Major Management Challenges and Program Risks: Department of Veterans
Affairs (Letter Report, 01/01/99, GAO/OCG-99-15).
As part of its Performance and Accountability Series, GAO provided
information on the major management challenges and program risks facing
the Department of Veterans Affairs (VA).
GAO noted that: (1) many VA facilities are deteriorating,
inappropriately configured, or no longer needed because of their age and
VA's shift in emphasis from providing specialized inpatient services to
providing primary care in an outpatient setting; (2) despite eliminating
about one-half of VA's hospital beds, excess capacity remains; (3) VA
lacks accurate, reliable, and consistent information for measuring the
extent to which: (a) veterans are receiving equitable access to health
care across the country; (b) all veterans enrolled in VA's health care
system are receiving the care they need; and (c) VA is maintaining its
capacity to care for special populations; (4) VA does not know how its
rapid move toward managed care is affecting the health status of
veterans because measures of the effects of its service delivery changes
on patient outcomes have not been established; (5) other public and
private health care providers have recognized the necessity--and the
difficulty--of creating such criteria and instruments; (6) in managing
non-health care benefits programs, VA needs to overcome a variety of
difficulties; (7) VA cannot ensure that its veterans' disability
compensation benefits are appropriately and equitably distributed
because its disability rating schedule does not accurately reflect
veterans' economic losses resulting from their disabilities; (8) also,
VA is compensating veterans for diseases that are neither caused nor
aggravated by military service; (9) VA has made progress in addressing
year 2000 challenges, but still has a number of associated issues to
address; (10) VA lacks adequate control and oversight of access to its
computer systems and has not yet institutionalized a disciplined process
for selecting, controlling, and evaluating information technology
investments as required by the Clinger-Cohen Act; (11) VA developed
strategic goals covering all its major programs and included objectives,
strategies, and performance goals to support its strategic goals; and
(12) VA has made progress in developing a framework for managing and
evaluating changes in service delivery.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: OCG-99-15
TITLE: Major Management Challenges and Program Risks: Department
of Veterans Affairs
DATE: 01/01/99
SUBJECT: Financial management
Health care services
Veterans benefits
Veterans
Risk management
Accountability
Performance measures
Information resources management
Systems conversions
Strategic planning
IDENTIFIER: Performance and Accountability Series 1999
VA Veterans Integrated Service Network
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Cover
================================================================ COVER
Performance and Accountability Series
January 1999
MAJOR MANAGEMENT CHALLENGES AND
PROGRAM RISKS - DEPARTMENT OF
VETERANS AFFAIRS
GAO/OCG-99-15
VA Challenges
Abbreviations
=============================================================== ABBREV
DOD - Department of Defense
OIG - Office of Inspector General
VA - Department of Veterans Affairs
VISN - Veterans Integrated Service Networks
Letter
=============================================================== LETTER
January 1999
The President of the Senate
The Speaker of the House of Representatives
This report addresses the major performance and management challenges
that confront the Department of Veterans Affairs (VA) in carrying out
its mission of service to America's veterans and their families. It
also addresses corrective actions that VA has taken or initiated on
these challenges and further actions that are needed. For many
years, we have reported significant management problems at VA. These
problems include obsolete infrastructure, poor monitoring of the
effects of health service delivery changes on patient outcomes,
inadequate data, and ineffective management of non-health-care
benefits and management information systems.
VA has made progress in developing a framework for managing and
evaluating changes in health care service delivery; however, much
more needs to be done. In its restructuring, VA must ensure that it
meets its educational and medical missions without compromising
efforts to improve efficiency and effectiveness. VA needs to improve
the accuracy and reliability of information for measuring the extent
to which veterans receive appropriate care, especially veterans with
special needs, and have equitable access to care across the country.
In managing non-health-care benefits challenges, VA must continue to
set results-oriented goals for compensating disabled veterans and
develop effective strategies for improving disability claims
processing and vocational rehabilitation. VA must also implement
adequate control and accountability mechanisms over its direct loan
and loan sales activities as well as institutionalize fundamental
changes to its approach to information systems management to ensure
that benefits are not disrupted in the year 2000.
This report is part of a special series entitled the Performance and
Accountability Series: Major Management Challenges and Program
Risks. The series contains separate reports on 20 agencies--one on
each of the cabinet departments and on most major independent
agencies as well as the U.S. Postal Service. The series also
includes a governmentwide report that draws from the agency-specific
reports to identify the performance and management challenges
requiring attention across the federal government. As a companion
volume to this series, GAO is issuing an update to those government
operations and programs that its work has identified as "high risk"
because of their greater vulnerabilities to waste, fraud, abuse, and
mismanagement. High-risk government operations are also identified
and discussed in detail in the appropriate performance and
accountability series agency reports.
The performance and accountability series was done at the request of
the Majority Leader of the House of Representatives, Dick Armey; the
Chairman of the House Government Reform Committee, Dan Burton; the
Chairman of the House Budget Committee, John Kasich; the Chairman of
the Senate Committee on Governmental Affairs, Fred Thompson; the
Chairman of the Senate Budget Committee, Pete Domenici; and Senator
Larry Craig. The series was subsequently cosponsored by the Ranking
Minority Member of the House Government Reform Committee, Henry A.
Waxman; the Ranking Minority Member, Subcommittee on Government
Management, Information, and Technology, House Government Reform
Committee, Dennis J. Kucinich; Senator Joseph I. Lieberman; and
Senator Carl Levin.
Copies of this report series are being sent to the President, the
congressional leadership, all other Members of the Congress, the
Director of the Office of Management and Budget, the Secretary of
Veterans Affairs, and the heads of other major departments and
agencies.
David M. Walker
Comptroller General of
the United States
OVERVIEW
=========================================================== Appendix 0
The Department of Veterans Affairs (VA) is responsible for
administering benefits and services that affect the lives of more
than 25 million veterans and approximately 44 million members of
their families. Through its budget--approximately $43 billion in
fiscal year 1999--VA provides an array of health care benefits;
non-health-care benefits, such as compensation and pensions; and
other supporting programs. Over 200,000 VA employees deliver these
services from more than 1,000 facilities. As it administers this
diverse group of programs, VA is confronting a number of serious
performance and management challenges.
