VA Health Care: Important Steps Taken to Enhance Veterans' Care  
by Aligning Inpatient Services with Projected Needs (02-MAR-05,  
GAO-05-160).							 
                                                                 
The Department of Veterans Affairs (VA) operates one of the	 
nation's largest health care systems. In 1999, GAO reported on	 
VA's aged, obsolete capital assets, noting that better management
of these assets could significantly reduce VA's operating costs. 
GAO further noted that VA could reinvest the savings to enhance  
veterans' health care services. In response, VA initiated its	 
Capital Asset Realignment for Enhanced Services (CARES) process. 
Through CARES, VA identified what health care services it should 
provide and in which locations through 2022. The CARES process	 
included assessing alternative ways to align inpatient services  
by closing or adding services at existing VA medical facilities  
or establishing new facilities. In May 2004, VA published its	 
CARES decisions, but did not provide a national comprehensive	 
summary of all its decisions about the alignment of inpatient	 
services. GAO was asked to provide additional information about  
the inpatient service assessments and decisions made by VA. To	 
provide a national, comprehensive summary, GAO summarized the	 
locations where VA (1) identified a need to evaluate alternative 
ways to align inpatient health care service to improve quality,  
efficiency, or access and (2) made decisions to realign inpatient
services or leave inpatient services as aligned, or deferred	 
decisions pending further study.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-160 					        
    ACCNO:   A18636						        
  TITLE:     VA Health Care: Important Steps Taken to Enhance	      
Veterans' Care by Aligning Inpatient Services with Projected	 
Needs								 
     DATE:   03/02/2005 
  SUBJECT:   Cost effectiveness analysis			 
	     Federal property management			 
	     Health care facilities				 
	     Health care planning				 
	     Health care services				 
	     Veterans						 
	     Veterans benefits					 
	     Veterans hospitals 				 
	     Health care programs				 
	     Patient care services				 
	     Financial management				 
	     Program evaluation 				 
	     Program goals or objectives			 
	     VA Capital Asset Realignment for			 
	     Enhanced Services Initiative			 
                                                                 

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GAO-05-160

United States Government Accountability Office

GAO 	Report to the Chairman, Subcommittee on VA, HUD, and Independent Agencies,
                    Committee on Appropriations, U.S. Senate

March 2005

VA HEALTH CARE

 Important Steps Taken to Enhance Veterans' Care by Aligning Inpatient Services
                              with Projected Needs

GAO-05-160

March 2005

VA HEALTH CARE

Important Steps Taken to Enhance Veterans' Care by Aligning Inpatient Services
with Projected Needs

                                 What GAO Found

Through CARES, VA identified 136 locations for evaluation of alternative
ways to align inpatient services. These locations included VA medical
facilities, health care markets (geographic areas established by VA for
the coordination of care), and health care networks (regional
organizations of VA health care facilities established to facilitate
management). Of the 136 locations, 99 were VA medical facilities with
potential duplication of services at another nearby VA medical facility or
low acute inpatient workload. In addition, VA identified limitations in
geographic access to inpatient services in 31 markets and 6 networks, for
example, when large numbers of veterans face lengthy driving times to VA
facilities that provide acute or tertiary care.

VA made alignment decisions for inpatient services at 120 locations and
deferred decisions for 16 locations pending further study. VA decided to
realign inpatient services at 30 locations and maintain inpatient services
as currently aligned at 90 locations. VA decided to close all inpatient
services at 5 facilities and add them at 5 nearby VA facilities where they
were not already available; close one or more, but not all, inpatient
services at 12 other facilities; add inpatient services to medical
facilities in 2 markets and 5 networks; and establish 1 new medical
facility in a location where VA did not own an inpatient facility when it
made its CARES decisions.

VA's decisions on inpatient alignment and planned studies are tangible
steps forward in improving management of its capital assets and enhancing
health care. Ultimately, however, accomplishing these goals will depend on
VA's success in completing its studies and implementing its CARES
decisions on inpatient and other health care services to better ensure
that resources now spent on unneeded capital assets are redirected to
health care.

VA concurred with GAO's findings.

VA's Decisions on Alignment of Inpatient Health Care Services at 136
Locations

                 United States Government Accountability Office

Contents

      Letter                                                                1 
                                     Results in Brief                       5 
                                        Background                          7 
                VA Identified 136 Locations for Evaluation of Alternative  
                             Alignments of Inpatient Services              10 
                VA Made Decisions on Alignment of Inpatient Services for   
                120                                                        
                Locations and Deferred Decisions for 16 Pending Completion 
                                                                        of 
                                         Studies                           24 
                                 Concluding Observations                   32 
                                     Agency Comments                       33 
    Appendix I                    Scope and Methodology                    
Appendix II        VA Medical Facilities Identified for Potential       
                          Duplication of Tertiary Care Services            
Appendix III       VA Medical Facilities Identified for Potential       
                          Duplication of Acute Inpatient Medicine Services 

  Appendix IV 	VA Medical Facilities Identified for Potential Duplication of
  Other Inpatient Services or Support Services

     Appendix V       VA's 172 Medical Facilities, Potential Service    
                       Duplication or Low Acute Inpatient Workload, and 
                                   Alignment Decisions                     43 
     Appendix VI      VA's 77 Markets, Limitations in Geographic Access 
                   to Inpatient Services, and Alignment Decisions          53 

Appendix VII VA's 21 Networks, Limitations in Geographic Access to
Specialized Inpatient Services, and Alignment Decisions

       Appendix VIII Comments from the Department of Veterans Affairs 70

Appendix IX GAO Contact and Acknowledgments 71

GAO Contact 71 Acknowledgments 71

Related GAO Products

  Tables

Table 1: VA Medical Facilities with Potential Duplication of Tertiary Care
Services 12 Table 2: VA Medical Facilities with Potential Duplication of
Acute Inpatient Medicine Services 14

Table 3: VA Medical Facilities with Potential Duplication of Other
Inpatient Services or Services That Support Inpatient Service Delivery 16

Table 4: VA Medical Facilities with Potential Low Acute Inpatient Workload
19 Table 5: VA's Driving Time Standards for Access to Acute Inpatient Care
and Tertiary Care 21

Table 6: VA Networks Where VA Identified Limitations in Access to
Specialized Inpatient Treatment for Spinal Cord Injury and Disorder or
Blind Rehabilitation 23

Table 7: VA's Decisions on the Alignment of Inpatient Services at 120
Locations 24

Table 8: VA's Decisions to Close All Inpatient Services at a VA Medical
Facility and Add Those Services to a Nearby VA Medical Facility When Not
Already Available There 25

Table 9: VA's Decisions to Close One or More, but Not All, Inpatient
Services at a VA Medical Facility 26 Table 10: VA Health Care Markets
Where VA Decided to Add Acute or Long-Term Inpatient Services 28

Table 11: VA Health Care Networks Where VA Decided to Add Specialized
Inpatient Treatment for Spinal Cord Injury and Disorder or Blind
Rehabilitation 29

Table 12: VA Medical Facilities Where Inpatient Alignment Decisions Were
Deferred Pending Further Study 31

  Figure

Figure 1: VA Medical Facilities Identified for Evaluation of Inpatient
Service Alignment Based on Potential Service Duplication, Low Acute
Inpatient Workload, or Both

Abbreviations

CARES Capital Asset Realignment for Enhanced Services VA Department of
Veterans Affairs

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United States Government Accountability Office Washington, DC 20548

March 2, 2005

The Honorable Christopher S. Bond
Chairman
Subcommittee on VA, HUD, and Independent Agencies
Committee on Appropriations
United States Senate

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) operates one of our nation's
largest health care systems. VA provided health care to nearly 5 million
veterans in fiscal year 2003 at a cost of about $26 billion.1 Most of VA's
inpatient care is provided in 172 medical facilities that it owns and
maintains.2 Many of VA's facilities were built more than 50 years ago and
are no longer well suited to providing accessible, high-quality, cost
effective health care in the 21st century. For example, some facilities
are
not located within reasonable driving times of veterans' residences and
others are structured to emphasize inpatient health care, as was the
practice when these facilities were constructed, rather than outpatient
health care, as is today's practice. Moreover, some facilities do not
conform to modern standards because, for example, they are not
configured to accommodate modern technology, lack fire sprinklers, or
are not seismically sound.

In 1999, we reported that VA's aged, obsolete inventory of capital assets
could be the biggest obstacle confronting VA's efforts to meet veterans'
health care needs efficiently and effectively.3 We noted that better

1These costs include the resources for operating VA's health care system,
education and training of health care providers, administrative support,
and capital investments necessary to support health care delivery.

2In this report, we consider medical facilities to be the capital assets
owned by VA at which it provides inpatient health care services to
veterans. Medical facilities include tertiary and acute hospitals, nursing
homes, and other extended care assets. VA also provides outpatient care at
most of these facilities and owns health care assets at other locations
where it provides only outpatient care. In addition, VA has arrangements
with other health care providers to provide inpatient or outpatient care
to veterans in certain locations where VA does not own assets.

3See GAO, Veterans' Affairs: Progress and Challenges in Transforming
Health Care, GAO/T-HEHS-99-109 (Washington D.C.: Apr. 15, 1999).

management of VA's buildings and land, which include more than 4,700
buildings and other structures and thousands of acres of land, could
significantly reduce funds needed to operate current assets and that these
funds could instead be used to enhance health care services for veterans.4
The challenge of capital asset management is not unique to VA, but is part
of a larger federal government challenge to effectively manage buildings
and land, referred to as real property. We have designated management of
federal real property as high risk because long-standing problems in this
area have multibillion-dollar cost implications and can seriously
jeopardize the ability of federal agencies to accomplish their missions.5

In response to our recommendations in 1999 for improving VA's capital
asset planning and budgeting, VA initiated a process known as Capital
Asset Realignment for Enhanced Services (CARES). CARES was designed to
assess VA's buildings and land ownership in light of expected demand for
VA inpatient and outpatient health care services through fiscal year 2022
(the CARES planning horizon). Through CARES, VA sought to determine what
health care services veterans would need in what locations. These
locations included VA's 172 medical facilities, 77 health care markets,6
and 21 health care networks.7 This process involved an examination of VA's
needs for capital assets at the locations where it has

4See GAO, VA Health Care: Capital Asset Planning and Budgeting Need
Improvement, GAO/T-HEHS-99-83 (Washington, D.C.: Mar. 10, 1999); VA Health
Care: Improvements Needed in Capital Asset Planning and Budgeting,
GAO/HEHS-99-145 (Washington D.C.: Aug. 13, 1999); and Budget Issues:
Agency Implementation of Capital Planning Principles Is Mixed, GAO-04-138
(Washington, D.C.: Jan. 1, 2004).

5In January 2003, we reported that over 30 federal agencies control a
valuable portfolio of facilities and land and that federal real property
is a high-risk area because of such longstanding problems as excess and
underutilized real property and deteriorating facilities. GAO's
designation of high-risk areas is intended to help Congress focus
attention on the most important issues and challenges facing the federal
government. See GAO, High-Risk Series: Federal Real Property, GAO-03-122
(Washington D.C.: January 2003). Also see GAO, Federal Real Property:
Vacant and Underutilized Properties at GSA, VA, and USPS,

GAO-03-747 (Washington, D.C.: Aug. 19, 2003).

6A health care market is a geographic area having sufficient population
and geographic size to (1) benefit from the coordination and planning of
health care services delivered by either VA facilities or non-VA
facilities and (2) support a continuum of care, including inpatient and
outpatient care.

7VA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, that are structured to manage and
allocate resources to VA health care facilities. Each VA network includes
from two to six markets. VA had 22 networks until January 2002, when it
merged Networks 13 and 14 to form a new network, Network 23.

medical facilities and at possible new locations. To do so, VA first
identified locations where specific factors suggested a need to evaluate
options for realigning its inpatient services. VA focused on three
specific factors to identify these locations. Two factors involved VA's
existing medical facilities. One of these factors was potential
duplication of inpatient services among two or more medical facilities
that are close enough geographically to consider whether the services are
needed at both facilities. A second factor was low acute inpatient
workload at individual medical facilities. The third factor was geographic
access limitations, which VA identified differently for different
inpatient services. For most inpatient services, including acute and
tertiary inpatient care, CARES addressed geographic access at the market
level, primarily by identifying markets where a large number of veterans
face lengthy driving times to access a VA medical facility. For two
specialized inpatient services, inpatient treatment for spinal cord injury
and disorder and inpatient blind rehabilitation, VA addressed geographic
access at the network level based on projected demand and referral
patterns. The CARES process was not designed to address another aspect of
veterans' access to health care-the time that veterans wait to obtain
appointments at VA medical facilities-because waiting times are related to
multiple operational issues, such as staffing and resources, in addition
to capital infrastructure.

On May 7, 2004, VA announced its CARES decisions on the alignment of
inpatient services at locations it identified for potential service
duplication, low workload, or limitations in geographic access (along with
its other CARES decisions, including those regarding outpatient services)
and published a report on these decisions.8 VA announced decisions for 74
of its 77 markets.9

In the context of the alignment of its inpatient services, VA's report
focused primarily on decisions involving medical facilities, markets, and
networks where VA's inpatient health care services are to be realigned or

8Department of Veterans Affairs, Secretary of Veterans Affairs: CARES
Decision (Washington, D.C.: May 7, 2004).

9In February 2002, VA completed a CARES pilot project that assessed
current and future use of health care assets in the three markets of
Network 12, which includes parts of five states: Illinois, Indiana,
Michigan, Minnesota, and Wisconsin. At that time, VA announced its
decision to, among other things, discontinue inpatient health care
services at its Lakeside medical facility in Chicago, Illinois, one of
eight inpatient medical facilities that VA had in these markets.

studied further. The report did not, however, provide a national,
comprehensive summary of the medical facilities, markets, and networks
that VA identified as needing evaluation for potential alternative
alignments of inpatient services and did not include a discussion of all
of the locations where it decided to leave inpatient services as currently
aligned. On the basis of your request that we examine VA's inpatient
service assessments and decisions, we developed (1) a national summary of
the medical facilities, markets, and networks where VA identified
potential service duplication, low workload, or geographic access
limitations as factors that could indicate a need to evaluate alternative
ways to align inpatient health care services and (2) a national summary of
the medical facilities, markets, and networks where VA made decisions- to
either realign inpatient services or leave inpatient services as aligned-
or deferred decisions pending further study.

To summarize the number of medical facilities, markets, and networks where
VA identified potential service duplication, low workload, or geographic
access limitations as factors that could indicate a need to evaluate
alternative ways to align inpatient health care services, we reviewed
major CARES documents for information about locations where VA identified
these factors. Because no one source includes all the information about
these factors, we reviewed CARES planning documents, VA's Draft National
CARES Plan, the report by an independent Commission appointed by VA that
was charged with making CARES recommendations to the Secretary, and the
Secretary's report of VA's CARES decisions. When identification of a
medical facility as one with potential service duplication or low workload
depended on the availability of acute inpatient medicine, we confirmed
that the facility provided that service during the first half of fiscal
year 2004, the time period immediately before VA made its CARES decisions,
by examining data provided by VA.

