolling veterans
                     may jeopardize the availability of care for
                     some veterans. As part of its 1996 eligibility
                     reform legislation, the Congress required VA
                     to develop a priority-based enrollment
                     system to allow VA to better manage access
                     while operating within its budgetary limits.
                     VA has determined that in fiscal year 1999 it
                     will serve each veteran who enrolls and is
                     assigned a primary health care provider
                     regardless of the veteran’s priority category.
                     VA projects that by the end of fiscal year
                     1999, it will have enrolled about 4.4 million
                     veterans. If each of these veterans received


                     Page 27                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




medical services from VA in fiscal year 1999,
the percentage of veterans receiving VA care
would increase about 47 percent compared
with the percentage of those served annually
in recent years.

Because enrolled veterans are eligible for all
needed hospital and medical care from VA
regardless of their priority category, care for
higher-priority veterans may be jeopardized
as medical centers provide care to all
enrollees, including high-income veterans
without service-connected conditions. VA
does not know how many enrollees will use
its services and what services they will need
to use. Several challenges result. VA may not
have sufficient systemwide funds to serve its
enrollees. For example, officials at one
medical center told us that they will need at
least an additional $5 million in fiscal year
1999 to serve newly enrolled veterans who
already numbered 8,000 early in the fiscal
year. In addition, VA’s allocation process may
not be able to distribute funds adequately to
ensure that access to care is equitable if
VISNs grow at different rates—that is, if the
number of veterans VISNs must serve begins
to vary widely. Furthermore, veterans’
waiting times to get an appointment
scheduled or be seen after arriving for an
appointment may increase greatly. Finally,


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Issues




VA’slocal and systemwide capacity to serve
special populations, such as those with
spinal cord injuries or amputations, may be
reduced because of the sheer number of
veterans seeking other services and the cost
of providing those services. For example,
veterans who do not have pharmacy benefits
available from Medicare or private insurers
may enroll in VA’s system to obtain these
benefits, potentially reducing resources
available for low-income veterans or those
with service-connected conditions. Without
knowing the number of enrollees who will
use services or the types and amounts of
services to be used, VA may be risking the
availability of services to veterans with
service-connected disabilities and those with
low incomes.

VA’s authority to retain collections from
third-party insurers for care provided to
veterans for conditions that are not
service-connected could help maintain VA’s
financial viability. For each of the last 6
fiscal years, VA’s financial collections
averaged about $544 million, with
$560.1 million collected in fiscal year 1998.
Increased collections resulting from
increased enrollment of privately insured
veterans could provide funds to help meet
infrastructure and direct care needs. VA has


Page 29                   GAO/OCG-99-15 VA Challenges
              Major Performance and Management
              Issues




              recently initiated efforts to improve its
              collections, such as automating the bill
              collection process. We have reported,
              however, that VA may have difficulty in
              achieving its goals for collecting third-party
              payments for two reasons. First, the number
              of veterans participating in private managed
              care organizations is increasing, and such
              organizations typically do not pay for care
              delivered outside their plans. In addition, the
              shift away from costly inpatient services to
              less costly outpatient care could reduce
              private insurance recoveries and increase
              recovery costs. To effectively manage its
              resources, VA needs to closely monitor and
              evaluate the impact of its decision to open
              enrollment to veterans in all priority
              categories.


Key Contact   Stephen P. Backhus, Director
              Veterans’ Affairs and Military Health Care
                Issues
              Health, Education, and Human Services
                Division
              (202) 512-7101
              backhuss.hehs@gao.gov




              Page 30                   GAO/OCG-99-15 VA Challenges
                 Major Performance and Management
                 Issues




VA Lacks         VA has made little progress in developing,
Outcome          implementing, and evaluating
Measures and     results-oriented outcome measures to assess
Data to Assess   the health status of veterans. Instead, VA’s
Impact of        efforts to determine how well it delivers
                 health care have relied primarily on
Managed Care
                 process-oriented performance measures. VA
Initiatives      needs to ensure that its rapid change toward
                 a managed care system is not adversely
                 affecting the appropriateness of health
                 services provided to veterans.

