VA Community Clinics: Networks' Efforts to Improve Veterans' Access to
Primary Care Vary (Letter Report, 06/15/98, GAO/HEHS-98-116).

Pursuant to a congressional request, GAO provided information on the
Veterans Health Administration's (VHA) use of community-based clinics to
improve veterans' access to primary care, focusing on: (1) VHA's
planning process for new community-based clinics; (2) networks'
implementation of VHA's planning guidelines; and (3) VHA and network
oversight of clinic operations.

GAO noted that: (1) VHA has strengthened the process that networks are
to use when establishing new community-based clinics, thereby addressing
several of GAO's recommendations; (2) VHA provided more detailed
guidance, including a 30-minute travel standard and an expectation that
clinics be established primarily to benefit current users rather than
attract new users; (3) VHA developed a more structured planning process,
including the development of network business plans covering a 5-year
period, and established a task force in accordance with VHA's
guidelines; (4) VHA's long-range goal is to increase the number of
community-based clinics; (5) to that end, VHA has approved 198 clinics,
and network business plans show that 402 additional clinics are to be
established between 1998 and 2002; (6) the plans, however, do not
address the percentage of current users who have reasonable access, or
what percentage of those without reasonable access are targeted to
receive enhanced access through the establishment of new clinics; (7) as
a result, VHA's network business plans cannot be used to determine on a
systemwide basis how well networks are using clinics to equalize
veterans' access to primary care; (8) based on the limited information
that networks can provide, it appears that the geographic accessibility
of VHA primary care currently varies widely among networks and that
while networks' efforts should reduce this variation, thousands of the
VHA's 3.4 million current users will likely continue to have inequitable
access for many years; (9) moreover, it appears that networks are
planning to improve access for thousands of lower priority new users
over the next two years, while thousands of higher priority current
users are waiting considerably longer periods of time for reasonable
access; (10) networks, which have primary responsibility for monitoring
community-based clinic performance, have developed evaluation plans for
proposed clinics, as VHA requires; (11) to date, few clinics have
operated for more than 12 months; (12) as a result, most evaluation
plans have not been implemented; and (13) network evaluation plans,
however, vary widely, with few containing a common set of criteria or
indicators that appear necessary to effectively assess clinic
evaluations to monitor performance within or among networks.

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

 REPORTNUM:  HEHS-98-116
     TITLE:  VA Community Clinics: Networks' Efforts to Improve 
             Veterans' Access to Primary Care Vary
      DATE:  06/15/98
   SUBJECT:  Health services administration
             Veterans hospitals
             Community health services
             Health care cost control
             Veterans benefits
             Health centers
             Veterans
             Strategic planning
             Health care planning
             Patient care services
IDENTIFIER:  VA Veterans Integrated Service Network
             
******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************


Cover
================================================================ COVER


Report to Congressional Requesters

June 1998

VA COMMUNITY CLINICS - NETWORKS'
EFFORTS TO IMPROVE VETERANS'
ACCESS TO PRIMARY CARE VARY

GAO/HEHS-98-116

Veterans' Access to VA Community Clinics

(406135)


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

  GPRA - Government Performance and Results Act
  VA - Department of Veterans Affairs
  VHA - Veterans Health Administration
  VISN - Veterans Integrated Service Network
  FY - fiscal year
  HUD - Department of Housing and Urban Development

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


B-270477

June 15, 1998

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

The Honorable Cliff Stearns
Chairman, Subcommittee on Health
Committee on Veterans' Affairs
House of Representatives

The Veterans Health Administration (VHA) operates one of the nation's
largest health care delivery systems at a cost of about $17 billion a
year.\1 The system includes 172 hospitals and 419 free-standing
outpatient facilities, which provide a wide range of primary and
specialized care.  Over a third of the 3.4 million veterans served by
these facilities each year must travel long or time-consuming
distances to receive care. 

In 1995, VHA announced plans to transition from a hospital-based
system of care to a health-care system rooted in primary and
ambulatory care.  VHA restructured its facilities into 22 service
delivery networks and encouraged network directors to establish
community-based outpatient clinics.  These clinics differ from
traditional free-standing VHA outpatient facilities in that they
basically provide primary care to veterans and frequently use non-VHA
providers.  The type of care veterans receive at these new clinics is
comparable to that available during visits to a private physician's
general practice office. 

In an April 1996 hearing, we discussed the networks' first 12
operating community-based clinics and planning efforts for additional
clinics.\2 We concluded that community-based clinics could be a
cost-effective way to enhance veterans' access to VHA primary care. 
We expressed concern, however, that it would be difficult, if not
impossible, to assess VHA's progress because networks had not
developed comprehensive plans to guide the development of new
clinics.  In a subsequent report,\3 we recommended that VHA require
networks to develop such plans and, in doing so, focus first on
improving access for current users, with a goal of equalizing access
systemwide on the basis of a consistent travel standard and in
accordance with veterans' statutory priorities for care.  In
response, VHA agreed to improve the process that networks use when
planning and operating new community-based clinics and to provide
more detailed guidelines. 

This report responds to your request for information on VHA's use of
community-based clinics to improve veterans' access to primary care. 
Specifically, it describes (1) VHA's planning process for new
community-based clinics, (2) networks' implementation of VHA's
planning guidelines, and (3) VHA and network oversight of clinic
operations. 

In conducting this study, we reviewed VHA guidance and the 22
networks' plans and proposals for 178 clinics approved between our
1996 testimony and February 1998.  We surveyed each network to obtain
additional information about their planning and oversight activities. 
In addition, we interviewed VHA officials responsible for developing
planning guidance for networks and for reviewing network activities. 
We also visited VHA's New York/New Jersey Network headquartered in
Bronx, New York; Southwest Healthcare Network in Phoenix, Arizona;
and Desert Pacific Healthcare Network in Long Beach, California.  We
selected these networks because they had widely varying service
areas, financial resources, and experiences in operating
community-based clinics.  For example, the New York/New Jersey
Network covers the smallest geographic area compared with the
Southwest Healthcare Network, which covers one of the largest areas. 
At each network, we interviewed staff, reviewed planning documents
and clinic evaluations, and toured hospitals and clinics.  At the
networks based in New York and California, we interviewed individual
veterans and conducted group discussions with approximately 40
veterans who had received care from their respective networks'
community-based clinics.\4 Our work was done between March 1997 and
May 1998 in accordance with generally accepted government auditing
standards. 


--------------------
\1 VHA, one of three organizational units within the Department of
Veterans Affairs (VA), is responsible for providing medical care to
eligible veterans. 

\2 VA Health Care:  Efforts to Improve Veterans' Access to Primary
Care Services (GAO/T-HEHS-96-134, Apr.  24, 1996). 

\3 VA Health Care:  Improving Veterans' Access Poses Financial and
Mission-Related Challenges (GAO/HEHS-97-7, Oct.  25, 1996). 

\4 A map and a summary profile of the three networks we visited are
in app.  I.  Selected characteristics of all networks' clinics
approved since October 1996 are provided in app.  II. 


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

VHA has strengthened the process that networks are to use when
establishing new community-based clinics, thereby addressing several
of our earlier recommendations.  First, VHA provided more detailed
guidance, including a 30-minute travel standard and an expectation
that clinics be established primarily to benefit current users rather
than attract new users.  Second, VHA developed a more structured
planning process, including the development of network business plans
covering a 5-year period, and established a task force to help
networks develop clinic proposals in accordance with VHA's
guidelines. 

