GAO Identifies VA Provider Productivity Measure Shortcomings

July 19, 2017 - The VA lacks appropriate provider productivity measures and clinical efficiency models to accurately capture medical center performance, the Government Accountability Office (GAO) recently reported.

A review of the VA Central Office and six VA medical centers in 2015 also revealed that the federal department does not systematically manage provider productivity and efficiency across all health settings.

“To the extent that VA’s productivity metrics and efficiency models do not provide complete and accurate information, they may misrepresent the true level of productivity and efficiency across VAMCs [VA medical centers] and limit VA’s ability to determine the extent to which its resources are being used effectively to provide healthcare services to veterans,” the GAO wrote.

The VA implemented provider productivity measures in 2013 to evaluate time and effort providers spent to deliver healthcare services in 32 clinical specialties.

The federal department also developed 12 statistical models to assess clinical efficiency at VA medical centers. The models determine each medical center’s healthcare spending for various high-volume or high-cost services, such as emergency department and urgent care services. They then compare each center’s healthcare costs and utilization to expected levels.

Department officials designed the measures and models to ensure the Veterans Health Administration appropriately spends its growing budget. The administration’s budget reached $91.2 billion in 2016 from just $37.8 billion a decade prior.

However, the GAO found several shortcomings with the VA provider productivity measures and clinical efficiency models. The federal watchdog reported the following limitations:

• Provider productivity measures were incomplete because they do not account for all provider types or clinical services, including contract physicians and advanced practice providers, and they do not capture evaluating and managing services for inpatient stays

• Measures may not correctly identify the intensity of clinical workloads because coding variations exist among providers  and providers do not always accurately code clinical intensity, or amount of effort required to perform clinical services

• Measures may not appropriately reflect clinical staffing levels because providers do not always correctly record the amount of time spent performing clinical responsibilities distinct from time spent on other duties

The provider productivity and efficiency measure challenges may result in models over- or understating clinical and administrative efficiency, the federal watchdog stated.

Additionally, the GAO review uncovered that the VA failed to systematically track clinical and provider productivity at VA medical centers despite actions taken to monitor and improve efficiency. The stated that the VA Central Office does not have ongoing processes to oversee medical center efforts to track and improve provider productivity.

The review showed that the VA does have policies in place regarding remediation plans. The federal department requires medical centers to create remediation plans to improve low clinical and provider productivity identified through the measures and models. The centers must submit the plans to their Veterans Integrated Service Network.

During the GAO review, the VA required three of the six medical centers studied to submit remediation plans. The centers fulfilled their responsibility and their respective Veterans Integrated Service Network reviewed the plans.

However, the federal watchdog found that the policy did not include language that medical centers or their networks must submit approved remediation plans to the VA Central Office. The policy also did not stipulate that medical centers and networks had to monitor remediation plan implementation.

In addition, VA policy did not mandate that medical centers use the established clinical efficiency models and improve issues identified by the models, the GAO stated. As a result, two of the medical centers had not acted to improve clinical inefficiencies pinpointed by the models.

To improve provider productivity measures and oversight, GAO recommended the VA extend existing measures to all healthcare providers, including contract physicians who are not VA employees. The federal department should also improve measure and model accuracy by ensuring the correctness of underlying workload and staffing information. For example, officials could implement coding clinical procedures training for providers.

In response, the VA agreed to create provider productivity measures for advanced practice providers acting as sole providers and improve clinical coding accuracy by reissuing existing policies and providing need-based training.

But the federal department did not comment on creating measures for contracted physicians nor did it provide information on its plans to improve the accuracy of provider staffing data.

The federal watchdog also suggested that the VA develop a policy mandating that medical centers track and improve clinical inefficiency through a standardized process. The VA could develop performance standards based on the clinical efficiency models and remediation plans for addressing challenges.

GAO also advised the VA to establish a process to systematically review medical center remediation plans and implementation.

The VA concurred with the GAO recommendations, stating that it would require medical centers to create remediation plans and review medical center progress with clinical and provider productivity improvements twice a year.