To summarize VA's decisions about the alignment of its inpatient services,
we reviewed major CARES documents to determine if VA made a decision to
realign inpatient services or leave inpatient services as aligned or if VA
deferred making a decision pending further study. We defined realignment
of an inpatient service as (1) eliminating the service in its entirety at
a facility where VA provided it, (2) adding an inpatient service to an
existing VA facility where VA did not provide the service, or (3)
establishing a new VA medical facility where VA did not own capital
assets. The inpatient services in our review included both acute and
long-term inpatient

services. Specifically, these inpatient services included tertiary care;10
the acute inpatient services of medicine, surgery, and psychiatry; and
other inpatient services. Other inpatient services included subacute and
intermediate medicine; the long-term inpatient services of nursing home
care, long-term psychiatry, domiciliary care,11 and residential
rehabilitation; and specialized inpatient services of blind rehabilitation
and treatment for spinal cord injury and disorder. To identify VA's
decisions on the alignment of inpatient services at the locations it
identified for evaluation, we reviewed CARES documents and information
provided by VA about the inpatient services provided at current facilities
that would be affected if VA's decisions were implemented. We classified a
decision as pending further study when VA determined that additional
information or analysis was necessary to determine whether to add or close
one or more inpatient services at that location. We compared data from
CARES with other information from VA about the inpatient services
available at its medical facilities and when we identified discrepancies,
resolved them through discussions with VA officials. We found the data to
be adequate for our purposes, and VA officials agreed that our methodology
was reasonable. We did not review VA's other CARES decisions such as those
for reconfiguring space to meet projected demand for services,
modernization needed to provide services appropriately, disposal of assets
that may no longer be needed, or the alignment of outpatient services. We
conducted our work from October 2003 through March 2005 in accordance with
generally accepted government auditing standards. See appendix I for a
more detailed discussion of our methodology.

Through its CARES process, VA identified 136 locations where potential
service duplication, low workload, or limitations in geographic access to
care indicated a need to evaluate alternative alignments of inpatient
health care services. These locations included 99 of VA's existing medical
facilities-72 medical facilities that potentially duplicated services with

10Tertiary care includes specialized diagnostic and treatment procedures,
such as open heart surgery or neurosurgery, that are not necessarily
available at all medical facilities that provide acute inpatient care. We
defined realignment of tertiary care services as either eliminating all
tertiary care at a facility that provided some tertiary care or adding
tertiary care to an existing or new VA facility where VA did not provide
any tertiary care.

11Domiciliary care involves coordinated rehabilitative and restorative
clinical care in an inpatient setting, with the goal of helping veterans
achieve and maintain the highest level of functioning and independence
possible. Domiciliary care differs from other types of inpatient care in
that bedside nursing is not required.

  Results in Brief

nearby VA medical facilities, 19 facilities that were expected to have low
inpatient workload (primarily for acute medicine, surgery, and psychiatry)
during the CARES planning horizon, and 8 other facilities that both
potentially duplicated services and were expected to have low workloads.
The 136 locations that VA identified also included 31 markets where VA
identified limitations in geographic access to care. VA identified
limitations to acute or tertiary care in markets where a large number of
veterans face lengthy driving times to a VA facility. It identified
limitations in access to long-term care in some locations based on
information such as referral patterns, for example, when veterans were
referred to a distant VA medical facility to obtain domiciliary care
because that service was not available at a VA medical facility nearer to
their residences. VA determined that it could not evaluate access to
long-term care services on a systematic, nationwide basis because VA had
not developed an adequate model for projecting demand for these services
at the time CARES decisions were made. VA also identified 6 networks where
projected demand and referral patterns indicated limitations in access to
specialized inpatient treatment for spinal cord injury and disorder or
blind rehabilitation.

VA made decisions on the alignment of inpatient health care services for
120 of the 136 locations it identified as needing evaluation of alignment
alternatives; decisions for 16 locations, primarily medical facilities
with service duplication or low workload, were deferred pending further
study of potential realignment options. Regarding the 120 locations, VA
decided to realign inpatient services for 30 locations and maintain its
inpatient services as aligned for 90 locations. Of the 30 locations, 22
involved realignment of inpatient services among medical facilities that
had potential service duplication or low workload. For 10 facilities, VA
decided to realign inpatient services, primarily by closing all inpatient
services at 5 facilities and adding services at 5 others. For 12 other
medical facilities, VA decided to close some, but not all, inpatient
services and refer patients to VA medical facilities that already provided
these services or enter into agreements for care from non-VA providers. Of
the remaining 8 locations, 3 were markets where VA identified limitations
in access to acute inpatient care or a long-term inpatient service and 5
were networks where VA identified limitations in access to specialized
inpatient treatment for spinal cord injury and disorder or blind
rehabilitation. To improve access for veterans in these locations, VA
decided to add such services at 7 existing medical facilities that had not
previously offered these services and to establish a new VA medical
facility where VA did not own capital assets. In addition to these
decisions to realign inpatient services, for 27 of the 90 locations where
VA decided to maintain its inpatient services as aligned,

Background

VA decided to enter into agreements with non-VA providers to improve
access to acute or tertiary inpatient services.

VA concurred with our findings.

VA dramatically transformed its health care delivery system over the last
decade. A central goal of this transformation has been to reduce the need
for, and the length of, inpatient hospital stays by providing primary care
in outpatient settings and taking advantage of technological advances that
reduce the need for hospitalization. VA developed a continuum of care
grounded in outpatient settings, made available a broader array of
services including preventive care, and opened hundreds of community-based
outpatient clinics. As a result, VA reduced the length of inpatient stays
while providing health care to a growing number of veterans. From fiscal
year 1996 through fiscal year 2003, VA's national acute inpatient daily
census fell by over 40 percent while the number of veterans who received
health care from VA increased by about 2 million (69 percent). As these
transformations occurred, VA was left with increasingly obsolete
infrastructure, including many hospitals built or acquired more than 50
years ago in locations that are sometimes far from where veterans live.

To address its obsolete infrastructure, VA initiated its CARES process-
the first comprehensive, long-range assessment of its health care system's
capital asset requirements since 1981. VA completed a pilot phase of the
CARES process in February 2002, when it announced decisions for Network
12, which consists of parts of five states: Illinois, Indiana, Michigan,
Minnesota, and Wisconsin. VA then assessed its other 20 networks. Through
CARES, VA compared the sizes, locations, and available health care
services of VA's existing medical facilities to projected demand for
health care services through fiscal year 2022.

In conducting this comparison, VA identified three factors that indicated
a need to evaluate alternative ways to align inpatient services-potential
duplication of services, low acute inpatient workload, and limitations in
geographic access to VA health care services.

o 	Duplication of inpatient services at VA inpatient medical facilities
that are close to one another geographically was of concern because
duplication could needlessly increase operating costs. Excess operating
costs can also occur when two facilities that are close to one another
geographically provide different inpatient services that could be provided
in a single location. In such situations, administrative services and
services that

support inpatient care, such as building maintenance, could be
unnecessarily duplicated. Consolidation or closure of duplicated services
in such circumstances could improve cost efficiency by eliminating the
need to maintain all or part of a medical facility and reducing resources
spent on inpatient services or services that support inpatient care. VA
also noted that realigning inpatient services could enhance the quality or
accessibility of care by placing related clinical services in the same
location.

o 	Low acute inpatient workload was of concern for reasons associated with
both the quality and cost-effectiveness of care. As VA noted, the medical
literature and consumer groups have suggested that higher workload volume
is generally related to better health care outcomes, particularly for
surgical procedures. Although VA noted that its small facilities with
lower inpatient workloads have often been leaders in the provision of
quality health care, it also noted that as medical care becomes more
technologically advanced, it could become more difficult and less
cost-effective for such facilities to maintain and use the tools and
skills necessary to provide high-quality care. In light of these concerns,
VA identified medical facilities with low acute inpatient workload to
evaluate the option of closing acute inpatient services.

o 	Limitations in veterans' geographic access to VA health care services
were also of concern. VA considered options for improving access to acute
and tertiary inpatient care in health care markets where large numbers of
veterans face lengthy driving times to obtain those health care services
from VA. VA also considered options for improving access to a long-term
inpatient care service in markets where information such as referral
patterns indicated limitations to access, for example, when veterans were
referred to a distant VA medical facility to obtain domiciliary care
because that service was not available at a VA medical facility nearer to
their residences. For two specialized inpatient services-treatment for
spinal cord injury and disorder and blind rehabilitation-VA used
information about projected demand and referral patterns to identify
networks where options for improving access to these specialized inpatient
services were to be evaluated.

Three major milestones have occurred in the CARES process since August
2003. First, on August 4, 2003, VA's Under Secretary for Health released
the Draft National CARES Plan for public review.12 In developing this
plan, VA officials, including those in the 20 networks covered by the
plan,

12Department of Veterans Affairs, Draft National CARES Plan (Washington,
D.C.: Aug. 4, 2003).

identified locations where changes to the existing health care delivery
system could address potential duplication of services, low workload, or
geographic access limitations. Network directors, working with input from
local stakeholders, studied those locations and proposed plans for the
alignment of health care services. After reviewing these plans, the Under
Secretary for Health made recommendations concerning the alignment of
health care services; these recommendations were presented in the Draft
National CARES Plan, along with other recommendations, such as those
concerning resizing of capacity and modernization of buildings that are
critical to VA's missions and disposal of unneeded (excess) buildings and
land.

Second, on February 12, 2004, an independent 16-member commission
appointed by the Secretary of Veterans Affairs issued recommendations to
the Secretary based on its review of the Draft National CARES Plan. In
developing its recommendations, the CARES Commission conducted 38 public
hearings, 81 site visits, and 10 public meetings; analyzed 212,000 written
comments13 from veterans and other stakeholders; reviewed VA documents
supporting the Draft National CARES Plan; and engaged experts to evaluate
key issues, such as the model used to project demand for VA health care
services. The CARES Commission documented its recommendations and findings
in a 609-page report to the Secretary of Veterans Affairs.14

Third, on May 7, 2004, VA's Secretary announced and published a report on
VA's CARES decisions concerning the alignment of VA's health care
services, based on his review of the CARES Commission's findings and
recommendations. In general, he stated his acceptance of the Commission's
report, noting that it provided a strategically sound path forward for
VA's health care system. He noted that when the Commission's report
provided options, he selected the option that would minimize the effect of
service realignments on continuity of care for those veterans who received
those services at the time VA made its CARES decisions. Moreover, he
stated that implementing these decisions will require substantial capital
investment-about $1 billion annually over at least the next 5 years-and
that not implementing the CARES decisions would also

13A large number of these comments addressed a small set of VA medical
facilities. For example, more than half of the comments were about a
single facility in upstate New York.

14CARES Commission, Capital Asset Realignment for Enhanced Services:
Report to the Secretary of Veterans Affairs (Washington, D.C.: Feb. 12,
2004).

require funding to maintain or renovate obsolete facilities and perpetuate
VA's need to manage redundant, outmoded, or poorly located facilities. In
anticipation of the Secretary's decision, Congress passed legislation in
December 2003 that requires the Secretary to notify Congress of decisions
involving reorganization, consolidation, and closure of health care
services and provide a period of at least 60 days during which Congress
can consider these CARES decisions before they are implemented.15

  VA Identified 136 Locations for Evaluation of Alternative Alignments of
  Inpatient Services

Through CARES, VA identified 136 locations where potential service
duplication, low acute inpatient workload, or geographic access
limitations indicated that alignment of inpatient health care services
should be evaluated. These locations included 99 of VA's existing medical
facilities where VA identified potential service duplication or low
inpatient workload, 31 markets where VA identified a need to evaluate
options for improving access to tertiary or acute inpatient care or a
long-term inpatient service, and 6 networks where VA identified a need to
evaluate options for improving access to specialized inpatient treatment
for spinal cord injury and disorder or blind rehabilitation.

    VA Identified 99 Medical Facilities with Potential Service Duplication or
    Low Acute Inpatient Workload

VA identified 99 of its medical facilities for evaluation of alternative
ways to align inpatient services because of potential service duplication
or low acute inpatient workload. Most of these facilities were identified
for potential service duplication (see fig. 1).

15Veterans Health Care, Capital Asset, and Business Improvement Act of
2003, Pub. L. No. 108-170, S: 222, 117 Stat. 2042, 2050-2051.

Figure 1: VA Medical Facilities Identified for Evaluation of Inpatient
Service Alignment Based on Potential Service Duplication, Low Acute
Inpatient Workload, or Both

Number of VA medical facilities

80

72

70

60

50

40

30

20

10

0 Service Low Both duplication workload

Source: GAO analysis of VA data.

VA identified potential service duplication when two or more inpatient
medical facilities were close enough geographically to consider whether
both should continue providing all the inpatient services that they
provided. VA identified 80 medical facilities that potentially duplicated
services. For our review, we classified these facilities as potentially
duplicating tertiary care services; acute inpatient medicine services; or
other services, including other types of inpatient care (such as long-term
psychiatry) or services that support inpatient care (such as
administration or maintenance). Some of the facilities that VA identified
potentially duplicated more than one of these types of inpatient service.

For tertiary care services, we determined if the medical facilities that
VA identified as potentially duplicating services were also identified by
VA as tertiary care facilities within 120 miles of another VA tertiary
care facility. VA selected 120 miles as a distance that would permit
tertiary care facilities to develop cooperative arrangements with one
another to provide tertiary care. Of the 80 medical facilities VA
identified as potentially duplicating services, 28 met these criteria for
potential duplication of tertiary care services (see table 1). Appendix II
lists these 28 facilities and the VA medical facilities close enough
geographically for VA to consider whether tertiary care services were
needed at both.

Table 1: VA Medical Facilities with Potential Duplication of Tertiary Care
                                    Services

1. Ann Arbor, Mich.

2. Augusta, Ga.-Downtown

3. Baltimore, Md.

4. Bay Pines, Fla.

5. Bronx, N.Y.

6. Brooklyn, N.Y.

7. Charleston, S.C.

8. Cincinnati, Ohio

9. Columbia, S.C.

10. Dayton, Ohio

11. Detroit, Mich.

12. East Orange, N.J.

13. Indianapolis, Ind.

14. Lexington, Ky.-Cooper

15. Loma Linda, Calif.

16. Long Beach, Calif.

17. Louisville, Ky.

18. Manhattan, N.Y.

19. Northport, N.Y.

20. Palo Alto, Calif.

21. Philadelphia, Pa.

22. Richmond, Va.

23. San Diego, Calif.

24. San Francisco, Calif.

25. Tampa, Fla.

26. Washington, D.C.

27. West Haven, Conn.

28. West Los Angeles, Calif.

Source: GAO analysis of VA data.

Note: These VA medical facilities provide tertiary care services, are
within 120 miles of another VA medical facility that provides tertiary
care services, and were identified by VA as potentially duplicating
inpatient services.