VHA's long-range goal is to increase the number of community-based
clinics.  To that end, VHA has approved 198 clinics, and network
business plans show that 402 additional clinics are to be established
between 1998 and 2002.\5 The plans, however, do not address the
percentage of current users who have reasonable access, as defined by
VHA's 30-minute standard, or what percentage of those without
reasonable access are targeted to receive enhanced access through the
establishment of new clinics.  As a result, VHA's network business
plans cannot be used to determine on a systemwide basis how well
networks are using clinics to equalize veterans' access to primary
care. 

On the basis of the limited information that networks can provide, it
appears that the geographic accessibility of VHA primary care
currently varies widely among networks and that while networks'
efforts should reduce this variation, thousands of VHA's 3.4 million
current users will likely continue to have inequitable access for
many years.  Moreover, it appears that networks are planning to
improve access for thousands of lower priority new users over the
next 2 years, while thousands of higher priority current users are
waiting considerably longer periods of time for reasonable access. 

Networks, which have primary responsibility for monitoring
community-based clinic performance, have developed evaluation plans
for proposed clinics, as VHA requires.  To date, few clinics have
operated for more than 12 months.  As a result, most evaluation plans
have not been implemented.  Network evaluation plans, however, vary
widely, with few containing a common set of criteria or indicators
that appear necessary to effectively assess clinic performance.  As a
result, VHA may have difficulties using clinic evaluations to monitor
performance within or among networks. 


--------------------
\5 Included in the 198 clinics are 20 community-based clinics
approved by VHA prior to its 1996 proposal requirement.  For a
complete list of community-based outpatient clinics by network and
their approval dates, see app.  III. 


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

Since 1930--when there was virtually no public or private health
insurance--VHA's health care system has evolved into a direct
delivery system, with government ownership and operation of
facilities.  However, of the 26 million veterans who are eligible for
care, about half live more than 25 miles from a VHA hospital and
about one-third live more than 25 miles from a VHA clinic.  Of the
approximately 3.4 million veterans VHA currently serves, we estimate
that about 1 million travel more than 25 miles to access VHA primary
care from a VHA hospital or clinic.  In addition, many eligible
veterans who are not currently receiving care say that they do not
use VHA primary care services because they live too far from a VHA
facility.\6

In the early 1990s, VHA began developing a strategy to expand its
ability to provide primary care, especially for veterans who had to
travel many miles to receive care from existing facilities.  In
January 1994, the VHA hospital in Amarillo, Texas--now a part of the
Southwest Network--established what is commonly recognized as the
first VHA community-based clinic. 

Until the establishment of the Amarillo clinic, VHA had required its
hospitals to meet rigid criteria to establish separate outpatient
facilities apart from hospitals.  These criteria included that
clinics had to serve a projected workload of 3,000 visits or more per
year and be located at least 100 miles or 3 hours travel time away
from the nearest VHA facility. 

Subsequently, VHA encouraged its hospitals to consider establishing
community-based clinics similar to Amarillo's.  In doing this, VHA
eliminated its restrictions concerning workload and location.  It
also encouraged hospitals to consider contracting with other
providers when it was in the interest of the veteran and the
hospital. 

In late 1995, VHA reorganized its field operations into 22 Veterans
Integrated Service Networks (VISN).  (See fig.  1.) These networks
are the basic budgetary and decisionmaking units of VHA's health care
system.  Networks have responsibility for making a wide range of
decisions about care delivery options, including planning and
establishing community-based outpatient clinics. 

   Figure 1:  Veterans Integrated
   Service Networks and
   Community-Based Clinics Visited
   by GAO in 1997

   (See figure in printed
   edition.)

In January and February 1995, VHA approved 15 proposals for new
community-based clinics.  Although networks submitted many more
proposals, VHA did not approve any additional clinics until October
1996.  Since the first community-based outpatient clinic was
established by VHA's Amarillo Medical Center in 1994, VHA has
approved a total of 198 community-based clinics. 


--------------------
\6 See VA Health Care:  How Distance From VA Facilities Affects
Veterans' Use of Services (GAO/HEHS-96-31, Dec.  20, 1995) and VA
Health Care:  Exploring Options to Improve Veterans' Access to VA
Facilities (GAO/HEHS-96-52, Feb.  6, 1996).  See Related GAO Products
at the end of this report. 


   NETWORKS' PLANNING ADHERES TO
   VHA'S IMPROVED GUIDELINES
------------------------------------------------------------ Letter :3

VHA issued its initial set of guidelines for community-based clinics
in February 1995.\7 In essence, these guidelines gave networks wide
discretion to establish community-based clinics wherever they deemed
appropriate to better serve veterans.  Networks were required,
however, to submit a brief summary, called a "white paper," for each
planned clinic to VHA for review.  These summaries were to describe
certain key operational elements, such as target population, service
availability, and cost. 

VHA revised its guidelines in August 1996 to require networks to
establish clinics primarily for current users who live more than 30
minutes from an existing VHA clinic.  VHA separately required
networks to develop annual business plans that, among other things,
are to include information on the number of community-based clinics
to be established and projected time frames.  In addition, VHA
provided guidance to networks for developing proposals--which were to
provide more details than the original white papers--and implemented
a process to help networks develop more consistent and thorough
proposals, in accordance with VHA's guidelines. 


--------------------
\7 Veterans Health Administration Interim Policy for Planning and
Activating Department of Veterans Affairs Access Points (VHA
Directive 10-95-017, Feb.  8, 1995). 


      PLANNING CRITERIA CLARIFY
      TARGET VETERAN POPULATION
---------------------------------------------------------- Letter :3.1

In our 1996 testimony and report, we concluded that VHA had not
adequately defined target veteran populations for new community-based
clinics or reasonable travel goals for use in locating new clinics. 
Given VHA's limited resources, we expressed concern about the
propriety of using clinics to provide convenient geographic access
for new users while current users continue to experience inconvenient
access.  We recommended that VHA state which veterans were to be the
primary group to be served by these new clinics and that they
establish a travel time or distance standard when planning for new
clinics. 

In response, VHA instructed networks to establish clinics primarily
to provide more convenient access to care for current users.  Toward
this end, VHA stated that it is desirable that a community-based
clinic be located generally within 30 minutes' travel time from a
veteran's home.  VHA noted, however, that differences in veterans'
medical conditions and other regional factors may affect veterans'
access to VHA care.  As a result, VHA also included several
exceptions to the 30-minute travel standard, including traffic
congestion, weather conditions, or overcrowding at existing VHA
facilities. 


      BUSINESS PLANS DOCUMENT TIME
      FRAMES FOR ESTABLISHING NEW
      COMMUNITY-BASED CLINICS
---------------------------------------------------------- Letter :3.2

In our prior work, we concluded that networks were not planning new
community-based clinics on a strategic basis and that an overall plan
was not available to permit an assessment of network activities from
a systemwide perspective.  Essentially, networks submitted proposals
for individual clinics to headquarters on an ad hoc basis, and
headquarters considered the proposals on their individual merit.  We
expressed concern that this approach would make it difficult, if not
impossible, to assess networks' planning efforts individually or
systemwide. 

