Major Management Challenges and Program Risks: Department of Veterans
Affairs (Letter Report, 01/01/2001, GAO/GAO-01-255).

This report, part of GAO's high-risk series, discusses the major
management challenges and program risks facing the Department of
Veterans Affairs. Health care access for veterans, compensation and
pension claims processing, and agencywide management strategies are some
of the most critical challenges facing the agency.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  GAO-01-255
     TITLE:  Major Management Challenges and Program Risks: Department
	     of Veterans Affairs
      DATE:  01/01/2001
   SUBJECT:  Risk management
	     Accountability
	     Public administration
	     Health resources utilization
	     Health care services
	     Health services administration
	     Internal controls
	     Veterans benefits
	     Claims processing
IDENTIFIER:  High Risk Series 2001
	     VA Capital Asset Realignment for Enhanced Services
	     Initiative
	     VA Canteen Service Program
	     VA Systematic Technical Accuracy Review System
	     VA Decision and Support System
	     VA Housing Credit Assistance Program

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GAO-01-255

Performance and Accountability Series

January 2001 Major Management Challenges and Program Risks

Department of Veterans Affairs

GAO- 01- 255

Letter 3 Overview 6 Major

11 Performance and Accountability Challenges

Related GAO 41

Products Performance

44 and Accountability Series

Lett er

January 2001 The President of the Senate The Speaker of the House of
Representatives

This report addresses the major performance and accountability challenges
facing the Department of Veterans Affairs (VA) as it seeks “to care
for him who shall have borne the battle and for his widow and his

orphan” stated in words VA adopted from Abraham Lincoln's Second
Inaugural Address. It includes a summary of actions that VA has taken and
that are under way to address these challenges. It also outlines further
actions that GAO believes are needed. This analysis should help the new
Congress and administration carry out their responsibilities and improve
government for

the benefit of the American people. This report is part of a special series,
first issued in January 1999, entitled the P erformance and Accountability
Series: Major Management Challenges and Program Risks. In that series, GAO
advised the Congress that it planned to reassess the methodologies

and criteria used to determine which federal government operations and
functions should be highlighted and which should be designated as
“high risk.” GAO completed the assessment, considered comments
provided on a publicly available exposure draft, and published its guidance
document, Determining Performance and Accountability Challenges and High
Risks (GAO- 01- 159SP), in

November 2000. This 2001 Performance and Accountability Series contains
separate reports on 21 agencieseach cabinet department, most major
independent agencies, and the U. S. Postal Service. The series also includes
a

governmentwide perspective on performance and management challenges across
the federal government. As a companion volume to this series, GAO is issuing
an update on those government operations and programs

that its work identified as “high risk” because of either their
greater vulnerabilities to waste, fraud, abuse, and mismanagement or major
challenges associated with their economy, efficiency, or effectiveness.
David M. Walker Comptroller General of the United States

Overview The Department of Veterans Affairs' (VA) mission reflects the
nation's historic commitment to care for veterans, their families, and their
survivors. VA administers a variety of programs, including one of the
world's largest health care systems. The Department estimates that, in
fiscal year 2000, it spent about $42 billion- more than 80 percent of its
total budget- to provide health care services to 3.6 million veterans and to
pay disability compensation and pensions to over 2. 5 million veterans and
their families and survivors. In providing these services and benefits, VA
faces several performance and accountability challenges.

Ensure timely and equitable access to quality VA health care ? Maximize VA's
ability to provide health care within

available resources ? Process veterans' disability claims promptly and

accurately ? Develop sound agencywide management

strategies to build a high- performing organization

Health Care Access Over the past several years, VA has undertaken many
initiatives to improve veterans' overall access to VAprovided health care,
such as shifting its emphasis from inpatient to outpatient primary care and
increasing the number of outpatient clinics it operates. VA has also
undertaken efforts to improve the quality of the care it provides, including
introducing patient safety initiatives.

However, several areas require continued emphasis if VA is to achieve its
goals. For example, VA cannot ensure that veterans receive timely care at VA
medical facilities. Nor can it ensure that it has maintained the capacity to
provide veterans who have spinal cord injuries, serious mental illnesses, or
other special needs the care that they require, as mandated by the Congress.
VA must also assess its capacity to provide long- term care for its aging
veteran population and respond to emerging health care needs, such as
treating veterans for hepatitis C. At the same time, VA is facing a
potential shortage of skilled

nurses- if nationwide projections for the next several years bear out- which
could have a significant effect on VA's quality of care initiatives.

To begin to respond to these concerns, VA must address long- standing
weaknesses in the quality and reliability of its workload and cost data.
Without good data, VA cannot link its strategic planning to areas that need
improvement or emphasis, appropriately budget for and allocate funds and
other resources, or measure its

performance in providing care for all veterans enrolled in its health care
system. We have made recommendations related to improving data on waiting
times and services for disabled veterans. More

specifically, we recommended that VA determine the extent and causes of
waiting times and then develop a spending plan with initiatives that would
solve the identified problems, as well as enhance monitoring of potential
service delivery problems for veterans. Health Care

To expand care to more veterans and respond to Resource Utilization emerging
health care needs, VA must continue to aggressively pursue opportunities to
use its health care resources- including its appropriation of about $20
billion- more wisely. VA has reduced its per- patient costs- one of its key
performance measures- by 16 percent, but it could achieve additional
efficiencies by realigning capital assets and human capital based on

changing demographics and veterans' health care needs. For example, VA needs
to further modify its infrastructure to support its increased reliance on
outpatient health care services and expand its use of alternative methods
for acquiring support services, such as food and laundry. VA spends as much
as one- quarter

of its annual health care budget to operate and maintain about 4,700
buildings and 18,000 acres of property. VA also needs to pursue additional
opportunities with the Department of Defense (DOD) to determine
costeffective ways to serve both veterans and military personnel, including
sharing services and facilities. In addition, VA must ensure that it
collects the money it is entitled to from third- party payers for health
care services provided to veterans whose conditions are not service-
connected.

To start to realize these efficiencies, VA has committed to systematically
assessing its future infrastructure and health care services needs within
its 22 Veterans Integrated Service Networks (VISN) as well as continuing to
involve key officials in its strategic planning efforts and decision- making
processes. 1 We have made several recommendations to VA that would help
improve its infrastructure planning, provide more cost- effective support
services, and enhance sharing with DOD.

1 As part of its restructuring, VA decentralized basic budgetary, planning,
and operating decisionmaking to its 22 VISNs. VISN directors are responsible
for ensuring that the funds allocated to their networks are used as
efficiently as possible and for identifying ways to provide health care
services more efficiently. Also, VISN directors are responsible for
assessing the future health care needs of veterans in their networks and
planning their facilities and services accordingly- for example, proposing
new outpatient clinics and consolidation of facilities.