For acute inpatient medicine services, we determined if the medical
facilities that VA identified as potentially duplicating services were
also identified by VA as providing acute inpatient medicine services
within 60 miles of another VA medical facility that provides acute
inpatient medicine services.16 VA selected 60 miles as a distance that
would permit acute inpatient facilities to develop cooperative
arrangements with one another to provide acute inpatient medical,
surgical, or psychiatric care. Of the 80 medical facilities VA identified
as potentially duplicating services, 27 potentially duplicated acute
medicine services during the first half of fiscal year 2004, the time
period immediately before CARES decisions were made (see table 2).
Appendix III lists these 27 facilities and the VA medical facilities close
enough geographically for VA to consider whether acute inpatient medicine
services were needed at both. About half of these medical facilities were
also identified as potentially duplicating tertiary care services.

16Some of these facilities also potentially duplicated acute inpatient
surgery or psychiatry services.

Table 2: VA Medical Facilities with Potential Duplication of Acute
Inpatient Medicine Services

1. Ann Arbor, Mich.

2. Baltimore, Md.

3. Bronx, N.Y.

4. Brooklyn, N.Y.

5. Castle Point, N.Y.

6. Cincinnati, Ohio

7. Dayton, Ohio

8. Detroit, Mich.

9. East Orange, N.J.

10. Gainesville, Fla.

11. Kansas City, Mo.

12. Lake City, Fla.

13. Leavenworth, Kans.

14. Little Rock, Ark.

15. Long Beach, Calif.

16. Manhattan, N.Y.

17. Murfreesboro, Tenn.

18. Nashville, Tenn.

19. North Little Rock, Ark.

20. Northport, N.Y.

21. Perry Point, Md.

22. Philadelphia, Pa.

23. Providence, R.I.

24. Washington, D.C.

25. West Los Angeles, Calif.

26. West Roxbury, Mass.

27. Wilmington, Del.

Source: GAO analysis of VA data.

Note: These VA medical facilities provide acute inpatient medicine
services, are within 60 miles of another VA medical facility that provides
acute inpatient medicine services, and were identified by VA as
potentially duplicating inpatient services.

For other services, we determined if the medical facilities that VA
identified as potentially duplicating services were ones where VA
determined that it should consider whether other inpatient services and
administrative or maintenance services that support inpatient care were
needed at both. VA did not specify a distance criterion for identifying
these

facilities as close enough geographically for it to consider whether
inpatient services were needed at both. The potentially duplicated
services generally included psychiatric and long-term inpatient care,
administrative services, and building maintenance and groundskeeping. Of
the 80 medical facilities VA identified as potentially duplicating
services, 50 potentially duplicated these other inpatient, administrative,
or maintenance services (see table 3). For example, in some cities VA has
two inpatient medical facilities that provide different inpatient
services, such as a tertiary care facility and a nursing home or one
facility that provides medical and surgical care and another that provides
psychiatric care. If it were possible to move all services to a single
facility, potential benefits include cost savings by avoiding duplication
of inpatient support services such as building maintenance at the two
facilities. In addition, VA noted that placing related clinical services
(such as acute medicine and acute psychiatry) in the same location has the
potential to enhance the quality or accessibility of care. Appendix IV
lists these 50 facilities and indicates which other VA medical facilities
were close enough geographically for VA to consider whether inpatient
services were needed at both.

Table 3: VA Medical Facilities with Potential Duplication of Other
Inpatient Services or Services That Support Inpatient Service Delivery

1. American Lake, Wash.

2. Augusta, Ga.-Downtown

3. Augusta, Ga.-Uptown

4. Batavia, N.Y.

5. Bedford, Mass.

6. Biloxi, Miss.

7. Brockton, Mass.

8. Brooklyn, N.Y.

9. Buffalo, N.Y.

10. Canandaigua, N.Y.

11. Castle Point, N.Y.

12. Cleveland, Ohio-Brecksville

13. Cleveland, Ohio-Wade Park

14. Des Moines, Iowa

15. East Orange, N.J.

16. Fort Meade, S. Dak.

17. Fort Wayne, Ind.

18. Gainesville, Fla.

19. Gulfport, Miss.

20. Hot Springs, S. Dak.

21. Jamaica Plain, Mass.

22. Kansas City, Mo.

23. Kerrville, Tex.

24. Knoxville, Iowa

25. Lake City, Fla.

26. Leavenworth, Kans.

27. Lexington, Ky.-Cooper

28. Lexington, Ky.-Leestown

29. Livermore, Calif.

30. Lyons, N.J.

31. Marion, Ind.

32. Miami, Fla.

33. Montgomery, Ala.

34. Montrose, N.Y.

35. Palo Alto, Calif.

36. Pittsburgh, Pa.-Heinz Center

37. Pittsburgh, Pa.-Highland Drive

38. Pittsburgh, Pa.-University Drive

39. Portland, Oreg.

40. Roseburg, Oreg.

41. San Antonio, Tex.

42. St. Albans, N.Y.

43. Temple, Tex.

44. Topeka, Kans.

45. Tuskegee, Ala.

46. Vancouver, Wash.

47. Waco, Tex.

48. West Palm Beach, Fla.

49. West Roxbury, Mass.

50. White City, Oreg.

Source: GAO analysis of VA data.

Note: These VA medical facilities were identified by VA as close enough
geographically to another VA medical facility for VA to consider whether
inpatient services other than tertiary care or acute inpatient medicine
were needed at both. The potentially duplicated inpatient services
generally included psychiatric and long-term inpatient care; services that
support inpatient care generally included administration and maintenance.

VA also evaluated the alignment of its inpatient services at its medical
facilities with potential low acute inpatient workload. VA identified low
acute inpatient workload based on projected need for acute inpatient beds,
viability of specific services, and changes in workload at one location
that could result from decisions made about other locations. VA identified
low total projected acute inpatient workload when a medical facility that
provides acute inpatient medicine services was projected to need fewer
than 40 acute medicine, surgery, and psychiatry beds (combined) in fiscal
years 2012 and 2022.17 In addition, VA identified low acute inpatient
workload at some other facilities even if the total projected number of
acute medicine, surgery, and psychiatry beds was expected to exceed 40 in
fiscal years 2012 or 2022. In some of these cases, VA questioned the
viability of a specific acute inpatient service, for example, when
projections indicated that few beds would be needed for inpatient surgery.
In other cases, VA noted that low acute inpatient workload could

17Of the medical facilities that VA identified using these criteria, we
included those that provided acute inpatient medicine services during the
first half of fiscal year 2004, the time period immediately before VA made
its CARES decisions.

result from decisions it made about inpatient health care at other
locations, for example, when a decision to enter into an agreement for
non-VA care could shift acute inpatient workload away from an existing VA
medical facility. Using these criteria, 27 medical facilities were
identified as having potentially low acute inpatient workload (see table
4).

Table 4: VA Medical Facilities with Potential Low Acute Inpatient Workload

1. Altoona, Pa.

2. Bath, N.Y.

3. Beckley, W.Va.

4. Big Spring, Tex.

5. Boise, Idaho

6. Butler, Pa.

7. Castle Point, N.Y.

8. Cheyenne, Wyo.

9. Chillicothe, Ohio

10. Des Moines, Iowa

11. Dublin, Ga.

12. Erie, Pa.

13. Fort Harrison, Mont.

14. Fort Wayne, Ind.

15. Grand Junction, Colo.

16. Hot Springs, S. Dak.

17. Huntington, W.Va.

18. Kerrville, Tex.

19. Marion, Ind.

20. Murfreesboro, Tenn.

21. Muskogee, Okla.

22. Poplar Bluff, Mo.

23. Prescott, Ariz.

24. Roseburg, Oreg.

25. Saginaw, Mich.

26. Spokane, Wash.

27. Walla Walla, Wash.

Source: GAO analysis of VA data.

Note: Low total projected acute inpatient workload was identified when a
VA medical facility that provided acute inpatient medicine services during
the first half of fiscal year 2004, the time period immediately before VA
made its CARES decisions, was projected to need fewer than 40 acute
medicine, surgery, and psychiatry beds (combined) in fiscal years 2012 and
2022. Other low acute inpatient workload was identified (1) when VA
questioned the viability of a specific acute inpatient service, for
example, because projections indicated that few beds would be needed for
inpatient surgery, or (2) when low acute inpatient workload at an existing
VA medical facility could result from decisions VA made about inpatient
health care at other locations, even if the total projected number of
acute medicine, surgery, and psychiatry beds was expected to exceed 40 in
fiscal years 2012 or 2022.

Appendix V provides a complete list of VA's inpatient medical facilities
and notes those at which VA identified potential service duplication, low
acute inpatient workload, or both as factors that indicated that
alternative ways to align inpatient services should be assessed.

    VA Identified 31 Markets Where Veterans Face Limitations in Geographic
    Access to Acute, Tertiary, or Long-Term Inpatient Services

VA identified 31 markets where veterans face limitations in geographic
access to acute, tertiary, or long-term inpatient services. VA's
identification of markets where veterans face limitations in access to
acute or tertiary care was based primarily on its analysis of the number
of veterans who face lengthy driving times to obtain VA health care, while
VA's identification of markets where veterans face limitations in access
to a long-term inpatient care service was based on information such as
referral patterns. Limitations in geographic access could occur in several
types of situations. In some markets where a VA facility provided acute or
tertiary inpatient care, too many veterans had lengthy driving times to
access these services. In some markets, there were no VA facilities
providing acute or tertiary inpatient care, and veterans had lengthy
driving times to access that care at VA facilities in other markets. In
other markets, VA had a facility, but the facility did not provide the
needed service.

To identify markets where a large number of veterans face lengthy driving
times from home to access acute or tertiary inpatient care at VA
facilities, VA used specific standards for driving times for urban, rural,
and highly rural areas (see table 5).18 VA considered a market to have a
large number of veterans facing lengthy driving times if driving time to
the nearest VA facility exceeded VA's standard for more than 35 percent of
those enrolled for VA health care residing in the market and exceeded VA's
standard for at least 12,000 enrolled veterans.

18VA used a zip-code-based analysis to calculate driving times from
veterans' homes to the nearest VA-owned or VA-affiliated medical facility
that provides acute or tertiary care. VAaffiliated medical facilities
include hospitals that are owned by non-VA providers where VA has arranged
for VA staff to provide care to veterans.

Table 5: VA's Driving Time Standards for Access to Acute Inpatient Care
and Tertiary Care

Type of inpatient Driving time for veterans to access

        health care Type of county health care at a VA medical facilitya

                 Acute care (medicine,           Urbanb            60 minutes 
              surgery, and psychiatry)           Ruralc            90 minutes 
                                          Highly rurald           120 minutes 
                         Tertiary care           Urbanb           240 minutes 
                                                 Ruralc           240 minutes 
                                          Highly rurald    Community standard 

Source: VA, Draft National CARES Plan.

aVA used a zip-code-based analysis to calculate driving times from
veterans' homes to the nearest VA-owned or VA-affiliated medical facility
that provides acute or tertiary care. VA-affiliated medical facilities
include hospitals that are owned by non-VA providers where VA has arranged
for VA staff to provide care to veterans.

bCounties designated as metropolitan by the U.S. Census Bureau and
counties with a population density of more than 166 people per square
mile.

cCounties that are not designated as metropolitan by the U.S. Census
Bureau and have a population density of 26 to 166 people per square mile.

dCounties with a population density of less than 26 people per square mile
and counties designated as highly rural by the VA health care network in
which the county is located.

Using these standards, VA identified 28 markets in which a large number of
veterans face lengthy driving times from home to access acute or tertiary
inpatient care at VA facilities (see app. VI). VA identified a need to
evaluate options for improving access to acute inpatient care (medicine,
surgery, and psychiatry) in 20 markets, tertiary care in 4 markets, and
both acute and tertiary care in 4 markets.

In addition, VA identified 3 markets where options to improve access to a
long-term care service needed evaluation by using information such as
referral patterns. VA determined that it could not evaluate access to
longterm care services on a systematic, nationwide basis because VA had
not developed an adequate model for projecting demand for these services
at the time CARES decisions were made.

o 	VA identified a need to assess options to improve access to domiciliary
care in the Washington, D.C., market of Network 5, a market that includes
the District of Columbia and parts of Maryland and Virginia. The network
proposed this evaluation because VA did not provide domiciliary care and
the market has a large population of homeless veterans who were referred
to a different market to obtain domiciliary care.

o 	VA identified a need to assess options to improve access to residential
rehabilitation for post-traumatic stress disorder and substance abuse in
the Michigan market of Network 11, a market that includes lower Michigan
and part of northwest Ohio. The CARES Commission proposed this evaluation
because many veterans with these disorders who live in the Detroit,
Michigan, area now travel about 125 miles to obtain inpatient residential
rehabilitation through VA's medical facility in Battle Creek, Michigan.19

o 	VA identified a need to assess options to improve access to nursing
home services and to ensure future access to acute inpatient care in the
Nevada market of Network 22, a market that includes southern Nevada. VA
did not own an inpatient medical facility in this market at the time it
made its CARES decisions; instead, it collaborated with the Department of
Defense to provide acute inpatient services in Las Vegas, Nevada, by
having VA staff provide services to veterans in the Department of Defense
hospital at Nellis Air Force Base. The network proposed an evaluation of
options for improving access to nursing home care because VA did not have
a nursing home in this market and the market has a large proportion of
veterans who are aged 65 or older. In addition, although VA did not
identify a limitation to veterans' access to acute inpatient care in this
market using its driving time standards, VA identified a need to assess
options to ensure future access to acute inpatient care in this market. It
did so in part because of questions about whether the rapid growth in
demand for inpatient services in the Nevada market could be accommodated
within the existing collaborative relationship with the Department of
Defense.

Appendix VI provides a list of all VA markets and indicates those in which
VA identified limitations in geographic access to tertiary, acute, or
longterm inpatient health care services. This appendix also summarizes
descriptions of the geographic areas that each market covers.

19The Commission recommended that residential rehabilitation and
domiciliary services be provided close to the towns or cities where
veterans who receive those services typically live. The Secretary stated
that VA's long-term care strategic plan would incorporate this
consideration.

    VA Identified Six Networks Where Options to Improve Veterans' Access to
    Specialized Inpatient Treatment for Spinal Cord Injury and Disorder or Blind
    Rehabilitation Needed Evaluation

To identify limitations in veterans' access to specialized inpatient
treatment services for spinal cord injury and disorder or blind
rehabilitation, VA used information about projected demand for these
services and referral patterns within and across networks. VA has
specialized inpatient treatment units for these two types of disability
that serve veterans in areas that are larger than the markets VA defined
for its other health care services. VA identified six networks where there
was a need to evaluate options to improve veterans' access to these
specialized services (see table 6).

