VA Long-Term Care: Trends and Planning Challenges in Providing
Nursing Home Care to Veterans (09-JAN-06, GAO-06-333T).
The Department of Veterans Affairs (VA) operates a nursing home
program that provides or pays for veterans' care in three nursing
home settings: VA-operated nursing homes, community nursing
homes, and state veterans' nursing homes. In addition, veterans
needing nursing home care may also receive it from non-VA
providers that are not funded by VA. VA is faced with a large
elderly veteran population, many of whom may be in need of
nursing home care. In 2004, 38 percent of the nation's veteran
population was over the age of 65, compared with 12 percent of
the general population. The Veterans Millennium Health Care and
Benefits Act (Millennium Act) of 1999 and VA policy require that
VA provide nursing home care to certain veterans. This statement
focuses on VA's nursing home program and trends in nursing home
expenditures, trends in the number of patients served, or
"patient workload," and key challenges VA faces in planning for
nursing home care for veterans. To examine these trends, GAO
updated information from prior work with spending and patient
workload data for fiscal year 2005 that VA provided. In a
November 2004 report, GAO presented spending and patient workload
data through fiscal year 2003. GAO discussed the updated
information with VA and incorporated comments as appropriate.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-333T
ACCNO: A44397
TITLE: VA Long-Term Care: Trends and Planning Challenges in
Providing Nursing Home Care to Veterans
DATE: 01/09/2006
SUBJECT: Health care costs
Health care services
Nursing homes
Statistical data
Strategic planning
Veterans benefits
Veterans hospitals
Health statistics
Cost analysis
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GAO-06-333T
Testimony
Before the Committee on Veterans' Affairs, U.S. Senate
United States Government Accountability Office
GAO
For Release on Delivery Expected at 10:00 a.m. HST
Lihue, Hawaii
Monday, January 9, 2006
VA LONG-TERM CARE
Trends and Planning Challenges in Providing Nursing Home Care to Veterans
Statement of Laurie E. Ekstrand
Director, Health Care
GAO-06-333T
Mr. Chairman and Members of the Committee:
We are pleased to be here today as you discuss issues regarding the
Department of Veterans Affairs (VA) health care program for veterans. One
important part of that program is nursing home care, which accounts for
about 9 percent of VA's health care expenditures. The VA nursing home
program provides care in three settings. It operates its own nursing homes
in 134 locations, including a nursing home in Honolulu; it pays for care
under contract in non-VA nursing homes, referred to as community nursing
homes, including two community nursing homes on the island of Oahu; and it
pays about one-third of the costs per day for veterans in state veterans'
nursing homes, one of which will be built in Hilo.1 In addition, veterans
needing nursing home care may also receive it from non-VA providers that
are not funded by VA. In its three settings, a range of nursing home
services is provided to veterans, including short-stay postacute care for
patients recovering from a condition such as a stroke to long-stay care
for patients who cannot be cared for at home because of severe, chronic
physical or mental limitations. VA nursing home care is part of a
continuum of long-term care services that VA provides, including services
to veterans in the community and in veterans' own homes.2
As you know, meeting veterans' nursing home care needs is a key issue for
VA nationally, and here in Hawaii, because of the large elderly veteran
population, many of whom are in need of such care. Nationwide, the issue
of meeting nursing home needs is even more urgent for the veteran
population than for the general population because the veteran population
is older. In 2004, 38 percent of the nation's veteran population was over
the age of 65, compared with 12 percent of the general population.
Similarly, in Hawaii, 38 percent of the veteran population was over the
age of 65, compared with almost 14 percent of the general population.
In my remarks today I will discuss trends in VA's overall nursing home
care expenditures,3 trends in the number of patients served, or "patient
workload," and key challenges VA faces in planning for nursing home care
for veterans. Examination of data on trends in the provision of nursing
home care and of challenges VA faces in planning for nursing home care is
important for oversight and strategic planning. Examination of these data
is also useful in assessing whether the nursing home program is meeting
current goals. My comments today are based primarily on work we have
previously completed.4 We updated information from our prior work with
spending and patient workload data for fiscal year 2005 that VA provided.
