VA Health Care: Persian Gulf Dependents' Medical Exam Program
Ineffectively Carried Out (Letter Report, 03/31/98, GAO/HEHS-98-108).

Pursuant to a congressional request, GAO reviewed the Department of
Veterans Affairs' (VA) implementation of the Persian Gulf Spouse and
Children Examination Program, focusing on: (1) outreach efforts; (2)
obstacles to family members' participation; and (3) contracting issues.

GAO noted that: (1) the Persian Gulf Spouse and Children Examination
Program has faced numerous implementation problems that have limited its
effectiveness in providing medical examinations; (2) to inform Persian
Gulf veterans and their family members about the program, VA approached
outreach in two ways--with a national campaign supplemented by local
efforts at coordinating VA medical centers; (3) GAO found that some
medical centers made efforts to contact Persian Gulf veterans and their
families, while others relied on headquarters' outreach efforts; (4)
however, GAO could not assess the effectiveness of these efforts because
of a lack of information on the potential number of Persian Gulf family
members who believe their illnesses are related to a family member's
service in the Gulf War; (5) although as of January 1998 coordinating
medical centers had received 2,802 requests for examinations, VA has
completed only 872; (6) forty-one percent of applicants either failed to
report for appointments, refused examinations, or had not yet answered
requests to schedule examinations; (7) program participants face a
lengthy and cumbersome scheduling process carried out through VA offices
other than the local VA medical centers; (8) GAO's analysis showed that
it takes an average of over 15 weeks for a participant to get an
examination; (9) in addition, because VA chose to administer the program
through only 36 of its 172 medical centers, examination sites are not
always easily accessible to participants; (10) three of the 16
coordinating medical centers GAO contacted have not conducted any
examinations because they have not contracted with their affiliated
medical schools or other providers; (11) VA headquarters officials were
unaware that examinations had not been conducted in two of the centers
because of turnover in key center positions, and because VA did not
start requiring monthly activity reports, which give the cumulative
status of examination requests, from coordinating medical centers until
October 1997; (12) GAO found that payment delays are caused in part by
contractors incorrectly completing required paperwork, which staff from
VA medical centers and affiliated medical schools told GAO is time
consuming to complete and lacks clear instructions; and (13) although VA
reserved $200,000 of authorized funds to cover the costs of tests,
medical center officials told GAO they would have requested more
referrals but believed resources were limited and the approval process
would require additional time and travel for participants.

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

 REPORTNUM:  HEHS-98-108
     TITLE:  VA Health Care: Persian Gulf Dependents' Medical Exam 
             Program Ineffectively Carried Out
      DATE:  03/31/98
   SUBJECT:  Health care services
             Veterans benefits
             Military personnel
             Military hospitals
             Military dependents
             Disease detection or diagnosis
             Health care programs
             Medical examinations
             Military procurement
IDENTIFIER:  VA Persian Gulf Spouse and Children Examination Program
             Gulf War Syndrome
             
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Cover
================================================================ COVER


Report to the Chairman and Ranking Minority Member, Committee on
Veterans' Affairs, U.S.  Senate

March 1998

VA HEALTH CARE - PERSIAN GULF
DEPENDENTS' MEDICAL EXAM PROGRAM
INEFFECTIVELY CARRIED OUT

GAO/HEHS-98-108

Persian Gulf Dependents' Medical Exam

(101611)


Abbreviations
=============================================================== ABBREV

  DOD - Department of Defense
  VA - Department of Veterans Affairs
  VHA - Veterans Health Administration
  VISN - Veterans Integrated Service Networks

Letter
=============================================================== LETTER


B-279416

March 31, 1998

The Honorable Arlen Specter
Chairman
The Honorable John D.  Rockefeller IV
Ranking Minority Member
Committee on Veterans' Affairs
United States Senate

Following service in the Persian Gulf War, some of the nearly 700,000
veterans who served in Operations Desert Shield and Desert Storm have
reported an array of symptoms including fatigue, skin rashes,
headaches, muscle and joint pain, memory loss, shortness of breath,
sleep disturbances, gastrointestinal conditions, and chest pain. 
Some spouses and children of Persian Gulf veterans have also reported
similar symptoms or resulting disorders. 