Compensation and VA must also continue to seek ways to ensure that

Pension Claims veterans are compensated for reduced earning capacity
Processing due to disabilities sustained or aggravated during military
service. VA has had long- standing difficulties in

ensuring timely and accurate decisions on veterans' claims for disability
compensation. VA has improved its quality assurance system in response to
our recommendations, but large and growing backlogs of pending claims and
lengthy processing times persist. Moreover, veterans are raising concerns
that claims

decisions are inconsistent across VA's 57 regional offices. VA has taken
steps to improve its information systems, performance measures, training
strategies, and processes for reviewing claims accuracy. However, VA also
needs better analyses of its processes in order to target error- prone types
of cases and identify processing bottlenecks- as well as determine if its

performance goals are realistic. VA also needs to be vigilant in its human
capital strategies to ensure that it maintains the necessary expertise to
process claims as newly hired employees replace many experienced claims
processors over the next 5 years. VA's human capital problems can be seen as
part of a broader pattern of human capital shortcomings that have eroded
mission capabilities across the federal government. (See our High- Risk
Series Update, GAO- 01- 263, Jan. 2001, for a discussion of human capital as
a newly designated governmentwide high- risk area.) Management Finally, VA
has more work to do to become a highperforming Capacity

organization and increase veterans' satisfaction with its services. It must
revise its budgetary structure and develop long- term, agencywide strategies
for ensuring an appropriate information technology (IT) infrastructure and
sound financial management. If its budgetary structure linked funding to
performance goals, rather than program operations, VA and the

Congress would be better positioned to determine the Department's funding
needs. VA's IT strategy, which aims to provide veterans and their families
coordinated services, must be successfully executed to ensure that VA can
produce reliable performance and workload data and safeguard financial,
health care, and benefits payment information. Last, similar to most other
major agencies, VA's financial management strategies must ensure that its
systems produce reliable cost data and address material internal control
weaknesses and

Federal Financial Management Improvement Act (FFMIA) requirements.

Major Performance and Accountability Challenges

VA's mission is “to care for him who shall have borne the battle and
for his widow and orphan”- stated in words VA adopted from Abraham
Lincoln's Second Inagural Address. VA provides primary care, specialized
care, and related medical and social support services to more than 4 million
health care enrollees- about one- sixth of the total veteran population-
through its more than 1, 000 service delivery locations or by purchasing
care from other providers. VA also supports medical education and research
and serves as primary backup to other federal

agencies during national emergencies. In addition, VA is responsible for
providing compensation and pension benefits for disabled veterans. These
responsibilities are carried out primarily by the Veterans Health
Administration (VHA) and the Veterans Benefits Administration (VBA) under
numerous health care and compensation and benefits programs. In recent
years, we have identified significant performance and accountability
challenges in these programs that VA needs to address to ensure that it is
effectively and efficiently achieving its mission to serve veterans and
their families.

Ensure Timely and As part of its effort to “honor and serve veterans
in life” Equitable Access

and “restore the capability of disabled veterans to the to Quality VA
greatest extent possible”- two of VA's strategic goals- Health Care

VA has taken significant steps to improve veterans' access to health care.
Access to high- quality health care is critical to VA's accomplishing these
goals. Over the

past several years, VA has created hundreds of community- based outpatient
clinics (CBOC) to provide care to veterans in outpatient settings rather
than less efficient inpatient settings. VA expects that between fiscal years
1997 and 2001, the number of veterans who receive VA care will increase by
24 percent to 3. 9 million (see fig. 1).

Figure 1: Increases in VA Patients and Community- Based Outpatient Clinics,
Fiscal Years 1997- 2001

1000 CBOCs

Patients (Thousands) 4,500 900

4,000 800

3,500 700

3,000 600

2,500 500

2,000 400

1,500 300

200 1,000

100 500

0 0

1997 1998 1999 2000 2001

(Estimate) (Estimate)

Fiscal year Total Number of CBOCs Unique Patients Treated (Thousands)

Note: Figures for fiscal years 2000 and 2001 are goals and targets. Source:
VHA data. VA is challenged to ensure that veterans receive the care they
need, when they need it, and that the care provided meets standards of
quality. However, the lack of adequate data often hampers VA's ability to
determine the most appropriate use of its resources and to assess the
quality and timeliness of the care it provides. This lack of data also
limits VA's ability to identify

performance problems and measures to improve performance. More Accurate Over
the past decade, VA has taken steps to improve the Measures of Waiting

timeliness and quality of VA- provided care. Since 1993, Times and we have
reported that veterans' waiting times to see Health Outcomes Are providers
were excessive. Veterans were waiting an Needed to Improve average of 8 to 9
weeks to get an appointment in Timeliness and specialty clinics and
frequently waiting up to 3 hours in Quality of Care

certain types of emergency and screening clinics to see a provider. VA's
Office of Inspector General (OIG) reported similar findings. Recent
anecdotal information from VA and veteran service organization officials
indicates that veterans continue to experience delays in obtaining care. In
response to these concerns and those of veterans'

service organizations, VA has established strategic targets for the time it
takes for veterans to get an appointment with a VA provider and the time
they spend

waiting in a provider's office. VA's target for obtaining initial, nonurgent
appointments and specialty appointments is 30 days (average); its target for
time spent in the waiting room to see a provider is within 20 minutes or
less of the scheduled appointment time. VA intends to spend $400 million in
fiscal year 2001 to begin meeting these waiting time targets. As part of its
strategy to reduce waiting times, VA has entered into short- term contracts
with consultants to help reduce the backlog of specialty appointments. While
the Department has begun to systematically collect and improve the quality
of waiting times data for its outpatient care, it currently does not have
adequate data to identify the magnitude of waiting time problems or the
facilities with the most serious problems. Nor does it have data to isolate
the causes of problems or measure the effectiveness of its initiatives to
reduce waiting times. In May 2000, we recommended that VA

first determine the extent of waiting times and their causes and then
develop a spending plan with initiatives that will result in solving waiting
time problems. We also recommended that VA develop a mechanism for

monitoring and tracking expenditures for improving timeliness to evaluate
how well targeted funds have reduced waiting times. Until these data are
available, VA will not be able to (1) set realistic annual national and
local performance goals and determine if its efforts to help veterans avoid
unnecessary delays and inconvenience in obtaining care are successful or (2)
target future spending on the most effective strategies to reduce waiting
times. To identify how much money is needed and how it should be spent, VA
needs to modify its budget formulation and execution practices.

VA also has a number of initiatives under way to improve the quality of VA-
provided care, including developing or revising systems for detecting and
preventing adverse events that could harm patients. Some VA systems are
exemplary- such as those incorporating the use of bar code technology to
prevent medical errors. However, VA is in the early stages of implementing
its quality of care initiatives and, like other health care providers, has a
long way to go.

Improved strategic planning could help VA further its efforts. For example,
while VA's strategic plan for fiscal years 2001 through 2006 lists improved
patient safety as a goal, it does not include outcome measures for
determining the effectiveness of its patient safety initiatives. We noted
that VA could also better ensure that it meets its goals if it identified
how and when VA's various patient safety initiatives will be implemented,

how they are aligned to support improved patient safety, and what
contribution each initiative can be expected to make toward the goal of
improved patient safety.