Table 6: VA Networks Where VA Identified Limitations in Access to
Specialized Inpatient Treatment for Spinal Cord Injury and Disorder or
Blind Rehabilitation

                 Type of specialized inpatient service Network

Spinal cord injury and disorder Blind rehabilitation

1. 	Network 2 (upstate New York X and parts of north central Pennsylvania)

2. 	Network 8 (most of Florida, part X of southern Georgia, Puerto Rico,
the U.S. Virgin Islands of St. Thomas and St. Croix, and Arecibo)

                          3. Network 16 (Louisiana; most of    X            X 
                                 Arkansas, Mississippi, and          
                               Oklahoma; eastern Texas; and          
                               parts of three other states:          
                            Alabama, Florida, and Missouri)          

4. 	Network 19 (Utah; most of X Colorado, Montana, and Wyoming; and parts
of five other states: Idaho, Kansas, Nebraska, Nevada, and North Dakota)

5. 	Network 22 (southern California X and southern Nevada)

6. 	Network 23 (Iowa and South X Dakota; most of Minnesota, Nebraska, and
North Dakota; and parts of five other states: Illinois, Kansas, Missouri,
Wisconsin, and Wyoming)

Source: GAO analysis of VA data.

Note: VA health care facilities are organized into 21 regional networks,
known as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

VA Made Decisions on Alignment of Inpatient Services for 120 Locations and
Deferred Decisions for 16 Pending Completion of Studies

Appendix VII provides a list of all VA networks and indicates those where
VA identified limitations in access to specialized inpatient services of
treatment for spinal cord injury and disorder or blind rehabilitation.
This appendix also summarizes descriptions of the geographic areas that
each network covers.

VA made decisions concerning the alignment of inpatient health care
services for 120 of the 136 locations that it identified for potential
service duplication, low acute inpatient workload, or limitations to
geographic access. For the remaining 16 locations, VA deferred decisions
pending further study of options that include adding or closing inpatient
services. For most of its 120 decisions, VA provided reasons that were
related to the feasibility of alternative ways of aligning inpatient
services or the effect of possible realignments of inpatient services on
such considerations as the quality or accessibility of care.

VA Made Decisions on VA made decisions to realign inpatient services for
30 locations and to Alignment of Inpatient leave services as aligned at 90
locations (see table 7).

Health Care Services for
120 Locations Table 7: VA's Decisions on the Alignment of Inpatient
Services at 120 Locations

                            Locations VA's decision

                                                          Networks with 
                                                         limitations in 
                               Medical Markets with geographic access   
                        facilities with limitations      to specialized 
                                                 in                     
                                  potential service inpatient treatment 
                                         geographic                     
                           duplication or access to      of spinal cord 
                                             acute,                     
                             low acute tertiary, or injury and disorder 
                                              long-                     
                           inpatient term inpatient            or blind 
                                 workloads services      rehabilitation Total 

Realign VA 22 3 5 30 inpatient services

Maintain VA 63 27 0 90
inpatient services
as aligned

                               Total 85 30 5 120

Source: GAO analysis of VA data.

VA Made Decisions to Realign Of the 22 medical facilities with potential
service duplication or low acute Inpatient Services for 30 inpatient
workload, VA's decisions for 10 involved realignments including Locations
the closure of all inpatient services at 5 facilities. In all but one of
these

closures, VA decided to add the closed services at a nearby VA medical
facility when the services were not already available there (see table 8).
For this closure, VA will contract for care from non-VA providers or refer
veterans to a VA medical facility approximately 130 miles away.

Table 8: VA's Decisions to Close All Inpatient Services at a VA Medical
Facility and Add Those Services to a Nearby VA Medical Facility When Not
Already Available There

Close all inpatient services Add inpatient services VA medical facility
Services to be closed VA medical facility Services to be addeda

Cleveland, Ohio-Brecksville  o  Acute psychiatry Cleveland, Ohio-Wade
Park, about  o  Long-term psychiatry

o  Long-term psychiatry 20 miles away  o  Nursing home care

o  Nursing home care  o  Domiciliary care

o  Domiciliary care

Fort Wayne, o  Acute medicine Not applicable (VA decided o  Not applicable 
Ind.                                      to                
                                   contract for care with      
                                           non-VA              
                                     providers or refer        
                                      veterans to its          
                                        Indianapolis, Ind.,    
                                          medical facility,    
                                   about 130 miles away)       

Gulfport, Miss.  o  Acute psychiatry Biloxi, Miss., about 8 miles away  o 
Acute psychiatry

o  Long-term psychiatry  o  Long-term psychiatry

o  Nursing home care

Knoxville, Iowa o   Acute psychiatry  Des Moines, Iowa o  Acute psychiatry 
                                         (about 45 miles     
                   o     Intermediate         away)       o      Nursing home 
                           medicine                                      care 
                   o  Nursing home care                      
                   o   Domiciliary care                      

                                Pittsburgh, Pa.-

                                 Highland Drive

o  Acute psychiatry

o  Long-term psychiatry

Pittsburgh, Pa.-University Drive, about 5 miles away

o  Acute psychiatry

o  Long-term psychiatry

o  Domiciliary care Residential rehabilitation

Pittsburgh, Pa.-Heinz Center, about 5 miles away

o  Domiciliary care

o  Residential rehabilitation

Source: GAO analysis of VA data.

aInpatient services already provided at the facility are not listed as
added services. In each case in which VA decided to close all inpatient
services at a medical facility and to add services to a nearby facility,
VA decided to add all the inpatient services that it decided to close that
are not already available at the nearby VA medical facility.

VA's decisions for 12 other medical facilities identified for potential
service duplication or low acute inpatient workload were to close one or
more inpatient services at a medical facility, but retain other inpatient
services provided at that facility (see table 9). In general, VA will not
add the service that will be closed at another VA facility, but instead
will enter

into agreements for that care from non-VA providers or refer veterans to a
VA medical facility that already provides that service. In one case, VA
will add services to a nearby medical facility that did not, at the time
VA made its CARES decisions, provide two inpatient services that VA
decided to close. Specifically, VA decided to add acute and long-term
psychiatry services to its medical facility in Castle Point, New York,
which is about 30 miles from its facility in Montrose, New York.

Table 9: VA's Decisions to Close One or More, but Not All, Inpatient
Services at a VA Medical Facility

Medical facility Inpatient service or services to be closed

1. American Lake, Wash. Acute medicine

2. Butler, Pa. Acute medicine

3. Canandaigua, N.Y. Acute psychiatry

4. Castle Point, N.Y. Treatment for spinal cord injury and disorder

5. Dublin, Ga. Surgery

6. Kerrville, Tex. Acute medicine

7. Livermore, Calif. Subacute medicine

8. Montrose, N.Y. Acute and long-term psychiatry and nursing home care

9. Murfreesboro, Tenn. Surgery

10. Muskogee, Okla. Surgery

11. Roseburg, Oreg. Surgery

12. Saginaw, Mich. Acute medicine

Source: GAO analysis of VA data.

Appendix V provides a complete list of VA medical facilities and VA's
decisions about the alignment of inpatient services at each.20

Our analysis of major CARES documents that describe VA's decisions to
realign inpatient services at 22 of its medical facilities indicated that
VA generally provided reasons for these decisions that involve factors
such as the quality, accessibility, or costs of care. For example, at 5 of
its medical facilities VA decided to realign acute psychiatry services so
that they would be provided in a medical facility that also provides acute
medicine services, which is consistent with VA's goal to improve the
quality of care.

20Through CARES, VA also decided to build a replacement for its hospital
in Denver, Colorado. Once the new medical facility is complete, VA will
close the existing facility and transfer all inpatient care to the new
facility.

When evaluating options for the alignment of health care services, CARES
guidelines were consistent with guidelines from the Office of Management
and Budget21 in calling for attention to the costs and benefits of
alternatives when evaluating options for the alignment of health care
services. CARES guidelines are also consistent with our previous analysis
and, in particular, our view of the importance of costs and benefits
associated with the quality of care, access to care, cost to the
government, support for VA's other strategic goals (such as medical
education of health care providers and research), and economic impact on
the local community.22

VA also made decisions to realign inpatient services in three health care
markets where VA identified limitations in access to acute or long-term
inpatient services (see table 10). VA had several options to address these
access limitations. VA could realign inpatient services by establishing
new VA medical facilities or adding services to existing VA medical
facilities. As an alternative to realigning its inpatient services, VA
also had the option of entering into agreements with non-VA providers. For
example, it could improve access by purchasing inpatient health care
services from non-VA providers, leasing space at non-VA medical
facilities, or collaborating with the Department of Defense. VA decided to
add inpatient services at two existing VA medical facilities and to
establish a new VA medical facility to provide inpatient services in Las
Vegas, Nevada.23

21Office of Management and Budget, Capital Programming Guide, Version 1.0
(Washington, D.C.: July 1997).

22See GAO, VA Health Care: Framework for Analyzing Capital Asset
Realignment for Enhanced Services Decisions, GAO-03-1103R (Washington,
D.C.: Aug. 18, 2003).

23At the time VA made its CARES decisions, VA collaborated with the
Department of Defense to provide inpatient hospital services in Las Vegas,
Nevada, by having VA staff provide services to veterans in a hospital at
Nellis Air Force Base.

Table 10: VA Health Care Markets Where VA Decided to Add Acute or
Long-Term Inpatient Services

                             VA alignment decisions

Add more inpatient

services to an existing Establish a new medical Markets facility facility

1. 	Washington, D.C., Domiciliary care at VA's Not applicable market of
Network 5 (the Washington, D.C., medical District of Columbia and facility
parts of both Maryland and Virginia)

2. 	Central market of Acute inpatient medicine, Not applicable Network 8
(the central surgery, and psychiatry at part of Florida) VA's Orlando,
Fla., medical

facilitya

              3. Nevada market of  Not applicable   Acute inpatient medicine, 
           Network 22 (southern                      surgery, psychiatry, and 
                          Nevada)                  nursing home services at a 
                                                   new VA medical facility in 
                                                       Las Vegas, Nev.b       

Source: GAO analysis of VA data.

aVA decided to add an acute care hospital to its medical facility-a
nursing home and domiciliary-in Orlando.

bVA did not have an inpatient facility in this market at the time it made
its CARES decisions. It collaborated with the Department of Defense to
provide acute inpatient hospital services in Las Vegas, Nev., by having VA
staff provide services to veterans in a hospital at Nellis Air Force Base.

Appendix VI provides a complete list of VA's health care markets and
indicates where VA identified limitations in geographic access to
tertiary, acute, or long-term inpatient health care services and VA's
decisions for improving veterans' access to these services.

VA also decided to add specialized centers for the inpatient treatment of
spinal cord injury and disorder or blind rehabilitation to existing VA
medical centers in five networks where it had identified limitations in
veterans' access to these services (see table 11). VA will add inpatient
centers for the treatment of spinal cord injury and disorder in three
networks and inpatient centers for blind rehabilitation in two networks
(see also app. VII).

Table 11: VA Health Care Networks Where VA Decided to Add Specialized
Inpatient Treatment for Spinal Cord Injury and Disorder or Blind
Rehabilitation

Network

1. 	Network 2 (upstate New York and parts of north central Pennsylvania)

2. 	Network 16 (Louisiana; most of Arkansas, Mississippi, and Oklahoma;
eastern Texas; and parts of three other states: Alabama, Florida, and
Missouri)

3. 	Network 19 (Utah; most of Colorado, Montana, and Wyoming; and parts of
five other states: Idaho, Kansas, Nebraska, Nevada, and North Dakota)

4. 	Network 22 (southern California and southern Nevada)

5. 	Network 23 (Iowa and South Dakota; most of Minnesota, Nebraska, and
North Dakota; and parts of five other states: Illinois, Kansas, Missouri,
Wisconsin, and Wyoming)

Inpatient services VA decided to add to an existing facility

Inpatient Spinal Cord Injury and Disorder Center at VA's Syracuse, N.Y.,
medical facility

Inpatient Blind Rehabilitation Center at VA's Biloxi, Miss., medical
facility

Inpatient Spinal Cord Injury and Disorder Center at VA's Denver, Colo.,
medical facility

Inpatient Blind Rehabilitation Center at VA's Long Beach, Calif., medical
facility

Inpatient Spinal Cord Injury and Disorder Center at VA's Minneapolis,
Minn., medical facility

VA Made Decisions to Maintain Its Inpatient Services as Currently Aligned
at 90 Locations

Source: GAO analysis of VA data.

Note: VA health care facilities are organized into 21 regional networks,
known as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

Appendix VII provides a complete list of VA's health care networks and
indicates those where VA identified limitations in veterans' access to
specialized inpatient treatment programs for spinal cord injury and
disorder or blindness and VA's decisions about the alignment of these
inpatient services.

VA decided to maintain its inpatient services as currently aligned in 90
locations-63 medical facilities identified as having potential service
duplication or low acute inpatient workload and 27 markets where VA
identified limitations in veterans' geographic access to tertiary or acute
inpatient services. VA provided reasons for its decisions to leave
services as aligned for most, but not all, of these locations. Generally
the reasons VA cited in major CARES documents for leaving inpatient
services as aligned at the 63 medical facilities were that realignment was
not feasible

(for example, because space limitations constrain consolidation of
potentially duplicative services) or would have a negative effect on the
quality of care, accessibility of care, cost of care, VA's strategic
missions, or the community's economy. As one example, VA decided to
maintain inpatient services as aligned at its medical facility in Hot
Springs, South Dakota, where acute inpatient workload is low, because
there are no hospitals within 60 miles that have been accredited by the
Joint Commission on Accreditation of Healthcare Organizations. As another
example, VA decided to maintain inpatient services as aligned at its two
medical facilities in Augusta, Georgia, because it concluded that space is
insufficient to make consolidation practical.

For the 27 markets where VA decided not to realign the inpatient health
care services at its existing medical facilities, VA decided instead to
purchase health care services through contracts with local non-VA
providers, lease space at non-VA medical facilities, or establish
collaborative arrangements with the Department of Defense. Each of these
markets was one where VA identified lengthy driving times to access
tertiary or acute care.

    VA Deferred Decisions on Alignment of Inpatient Health Care Services for 16
    Locations Pending Further Study

VA deferred decisions about the alignment of inpatient health care
services for 16 locations,24 including

o 	14 existing VA medical facilities that have service duplication or low
acute inpatient workload (see table 12);

o 	1 market where VA identified limitations in access to a long-term care
service, namely, residential rehabilitation for post-traumatic stress
disorder and substance abuse in the Michigan market of Network 11 (which
includes lower Michigan and part of northwest Ohio); and

24VA also deferred, pending further study, some decisions about potential
alignment options at one medical facility and one network where it had
already made some decisions on inpatient services. These locations are
VA's medical facility at Muskogee, Oklahoma, and Network 16, which
includes Louisiana; most of Arkansas, Mississippi, and Oklahoma; eastern
Texas; and parts of Alabama, Florida, and Missouri. In addition to its
decision to close inpatient surgery at the facility in Muskogee, Oklahoma,
VA will study further whether to add inpatient psychiatry services to that
facility and whether to contract with non-VA providers to meet veterans'
inpatient health care needs in the Muskogee/Tulsa region. In addition to
VA's decision to add an inpatient blind rehabilitation center in Network
16, VA will study further which of its medical facilities in Network 16
would be the best location for a new inpatient center for the treatment of
spinal cord injury and disorder.

o 	1 network where VA identified limitations in access to specialized
inpatient treatment for spinal cord injury and disorder, namely, Network 8
(which includes most of Florida, part of southern Georgia, Puerto Rico,
the U.S. Virgin Islands of St. Thomas and St. Croix, and Arecibo).