THE CHALLENGES
VA HEALTH CARE
INFRASTRUCTURE DOES NOT MEET
CURRENT AND FUTURE NEEDS
------------------------------------------------------- Appendix 0:0.1
Many VA facilities are deteriorating, inappropriately configured, or
no longer needed because of their age and VA's shift in emphasis from
providing specialized inpatient services to providing primary care in
an outpatient setting. Despite eliminating about one-half of VA's
hospital beds, excess capacity remains.
VA LACKS ADEQUATE
INFORMATION TO ENSURE THAT
VETERANS HAVE ACCESS TO
NEEDED HEALTH CARE SERVICES
------------------------------------------------------- Appendix 0:0.2
VA lacks accurate, reliable, and consistent information for measuring
the extent to which (1) veterans are receiving equitable access to
care across the country, (2) all veterans enrolled in VA's health
care system are receiving the care they need, and (3) VA is
maintaining its capacity to care for special populations.
VA LACKS OUTCOME MEASURES
AND DATA TO ASSESS IMPACT OF
MANAGED CARE INITIATIVES
------------------------------------------------------- Appendix 0:0.3
VA does not know how its rapid move toward managed care is affecting
the health status of veterans because measures of the effects of its
service delivery changes on patient outcomes have not been
established. Other public and private health care providers have
recognized the necessity--and the difficulty--of creating such
criteria and instruments.
VA FACES MAJOR CHALLENGES IN
MANAGING NON-HEALTH-CARE
BENEFITS PROGRAMS
------------------------------------------------------- Appendix 0:0.4
In managing non-health-care benefits programs, VA needs to overcome a
variety of difficulties. Currently, VA cannot ensure that its
veterans' disability compensation benefits are appropriately and
equitably distributed because its disability rating schedule does not
accurately reflect veterans' economic losses resulting from their
disabilities. Also, VA is compensating veterans for diseases that
are neither caused nor aggravated by military service. In addition,
claims processing in VA's compensation and pension program continues
to be slow, and the vocational rehabilitation program has yielded
limited results. Moreover, the data that VA will use to measure
compensation and pension program performance are questionable.
Furthermore, VA has inadequate control and accountability over the
direct loan and loan sales activities within VA's Housing Credit
Assistance program.
VA NEEDS TO MANAGE ITS
INFORMATION SYSTEMS MORE
EFFECTIVELY
------------------------------------------------------- Appendix 0:0.5
VA has made progress in addressing Year 2000 challenges but still has
a number of associated issues to address. In addition, VA lacks
adequate control and oversight of access to its computer systems and
has not yet institutionalized a disciplined process for selecting,
controlling, and evaluating information technology investments, as
required by the Clinger-Cohen Act.
PROGRESS AND NEXT STEPS
As required by the Government Performance and Results Act of 1993,
commonly known as the Results Act, VA submitted a strategic plan for
fiscal years 1998 to 2003. In this plan, VA developed strategic
goals covering all its major programs and included objectives,
strategies, and performance goals to support its strategic goals. VA
has made progress in developing a framework for managing and
evaluating changes in service delivery. However, there is still much
more to do.
In particular, VA must determine whether it will better serve
veterans' needs for health care services by repairing, renovating,
and maintaining existing buildings or by spending resources directly
on patient care. In its restructuring, VA must ensure that it meets
its educational and medical missions without compromising efforts to
improve efficiency and effectiveness, and it must consider the impact
such changes may have on its role in national emergencies. VA must
also improve its management information to help it ensure that
veterans have equitable access to care across the country, that it
maintains its capacity to serve special populations, and that it can
meet enrolled veterans' demand for care. Furthermore, VA needs to
have clearly understandable, reliable, and consistent information
available to its health care managers at all levels to identify and
correct negative trends in health outcomes in a timely manner.
In addressing non-health-care benefits challenges, VA must continue
to set results-oriented goals, such as whether disabled veterans are
being compensated appropriately under the existing disability
program. VA must develop effective strategies for resolving its
long-term disability claims processing and vocational rehabilitation
shortcomings. Also, VA must implement adequate control and
accountability over its direct loan and loan sales activities to
ensure that the true cost associated with these activities can be
measured. Furthermore, VA must implement and institutionalize
fundamental changes to its approach to information systems management
to ensure that benefits payments and medical care to veterans are not
disrupted in the year 2000, unauthorized access to and misuse of VA
systems do not occur, and sound information technology investment
practices continue.
MAJOR PERFORMANCE AND MANAGEMENT
ISSUES
=========================================================== Appendix 1
VA directly touches the lives of millions of veterans and their
families every day through its health care and non-health-care
benefits programs. VA serves the medical care needs of veterans by
providing primary care, specialized care, and related medical and
social support services at hundreds of service delivery locations or
by purchasing that care from other providers. In addition, VA
supports medical education and research and serves as a primary
medical backup to other federal agencies during national emergencies.
In the last several years, VA has introduced two major initiatives to
change the way it manages its approximately $18 billion health care
system. In fiscal year 1996, VA decentralized its management
structure to form 22 geographically distinct Veterans Integrated
Service Networks (VISN) to coordinate the activities of VA's
hospitals, outpatient clinics, nursing homes, and other facilities.
VA has also been making fundamental changes in the way it delivers
health care services by applying managed care practices, such as
primary, outpatient, and preventive care, and decreasing its emphasis
on providing inpatient care. In addition to providing health care
services to veterans, VA provides non-health-care benefits of over
$20 billion each year to about 3.3 million veterans, their
dependents, and their survivors. The non-health-care benefits
include disability payments, compensation, pensions, and vocational
rehabilitation assistance programs that are administered through VA's
58 regional benefits offices.
Over the past several years, our reports and those of VA's Inspector
General and others have documented problems with VA's performance in
carrying out its complex mission and have identified several
management challenges that VA must address. This report highlights
some of the serious management challenges that VA must overcome to
meet its strategic goals of efficiently and effectively delivering
services to veterans and their families. These challenges include an
infrastructure that does not meet current and future needs,
inadequate information for ensuring that health care services are
available to eligible veterans, poor monitoring of the effects of
health service delivery changes on patient outcomes, ineffective
management of non-health-care benefits programs, disability
compensation payments that are inappropriately and inequitably
distributed, and ineffective management of information systems.
