Policy & Regulation News

Does Veterans’ Care Delivery Require Stronger Monitoring?

By Jacqueline DiChiara

- The Department of Veterans Affairs (VA) via the Veterans Health Administration (VHA) spent over $58 billion last year providing care to over 6.5 million veterans, including an aging veteran population and an increasing number of younger veterans returning from military service in Afghanistan and Iraq. Problems with such have arisen.

Veterans Health Administration United States Government Accountability Office

Data regarding VA's patient portfolio, which spans across 150 medical facilities – including medical centers and over 800 community based outpatient clinics – is “unreliable,” says a new draft report (GAO-15-776) from the United States Government Accountability Office (GAO).

The VA has failed to provide veterans with timely access to care, says GAO. The VA's data “cannot be used to monitor facilities’ management of primary care,” confirms last week’s testimony from Randall B. Williamson, Health Care Director, before the Subcommittee on Health, the Committee on Veterans Affairs, and the House of Representatives. Such identified a variety of “missing values and other inaccuracies” upon review of the VA’s data. 

Veterans may not be receiving timely, efficient care delivery

Data reliability concerns are tangible, Williamson says. According to officials from VA’s Primary Care Operations Office facilities, such data is “sometimes” recorded and self-reported inaccurately or in misalignment with VA’s policy mandates.

6 of 7 selected facilities’ data contained inaccuracies with noted variances in actual panel size – the number of patients for whom a healthcare provider and support staff can “reasonably” delivery primary care according to the VA’s estimates – from 23 percent below to 11 percent above the modeled panel size, says Williamson.

“Such wide variation raises questions about whether veterans are receiving access to timely care and the appropriateness of the size of provider workload at these facilities,” Williamson states.

GAO confirms although VA’s primary care panel management policy necessitates for facilities to guarantee panel size data consistency, the VA Central Office and other networks are not responsible for the execution of either data verification procedures or the monitoring of Federal internal control standards.

Therefore, there is no safeguard in place to verify data reliability, says GAO. The absence of such means such information cannot be used to assess the ongoing progression of performance quality.

“Because VA’s panel management policy is inconsistent with federal internal control standards, VA lacks assurance that its facilities’ data are reliable and that the facilities are managing primary care panels in a manner that meets VA’s goals of providing efficient, timely, and quality care to veterans,” GAO maintains.

Variation in relation to cost puts quality on the back burner

Expenditures per primary care encounter, found GAO, varied sizably from a low of $150 to a high of nearly $400, according to geographic labor cost variations.

“In contrast to VA’s panel data, GAO found that primary care encounter and expenditure data reported by all VA medical facilities are reliable, although the data show wide variations across facilities,” states GAO’s report to Congressional requesters.

Williamson maintains wide variations point to inefficient service delivery where per encounter costs are notably higher.

“Federal internal control standards state that agencies need both operational and financial data to determine whether they are meeting strategic goals and should use such data to assess the quality of performance over time,” GAO states.

“Using panel size data in conjunction with encounter and expenditure data would allow VA to assess facilities’ capacity to provide primary care services and the efficiency of their care delivery. By not using available encounter and expenditure data in this manner, VA is missing an opportunity to potentially improve the efficiency of primary care service delivery,” the organization adds.

“The absence of reliable panel size data and oversight processes could significantly inhibit VA’s ability to ensure that facilities are providing veterans with timely, quality care and delivering that care efficiently, GAO’s report to Congressional requesters explains.

“By not having in place a process to verify the reliability of facilities’ panel size data or to monitor wide variations between facilities’ reported and modeled panel sizes, VA will likely continue to receive unreliable data and miss opportunities to assess the impact of panel sizes on veterans’ access to care," maintains GAO. "VA Central Office and the networks are also missing opportunities to use readily available encounter and expenditure data to potentially improve the efficiency of primary care service delivery."

GAO recommends improvements and primary care management revisions

The GAO recommends implementation of the following two actions to improve data reliability for primary care panel size data and improve VA Central Office and network oversight of primary care management:

  • Incorporate in policy an oversight process for primary care panel management that assigns responsibility, as appropriate, to VA Central Office and networks for (1) verifying each facility’s reported panel size data currently in PCMM and in web-PCMM, if the software is rolled out nationally, including such data as the number of primary care patients, providers, support staff, and exam rooms; and (2) monitoring facilities’ reported panel sizes in relation to the modeled panel size and assisting facilities in taking steps to address situations where reported panel sizes vary widely from modeled panel sizes.
  • Review and document how to use encounter and expenditure data in conjunction with panel size data to strengthen monitoring of facilities’ management of primary care.

Concurrence on behalf of the VA was confirmed. Robert L. Nabors II, VA Chief of Staff, in a letter to Williamson, wrote, “VA agrees with GAO’s conclusions and concurs with GAO’s recommendations to the Department.” VA additionally described the agency’s ongoing outlined plans to implement GAO’s recommendations.