As part of its overall restructuring efforts, VHA requires networks
to develop annual business plans that are to show how a network
intends to spend its resources.  In response to our concern, VHA
instructed networks to include, as part of their business plans, the
number of clinics to be established, time frames for establishing
clinics, and locations of planned clinics.  VHA stated its intent to
consolidate the 22 network plans into a national business plan, which
would permit an assessment of network activities from a systemwide
perspective. 

With the networks' 1997 and 1998 business plans completed--and their
1999 business plans to be completed over the next 3 months--the
evolving nature of clinic planning activities can be seen.  In their
1997 business plans, the 22 networks reported their intent to
establish 211 clinics by the year 2001.\8 As networks gained
experience in planning and operating clinics, the number of clinics
to be established grew significantly.  Networks' 1998 business plans
show that 402 additional clinics are to be established by 2002,
although a target year had not been selected for 93 of these clinics. 
(See table 1.) We surveyed networks about 2 months after their
business plans were submitted and found that they had since decided
to establish most of the 93 clinics in years 1999 through 2002. 



                          Table 1
          
              Aggregate Number of Clinics That
           Networks Plan to Establish, by Fiscal
                            Year

                 Year expected to be established
        --------------------------------------------------
Busine
ss
plan                                        Unspecif  Tota
term    1997  1998  1999  2000  2001  2002       ied     l
------  ----  ----  ----  ----  ----  ----  --------  ----
FY       124    44    20    12    11    NA         0   211
 1997
FY        NA   180    68    44    11     6        93   402
 1998
----------------------------------------------------------
Note:  NA = not applicable. 

The 22 business plans are intended to provide estimates of the number
of clinics networks plan to propose and projected time frames for
when the clinics will become operational.  Collectively, the
estimates and projections have been fairly reliable.  For example, of
the 124 clinics total planned for in the networks' 1997 business
plans, 122 were actually proposed.  However, only four networks
proposed the same number of clinics as they had indicated in their
business plans.  Of the remaining 18 networks, 10 proposed a total of
29 more clinics than they had planned and 8 proposed 31 fewer. 
Still, the majority of networks that proposed more or less than they
had stated in their business plans were within three clinics of their
estimates. 

In April 1997, VHA consolidated the 22 network plans into its
national business plan.\9 The consolidated plan summarizes the number
of community-based clinics that networks have established and plan to
establish.  However, the plan does not provide sufficient information
to assess the impact of community-based clinics on veterans' access
to care on a systemwide basis.  In July 1997, VHA was directed by the
Senate Appropriations Committee to address the need for a national
plan and to respond to the findings and recommendations in our
October 1996 report.\10 In its report to the Committee, submitted in
April 1998, VHA stated that its response to our October 1996 report
remained essentially unchanged from its original comments summarized
in our report.  In other words, VHA believes that its April 1997
national plan--based on the total number of clinics contained in the
22 individual business plans--is responsive to our concerns. 

At the time of our earlier report, we did agree that VHA's intended
national business plan could provide a means to achieve the intent of
our recommendations.  However, it was not known at the time whether
the plan would ultimately provide sufficient detail to afford the
Congress enough information to determine the overall extent and cost
of establishing community-based clinics.  Now that we have had the
opportunity to review networks' 1997 and 1998 business plans, VHA's
national plan, and VHA's report to the Senate, our concerns remain. 

In contradiction to VHA's contention that the sum of clinics
contained in 22 individual network business plans can serve as an
adequate national plan for establishing community-based clinics, we
believe it contains less information than do the individual business
plans upon which it is based.  If it is impossible to determine
equity of access issues from individual network business plans, it
is, therefore, also impossible to make that same assessment with
VHA's national business plan. 


--------------------
\8 The plans do not discuss how many veterans will be served, which
veteran populations are targeted, how clinics will be funded, or how
they will operate.  Rather, VHA requires networks to address these
issues when new clinics are proposed. 

\9 Veterans Health Administration, Journey of Change (Washington,
D.C.:  Department of Veterans Affairs, Apr.  1997). 

\10 Senate Committee on Appropriations, Report 105-33, July 17, 1997;
to accompany S.  1034, p.  14. 


      VHA TASK FORCE ASSISTS
      NETWORKS IN DEVELOPING
      CLINIC PROPOSALS
---------------------------------------------------------- Letter :3.3

When planning a new clinic, networks must describe, as required by
VHA's 1995 guidelines,

  -- justification for the clinic,

  -- service delivery options,

  -- the targeted veteran population and anticipated workload,

  -- services to be provided,

  -- funding sources,

  -- an implementation plan, and

  -- stakeholder comments. 

While networks were required to involve stakeholders, such as
veterans, in the development of clinic proposals, the guidelines
afforded networks considerable discretion in deciding how to describe
these elements and present their results in proposal documents.  To
obtain greater consistency among proposals for community-based
clinics, VHA provided in August 1996 additional guidance on
determining how key elements apply to the needs of the veterans who
would be served by the proposed clinics and the network's ability to
fund such clinics.  The guidance also provided a standard format for
presenting their planning assessment results. 

Along with the new proposal guidelines, VHA also implemented a new
management process to help ensure more thorough and consistent
oversight of network proposals.  VHA established a task force to
assist networks in developing their proposals and to serve as a
resource to both network and VHA management.  The task force was
responsible for ensuring that the information contained in the
proposals was complete, accurate, and met VHA requirements.  In doing
its work, the task force also trained and developed network staff in
the skills of preparing clinic proposals.  As part of its work, it
prepared and distributed guidelines that contained a standardized
proposal format with examples and sample wording network planners
could use to develop their own proposals. 

The task force reviewed proposals for 178 clinics and determined that
each met VHA's guidelines.  The task force was disbanded in February
1998 and its duties transferred to VHA's Network Office in
headquarters. 

Our assessment of the 133 proposals reviewed by the task force during
fiscal years 1996 and 1997\11 shows they are designed to serve
primarily current users, as VHA guidelines suggest.  Of the 272,000
veterans expected to use the new clinics, about 17 percent are
estimated to be new VHA users, ranging from 0 percent to 62 percent. 

Clinics are to be operated in accordance with options contained in
VHA's clinic guidance.  Of the 133 proposed clinics we reviewed, 77
will be operated by VHA, 53 by contractual arrangement with other
healthcare providers, 2 by combined VHA-contractor arrangement, and 1
by the Department of Defense.  On average, VHA-operated clinics plan
to serve more veterans than will non-VHA-operated clinics (2,400
versus 1,800). 

The distance between community-based clinics and VHA hospitals range
from 2 to 250 miles.  Twenty-one community-based clinics are located
25 miles or less from a VHA hospital to reduce overcrowding in
existing facilities or help veterans avoid traffic-congested areas,
and 112 are located 25 miles or more from a VHA hospital.  This
geographic distribution of VHA health care facilities meets VHA
standards. 


--------------------
\11 Forty-five proposals were approved in February 1998 after our
fieldwork was completed and are not included in our detailed review
or analyses. 


   NETWORKS' PLANNING DOES NOT
   ADDRESS ACCESS INEQUITIES
------------------------------------------------------------ Letter :4

In our April 1996 testimony and October 1996 report, we expressed
long-standing concerns about inequities in veterans' access to VHA
care.  We concluded that given VHA's limited resources, networks
should focus on improving geographic access for current users in a
manner that ensures that a comparable percentage of users in each
network has reasonable access as defined by VHA's travel standards. 
VHA agreed with the need to minimize inequities in access among
networks but preferred to encourage such outcomes without mandating
national standards for equity of access. 