VA HEALTH CARE INFRASTRUCTURE DOES
NOT MEET CURRENT AND FUTURE NEEDS
Because of their age and recent changes in the way VA delivers health
care, many VA facilities are deteriorating, unneeded, or
inappropriately configured. As VA shifts its emphasis from providing
specialized inpatient services to providing primary care in an
outpatient setting, less of VA's existing hospital space is needed.
Unneeded vacant space creates a financial drain on VA: maintaining
unproductive assets siphons valuable resources away from providing
direct medical services. In confronting this challenge, VA needs to
make important management decisions about whether and how to
maintain, renovate, liquidate, or redirect the use of these buildings
and grounds. VA will need to identify services that could be
consolidated across its facilities as well as those that could be
offered more efficiently by other public and private providers who
contract with VA. These decisions must be made in the context of a
decreasing population of veterans--one that has a rapidly increasing
proportion of members aged 85 and older who will require more
intensive services, such as nursing home care. Furthermore, these
decisions are likely to affect how VA meets its medical education
mission to train physicians and other clinical care providers and
will require VA to restructure its affiliation agreements with
medical schools and other institutions. All these decisions will be
of critical importance in shaping how VA fulfills its health care
role well into the next century.
MANY VA FACILITIES ARE
INADEQUATE FOR DELIVERING
HEALTH CARE
------------------------------------------------------- Appendix 1:0.1
Many of VA's facilities--its buildings and grounds--are no longer
adequate for efficiently and effectively delivering health care to
veterans. Many facilities are poorly configured for the way in which
VA delivers health care services today and plans to deliver services
in the future. For example, most VA facilities were constructed as
hospitals with an array of bed sections, treatment rooms, surgical
suites, and other accommodations and equipment for treating an
inpatient population. The layout of these facilities is often poorly
suited for delivering care to an ambulatory population on an
outpatient basis. Although changing care practices and efficiency
initiatives, such as emphasizing outpatient care and facility
integration, have allowed VA to eliminate approximately half of its
52,000 acute-care hospital beds since 1994, excess capacity remains.
Furthermore, the veteran population is declining: VA projects that
the number of veterans in the country will drop about 21 percent from
1997 to 2010. We have reported that if past efficiency trends and
demographic projections are realized, VA will need only about 10,000
of its current 26,000 acute-care beds to meet veterans' health care
needs in 2010. As a result, VA will likely need to close some
facilities.
Meanwhile, VA continues to serve some veterans in aged and
deteriorating buildings that will require billions of dollars to
renovate or replace in order to meet current industry standards and
accommodate changing health care practices. As it considers
priorities for renovating or redirecting the use of these buildings,
VA should also be planning for the needs of the increasingly older
veteran population. As the nation's World War II and Korean War
veteran populations age, their health care needs are shifting from
acute hospital care to nursing home and other long-term care
services. For example, the number of veterans aged 85 and older is
projected to increase to about 1.3 million in 2010, a fourfold
increase from 1995.
VA's major initiative to integrate various clinical and support
operations across some of its facilities recognizes that some
facilities cannot meet VA's current and future needs without
extensive renovations. For example, we have reported that
consolidating services from four to three locations in the Chicago
area could save $6 million to $27 million in future renovation costs.
Integrations are also intended to enhance the efficiency and
effectiveness of VA's health care delivery system by reducing
unnecessary duplication of services. We have reported that the 23
facility integrations involving 48 health care facilities that have
been completed or are under way will produce millions of dollars in
savings that can be used to enhance veterans' health care. We
believe VA needs to identify additional opportunities for integrating
facilities. For example, we have reported that if VA closed one of
its four hospitals in the Chicago area, it could save $20 million
annually and enhance veterans' access to services.
We have also reported, however, that VA's planning and implementation
efforts for the integrations it has undertaken have been inadequate.
First, in planning integrations VA generally did not conduct
comprehensive evaluations thoroughly assessing all potential
resources needed to meet the expected workload in a given location
over the next 5 to 10 years. As a result of inadequate planning, VA
has spent hundreds of millions of dollars over the last decade
constructing and renovating inpatient capacity that is no longer
needed. Second, VA has implemented some changes before completing
the planning phases and providing detailed integration plans to
stakeholders. Third, VA has not used independent planners--that is,
planners without vested interests in the geographic area.
Consequently, VA has encountered opposition from stakeholders such as
veterans, facility personnel, affiliated medical school personnel,
and Members of the Congress who represent these groups when it
proposed facility integrations. However, VA has recently developed a
guidebook for planners to use in developing, implementing, and
evaluating potential facility integrations. While this is a step
forward, VA needs to apply this framework and evaluate its
effectiveness in saving resources for both the short and the long
term.
One additional factor that may affect the need for continued use of
some VA facilities is the expanded authority to contract for health
care services that the Congress provided VA in 1996. Under this
authority, VA can contract with public or private providers, who can
provide care at lower cost or care that VA does not offer in a
particular geographic location. To the extent that VA uses this
authority, it may create additional excess capacity in existing
facilities. VA needs to determine whether it will better serve
veterans by repairing, renovating, and maintaining existing buildings
or by spending resources directly on patient care--for example, by
contracting for that care with other providers. In making its
decisions and in planning future construction and integrations, VA
has the opportunity to dramatically reshape its delivery system to
meet the changing medical and long-term-care needs of its veteran
population. VA generally agrees that it must take a comprehensive,
long-range approach to planning to help ensure that it efficiently
and effectively meets the needs of veterans in the future.
INFRASTRUCTURE CHANGES ARE
COMPLICATED BY VA'S MEDICAL
SCHOOL AFFILIATIONS,
RESEARCH ACTIVITIES, AND
EMERGENCY BACKUP ROLE
------------------------------------------------------- Appendix 1:0.2
VA's restructuring efforts, particularly integrating administrative
and clinical services across two or more medical centers, are
complicated by affiliation agreements that VA facilities have with
medical schools and agreements with federal agencies regarding VA's
role in national emergencies. VA has met its education mission by
forging close relationships with medical schools. Since VA's medical
education program began in 1946, 130 VA medical centers have
affiliated with 105 medical schools to provide training opportunities
for medical students and residents. Today, about 70 percent of all
physicians employed by VA hold faculty appointments at these schools.