The Persian Gulf Spouse and Children Examination Program was
implemented under section 107 of the Persian Gulf War Veterans'
Benefits Act (P.L.  103-446) enacted on November 2, 1994.  The
program was established to provide diagnostic testing and medical
examinations to spouses and children of Persian Gulf veterans for a
study to determine whether an association exists between illnesses of
veterans and illnesses or disorders of their family members.  The
Congress authorized $2 million from existing Department of Veterans
Affairs (VA) appropriations and authorized VA to implement the
program by contracting with outside providers to conduct testing and
examinations.  VA was directed to start the program in November 1994. 
However, program implementation was delayed 17 months because VA and
members of the Senate differed over the best approach for
implementing it.  The program began in April 1996 and is set to
expire in December 1998.  VA planned to determine, by using a
research approach, whether an association existed between the
illnesses of Persian Gulf veterans and the illnesses of their family
members. 

As you requested, we reviewed VA's implementation of the program,
including outreach efforts, obstacles to family members'
participation, contracting issues, and referrals to medical
specialists for additional diagnostic tests.  Our information is
based on interviews with program officials at VA headquarters and 16
of the 36 coordinating VA medical centers for the Persian Gulf Spouse
and Children Examination Program.  We visited eight coordinating
medical centers located in Chicago, Denver, East Orange, Houston,
Minneapolis, Salt Lake City, Seattle, and Washington, D.C.  We also
contacted by telephone centers in Augusta, Birmingham, Dayton,
Honolulu, Palo Alto, Philadelphia, San Diego, and Tampa.  Because of
time constraints, we did not contact program participants or
individuals who have requested examinations.  We conducted our work
from December 1997 to March 1998 in accordance with generally
accepted government auditing standards.  (See app.  I for more detail
on our scope and methodology.)


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The Persian Gulf Spouse and Children Examination Program has faced
numerous implementation problems that have limited its effectiveness
in providing medical examinations.  To inform Persian Gulf veterans
and their family members about the program, VA approached outreach in
two ways--with a national campaign supplemented by local efforts at
coordinating VA medical centers.  We found that some medical centers
made efforts to contact Persian Gulf veterans and their families,
while others relied on headquarters' outreach efforts.  However, we
could not assess the effectiveness of these efforts because of a lack
of information on the potential number of Persian Gulf family members
who believe their illnesses are related to a family member's service
in the Gulf War. 

Although as of January 1998 coordinating medical centers had received
2,802 requests for examinations, VA has completed only 872 (31
percent).  Forty-one percent of applicants either failed to report
for appointments, refused examinations, or had not yet answered
requests to schedule examinations.  We identified several factors
contributing to the low completion rate.  Program participants face a
lengthy and cumbersome scheduling process carried out through VA
offices other than the local VA medical centers.  Our analysis showed
that it takes an average of over 15 weeks for a participant to get an
examination.  In addition, because VA chose to administer the program
through only 36 of its 172 medical centers, examination sites are not
always easily accessible to participants.  And if participants do
travel long distances to receive the examinations, VA is not
authorized under this program to reimburse them for travel, lodging,
or lost wages. 

Three of the 16 coordinating medical centers we contacted have not
conducted any examinations because they have not contracted with
their affiliated medical schools or other providers.  VA headquarters
officials were unaware that examinations had not been conducted in
two of the centers because of turnover in key center positions,
including program coordinators, and because VA did not start
requiring monthly activity reports, which give the cumulative status
of examination requests, from coordinating medical centers until
October 1997.  Additionally, citing fewer requests for examinations
and delays in receiving payment for their services, medical schools
affiliated with VA's Denver and Minneapolis medical centers did not
renew their contracts with VA.  Other medical schools still under
contract made similar complaints.  We found that payment delays are
caused in part by contractors incorrectly completing required
paperwork, which staff from VA medical centers and affiliated medical
schools told us is time consuming to complete and lacks clear
instructions. 