As stated in VA's fiscal year 1999 performance plan, VHA has
established a goal of increasing the number of community-based
clinics as part of its efforts to implement the Government
Performance and Results Act of 1993 (GPRA).\12

This goal, however, focuses on outputs--the number of clinics--rather
than on the desired outcome of increasing the percentage of current
users having reasonable geographic access to primary care. 

As a result, networks' planning efforts focus on the number of
community-based clinics to be established and do not address the
extent to which new clinics will achieve equity of access for current
users among networks or enroll new users in accordance with statutory
priorities.  Moreover, VHA has not tried to measure networks'
progress in planning community-based clinics to achieve these
outcomes.  Consequently, we remain concerned about how effectively
these clinics are used to equalize veterans' access to VHA primary
care within and among networks. 


--------------------
\12 GPRA (P.L.  103-62) requires agencies to set goals, measure
performance, and report on their accomplishments.  The intent is for
an agency to define what desired results it wishes to achieve,
identify the strategy to achieve the desired results, and then
determine how well it succeeded in reaching results-oriented goals
and achieving objectives. 


      EQUALIZING ACCESS FOR
      CURRENT USERS
---------------------------------------------------------- Letter :4.1

Networks do not present information on how the 402 clinics included
in business plans or the 198 approved clinic proposals will reduce
access inequities for current users within networks or among
networks.  Moreover, network officials told us that they do not
collect on a networkwide basis information needed to determine the
number of current users who have reasonable access or the number who
have unreasonable access.  As a result, data are not available on the
magnitude of access inequities or the impact of networks' planned
clinics on reducing such inequities. 

To demonstrate how access inequities could be measured and a
results-oriented performance goal established, we asked networks to
estimate the percentage of current users who

  -- had reasonable access in 1997 and met VHA's 30-minute travel
     standard and

  -- will have reasonable access by 2002 if new clinics are
     established as planned. 

Of the 22 networks, 14 provided estimates to us.\13 These 14 networks
account for nearly two-thirds of the clinics VHA has approved to date
and nearly three-quarters of the clinics planned to be established by
2002.  Our analysis of the 14 networks' estimates shows that
accessibility among networks currently varies widely and inequities
are likely to remain for many years. 

Networks' estimates suggest that their levels of access differed
significantly when they started establishing community-based clinics,
and these differences remain largely unchanged today.  Our assessment
of the networks' estimates shows that the 14 networks had averaged
about 53 percent of their total users residing within 30 minutes of
one of their primary care facilities in 1995.  The 14 networks
estimate that 63 percent of users resided within 30 minutes in 1997,
with this increase attributable primarily to the new clinics. 
Despite these improvements, the variability in the percentage of
veterans having reasonable access in the 14 networks remains large. 
(See table 2.)



                          Table 2
          
             Percentage of Current Users in 14
           Networks Estimated to Have Reasonable
            Access to VHA Primary Care, 1995 and
                            1997

                                    Number of networks
                                --------------------------
Percentage of current users
within 30 minutes of VHA
primary care                            1995          1997
------------------------------  ------------  ------------
90 or higher                               0             0
80-89                                      0             1
70-79                                      1             1
60-69                                      1             8
50-59                                      8             2
Less than 50                               4             2
----------------------------------------------------------
Note:  Eight networks were unable to provide estimates. 

The 14 networks' estimates show that, on average, about 85 percent of
current users are expected to have reasonable access by 2002.  This
is attributable primarily to the additional clinics that the networks
plan to establish over the next 5 years.  If established as planned,
these clinics could significantly reduce access variabilities among
networks, while greatly raising the accessibility levels within
networks.  (See table 3.)



                          Table 3
          
             Percentage of Current Users in 14
           Networks Estimated to Have Reasonable
            Access to VHA Primary Care, 1997 and
                            2002

                                    Number of networks
                                --------------------------
Percentage of current users
within 30 minutes of VHA
primary care                            1997          2002
------------------------------  ------------  ------------
90 or higher                               0             5
80-89                                      1             5
70-79                                      1             4
60-69                                      8             0
50-59                                      2             0
Less than 50                               2             0
----------------------------------------------------------
Note:  Eight networks were unable to provide estimates. 

Overall, the 14 networks expect to provide reasonable access for 36
percent more current users in 2002.  Most of these networks, however,
are increasing access at widely varying rates.  For example, four
networks estimate that they will provide reasonable access to 50
percent more current users in 2002 than in 1997. 

Networks' estimates, however, suggest that it will take several years
beyond 2002 for the least accessible networks to achieve equity with
the most accessible networks.  For example, 5 of the 14 estimate that
their accessibility level will be below the estimated network average
of 85 percent in 2002.  (See table 4.)



                          Table 4
          
             Percentage of Current Users in 14
           Networks Estimated to Have Reasonable
             Access to VHA Primary Care in 2002

Percentage of current users estimated
to be within 30 minutes of VHA primary
care by 2002                            Number of networks
--------------------------------------  ------------------
90-95                                                    5
85-89                                                    4
80-84                                                    1
75-79                                                    2
70-74                                                    2
----------------------------------------------------------
Note:  Eight networks were unable to provide estimates. 

We estimate that the five networks could provide reasonable access
for 85 percent of users between 2003 and 2008 if they continue to
establish clinics at their current 1997 to 2002 rates.  To achieve
85-percent accessibility, these five networks would have to increase
the number of new clinics established over the next 5 years from the
119 currently planned to 178--an average of approximately 12
additional clinics per network. 

Nine of the 14 networks estimate that less than 90 percent of current
users will have reasonable access by 2002.  We estimate that these
nine could achieve a 90-percent accessibility level between 2003 and
2011 if they continued establishing clinics at their current rates. 
To achieve 90-percent accessibility, these nine networks would have
to increase the number of new clinics established over the next 5
years from the 199 currently planned to 312--an average of
approximately 13 additional clinics per network. 


--------------------
\13 According to representatives from the remaining eight networks,
they could not provide us with both estimates. 


      SERVING USERS IN
      COMMUNITY-BASED CLINICS IN
      ACCORDANCE WITH STATUTORY
      PRIORITIES
---------------------------------------------------------- Letter :4.2

By law and under VA regulations, veterans are accorded different
priorities for enrollment and care based on several factors. 
Generally, veterans with service-connected disabilities have the
highest priority, followed by lower income veterans, and then higher
income veterans.  While VHA has directed networks to establish new
clinics to improve access for current users who have been
"historically underserved," VHA does not specify who these veterans
are or how priority applies to such veterans.  Our assessment of
network business plans and proposals for the 133 clinics suggests
that the result of network planning will be to improve access for
thousands of lower priority new users in 1998 and 1999, while
thousands of higher priority current users may wait until 2000 or
beyond for improved access. 

To date, networks have generally defined historically underserved
veterans to be those traveling greater than 30 minutes to a VHA
primary facility, regardless of whether they currently receive care
in a VHA facility.  Because networks seldom consider the statutory
priorities when they plan clinics, data are not available to show
whether networks' plans will improve access for high-priority
veterans first.  Business plans provide no information on the target
populations to be served and only 18 of the proposals for the 133
clinics we examined considered service-connected disabilities when
differentiating among other current and future users to be served. 
This approach assumes that veterans with varying priorities and
conditions are evenly distributed geographically and throughout each
network. 