                 Responsibility for monitoring quality
                 assurance shifted several times in the last
                 few years among headquarters and VISN
                 offices, and VA’s Inspector General and
                 veterans’ service organizations raised
                 concerns that VA had weakened its quality
                 assurance efforts with some of these shifts.
                 In response, in fiscal year 1998, VA realigned
                 the Office of Performance and Quality to
                 report directly to the Under Secretary for
                 Health. The realignment has the potential to
                 improve VA’s quality assurance efforts
                 because this office is situated to more
                 readily identify emerging challenges across
                 the health care system, implement and
                 oversee local and national corrective actions
                 when needed, and help create the single
                 standard of care required by accrediting
                 agencies.


                 Page 31                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




Providing centralized oversight is an
important step, but until recently, VA has
made little progress in developing,
implementing, and evaluating
results-oriented outcome measures to assess
the health status of veterans. Instead, VA’s
efforts to determine how well it delivers
health care have relied primarily on
process-oriented performance measures. For
example, VA has been tracking the number of
beds in use, the number of patients served,
and the number of patients receiving certain
diagnostic tests. Although these measures
can provide useful information on progress
toward meeting managed care goals, they
provide little information on the specific
impact of changes on the health status of
veterans.

Moreover, although VA has designed one
performance measure to assess the
functioning of seriously mentally ill patients
and another to assess the functioning of
patients with a primary diagnosis of
substance abuse, VA has generally not
performed the program evaluations
necessary to determine whether these are
the most appropriate or sensitive measures
for assessing responses to treatment and
changes in health outcomes. The need for
such measures is critical, given the multitude


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of changes in delivering care that VA has
introduced over the last few years. Indeed,
the need is exacerbated by the flexibility
VISNs and medical centers have in choosing
how they deliver care in VA’s decentralized
management structure. VA recognizes that it
needs to ensure that the changes made to
improve its efficiency and effectiveness do
not unintentionally compromise the health
status of veterans. VA is not alone in its need
to design, implement, and evaluate health
outcome measures. Other public and private
providers have recognized the necessity—
and the difficulty—of creating such criteria
and instruments.

VA’schallenges in assessing outcomes are
further complicated by poor data. We and
others have reported numerous concerns
with VA’s outcome data. These concerns,
which are similar to those with VA’s access
data, include inconsistent, incompatible, and
inaccurate databases; changes in data
definitions over time; and lack of timely and
useful reporting of information to medical
center, VISN, and national program managers.
For example, in evaluating VA’s fiscal year
1999 performance plan, we reported that VA
identified data sources and collection
methods for many of its performance
measures but provided little information


Page 33                   GAO/OCG-99-15 VA Challenges
                  Major Performance and Management
                  Issues




                  about how these data would be verified or
                  validated. Given VA’s history of data
                  weaknesses, such an omission is potentially
                  quite damaging. Prudent management
                  requires that managers of local programs,
                  VISNs, and national programs have ready
                  access to clearly understandable, reliable,
                  and consistent information in order to
                  identify and correct negative trends in health
                  outcomes in a timely manner.


Key Contact       Stephen P. Backhus, Director
                  Veterans’ Affairs and Military Health Care
                    Issues
                  Health, Education, and Human Services
                    Division
                  (202) 512-7101
                  backhuss.hehs@gao.gov


VA Faces Major    We have reported that VA’s current disability
Challenges in     rating schedule does not reflect the
Managing          economic loss experienced by veterans
Non-Health-Care   today and may not be equitably distributing
Benefits          disability compensation funds. We have also
                  reported that VA is compensating veterans
Programs
                  for diseases that are neither caused nor
                  aggravated by military service, calling into
                  question the fairness of VA’s treatment of
                  veterans who were disabled because of their


                  Page 34                   GAO/OCG-99-15 VA Challenges
                    Major Performance and Management
                    Issues




                    service. In addition, slow claims processing
                    in the compensation and pension program
                    and lack of program results in the vocational
                    rehabilitation program have been
                    long-standing challenges for VA. Moreover,
                    concerns have been raised recently about
                    the accuracy and reliability of the data VA
                    will use to measure compensation and
                    pension program performance. Furthermore,
                    there is concern about VA’s accountability
                    over the direct loan and loan sales activities
                    within VA’s Housing Credit Assistance
                    program.