Thus we present the most current information available at the time of our
November 2004 report5 alongside the most current information available now
to assess trends between these two points in time. For fiscal year 2005,
VA used a different cost accounting system to develop expenditure totals
for each nursing home setting. VA told us that the accounting system used
in fiscal year 2005 would result in higher expenditures than the
accounting system VA used in fiscal year 2003. VA could not provide the
2005 expenditure totals using the 2003 cost accounting system, which could
be used to determine the extent to which the change in expenditures
resulted from real changes in the level of nursing home care expenditures
or from the change in cost accounting systems. As in our previous work, we
measured patient workload by using the average daily census, which
reflects the average number of veterans receiving nursing home care on any
given day during the course of the year. In doing our work, we discussed
the updated information with VA, determined the information was adequate
for our purposes, and incorporated comments from VA as appropriate. We
conducted our review from December 2005 through January 2006 in accordance
with generally accepted government auditing standards.
1In addition to operating expenses, VA also pays about two-thirds of the
costs of construction for state veterans' nursing homes.
2VA noninstitutional services include home-based primary care,
homemaker/home-health aid, adult day health care, skilled home health
care, and home-respite care.
3These expenditures do not include construction costs.
In summary, VA's reported overall nursing home care expenditures in its
three settings increased from $2.3 billion to almost $3.2 billion from
fiscal year 2003 through fiscal year 2005. VA officials attributed the
expenditure increase from fiscal year 2003 to fiscal year 2005, in part,
to a change in the cost accounting system used to develop expenditure
totals for each nursing home setting. Based on VA's reported expenditures,
VA-operated nursing homes continued to account for about three-quarters of
VA's overall nursing home care expenditures in fiscal year 2005, as they
did in fiscal year 2003. In fiscal year 2005, 77 percent of nursing home
care expenditures were accounted for by VA-operated nursing homes,
compared to 73 percent in 2003. VA spent the remainder on state veterans'
nursing homes and community nursing homes. From fiscal year 2003 through
fiscal year 2005, the percentage of overall expenditures for state
veterans' nursing homes declined from 15 to 12 percent and the percentage
of overall expenditures for community nursing homes declined from 12 to 11
percent.
4See Related GAO Products at the end of this statement.
5See GAO, VA Long-Term Care: Oversight of Nursing Home Program Impeded by
Data Gaps, GAO-05-65 (Washington D.C.: Nov. 10, 2004).
VA's overall patient workload in nursing homes increased to an average of
34,375 patients per day by fiscal year 2005, 3.5 percent above the fiscal
year 2003 workload. State veterans' nursing homes accounted for over half
of VA's patient workload in fiscal year 2005. The workload percent is
higher than the 12 percent expenditure in state veterans' nursing homes
partly because VA pays on average about one-third of the costs for care
veterans receive in state veterans' nursing homes, compared to the full
cost in other settings. From fiscal year 2003 through fiscal year 2005,
the percentage of workload provided in state veterans' nursing homes
increased from 50 to 52 percent. In contrast, the percentage of patient
workload provided in VA-operated nursing homes declined from 37 to 35
percent. The percentage of workload in community nursing homes stayed the
same at 13 percent.
VA faces two key challenges in planning for the provision of nursing home
care. The first challenge is estimating who will seek care from VA and
what their nursing home care needs will be. This includes estimating the
number of veterans that will be eligible for nursing home care, based on
law and VA policy, and the extent to which these veterans will be seeking
care for short-stay postacute needs or long-stay chronic needs. A second
key challenge VA faces is determining whether it will maintain or increase
the proportion of nursing home care demand it meets in each of the three
nursing home settings or whether veterans will need to rely more on other
non-VA nursing home care providers that are funded by other programs, such
as Medicaid and Medicare.
Background
VA has provided nursing home care to veterans for over 40 years. The
Veterans Millennium Health Care and Benefits Act (Millennium Act)6 made
important changes in VA's nursing home program. This act required that
through December 31, 2003, VA provide nursing home care to veterans with a
service-connected disability rating of 70 percent or greater,7 veterans
requiring nursing home care because of a condition related to their
service, and veterans who were receiving care in a VA nursing home on
November 30, 1999. Subsequent law extended these provisions through
December 31, 2008.8 VA also has established a policy to provide nursing
home care to veterans with a 60 percent service-connected disability
rating who also were classified as unemployable or permanently and totally
disabled. For all other veterans, VA provides care in VA-operated nursing
homes and contract community nursing homes on a discretionary basis,
depending on available resources, with certain patients having higher
priority, including veterans who require postacute care after a hospital
stay. VA pays a portion of the cost to treat veterans who seek care in
state veterans' nursing homes.
