VA Health Care: Community-Based Clinics Improve Primary Care
Access (02-MAY-01, GAO-01-678T).
This testimony discusses the Veterans Health Administration's
(VHA) efforts to improve veterans' access to health care through
its Community-Based Outpatient Clinics Initiative. Overall,
through its clinics, VHA is steadily making primary care more
available within reasonable proximity of patients who have used
VHA's system in the past. However, the uneven distribution of
patients living more than 30 miles from a VHA primary care
facility suggests that access inequities across networks may
exist. Also, the improvements likely to result from VHA's planned
clinics indicate that achieving equity of access may be
difficult. In addition, GAO's assessment suggests that new
clinics may have contributed to, but are not primarily
responsible for, the marked rise in the number of higher-income
patients who have sought health care through VHA in recent years.
Although the clinics have undoubtedly attracted some new patients
to VHA, GAO's analysis suggests that new patients would have
sought care at other VHA facilities in the absence of the
clinics. Enhanced benefits and access improvements afforded by
eligibility reform may have attracted more new patients,
including those with higher incomes.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-01-678T
ACCNO: A00940
TITLE: VA Health Care: Community-Based Clinics Improve Primary
Care Access
DATE: 05/02/2001
SUBJECT: Community health services
Health resources utilization
Patient care services
Veterans benefits
Veterans hospitals
VA Community Based Outpatient Clinics
Initiative
VA Veterans Integrated Service Network
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GAO-01-678T
Testimony Before the Subcommittee on VA, HUD and Independent Agencies,
Committee on Appropriations, U. S. Senate
United States General Accounting Office
GAO For Release on Delivery Expected at 10 a. m. Wednesday, May 2, 2001 VA
HEALTH CARE
Community- Based Clinics Improve Primary Care Access
Statement for the record by Cynthia Bascetta Director, Health Care-
Veterans' Health and Benefits Issues
GAO- 01- 678T
Page 1 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Chairman Bond, Ranking Member Mikulski, and Members of the Subcommittee:
We are pleased to contribute this statement for the record of the
Subcommittee?s deliberations on the President?s fiscal year 2002 budget
request for the Department of Veterans Affairs (VA). This budget proposes
$22.3 billion for health care system expenditures by the Veterans Health
Administration (VHA) to serve an estimated 4.1 million veterans and other
beneficiaries. 1 This system comprises 22 health care networks, which
operate over 700 medical facilities, most of which are community- based
outpatient clinics (CBOC).
As you know, VHA launched a major initiative in February 1995 to expand its
network of CBOCs. Before 1995, VHA operated about 175 communitybased
clinics, as well as 172 hospitals, which also offered outpatient services.
Since VHA launched its initiative, about 400 CBOCs have opened and another
145 CBOCs are currently planned. These newly opened and planned clinics,
hereafter referred to as Initiative CBOCs, were to operate essentially as
physicians? offices focusing on primary care and were to be located in close
proximity to VHA?s patients.
VHA?s stated goals for its Initiative CBOCs emphasized making access to care
more convenient for its existing users, especially those with compensable
service- connected disabilities or incomes below established thresholds. 2
For these high priority veterans- VHA?s traditional population- Initiative
CBOCs were expected to improve access, for example, by reducing the need to
travel long distances or to travel in congested urban traffic.
My comments focus on (1) the accessibility of VHA primary care for patients
who used VHA health care in the past, including the potential improvements
that would result from opening planned Initiative CBOCs, and (2) the
characteristics of Initiative CBOC users. To conduct our work, we surveyed
VHA?s 22 networks concerning their existing and planned CBOCs, analyzed
VHA?s outpatient care database for use patterns and
1 About 9 percent of VHA?s patients nationwide are nonveterans, for example,
dependents of veterans who died of service- connected disabilities, patients
provided humanitarian care, employees given preventive immunizations, and
beneficiaries seen through sharing agreements with the Department of
Defense.
2 VHA uses a sliding scale of income thresholds, depending on number of
dependents.
Page 2 GAO- 01- 678T VA's Community- Based Outpatient Clinics
demographic information, and analyzed information in a VHA database that
identifies the geographic location of VHA?s patients to determine the effect
of recently opened and planned CBOCs on their proximity to VHA?s health care
facilities.