If additional diagnostic testing is needed to better understand a
patient's symptoms, examining physicians may refer participants to
medical specialists.  However, VA guidance stipulates that physicians
first obtain approval from VA headquarters if the costs of the
examination and additional diagnostic tests exceed $400.  According
to VA officials, all requests for referrals for additional diagnostic
tests--about 20--have been approved.  Although VA reserved $200,000
of authorized funds to cover the costs of these tests, medical center
officials told us they would have requested more referrals but they
believed resources were limited and the approval process would
require additional time and travel for participants. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Section 107 of the Persian Gulf War Veterans' Benefits Act required
VA to conduct a study to evaluate the health status of spouses and
children of Persian Gulf War veterans.  Under the study, VA was
directed to provide diagnostic testing and medical examinations to
any individual who (1) is the spouse or child of a veteran listed in
VA's Persian Gulf War Veterans' Registry\1

who is suffering from an illness or disorder; (2) is apparently
suffering from, or may have suffered from, an illness or disorder
(including a birth defect, miscarriage, or stillbirth) that cannot be
disassociated from the veteran's service in the Southwest Asia
theater of operations; and (3) in the case of a spouse, has granted
VA permission to include relevant medical data in the Registry. 
These tests and examinations were to be used to determine the nature
and extent of the association, if any, between the illness or
disorder of the spouse or child and the illness of the veteran. 

The Congress authorized VA to use contractors to provide the medical
examinations and specified that the amount spent for the program may
not exceed $2 million.  The entire $2 million was designated for
examinations; the program administrative costs are to be covered by
each coordinating medical center's operating budget.  The act does
not authorize funding for the treatment of family members of Persian
Gulf veterans or reimbursement of participants for travel, lodging,
or lost wages.  The act stipulated that the program was to be carried
out from November 1, 1994, through September 30, 1996. 

Program implementation was delayed until April 1996 because of a
disagreement between VA and members of the Senate over the
appropriate approach for establishing the program.  VA proposed doing
research, via the National Health Survey of Persian Gulf Veterans,
which was designed to gather information on the incidence and nature
of health problems occurring in Persian Gulf veterans and their
families.  The survey includes the examination of randomly selected
Persian Gulf spouses and children as well as a control group, for
comparison, of nondeployed Persian Gulf-era veterans and their
families.  (See app.  II for a description of the National Health
Survey of Persian Gulf Veterans.) However, in a November 1995 letter,
the Ranking Minority Member of the Senate Committee on Veterans'
Affairs and the Senate Minority Leader notified VA that its approach
would not meet the mandate expressed in section 107 of the act.  The
letter stated that VA was expected to provide spouses and children
the opportunity to seek medical examinations for conditions that
family members believe are related to Persian Gulf service and to
enter the examination information in the Persian Gulf Registry.  The
letter further stated that, while the survey was viewed as an
important epidemiological study for which the Congress expressed
approval by enactment of section 109 of the act, it would not meet
the mandate of section 107 of the act. 

In response to these concerns, the Secretary of Veterans Affairs
indicated in a February 1996 letter to the Ranking Minority Member of
the Senate Committee on Veterans' Affairs that the Veterans Health
Administration (VHA) would proceed immediately to provide voluntary
examinations to Persian Gulf family members.  VA initiated the
Persian Gulf Spouse and Children Examination Program in April 1996
when it began accepting requests for clinical examinations.  On
October 9, 1996, the Veterans' Health Care Eligibility Reform Act of
1996 (P.L.  104-262) extended the program through December 31, 1998. 
The program is administered through VHA's Office of Public Health and
Environmental Hazards and is implemented through coordinating VA
medical centers established in each of VA's 22 Veterans Integrated
Service Networks (VISN).\2

The program is offered at 36 of VA's 172 medical centers.  (See fig. 
1 for a map showing locations of the VISNs and the 36 coordinating
medical centers).  Coordinating medical centers are responsible for
establishing contracts, usually with their university-affiliated
medical schools, for the examination of Persian Gulf spouses and
children using standard medical protocols and guidelines developed by
VA. 

   Figure 1:  VISNs and
   Coordinating Medical Centers

   (See figure in printed
   edition.)



   (See figure in printed
   edition.)

Note:  Numbers indicate VISN number. 


--------------------
\1 Because all Persian Gulf veterans have not taken VA's registry
examination (67,053 as of Nov.  30, 1997), VA also checks the
Department of Defense (DOD) Persian Gulf Registry and DOD's Persian
Gulf Deployment Listing to establish eligibility for program
services. 

\2 VA established the VISN management structure in 1995.  The
structure shifted management authority from VA headquarters to the
new regional networks, which oversee medical center operations. 