6Pub. L. No. 106-117, S:101(a)(1), 113 Stat. 1545, 1547-51 (1999).
The state veterans' nursing homes receive VA funds as part of their
participation in VA's program. As of fiscal year 2005, 116 state veterans'
nursing homes in 44 states and Puerto Rico received payment from VA to
provide care. In fiscal year 2005, VA paid $59.36 per day per veteran to
these state veterans' nursing homes and awarded grants to states for
renovations to existing facilities or construction of new state veterans'
homes. States are responsible for obtaining financing sources to pay for
their portion of veterans' daily cost of care and for their portion
related to renovations to existing facilities or construction of new state
veterans' homes.
Most veterans, however, do not receive their nursing home care from the VA
program but instead receive it from other providers. Care from others
includes both long-stay nursing home care to assist with daily activities,
such as eating and bathing, and short-stay care requiring skilled nursing
home care following hospitalization. For veterans who do not receive their
nursing home care from the VA program, care is financed by programs such
as Medicaid, Medicare, private health or long-term care insurance, or
"self-financing" by the patients.9 States administer Medicaid programs
that include coverage for long-stay nursing home care. State Medicaid
programs are the primary funders of nursing homes, and self-financing is
the next most common source. Medicare primarily covers acute care health
costs and therefore limits its nursing home coverage to short stays.
Private health insurance pays for a smaller portion of nursing home
expenditures than the other three main sources.10
7A service-connected disability is an injury or disease that was incurred
or aggravated while on active duty. VA classifies veterans with
service-connected disabilities according to the extent of their
disability. These classifications are expressed in terms of
percentages-for example, the most severely disabled veteran would be
classified as having a service-connected disability of 100 percent.
Percentages are assigned in increments of 10 percent.
8The Veterans Health Care, Capital Asset, and Business Improvement Act of
2003, Pub. L. No. 108-170, S: 106 (b), 117 Stat. 2042, 2045-46.
Reported Overall Nursing Home Expenditures Increased, with VA-Operated Nursing
Homes Continuing to Account for Almost Three-Quarters of Expenditures
VA's reported overall nursing home care expenditures increased from $2.3
billion to almost $3.2 billion from fiscal year 2003 through fiscal year
2005. (See table 1.) Expenditures increased in each nursing home setting.
From fiscal year 2003 through fiscal year 2005, expenditures increased by
$743 million in VA-operated nursing homes, $80 million in community
nursing homes, and $30 million in state veterans' nursing homes. VA
officials attributed the expenditure increase from fiscal year 2003 to
fiscal year 2005, in part, to a change in the cost accounting system used
to develop expenditure totals for each nursing home setting.11
9VA is not authorized, in most cases, to bill and collect payments from
Medicaid and Medicare, nor can VA bill other insurers for health care
services that are related to a service-connected disability. However, a
veteran's eligibility to participate in VA's nursing home program does not
prohibit him or her from using these financing sources for nursing home
care outside of VA's health care system, if eligible.
10See GAO, Long-Term Care: Aging Baby Boom Generation Will Increase Demand
and Burden on Federal and State Budgets, GAO-02-544T (Washington, D.C.:
Mar. 21, 2002).
11The change in cost accounting systems may explain why the annual growth
in nursing home expenditures from fiscal year 2003 to fiscal year 2005 of
over 18 percent was more than double the growth rate of almost 8 percent
from fiscal year 1998 through fiscal year 2003.
Table 1: Change in Reported Nursing Home Care Expenditures, Fiscal Years
2003 and 2005
Dollars in millions
Nursing home setting Change from FY 2003 to FY
FY 2003 FY 2005 2005
VA-operated nursing homes $1,697 $2,441 $743
Community nursing homes $272 $352 $80
State veterans' nursing $352 $382 $30
homes
Total $2,321 $3,174 $853
Source: VA.
Note: Dollar amounts may not add due to rounding. VA officials attributed
the increase in expenditures during this period, in part, to a change in
the cost accounting system used to estimate expenditures for each nursing
home setting.