Lack of Data and Facing budget pressures as it reorganized its health care
Decentralization system, VA has been challenged to ensure that veterans
Weaken VA's Ability with certain disabling conditions continue to have to
Ensure Adequate reasonable access to specialized treatment and Capacity for
Treating

rehabilitative services, as mandated by the Congress. 1 Veterans With
Special While VA has concluded that it has maintained the Disabilities
capacity to serve these veterans, it does not have sufficient data to
support this conclusion. For example, VA does not have precise enough data
to calculate workload and expenditure statistics for veterans with special
disabilities. Moreover, VA based its conclusions

on national statistics that indicated more disabled veterans were served
with fewer resources. However, because VA has not yet fully developed
outcome measures- which it committed to do by 1999- it cannot determine
whether the quality of the care provided to veterans in special disability
categories has been maintained, enhanced, or diminished. Accountability is
difficult to assign because responsibility for implementing the mandate to
maintain capacity in special disability programs is divided among several
headquarters units, including the Office of Policy and Planning, the Chief
Network Office, and the Office of Patient Care Services. The Office of
Policy and Planning is primarily responsible for coordinating the
development of capacity statistics and program definitions; the Chief
Network Officer is the primary contact for VISNs, providing operational
direction and supervision; and the Office of Patient Care Services develops
patient care policies and guidelines, acts as program consultant to the
special disability programs, and provides advice and consultation to VISN
and facility directors. However, none has responsibility for

1 Six disabling conditions were identified by the Congress and VA: spinal
cord dysfunction, blindness, amputation, serious mental illness, traumatic
brain injury, and post- traumatic stress disorder.

monitoring field locations' capacity to serve special disability
populations. We recommended that VA assign a lead office to be accountable
for enhanced monitoring and follow- up to augment VA's current limited
capacity measures and performance monitors. In addition to helping identify
data reliability issues, such monitoring efforts could also identify
locations with potential service delivery problems to special disability
populations. Although VA appointed a Clinical Coordinator for Special
Disability Programs, it has not specifically addressed developing employee
performance standards. VA Needs to Better

VA officials estimate that as much as 10 percent of its Position Itself to

approximately 4 million health care system enrollees are Respond to Shifts
in

infected with the hepatitis C virus- a rate five times that Veterans' Health

of the general U. S. population. Over the past 2 years, VA Care Needs and
has earmarked more than $260 million of its health care Workforce Issues
funding to screen all patients for hepatitis C risk factors, develop
treatment protocols, and create a public health awareness campaign. VA
projects that it will spend an additional $340 million in fiscal year 2001
for its

hepatitis C efforts. However, VA has not provided clear guidance to its 22
VISNs on this initiative, nor has it developed basic procedures to capture
accurate hepatitis C workload data. Moreover, only one- half of the funding
reflected in VA's fiscal year 2000 budget for

hepatitis C was spent on activities supporting the initiative. Consequently,
VA cannot determine how many veterans with the hepatitis C virus have been
identified,

nor can it fully account for its fiscal year 2000 hepatitis C expenditures
to ensure that these funds have been appropriately targeted.

VA must also position itself to be able to meet the changing health care
needs of an aging veteran population. VA expects the number of veterans over
age 85 to almost double between fiscal years 1998 and 2003 and double again
over the following decade, peaking at

about 1.3 million by fiscal year 2013. This aging is likely to add to the
demand for long- term care because the prevalence of chronic health
conditions and disabilities increases markedly at advanced age. However, VA
is not currently positioned to meet this demand, and the fiscal implications
are uncertain. Ensuring the quality of the care provided will also pose a
challenge. VA needs to explore alternatives, such as home- and
communitybased

settings, for providing long- term care. VA nursing homes- the costliest
long- term care settings- are the second most- used setting for long- term
care. While recent legislation limits the extent to which VA can provide
care through other long- term care settings and reduce its use of VA nursing
homes, VA has other options. For example, the Veterans Millennium Health
Care and Benefits Act (P. L. 106- 117), enacted in November 1999, authorizes
VA to conduct a pilot

program to evaluate the feasibility of using assisted living services as an
alternative to nursing home care. A VA task force is reviewing the
Department's options. VA also faces workforce challenges. For example,
between 1983 and 1998, the number of working nurses younger than 30
decreased by 41 percent compared to the number of all workers in the United
States, which

decreased less than 1 percent. Moreover, the number of new nursing graduates
entering the profession is not keeping up with the number of nurses leaving
the profession due to retirement or other reasons. A national nursing
shortage could adversely affect VA's efforts to improve patient safety in VA
facilities and put veterans at risk. According to the Institute of Medicine,
2 sufficient staffing, workloads, and patient care are

directly related to safety. VA is assessing the adequacy of its current
nursing workforce. Recent legislation 2 Institute of Medicine, To Err Is
Human: Building a Safer Health System (Washington, D. C.: National Academy
Press, Nov. 1999).

authorizing higher salaries for VA nurses could help VA in these efforts.
Key Contact Cynthia A. Bascetta, Director

Health Care, Veterans Health and Benefit Issues (202) 512- 7101 bascettac@
gao. gov

Maximize VA's Over the past several years, VA has made much more Ability to
Provide efficient use of its available health care resources- a Health Care
Within

critical element to VA achieving its strategic goals. The Available
Resources

Department is serving more patients, providing more care in less costly
outpatient settings, and achieving some health care efficiency improvements
(see fig. 2). VA estimates that between fiscal years 1997 and 2001, it will
have reduced its per- patient costs- one of its key performance goals- by 16
percent.

Figure 2: Inpatient and Outpatient Care, Fiscal Years 1997- 2001

900,000 Inpatient

Outpatient (Thousands) 45,000 800,000

40,000 700,000

35,000 600,000

30,000 500,000

25,000 400,000

20,000 300,000

15,000 200,000

10,000 100,000

5,000 0

0 1997 1998 1999 2000

2001 (Estimate)

(Estimate)

Inpatient Visits Outpatient Visits

Source: VHA data.

However, these significant accomplishments now introduce additional
challenges to VA because many of the facilities it owns, which cost vast
sums of money to maintain, are unoccupied or underused. To ensure progress
in both increasing access and improving quality of care, VA must (1) realign
its capital assets to ensure the best use of its resources; (2) continue to
expand the use of cost- effective alternatives to providing support
services, such as food and laundry; and (3) pursue additional opportunities
to share health care services

and facilities with DOD. In addition, VA needs to take steps to reverse the
decline in collections from thirdparty insurers.