In addition, over 100,000 health professionals from more than 1,000
educational institutions receive clinical experience in VA medical
centers each year. VA management decisions about infrastructure
affect not only affiliation agreements with medical schools but also
VA's responsibility to support the nation's medical needs during
national emergencies.
Currently, most VA medical centers are affiliated with a single,
nearby medical school, making it easy for students, residents,
faculty, and researchers to fulfill their obligations. Transforming
VA's health care delivery system from an inpatient to an outpatient
focus, increasing reliance on primary care, and integrating services
in fewer hospitals are all causing VA and medical schools to rethink
their affiliation arrangements. As medical services are eliminated
or transferred from one VA facility to another to improve program
efficiencies, educational opportunities available in VA facilities
will change, which is likely to affect VA medical center affiliation
agreements with medical schools. For example, instead of continuing
inpatient surgery and intensive care at both the Montgomery and
Tuskegee medical centers, VA removed these services from Tuskegee and
consolidated them at Montgomery, which is 35 miles away. In
addition, because VA is shifting its emphasis from specialized care
to primary care, it has begun to change the mix of training
opportunities for medical residents. VA's goal is to offer 48
percent of its medical resident training slots to primary care
physicians by the year 2000--an increase of 20 percent from fiscal
year 1997. Furthermore, between fiscal years 1996 and 2000, VA plans
to reduce the number of medical residents in specialist training by
1,000 (18 percent) by reallocating 750 specialty slots to primary
care and eliminating 250 others. Although some medical schools, such
as those in the Chicago area, have raised numerous concerns about
potential VA integrations, it seems inevitable that more than one
medical school will need to share inpatient educational and research
opportunities at a single VA facility. VA must work with the medical
schools to ensure it meets its educational and medical missions
without compromising efforts to improve its efficiency and
effectiveness.
Since 1982, VA has served as the primary medical system backup to the
Department of Defense (DOD). VA also works with the Federal
Emergency Management Agency and the National Disaster Medical System
during national emergencies. For example, as DOD's backup, VA has
agreed to make beds available in case of war or other military need.
The integration of facilities' administrative functions, the
consolidation of medical services in fewer VA locations, and VA's
reduced reliance on providing specialized care may alter the way VA
is able to support DOD and the federal emergency and disaster
systems. VA has identified DOD and others as stakeholders that are
to be involved in its planning process but has not specified the
steps it will take to ensure that its plans for restructuring health
care delivery consider the impact such changes may have on its role
in national emergencies.
KEY CONTACT
------------------------------------------------------- Appendix 1:0.3
Stephen P. Backhus, Director
Veterans' Affairs and Military Health Care
Issues
Health, Education, and Human Services
Division
(202) 512-7101
[email protected]
VA LACKS ADEQUATE INFORMATION TO
ENSURE THAT VETERANS HAVE ACCESS
TO NEEDED HEALTH CARE SERVICES
Because VA lacks accurate, reliable, and consistent information on
how resources are being allocated, it cannot ensure that veterans are
receiving equitable access to care across the country. VA has also
been unable to ensure that veterans in need of costly specialized
treatment and rehabilitative services have access to such care.
Finally, VA has not developed information that would enable it to
ensure that it meets the increased demand for care generated by its
new enrollment process.
VA DOES NOT KNOW WHETHER
VETERANS HAVE EQUITABLE
ACCESS TO CARE
------------------------------------------------------- Appendix 1:0.4
VA cannot ensure that veterans who have similar economic status and
eligibility priority and who are eligible for medical care have
similar access to care regardless of the region of the country in
which they live, as required by the Congress. The Congress was
concerned that the dramatic shift in the veteran population from the
Northeast and Midwest to the South and West had occurred without a
corresponding shift in VA health care resources. In fiscal year
1997, therefore, VA introduced a new resource allocation system to
begin to correct historical inequities in allocating resources, with
the intent of improving the equity of veterans' access to care.
Instead of allocating resources directly to medical centers on the
basis of their budget for the previous year, VA now allocates funds
to its 22 VISNs. A key factor in these allocations is the number of
veterans each VISN has served. VISNs, in turn, allocate resources to
the facilities in their geographic area.
We have reported that while the new method has indeed improved the
equity of resource distribution among VISNs, VA does not know if it
is making progress in providing similar services to similarly
situated veterans. VA's strategic plan does not include a goal for
achieving equitable access, and VA does not monitor the extent to
which equitable access is being achieved among or within VISNs.
Instead, VA has focused its efforts on increasing access
generally--apparently expecting this to lead to more equitable access
sometime in the future. Furthermore, we have reported that VA
headquarters neither provides criteria for VISNs to use to equitably
allocate resources nor reviews VISNs' allocations for equity.
Although VA has made progress in improving the equity of resource
allocations nationwide among the networks, it has done little to
ensure that when networks allocate funds to their facilities, the
promise of the new system is fulfilled. Although VA told us that
having national indicators to monitor improvements in equitable
access was contrary to its philosophy of decentralizing authority and
accountability, we have reported that VA could use such indicators
without being so prescriptive that local authority and accountability
were compromised. For example, VA has already used performance
measures based on national criteria to hold VISN directors
accountable for achieving national goals.
We have also reported that VA's data for measuring changes in access
are seriously flawed because different measures are used for the same
indicator, users do not clearly understand the measures, and
obtaining the same measure over time for comparison purposes can be
difficult. As a result, VA does not know whether changes in resource
distribution from its new allocation method and other initiatives to
improve access (for example, emphasizing primary care in existing
medical centers and expanding the number of community-based
outpatient clinics throughout the country) are equalizing access
nationwide. VA does not know whether additional changes in resource
allocation, strategic planning, or management decisionmaking are
needed to ensure more equitable access. Without accurate, reliable,
and consistent information on changes in the equity of access, VA
does not know whether the number of veterans it has served has
increased at the expense of reduced access to services for veterans
who have been historically underserved.