In summary, Initiative CBOCs have contributed to improved accessibility of
VHA primary care for patients who used VHA facilities in the past; however,
access remains unevenly distributed across the networks. Planned CBOCs
should help to further improve access, although network variation is not
likely to be diminished much. While 87 percent of VHA?s patients systemwide
live in reasonable proximity to primary care clinics, 3 13 percent- about
432,000 patients concentrated in 6 networks- still live more than 30 miles
from a VHA primary care clinic. VHA?s currently planned CBOCs could provide
reasonable proximity to primary care for an additional 68,000 patients, but
the majority of those who live more than 30 miles from a primary care clinic
would still reside in 6 of the 22 networks. The difficulties in providing
cost- effective VHA- staffed CBOCs or contract care in areas with few
patients make it hard to improve accessibility, according to network
managers.
Although Initiative CBOCs largely serve patients who have received VHA
health care in the past, they have also facilitated access for new patients.
4 In fiscal year 2000, for example, about 135,000 Initiative CBOC users were
new patients, including 56,000 higher- income veterans. During the same
year, 158, 000 new higher- income patients used other VHA outpatient
facilities, but not Initiative CBOCs. Although their numbers are growing,
new higher- income patients remain a relatively small segment of both
patients using Initiative CBOCs and patients using any VHA outpatient health
care.
Regional directors of VHA?s 22 health care networks (known as Veterans
Integrated Service Networks, or VISNs) 5 were given responsibility for
3 VHA?s primary care clinics include Initiative CBOCs, hospital- based
clinics, and preexisting community outpatient clinics. 4 New patients are
defined as those who did not obtain health care through VA for 3 fiscal
years before a visit. Past patients, in contrast, are those who did receive
VA health care at any time during the 3 preceding fiscal years.
5 In 1995, VHA created 22 VISNs, a new management structure to coordinate
the activities of and allocate funds to VHA medical facilities in each
region. See appendix I for a list of these networks. Background
Page 3 GAO- 01- 678T VA's Community- Based Outpatient Clinics
CBOC planning. VHA guidance stated that attracting new patients should not
be the sole or primary goal of a new CBOC. This guidance instead noted that
planners should exercise caution because any new patients attracted to CBOCs
must be accommodated within existing resource constraints.
Since VHA?s CBOC initiative was launched in February 1995, the number of
CBOCs has more than tripled. As of February 28, 2001, VHA had 573 operating
CBOCs, including nearly 400 Initiative CBOCs. According to network
officials, firm plans for another 100 CBOCs have already been authorized by
the Congress or have been submitted to VHA headquarters or the Congress for
consideration. 6 Tentative plans for 45 CBOCs are in the development phase.
7 Network managers expect most of these plans to be implemented within the
next 3 years. Networks vary in their numbers of existing and planned CBOCs,
as figure 1 shows.
6 Of these planned CBOCs, 12 have already opened. Because they opened after
our reference date of February 28, 2001, we counted them among the firmly
planned CBOCs. 7 Network managers also indicated that an additional 70
locations are being considered. Because the plan development phase has not
begun, we excluded them from our analyses.
Page 4 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Figure 1: Number of Existing and Planned CBOCs in Each Network as of
February 28, 2001
a Appendix I identifies networks by location. Source: Managers within VHA?s
22 networks
Although new CBOCs continue to open, the peak of expansion seems to have
passed. From March 1998 through February 1999, 124 Initiative CBOCs opened.
Fewer have opened each year since. If networks implement all planned CBOCs
within the next 3 years, then new openings will average about 50 CBOCs
annually.
Existing CBOCs (including both Initiative and pre- existing CBOCs) differ
somewhat in the services they provide. The vast majority- more than 90
0 10
20 30
40 50
60 70
1 2 3 4 5 6 7 8 9 10 1112 1314 1516 17 1819 2021 22 Number of operating and
planned CBOCs
VISN
Tentatively planned CBOCs Firmly planned CBOCs Operating CBOCs
Page 5 GAO- 01- 678T VA's Community- Based Outpatient Clinics
percent- offer primary care, and about half offer mental health services. 8
In addition, one- third offer other services as well. 9
Systemwide, VHA staff operate about 75 percent of VHA?s current CBOCs using
VA- owned or leased space. Contract arrangements are, however, becoming
increasingly common. Contractors operated only about 1 in 25 CBOCs opened
before February 1995. In contrast, one in three Initiative CBOCs are
contract- run, and one in two of VHA?s planned CBOCs are expected to involve
contracted staff and space.