VA Cannot Ensure    VA’s largest non-health-care benefits program
That Veterans’      is disability compensation. Under this
Disability          program, VA compensates veterans for
Compensation        disabilities incurred or aggravated during
Benefits Are
                    their military service. Since fiscal year 1996,
Appropriately and
Equitably           cash benefits to veterans and their survivors
Distributed         have steadily increased by about $1 billion
                    annually. In fiscal year 1998, VA received over
                    $17 billion in appropriations to provide
                    benefits to 2.3 million veterans, and VA
                    requested an additional $1.2 billion for fiscal
                    year 1999. VA’s disability program is required
                    by law to compensate veterans for the
                    average loss in earning capacity in civilian
                    occupations that results from injuries or
                    conditions incurred or aggravated during


                    Page 35                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




military service. The disability ratings in VA’s
current schedule are primarily based on
physicians’ and lawyers’ judgments made in
1945 about the effect service-connected
conditions had on the average individual’s
ability to perform jobs requiring manual or
physical labor. Although the ratings in the
schedule have not changed substantially
since 1945, dramatic changes have occurred
in the labor market and in society. Advances
in the management of disabilities, like
medication to control mental illness and
computer-aided prosthetic devices that
return some functioning to the physically
impaired, have helped reduce the severity of
the functional loss caused by some mental
and physical disabilities. Moreover,
electronic communications and assistive
technologies, such as synthetic voice
systems, standing wheelchairs, and modified
automobiles and vans, have given people
with certain types of disabilities more
independence and potential to work.

In the late 1960s, VA conducted a study of the
1945 version of the schedule to determine
whether the schedule constituted an
adequate basis for compensating veterans
with service-connected conditions. The
study concluded that at least some disability
ratings in the schedule did not accurately


Page 36                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




reflect the average impairment in earning
capacity among disabled veterans and
needed to be adjusted. Specifically, VA found
that of the schedule’s approximately 700
diagnostic codes, 330 overestimated
veterans’ average loss in earnings as a result
of their conditions, and about 75
underestimated the average loss among
veterans. Despite the results of this study,
however, VA has done little to ensure that the
schedule’s assessments of the economic loss
associated with service-connected
conditions are accurate. Instead, VA’s efforts
to maintain the schedule have concentrated
on improving the appropriateness, clarity,
and accuracy of the descriptions of the
conditions. Basing disability ratings at least
in part on actual earnings losses rather than
solely on physicians’ and lawyers’ judgments
of loss in functional capacity as determined
using a rating scale that is over 50 years old
would help to ensure that veterans are
compensated commensurately with their
economic losses and that compensation
funds are distributed equitably. Successful
implementation of a revised rating schedule
to reflect actual earnings losses would likely
require congressional action.

In addition to compensating disabled
veterans on the basis of a rating schedule


Page 37                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




that does not accurately reflect economic
losses, according to a 1996 Congressional
Budget Office report, VA was paying about
230,000 veterans about $1.1 billion in
disability compensation payments annually
for diseases or injuries neither caused nor
aggravated by military service. VA regulations
provide that a disease or injury resulting in
disability is considered service-connected if
it was incurred during a veteran’s military
tour of duty or, if incurred before the veteran
entered service, was aggravated by service.
No causal connection is required between
the circumstances of the disability and
official military duty. Thus, veterans can
receive compensation for diseases related to
heredity or life-style, such as heart disease
and diabetes, rather than military service.
Our 1993 study of five countries showed that
most of those countries do not compensate
veterans under such circumstances; rather,
they require that a disability be closely
related to the performance of a military duty
for a veteran to qualify for disability benefits.
Eliminating disability compensation to those
veterans whose disabilities were not clearly
caused by their military service could
control entitlement spending without
penalizing veterans disabled because of their
service, but such a change would likely
require congressional action.