VA CANNOT ENSURE IT HAS
MAINTAINED THE CAPACITY TO
SERVE SPECIAL POPULATIONS
------------------------------------------------------- Appendix 1:0.5
VA has not been able to adequately address congressional concern that
VA maintain its level of certain high-cost specialized services in
the face of the many initiatives to become a more efficient provider
of care. The Congress required VA to ensure that its capacity for
specialized treatment and rehabilitative services for certain
conditions was not reduced below October 1996 levels and that
veterans with these conditions had reasonable access to care. The
Congress identified four disabling conditions requiring specialized
care: spinal cord dysfunction, blindness, amputation, and mental
illness. VA identified two additional conditions: traumatic brain
injury and post-traumatic stress disorder.
We have reported that much more information and analyses are needed
to support VA's conclusion that it is maintaining its national
capacity to treat special disability groups. For example, VA's data
indicate that from fiscal year 1996 to fiscal year 1997, the number
of veterans served increased by 6,000 (or 2 percent), but spending
for specialized disability programs decreased by $52 million (or 2
percent). VA attributes the decreased spending to reducing
unnecessarily duplicative services and replacing more expensive
hospital inpatient treatment with outpatient care. Such aggregate
data and assertions may, however, mask potential adverse effects on
specific programs and locations. For example, VA data also show that
expenditures were reduced for veterans with serious mental illness
and post-traumatic stress disorder. In addition, VA data show that
about 3,000 fewer substance abuse patients with serious mental
illness were served, and $112 million less was spent.
Consistent with the Results Act, VA plans to develop outcome measures
to track, among other things, whether the care provided to disabled
veterans is effective as a result of VA's shift from inpatient to
outpatient care. While this is a step in the right direction, we and
two of VA's advisory committees have questioned the accuracy of VA's
data for these populations. We have reported difficulties arising
from changing definitions for data that make it difficult to
establish baselines for comparison purposes; inaccurate reporting at
the local level; and irreconcilable differences among medical center,
VISN, and national data. For example, we reported that in its 1997
and 1998 reports to the Congress, VA used different 1996 baseline
expenditure capacity data for each of the six special disability
programs. VA needs to develop more comprehensive, uniform, accurate,
and reliable information on these programs.
VA MAY NOT BE ABLE TO MEET
ENROLLED VETERANS' DEMAND
FOR CARE
------------------------------------------------------- Appendix 1:0.6
VA has not developed information to help ensure that it meets the
increased demand for care generated by its new process for enrolling
veterans in its health care system. As a result, VA's success in
enrolling veterans may jeopardize the availability of care for some
veterans. As part of its 1996 eligibility reform legislation, the
Congress required VA to develop a priority-based enrollment system to
allow VA to better manage access while operating within its budgetary
limits. VA has determined that in fiscal year 1999 it will serve
each veteran who enrolls and is assigned a primary health care
provider regardless of the veteran's priority category. VA projects
that by the end of fiscal year 1999, it will have enrolled about 4.4
million veterans. If each of these veterans received medical
services from VA in fiscal year 1999, the percentage of veterans
receiving VA care would increase about 47 percent compared with the
percentage of those served annually in recent years.
Because enrolled veterans are eligible for all needed hospital and
medical care from VA regardless of their priority category, care for
higher-priority veterans may be jeopardized as medical centers
provide care to all enrollees, including high-income veterans without
service-connected conditions. VA does not know how many enrollees
will use its services and what services they will need to use.
Several challenges result. VA may not have sufficient systemwide
funds to serve its enrollees. For example, officials at one medical
center told us that they will need at least an additional $5 million
in fiscal year 1999 to serve newly enrolled veterans who already
numbered 8,000 early in the fiscal year. In addition, VA's
allocation process may not be able to distribute funds adequately to
ensure that access to care is equitable if VISNs grow at different
rates--that is, if the number of veterans VISNs must serve begins to
vary widely. Furthermore, veterans' waiting times to get an
appointment scheduled or be seen after arriving for an appointment
may increase greatly. Finally, VA's local and systemwide capacity to
serve special populations, such as those with spinal cord injuries or
amputations, may be reduced because of the sheer number of veterans
seeking other services and the cost of providing those services. For
example, veterans who do not have pharmacy benefits available from
Medicare or private insurers may enroll in VA's system to obtain
these benefits, potentially reducing resources available for
low-income veterans or those with service-connected conditions.
Without knowing the number of enrollees who will use services or the
types and amounts of services to be used, VA may be risking the
availability of services to veterans with service-connected
disabilities and those with low incomes.
VA's authority to retain collections from third-party insurers for
care provided to veterans for conditions that are not
service-connected could help maintain VA's financial viability. For
each of the last 6 fiscal years, VA's financial collections averaged
about $544 million, with $560.1 million collected in fiscal year
1998. Increased collections resulting from increased enrollment of
privately insured veterans could provide funds to help meet
infrastructure and direct care needs. VA has recently initiated
efforts to improve its collections, such as automating the bill
collection process. We have reported, however, that VA may have
difficulty in achieving its goals for collecting third-party payments
for two reasons. First, the number of veterans participating in
private managed care organizations is increasing, and such
organizations typically do not pay for care delivered outside their
plans. In addition, the shift away from costly inpatient services to
less costly outpatient care could reduce private insurance recoveries
and increase recovery costs. To effectively manage its resources, VA
needs to closely monitor and evaluate the impact of its decision to
open enrollment to veterans in all priority categories.
KEY CONTACT
------------------------------------------------------- Appendix 1:0.7
Stephen P. Backhus, Director
Veterans' Affairs and Military Health Care
Issues
Health, Education, and Human Services
Division
(202) 512-7101
[email protected]
VA LACKS OUTCOME MEASURES AND DATA
TO ASSESS IMPACT OF MANAGED CARE
INITIATIVES
VA has made little progress in developing, implementing, and
evaluating results-oriented outcome measures to assess the health
status of veterans. Instead, VA's efforts to determine how well it
delivers health care have relied primarily on process-oriented
performance measures. VA needs to ensure that its rapid change
toward a managed care system is not adversely affecting the
appropriateness of health services provided to veterans.
Responsibility for monitoring quality assurance shifted several times
in the last few years among headquarters and VISN offices, and VA's
Inspector General and veterans' service organizations raised concerns
that VA had weakened its quality assurance efforts with some of these
shifts. In response, in fiscal year 1998, VA realigned the Office of
Performance and Quality to report directly to the Under Secretary for
Health. The realignment has the potential to improve VA's quality
assurance efforts because this office is situated to more readily
identify emerging challenges across the health care system, implement
and oversee local and national corrective actions when needed, and
help create the single standard of care required by accrediting
agencies.