VHA?s initiative to expand CBOCs was one component of a broader set of
changes intended to improve veterans? access to health care. Notably, the
Veterans Health Care Eligibility Reform Act of 1996 authorized a uniform
package of health care benefits for all veterans. As a result, VHA?s
traditional veteran patients became eligible for a broader array of services
(including preventive care) than was previously available. In addition,
veterans with incomes higher than established thresholds could also receive
the same uniform benefit package if VHA determines that it has more
resources than it needs to serve traditional patients.
Over the last 6 years, VHA?s patient base has increased dramatically. For
example, VHA served 2.8 million patients in fiscal year 1995 compared to 3.8
million in fiscal year 2000, a 36 percent increase. VHA?s fiscal year 2002
budget projects that about 4.1 million patients will be served, representing
an increase of almost 50 percent since 1995.
8 The Veterans Health Care Eligibility Reform Act (P. L. 104- 262)
authorized VHA to provide preventive care. Consistent with this, more than
97 percent of Initiative and planned CBOCs offer primary care, compared to
82 percent of pre- existing CBOCs. In contrast, more than 80 percent of pre-
existing CBOCs offer mental health services, compared to 45 percent of
Initiative CBOCs.
9 These other services typically include ancillary or preventive services
(such as laboratory testing or nutritional counseling), although some CBOCs
offer limited specialty care as well.
Page 6 GAO- 01- 678T VA's Community- Based Outpatient Clinics
As the number of Initiative CBOCs has increased, the percentage of VHA?s
patients who live in reasonable proximity to a VHA primary care facility has
increased to 87 percent. In 1995, we found that about two- thirds of VHA
patients had reasonable proximity to VHA health care facilities, which we
then measured as living within 25 miles of an outpatient clinic. 10 After we
recommended that VHA establish a time or distance standard for CBOCs, 11 VHA
began to report the number of patients who lived within 30 miles of its
facilities.
VHA?s most recent report 12 showed that about 86 percent of its total fiscal
year 1999 patient population, 3.4 million patients, lived within 30 miles of
a VHA outpatient facility. Since that time, VHA has opened about 100
additional Initiative CBOCs, and we estimate that the percentage of those
patients living within 30 miles of a VHA primary care clinic has increased
to 87 percent. 13
However, the percentage of the patients who live 30 miles or less from a
primary care clinic is not evenly distributed among VHA?s networks. As
figure 2 shows, the percentage of patients who are within 30 miles of VHA
primary care ranges from less than 70 percent in some largely rural
networks, such as the VHA Upper Midwest Health Care Network (VISN 13), to
nearly 100 percent in largely urban networks, such as the Veterans
Integrated Service Network- Bronx (VISN 3).
10 VA Health Care: How Distance From VA Facilities Affects Veterans? Use of
VA Services (GAO/ HEHS- 96- 31, Dec. 20, 1995). 11 VA Health Care: Improving
Veterans? Access Poses Financial and Mission- Related Challenges (GAO/ HEHS-
97- 7, Oct. 25, 1996). 12 Geographic Access to Veterans Health
Administration (VHA) Services in Fiscal Year 1999: A National and Network
Perspective, report by the planning systems support group, a field unit of
the VHA Office of Policy & Planning (April 2000). 13 Overall, 88 percent of
VHA?s patients live within 30 miles of a VHA outpatient facility, but not
all of these facilities offer primary care. CBOCs Are Improving
Primary Care Access, but Results Vary Among Networks
Page 7 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Figure 2: Percentage of Each Network?s Patients Who Live Within 30 Miles of
a VHA Primary Care Clinic Given CBOCs Operating on February 28, 2001
Source: GAO analysis of information provided by VHA and network managers.
Moreover, approximately 432,000 patients- or about 13 percent of VHA?s
patient population- live more than 30 miles from a VHA primary care clinic.
As figure 3 shows, almost 60 percent of these 432,000 patients live in six
networks.
0% 10%
20% 30%
40% 50%
60% 70%
80% 90%
100% 1 2 3 4 5 6 78 910111213141516171819202122
VISN Percentage of patients
Page 8 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Figure 3: Percentage of the 432,000 Patients Who Live More Than 30 Miles
From a VHA Primary Care Clinic Given CBOCs Operating on February 28, 2001
Source: GAO analysis of information provided by VHA and network managers.