Based on VA's reported nursing home care expenditures, VA-operated nursing
homes continued to account for about three-quarters of VA's overall
nursing home care expenditures in fiscal year 2005, as they did in fiscal
year 2003. (See fig. 1.) In fiscal year 2005, 77 percent of nursing home
care expenditures were accounted for by VA-operated nursing homes,
compared to 73 percent in 2003. From fiscal year 2003 to fiscal year 2005,
the percentage of overall expenditures for state veterans' nursing homes
and community nursing homes declined. The percentage of overall
expenditures for state veterans' nursing homes declined during this period
because expenditures in VA-operated nursing homes increased more rapidly
than expenditures for state veterans' nursing homes. Growth in the
percentage of overall nursing home expenditures accounted for by
VA-operated nursing homes, as well as the decline in community nursing
homes during this 3-year period, was similar to the pattern we observed
from fiscal year 1998 through fiscal year 2003.12 In contrast, the
percentage of overall nursing home expenditures accounted for by state
veterans' nursing homes increased in the prior period, but decreased from
fiscal year 2003 through fiscal year 2005.
12See GAO-05-65.
Figure 1: Percentage of Reported Overall Nursing Home Care Expenditures by
Setting, Fiscal Years 2003 and 2005
Note: We calculated these percentages based on VA's reported nursing home
care expenditures, which were based on expenditure totals from different
cost accounting systems VA used in each fiscal year.
Overall Patient Workload Increased Slightly, with State Veterans' Nursing Homes
Continuing to Account for about Half of VA's Overall Patient Workload
VA's overall patient workload in all three nursing home settings, as
measured by average daily census, increased to an average of 34,375
patients per day by fiscal year 2005, 3.5 percent above the fiscal year
2003 workload. (See table 2.) However, the small increase in overall
workload masked different workload trends in VA's three settings. Strong
growth in state veterans' patient workload offset a small increase in
community patient workload and a decline in VA-operated patient workload.
From fiscal year 2003 through fiscal year 2005, average daily patient
workload in the nursing homes VA operated declined by 215, whereas
workload in community nursing homes increased by 221 and workload in state
veterans' nursing homes increased by 1,155. The continued strong growth in
workload in state veterans' nursing homes largely contributed to growth in
overall patient workload during this 3-year period and was consistent with
the trends that we observed from fiscal year 1998 through fiscal year
2003.
Table 2: Change in Patient Workload, Fiscal Years 2003 and 2005
Average Daily Census
Nursing home setting Change from FY 2003 to FY
FY 2003 FY 2005 2005
VA-operated nursing homes 12,373 12,158 (215)
Community nursing homes 4,202 4,423 221
State veterans' nursing 16,639 17,794 1,155
homes
Total 33,214 34,375 1,161
Source: VA.
Note: The workload measure is average daily census, which represents the
total number of days of nursing home care provided in a year divided by
the number of days in the year.
The percentage of workload provided in state veterans' nursing homes
continued to account for about half of VA's overall patient workload,
increasing from 50 percent in fiscal year 2003 to 52 percent in fiscal
year 2005. In contrast, the percentage of patient workload provided in
VA-operated nursing homes declined. The percentage provided in community
nursing homes stayed the same. (See fig. 2.) In fiscal year 2005, state
veterans' nursing homes accounted for over half of VA's overall workload,
and they accounted for 12 percent of overall expenditures for patient
care. The relatively low proportion of expenditures can be explained in
large part by VA's per-diem rate for care in state veterans' nursing
homes, which on average accounts for about one-third of the cost for care
in this setting. Continued growth in the percentage of overall patient
workload accounted for by state veterans' nursing homes during this 3-year
period was similar to the pattern we observed from fiscal year 1998
through fiscal year 2003.
Figure 2: Percentage of Overall Patient Workload by Setting, Fiscal Years
2003 and 2005
Note: The workload measure is average daily census, which represents the
total number of days of nursing home care provided in a year divided by
the number of days in the year.
VA Faces Two Key Challenges in Planning for Nursing Home Care
VA faces two key challenges in planning for the provision of nursing home
care. The first challenge is estimating who will seek care from VA and
what their nursing home care needs will be. To do this, VA will need to
estimate the number of veterans that will be eligible for nursing home
care based on the Millennium Act and VA policy or that will be able to
receive such care on a discretionary basis, based on available resources.