Networks are establishing new clinics over a 5-year period, in large
part because of the limited resources available.  VHA requires
networks to establish clinics with existing resources, and most
networks are implementing efficiency initiatives as a primary means
to generate the resources needed for new clinics.  To date, networks
have budgeted about $85 million to establish 178 clinics, or about
$258 per veteran served.  Networks may spend $190 million to
establish the 402 clinics planned for the next 5 years if their cost
per veteran continues to average $258. 


   NETWORK OVERSIGHT OF CLINIC
   OPERATIONS VARIES WIDELY
------------------------------------------------------------ Letter :5

Networks included a description of their evaluation plans in their
clinic proposals, as VHA guidelines require.  The actual evaluation
plans vary widely, and some are still being developed.  In addition,
few have been implemented, primarily because most clinics have
operated less than 6 months.  VHA obtains information on clinic
performance as needed rather than periodically receiving network
evaluation results on a systematic basis. 


      NETWORKS DESCRIBE EVALUATION
      PLANS IN PROPOSALS
---------------------------------------------------------- Letter :5.1

All networks included a description of their plans to evaluate their
clinics' performance in their clinic proposals, as VHA requires.  Our
analysis of the proposals for the 133 community-based clinics
approved as of November 1997 shows that evaluation plans were broadly
defined and items to be evaluated were described in general terms. 
Proposals rarely contained an explanation of exactly what would be
measured, how it would be measured, the frequency of measure, who
would conduct the evaluation, or how the results of an evaluation
would be used and by whom. 

VHA's August 1996 guidelines added a requirement that networks
develop evaluation plans for each new clinic proposed.  VHA gave
networks wide discretion in how evaluations are to be conducted and
results used.  In essence, VHA directed networks to evaluate how
clinics are achieving their purposes, overall goals, and objectives. 
Each network is to coordinate evaluation efforts among clinics to
ensure that "the same minimal criteria" are evaluated throughout the
network.  Networks are to define "specific performance measures" for
assessing their clinics' effectiveness. 

Toward this end, VHA's guidance identified a number of key indicators
that networks can use to measure their clinics' operational
effectiveness.  These include reduced beneficiary travel expenditures
(by having patients travel to nearby clinics rather than compensating
them for traveling greater distances to a medical center), shortened
waiting times (by scheduling appointments with clinics that serve
fewer clients), and reduced fee-basis care (by serving veterans at
VHA-operated or VHA-funded clinics rather than sending them to a
private provider). 

VHA also issued guidance to help networks develop evaluations.\14
This guidance defines a program evaluation as a method used to
provide specific information about a clinical or administrative
initiative's activities, outcomes, costs, and effectiveness in
meeting its goals.  It further explains that new programs should
build in monitoring systems for capturing near-term and long-term
data to provide information about how well the program is meeting its
goals and that a deliberately planned and executed program evaluation
is most likely to be useful to managers.  Evaluations should be
ongoing in order to provide managers with information they can use to
adjust or fundamentally change the structure and processes of a
program to improve its outcomes.  Policymakers, managers, and
clinicians alike use program evaluation as a tool to assist them in
making informed decisions on the objectives, implementation, and
progress of their programs. 

We included several questions in our network survey about their
evaluation plans to understand how networks implemented the broadly
described evaluation plans contained in their proposals.  First, we
asked if they were using a standard networkwide evaluation, a
clinic-specific evaluation, or some other evaluation plan.  Three
indicated they were using a networkwide evaluation; 11 indicated they
would use a clinic-specific evaluation; and 7 indicated they were
still developing their evaluation plans, would use some other
plan--such as a product-line approach--or would establish a task
force to develop an evaluation plan.  One network did not answer the
question. 

Second, we asked the 18 that said they would conduct either a
clinic-specific evaluation or some other plan if there was a common
set of minimal criteria that would be evaluated throughout the
network for other community-based clinics, as required by VHA.  Five
networks reported that they did not have a common set of criteria. 
Of the five, two did not clarify further.  Of the remaining three,
one reported that it collected data--but not on a regular basis--and
that it intended to develop a core set of data items.  One reported
that evaluations are the responsibility of the clinic's parent
medical center, which can develop its own criteria.  The fourth
network reported that a clinical practice council would develop and
perform community-based evaluations of its clinics. 


--------------------
\14 Veterans Health Administration, Program Evaluation for Managers,
Primer (Washington, D.C.:  Department of Veterans Affairs, 1997). 


      NETWORKS HAVE PERFORMED FEW
      CLINIC EVALUATIONS
---------------------------------------------------------- Letter :5.2

Our assessment of the evaluations performed to date shows that clinic
evaluations do not adequately address VHA's intent that clinics be
evaluated to show how they are achieving the network's purposes,
goals, and objectives.  Nor do the evaluations include specific
performance measures that can be used to manage clinics or assess
their effectiveness. 

As of November 1997, only 6 of the 22 networks reported completing 20
clinic evaluations.  This is because most clinics had either not yet
opened or had operated for less than 6 months.  Nine had operated 1
year or longer, and 11 operated less than 1 year.  We asked networks
to give us copies of the 20 completed evaluations; networks were able
to provide us with 15. 

Our assessment of the 15 shows considerable variability in terms of
what had been described in the proposals and what was actually done. 
With the exception of one clinic, the evaluations were limited to
processes and did not include results-oriented outcomes.  For
example, 6 of the 15 evaluations were memorandums documenting site
visits where administrative and patient records were reviewed for
legibility, physicians were checked for proper credentialing, and
checks were performed to ensure that data entry was being performed
correctly and in a timely fashion.  In one instance, where the clinic
had been operating for more than 1 year, the memorandum documenting
the evaluation stated "This review was intuitive, not explicit.  The
goal was to obtain a general idea of how well Dr.  [X] was doing [and
an] ongoing review should probably be done at 6-month intervals."

In the instance of the one clinic that we considered to have been
evaluated, the evaluation plan contained a list of indicators with
measurable criteria that could be used to compare against actual
performance.  (See table 5.)



                          Table 5
          
          Example of an Evaluation Plan Used by a
           Community-Based Clinic With Indicators
                        and Criteria

Indicator                     Criteria
----------------------------  ----------------------------
Uniques (new)\a               4% growth

Uniques (old)\b               500 for 1.25 full-time
                              employment equivalents

Visits                        4,000 visits (8 visits per
                              patient) in 1 year

Total Category A              95% of census

Total Category C              5% of census

Total tri-care (uniques)      One beneficiary per week

Total tri-care (visits)       Eight visits per year

Total referred for specialty  Less than 5%
care

Operating budget (including   Within budget
staff, lease, utilities, and
supplies)

Exceeding current maximum     (See uniques (old) and
workload                      visits, above)

Uniques hospitalized          One per month

Bed days of care              84/1,000

Number receiving travel       Less than 1%

Overbookings                  Less than 5%

Number receiving fee-for-     Less than 1%
service care

Number receiving home health  Less than 5%
services

Number in community nursing   Less than 1%
homes

Customer survey performed     Quarterly

Implemented prevention or     One group per month
health groups

Number in halfway house       Less than 1%
----------------------------------------------------------
\a "Uniques (new)" is an unduplicated count of veterans, based on
Social Security numbers, who have not received care from VHA within
the past 3 years. 