Providing centralized oversight is an important step, but until
recently, VA has made little progress in developing, implementing,
and evaluating results-oriented outcome measures to assess the health
status of veterans. Instead, VA's efforts to determine how well it
delivers health care have relied primarily on process-oriented
performance measures. For example, VA has been tracking the number
of beds in use, the number of patients served, and the number of
patients receiving certain diagnostic tests. Although these measures
can provide useful information on progress toward meeting managed
care goals, they provide little information on the specific impact of
changes on the health status of veterans.
Moreover, although VA has designed one performance measure to assess
the functioning of seriously mentally ill patients and another to
assess the functioning of patients with a primary diagnosis of
substance abuse, VA has generally not performed the program
evaluations necessary to determine whether these are the most
appropriate or sensitive measures for assessing responses to
treatment and changes in health outcomes. The need for such measures
is critical, given the multitude of changes in delivering care that
VA has introduced over the last few years. Indeed, the need is
exacerbated by the flexibility VISNs and medical centers have in
choosing how they deliver care in VA's decentralized management
structure. VA recognizes that it needs to ensure that the changes
made to improve its efficiency and effectiveness do not
unintentionally compromise the health status of veterans. VA is not
alone in its need to design, implement, and evaluate health outcome
measures. Other public and private providers have recognized the
necessity--
and the difficulty--of creating such criteria and instruments.
VA's challenges in assessing outcomes are further complicated by poor
data. We and others have reported numerous concerns with VA's
outcome data. These concerns, which are similar to those with VA's
access data, include inconsistent, incompatible, and inaccurate
databases; changes in data definitions over time; and lack of timely
and useful reporting of information to medical center, VISN, and
national program managers. For example, in evaluating VA's fiscal
year 1999 performance plan, we reported that VA identified data
sources and collection methods for many of its performance measures
but provided little information about how these data would be
verified or validated. Given VA's history of data weaknesses, such
an omission is potentially quite damaging. Prudent management
requires that managers of local programs, VISNs, and national
programs have ready access to clearly understandable, reliable, and
consistent information in order to identify and correct negative
trends in health outcomes in a timely manner.
KEY CONTACT
------------------------------------------------------- Appendix 1:0.8
Stephen P. Backhus, Director
Veterans' Affairs and Military Health Care
Issues
Health, Education, and Human Services
Division
(202) 512-7101
[email protected]
VA FACES MAJOR CHALLENGES IN
MANAGING NON-HEALTH-CARE BENEFITS
PROGRAMS
We have reported that VA's current disability rating schedule does
not reflect the economic loss experienced by veterans today and may
not be equitably distributing disability compensation funds. We have
also reported that VA is compensating veterans for diseases that are
neither caused nor aggravated by military service, calling into
question the fairness of VA's treatment of veterans who were disabled
because of their service. In addition, slow claims processing in the
compensation and pension program and lack of program results in the
vocational rehabilitation program have been long-standing challenges
for VA. Moreover, concerns have been raised recently about the
accuracy and reliability of the data VA will use to measure
compensation and pension program performance. Furthermore, there is
concern about VA's accountability over the direct loan and loan sales
activities within VA's Housing Credit Assistance program.
VA CANNOT ENSURE THAT
VETERANS' DISABILITY
COMPENSATION BENEFITS ARE
APPROPRIATELY AND EQUITABLY
DISTRIBUTED
------------------------------------------------------- Appendix 1:0.9
VA's largest non-health-care benefits program is disability
compensation. Under this program, VA compensates veterans for
disabilities incurred or aggravated during their military service.
Since fiscal year 1996, cash benefits to veterans and their survivors
have steadily increased by about $1 billion annually. In fiscal year
1998, VA received over $17 billion in appropriations to provide
benefits to 2.3 million veterans, and VA requested an additional $1.2
billion for fiscal year 1999. VA's disability program is required by
law to compensate veterans for the average loss in earning capacity
in civilian occupations that results from injuries or conditions
incurred or aggravated during military service. The disability
ratings in VA's current schedule are primarily based on physicians'
and lawyers' judgments made in 1945 about the effect
service-connected conditions had on the average individual's ability
to perform jobs requiring manual or physical labor. Although the
ratings in the schedule have not changed substantially since 1945,
dramatic changes have occurred in the labor market and in society.
Advances in the management of disabilities, like medication to
control mental illness and computer-aided prosthetic devices that
return some functioning to the physically impaired, have helped
reduce the severity of the functional loss caused by some mental and
physical disabilities. Moreover, electronic communications and
assistive technologies, such as synthetic voice systems, standing
wheelchairs, and modified automobiles and vans, have given people
with certain types of disabilities more independence and potential to
work.
In the late 1960s, VA conducted a study of the 1945 version of the
schedule to determine whether the schedule constituted an adequate
basis for compensating veterans with service-connected conditions.
The study concluded that at least some disability ratings in the
schedule did not accurately reflect the average impairment in earning
capacity among disabled veterans and needed to be adjusted.
Specifically, VA found that of the schedule's approximately 700
diagnostic codes, 330 overestimated veterans' average loss in
earnings as a result of their conditions, and about 75 underestimated
the average loss among veterans. Despite the results of this study,
however, VA has done little to ensure that the schedule's assessments
of the economic loss associated with service-connected conditions are
accurate. Instead, VA's efforts to maintain the schedule have
concentrated on improving the appropriateness, clarity, and accuracy
of the descriptions of the conditions. Basing disability ratings at
least in part on actual earnings losses rather than solely on
physicians' and lawyers' judgments of loss in functional capacity as
determined using a rating scale that is over 50 years old would help
to ensure that veterans are compensated commensurately with their
economic losses and that compensation funds are distributed
equitably. Successful implementation of a revised rating schedule to
reflect actual earnings losses would likely require congressional
action.