If networks implement all firm plans for 100 new CBOCs, then more than
50,000 additional patients will be within reasonable proximity to VHA
primary care. In addition, another 18, 000 patients will have reasonable
0 5
10 15
20 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
VISN Percent
Numbered Areas Specify VISN Designations Percentage of VA's 432,000
patients who live more than 30 miles from a VA primary care clinic
<1% 1 to 7% >7% 5
4 3 2
1 11 12 13
14 17 18 19
20 21 20
16 15 6
7 8 9
10 8 21
22
Page 9 GAO- 01- 678T VA's Community- Based Outpatient Clinics
proximity to primary care if the tentative plans for 45 more CBOCs are also
implemented. 14
However, opening all planned CBOCs would not eliminate uneven access across
the networks. Specifically, we estimate that 364,000 patients would remain
more than 30 miles from VHA primary care, and the same six networks would
still account for the majority (60 percent) of these patients. Moreover,
more than 68,000 patients (19 percent) live in one network- the Veterans
Integrated Service Network- Jackson (VISN 16)- and more than 148,000
patients (41 percent) live in the other five networks.
Managers in these networks noted challenges to improving the proximity of
VHA primary care to their patients. In some areas, there are not enough VHA
patients to support a cost- effective VHA- run CBOC. Even where there are
enough patients, network managers reported that there can be difficulties
recruiting VHA medical personnel to staff CBOCs or obtaining appropriate,
affordable space. They also noted obstacles to arranging contract care. For
example, some network managers mentioned difficulties in finding local
providers who were willing to enter into contracts to provide primary care
to veterans at reasonable costs.
Network managers nationwide noted that reducing the number of patients who
live more than 30 miles from a VHA health care facility is not their only
goal when planning CBOCs. Many, for example, mentioned reducing veterans?
travel time to 30 minutes or less- whether because of distance, congested
urban traffic, or other factors. VHA is in the process of estimating the
time its patients must spend traveling to VHA health care facilities, an
endeavor made possible by recent advances in computer mapping software.
Because many patients who are within a 30- mile radius of a health care
facility may need to travel more than 30 minutes to reach it, switching to a
time- based measure of access will likely reduce the number of patients
considered to have reasonable access. As a result, the uneven accessibility
across networks portrayed in figure 2 is likely to change once VHA begins
measuring access in terms of travel time rather than distance.
14 If all plans for CBOCs were implemented, about 89 percent of VA?s
patients would live within 30 miles of a VA primary care clinic, an increase
of about 2 percentage points over current levels.
Page 10 GAO- 01- 678T VA's Community- Based Outpatient Clinics
New VHA patients have represented about 30 percent of Initiative CBOC users
in each of the last 4 years, although their numbers are growing. In fiscal
year 2000, for example, 454,000 patients used Initiative CBOCs, 15 including
135,000 who were new patients to the VHA system. In contrast, less than 10,
000 new VHA patients were Initiative CBOCs users in fiscal year 1997. As
figure 4 shows, each year since 1998 VHA has experienced significant
increases in the use of Initiative CBOCs by both new patients and patients
who had previously used other VHA outpatient facilities.
15 Most patients who used Initiative CBOCs also used VHA?s other facilities
to obtain health care services. CBOCs and Other
Outpatient Facilities Serving A Relatively Small, but Growing Number of New,
Higher- Income Veterans
Page 11 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Figure 4: Number of New and Past Patients Who Used Initiative CBOCs in
Fiscal Years 1997- 2000
Note: The number of patients who used Initiative CBOCs in fiscal years 1995
and 1996 cannot be counted accurately because outpatient visits to CBOCs
during those years were often counted as visits to the medical centers that
had administrative responsibility for their operations. Almost all CBOCs now
report their workloads separately from those of medical centers.
Source: GAO analysis of information provided by VHA.
0 50,000
100,000 150,000
200,000 250,000
300,000 350,000
400,000 450,000
500,000 1997 1998 1999 2000
Fiscal Year Number of patients using Initiative
CBOCs
Patients who had previously obtained health care through VHA New patients
Page 12 GAO- 01- 678T VA's Community- Based Outpatient Clinics
The percentage of Initiative CBOC patients who were new to VHA varied across
networks. In fiscal year 2000, for example, new VHA patients who used CBOCs
ranged from 16 to 42 percent, as table 1 shows. 16
Table 1: Percentage of Initiative CBOC Patients Who Were New VHA Patients in
Fiscal Year 2000
Percent Number of networks
16 - 20 3 21 - 25 4 26 - 30 8 31 - 35 3 36 - 40 2 40 - 42 2
Note: These analyses are based on the network in which patients reside,
rather than the location of the Initiative CBOC used.