\b "Uniques (old)" is an unduplicated count of veterans, based on
Social Security numbers, who have received care from VHA within the
past 3 years. 

We believe that using indicators with measurable criteria such as
these could be helpful in measuring the effectiveness of VHA's
community-based clinics and is consistent with VHA's evaluation
guidance and the intent of its clinic evaluation requirement. 


      VHA OBTAINS LIMITED
      INFORMATION ON CLINIC
      PERFORMANCE
---------------------------------------------------------- Letter :5.3

Since networks started establishing new community-based clinics in
1995, VHA has generally collected information on clinic operations as
questions or concerns are raised by VA officials and others, such as
in the following cases: 

  -- VHA surveyed the 22 networks in July 1997 to gather selected
     information on the status of 90 approved clinics, including
     whether clinics had started operating, budget information, and
     the number of visits clinics had actually experienced compared
     with what had been estimated. 

  -- VHA prepared a report for the Senate Appropriations Committee
     addressing the need for a national plan for community-based
     clinics and to respond to the findings and recommendations
     contained in our October 1996 report.  The VHA report basically
     held that a national plan for such clinics is unnecessary and
     presented no information that had not already been presented or
     discussed. 

  -- VA's Capital Budgeting and Oversight Service examined the
     operations of four clinics in one network in spring 1997.  The
     report of that examination is still in draft form, but VHA
     officials told us that they looked at problems associated with
     contractors and monitoring clinics. 

Our assessment of VHA's evaluation and community-based clinic
guidance, evaluations conducted so far, and VHA's call for
information on an as-needed basis suggests that VHA's guidance is not
being implemented as it was intended and that VHA may not be aware
that this is happening. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

VHA continues to lack the information needed to help ensure that
networks are establishing community-based clinics in a consistent and
equitable manner.  Neither VHA nor network officials are able to
adequately answer basic questions such as the following: 

  -- How many VHA primary care facilities in each network meet VHA's
     travel standard by providing veterans reasonable access to
     health care (within 30 minutes of their homes)? 

  -- How many current users in each network do not have reasonable
     access to VHA primary care? 

  -- Of those veterans, how many have service-connected disabilities
     (highest priority for care)? 

  -- How many current users will obtain reasonable access through the
     establishment of new clinics in the next 5 years? 

  -- Of those veterans, how many have service-connected disabilities? 

  -- How many newly established clinics meet VHA's performance goals
     and objectives? 

Network business plans, proposals, and responses to our surveys
failed to provide adequate information to answer these key questions. 
Information available suggests considerable variation among networks,
which raises concerns about the equity of veterans' access to care
even though networks have improved access for thousands of current
users.  This is because networks started at different access levels
and have established clinics at widely varying rates.  Moreover,
networks appear to be planning without regard to the priorities.  As
a result, they will spend limited resources on lower priority new
users in 1997 and 1998, while improved access for thousands of higher
priority current users will not be available until 2000 and beyond. 

In order to avoid such potential undesirable situations, and
consistent with GPRA, VHA would need to establish results-oriented
goals to ensure that each network

  -- affords reasonable access to VHA primary care for a minimum
     percentage of current users by 2002 with the intent of
     equalizing access systemwide to the maximum extent practical,

  -- establishes clinics so as to provide veterans improved access
     consistent with statutory priorities for care, and

  -- evaluates its clinics' performance using a consistent set of
     minimal criteria. 

VHA appears to have a timely opportunity to improve network planning
activities, given the networks plan to complete their 1999 business
plans within the next 3 months.  Additional VHA guidance and other
VHA assistance in developing networks' 1999 business plans could
result in a more consistent and thorough strategy for using clinics
to equalize veterans' geographic access to VHA primary care
systemwide. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

We recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health to take the following actions: 

  -- Set a national target level of performance that focuses each
     network on a goal of providing reasonable geographic access to
     VHA primary care for the highest percentage of current users
     practical by 2002. 

  -- Require networks to include in their business plans the
     percentage of (1) current users, by priority status, who have
     reasonable access; (2) the remaining current users (without
     reasonable access), by priority status, who are targeted to
     receive improved access through the establishment of community
     clinics by 2002; and (3) current users, by priority status, who
     will not have reasonable access by 2002. 

  -- Require networks to plan and propose new community-based clinics
     in a manner that ensures that veterans with highest statutory
     priorities achieve reasonable access as quickly as possible,
     consistent with the requirements of the Veteran Health Care
     Reform Act of 1996 (P.L.  104-292). 

  -- Establish minimum criteria that all networks are to use annually
     for evaluating new clinics' performance. 

  -- Require networks to annually report their evaluation results to
     the Capital Budgeting and Oversight Service, a unit within VA,
     and to others for their use in reviewing proposals for new
     clinics and other purposes. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :8

In commenting on our draft report, VHA officials generally agreed
with our findings and recommendations.  To improve planning, actions
are being taken to incorporate in networks' business plans
information on current users' access to care now and by 2002.  While
agreeing that there is variation in access, VHA pointed out that it
was not clear that a national target for access is required to focus
networks.  VHA bases this response on its preliminary analysis of
clinic data, which indicates that by 2002, 80 percent of
high-priority veterans will, on average, have improved access to
care.  We agree that networks seem focused on improving access for
current users by 2002, but we remain concerned about the potentially
large variability among networks, which could be between 70 and 95
percent based on estimates provided to us.  As such, we believe that
establishment of a national target or goal could help ensure that
networks remain focused on achieving reasonable access for the
highest percentage of veterans practical, while reducing the
variations among networks to the greatest extent practical. 

VHA also agreed that minimum criteria should be established to
evaluate clinic performance; VHA said it will identify a minimum
criteria set for all networks that will focus on evaluation of
outcomes.  While noting that annual reporting seems excessive, VHA
said it will perform annual evaluations until it can determine what a
more reasonable time frame would be.  VA also said it will report the
results to the Capital Budgeting and Oversight Service, as
recommended.  Thereafter, VA suggested, and we agreed, that it seems
reasonable to review and adjust clinic performance as part of the
networks' planning processes. 

VHA officials agreed with the spirit of our recommendation requiring
networks to plan and propose clinics to ensure that the highest
statutory priority veterans (those with service-connected
disabilities) achieve access as quickly as possible.  VHA explained,
however, that the Veteran Health Care Reform Act of 1996 will change
veterans' eligibility for medical services beginning October 1, 1998,
by requiring veterans to enroll for care.  Service-connected veterans
are in the higher enrollment priorities, but once veterans are
enrolled, it will no longer differentiate among enrolled veterans by
priority status.  In other words, all enrolled veterans--not just
those with the highest priorities--are to have equal access to needed
services, and networks will necessarily need to address access for
all enrolled veterans when planning community-based clinics.  VHA
suggested, and we agreed, that our recommendation require networks to
plan clinics for veterans with the highest priorities in a manner
consistent with the act. 

Please call me at (202) 512-7101 if you have any questions or need
additional assistance.  Other major contributors to this report
include Paul Reynolds, Assistant Director; Michael O'Dell, Senior
Social Science Analyst; Carolina Morgan, Senior Evaluator; Lawrence
Moore, Evaluator; Barry Bedrick, Associate General Counsel; and Joan
Vogel, Senior Evaluator (Computer Science). 