Table 12: VA Medical Facilities Where Inpatient Alignment Decisions Were
Deferred Pending Further Study

1. Bedford, Mass.

2. Big Spring, Tex.

3. Brockton, Mass.

4. Brooklyn, N.Y.

5. Chillicothe, Ohio

6. Jamaica Plain, Mass.

7. Lake City, Fla.

8. Manhattan, N.Y.

9. Montgomery, Ala.

10. Poplar Bluff, Mo.

11. Temple, Tex.

12. Waco, Tex.

13. Walla Walla, Wash.

14. West Roxbury, Mass.

Source: GAO analysis of VA data.

Note: In addition, VA chose to further study potential alignment options
at its medical facility at Muskogee, Oklahoma, where it had already made
one decision about inpatient services. VA decided to close inpatient
surgery at Muskogee and to study the potential to add inpatient
psychiatric services or to use non-VA providers to meet veterans'
inpatient health care needs in the Muskogee/Tulsa region.

In general, VA indicated that it plans to study ways to align inpatient
health care services at these locations because it concluded that
sufficient information was not available to reach a decision by May 7,
2004. For example, VA concluded that it lacked adequate data about the
feasibility and cost-effectiveness of building a single new inpatient
medical facility in Boston, Massachusetts, to replace its inpatient
medical facilities in Bedford, Brockton, Jamaica Plain, and West Roxbury,
Massachusetts. As another example, VA concluded that further information
would be needed to determine whether to add a new inpatient center for the
treatment of spinal cord injury and disorder or to expand an existing
center for that treatment in southern Florida. When VA announced its CARES
decisions, it reported that it planned to complete most of these studies
by the end of 2004 or the beginning of 2005; a VA official reported in
November 2004

that VA now expects that most of the studies will be completed by the end
of 2005.25

In addition, VA plans to develop crosscutting strategic plans for
long-term care and mental health services that could result in decisions
to realign inpatient services at locations where VA has decided to realign
other inpatient services and at locations where no realignment decisions
have been made. Although VA made some decisions about the alignment of
long-term care services at facilities it had identified for potential
duplication of services, the CARES process did not include a systematic
analysis of VA's long-term care services (including nursing home care,
long-term psychiatric care, domiciliary care, and residential
rehabilitation) because VA had not developed an adequate model to project
future need for these services. VA reported that it is now working on a
strategic plan for long-term care that will include nursing home and
long-term psychiatric care needs and will be adjusted to determine whether
access to domiciliary care can be improved by realigning such services
from rural to urban medical facilities. VA also reported that it plans to
develop a mental health strategic plan that could suggest additional
realignments of inpatient psychiatry services because it will address the
collocation of acute inpatient psychiatric services with other acute
inpatient services- an arrangement that VA noted can enhance the quality
of acute psychiatric care-and better ensure equitable access to inpatient
psychiatric services.

Through the CARES process, VA has taken important steps in assessing and
making decisions on the alignment of its future inpatient health care
services and capital assets in light of projected health care needs.
Specifically, VA identified 136 locations where potential service
duplication, low acute inpatient workload, or limitations in veterans'
geographic access to VA health care indicated the need to evaluate
alternatives to alignment of inpatient services that could enhance health
care for veterans. In its evaluation, VA decided to realign services at 30
locations, generally citing reasons to maintain or enhance the quality of
care, improve veterans' access to care, or increase the cost efficiency of

Concluding Observations

25VA has decided to use a contractor to complete most of these studies. It
expects the contractor to begin the studies by spring of 2005. VA expects
that most of the studies will require from 4 to 9 months to complete. VA
also reported that one study has already been completed and that one other
study will not begin for approximately 5 years because options for
realignment of inpatient workload at the medical facility to be studied
depend on major construction at a nearby VA medical facility.

care and decided to maintain the alignment of inpatient services at 90
locations. Among the 90 locations, VA decided to improve veterans' access
to inpatient health services by entering into agreements for care from
non-VA providers in the 27 locations where a large number of veterans face
lengthy driving times to access VA health care and where VA decided not to
add inpatient services.

VA, however, did not complete its assessment of the alignment of inpatient
services at all locations identified as having potential service
duplication, low acute inpatient workload, or limitations in veterans'
geographic access to inpatient care. VA made no decisions on the alignment
of inpatient services in 16 locations pending completion of further
studies because VA believed it had insufficient information to make a
decision. In addition, VA plans other studies concerning alignment of
other inpatient services, such as nursing home and mental health care,
that could affect the alignment of these services at other medical
facilities.

VA's decisions to realign inpatient services have the potential to enhance
health care services for veterans. Some veterans who will be directly
affected by VA's decisions to realign inpatient services may benefit from
enhanced quality or accessibility of VA health care. Moreover, cost
savings associated with the closure of VA medical facilities and
elimination of duplicative services can be redirected to better serve the
health care needs of veterans. VA's efforts to realign its inpatient
services and improve management of its capital assets are essential to
meeting the health care needs of veterans in the 21st century. VA's
alignment decisions and planned studies of additional alternatives for the
alignment of inpatient services are tangible steps forward in this
process. Ultimately, however, accomplishing these goals will depend on
VA's success in completing its studies and implementing its CARES
decisions on inpatient and other health care services to better ensure
that resources now spent on unneeded capital assets are redirected to
health care.

Agency Comments 	In written comments on a draft of this report, VA
concurred with our findings. VA comments are reprinted in appendix VIII.

As we agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days from its date. We will then send copies of this report to the
Secretary of Veterans Affairs, appropriate congressional committees, and
other interested parties. We will also make copies available to others
upon

request. This report will be available at no charge on GAO's Web site at
http://www.gao.gov. If you or your staff have any questions, please call
me at (202) 512-7101. Another contact and key contributors are listed in
appendix IX.

Sincerely yours,

Cynthia A. Bascetta Director, Health Care-Veterans' Health and Benefits
Issues

                       Appendix I: Scope and Methodology

On May 7, 2004, the Secretary of Veterans Affairs published decisions the
Department of Veterans Affairs (VA) reached through its Capital Asset
Realignment for Enhanced Services (CARES) process.1 The Secretary's report
included VA's CARES decisions about the alignment of inpatient services at
locations it identified for potential service duplication, low acute
inpatient workload, or limitations in geographic access, along with its
other CARES decisions. These decisions covered 74 of VA's 77 markets in 20
of its 21 networks.2 In the context of the alignment of its inpatient
services, VA's report focused primarily on decisions involving medical
facilities, markets, and networks where VA's inpatient health care
services are to be realigned or studied further. The report did not,
however, provide a national, comprehensive summary of the medical
facilities, markets, and networks that VA identified as needing evaluation
for potential alternative alignments of inpatient services and did not
include a discussion of all of the locations where it decided to leave
inpatient services as currently aligned.

We examined VA's inpatient service assessments and decisions to develop a
national summary of the medical facilities, markets, and networks where
(1) VA identified potential service duplication, low workload, or
geographic access limitations as factors that could indicate a need to
evaluate alternative ways to align inpatient health care services and (2)
VA made decisions to either realign inpatient services or leave inpatient
services as aligned, or deferred decisions pending further study. Our
summary of the decisions VA made through CARES focuses on inpatient health
care services that VA provides in medical facilities that it owns in the
20 networks covered by the Secretary's May 7, 2004, CARES decisions.
Because no one source includes all the information about these factors, we
reviewed the major CARES documents, namely, CARES planning documents such
as network market plans, VA's Draft National CARES Plan, the report by an
independent Commission appointed by VA that was charged with making CARES
recommendations, and the Secretary's report of VA's CARES decisions.

1Department of Veterans Affairs, Secretary of Veterans Affairs: CARES
Decision (Washington, D.C.: May 7, 2004).

2In February 2002, VA completed a CARES pilot project that assessed
current and future use of health care assets in the three markets of
Network 12, which includes parts of five states: Illinois, Indiana,
Michigan, Minnesota, and Wisconsin. At that time, VA announced its
decision to, among other things, discontinue inpatient health care
services at its Lakeside medical facility in Chicago, Illinois, one of
eight inpatient medical facilities that VA had in these markets.

Appendix I: Scope and Methodology

To summarize the number of medical facilities,3 health care markets, and
health care networks where VA identified potential service duplication,
low acute inpatient workload, or geographic access limitations as factors
that could indicate a need to evaluate alternative ways to align inpatient
health care services, we reviewed major CARES documents for information
about these factors. We classified the medical facilities that VA
identified as potentially duplicating inpatient services as potentially
duplicating one or more of three types of inpatient services, namely,
tertiary care services; acute inpatient medicine services; or other
services, including other types of inpatient care (such as long-term
psychiatry) or services that support inpatient care (such as
administration or maintenance). When our identification of a medical
facility as one with potential service duplication or low workload
depended on the availability of acute inpatient medicine, we confirmed
that the facility provided that service during the first half of fiscal
year 2004, the time period immediately before VA made its CARES decisions,
by examining data provided by VA. We resolved discrepancies in the
characterization of medical facilities as potentially duplicating
inpatient services or having low acute inpatient workload through
discussions with VA officials.

To summarize VA's decisions about the alignment of inpatient services, we
reviewed major CARES documents to determine if VA made a decision to
realign inpatient services or leave inpatient services as aligned or if VA
deferred making a decision pending further study. We defined realignment
of an inpatient service as (1) eliminating the service in its entirety at
a facility where VA provided it, (2) adding an inpatient service to an
existing VA facility where VA did not provide the service, or (3)
establishing a new VA medical facility where one had not existed. We did
not examine the number of beds that VA decided to add or close. The
inpatient services in our review included both acute and long-term
inpatient services. Specifically, these inpatient services included
tertiary care; the acute inpatient services of acute medicine, surgery,
and psychiatry; and other inpatient services. Other inpatient services
included subacute and intermediate medicine; the long-term inpatient
services of nursing home

3In this report, we consider medical facilities to be the capital assets
owned by VA at which it provides inpatient health care services to
veterans. Medical facilities include tertiary and acute hospitals, nursing
homes, and other extended care assets.

Appendix I: Scope and Methodology

care, long-term psychiatry, domiciliary care,4 and residential
rehabilitation; and specialized inpatient services of treatment for spinal
cord injury and disorder and blind rehabilitation. In some cases in which
VA decided to close an inpatient service at one medical facility and refer
patients to another VA medical facility, CARES documents did not indicate
whether that inpatient service was already available at that medical
facility. To determine whether VA had decided to add the inpatient service
in these cases, we obtained additional information from VA. We classified
a decision as pending further study when VA determined that additional
information or analysis was necessary to determine whether to add or close
one or more inpatient services at a location. We compared data from CARES
with other information from VA about the inpatient services available at
its medical facilities and when we identified discrepancies, resolved them
through discussions with VA officials. To identify the reasons VA provided
for its decisions about the alignment of inpatient services, we reviewed
major CARES documents. We examined the stated rationale associated with
each decision for references to feasibility or costs and benefits
involving the quality of care, access to care, cost to the government,
support for VA's other strategic goals (such as medical education and
research), and economic impact on the local community. We did not evaluate
the stated reasons.

We found the data to be adequate for our purposes, and VA officials agreed
that our methodology was reasonable. We did not review VA's other CARES
decisions such as those for reconfiguring space to meet projected demand
for services, modernization needed to provide services appropriately,
disposal of assets that may no longer be needed, or the alignment of
outpatient services. We conducted our work from October 2003 through March
2005 in accordance with generally accepted government auditing standards.

4Domiciliary care involves coordinated rehabilitative and restorative
clinical care in an inpatient setting, with the goal of helping veterans
achieve and maintain the highest level of functioning and independence
possible. Domiciliary care differs from other types of inpatient care in
that bedside nursing is not required.

Appendix II: VA Medical Facilities Identified for Potential Duplication of
Tertiary Care Services

                                      VA medical facility or facilities close 
                                        enough (within 120 miles) to consider 
                                                                      whether 
VA medical facilitya  Networkb tertiary care services were needed at both  
     Ann Arbor, Mich.          11               Detroit, Mich.                
Augusta, Ga.-Downtown        7               Columbia, S.C.                
      Baltimore, Md.            5   Philadelphia, Pa., and Washington, D.C.   
      Bay Pines, Fla.           8                 Tampa, Fla.                 
                                  Brooklyn, N.Y.; East Orange, N.J.;          
                                3 Manhattan, N.Y.; Northport, N.Y.;           
        Bronx, N.Y.               Philadelphia, Pa.;                          
                                             and West Haven, Conn.            
                                  Bronx, N.Y.; East Orange, N.J.; Manhattan,  
                                3 N.Y.; Northport, N.Y.; Philadelphia, Pa.;   
      Brooklyn, N.Y.              and                                         
                                               West Haven, Conn.              
     Charleston, S.C.           7               Columbia, S.C.                
     Cincinnati, Ohio          10      Dayton, Ohio; Indianapolis, Ind.;      
                                  Lexington, Ky.-Cooper; and Louisville, Ky.  
      Columbia, S.C.            7 Augusta, Ga.-Downtown and Charleston, S.C.  
       Dayton, Ohio            10  Cincinnati, Ohio, and Indianapolis, Ind.   
      Detroit, Mich.           11              Ann Arbor, Mich.               
                                    Bronx, N.Y.; Brooklyn, N.Y.; Manhattan,   
                                3  N.Y.; Northport, N.Y.; Philadelphia, Pa.;  
     East Orange, N.J.                                and                     
                                               West Haven, Conn.              
    Indianapolis, Ind.         11     Cincinnati, Ohio; Dayton, Ohio; and     
                                                Louisville, Ky.               
Lexington, Ky.-Cooper        9    Cincinnati, Ohio, and Louisville, Ky.    
    Loma Linda, Calif.         22 Long Beach, Calif.; San Diego, Calif.; and  
                                           West Los Angeles, Calif.           
    Long Beach, Calif.         22 Loma Linda, Calif.; San Diego, Calif.; and  
                                           West Los Angeles, Calif.           
                                9  Cincinnati, Ohio; Indianapolis, Ind.; and  
      Louisville, Ky.                        Lexington, Ky.-Cooper            

       Manhattan, N.Y.       3 Bronx, N.Y.; Brooklyn, N.Y.; East Orange,      
                               N.J.; Northport, N.Y.; Philadelphia, Pa.; and  
                                             West Haven, Conn.                
       Northport, N.Y.       3      Bronx, N.Y.; Brooklyn, N.Y.; East Orange, 
                                 N.J.; Manhattan, N.Y.; and West Haven, Conn. 
      Palo Alto, Calif.     21             San Francisco, Calif.              
      Philadelphia, Pa.      4  Baltimore, Md.; Bronx, N.Y.; Brooklyn, N.Y.;  
                                   East Orange, N.J.; and Manhattan, N.Y.     
        Richmond, Va.        6                Washington, D.C.                
      San Diego, Calif.     22   Loma Linda, Calif., and Long Beach, Calif.   
    San Francisco, Calif.   21               Palo Alto, Calif.                
         Tampa, Fla.         8                Bay Pines, Fla.                 
       Washington, D.C.      5       Baltimore, Md., and Richmond, Va.        
      West Haven, Conn.      1 Bronx, N.Y.; Brooklyn, N.Y.; East Orange,      
                               N.J.; Manhattan, N.Y.; and Northport, N.Y.     
West Los Angeles, Calif. 22   Loma Linda, Calif., and Long Beach, Calif.   