Further Realignment As much as 25 percent of VA's annual health care budget
of VA's Infrastructure could be spent to operate, maintain, and improve
Could Better Meet roughly 4,700 buildings and 18, 000 acres of property-

Veterans' Health Care including unused and underused hospitals and other

Needs facilities. While VA has closed several underused

inpatient facilities as it increased its use of CBOCs, further realignment
of its capital assets could free up significant funds for patient treatment.
In the Chicago

area alone, we found that as much as $20 million could be freed up annually
through capital asset realignment if VA served this population with three
instead of four

hospitals. Realigning VA's infrastructure to achieve efficiencies and
effectively meet veterans' current and future needs- while mitigating the
potential effects on staffing, communities, and other VA missions- will
require skilled capital asset management. VA's realignment decisions have
largely been made ad hoc and based on subjective criteria without proactive
senior management involvement. In addition, realignment decisions have often
met with public opposition and concerns of medical schools affiliated with
VA facilities. Realignment in the Chicago area, for example, involves

affiliation agreements among four medical schools and four VA hospitals. As
a result, VA's decisions about how to realign its assets- especially those
aimed at consolidating administrative and clinical services across two or
more nearby medical centers- have often been delayed.

In August 1999, we recommended that VA develop assetrestructuring plans for
its 106 health care markets to guide its planning and management of health
care assets. In response, VA established the Capital Asset Realignment for
Enhanced Services (CARES) program,

which is designed to provide objective criteria and give senior management a
more proactive leadership role. The program calls for assessments of
veterans' health

care needs and available service delivery options to meet those needs in
each health care market. 3 VA has developed specific criteria for making
these assessments. In addition, current testing of CARES in Chicago will
provide valuable information on the feasibility and credibility of the
program. Ultimately, the success of this program depends on good strategic
planning and appropriate organizational realignment. Expanded Use of VA
facilities have initiated management efficiencies in a Alternative Methods
variety of nonpatient care support services. For for Support

example, some VA facilities consolidated inpatient food Services Could

and laundry services. Over the past several decades, VA Realize Additional
has consolidated 28 food production locations into 10, Savings

used lower- cost Veterans Canteen Service (VCS) workers instead of higher-
paid Nutrition and Food Service workers in 9 locations, and contracted out
food services at 2 locations. VA has also consolidated 116 laundries into
67; contracted for labor to operate 2 VA laundries; and contracted out
laundry at 15 facilities to 10 commercial laundries.

However, VA needs to systematically explore, through strategic planning,
further use of such options across its health care system. We have
identified another 63 food production locations that could be consolidated
into 29, saving an estimated $12 million annually, after an initial

$11 million investment in one- time equipment purchases. Using lower- cost
VCS employees at all VA food production locations could save an additional
$67 million annually. We similarly found the potential for savings in
laundry services. We estimated that an additional $2 million could be saved
by consolidating 13 laundries, plus avoiding an estimated $9 million in
onetime equipment and renovation costs. VA may also be 3 These assessments
are expected to be completed over the next 3 years.

able to reduce its food and laundry service costs at some facilities through
competitive outsourcing- where VA would determine whether it would be more
costeffective to contract out these services or provide them inhouse. In
November 2000, we recommended that VA conduct studies at all of its food
preparation and laundry locations to identify and implement the most
costeffective

way to provide these services at each location. However, VA must ensure that
contract terms on payments and service quality standards are met. For
example, we found that weaknesses in the monitoring of VA's Albany, New
York, laundry contract appear to have resulted in overpayments, reducing
potential savings.

VA and DOD Need to In an effort to save federal dollars, VA and DOD have
Increase Joint sought ways to share excess health care resources. For

Activities to example, local VA medical centers and military Maximize
Federal

treatment facilities have entered into agreements to Health Care exchange
inpatient, outpatient, and specialty care Resources services, as well as
support services. Some local VA and DOD facilities have entered into joint
ventures, pooling resources to build a joint medical facility or capitalize
on an existing facility. Local facilities have also arranged to jointly
purchase pharmaceuticals, laboratory services,

medical supplies, and equipment. VA and DOD officials have found that, by
sharing resources, better use has been made of their local facilities,
staff, and equipment; in some cases, beneficiary access and patient
satisfaction have improved. However, most sharing activity is occurring

through a relatively small number of sharing agreements and joint ventures.
Overall, 75 percent of direct medical care episodes provided under the
sharing program occurred under just 12 agreements for inpatient care, 19
agreements for outpatient care, and

12 agreements for ancillary care. Most joint venture activity occurred in
Albuquerque, New Mexico, and in southern Nevada. In addition, relatively few
VA facilities

are participating in national sharing initiatives being developed by the VA/
DOD Executive Council. To ensure sharing occurs to the fullest extent
possible, VA needs to continue to work with DOD to address a number of
barriers. For example, some VA and DOD facilities try to shift
responsibility to each other for treatment and payment of dual eligible
beneficiaries- retired military who are also veterans- making it difficult
to reach agreements for treating these beneficiaries.

It is particularly critical that VA take a long- term approach to improving
the sharing database, which it administers. While the database captures
information on the number of agreements and the range of services covered,
these data are inadequate to assess progress.

VA and DOD need to collect data on the volume of services provided, the
amounts of reimbursements collected, and the costs avoided through the use
of sharing agreements. Further, improvements are needed in the accuracy of
information in the joint VA- DOD

database. Without a baseline of activity or complete and accurate data, VA
and DOD- and the Congress- cannot assess the progress of VA and DOD sharing.
We made several recommendations aimed at removing barriers to sharing and
for improving information on the results of sharing agreements in the joint
VA/ DOD sharing database. Additional opportunities also exist for VA and DOD
to jointly purchase pharmaceuticals and exact higher discounts from
manufacturers. VA and DOD's combined annual spending for pharmaceuticals is
more than

$2. 4 billion. In fiscal year 2000, the two Departments saved an estimated
$51 million from jointly awarded national committed- use contracts with
suppliers to purchase 4 percent of their total drug requirements. While
these savings are impressive, our analysis of

actual purchases has shown that significantly more federal health care
dollars could be saved if VA and DOD expanded the use of national committed-
use contracts. However, officials from VA and DOD indicated that the
prospects for further joint contracting are limited because their patient
populations and drug formularies 4 differ. VA needs to continue to work with
DOD to take advantage of recent legislation encouraging the two

Departments to increase their cooperation in the procurement of
pharmaceuticals to the maximum extent possible.

VA Efforts May Not Over the past 5 fiscal years, collections from third-
party Reverse Declining insurers, which VA relies on to supplement its
medical

Third- Party care appropriations, have declined. 5 In fiscal year 2000,

Collections VA collected $387 million from third- party insurers-$ 35
million less than collected the year before (see fig. 3).

4 A formulary is a list of drugs, grouped by therapeutic class, that a
health care organization prefers that its physicians prescribe. 5 VA can
bill insurers for care it provides to veterans for medical conditions not
related to service- connected disabilities. Because VA cannot bill Medicare
without legislative action giving it authority to do

so, VA reduced its third- party collection goals. Historically, these
collections have determined, in part, VA's appropriations.

Figure 3: VA Third- Party Collections, Fiscal Years 1995- 2000

600 Dollars in Millions

500 400 300 200 100

0 1995 1996 1997 1998 1999 2000 Fiscal Year

Source: VHA data.

Several factors contributing to this decline are outside VA's control. For
example, an increasing percentage of veterans are becoming eligible for
Medicare- which, by law, cannot pay for VA- provided care. More veterans are

also enrolling in managed care organizations, from which VA cannot typically
collect because it is not a participating provider. In addition, the net
effect that VA's shift to less expensive outpatient care will have on
collections is uncertain.