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


PROFILES OF NETWORKS WE CONTACTED
=========================================================== Appendix I

Figures I.1 through I.3 provide brief profiles--including the number
of facilities, fiscal year budgets, total veteran population, and
number of veteran patients served in the network area--for the three
networks we visited. 

   Figure I.1:  New York/New
   Jersey Network Profile

   (See figure in printed
   edition.)

\a Clinic shared with the VA Healthcare Network Upstate New York. 

\b Hudson Valley Healthcare System. 

\c New Jersey Healthcare System. 

\d Part of the multifacility Brooklyn Medical Center. 

\e Clinic shared with the VA Stars and Stripes Healthcare Network. 

   Figure I.2:  Southwest
   Healthcare Network Profile

   (See figure in printed
   edition.)

   Figure I.3:  Desert Pacific
   Healthcare Network Profile

   (See figure in printed
   edition.)

\a These clinics comprise the Southern California System of Clinics. 


SUMMARY OF SELECTED
CHARACTERISTICS OF CLINICS
APPROVED SINCE OCTOBER 1996
========================================================== Appendix II



                                        Table II.1
                         
                          Number of Community-Based Clinics and
                            Veterans to Be Served, by Network

                  Number of clinics                       Veterans to be served
       ----------------------------------------  ----------------------------------------
Netwo                     Non-VHA                                   Current
rk     VHA operated      operated         Total     New users         users       Total\a
-----  ------------  ------------  ------------  ------------  ------------  ------------
1                 9             0             9         3,048         6,185        22,440
2                 1             6             7         3,285         9,968        13,253
3                 7             0             7         5,273        10,009        18,282
4                15             5            20         3,375        20,355        35,154
5                 3             0             3         3,452         3,392         6,844
6                 1             2             3           260         4,593         4,853
7                 1             5             6         1,833        12,625        17,033
8                10             1            11         7,406        19,978        28,584
9                 3             5             8         2,029        12,971        17,137
10               10             1            11           908        25,005        28,513
11                0             2             2             0         3,500         3,500
12                3             6             9         1,180         9,372        11,102
13                2             6             8             0         2,858         2,858
14                1             1             2         1,790         5,252         7,042
15                8             4            12           911         7,593        17,488
16                2             5             7         1,296         5,120        10,016
17                2            14            16             0         3,391         7,448
18                5             0             5            86         3,636         6,932
19                7             2             9         2,867        10,893        21,209
20                2             4             6           752        10,076        12,405
21                2             1             3         2,160         3,632         9,642
22               10             4            14         2,930        24,056        28,986
=========================================================================================
Total           104            74           178        44,841       214,460       330,721
-----------------------------------------------------------------------------------------
\a Totals may exceed the sum of "new users" plus "current users"
because some proposals only provided totals and did not indicate who
they planned to serve. 


VHA'S APPROVED COMMUNITY-BASED
CLINICS
========================================================= Appendix III



                        Table III.1
          
           Community-Based Clinics' Locations and
                  Approval Dates, by VISN

Clinic                                       Date approved
--------------------------------------  ------------------
VISN 1: New England Healthcare System
----------------------------------------------------------
Bennington, Vt.                              February 1998
Essex County/Lynn, Mass.                         June 1997
Framingham, Mass.                            November 1997
Haverhill, Mass.                             February 1998
Hyannis, Mass.                                   June 1997
Portsmouth, N.H.                              January 1997
Torrington, Conn.                            February 1998
Waterbury, Conn.                             February 1998
Windham, Conn.                               February 1998

VISN 2: Healthcare Network Upstate New York
----------------------------------------------------------
Binghamton, N.Y.                              October 1996
Glens Falls, N.Y.                             January 1997
Kingston, N.Y. (with VISN 3)                 November 1997
Niagara Falls, N.Y.                              June 1997
Rensselaer County, N.Y.                      November 1997
Schenectady County, N.Y.                     November 1997
South Saratoga County, N.Y.                  November 1997

VISN 3: New York/New Jersey Network
----------------------------------------------------------
Bergen County, N.J.                             March 1995
Central Harlem, N.Y.                          October 1996
Elizabeth, N.J.                                  June 1997
Ft. Dix, N.J. (with VISN 4)                   January 1997
Jersey City, N.J.                            November 1997
New Brunswick, N.J.                          November 1997
Rockland County, N.Y.                         January 1997
Staten Island, N.Y.                           October 1996
Trenton, N.J.                                November 1995
Yonkers, N.Y.                                    June 1997

VISN 4: Stars and Stripes Healthcare Network
----------------------------------------------------------
Aliquippa, Pa.                               November 1997
Armstrong County, Pa.                        February 1998
Ashtabula County, Ohio                       November 1997
Bucks County, Pa.                            February 1998
Cape May, N.J.                                October 1996
Centre, Pa.                                      June 1997
Clarion, Pa.                                 February 1998
Clearfield, Pa.                                  June 1997
Crawford County, Pa.                         November 1997
Greensburg, Pa.                                  June 1997
Lancaster, Pa.                               November 1997
Lawrence County, Pa.                         February 1998
McKean County, Pa.                           November 1997
Mercer County, Pa.                           February 1998
Schuylkill, Pa.                                  June 1997
Seaford, Del.                                November 1997
Tobyhanna, Pa.                                   June 1997
West Middlesex, Pa.                          February 1998
Williamsport, Pa.                             October 1996

VISN 5: Capitol Network
----------------------------------------------------------
Charlotte Hall, Md.                          November 1997
Fairfax, Va. (Vet Center)                    November 1997
Hagerstown, Md.                              November 1997

VISN 6: Mid Atlantic Network
----------------------------------------------------------
Charlotte, N.C.                                  June 1997
Greenville, N.C.                             November 1997
Tazewell, Va.                                 January 1997

VISN 7: Healthcare System of Atlanta
----------------------------------------------------------
Albany, Ga.                                  November 1997
Dothan, Ala.                                  October 1996
Florence, S.C.                               November 1997
Macon, Ga.                                   November 1997
Myrtle Beach, S.C.                           November 1997
Northeast Georgia                            February 1998
Walker County, Ala.                             March 1995

VISN 8: Florida/Puerto Rico Sunshine Healthcare Network
----------------------------------------------------------
Bartow, Fla.                                     June 1997
Brookville, Fla.                             November 1997
Cecil Field, Fla.                            February 1998
Ft. Pierce, Fla.                             November 1997
Homestead, Fla.                               October 1996
North Pinellas County, Fla.                  November 1997
Ocala, Fla.                                  November 1997
Sarasota, Fla.                                January 1997
South St. Petersburg, Fla.                   November 1997
Southwest Broward County, Fla.               November 1997
Valdosta, Ga.                                November 1997

VISN 9: Mid South Healthcare Network
----------------------------------------------------------
Bowling Green, Ky.                            January 1997
Charleston, W.V.                             November 1997
Ft. Knox, Ky.                                February 1998
Hopkinsville, Ky.                             January 1997
Madison, Tenn.                                   June 1997
Smithville, Miss.                            November 1997
Somerset, Ky.                                November 1997
Southern Indiana                             February 1998