Source: GAO analysis of VA data.

aVA medical facilities that provide tertiary care services and are within
120 miles of another VA medical facility that provides tertiary care
services and that VA identified as potentially duplicating inpatient
services.

Appendix II: VA Medical Facilities Identified for Potential Duplication of
Tertiary Care Services

bVA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

Appendix III: VA Medical Facilities Identified for Potential Duplication of
Acute Inpatient Medicine Services

                                      VA medical facility or facilities close 
                                 enough (within 60 miles) to consider whether 
VA medical facilitya Networkb    acute inpatient medicine services were    
                                                needed at both                
     Ann Arbor, Mich.         11                Detroit, Mich.                
      Baltimore, Md.           5    Perry Point, Md., and Washington, D.C.    
                                 Brooklyn, N.Y.; Castle Point, N.Y.; East     
                               3 Orange, N.J.; Manhattan, N.Y.; and           
       Bronx, N.Y.               Northport,                                   
                                                     N.Y.                     
      Brooklyn, N.Y.           3  Bronx, N.Y.; East Orange, N.J.; Manhattan,  
                                          N.Y.; and Northport, N.Y.           
    Castle Point, N.Y.         3                 Bronx, N.Y.                  
     Cincinnati, Ohio         10                 Dayton, Ohio                 
       Dayton, Ohio           10               Cincinnati, Ohio               
      Detroit, Mich.          11               Ann Arbor, Mich.               
    East Orange, N.J.          3   Bronx, N.Y.; Brooklyn, N.Y.; Manhattan,    
                                          N.Y.; and Northport, N.Y.           
    Gainesville, Fla.          8               Lake City, Fla.                
     Kansas City, Mo.         15              Leavenworth, Kans.              
     Lake City, Fla.           8              Gainesville, Fla.               
    Leavenworth, Kans.        15               Kansas City, Mo.               
    Little Rock, Ark.         16           North Little Rock, Ark.            
    Long Beach, Calif.        22           West Los Angeles, Calif.           
     Manhattan, N.Y.           3    Bronx, N.Y.; Brooklyn, N.Y.; and East     
                                                 Orange, N.J.                 
Murfreesboro, Tenn.         9               Nashville, Tenn.               

Nashville, Tenn. 9 Murfreesboro, Tenn.
North Little Rock, Ark. 16 Little Rock, Ark.
Northport, N.Y. 3 Bronx, N.Y.; Brooklyn, N.Y.; and East Orange, N.J.
Perry Point, Md. 5 Baltimore, Md., and Wilmington, Del.
Philadelphia, Pa. 4 Wilmington, Del.
Providence, R.I. 1 West Roxbury, Mass.
Washington, D.C. 5 Baltimore, Md.
West Los Angeles, Calif. 22 Long Beach, Calif.
West Roxbury, Mass. 1 Providence, R.I.
Wilmington, Del. 4 Perry Point, Md., and Philadelphia, Pa.

Source: GAO analysis of VA data.

aVA medical facilities that provide acute inpatient medicine services and
are within 60 miles of another VA medical facility that provides acute
inpatient medicine services and that VA identified as potentially
duplicating inpatient services.

bVA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

Appendix IV: VA Medical Facilities Identified for Potential Duplication of Other
Inpatient Services or Support Services

                                            VA medical facility or facilities 
                                               close enough geographically to 
                                                                     consider 
      VA medical facilitya     Networkb    whether inpatient services were    
                                                   needed at both             
      American Lake, Wash.           20           White City, Oreg.           
      Augusta, Ga.-Downtown           7          Augusta, Ga.-Uptown          
       Augusta, Ga.-Uptown            7         Augusta, Ga.-Downtown         
          Batavia, N.Y.               2 Buffalo, N.Y., and Canandaigua, N.Y.  
         Bedford, Mass.               1    Brockton, Mass.; Jamaica Plain,    
                                           Mass.; and West Roxbury, Mass.     
          Biloxi, Miss.              16            Gulfport, Miss.            
         Brockton, Mass.              1 Bedford, Mass.; Jamaica Plain, Mass.; 
                                               and West Roxbury, Mass.        
         Brooklyn, N.Y.               3           St. Albans, N.Y.            
          Buffalo, N.Y.               2             Batavia, N.Y.             
        Canandaigua, N.Y.             2             Batavia, N.Y.             
       Castle Point, N.Y.             3            Montrose, N.Y.             
Cleveland, Ohio-Brecksville       10       Cleveland, Ohio-Wade Park       
    Cleveland, Ohio-Wade Park        10      Cleveland, Ohio-Brecksville      
        Des Moines, Iowa             23            Knoxville, Iowa            
        East Orange, N.J.             3              Lyons, N.J.              
       Fort Meade, S. Dak.           23         Hot Springs, S. Dak.          
        Fort Wayne, Ind.             11             Marion, Ind.              
        Gainesville, Fla.             8            Lake City, Fla.            
         Gulfport, Miss.             16             Biloxi, Miss.             
      Hot Springs, S. Dak.           23          Fort Meade, S. Dak.          
      Jamaica Plain, Mass.            1 Bedford, Mass.; Brockton, Mass.; and  
                                                 West Roxbury, Mass.          
        Kansas City, Mo.             15          Leavenworth, Kans.           
         Kerrville, Tex.             17           San Antonio, Tex.           
         Knoxville, Iowa             23           Des Moines, Iowa            
         Lake City, Fla.              8           Gainesville, Fla.           
       Leavenworth, Kans.            15  Kansas City, Mo., and Topeka, Kans.  
      Lexington, Ky.-Cooper           9        Lexington, Ky.-Leestown        
     Lexington, Ky.-Leestown          9         Lexington, Ky.-Cooper         
        Livermore, Calif.            21           Palo Alto, Calif.           
           Lyons, N.J.                3           East Orange, N.J.           
          Marion, Ind.               11           Fort Wayne, Ind.            
           Miami, Fla.                8         West Palm Beach, Fla.         
        Montgomery, Ala.              7            Tuskegee, Ala.             
         Montrose, N.Y.               3          Castle Point, N.Y.           
        Palo Alto, Calif.            21           Livermore, Calif.           

Appendix IV: VA Medical Facilities Identified for Potential Duplication of
Other Inpatient Services or Support Services

                                            VA medical facility or facilities 
                                               close enough geographically to 
                                                                     consider 
       VA medical facilitya     Networkb   whether inpatient services were    
                                                    needed at both            
Pittsburgh, Pa.-Heinz Center        4  Pittsburgh, Pa.-Highland Drive and  
                                           Pittsburgh, Pa.-University Drive   
     Pittsburgh, Pa.-Highland          4   Pittsburgh, Pa.-Heinz Center and   
              Drive                        Pittsburgh, Pa.-University Drive   
    Pittsburgh, Pa.-University         4   Pittsburgh, Pa.-Heinz Center and   
              Drive                         Pittsburgh, Pa.-Highland Drive    
         Portland, Oreg.              20           Vancouver, Wash.           
         Roseburg, Oreg.              20          White City, Oreg.           
        San Antonio, Tex.             17           Kerrville, Tex.            
         St. Albans, N.Y.              3            Brooklyn, N.Y.            
           Temple, Tex.               17              Waco, Tex.              
          Topeka, Kans.               15          Leavenworth, Kans.          
          Tuskegee, Ala.               7           Montgomery, Ala.           
         Vancouver, Wash.             20           Portland, Oreg.            
            Waco, Tex.                17             Temple, Tex.             
      West Palm Beach, Fla.            8             Miami, Fla.              
       West Roxbury, Mass.             1 Bedford, Mass.; Brockton, Mass.; and 
                                                 Jamaica Plain, Mass.         
                                      20 American Lake, Wash., and Roseburg,  
        White City, Oreg.                               Oreg.                 

Source: GAO analysis of VA data.

aVA medical facilities that VA identified as close enough geographically
to another VA medical facility for VA to consider whether inpatient
services other than tertiary care or acute inpatient medicine were needed
at both. The potentially duplicated inpatient services generally included
psychiatric and longterm inpatient care; services that support inpatient
care generally included administration and maintenance.

bVA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or Low
Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

1. Albany, N.Y. 2

2. 	Albuquerque,
N. Mex. 18

3. Alexandria, La. 16

4. Altoona, Pa. 4 X

5. Amarillo, Tex. 18

6. 	American
Lake, Wash. 20 X X

7. 	Anchorage,
Alaska 20

8. 	Ann Arbor,
Mich. 11X X

9. Asheville,
N.C. 6

10. Atlanta, Ga. 7

11. 	Augusta,
Ga.-
Downtown 7X X

12. 	Augusta,
Ga.-Uptown 7X

13. Baltimore, Md. 5 X X

14. Batavia, N.Y. 2 X

15. Bath, N.Y. 2 X

16. 	Battle Creek,
Mich. 11

17. Bay Pines, Fla. 8 X

18. 	Beckley,
W.Va. 6 X

19. Bedford,
Mass. 1 X X

20. 	Big Spring,
Tex. 18 X X

21. Biloxi, Miss. 16 X X

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

22. 	Birmingham,
Ala. 7

23. Boise, Idaho 20 X

24. Bonham, Tex. 17

25. 	Brockton,
Mass. 1 X X

26. Bronx, N.Y. 3 X X

27. Brooklyn, N.Y. 3 X X X X

28. Buffalo, N.Y. 2 X

29. Butler, Pa. 4 X X

30. 	Canandaigua,
N.Y. 2 X X

31. 	Castle Point,
N.Y. 3 XXX XX

32. 	Charleston,
S.C. 7 X

33. 	Cheyenne,
Wyo. 19 X

34. 	Chicago, Ill.- West Side 12k

35. 	Chillicothe,
Ohio 10 X X

36. 	Cincinnati,
Ohio 10X X

37. 	Clarksburg,
W.Va. 4

38. 	Cleveland, Ohio- Brecksville 10X Xl

39. Cleveland,
Ohio-Wade
Park 10X X

40. Coatesville, Pa. 4

41. Columbia, Mo. 15

42. Columbia, S.C. 7 X

43. Dallas, Tex. 17

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

 Study ways to align inpatient servicesj Add one or more inpatient service(s)h
                    Close one or more inpatient service(s)i

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

44. Danville, Ill. 11

45. Dayton, Ohio 10 X X

46. Denver, Colo.m 19 X

47. 	Des Moines,
Iowa 23 XX X

48. Detroit, Mich. 11 X X

49. Dublin, Ga. 7 X X

50. Durham, N.C. 6

51. 	East Orange,
N.J. 3 X X X

52. Erie, Pa. 4 X

53. Fargo, N. Dak. 23

54. 	Fayetteville,
Ark. 16

55. 	Fayetteville,
N.C. 6

56. 	Fort Harrison,
Mont. 19  X

57. 	Fort Meade,
S. Dak. 23 X

58. 	Fort Thomas,
Ky. 10

59. Fort Wayne, Ind. 11 XX Xl

60. Fresno, Calif. 21

61. 	Gainesville,
Fla. 8 XX

62. 	Grand Island,
Nebr. 23

63. 	Grand
Junction, Colo. 19 X

64. Gulfport, Miss. 16 X Xl

65. Hampton, Va. 6

66. Hines, Ill. 12k

67. 	Honolulu,
Hawaii 21

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

68. 	Hot Springs,
S. Dak. 23 X X

69. Houston, Tex. 16

70. 	Huntington,
W.Va. 9 X

71. 	Indianapolis,
Ind. 11 X

72. Iowa City, Iowa 23

73. 	Iron Mountain, Mich. 12k

74. Jackson, Miss. 16

75. 	Jamaica
Plain, Mass. 1 X X

76. 	Kansas City,
Mo. 15 XX

77. Kerrville, Tex. 17 X X X

78. Knoxville, Iowa 23 X Xl

79. Lake City, Fla. 8 X X X

80. 	Leavenworth,
Kans. 15 XX

81. Lebanon, Pa. 4

82. 	Lexington,
Ky.-Cooper 9X X

83. 	Lexington,
Ky.-
Leestown 9X

84. Little Rock, Ark. 16 X

85. 	Livermore,
Calif. 21 X X

86. 	Loch Raven,
Md. 5

87. 	Loma Linda,
Calif. 22 X

88. 	Long Beach,
Calif. 22X X X

89. Louisville, Ky. 9 X

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

90. Lyons, N.J. 3 X

91. Madison, Wis. 12k

92. Manchester,
N.H. 1

93. Manhattan,
N.Y. 3XX X

94. Marion, Ill. 15

95. Marion, Ind. 11 X X

96. Martinez, Calif. 21

97. Martinsburg,
W.Va. 5

98. Memphis,
Tenn. 9

99. Menlo Park,
Calif. 21

100. Miami, Fla. 8 X

101. Miles City,
Mont. 19

102. Milwaukee, Wis. 12k

103. Minneapolis,
Minn. 23 X

104. Montgomery,
Ala. 7 X X

105. Montrose,
N.Y.3 X X

106. Mountain
Home, Tenn. 9

107. Murfreesboro,
Tenn. 9X X X

108. Muskogee,
Okla. 16 X XX

109. Nashville,
Tenn. 9 X

110. New Orleans,
La. 16

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

111. North Chicago, Ill. 12k

112. North Little
Rock, Ark. 16 X

113. Northampton,
Mass. 1

114. Northport, N.Y. 3 X X

115. Oklahoma
City, Okla. 16

116. Omaha, Nebr. 23

117. Orlando, Fla. 8 X

118. Palo Alto,
Calif. 21 X X

119. Perry Point,
Md. 5X

120. Philadelphia,
Pa. 4XX

121. Phoenix, Ariz. 18

122. Pittsburgh,
Pa.-Heinz
Center 4X X

123. Pittsburgh, Pa.-Highland Drive 4X Xl

124. Pittsburgh, Pa.-

University
Drive 4X X

125. Poplar Bluff,
Mo. 15 X X

126. Portland,
Oreg. 20 X

127. Prescott, Ariz. 18 X

128. Providence,
R.I. 1X

129. Reno, Nev. 21

130. Richmond, Va. 6 X

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

 Study ways to align inpatient servicesj Add one or more inpatient service(s)h
                    Close one or more inpatient service(s)i