In September 1999, VA began to bill insurers based on “reasonable
charges” for actual care provided, rather than charging rates based on
average cost of care. While VA expects its new billing to increase
collections, reverses in declining third- party collections will not

occur until VA implements its improved billing processes. For example,
information on veterans' insurance coverage that VA has collected has been
inadequate to identify opportunities to bill insurers or to avoid billing
insurers inappropriately for care not covered. VA's processes for following
up on outstanding bills have also been inadequate to guarantee timely
payments from insurers. Weaknesses such as these affect collections under
VA's reasonable charges billing. For example, to meet the strict standards
placed on private providers who bill the Medicare program, VA must
accurately and completely document the care provided. VA has begun to update
its billing and records systems and bring them in line with industry
standards and needs to continue these efforts. VA has also undertaken
several initiatives to address collections weaknesses. First, VA has
contracted with a collection agency to assist

facilities in collecting third- party bills that are outstanding for more
than 90 days. VA has also distributed brochures to veterans and VA
collections staff explaining the need for information on veterans' insurance
coverage. Finally, VA has begun to develop training for medical records
staff in documenting and coding of care provided to patients and has
provided training to staff responsible for obtaining precertifications from
insurers.

Key Contact Stephen P. Backhus, Director Health Care, Veterans and Military
Health Care Issues (202) 512- 7101 backhuss@ gao. gov

Cynthia A. Bascetta, Director Health Care, Veterans Health and Benefit
Issues (202) 512- 7101 bascettac@ gao. gov

Process Veterans' As part of its effort to “restore the capability of
disabled Disability Claims veterans to the greatest extent possible and
improve the Promptly and

quality of their lives,” VA provides over $20 billion a year
Accurately in disability compensation and pension benefits to more than 2. 5
million veterans, family members, and

survivors. However, long- standing processing delays have resulted in an
increasing backlog of veterans' initial and repeat claims for disability
compensation. 6 Between fiscal years 1995 and 1999, the average time for

processing initial compensation claims jumped from 161 days to 205 days (see
fig. 4), and the average time to resolve veterans' appeals of VA's claims
decisions continued to exceed 2 years. 6 VA reviews veterans' initial claims
to establish eligibility for disability benefits and reviews repeat claims
to increase the amount compensated.

Figure 4: Average Number of Days for Processing of VA Initial Compensation
Claims, Fiscal Years 1990- 1999

Number of Days 250

213 205

200 189

164 164 161 168

151 144 150

133 100

50 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Fiscal Year

Source: VBA data.

By the end of fiscal year 1999, about 69, 000 initial compensation claims
were pending- 34 percent of which had been pending for more than 6 months-
and VA had a backlog of about 138, 000 repeat claims by veterans who already
received compensation. In addition to these delays and backlogs, there were
concerns about the high rate of claims errors and about the consistency of
decisions among VA's 57 regional offices. Under its current quality
measurement system, VA found that nearly one- third of decisions are
incorrect or have technical or procedural errors. Delays and

errors also affect veterans' eligibility and priority for other VA benefits
and services, such as health care and vocational rehabilitation, since they
are based in part on VA's assigned disability ratings.

VA has addressed a number of key management issues- such as implementing new
performance measures, modernizing its information technology systems, and
developing training. However, it is unclear to what extent these measures
will improve the timeliness and

accuracy of its claims processing because the underlying causes of the
problems have not yet been identified. At the same time, many experienced
staff are expected to retire and veterans are seeking compensation for more
service- connected disabilities per claim. Many of these problems stem from
the growing complexity of claims processing caused by increased procedural
and documentation requirements.

Effectiveness of VA's Addressing the problems that weaken its claims Efforts
to Improve processing performance- including improving the Claims Processing
quality of its data and ensuring sufficient staff to process Performance Not
Yet

claims- are major management challenges for VA. While Known VA has taken a
number of steps to address these problems, it has not identified their
underlying causes. Without such information, VA cannot ensure that its

corrective actions will improve its claims processing performance. In
addition, VA's training and recruitment programs may not be adequate to
ensure a sufficient workforce of competent claims processors. Consequently,
existing problems of claims backlogs and errors will likely persist,
delaying outcomes to provide veterans and their families with timely and
accurate disability payments.

In September 1998, VA's Inspector General reported that, due to data entry
errors, VA's claims processing database overstated claims processing
timeliness. In March 1999, we found that while VA has taken significant
steps to measure the accuracy of its claims processing decisions,

additional measures are needed to ensure that errorprone cases are
identified and processes for reviewing the accuracy of claims meet the
government's internal

control standards. In light of these findings and our recommendations, VA is
implementing ? a system to identify regional offices with accuracy problems,
so that more detailed reviews can be done at these offices to identify the
underlying causes of inaccuracies, corrective actions, and needs for
additional staff training;

? a case management approach to claims processing to hold individuals and
teams accountable for every aspect of the claims process and to establish a
case manager contact to keep the veteran informed of the status of the
claim; and ? a major IT effort to replace its existing compensation and
pension payment systems with a new state- ofthe- art system expected to
manage claims development processes, establish veterans' records,

compute the award or payment amount based on the results of the rating
process, develop the payment record, and handle all accounting functions.

However, until VBA identifies the underlying causes of its claims processing
problems and measures its progress, the effectiveness of these initiatives
cannot be determined. Moreover, VA's top management has yet to approve a
complete IT management plan and schedule

or an approved strategy to convert data from the existing systems into the
new system. VBA officials acknowledged these issues and informed us that
efforts are under way to address them.

VA has also been faced with the challenge of ensuring an adequate workforce
to process claims. VA estimates that by 2005, 1, 100 of its claims
processing workforce will retire. To prepare for this loss of experienced
staff, VA planned to add more than 400 new staff to its

compensation and pension programs in fiscal year 2000. VA plans to redirect
or hire an additional 400 staff for fiscal year 2001. While VA plans to
provide training to

new staff, their lack of experience will likely limit VA's ability to ensure
that the benefits and pension claims process will be timely and accurate.
According to VA, it takes 2 to 3 years on the job for claims processors to
achieve a full level of decision- making expertise, making it critical that
an effective training program be in place.

VBA has begun to implement a centralized training program. However, the
comprehensiveness and effectiveness of this program are unknown at this
time.

External Challenges Prior to 1989, veterans dissatisfied with their claims
May Constrain VA's determinations could ask for a review of their case by
Ability to Improve Its

the Board of Veterans' Appeals, whose decisions were Claims Processing
final. Veterans now have the option to appeal the Board's Performance

decision to an independent Court of Veterans Appeals. 7 Further, both
veterans and VA may appeal these decisions to the Court of Appeals for the
Federal Circuit. The establishment of the Court of Veterans Appeals
introduced a number of complex procedural and documentation requirements
with which VA must comply. Before 1989, the rationale for VA's
determination- including the degree of the rating for

each disability claimed- was summarized in a brief statement for each claim.
Under the new requirements, VA claims processing staff must describe for
each disability issue the evidence and rationale leading to the decision.
While this initial investment may improve veteran satisfaction- and increase
understanding of the factors that led to the decision- providing this
rationale

adds up- front time to process cases. In the long run, however, time may be
saved if this effort results in a decrease in remands.