In addition to compensating disabled veterans on the basis of a
rating schedule that does not accurately reflect economic losses,
according to a 1996 Congressional Budget Office report, VA was paying
about 230,000 veterans about $1.1 billion in disability compensation
payments annually for diseases or injuries neither caused nor
aggravated by military service. VA regulations provide that a
disease or injury resulting in disability is considered
service-connected if it was incurred during a veteran's military tour
of duty or, if incurred before the veteran entered service, was
aggravated by service. No causal connection is required between the
circumstances of the disability and official military duty. Thus,
veterans can receive compensation for diseases related to heredity or
life-style, such as heart disease and diabetes, rather than military
service. Our 1993 study of five countries showed that most of those
countries do not compensate veterans under such circumstances;
rather, they require that a disability be closely related to the
performance of a military duty for a veteran to qualify for
disability benefits. Eliminating disability compensation to those
veterans whose disabilities were not clearly caused by their military
service could control entitlement spending without penalizing
veterans disabled because of their service, but such a change would
likely require congressional action.
VA CONTINUES TO FACE
CHALLENGES IN PROCESSING
CLAIMS AND REHABILITATING
DISABLED VETERANS
------------------------------------------------------ Appendix 1:0.10
In 1997, the National Academy of Public Administration reported that
the timeliness and quality of adjudication decisions and slow
appellate decisions continued to be a major challenge in VA's
compensation and pension program. VA reported in fiscal year 1997
that it took an average of 133 days to complete the processing of a
veteran's original disability compensation claim. While this is
substantially faster than the average of 213 days required in fiscal
year 1994, VA's goal is to reduce the average to 53 days in fiscal
year 2002. Furthermore, veterans who appeal VA's initial decision
may have to wait 2 years or more for a final decision. In addition,
VA's vocational rehabilitation program continues to place few
disabled veterans in jobs. Our 1996 review of records of about
74,000 applicants for vocational rehabilitation between October 1991
and September 1995, who were classified by VA as eligible for
assistance, showed that only 8 percent had completed the vocational
rehabilitation process by finding a suitable job and holding it for
at least 60 days.
Moreover, VA's Under Secretary for Benefits has raised concerns about
the accuracy of VA's existing management reporting systems that will
be used for measuring compensation and pension program performance.
In September 1998, VA's Office of Inspector General (OIG) reported on
its audit of three key compensation and pension claims processing
performance measures. The OIG found that the performance measures
lacked integrity because the compensation and pension program's
automated information system was vulnerable both to reporting errors
and to manipulation of data by regional offices to show better
performance than was actually achieved.
VA is implementing a number of initiatives to address its
compensation and pension claims processing and vocational
rehabilitation performance weaknesses, including establishing
performance measures for processing times and unit costs, initiating
quality assurance efforts, and reassessing its business process
reengineering. VA is in the process of developing results-oriented
goals for its compensation, pension, and vocational rehabilitation
and counseling programs. Also, VA has developed a results-oriented
objective to increase the number of vocational rehabilitation
participants who get and keep suitable employment. VA also has plans
to review and revise its operations to focus the vocational
rehabilitation program less on training and more on helping veterans
get jobs. For example, program applications, brochures, and other
forms of written communication will be revised to ensure that they
clearly communicate the program's focus on employment.
VA has also begun to address the need to ensure that it has accurate
and reliable data for planning and management purposes. It is taking
action in response to the OIG's September 1998 report on compensation
and pension workload data concerns by (1) collecting and analyzing
historical data to identify suspect transactions in the compensation
and pension information system and (2) conducting on-site inspections
of transaction processing at VA regional benefits offices.
While VA has taken steps toward improving its strategic planning,
performance measures, and accountability to improve its
non-health-care programs, it has much more to do. VA faces
significant challenges in setting clear strategies for achieving the
goals it has established and in measuring program performance. For
example, VA considers its business process reengineering efforts to
be essential to the success of key performance goals, such as
reducing the number of days it takes to process a veteran's
disability compensation claim. VA is in the process of reexamining
the business process reengineering implementation; at this point,
however, it is unclear exactly how VA expects reengineered processes
to improve claims processing timeliness. VA is also currently
identifying and developing key data it needs to measure its progress
in achieving specific goals. At the same time, VA is working to make
its data more accurate and reliable with its existing management
reporting systems. Until these issues are resolved, veterans and
other beneficiaries of VA's non-health-care benefits programs will
continue to suffer from slow claims processing and poor customer
service.
VA DOES NOT HAVE ADEQUATE
CONTROL AND ACCOUNTABILITY
OVER ITS DIRECT LOAN AND
LOAN SALES ACTIVITIES
------------------------------------------------------ Appendix 1:0.11
VA's Annual Accountability Report, Fiscal Year 1997 described several
deficiencies that contributed to VA's receiving a qualified opinion.
Among the areas of concern was the level of control and
accountability over the direct loan and loan sale activities within
VA's Housing Credit Assistance program. Specifically, the auditors
were unable to conclude that the $3 billion loans receivable account
balance was accurate because of inadequate controls and incomplete
records. In addition, the auditors identified a number of errors,
including inaccurate recording of loan sales transactions and
improper accounting for loan guarantees.
When VA transferred the servicing of its direct loan portfolio to a
contractor in fiscal year 1997, it did not adequately plan the
transfer. VA converted only those loans that were fully documented
on its legacy system to the contractor's system. Furthermore, once
VA shut down its legacy system, it no longer had a centralized
automated system to record those loans that were in process. Without
such a system, VA transferred responsibility for tracking and
recording loans in process to the regional offices. As a result of
the contractor's having incomplete records, significant delays
occurred in recording new loans in the contractor's accounting
records, processing borrowers' loan payments, and paying property
taxes and insurance from escrow accounts.
In addition, VA did not appropriately account for or report its loan
sale activities. Proceeds from the loan sales were not accurately
recorded in the accounting records, and the liability of the loan
guarantees was not estimated and reported in accordance with federal
accounting standards. Because VA did not account for its loan sales
activities as required under federal accounting standards, the true
cost associated with this activity could not be measured.