Page 38                   GAO/OCG-99-15 VA Challenges
                     Major Performance and Management
                     Issues




VA Continues to      In 1997, the National Academy of Public
Face Challenges in   Administration reported that the timeliness
Processing Claims    and quality of adjudication decisions and
and Rehabilitating   slow appellate decisions continued to be a
Disabled Veterans
                     major challenge in VA’s compensation and
                     pension program. VA reported in fiscal year
                     1997 that it took an average of 133 days to
                     complete the processing of a veteran’s
                     original disability compensation claim. While
                     this is substantially faster than the average
                     of 213 days required in fiscal year 1994, VA’s
                     goal is to reduce the average to 53 days in
                     fiscal year 2002. Furthermore, veterans who
                     appeal VA’s initial decision may have to wait
                     2 years or more for a final decision. In
                     addition, VA’s vocational rehabilitation
                     program continues to place few disabled
                     veterans in jobs. Our 1996 review of records
                     of about 74,000 applicants for vocational
                     rehabilitation between October 1991 and
                     September 1995, who were classified by VA
                     as eligible for assistance, showed that only
                     8 percent had completed the vocational
                     rehabilitation process by finding a suitable
                     job and holding it for at least 60 days.

                     Moreover, VA’s Under Secretary for Benefits
                     has raised concerns about the accuracy of
                     VA’s existing management reporting systems
                     that will be used for measuring
                     compensation and pension program


                     Page 39                   GAO/OCG-99-15 VA Challenges
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performance. In September 1998, VA’s Office
of Inspector General (OIG) reported on its
audit of three key compensation and pension
claims processing performance measures.
The OIG found that the performance
measures lacked integrity because the
compensation and pension program’s
automated information system was
vulnerable both to reporting errors and to
manipulation of data by regional offices to
show better performance than was actually
achieved.

VA is implementing a number of initiatives to
address its compensation and pension
claims processing and vocational
rehabilitation performance weaknesses,
including establishing performance
measures for processing times and unit
costs, initiating quality assurance efforts,
and reassessing its business process
reengineering. VA is in the process of
developing results-oriented goals for its
compensation, pension, and vocational
rehabilitation and counseling programs.
Also, VA has developed a results-oriented
objective to increase the number of
vocational rehabilitation participants who
get and keep suitable employment. VA also
has plans to review and revise its operations
to focus the vocational rehabilitation


Page 40                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




program less on training and more on
helping veterans get jobs. For example,
program applications, brochures, and other
forms of written communication will be
revised to ensure that they clearly
communicate the program’s focus on
employment.

VA has also begun to address the need to
ensure that it has accurate and reliable data
for planning and management purposes. It is
taking action in response to the OIG’s
September 1998 report on compensation and
pension workload data concerns by
(1) collecting and analyzing historical data to
identify suspect transactions in the
compensation and pension information
system and (2) conducting on-site
inspections of transaction processing at VA
regional benefits offices.

While VA has taken steps toward improving
its strategic planning, performance
measures, and accountability to improve its
non-health-care programs, it has much more
to do. VA faces significant challenges in
setting clear strategies for achieving the
goals it has established and in measuring
program performance. For example, VA
considers its business process reengineering
efforts to be essential to the success of key


Page 41                   GAO/OCG-99-15 VA Challenges
                       Major Performance and Management
                       Issues




                       performance goals, such as reducing the
                       number of days it takes to process a
                       veteran’s disability compensation claim. VA is
                       in the process of reexamining the business
                       process reengineering implementation; at
                       this point, however, it is unclear exactly how
                       VA expects reengineered processes to
                       improve claims processing timeliness. VA is
                       also currently identifying and developing key
                       data it needs to measure its progress in
                       achieving specific goals. At the same time, VA
                       is working to make its data more accurate
                       and reliable with its existing management
                       reporting systems. Until these issues are
                       resolved, veterans and other beneficiaries of
                       VA’s non-health-care benefits programs will
                       continue to suffer from slow claims
                       processing and poor customer service.


VA Does Not Have       VA’s Annual Accountability Report, Fiscal
Adequate Control       Year 1997 described several deficiencies that
and Accountability     contributed to VA’s receiving a qualified
Over Its Direct Loan   opinion. Among the areas of concern was the
and Loan Sales
                       level of control and accountability over the
Activities
                       direct loan and loan sale activities within
                       VA’s Housing Credit Assistance program.
                       Specifically, the auditors were unable to
                       conclude that the $3 billion loans receivable
                       account balance was accurate because of
                       inadequate controls and incomplete records.


                       Page 42                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




In addition, the auditors identified a number
of errors, including inaccurate recording of
loan sales transactions and improper
accounting for loan guarantees.