Source: GAO analysis of information provided by VHA.
Of the 135,000 new VHA patients using Initiative CBOCs in fiscal year 2000,
about 56,000 were higher- income veterans, up from 1,300 in fiscal year
1997. 17 Moreover, higher- income veterans as a share of new patients who
use Initiative CBOCs have risen from 14 to 41 percent from fiscal year 1997
through fiscal year 2000 (see figure 5). 18
16 These analyses are based on the network in which patients reside, rather
than the location of the Initiative CBOC used. That is, our numbers describe
patients who live within a network, rather than patients who use the
facilities within that network. For example, patients who live in VISN 6 may
have used Initiative CBOCs in a neighboring network, such as VISN 5. Such
patients would be included only in the data reported for VISN 6.
17 In fiscal year 2000, a total of about 100,000 higher- income veterans
used Initiative CBOCs; however, 44,000 had previously obtained outpatient
health care from VHA. 18 A small percentage of Initiative CBOC patients do
not fall into either the traditional veteran population (those with
compensable service- connected disabilities or low income) or the higher-
income veteran population. These patients include nonveterans, veterans
whose eligibility for benefits was being assessed, and veterans whose
disability and income status were not identified in the outpatient database.
They accounted for about 5 percent of Initiative CBOC patients in fiscal
year 1997, but less than 4 percent of Initiative CBOC patients in fiscal
years 1998 through 2000.
Page 13 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Figure 5: Number of New Patients Who Used Initiative CBOCs in Fiscal Years
1997- 2000
Source: GAO analysis of information provided by VHA.
Like the percentage of new patients, the percentage of new higher- income
patients using Initiative CBOCs varied across networks. In fiscal year 2000,
for example, new higher- income veterans who used Initiative CBOCs ranged
from 15 to 62 percent, as table 2 shows.
0 20,000
40,000 60,000
80,000 100,000
120,000 140,000
160,000 1997 1998 1999 2000
Fiscal Year Number of new patients
Higher- income veterans Veterans with service- connected disabilities or low
incomes
Page 14 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Table 2: Percentage of New Initiative CBOC Patients Who Were Higher- Income
Veterans in Fiscal Year 2000
Percent Number of networks
15 - 24 2 25 - 34 7 35 - 44 5 45 - 54 6 55 - 62 2
Note: These analyses are based on the network in which patients reside,
rather than the location of the Initiative CBOC used.
Source: GAO analysis of information provided by VHA.
Systemwide, most new higher- income veterans do not use Initiative CBOCs,
but instead use only other VHA outpatient facilities. Nevertheless, the
number and share of new higher- income patients using Initiative CBOCs have
increased dramatically. The proportion of new higher- income veterans who
use Initiative CBOCs has grown from 2 percent in fiscal year 1997 to 26
percent in fiscal year 2000. 19 As previously discussed, the number of these
new higher- income patients has increased from 1,300 in fiscal year 1997 to
56,000 in fiscal year 2000. To put this in perspective, during the same
period, the number of new higher- income veterans using other VHA outpatient
facilities exclusively grew from 57,000 to 158,000, as shown in figure 6.
19 This is consistent with CBOCs growing share of total higher- income
veterans (new and past users) using Initiative CBOCs; from fiscal year 1997
through fiscal year 2000, the percentage of higher- income veterans using
CBOCs grew from 2 percent to 21 percent.
Page 15 GAO- 01- 678T VA's Community- Based Outpatient Clinics
Figure 6: Number of New Higher- Income Patients Using Initiative CBOCs and
Other VHA Outpatient Facilities in Fiscal Years 1997- 2000
Source: GAO analysis of information provided by VHA.
Nonetheless, new higher- income veterans remained a small segment- about 6
percent- of all patients using VHA?s outpatient facilities in fiscal year
2000, up from 2 percent in fiscal year 1997.