   PERSIAN GULF DEPENDENTS'
   EXAMINATION PROGRAM HAS HAD
   IMPLEMENTATION PROBLEMS
------------------------------------------------------------ Letter :3

The Persian Gulf Spouse and Children Examination Program has faced
implementation problems that, to this point, have limited the
program's effectiveness.  To inform potential participants about the
program, VA headquarters initiated national, broad-based outreach
efforts with coordinating medical centers providing for local
outreach.  As of January 1998, VA coordinating medical centers have
received 2,802 requests for examinations, but only 31 percent (872)
of requested examinations have been completed.  Factors contributing
to the low completion rate include the lengthy and cumbersome process
for scheduling examinations, which we found takes an average of 15
weeks from the time applicants first apply to the time examinations
are completed.  Also, examination sites are not easily accessible for
some participants because only 36 of VA's 172 medical centers
participate in the program, and the law does not allow for VA to
reimburse participants for costs such as travel and lodging.  In
addition, as of January 1998, no examinations had been conducted in 3
of the 16 coordinating medical centers we contacted because those
centers had not negotiated contracts with affiliated medical schools
or other providers.  Problems also existed with obtaining additional
diagnostic testing in some locations. 


      EFFECTIVENESS OF OUTREACH
      EFFORTS IS DIFFICULT TO
      ASSESS
---------------------------------------------------------- Letter :3.1

VA headquarters initiated national outreach through notices about the
program in the Persian Gulf Review (a quarterly newsletter sent to
about 67,000 Persian Gulf veterans in the Registry), public service
television announcements, nationally broadcast television interviews
with VA officials about Persian Gulf issues, and announcements on the
Internet.  The Office of Public Affairs, through its regional
structure, provided coordinating VA medical centers with press
releases about the program.  All 172 VA medical centers received
basic information about the Persian Gulf Spouse and Children
Examination Program.  Also, one nationwide teleconference, available
to all VA medical centers, was held at the start of the program to
encourage centers to inform veterans about the availability of free
examinations for the family members of Persian Gulf veterans. 

According to a VA program official, local outreach was the
responsibility of the 36 coordinating VA medical centers.  Outreach
efforts at the medical centers we contacted ranged from direct
mailings to veterans on the Persian Gulf Registry to relying only on
national outreach efforts.  For example, the Tampa and Seattle
medical centers contacted all veterans who had received Persian Gulf
Registry examinations at their centers by letter or telephone.  Some
medical centers sent brochures to Persian Gulf veterans, and Persian
Gulf coordinators visited reserve units and service organizations and
informed them about the program.  However, the Denver and Salt Lake
City medical centers relied on national outreach efforts to provide
program information. 

Without information on how participants learned of the program or
knowledge of the potential universe of Persian Gulf spouses and
children who believe their illnesses or disorders may be related to a
family member's service in the Gulf, it is difficult to assess the
effectiveness of national or local outreach efforts.  However, VA
estimated that, on the basis of the $2 million authorized for the
program, it could provide about 4,500 examinations, based on an
average cost of $400 per examination, and have a reserve of $200,000
to cover the cost of additional diagnostic tests.  Examinations were
offered on a first come, first served basis.  As of January 1998,
coordinating medical centers reported they had received 2,802
requests for examinations.  By January 1998, about 7 percent
($148,916) had been expended from the $2 million allocated for the
program. 


      OBSTACLES TO PARTICIPATION
---------------------------------------------------------- Letter :3.2

Eight hundred seventy-two examinations of spouses and children, 31
percent of examinations requested, had been completed as of January
1998.  Forty-one percent of family members who requested examinations
did not report for appointments, refused examinations, or had not yet
responded to requests to schedule examinations, as shown in table 1. 



                                Table 1
                
                VA's Monthly Cumulative Activity Report
                           as of January 1998

--------------------------------------------------------------  ------
Applications received                                            2,802
Completed examinations                                             872
Pending examinations\a                                             712
Transfers to other coordinating centers                             73
Participant did not report for scheduled examination               348
Participant refused examination                                    251
Waiting list\b                                                     546
----------------------------------------------------------------------
\a Includes scheduled examinations, examinations in process but not
completed, and participants contacted but examination provider
waiting for response from spouse/veteran to schedule examination.  If
examination provider has waited beyond 45 days for a response, status
is moved to "waiting list."

\b Denotes spouses or children who have not responded to requests to
schedule examinations for more than 45 days. 