When VA transferred the servicing of its
direct loan portfolio to a contractor in fiscal
year 1997, it did not adequately plan the
transfer. VA converted only those loans that
were fully documented on its legacy system
to the contractor’s system. Furthermore,
once VA shut down its legacy system, it no
longer had a centralized automated system
to record those loans that were in process.
Without such a system, VA transferred
responsibility for tracking and recording
loans in process to the regional offices. As a
result of the contractor’s having incomplete
records, significant delays occurred in
recording new loans in the contractor’s
accounting records, processing borrowers’
loan payments, and paying property taxes
and insurance from escrow accounts.

In addition, VA did not appropriately account
for or report its loan sale activities. Proceeds
from the loan sales were not accurately
recorded in the accounting records, and the
liability of the loan guarantees was not
estimated and reported in accordance with
federal accounting standards. Because VA did


Page 43                   GAO/OCG-99-15 VA Challenges
               Major Performance and Management
               Issues




               not account for its loan sales activities as
               required under federal accounting standards,
               the true cost associated with this activity
               could not be measured.


Key Contacts   For compensation and pension issues:

               Stephen P. Backhus, Director
               Veterans’ Affairs and Military Health Care
                 Issues
               Health, Education, and Human Services
                 Division
               (202) 512-7101
               backhuss.hehs@gao.gov

               For housing credit assistance issues:

               Gloria L. Jarmon, Director
               Health, Education, and Human Services
                  Accounting and Financial Management
               Accounting and Information Management
                  Division
               (202) 512-4476
               jarmong.aimd@gao.gov




               Page 44                   GAO/OCG-99-15 VA Challenges
               Major Performance and Management
               Issues




VA Needs to    VA faces significant information systems
Manage Its     challenges. It does not know the full extent
Information    of its health-care-related Year 2000
Systems More   challenges; it lacks adequate control and
Effectively    oversight of access to its computer systems;
               and it has not yet institutionalized a
               disciplined process for selecting, controlling,
               and evaluating information technology
               investments, as required by the
               Clinger-Cohen Act. Failure to adequately
               address these issues could result in
               disruptions in benefits payments and
               medical care to veterans, unauthorized
               access to and misuse of VA systems, and poor
               information technology investment
               practices.

               VA  could face widespread computer system
               failures at the turn of the century if its
               systems cannot adequately distinguish the
               year 2000 from the year 1900. Thus, veterans
               who are due to receive benefits and medical
               care could appear ineligible. VA recognizes
               the urgency of addressing this issue and has
               made progress, but challenges remain. For
               example, VA does not know the full extent of
               its Year 2000 challenges regarding its health
               care services. Furthermore, VA has not
               completed development of its Year 2000
               business continuity and contingency plans.
               Failure to adequately address these issues


               Page 45                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




could result in disruptions in benefits
payments and medical care to millions of
veterans and their dependents.

Significant challenges also exist in VA’s
control and oversight of access to computer
systems. For example, VA has not established
effective controls to prevent individuals,
both internal and external, from gaining
unauthorized access to VA systems. VA’s
access control weaknesses are compounded
by ineffective procedures for monitoring and
overseeing systems designed to call
attention to unusual or suspicious access
activities. In addition, VA is not providing
adequate physical security for its computer
facilities, assigning duties in such a way as to
segregate incompatible functions,
controlling changes to powerful operating
system software, or updating and testing
disaster recovery plans to prepare its
computer operations to maintain or regain
critical functions in emergency situations. VA
also does not have a comprehensive
computer security planning and management
program. If these control weaknesses are not
corrected, VA operations, such as financial
management, health care delivery, benefits
payments, life insurance services, and home
mortgage loan guarantees—and the assets



Page 46                   GAO/OCG-99-15 VA Challenges
Major Performance and Management
Issues




associated with these operations—are at risk
of misuse and disruption.

Finally, VA has not yet institutionalized a
disciplined process for selecting, controlling,
and evaluating information technology
investments. Information technology
accounted for approximately $1 billion of
VA’s fiscal year 1999 budget request of
$43 billion. At the time of the budget request,
VA decisionmakers did not have current and
complete information, such as cost, benefit,
schedule, risk, and performance data at the
project level, which is essential to making
sound investment decisions. In addition, VA’s
process for controlling and evaluating its
investment portfolio has deficiencies in
in-process and postimplementation reviews.
As a result, decisionmakers do not have the
information needed to (1) detect and avoid
difficulties early and (2) improve VA’s
investment process. Consequently, VA does
not know whether it is making the right
investments, how to control these
investments effectively, or whether these
investments have provided mission-related
benefits in excess of their costs.