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

131. Roseburg,
Oreg. 20 X X X

132. Sacramento,
Calif. 21

133. Saginaw,
Mich. 11 X X

134. Salem, Va. 6

135. Salisbury, N.C. 6

136. Salt Lake City,
Utah 19

137. San Antonio,
Tex. 17 X

138. San Diego,
Calif. 22 X

139. San Francisco,
Calif. 21 X

140. San Juan, P.R. 8

141. Seattle, Wash. 20

142. Sepulveda,
Calif. 22

143. Sheridan,
Wyo. 19

144. Shreveport,
La. 16

145. Sioux Falls,
S. Dak. 23

146. Spokane,
Wash. 20 X

147. St. Albans,
N.Y.3 X

148. St. Cloud,
Minn. 23

149. St. Louis, Mo.-

Jefferson
Barracks 15

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                              Acute medicine cared

Other caree

                            Total projected demandf

Other basisg

VA medical
facilitya Networkb

150. St. Louis, Mo.
-John
Cochran 15

151. Syracuse, N.Y. 2 X

152. Tampa, Fla. 8 X

153. Temple, Tex. 17 X X

154. Togus, Maine 1

                              155. Tomah, Wis. 12k

156. Topeka, Kans. 15 X

157. Tucson, Ariz. 18

158. Tuscaloosa,
Ala. 7

159. Tuskegee, Ala. 7 X

160. Vancouver,
Wash. 20 X

161. Waco, Tex. 17 X X

162. Walla Walla,
Wash. 20 X X

163. Washington,
D.C. 5XX X

164. West Haven,
Conn. 1 X

165. West Los
Angeles, Calif. 22 X X

166. West Palm
Beach, Fla. 8 X

167. West Roxbury,
Mass. 1 X X X

168. White City,
Oreg. 20 X

169. White River
Junction, Vt. 1

170. Wichita, Kans. 15

171. Wilkes-Barre,
Pa. 4

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

     VA's May 7, 2004, decisions to add, close, or study inpatient services

Potential inpatient service duplication

Low acute inpatient workload

                                                                      Study   
                                                   Add one or Close           
                                                                one   ways to
                                                 more or more         align   
                                                 inpatient                    
                                                 inpatient          inpatient
                                                        service(s)h servicesj 
                                                        service(s)i 

Tertiary carec

                  Acute medicine cared Total projected demandf

Other basisg

VA medical
facilitya Networkb

Other caree

172. Wilmington, Del. 4X

Source: GAO analysis of VA data.

aVA medical facilities where VA owns capital assets that are used, at
least in part, for inpatient health care services.

bVA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

cVA medical facilities that provide tertiary care services and are within
120 miles of another VA medical facility that provides tertiary care
services and that VA identified as potentially duplicating inpatient
services.

dVA medical facilities that provide acute inpatient medicine services and
are within 60 miles of another VA medical facility that provides acute
inpatient medicine services and that VA identified as potentially
duplicating inpatient services.

eVA medical facilities that VA identified as close enough geographically
to another VA medical facility for VA to consider whether inpatient
services other than tertiary care or acute inpatient medicine were needed
at both. The potentially duplicated inpatient services generally included
psychiatric and longterm inpatient care; services that support inpatient
care generally included administration and maintenance.

fWe identified low total projected acute inpatient demand when a VA
medical facility that provided acute inpatient medicine services during
the first half of fiscal year 2004, the time period immediately before VA
made its CARES decisions, was projected to need fewer than 40 acute
medicine, surgery, and psychiatry beds (combined) in fiscal years 2012 and
2022.

gVA identified other low acute inpatient workload, even if the total
projected number of acute medicine, surgery, and psychiatry beds was
expected to exceed 40 in fiscal years 2012 or 2022, when (1) it questioned
the viability of a specific acute inpatient service, for example, because
projections indicated that few beds would be needed for inpatient surgery
or (2) low acute inpatient workload at an existing VA medical facility
could result from decisions VA made about inpatient health care at other
locations.

hVA's decision to add an inpatient service means that one or more
inpatient services will be added to an existing VA medical facility that
did not provide the service.

iVA's decision to close an inpatient service means that one or more
inpatient services will be eliminated at a VA medical facility that
provided the service.

jWe defined a study as one that could result in a decision to add or close
an inpatient service at a VA medical facility.

kVA studied its facilities in Network 12 during a pilot phase of CARES
that was completed in February 2002.

lVA decided to close all inpatient services at this medical facility.

Appendix V: VA's 172 Medical Facilities, Potential Service Duplication or
Low Acute Inpatient Workload, and Alignment Decisions

mIn addition to its decision to add inpatient treatment for spinal cord
injury and disorder to its medical facility in Denver, Colorado, VA also
decided to build a replacement for this facility. Once the new medical
facility is complete, VA will close the existing facility and transfer all
inpatient care to the new facility.

Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

1-East 	This market includes Rhode Island and eastern Massachusetts. VA
owns five inpatient medical facilities in this market, located in Bedford,
Brockton, Jamaica Plain, and West Roxbury, Mass., and Providence, R.I.

1-Far North        This market includes                 X               Xe 
                      Maine. VA owns one                            
                      inpatient medical facility in                 
                      this market, located in                       
                      Togus, Maine.                                 

1-North          This market includes New            X                  Xe 
                    Hampshire and Vermont.                         
                    VA owns two inpatient                          
                    medical facilities in this                     
                    market, located in                             
                    Manchester, N.H., and                          
                    White River Junction, Vt.                      

1-West 	This market includes Connecticut and western Massachusetts. VA
owns two inpatient medical facilities in this market, located in
Northampton, Mass., and West Haven, Conn.

2-Central 	This market includes east central upstate New York. VA owns one
inpatient medical facility in this market, located in Syracuse, N.Y.

2-Eastern 	This market includes eastern upstate New York. VA owns one
inpatient medical facility in this market, located in Albany, N.Y.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

VA identification of limitations in geographic access to inpatient care VA's May
    7, 2004, decisions for improving access to tertiary, acute, or long-term
                                 inpatient care

Network and marketa Geographic area covered by market and the VA inpatient
medical facilities within it

 Add one or more VA inpatient service(s) Enter agreement with non-VA providersd
                             Study options for care

Tertiary careb

Acute carec

Long-term care

2-Finger This market includes west Lakes/ central upstate New York
Southern Tier and parts of north central

Pennsylvania. VA owns two inpatient medical facilities in this market,
located in Bath and Canandaigua, N.Y.

2-Western 	This market includes western upstate New York. VA owns two
inpatient medical facilities in this market, located in Batavia and
Buffalo, N.Y.

3-Long Island	This market includes Long Island, New York. VA owns one
inpatient medical facility in this market, located in Northport, N.Y.

3-Metro New This market includes New

York 	York City and the Hudson Valley area of New York. VA owns six
inpatient medical facilities in this market, located in Brooklyn, the
Bronx, Castle Point, Manhattan, Montrose, and St. Albans, N.Y.

3-New Jersey	This market includes northern New Jersey. VA owns two
inpatient medical facilities in this market, located in East Orange and
Lyons, N.J.

4-Eastern 	This market includes Delaware, southern New Jersey, eastern
Pennsylvania, and part of New York. VA owns five inpatient medical
facilities in this market, located in Coatesville, Lebanon, Philadelphia,
and Wilkes-Barre, Pa., and Wilmington, Del.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

VA identification of limitations in geographic access to inpatient care VA's May
    7, 2004, decisions for improving access to tertiary, acute, or long-term
                                 inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

4-Western 	This market includes western Pennsylvania and parts of three
other states: New York, Ohio, and West Virginia. VA owns seven inpatient
medical facilities in this market, located in Altoona, Butler, Erie, and
Pittsburgh, Pa. (Heinz Center, Highland Drive, and University Drive), and
Clarksburg, W.Va.

5-Baltimore 	This market includes eastern Maryland. VA owns three
inpatient medical facilities in this market, located in Baltimore, Loch
Raven, and Perry Point, Md.

5-Martinsburg	This market includes western Maryland, northwestern
Virginia, eastern West Virginia, and part of Pennsylvania. VA owns one
inpatient medical facility in this market, located in Martinsburg, W.Va.

5-                 This market includes the                    Xf       Xf 
Washington,        District of Columbia and                       
D.C.               parts of both Maryland and                     
                      Virginia. VA owns one                          
                      inpatient medical facility in                  
                      this market, located in                        
                      Washington, D.C.                               

6-Northeast 	This market includes parts of eastern Virginia and
northeastern North Carolina. VA owns two inpatient medical facilities in
this market, located in Hampton and Richmond, Va.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

6-Northwest 	This market includes parts of western Virginia and
southeastern West Virginia. VA owns two inpatient medical facilities in
this market, located in Beckley, W.Va., and Salem, Va.

6-Southeast         This market includes most           X               Xe 
                       of eastern North Carolina                    
                       and part of South Carolina.                  
                       VA owns two inpatient                        
                       medical facilities in this                   
                       market, located in Durham                    
                       and Fayetteville, N.C.                       

6-Southwest 	This market includes most of western North Carolina. VA owns
two inpatient medical facilities in this market, located in Asheville and
Salisbury, N.C.

7-Alabama          This market includes most          X                 Xe 
                      of Alabama and part of                       
                      western Georgia. VA owns                     
                      four inpatient medical                       
                      facilities in this market,                   
                      located in Birmingham,                       
                      Montgomery, Tuscaloosa,                      
                      and Tuskegee, Ala.                           

7-Georgia 	This market includes most of Georgia and part of South
Carolina. VA owns four inpatient medical facilities in this market,
located in Atlanta, Augusta (Downtown and Uptown), and Dublin, Ga.

7-South          This market includes most            X                 Xe 
Carolina         of South Carolina and part                     
                    of Georgia. VA owns two                        
                    inpatient medical facilities                   
                    in this market, located in                     
                    Charleston and Columbia,                       
                    S.C.                                           

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

8-Atlantic 	This market includes southeast Florida. VA owns two inpatient
medical facilities in this market, located in Miami and West Palm Beach,
Fla.

8-Central         This market includes the                X             Xg 
                     central part of Florida. VA                   
                     owns two inpatient medical                    
                     facilities in this market,                    
                     located in Orlando and                        
                     Tampa, Fla.                                   

8-Gulf          This market includes part of          X                 Xe 
                   southwestern Florida. VA                        
                   owns one inpatient medical                      
                   facility in this market,                        
                   located in Bay Pines, Fla.                      

8-North          This market includes most            X                 Xe 
                    of northern Florida and part                   
                    of southern Georgia. VA                        
                    owns two inpatient medical                     
                    facilities in this market,                     
                    located in Gainesville and                     
                    Lake City, Fla.                                

8-Puerto Rico	This market includes Puerto Rico, the U.S. Virgin Islands of
St. Thomas and St. Croix, and Arecibo. VA owns one inpatient medical
facility in this market, located in San Juan, P.R.

9-Central 	This market includes central Tennessee and parts of both
Georgia and Kentucky. VA owns two inpatient medical facilities in this
market, located in Murfreesboro and Nashville, Tenn.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

9-Eastern 	This market includes eastern Tennessee and parts of three other
states: Kentucky, North Carolina, and Virginia. VA owns one inpatient
medical facility in this market, located in Mountain Home, Tenn.

9-Northern 	This market includes most of Kentucky and parts of three other
states: Indiana, Ohio, and West Virginia. VA owns four inpatient medical
facilities in this market, located in Huntington, W.Va., and Lexington
(Cooper and Leestown) and Louisville, Ky.

9-Western 	This market includes eastern Arkansas, northern Mississippi,
and western Tennessee. VA owns one inpatient medical facility in this
market, located in Memphis, Tenn.

10-Central         This market includes the             X               Xe 
                      southern central portion of                   
                      Ohio. VA owns one                             
                      inpatient medical facility in                 
                      this market, located in                       
                      Chillicothe, Ohio.                            

10-Eastern         This market includes               X                 Xe 
                      northeastern Ohio. VA                        
                      owns two inpatient medical                   
                      facilities in this market,                   
                      located in Cleveland, Ohio                   
                      (Brecksville and Wade                        
                      Park).                                       

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

VA identification of limitations in geographic access to inpatient care VA's May
    7, 2004, decisions for improving access to tertiary, acute, or long-term
                                 inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

10-Western 	This market includes southwestern Ohio and parts of both
Indiana and Kentucky. VA owns three inpatient medical facilities in this
market, located in Cincinnati and Dayton, Ohio, and Fort Thomas, Ky.

11-Central         This market includes the             X               Xe 
Illinois           eastern central portion of                    
                      Illinois and part of western                  
                      Indiana. VA owns one                          
                      inpatient medical facility in                 
                      this market, located in                       
                      Danville, Ill.                                

11-Indiana 	This market includes most of Indiana and part of Ohio. VA owns
three inpatient medical facilities in this market, located in Fort Wayne,
Indianapolis, and Marion, Ind.

      11-Michigan         This market includes lower         Xh            Xh 
                             Michigan and part of                   
                            northwest Ohio. VA owns                 
                            four inpatient medical                  
                          facilities in this market,                
                         located in Ann Arbor, Battle               
                              Creek, Detroit, and                   
                                Saginaw, Mich.                      

12-Centrali	This market includes most of Wisconsin and parts of both
Illinois and Minnesota. VA owns three inpatient medical facilities in this
market, located in Madison, Milwaukee, and Tomah, Wis.

12-Northerni	This market includes Michigan's Upper Peninsula and
northeastern Wisconsin. VA owns one inpatient medical facility in this
market, located in Iron Mountain, Mich.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

VA identification of limitations in geographic access to inpatient care VA's May
    7, 2004, decisions for improving access to tertiary, acute, or long-term
                                 inpatient care

Network and marketa Geographic area covered by market and the VA inpatient
medical facilities within it

 Add one or more VA inpatient service(s) Enter agreement with non-VA providersd
                             Study options for care

Tertiary careb

Acute carec

Long-term care

12-Southerni	This market includes parts of northeastern Illinois and
northwestern Indiana. VA owns three inpatient medical facilities in this
market, located in Chicago-West Side, Hines, and North Chicago, Ill.

15-Central 	This market includes eastern Kansas, most of western Missouri,
and part of Illinois. VA owns four inpatient medical facilities in this
market, located in Columbia and Kansas City, Mo., and Leavenworth and
Topeka, Kans.

15-Eastern 	This market includes southern Illinois, western Kentucky,
eastern Missouri, and parts of both Arkansas and Indiana. VA owns four
inpatient medical facilities in this market, located in Marion, Ill., and
Poplar Bluff and St. Louis (Jefferson Barracks and John Cochran), Mo.

15-Western 	This market includes most of western Kansas. VA owns one
inpatient medical facility in this market, located in Wichita, Kans.

16-Central This market includes

Lower 	western Louisiana, eastern Texas, and part of Arkansas. VA owns
three inpatient medical facilities in this market, located in Alexandria
and Shreveport, La., and Houston, Tex.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

16-Central This market includes

Southern 	eastern Louisiana and most of Mississippi. VA owns four
inpatient medical facilities in this market, located in Biloxi, Gulfport,
and Jackson, Miss., and New Orleans, La.