Source:  VHA, Office of Public Health and Environmental Hazards. 

Several factors contribute to the low completion rate for requested
examinations.  For example, obtaining an examination requires several
steps in a lengthy and cumbersome process.  Individuals cannot
contact a VA medical center to request an examination.  Instead,
requests for examinations are made by calling (toll free) the Persian
Gulf War Veterans' Helpline.  Next, Helpline staff forward requests
to VA headquarters, which checks the VA and DOD Persian Gulf
registries or the DOD Persian Gulf Deployment Listing to see if the
veteran served in the Persian Gulf.\3 VA headquarters then refers
requests to one of the 36 coordinating VA medical centers to further
establish eligibility.  The medical center contacts the individual
requesting the examination and asks him or her to provide a marriage
certificate (for a spouse) or a birth certificate (for a child). 
Finally, the medical center sends the validated request to the
affiliated medical school or provider, whose representative schedules
an examination appointment with the requester.  Our analysis showed
that the process from requesting an examination to completion of the
examination takes an average of over 15 weeks. 

According to a VA program official, the process for scheduling
examinations was established as an efficient way to control, verify,
and forward requests to the nearest coordinating medical center. 
Because the Persian Gulf Helpline already existed and operated 24
hours a day, it offered a means to monitor the number of requests
received nationally.  Also, Helpline staff were knowledgeable about a
range of Persian Gulf issues and services available for veterans. 
Verification of veterans' service in the Persian Gulf is centrally
administered because VA headquarters staff have access to the VA and
DOD Persian Gulf registries and the Persian Gulf Deployment Listing. 
Verification of the child or spousal relationship is assigned to
medical center staff who also provide a local VA contact and forward
verified requests to examination providers to schedule appointments. 

Another major deterrent to obtaining examinations is the distance to
examination sites or the accessibility of sites.  VA implemented the
program through 36 of its 172 medical centers.  VA's Office of Public
Health and Environmental Hazards issued a directive through the Chief
Network VISN Office for each network to identify at least one medical
center to participate in the program.  All VISNs identified at least
one coordinating medical center, 12 networks established two
coordinating centers, and one VISN established three coordinating
medical centers.  A VA official stated that medical center decisions
to participate in the program were based on the demographics of the
Persian Gulf veteran population and the medical centers' ability to
obtain contracts with their affiliated medical schools. 

Our analysis of the median distance between requesters' residences
and the designated coordinating medical center showed that 48
requesters from Arizona were required to travel a median distance of
326 miles to the Albuquerque medical center to receive an
examination.  Our analysis also showed that 44 requesters from North
Dakota, South Dakota, and Minnesota traveled a median distance of 219
miles for an examination in Minneapolis.  According to a Washington,
D.C., medical center official, family members considered the
Georgetown University site to be inconvenient because it is not
easily accessible by public transportation.  Additional deterrents to
obtaining examinations are lost income when taking time off from work
and lack of reimbursement for travel and overnight lodging expenses. 
According to VA headquarters officials, enabling legislation would be
necessary for VA to pay these expenses. 


--------------------
\3 According to a VA program official, this review has resulted in 40
requests for which VA has not been able to verify Persian Gulf
veterans' status. 


      CONTRACTING DIFFICULTIES IN
      SOME AREAS RESULTED IN
      EXAMINATIONS NOT BEING
      AVAILABLE
---------------------------------------------------------- Letter :3.3

VA decided to contract with affiliated medical schools where possible
because established working relationships facilitated starting a
program that had already been delayed.  Program officials told us
they were being flexible in also allowing medical centers to enter
into agreements with managed care organizations or local physicians
to examine family members in the absence of contracts with an
affiliated medical school.  However, no examinations were provided by
3 of the 16 coordinating medical centers we contacted--Augusta,
Dayton, and Philadelphia--because they had not entered into
agreements with their affiliated medical schools or other health care
providers.  Because Philadelphia was the only medical center
participating in the program in VISN 4, no examinations had been
given, as of January 1998, to the 88 family members who had requested
examinations in the network.  (See app.  III for a table of
coordinating medical centers and their affiliated medical schools.)