Over the past several years, we have made
numerous recommendations to help VA
address information systems management


Page 47                   GAO/OCG-99-15 VA Challenges
              Major Performance and Management
              Issues




              issues. VA has concurred with most of these
              recommendations and has taken actions to
              implement many of them. Such actions
              include making fundamental changes to its
              methodology and approach to information
              systems management. For example, the
              Veterans Benefits Administration changed its
              Year 2000 strategy from developing new
              systems to converting existing ones. In
              another major change, VA separated the
              Chief Information Officer function from the
              Chief Financial Officer function and
              established a new Assistant Secretary
              position to serve as Chief Information
              Officer reporting directly to the Secretary on
              all information resources issues. This newly
              established position should help VA ensure
              prompt and efficient handling of information
              resources management issues.


Key Contact   Joel C. Willemssen, Director
              Civil Agencies Information Systems
              Accounting and Information Management
                Division
              (202) 512-6408
              willemssenj.aimd@gao.gov




              Page 48                   GAO/OCG-99-15 VA Challenges
Related GAO Products



VA Health Care     VA Health Care: VA’s Plan for the Integration
Infrastructure     of Medical Services in Central Alabama
                   (GAO/HEHS-98-245R, Sept. 23, 1998).

                   Veterans’ Health Care: Challenges Facing
                   VA’s Evolving Role in Serving Veterans
                   (GAO/T-HEHS-98-194, June 17, 1998).

                   VAHospitals: Issues and Challenges for the
                   Future (GAO/HEHS-98-32, Apr. 30, 1998).

                   VAHealth Care: Closing a Chicago Hospital
                   Would Save Millions and Enhance Access to
                   Services (GAO/HEHS-98-64, Apr. 16, 1998).

                   VA Health Care: Opportunities to Enhance
                   Montgomery and Tuskegee Service
                   Integration (GAO/T-HEHS-97-191, July 28, 1997).


Veterans’ Access   VA Health Care: More Veterans Are Being
to Needed Health   Served, but Better Oversight Is Needed
Care Services      (GAO/HEHS-98-226, Aug. 28, 1998).

                   VAHealth Care: VA’s Efforts to Maintain
                   Services for Veterans With Special
                   Disabilities (GAO/T-HEHS-98-220, July 23, 1998).

                   Veterans’ Health Care: Challenges Facing
                   VA’s Evolving Role in Serving Veterans
                   (GAO/T-HEHS-98-194, June 17, 1998).


                   Page 49                 GAO/OCG-99-15 VA Challenges
               Related GAO Products




               VACommunity Clinics: Networks’ Efforts to
               Improve Veterans’ Access to Primary Care
               Vary (GAO/HEHS-98-116, June 15, 1998).

               VA Health Care: Resource Allocation Has
               Improved, but Better Oversight Is Needed
               (GAO/HEHS-97-178, Sept. 17, 1997).


Impact of VA   VA Health Care: More Veterans Are Being
Managed Care   Served, but Better Oversight Is Needed
Initiatives    (GAO/HEHS-98-226, Aug. 28, 1998).

               VAHealth Care: VA’s Efforts to Maintain
               Services for Veterans With Special
               Disabilities (GAO/T-HEHS-98-220, July 23, 1998).

               Veterans’ Health Care: Challenges Facing
               VA’s Evolving Role in Serving Veterans
               (GAO/T-HEHS-98-194, June 17, 1998).

               Results Act: Observations on VA’s Fiscal Year
               1999 Performance Plan (GAO/HEHS-98-181R,
               June 10, 1998).

               Managing for Results: Agencies’ Annual
               Performance Plans Can Help Address
               Strategic Planning Challenges (GAO/GGD-98-44,
               Jan. 30, 1998).




               Page 50                 GAO/OCG-99-15 VA Challenges
                  Related GAO Products




VA                Veterans Benefits Administration: Progress
Non-Health-Care   and Challenges in Implementing the Results
Benefits          Act (GAO/T-HEHS-98-125, Mar. 26, 1998).