Individual veteran's cases are also becoming more complex, complicating the
claims process. For example, 7 The court was established under the Veterans'
Judicial Review Act of 1988 (P. L. 100- 687).

in fiscal year 1998, VA found that a sample of about 69, 000 veterans filed
claims for a total of about 316, 000 disabilities. Each of these
disabilities requires a separate rating. In addition, veterans can file
repeat claims to include new evidence or to respond to changes in
regulations that occur after a case has been sent to the Appeals Board.
Veterans can also file as many repeat claims for disability compensation as
they desire if their condition worsens or if they develop a new disability.
In fiscal year 1998, repeat claims outnumbered initial claims by about three
to one, further burdening regional office workloads. Key Contact Cynthia A.
Bascetta, Director

Health Care, Veterans Health and Benefit Issues (202) 512- 7101 bascettac@
gao. gov

Develop Sound VA faces additional challenges in several areas critical to
Agencywide building a high- performing organization: budget Management

formulation and execution, information technology, and Strategies to Build
financial management. To meet its strategic goal to a High- Performing
create an environment that fosters the delivery of “One Organization
VA” world- class service to veterans and their families, VA has begun
to address some of these issues through its plans to implement an
information technology framework that supports the integration of
information across the Department and to continue to achieve unqualified
audit opinions on its annual financial

statements. VA's Budget Systems A significant management challenge for VA is
to develop Need to Be Aligned to budget formulation and execution systems
that allow it Link Funding to to link the funds it spends, or proposes to
spend, to its Performance

performance- as required by the Government Performance and Results Act.
However, VA's current budget structure- like those of other federal
agencies-

does not allow such linkages. Most of VA's budget accounts are organized
around program elements rather than strategic goals and objectives. For
example, VA's medical care budget account is organized according to program
activities based on types of health care provided- such as acute hospital
care and outpatient care. VA's compensation and pension account breaks out
compensation and pension funding according to the veterans' periods of
military service. Instead, VA needs its budget request to show the amount of
funding it requires to meet the levels of performance it expects to achieve.
VA is working with the Office of Management and Budget on developing a
performance- based budget. VA's fiscal year 2001 budget request included
some improvement in presenting budget information linked to performance
measurement. VBA's request included a

business plan, with information on the amounts of funding requested for
specific initiatives. These initiatives were, in turn, tied to specific
performance goals to improve VBA's program operations- notably, claims
processing timeliness and accuracy. For example, VBA's request identified
the funding and staffing increases requested to implement its Systematic
Technical Accuracy Review (STAR) system, which is designed to identify VBA
regional offices with claims

processing problems, so VBA can target training for claims processing staff
to these offices. Another improvement is in the National Cemetery
Administration's (NCA) budget request. In addition to providing information
on funding needs to address

specific performance improvement initiatives, NCA provided a summary of VA's
requests and prior- year funding data for seven accounts that help fund VA's
burial program, including accounts that fund national cemetery operations,
grants to states for construction of state veterans' cemeteries, funding for
construction and expansion of VA national cemeteries, and other

memorial activities such as the acquisition of headstones and grave markers.
Another budget formulation and execution challenge for VA is to implement
systems that provide adequate workload and cost data. Such data are needed
so VA can

determine the levels of performance it can expect from different levels of
funding and to ensure that funds are allocated to VA facilities in ways that
ensure that veterans receive equitable VA services nationwide. For example,
to ensure equitable access to health care for veterans across the country,
VA needs adequate data to identify the locations and causes of access
problems.

Because VA lacks such data, it cannot target funds earmarked for improving
equity of access to the facilities where they are needed most.

VA has implemented a health care workload and cost information system- the
Decision Support System (DSS)- for VISNs and individual facilities to use to
help prepare budgets, allocate resources, and generate productivity analyses
and patient- specific costs. However, only one VISN has reported using DSS
for resource allocation, and only eight reported using it for

budget formulation. To ensure that all of its health care networks and
facilities are using this system, VA has required that fiscal year 2002
funding allocations be based on DSS data and that VISNs' applications for
new CBOCs include data on VA health care users with and

without reasonable access to care. VA's Efforts to Use

Since 1996, VA has spent an estimated $5 billion on IT Information
initiatives to help realize its vision of providing seamless Technology to
Help

service to veterans and their families. VA expects its IT Serve Veterans
Need

expenditures to increase over the next 5 years from Improvement about $1. 5
billion in fiscal year 2001 to more than $2. 1 billion by fiscal year 2005.
VA's IT strategy must be successfully executed to ensure that VA can produce
reliable performance and workload data, as well as

safeguard financial, health care, and benefits payment information. In 1999,
we noted that VA had made progress in addressing year 2000 challenges but
still had some issues to address. The Department addressed these

issues and made a successful transition to the year 2000 without any
significant incidents, disruption of benefits to veterans, or risk to
patient health and safety. In August 2000, we recommended that VA take
certain actions to improve its IT investment decision- making process and
fully implement key provisions of the Clinger- Cohen Act of 1996, which aims
to strengthen IT leadership and management at federal agencies.

However, the Department is struggling with how to integrate complex
technologies and management processes so that they are aligned with VA's
missions, goals, strategies, programs, and business processes. VA has yet to
sufficiently address seven challenges to strengthen the leadership and
management of its IT initiatives. Table 1 summarizes these challenges and
VA's status in responding to each.

Table 1: Status of IT Challenges Facing VA Challenge Status Appointment of
Chief Information Officer (CIO)

CIOs provide leadership and partner with senior In 1998, VA established the
position of assistant officials to develop strategic plans and policies,
secretary for information and technology to serve as build credible
information management VA's CIO. However, the President did not nominate
organizations, and develop and organize someone to the position until
September 19, 2000; information management capabilities to meet the position
remains unfilled.

agency mission needs.

(Continued From Previous Page)

Challenge Status IT investment management

VA needs to maximize the value and return on its In 1999, VA established a
process for selecting, IT investments and mitigate associated risks.
controlling, and evaluating its IT capital investments. VA has efforts under
way to implement the improvements we recommended: (1) establish and monitor
deadlines for completing formal in- process reviews at key project
milestones, (2) provide data

to decisionmakers on lessons learned from postimplementation reviews, and
(3) develop guidance to better manage projects below thresholds established
by VA's Capital Investment Board. a

Integrated business process reengineering

Before making major IT investments, agencies are VA has not developed a
departmentwide strategy required under the Clinger- Cohen Act to analyze

specifying needed reengineering and improvement their missions and revise
and improve missionrelated projects or their relation and priority. VA did
not and administrative processes accordingly. concur with our August 2000
recommendation to To do this, agencies should have an overall

reassess its decision to delegate business process business process
improvement strategy- one that reengineering to individual administrations
and still coordinates and integrates ongoing reengineering

plans to rely on VHA, VBA, and its other and improvement projects, sets
priorities, and administrations to pursue their own reengineering makes
appropriate departmentwide budget initiatives, believing they best
understand the

decisions. means to achieve their missions. However, until VA develops a
departmentwide reengineering strategy, it is unlikely to achieve its
“One VA” vision.