VISN 10: Healthcare System of Ohio
----------------------------------------------------------
Akron, Ohio                                  November 1997
Athens, Ohio                                  January 1997
Lima, Ohio                                   November 1997
Lorain County, Ohio                           January 1997
Mansfield, Ohio                              November 1997
Middletown, Ohio                                 June 1997
Northern Kentucky                            February 1998
Portsmouth, Ohio                             November 1997
Sandusky, Ohio (with VISN 11)                    June 1997
Springfield, Ohio                            November 1997
Zanesville, Ohio                             November 1997

VISN 11: Veterans Integrated Service Network
----------------------------------------------------------
South Bend, Ind.                                 June 1997
Yale, Mich.                                      June 1997

VISN 12: Great Lakes Healthcare System
----------------------------------------------------------
Aurora, Ill.                                 November 1997
Chicago Heights, Ill.                            June 1997
Elgin, Ill.                                  November 1997
Hancock, Mich.                                January 1997
LaSalle County, Ill.                         November 1997
Menominee, Mich.                             February 1998
Rhinelander, Wis.                            November 1997
Union Grove, Wis.                                June 1997
Wausau, Wis.                                 November 1997
Woodlawn, Ill.                                  March 1995

VISN 13: Upper Midwest Network
----------------------------------------------------------
Bismarck, N.D.                                   June 1997
Brainerd, Minn.                               January 1997
Fergus Falls, Minn.                           January 1997
Hibbing, Minn.                                January 1997
Mankato, Minn.                                January 1997
Owatonna, Minn.                               January 1997
Pierre, S.D.                                 November 1997
Worthington, Minn.                            January 1997

VISN 14: Central Plains Network
----------------------------------------------------------
Norfolk, Nebr.                                   June 1997
Waterloo, Iowa                                   June 1997

VISN 15: Heartland Network
----------------------------------------------------------
Cape Girardeau, Mo.                              June 1997
Carmi, Ill.                                      June 1997
Ft. Leonardwood, Mo.                         February 1998
Garden City, Kans.                           February 1998
Hays, Kans.                                  February 1998
Kirksville, Mo.                              February 1998
Mt. Vernon, Ill.                              January 1997
Paducah, Ky.                                     June 1997
Paragould, Ark.                                  June 1997
Richards-Gebaur/Belton, Mo.                  February 1998
St. Joseph, Mo.                                  June 1997
West Plains, Mo.                                 June 1997

VISN 16: Veterans Integrated Service Network
----------------------------------------------------------
Durant, Miss.                                 January 1997
Greenville, Miss.                            February 1998
McAlester, Okla.                             February 1998
Meridian, Miss.                              February 1998
Mountain Home, Ark.                          November 1997
Panama City, Fla.                            November 1997
Ponca City, Okla.                                June 1997

VISN 17: Heart of Texas Healthcare
----------------------------------------------------------
Alice, Tex.                                  February 1998
Beeville, Tex.                               February 1998
Bonham, Tex.                                 November 1997
Brownsville, Tex.                             October 1996
Brownwood, Tex.                              February 1998
Decatur, Tex.                                February 1998
Del Rio, Tex.                                 October 1996
Denton, Tex.                                 February 1998
Eagle Pass, Tex.                              October 1996
Eastland, Tex.                               February 1998
Ft. Worth, Tex.                              November 1995
Hamilton, Tex.                                  March 1995
Kingsville, Tex.                             February 1998
McKinney, Tex.                               February 1998
Palestine, Tex.                              November 1997
Pleasant Grove, Tex.                             June 1997
Tyler, Tex.                                   January 1997
Uvalde, Tex.                                 February 1998

VISN 18: Southwest Healthcare Network
----------------------------------------------------------
Abilene, Tex.                                   March 1995
Casa Grande, Ariz.                           February 1998
Ft. Stockton, Tex.                              March 1995
Hobbs, N.M.                                  November 1995
Kingman, Ariz.                               November 1997
Liberal, Kans.                                 August 1996
Monahans, Tex.                               November 1995
Odessa, Tex.                                 November 1995
Safford, Ariz.                               February 1998
San Angelo, Tex.                             November 1995
Santa Rosa, N.M.                                March 1995
Sierra Vista, Ariz.                           January 1997
Stamford, Tex.                               November 1995
Yuma, Ariz.                                   January 1997

VISN 19: Rocky Mountain Network
----------------------------------------------------------
Aurora, Colo.                                November 1997
Casper, Wyo.                                  January 1997
Gallatin Valley, Mont.                       February 1998
Great Falls, Mont.                               June 1997
Greeley, Colo.                               February 1998
Missoula, Mont.                                  June 1997
Montrose County, Colo.                       February 1998
Riverton, Wyo.                               February 1998
Weber-Davis County/Ogden, Utah               February 1998

VISN 20: Northwest Network
----------------------------------------------------------
Bend, Oreg.                                  November 1997
Brookings, Oreg.; Cresent City, Calif.       February 1998
Salem, Oreg.                                 November 1997
Seattle/Puget Sound, Wash.                   November 1997
Tri-Cities Area, Wash.                       November 1997
Twin Falls, Idaho                            February 1998

VISN 21: Sierra Pacific Network
----------------------------------------------------------
Auburn, Calif.                               November 1997
Merced, Calif.                               November 1997
Vallejo, Calif.                               October 1996

VISN 22: Desert Pacific Healthcare Network
----------------------------------------------------------
Anaheim, Calif.                                  June 1997
Chula Vista, Calif.                              June 1997
Culver City, Calif.                          February 1998
El Centro, Calif.                            November 1995
Gardena, Calif.                               January 1997
Henderson, Nev.                                  June 1997
Hollywood, Calif.                            February 1998
Lancaster, Calif.                                June 1997
Las Vegas, Nev.                                  June 1997
Lompoc, Calif.                               November 1997
Oxnard, Calif.                               November 1997
San Louis Obispo, Calif.                     November 1997
Santa Ana, Calif.                                June 1997
Victorville, Calif.                           January 1997
Vista, Calif.                                    June 1997
----------------------------------------------------------
RELATED GAO PRODUCTS

VA Hospitals:  Issues and Challenges for the Future (GAO/HEHS-98-32,
Apr.  30, 1998). 

VA Health Care:  Status of Efforts to Improve Efficiency and Access
(GAO/HEHS-98-48, Feb.  6, 1998). 

VA Health Care:  Improving Veterans' Access Poses Financial and
Mission-Related Challenges (GAO/HEHS-97-7, Oct.  25, 1996). 

VA Health Care:  Opportunities for Service Delivery Efficiencies
Within Existing Resources (GAO/HEHS-96-121, July 25, 1996). 

Veterans' Health Care:  Challenges for the Future (GAO/T-HEHS-96-172,
June 27, 1996). 

VA Health Care:  Efforts to Improve Veterans' Access to Primary Care
Services (GAO/T-HEHS-96-134, Apr.  24, 1996). 

VA Health Care:  Opportunities to Increase Efficiency and Reduce
Resource Needs (GAO/T-HEHS-96-99, Mar.  8, 1996). 

VA Health Care:  Exploring Options to Improve Veterans' Access to VA
Facilities (GAO/HEHS-96-52, Feb.  6, 1996). 

VA Health Care:  How Distance From VA Facilities Affects Veterans'
Use of VA Services (GAO/HEHS-96-31, Dec.  20, 1995). 

VA Clinic Funding (GAO/HEHS-95-273R, Sept.  19, 1995). 


*** End of document. ***