                  Vocational Rehabilitation: Opportunities to
                  Improve Program Effectiveness
                  (GAO/T-HEHS-98-87, Feb. 4, 1998).

                  VADisability Compensation: Disability
                  Ratings May Not Reflect Veterans’ Economic
                  Losses (GAO/HEHS-97-9, July 7, 1997).

                  Disabled Veterans Programs: U.S. Eligibility
                  and Benefit Types Compared With Five
                  Other Countries (GAO/HRD-94-6, Nov. 24, 1993).

                  VA Benefits: Law Allows Compensation for
                  Disabilities Unrelated to Military Service
                  (GAO/HRD-89-60, July 31, 1989).


VA Information    Year 2000 Computing Crisis: Leadership
Systems           Needed to Collect and Disseminate Critical
                  Biomedical Equipment Information
                  (GAO/T-AIMD-98-310, Sept. 24, 1998).

                  Information Systems: VA Computer Control
                  Weaknesses Increase Risk of Fraud, Misuse,
                  and Improper Disclosure (GAO/AIMD-98-175,
                  Sept. 23, 1998).



                  Page 51                GAO/OCG-99-15 VA Challenges
Related GAO Products




Year 2000 Computing Crisis: Progress Made
in Compliance of VA Systems, But Concerns
Remain (GAO/AIMD-98-237, Aug. 21, 1998).

VA Information Technology: Improvements
Needed to Implement Legislative Reforms
(GAO/AIMD-98-154, July 7, 1998).




Page 52                GAO/OCG-99-15 VA Challenges
Performance and Accountability Series



             Major Management Challenges and Program
             Risks: A Governmentwide Perspective
             (GAO/OCG-99-1)

             Major Management Challenges and Program
             Risks: Department of Agriculture
             (GAO/OCG-99-2)

             Major Management Challenges and Program
             Risks: Department of Commerce
             (GAO/OCG-99-3)

             Major Management Challenges and Program
             Risks: Department of Defense (GAO/OCG-99-4)

             Major Management Challenges and Program
             Risks: Department of Education
             (GAO/OCG-99-5)

             Major Management Challenges and Program
             Risks: Department of Energy (GAO/OCG-99-6)

             Major Management Challenges and Program
             Risks: Department of Health and Human
             Services (GAO/OCG-99-7)

             Major Management Challenges and Program
             Risks: Department of Housing and Urban
             Development (GAO/OCG-99-8)




             Page 53              GAO/OCG-99-15 VA Challenges
Performance and Accountability Series




Major Management Challenges and Program
Risks: Department of the Interior
(GAO/OCG-99-9)

Major Management Challenges and Program
Risks: Department of Justice (GAO/OCG-99-10)

Major Management Challenges and Program
Risks: Department of Labor (GAO/OCG-99-11)

Major Management Challenges and Program
Risks: Department of State (GAO/OCG-99-12)

Major Management Challenges and Program
Risks: Department of Transportation
(GAO/OCG-99-13)

Major Management Challenges and Program
Risks: Department of the Treasury
(GAO/OCG-99-14)

Major Management Challenges and Program
Risks: Department of Veterans Affairs
(GAO/OCG-99-15)

Major Management Challenges and Program
Risks: Agency for International Development
(GAO/OCG-99-16)




Page 54                     GAO/OCG-99-15 VA Challenges
Performance and Accountability Series




Major Management Challenges and Program
Risks: Environmental Protection Agency
(GAO/OCG-99-17)

Major Management Challenges and Program
Risks: National Aeronautics and Space
Administration (GAO/OCG-99-18)

Major Management Challenges and Program
Risks: Nuclear Regulatory Commission
(GAO/OCG-99-19)

Major Management Challenges and Program
Risks: Social Security Administration
(GAO/OCG-99-20)

Major Management Challenges and Program
Risks: U.S. Postal Service (GAO/OCG-99-21)

High-Risk Series: An Update (GAO/HR-99-1)




The entire series of 21 performance and
accountability reports and the high-risk
series update can be ordered by using
the order number GAO/OCG-99-22SET.




Page 55                     GAO/OCG-99-15 VA Challenges
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