Integrated IT architecture

In achieving the agency's strategic and IT goals, To date, VA has completed
only the technical CIOs are charged with implementing a twocomponent
component of its architecture. For the second

architecture that will provide a component, the logical architecture, VA
plans to framework for maintaining existing IT and for

implement a strategy that will likely result in at least acquiring new IT. b
three separate architectures. To help achieve its “One VA”
vision- and comply with requirements of the Clinger- Cohen Act- VA needs to
reassess this strategy and work with VBA and VHA to develop an

integrated, departmentwide logical architecture.

Tracking IT expenditures

VA needs to establish a uniform mechanism for Although VA Directive 6000 c
and VA's capital tracking IT expenditures to make informed

investment guide require it to maintain complete decisions about whether to
modify, accelerate, or and accurate cost data for IT projects, there is no
discontinue projects.

uniform mechanism for tracking IT expenditures across the department. VA has
delegated this responsibility to managers in VA's administrations and
offices, resulting in varying tracking approaches and difficulty in
identifying VA's total IT costs.

Assessing IT performance

The Clinger- Cohen Act requires executive branch While VA's FY 2001
performance plan identified IT agencies to establish performance measures
that initiatives for improving claims processing accuracy relate to how well
IT supports their programs.

and timeliness, it did not include performance goals. Without such goals, it
will be difficult to assess the performance of these initiatives.

(Continued From Previous Page)

Challenge Status Computer security

VA also needs to implement appropriate security Since September 1998, we
have reported on VA's measures to ensure that financial, health care,
computer security weaknesses, which have placed and benefits payment
information are not at risk of financial, health care, and benefits payment
inadvertent or deliberate misuse, fraud, improper

information at risk of misuse, fraud, improper disclosure, or destruction.

disclosure, or destruction- possibly occurring without detection. VA has not
adequately limited access granted to authorized users, segregated
incompatible duties among computer personnel, managed user identification
and passwords, or monitored access activity. As of September 2000, VA had
not yet fully implemented an integrated

security management program and VHA had not effectively managed computer
security at its medical facilities. Agreeing with our recommendation to
create a comprehensive, coordinated security management program that would
encompass VHA and other VA organizations, VA intends to develop an
accelerated plan to improve information security at its facilities. VA also
plans to develop departmentwide policy, guidance, and processes.

a The Capital Investment Board reviews projects that exceed specific dollar
thresholds set for each of VA's administrations or that are seen as high
risk or high visibility. b An integrated IT architecture is a blueprint,
consisting of logical and technical components, to guide and constrain the
development and evolution of a collection of related systems. At the logical
level, the architecture provides a high- level description of an
organization's mission, the business functions performed and the
relationships among them, the information needed to perform the functions,
and the

flow of information among functions. At the technical level, the
architecture provides the rules and standards needed to ensure that the
interrelated systems are built to be interoperable and

maintainable. These include specifications of critical aspects of component
systems' hardware, software, communication, data, security, and performance
characteristics. c VA Information Resources Management Framework, VA
Directive 6000, Sept. 17, 1997.

Many Financial In March 2000, VA's Office of Inspector General (OIG)
Management issued an unqualified audit opinion on VA's consolidated
Weaknesses Remain

financial statements for fiscal years 1999 and 1998. 8 Despite Unqualified
However, many systems and control problems, as Audit Opinion

reported by VA's OIG and by GAO, remain unresolved. For example, VA's
accounting systems still require

updating, and several material internal control weaknesses have not yet been
corrected. In addition, VA's accounting systems- similar to those of most
other major agencies- did not comply substantially with Federal Financial
Management Improvement Act (FFMIA) requirements. These weaknesses continue
to make VA's program and financial data vulnerable to error and fraud and
limit the Department's ability to monitor programs through timely internal
financial reports throughout the fiscal year.

VA's unqualified opinion was achieved by reconciling medical accounts
receivable balances and correcting a number of material credit reform and
loan guaranty accounting deficiencies. While this was a major accomplishment
for VA, the OIG's audit report also points out a number of material internal
control

weaknesses related to information security controls, Housing Credit
Assistance (HCA) program accounting, and fund balance with Treasury
reconciliations. Specifically, VA's OIG found that

? departmentwide weaknesses in general controls over automated data
processing continue to make VA's program and financial data vulnerable to
error or fraud; ? material weaknesses continue to impede timely completion
of financial statements and reduce the

use and value of internal financial reports for management control and
program monitoring of its direct loans and related foreclosed properties 9 ;
and

8 See Report of Audit of the Department of Veterans Affairs Consolidated
Financial Statements for Fiscal Years 1999 and 1998, (Report No. 99.00006.
46, Mar. 14, 2000). 9 The Department reported information systems security
controls and HCA program accounting issues as material weaknesses in their
FFMIA reports for fiscal years 1999 and 1998.

? the Austin Finance Service Center's reconciliations were incomplete due to
cumbersome, labor- intensive processes, and weaknesses in the existing
accounting system and Treasury reporting and reconciliation processes.

The VA OIG's audit report also discusses VA noncompliance with several FFMIA
requirements, impeding VA's ability to provide reliable, useful, and timely
information needed to manage day- to- day operations. First, VA's HCA
financial management systems were not in substantial compliance with federal

financial system requirements. Specifically, VA's HCA general ledger and
subsidiary program systems did not interface with VA's core financial
system, and processes were not in place for reconciling general ledger and
subsidiary foreclosed property data and for providing reliable financial
information that could be used to monitor HCA programs. Additionally, the
HCA systems did not provide the timely data necessary for preparing VA's
Consolidated Financial Statements. Second, VA's OIG reported that, with the
exception of the Austin Automation Center, VA lacked sufficient information

system security, making VA's program and financial data vulnerable to error
or fraud. Finally, VA's systems did not accumulate and report cost data at
the activity level. Reliable cost information is needed for VA to assess its
operating performance. However, in preparing the fiscal year 1999 financial
statements, VA was able to develop and allocate costs on a reasonable basis
to the lines of business defined in the Statement of Net Cost.

In 1999, we reported that VA's management and operational controls were
insufficient to maintain accountability over its direct loan and loan sale
activities and did not comply with credit reform accounting requirements.
For example, when VA transferred the servicing of its direct loan portfolio
to a contractor in fiscal year 1997, it shut down its automated direct loan
system and surrendered to the contractor

almost all hard copy loan records needed to manage its loans. 10 As a
result, VA was unable to determine the composition and value of its loan
portfolio, reconcile

cash flows, or properly monitor the contractor's work. We also found that
VA's failure to monitor in a timely manner the contractors that service
loans that VA sold allowed inefficiencies and improper actions to go
unchecked, costing VA more than $6 million.