Moreover, VA will need to estimate the extent to which these veterans will
be seeking care for short-stay postacute needs or long-stay chronic needs.
To meet this challenge, VA needs to establish a baseline for current
nursing home needs being met by obtaining more complete information on the
eligibility of veterans currently receiving services and on whether they
are using short-stay or long-stay nursing home care. Although VA collects
data on eligibility and length of stay for its VA-operated nursing homes,
it lacks comparable data on eligibility and length of stay for state
veterans' nursing homes and on length of stay for community nursing homes.
We recommended in November 2004 that VA work to close this gap.13 VA
agreed to do so, but has not fully implemented our recommendations. VA has
begun to collect and report eligibility data on veterans receiving care in
VA community nursing homes. Data on eligibility and length of stay for
state veterans' nursing homes and community nursing homes are especially
critical because these two settings account for almost two-thirds of VA's
overall nursing home workload. Without these data, VA does not know how
the three settings in combination are being used to serve veterans of
different eligibility, and what proportion of short-stay and long-stay
needs are being met in all three settings. As a result, VA does not have a
baseline from which to estimate future demand for nursing home care in
each setting as the overall veteran population and its needs change over
time.
13GAO-05-65.
A second key challenge VA faces is determining whether it will maintain or
increase the proportion of nursing home care demand it meets in each of
the three nursing home settings or whether veterans will need to rely more
on other non-VA nursing home care providers that are funded by other
programs, such as Medicaid and Medicare. To meet this challenge, VA needs
to make policy determinations concerning which veterans it will provide
nursing home care to in the future and the mix of short-stay and long-stay
services it will offer. For example, to what extent will VA continue to
provide nursing home care to veterans in addition to those that it is
required to serve under the Millennium Act? To what extent will VA provide
short-stay nursing home care, and to what extent will it provide long-stay
nursing home care? VA told us that such policy decisions have not been
made. These policy decisions are needed to establish criteria to be used
to identify which veterans VA will serve and what nursing home services it
will offer as a matter of policy, in addition to those required by law.
Then VA can begin to generate the information it needs for planning. This
may include, for example, how many nursing homes are needed in each
setting and where they should be located.
VA is working on these challenges and has developed a draft long-term care
strategic plan. Completing the long-term care strategic plan could help VA
determine how to maximize the use of resources for meeting nursing home
needs of veterans across the country in each of the three nursing home
settings. VA has not given a timeline for completion of the long-term care
strategic plan. In May 2004, the Secretary of Veterans Affairs
acknowledged that a strategic plan would be necessary to help achieve VA's
goals, including ensuring that veterans have access to an appropriate
range of services.14
Mr. Chairman, this concludes my prepared remarks. I will be pleased to
answer any questions you or other Members of the Committee may have.
Contact and Acknowledgments
For further information, please contact Laurie E. Ekstrand at (202)
512-7101 or ekstrandl@gao.gov. Individuals making key contributions to
this testimony include James C. Musselwhite, assistant director, Roseanne
Price, and Thomas A. Walke.
14Department of Veterans Affairs, Secretary of Veterans Affairs: CARES
Decision (Washington, D.C.: May 7, 2004). The Capital Asset Realignment
for Enhanced Services (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. Through this process, VA
sought to determine what health care services veterans would need in what
locations.
Related GAO Products
VA Health Care: Key Challenges to Aligning Capital Assets and Enhancing
Veterans' Care. GAO-05-429. Washington D.C.: August 5, 2005.
VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data Gaps.
GAO-05-65. Washington, D.C.: November 10, 2004.
VA Long-Term Care: More Accurate Measure of Home-Based Primary Care
Workload Is Needed. GAO-04-913. Washington, D.C.: September 8, 2004.
VA Long-Term Care: Changes in Service Delivery Raise Important Questions.
GAO-04-425T. Washington, D.C.: January 28, 2004.
VA Long-Term Care: Veterans' Access to Noninstitutional Care Is Limited by
Service Gaps and Facility Restrictions. GAO-03-815T. Washington, D.C.: May
22, 2003.
VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans'
Access to Noninstitutional Care. GAO-03-487. Washington, D.C.: May 9,
2003.
Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.
VA Long-Term Care: The Availability of Noninstitutional Services Is
Uneven. GAO-02-652T. Washington, D.C.: April 25, 2002.
VA Long-Term Care: Implementation of Certain Millennium Act Provisions Is
Incomplete, and Availability of Noninstitutional Services Is Uneven.
GAO-02-510R. Washington, D.C.: March 29, 2002.
VA Long-Term Care: Oversight of Community Nursing Homes Needs
Strengthening. GAO-01-768. Washington, D.C.: July 27, 2001.
(290515)
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Highlights of GAO-06-333T, a testimony before the Committee on Veterans'
Affairs, U.S. Senate
January 9, 2006
VA LONG-TERM CARE
Trends and Planning Challenges in Providing Nursing Home Care to Veterans
The Department of Veterans Affairs (VA) operates a nursing home program
that provides or pays for veterans' care in three nursing home settings:
VA-operated nursing homes, community nursing homes, and state veterans'
nursing homes. In addition, veterans needing nursing home care may also
receive it from non-VA providers that are not funded by VA. VA is faced
with a large elderly veteran population, many of whom may be in need of
nursing home care. In 2004, 38 percent of the nation's veteran population
was over the age of 65, compared with 12 percent of the general
population. The Veterans Millennium Health Care and Benefits Act
(Millennium Act) of 1999 and VA policy require that VA provide nursing
home care to certain veterans.
This statement focuses on VA's nursing home program and trends in nursing
home expenditures, trends in the number of patients served, or "patient
workload," and key challenges VA faces in planning for nursing home care
for veterans.
To examine these trends, GAO updated information from prior work with
spending and patient workload data for fiscal year 2005 that VA provided.
In a November 2004 report, GAO presented spending and patient workload
data through fiscal year 2003. GAO discussed the updated information with
VA and incorporated comments as appropriate.
VA's reported overall nursing home care expenditures in its three settings
increased from $2.3 billion to almost $3.2 billion from fiscal year 2003
through fiscal year 2005. VA officials attributed the expenditure increase
from fiscal year 2003 to fiscal year 2005, in part, to a change in the
cost accounting system used to develop expenditure totals for each nursing
home setting. Based on VA's reported expenditures, VA-operated nursing
homes continued to account for about three-quarters of VA's overall
nursing home care expenditures in fiscal year 2005, as they did in fiscal
year 2003. In fiscal year 2005, 77 percent of nursing home care
expenditures were accounted for by VA-operated nursing homes, compared to
73 percent in 2003. VA spent the remainder on state veterans' nursing
homes and community nursing homes. From fiscal year 2003 through fiscal
year 2005, the percentage of overall expenditures for state veterans'
nursing homes declined from 15 to 12 percent and the percentage of overall
expenditures for community nursing homes declined from 12 to 11 percent.
VA's overall patient workload in nursing homes increased to an average of
34,375 patients per day by fiscal year 2005, 3.5 percent above the fiscal
year 2003 workload. State veterans' nursing homes accounted for over half
of VA's patient workload in fiscal year 2005. The workload percent is
higher than the 12 percent expenditure in state veterans' nursing homes
partly because VA pays on average about one-third of the costs for care
veterans receive in state veterans' nursing homes, compared to the full
cost in other settings. From fiscal year 2003 through fiscal year 2005,
the percentage of workload provided in state veterans' nursing homes
increased from 50 to 52 percent. In contrast, the percentage of patient
workload provided in VA-operated nursing homes declined from 37 to 35
percent. The percentage of workload in community nursing homes stayed the
same at 13 percent.
VA faces two key challenges in planning for the provision of nursing home
care. The first challenge is estimating who will seek care from VA and
what their nursing home care needs will be. This includes estimating the
number of veterans that will be eligible for nursing home care, based on
law and VA policy, and the extent to which these veterans will be seeking
care for short-stay postacute needs or long-stay chronic needs. A second
key challenge VA faces is determining whether it will maintain or increase
the proportion of nursing home care demand it meets in each of the three
nursing home settings or whether veterans will need to rely more on other
non-VA nursing home care providers that are funded by other programs, such
as Medicaid and Medicare.
*** End of document. ***