VA headquarters officials were not aware that two of the three
centers had not provided any examinations until we inquired about the
program's status in January 1998.  Because of turnover in key medical
center positions, including program coordinators, VA officials
indicated that they were unaware of the status of some requests for
examinations.  Also, VA did not require monthly activity reports from
coordinating medical centers until October 1997--1-1/2 years after
the start of the program.  In addition, the headquarters program
office lacks the capacity to validate information reported by medical
center staff and has no line authority over field units that
implement the program.  In the December 1997 activity report, six of
the coordinating medical centers had not submitted their information
to headquarters.  As a result, VA headquarters did not know the
status of the program in terms of the number of applicants contacted,
number of examinations given, and the number of coordinating medical
centers that had active programs. 

After our inquiries, coordinating medical centers without active
contracts with their affiliated medical schools were attempting to
establish contracts with managed care organizations or private
physicians, or were providing examinations in-house.  For example,
the Minneapolis VA medical center plans to provide examinations to
women by using VA medical center staff from the Women's Clinic and to
children by contracting with a local pediatrician.  Additionally, the
San Diego medical center contracted with a doctor with pediatric
experience to conduct all of its examinations at a VA outpatient
clinic.  Women applicants receive additional tests from a VA nurse
practitioner. 

Medical schools affiliated with the Denver and Minneapolis VA medical
centers did not renew their contracts with VA because the volume of
examinations was lower than expected and they were not paid in a
timely manner.  Other affiliated medical schools that still have
contracts made similar complaints.  For example, the Denver medical
center told its affiliated medical school to anticipate conducting
200 examinations.  However, only 54 requests for examinations were
received, and the affiliated medical school ultimately performed only
16 examinations.\4 In January 1998, the medical school received
payment for 10 completed examinations that had been initially
submitted for payment 9 months earlier in April 1997. 

We found that payment delays are caused, in part, because code
sheets, which capture medical information for entry into the registry
database, are rejected by VA's Austin, Texas, processing center when
they are not properly completed.  VA headquarters' guidance for
establishing contracts stipulates that payment should be made only
after satisfactory completion and submission to VA of all forms and
code sheets.  Staff from VA medical centers and affiliated medical
schools complained that code sheets were difficult and time consuming
to complete and lacked clear instructions.  In addition, VA attempted
to enter data into the registry using scannable code sheets. 
However, at one point, the program experienced a 100-percent
rejection rate for code sheets because of problems with the scanning
system.  As a result, VA staff had to spend additional time
correcting rejected code sheets.  VA has since resorted to manually
inputting the data.  According to VA medical center officials,
additional reasons for delayed payment include affiliated medical
schools completing paperwork incorrectly, submitting untimely bills,
and billing the wrong party.  As of January 1998, of the 872
examinations completed, 541 examinations had been approved for
payment. 


--------------------
\4 As of January 1998, of the 54 requests received, the affiliated
medical center provided 16 examinations, 12 requests are pending, 17
family members did not keep their scheduled appointments, 7 refused
to have the examination after being contacted, and 2 are on a waiting
list. 


      FEW PARTICIPANTS RECEIVE
      REFERRALS FOR ADDITIONAL
      DIAGNOSTIC TESTING
---------------------------------------------------------- Letter :3.4

To conduct the examinations for spouses and children, VA developed a
protocol that defines the standard tests and medical information
collected during examinations.  VA officials characterized the
examination as a basic but complete physical.  Adults receive
diagnostic laboratory tests including blood count, blood chemistries,
urinalysis, and, for women, a Pap smear.  Children receive a physical
examination and a medical history, including details on the
development of symptoms.  The children's protocol does not require
routine diagnostic testing.  Examination results are conveyed to
family members with a form letter from the examining physician. 

If physicians determine that a referral to a medical specialist for
additional diagnostic testing would be helpful to understanding a
patient's symptoms, VA headquarters must give written approval if
total examination and additional diagnostic testing costs exceed
$400.  At the locations we visited, examination costs ranged from
$140 to $473.  VA headquarters officials told us they approved all
requests received for referrals to medical specialists--about 20. 
But officials at the Houston medical center said that although their
examining physician requested only two referrals, she wanted to refer
about 20 percent of those examined (47 patients) for additional
diagnostic tests.  However, these officials did not ask for
additional referrals because they believed resources were constrained
and the approval process would take additional time and require
participants to make another trip to the medical school.  On the
other hand, the medical school affiliated with the Minneapolis
medical center performed additional diagnostic tests without
requesting approval.  This strained the contractual relationship with
the medical center because the medical school was not reimbursed for
these additional tests. 