16-Eastern         This market includes parts         X                 Xe 
Southern           of southern Alabama and                      
                      western Florida. VA does                     
                      not own any inpatient                        
                      medical facilities in this                   
                      market.                                      

16-Upper This market includes most

Western 	of Arkansas and Oklahoma and parts of both Missouri and Texas. VA
owns five inpatient medical facilities in this market, located in
Fayetteville, Little Rock, and North Little Rock, Ark., and Muskogee and
Oklahoma City, Okla.

17-Central         This market includes the             X               Xe 
                      central portion of Texas. VA                  
                      owns two inpatient medical                    
                      facilities in this market,                    
                      located in Temple and                         
                      Waco, Tex.                                    

17-North 	This market includes part of north Texas and part of Oklahoma.
VA owns two inpatient medical facilities in this market, located in Bonham
and Dallas, Tex.

17-Southern 	This market includes south central Texas. VA owns two
inpatient medical facilities in this market, located in Kerrville and San
Antonio, Tex.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

17-Valley -          This market includes               X               Xe 
Coastal Bend         southern Texas. VA does                     
                        not own any inpatient                       
                        medical facilities in this                  
                        market.                                     

18-Arizona 	This market includes Arizona. VA owns three inpatient medical
facilities in this market, located in Phoenix, Prescott, and Tucson, Ariz.

18-New             This market includes New            X    X         Xe,j 
Mexico - West      Mexico, western Texas,                         
Texas              and parts of southern                          
                      Colorado and western                           
                      Oklahoma. VA owns three                        
                      inpatient medical facilities                   
                      in this market, located in                     
                      Albuquerque, N. Mex., and                      
                      Amarillo and Big Spring,                       
                      Tex.                                           

19-Eastern         This market includes               X                 Xe 
Rockies            eastern Colorado,                            
                      southeastern Wyoming,                        
                      and parts of both Kansas                     
                      and Nebraska. VA owns                        
                      two inpatient medical                        
                      facilities in this market,                   
                      located in Denver, Colo.,                    
                      and Cheyenne, Wyo.                           

19-Grand This market includes

Junction	western Colorado and southeastern Utah. VA owns one inpatient
medical facility in this market, located in Grand Junction, Colo.

19-Montana       This market includes most           X    X           Xe,j 
                    of Montana and part of                          
                    western North Dakota. VA                        
                    owns two inpatient medical                      
                    facilities in this market,                      
                    located in Fort Harrison and                    
                    Miles City, Mont.                               

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

19-Western This market includes most

Rockies 	of Utah and parts of three other states: Idaho, Nevada, and
Wyoming. VA owns one inpatient medical facility in this market, located in
Salt Lake City, Utah.

19-Wyoming	This market includes most of northern Wyoming. VA owns one
inpatient medical facility in Sheridan, Wyo.

20-Alaska         This market includes                  X               Xj 
                     Alaska. VA owns one                            
                     inpatient medical facility in                  
                     this market, located in                        
                     Anchorage, Alaska.                             

20-Inland       This market includes                X    X            Xe,j 
North           eastern Washington,                              
                   northern Idaho,                                  
                   northeastern Oregon, and                         
                   part of northwest Montana.                       
                   VA owns two inpatient                            
                   medical facilities in this                       
                   market, located in Spokane                       
                   and Walla Walla, Wash.                           

20-Inland          This market includes parts         X                 Xj 
South              of eastern Oregon and                        
                      southern Idaho. VA owns                      
                      one inpatient medical                        
                      facility in this market,                     
                      located in Boise, Idaho.                     

20-South         This market includes                 X                 Xe 
Cascades         western Oregon,                                
                    southwestern Washington,                       
                    and part of northwestern                       
                    California. VA owns four                       
                    inpatient medical facilities                   
                    in this market, located in                     
                    Portland, Roseburg, and                        
                    White City, Oreg., and                         
                    Vancouver, Wash.                               

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

20-Western This market includes most

Washington 	of western Washington. VA owns two inpatient medical
facilities in this market, located in American Lake and Seattle, Wash.

21-North This market includes

Coast 	northern coastal California. VA owns two inpatient medical
facilities in this market, located in Martinez and San Francisco, Calif.

21-North This market includes north

Valley 	central California. VA owns one inpatient medical facility in this
market, located in Sacramento, Calif.

21-Pacific         This market includes                 X               Xj 
Islands            Hawaii and other Pacific                      
                      Islands such as Guam, the                     
                      Philippines, and American                     
                      Samoa. VA owns one                            
                      inpatient medical facility in                 
                      this market, located in                       
                      Honolulu, Hawaii.                             

21-Sierra         This market includes                X                 Xj 
Nevada            northeastern California and                   
                     western Nevada. VA owns                       
                     one inpatient medical                         
                     facility in this market,                      
                     located in Reno, Nev.                         

21-South         This market includes part of         X                 Xe 
Coast            central California. VA owns                    
                    three inpatient medical                        
                    facilities in this market,                     
                    located in Livermore, Menlo                    
                    Park, and Palo Alto, Calif.                    

21-South This market includes part of

Valley 	central California. VA owns one inpatient medical facility in this
market, located in Fresno, Calif.

  Appendix VI: VA's 77 Markets, Limitations in Geographic Access to Inpatient
                       Services, and Alignment Decisions

    VA's May 7, 2004, decisions for improving access to tertiary, acute, or
 long-term inpatient care VA identification of limitations in geographic access
                               to inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

22-California	This market includes southern California. VA owns five
inpatient medical facilities in this market, located in Loma Linda, Long
Beach, San Diego, Sepulveda, and West Los Angeles, Calif.

22-Nevada       This market includes               Xk      Xl         Xg,l 
                   southern Nevada. VA does                         
                   not own any inpatient                            
                   medical facilities in this                       
                   market.                                          

23-Iowa          This market includes most           X                  Xe 
                    of Iowa and parts of both                      
                    Illinois and Missouri. VA                      
                    owns three inpatient                           
                    medical facilities in this                     
                    market, located in Des                         
                    Moines, Iowa City, and                         
                    Knoxville, Iowa.                               

23-Minnesota         This market includes most          X               Xe 
                        of Minnesota and part of                    
                        northwestern Wisconsin.                     
                        VA owns two inpatient                       
                        medical facilities in this                  
                        market, located in                          
                        Minneapolis and St. Cloud,                  
                        Minn.                                       

23-Nebraska	This market includes most of Nebraska and parts of three other
states: Iowa, Kansas, and Missouri. VA owns two inpatient medical
facilities in this market, located in Grand Island and Omaha, Nebr.

23-North        This market includes most          X    X             Xe,j 
Dakota          of North Dakota and parts                       
                   of both Minnesota and                           
                        South Dakota. VA owns                      
                   one inpatient medical                           
                   facility in this market,                        
                      located in Fargo, N. Dak.                    

Appendix VI: VA's 77 Markets, Limitations in Geographic Access to
Inpatient Services, and Alignment Decisions

VA identification of limitations in geographic access to inpatient care VA's May
    7, 2004, decisions for improving access to tertiary, acute, or long-term
                                 inpatient care

Network and marketa

            Geographic area                   Add one or        Enter         
         covered by market and                   more VA            agreement 
       the VA inpatient medical                inpatient          with non-VA 
         facilities within it                 service(s)          providers d 

                             Study options for care

Tertiary careb

Acute carec

Long-term care

23-South         This market includes most            X                 Xe 
Dakota           of South Dakota and parts                      
                    of five other states: Iowa,                    
                    Minnesota, Nebraska,                           
                    North Dakota, and                              
                    Wyoming. VA owns three                         
                    inpatient medical facilities                   
                    in this market, located in                     
                    Fort Meade, Hot Springs,                       
                    and Sioux Falls, S. Dak.                       

Source: GAO analysis of VA data.

Notes: Markets with three blank cells under the heading "VA identification
of limitations in geographic access to inpatient care" were not identified
by VA as having limitations in geographic access to tertiary, acute, or
long-term care and will therefore have blank entries in the cells under
the heading "VA's May 7, 2004, decisions for improving access to tertiary,
acute, or long-term inpatient care." VA's May 7, 2004, decisions did not
address another aspect of veterans' access to health care-the time that
veterans wait to obtain appointments at VA medical facilities-because
waiting times are related to multiple operational issues, such as staffing
and resources, in addition to capital infrastructure.

aVA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23. VA defines a health care market as a geographic
area having a sufficient population and geographic size to benefit from
the coordination and planning of health care services and to support a
full health care delivery system. Each VA network includes from 2 to 6
markets; nationwide, VA has 77 markets.

bVA identified limitations in geographic access to tertiary care in a
market when more than 35 percent and at least 12,000 of the veterans
enrolled for VA health care who reside in that market exceeded VA's
driving time standards for reaching a VA health care facility of 240
minutes for urban and rural areas or the community standard for highly
rural areas. Urban areas included counties designated as metropolitan by
the U.S. Census Bureau and counties with a population density of more than
166 people per square mile. Rural areas included counties that are not
designated as metropolitan and have a population density of 26 to 166
people per square mile. Highly rural counties included counties with a
population density of less than 26 people per square mile and counties
designated as highly rural by the VA health care network in which the
county is located.

cVA identified limitations in geographic access to acute inpatient care in
a market when more than 35 percent, and at least 12,000, of the veterans
enrolled for VA health care who reside in that market exceeded VA's
driving time standards for reaching a VA health care facility of 60
minutes for urban areas, 90 minutes for rural areas, and 120 minutes for
highly rural areas. Urban areas included counties designated as
metropolitan by the U.S. Census Bureau and counties with a population
density of more than 166 people per square mile. Rural areas included
counties that are not designated as metropolitan and have a population
density of 26 to 166 people per square mile. Highly rural counties
included counties with a population density of less than 26 people per
square mile and counties designated as highly rural by the VA health care
network in which the county is located.

dOptions for VA to enter into an agreement with non-VA providers include
contracting with non-VA providers, leasing space at non-VA medical
facilities, or collaborating with the Department of Defense.

Appendix VI: VA's 77 Markets, Limitations in Geographic Access to
Inpatient Services, and Alignment Decisions

eAcute inpatient care.

fDomiciliary care.

gInpatient medicine, surgery, and psychiatry to be provided in a new
VA-owned hospital.

hResidential rehabilitation for post-traumatic stress disorder and
substance abuse in the Detroit area.

iVA studied its markets in Network 12 during a pilot phase of CARES that
was completed in February 2002.

jTertiary care.

kAt the time VA made its CARES decisions, VA collaborated with the
Department of Defense to provide acute inpatient health care services in
Las Vegas, Nev., by having VA staff provide services to veterans in a
hospital at a local Air Force base. Through CARES, VA identified the
Nevada market as needing evaluation of options for improving access to
acute inpatient services based on its concern that this collaborative
arrangement would not provide sufficient capacity to meet veterans' needs
throughout the CARES planning horizon.

lNursing home care.

Appendix VII: VA's 21 Networks, Limitations in Geographic Access to Specialized
Inpatient Services, and Alignment Decisions

VA's May 7, 2004, decisions for improving access to specialized inpatient
      treatment of spinal cord injury and disorder or blind rehabilitation

Type of specialized inpatient care

              Spinal cord injury and disorder Blind rehabilitation

Add inpatient VA service

Study options for care

Networka Description of geographic area

This network includes Connecticut, Maine, Massachusetts, New Hampshire,
Rhode Island, and Vermont.

This network includes upstate New York and X Xb parts of north central
Pennsylvania.

This network includes parts of New York (the Hudson Valley, Long Island,
and New York City) and northern New Jersey.

This network includes Delaware; most of Pennsylvania; southern New Jersey;
and parts of three other states: New York, Ohio, and West Virginia.

This network includes the District of Columbia, Maryland, northern
Virginia, eastern West Virginia, and part of Pennsylvania.

This network includes most of North Carolina and Virginia, southeastern
West Virginia, and part of South Carolina.

This network includes most of Alabama, Georgia, and South Carolina.

           This network includes most of Florida, part of     X             X 
           southern Georgia, Puerto Rico, the U.S. Virgin           
          Islands of St. Thomas and St. Croix, and                  
                          Arecibo.                                  

This network includes Tennessee; most of Kentucky; eastern Arkansas;
northern Mississippi; and parts of six other states: Georgia, Indiana,
North Carolina, Ohio, Virginia, and West Virginia.

10 	This network includes most of Ohio and parts of both Indiana and
Kentucky.

11 	This network includes the eastern central portion of Illinois, most of
Indiana, lower Michigan, and part of Ohio.

12 	This network includes Michigan's Upper Peninsula, most of Wisconsin,
northern Illinois, and parts of both Indiana and Minnesota.

Appendix VII: VA's 21 Networks, Limitations in Geographic Access to
Specialized Inpatient Services, and Alignment Decisions

VA's May 7, 2004, decisions for improving access to specialized inpatient
      treatment of spinal cord injury and disorder or blind rehabilitation

Type of specialized inpatient care

              Spinal cord injury and disorder Blind rehabilitation

Add inpatient VA service

Study options for care

Networka Description of geographic area

This network includes most of Kansas and Missouri; southern Illinois; and
parts of three other states: Arkansas, Indiana, and Kentucky.

       This network includes Louisiana; most of        X     X     Xc       X 
        Arkansas, Mississippi, and Oklahoma; eastern                    
        Texas; and parts of three other states:                         
            Alabama, Florida, and Missouri.                             

This network includes central Texas and part of Oklahoma.

This network includes Arizona, New Mexico, western Texas, and parts of
southern Colorado and western Oklahoma.

           This network includes Utah; most of Colorado, X                 Xb 
           Montana, and Wyoming; and parts of five other           
            states: Idaho, Kansas, Nebraska, Nevada, and           
North Dakota.                                                   

This network includes Alaska, Oregon, and Washington; most of Idaho; and
parts of both California and Montana.

This network includes Hawaii; northern California; western Nevada; and
Pacific Islands such as Guam, the Philippines, and American Samoa.

This network includes southern California and X Xc southern Nevada.

               This network includes Iowa and South Dakota; X              Xb 
            most of Minnesota, Nebraska, and North                   
          Dakota; and parts of five other states: Illinois,          
                  Kansas, Missouri, Wisconsin, and Wyoming.          

Source: GAO analysis of VA data.

aVA health care facilities are organized into 21 regional networks, known
as Veterans Integrated Service Networks, which are to coordinate the
activities of and allocate resources to VA health care facilities. VA had
22 networks until January 2002, when it merged Networks 13 and 14 to form
a new network, Network 23.

bInpatient treatment for spinal cord injury and disorder.

cInpatient blind rehabilitation.

Appendix VIII: Comments from the Department of Veterans Affairs

Appendix IX: GAO Contact and Acknowledgments

GAO Contact James C. Musselwhite, (202) 512-7259

Acknowledgments 	In addition to the person named above, key contributors
to this report were Kristen Joan Anderson, Frederick Caison, Steven R.
Gregory, Janet Overton, and Paul Reynolds.

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