VA has made substantial progress in implementing our recommendations for
gaining accountability and control over its direct loan and loan sale
activities and for complying with credit reform accounting requirements.
However, it still needs to develop a direct loan database that includes a
complete inventory of all loans originated and a database to record all
loans being assumed by VA to provide a basis for monitoring and controlling
loan and foreclosed property assets.

Key Contacts Cynthia A. Bascetta, Director Health Care, Veterans Health and
Benefit Issues (202) 512- 7101 bascettac@ gao. gov

Joel Willemssen, Managing Director Information Technology Issues (202) 512-
6408 willemsenj@ gao. gov

McCoy Williams, Acting Director Financial Management and Assurance (202)
512- 6906 williamsml@ gao. gov

10 The data transferred to the contractor were also incomplete and
inconsistent.

Related GAO Products Provide Timely

VA Patient Safety: Initiatives Promising but Continued and Equitable
Progress Requires Culture Change

Access to Quality (GAO/ T- HEHS- 00- 167, July 27, 2000).

VA Health Care Veterans' Health Care: VA Needs Better Data on Extent and
Causes of Waiting Times (GAO/ HEHS- 00- 90, May 31, 2000).

Disabled Veterans' Care: Better Data and More Accountability Needed to
Adequately Assess Care (GAO/ HEHS- 00- 57, Apr. 21, 2000). Maximize VA's VA
Laundry Services: Consolidations and Competitive Ability to Provide

Sourcing Services Could Save Millions (GAO/ 01- 61, Health Care Within

Nov. 30, 2000). Available

VA Health Care: Expanding Food Service Initiatives Resources

Could Save Millions (GAO- 01- 64, Nov. 30, 2000). VA and Defense Health
Care: Evolving Health Care Systems Require Rethinking of Resource Sharing
Strategies (GAO/ HEHS- 00- 52, May 17, 2000).

VA Health Care: VA Is Struggling to Address Asset Realignment Challenges
(GAO/ T- HEHS- 00- 88, Apr. 5, 2000).

VA Health Care: Collections Fall Short of Expectations (GAO/ T- HEHS- 99-
196, Sept. 23, 1999). VA Health Care: Improvements Needed in Capital Asset
Planning and Budgeting (GAO/ HEHS- 99- 145, Aug. 13, 1999).

Process Veterans' Veterans Benefits Administration: Problems and

Disability Claims Challenges Facing Disability Claims Processing Promptly
and

(GAO/ T- HEHS/ AIMD- 00- 146, May 18, 2000). Accurately

Develop Sound Managing for Results: Emerging Benefits From Selected
Agencywide Agencies' Use of Performance Agreements (GAO- 01- 115, Management

Oct. 30, 2000). Strategies to Build a

VA Information Technology: Progress Continues High- Performing

Although Vulnerabilities Remain (GAO/ T- AIMD- 00- 321, Organization

Sept. 21, 2000). Computer Security: Critical Operations and Assets Remain at
Risk (GAO/ T- AIMD- 00- 314, Sept. 11, 2000)

VA Information Systems: Computer Security Weaknesses Persist at the Veterans
Health Administration (GAO/ AIMD- 00- 232, Sept. 8, 2000). Information
Technology: VA Actions Needed to Implement Critical Reforms (GAO/ AIMD- 00-
226, Aug. 16, 2000). Information Technology: Update on VA Actions to
Implement Critical Reforms (GAO/ T- AIMD- 00- 74, May 11, 2000). CIO
Executive Guide: Maximizing the Success of Chief Information Officers,
Lessons From Leading Organizations (GAO/ AIMD- 00- 83, Mar. 2000).

Information Systems: The Status of Computer Security at the Department of
Veterans Affairs (GAO/ AIMD- 00- 5, Oct. 4, 1999).

Internal Controls: VA Lacked Accountability Over Its Direct Loan and Loan
Sale Activities (GAO/ AIMD- 99- 24, Mar. 24, 1999). Credit Reform: Key
Credit Agencies Had Difficulty Making Reasonable Loan Program Cost Estimates
(GAO/ AIMD- 99- 31, Jan. 29, 1999).

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

Business Process Reengineering Guide (GAO/ AIMD- 10. 1.15, Apr. 1, 1997).
Observations on the Department of Veterans Affairs' Fiscal Year 1999
Performance Report and Fiscal Year 2001 Performance Plan (HEHS- 00- 124R,
June 30, 2000).

Performance and Accountability Series

Major Management Challenges and Program Risks: A Governmentwide Perspective
(GAO- 01- 241)

Major Management Challenges and Program Risks: Department of Agriculture
(GAO- 01- 242)

Major Management Challenges and Program Risks: Department of Commerce (GAO-
01- 243)

Major Management Challenges and Program Risks: Department of Defense (GAO-
01- 244)

Major Management Challenges and Program Risks: Department of Education (GAO-
01- 245)

Major Management Challenges and Program Risks: Department of Energy (GAO-
01- 246)

Major Management Challenges and Program Risks: Department of Health and
Human Services (GAO- 01- 247)

Major Management Challenges and Program Risks: Department of Housing and
Urban Development (GAO- 01- 248)

Major Management Challenges and Program Risks: Department of the Interior
(GAO- 01- 249)

Major Management Challenges and Program Risks: Department of Justice (GAO-
01- 250)

Major Management Challenges and Program Risks: Department of Labor (GAO- 01-
251)

Major Management Challenges and Program Risks: Department of State (GAO- 01-
252)

Major Management Challenges and Program Risks: Department of Transportation
(GAO- 01- 253)

Major Management Challenges and Program Risks: Department of the Treasury
(GAO- 01- 254)

Major Management Challenges and Program Risks: Department of Veterans
Affairs (GAO- 01- 255)

Major Management Challenges and Program Risks: Agency for International
Development (GAO- 01- 256)

Major Management Challenges and Program Risks: Environmental Protection
Agency (GAO- 01- 257)

Major Management Challenges and Program Risks: National Aeronautics and
Space Administration (GAO- 01- 258)

Major Management Challenges and Program Risks: Nuclear Regulatory Commission
(GAO- 01- 259)

Major Management Challenges and Program Risks: Small Business Administration
(GAO- 01- 260)

Major Management Challenges and Program Risks: Social Security
Administration (GAO- 01- 261)

Major Management Challenges and Program Risks: U. S. Postal Service (GAO-
01- 262)

High- Risk Series: An Update (GAO- 01- 263)

Lett er

GAO United States General Accounting Office

Page 1 GAO- 01- 255 VA Challenges

Contents

Page 2 GAO- 01- 255 VA Challenges

Comptroller General of the United States

Page 3 GAO- 01- 255 VA Challenges United States General Accounting Office

Washington, D. C. 20548

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Overview Page 7 GAO- 01- 255 VA Challenges

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Overview Page 9 GAO- 01- 255 VA Challenges

Overview Page 10 GAO- 01- 255 VA Challenges

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