   CONCLUSIONS
------------------------------------------------------------ Letter :4

After more than 1-1/2 years of operation, VA has yet to fully
implement the program to provide medical examinations to spouses and
children of Persian Gulf veterans.  Only 872 of the 2,802 requested
examinations have been completed as of January 1998.  Although a
program of clinical examinations may not resolve issues related to
whether illnesses among Persian Gulf family members are related to
illnesses of veterans, the clinical examination approach provides
Persian Gulf family members an opportunity to visit with a physician
and to receive a free medical examination.  Standardized examinations
also give VA a health surveillance tool for cataloging prominent
symptoms among Persian Gulf family members. 

The Persian Gulf Spouse and Children Program is scheduled to expire
in December 1998.  At the current rate of examinations, it is not
likely that significant numbers of additional examinations will be
completed by that date.  If the Congress gives Persian Gulf family
members the opportunity to be examined beyond December 1998, VA will
need to seek ways to reduce barriers to participation, ensure that
the necessary health care providers are available to provide
examinations, and improve its capacity to monitor program
implementation. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :5

If the Congress gives Persian Gulf family members the opportunity to
be examined beyond December 1998, we recommend that the
Secretary-designate of Veterans Affairs direct the Under Secretary
for Health to

  -- simplify the process for requesting and scheduling examinations,

  -- offer examinations in more locations and seek approval to
     reimburse participants who are required to travel long distances
     to receive examinations, and

  -- enhance the capacity of the Office of Public Health and
     Environmental Hazards to monitor program implementation by field
     personnel. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :6

We provided a draft of this report to VA for comment, but VA did not
provide comments in time to be included in this report.  However, VA
provided technical comments on March 19, 1998, which we incorporated
where appropriate. 


---------------------------------------------------------- Letter :6.1

As arranged with your offices, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days after the date of this letter.  At that time we will
send copies of this report to the Secretary-designate of Veterans
Affairs and interested congressional committees.  We will also make
copies available to others upon request. 

Please contact me on (202) 512-7101 if you or your staff have any
questions concerning this report.  Major contributors included George
Poindexter, Brian Eddington, Jean Harker, Mike Gorin, and Alan Wernz. 

Stephen P.  Backhus
Director, Veterans' Affairs and
 Military Health Care Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

We obtained information for our review by visiting 8 of the 36
coordinating VA medical centers for the Persian Gulf Spouse and
Children Examination Program in Chicago, Denver, East Orange,
Houston, Minneapolis, Salt Lake City, Seattle, and Washington, D.C. 
We also contacted by telephone eight additional coordinating medical
centers--Augusta, Birmingham, Dayton, Honolulu, Palo Alto,
Philadelphia, San Diego, and Tampa.  We selected these sites on the
basis of their geographic mix, volume of examinations, and
recommendations from VA and the Senate Committee on Veterans'
Affairs.  In some instances, medical school or clinic representatives
were present during our visits.  We telephoned some medical school
representatives who were not present during site visits to obtain
their views on the program and its implementation.  Because of time
constraints, we did not contact individual veterans or their family
members. 

We interviewed officials at VA headquarters and the VA payment center
located in Denver and also contacted the Office of Public Affairs
concerning its outreach efforts.  We reviewed reports on the status
of contractual agreements, the number of examinations scheduled and
completed, and the amount of funds disbursed for examinations.  We
analyzed data from VA's Austin data center (all 321 completed code
sheets) and corresponding data from the Persian Gulf War Veterans'
Helpline (requests for examinations that included the date the
veteran or family member called) to determine the average length of
time required to schedule and obtain an examination.  We also
analyzed data from the Persian Gulf Helpline to determine the
distance to the nearest coordinating medical center for selected
areas.  We did not verify the accuracy of data received from either
the Austin data center or the Persian Gulf Helpline.  As agreed with
your staffs, we did not evaluate the appropriateness of the survey
instruments or medical evaluations used in the program. 