Overall, through its Initiative CBOCs, VHA is steadily making primary care
more available within reasonable proximity of patients who have used VHA?s
system in the past. However, the uneven distribution of patients living more
than 30 miles from a VHA primary care facility suggests that access
inequities across networks may exist. Also, the improvements likely to
result from VHA?s planned CBOCs indicate that achieving equity Concluding
Observations
0 50,000
100,000 150,000
200,000 250,000
1997 1998 1999 2000 Fiscal Year Number of new higher income patients One or
more visits to an Initiative CBOC
No visits to an Initiative CBOC
Page 16 GAO- 01- 678T VA's Community- Based Outpatient Clinics
of access may be difficult. Nonetheless, we believe VHA?s effort to assess
the time it takes patients to reach a VHA outpatient clinic could provide a
better measure and, therefore, a clearer understanding of access differences
among networks.
In addition, our assessment suggests that new CBOCs may have contributed to,
but are not primarily responsible for, the marked increase in the number of
higher- income patients who have sought health care through VHA over the
past few years. While Initiative CBOCs have undoubtedly attracted some new
patients to VHA, our analysis suggests that new patients would have sought
care at other VHA facilities in the absence of Initiative CBOCs. In that
regard, enhanced benefits and access improvements afforded by eligibility
reform may have attracted more new patients, including those with higher
incomes, than VHA?s Initiative CBOCs.
For more information about this statement, please call Cynthia A. Bascetta,
Director, Health Care- Veterans? Health and Benefits Issues, at (202) 512-
7101, or Paul Reynolds, Assistant Director, at (202) 512- 7109. Key
contributors to this statement include Kristen Joan Anderson, Deborah
Edwards, Michael O?Dell, Peter Schmidt, Thomas Walke, and Connie Wilson. GAO
Contacts and
Staff Acknowledgments
Page 1 GAO- 01- 678T VA's Community- Based Outpatient Clinics
VISN 1: VA New England Health care System (Boston) VISN 2: VA Health care
Network Upstate New York (Albany) VISN 3: Veterans Integrated Service
Network (Bronx) VISN 4: VA Stars & Stripes Health care Network (Pittsburgh)
VISN 5: VA Capitol Health Care Network (Baltimore) VISN 6: The Mid- Atlantic
Network (Durham) VISN 7: The Atlanta Network (Atlanta) VISN 8: VA Sunshine
Health care Network (Bay Pines) VISN 9: Mid South Veterans Health care
Network (Nashville) VISN 10: VA Health care System of Ohio (Cincinnati) VISN
11: Veterans Integrated Service Network (Ann Arbor) VISN 12: The Great Lakes
Health Care System (Chicago) VISN 13: VA Upper Midwest Health Care Network
13 (Minneapolis) VISN 14: Central Plains Health Network (Omaha) VISN 15: VA
Heartland Network (Kansas City) VISN 16: Veterans Integrated Service Network
(Jackson) VISN 17: VA Heart of Texas Health Care Network (Dallas) VISN 18:
VA Southwest Health Care Network (Phoenix) VISN 19: Rocky Mountain Network
(Denver) VISN 20: Northwest Network (Portland) VISN 21: Sierra Pacific
Network (San Francisco) VISN 22: Desert Pacific Health care Network (Long
Beach) Appendix I:
Veterans Integrated Service Networks
Page 1 GAO- 01- 678T VA's Community- Based Outpatient Clinics
VA Community Clinics: Networks? Efforts to Improve Veterans? Access to
Primary Care Vary (GAO/ HEHS- 98- 116, June 15, 1998).
VA Health Care: Status of Efforts to Improve Efficiency and Access (GAO/
HEHS- 98- 48, Feb. 6, 1998).
VA Health Care: Improving Veterans? Access Poses Financial and
MissionRelated Challenges (GAO/ HEHS- 97- 7, Oct. 25, 1996).
VA Health Care: Efforts to Improve Veterans? Access to Primary Care Services
(GAO/ T- HEHS- 96- 134, Apr. 24, 1996).
VA Health Care: Opportunities to Increase Efficiency and Reduce Resource
Needs (GAO/ T- HEHS- 96- 99, Mar. 8, 1996).
VA Health Care: Exploring Options to Improve Veterans? Access to VA
Facilities (GAO/ HEHS- 96- 52, Feb. 6, 1996).
VA Health Care: How Distance From VA Facilities Affects Veterans? Use of VA
Services (GAO/ HEHS- 96- 31, Dec. 20, 1995).
VA Clinic Funding (GAO/ HEHS- 95- 273R, Sept. 19, 1995). Related GAO
Products
(406196)
*** End of document ***