NATIONAL HEALTH SURVEY OF PERSIAN
GULF VETERANS
========================================================== Appendix II

Initiated in July 1994, the National Health Survey of Persian Gulf
Veterans is an epidemiological research study designed to estimate
the prevalence of various symptoms and other health outcomes for
Persian Gulf veterans and their families.  The study is being
conducted in three phases.  In phase I, a questionnaire was mailed to
each of 30,000 veterans (15,000 Persian Gulf veterans and 15,000
non-Persian Gulf veterans).  In phase II, a sample of 8,000
nonrespondents was randomly selected for follow-up telephone calls to
assess potential nonrespondent bias and to supplement the mailed
survey data.  In addition, during phase II, selected self-reported
data collected during phase I was validated through records reviews
for 2,000 veterans from each group. 

VA has completed the first two phases of this survey.  In phase III,
the same 2,000 veteran respondents and family members from each group
will be invited to participate in a physical examination under a
uniform comprehensive clinical examination protocol.  VA is currently
identifying 15 of its medical centers to examine veterans and family
members over an 18-month period.  The medical centers will be
selected in a way that ensures a medical center will be within 3 to 4
hours driving time of the majority of the families sampled.  Veterans
will be examined at VA medical centers.  The requested budget also
permits up to half of the spouses and all of the children to be
examined at affiliated medical schools.  Veterans and spouses will be
paid $200 per adult examination and $100 per child examination to
compensate them for their time and inconvenience.  Mileage or
airfare, per diem, and lodging costs will be paid for families who
live far enough away to require overnight stays.  According to a VA
official, these payments are allowable costs as part of this research
project.  The estimated report date for the survey is December 2000. 


COORDINATING MEDICAL CENTERS AND
AFFILIATED MEDICAL SCHOOLS AS OF
DECEMBER 1997
========================================================= Appendix III

VISN        Coordinating
number      medical center      Affiliated medical schools
----------  ------------------  --------------------------
1           Boston, MA          Spouse: Evans Medical
                                Foundation, Boston Medical
                                Center
                                Children: Child Health
                                Foundation of Boston

2           Syracuse, NY        Spouse: Syracuse VA
                                Medical Center
                                Children: SUNY Health
                                Science Center

3           East Orange, NJ     New Jersey University of
                                Medicine and Dentistry

4           Philadelphia, PA    No affiliated medical
                                school contract

5           Washington, DC      Georgetown University

6           Durham, NC          Duke University

            Richmond,VA         Medical College of
                                Virginia

7           Augusta, GA         No affiliated medical
                                school contract

            Birmingham, AL      University of Alabama

8           Tampa, FL           University of South
                                Florida

            San Juan, PR        University of Puerto Rico
                                School of Medicine

9           Memphis, TN         University of Tennessee
                                Medical Group

            Nashville, TN       The Wilson Group,
                                Vanderbilt University

10          Cleveland, OH       Cleveland University
                                Hospital

            Dayton, OH          No affiliated medical
                                school contract

11          Allen Park/         Wayne State University
            Detroit, MI         Medical School

            Indianapolis, IN    Indiana University Health
                                Care

12          Hines/Chicago, IL   Loyola University


            Milwaukee, WI       Medical College of
                                Wisconsin

13          Minneapolis, MN     No affiliated medical
                                school contract

14          Iowa City, IA       University of Iowa


            Omaha, NE           Creighton Family Practice
                                Clinic

15          Columbia, MO        University of Missouri
                                Health Science Center


            Kansas City, MO     University of Kansas

            St. Louis, MO       St. Louis University

16          Houston, TX         Baylor College of Medicine


            Jackson, MI         Lakeland Family Practice,
                                University Medical Center

17          San Antonio, TX     University Clinic

18          Albuquerque, NM     University of New Mexico

19          Denver, CO          No affiliated medical
                                school contract

            Salt Lake City, UT  Sugarhouse Health Center,
                                University of Utah

20          Portland, OR        Oregon Health Science
                                University

            Seattle, WA         University of Washington
                                Family Clinic

21          Palo Alto, CA       Stanford University


            Honolulu, HI        No affiliated medical
                                school contract

22          San Diego, CA       No affiliated medical
                                school contract
----------------------------------------------------------
Source:  VHA, Office of Public Health and Environmental Hazards.

Note:  Medical centers with no affiliated medical school contract may
provide examinations by contracting with health maintenance
organizations, private physicians, or other health care providers, or
by using in-house VA staff.  In some cases, medical centers are still
finalizing such arrangements. 


*** End of document. ***