KEY CONTACTS
------------------------------------------------------ Appendix 1:0.12
For compensation and pension issues:
Stephen P. Backhus, Director
Veterans' Affairs and Military Health Care
Issues
Health, Education, and Human Services
Division
(202) 512-7101
[email protected]
For housing credit assistance issues:
Gloria L. Jarmon, Director
Health, Education, and Human Services
Accounting and Financial Management
Accounting and Information Management
Division
(202) 512-4476
[email protected]
VA NEEDS TO MANAGE ITS INFORMATION
SYSTEMS MORE EFFECTIVELY
VA faces significant information systems challenges. It does not
know the full extent of its health-care-related Year 2000 challenges;
it lacks adequate control and oversight of access to its computer
systems; and it has not yet institutionalized a disciplined process
for selecting, controlling, and evaluating information technology
investments, as required by the Clinger-Cohen Act. Failure to
adequately address these issues could result in disruptions in
benefits payments and medical care to veterans, unauthorized access
to and misuse of VA systems, and poor information technology
investment practices.
VA could face widespread computer system failures at the turn of the
century if its systems cannot adequately distinguish the year 2000
from the year 1900. Thus, veterans who are due to receive benefits
and medical care could appear ineligible. VA recognizes the urgency
of addressing this issue and has made progress, but challenges
remain. For example, VA does not know the full extent of its Year
2000 challenges regarding its health care services. Furthermore, VA
has not completed development of its Year 2000 business continuity
and contingency plans. Failure to adequately address these issues
could result in disruptions in benefits payments and medical care to
millions of veterans and their dependents.
Significant challenges also exist in VA's control and oversight of
access to computer systems. For example, VA has not established
effective controls to prevent individuals, both internal and
external, from gaining unauthorized access to VA systems. VA's
access control weaknesses are compounded by ineffective procedures
for monitoring and overseeing systems designed to call attention to
unusual or suspicious access activities. In addition, VA is not
providing adequate physical security for its computer facilities,
assigning duties in such a way as to segregate incompatible
functions, controlling changes to powerful operating system software,
or updating and testing disaster recovery plans to prepare its
computer operations to maintain or regain critical functions in
emergency situations. VA also does not have a comprehensive computer
security planning and management program. If these control
weaknesses are not corrected, VA operations, such as financial
management, health care delivery, benefits payments, life insurance
services, and home mortgage loan guarantees--and the assets
associated with these operations--are at risk of misuse and
disruption.
Finally, VA has not yet institutionalized a disciplined process for
selecting, controlling, and evaluating information technology
investments. Information technology accounted for approximately $1
billion of VA's fiscal year 1999 budget request of $43 billion. At
the time of the budget request, VA decisionmakers did not have
current and complete information, such as cost, benefit, schedule,
risk, and performance data at the project level, which is essential
to making sound investment decisions. In addition, VA's process for
controlling and evaluating its investment portfolio has deficiencies
in in-process and postimplementation reviews. As a result,
decisionmakers do not have the information needed to (1) detect and
avoid difficulties early and (2) improve VA's investment process.
Consequently, VA does not know whether it is making the right
investments, how to control these investments effectively, or whether
these investments have provided mission-related benefits in excess of
their costs.
Over the past several years, we have made numerous recommendations to
help VA address information systems management issues. VA has
concurred with most of these recommendations and has taken actions to
implement many of them. Such actions include making fundamental
changes to its methodology and approach to information systems
management. For example, the Veterans Benefits Administration
changed its Year 2000 strategy from developing new systems to
converting existing ones. In another major change, VA separated the
Chief Information Officer function from the Chief Financial Officer
function and established a new Assistant Secretary position to serve
as Chief Information Officer reporting directly to the Secretary on
all information resources issues. This newly established position
should help VA ensure prompt and efficient handling of information
resources management issues.
KEY CONTACT
------------------------------------------------------ Appendix 1:0.13
Joel C. Willemssen, Director
Civil Agencies Information Systems
Accounting and Information Management
Division
(202) 512-6408
[email protected]
RELATED GAO PRODUCTS
=========================================================== Appendix 2
VA HEALTH CARE INFRASTRUCTURE
VA Health Care: VA's Plan for the Integration of Medical Services in
Central Alabama (GAO/HEHS-98-245R, Sept. 23, 1998).
Veterans' Health Care: Challenges Facing VA's Evolving Role in
Serving Veterans (GAO/T-HEHS-98-194, June 17, 1998).
VA Hospitals: Issues and Challenges for the Future (GAO/HEHS-98-32,
Apr. 30, 1998).
VA Health Care: Closing a Chicago Hospital Would Save Millions and
Enhance Access to Services (GAO/HEHS-98-64, Apr. 16, 1998).
VA Health Care: Opportunities to Enhance Montgomery and Tuskegee
Service Integration (GAO/T-HEHS-97-191, July 28, 1997).
VETERANS' ACCESS TO NEEDED HEALTH
CARE SERVICES
VA Health Care: More Veterans Are Being Served, but Better Oversight
Is Needed (GAO/HEHS-98-226, Aug. 28, 1998).
VA Health Care: VA's Efforts to Maintain Services for Veterans With
Special Disabilities (GAO/T-HEHS-98-220, July 23, 1998).
Veterans' Health Care: Challenges Facing VA's Evolving Role in
Serving Veterans (GAO/T-HEHS-98-194, June 17, 1998).
VA Community Clinics: Networks' Efforts to Improve Veterans' Access
to Primary Care Vary (GAO/HEHS-98-116, June 15, 1998).
VA Health Care: Resource Allocation Has Improved, but Better
Oversight Is Needed (GAO/HEHS-97-178, Sept. 17, 1997).
IMPACT OF VA MANAGED CARE
INITIATIVES
VA Health Care: More Veterans Are Being Served, but Better Oversight
Is Needed (GAO/HEHS-98-226, Aug. 28, 1998).
VA Health Care: VA's Efforts to Maintain Services for Veterans With
Special Disabilities (GAO/T-HEHS-98-220, July 23, 1998).
Veterans' Health Care: Challenges Facing VA's Evolving Role in
Serving Veterans (GAO/T-HEHS-98-194, June 17, 1998).
Results Act: Observations on VA's Fiscal Year 1999 Performance Plan
(GAO/HEHS-98-181R, June 10, 1998).
Managing for Results: Agencies' Annual Performance Plans Can Help
Address Strategic Planning Challenges (GAO/GGD-98-44, Jan. 30,
1998).
VA NON-HEALTH-CARE BENEFITS
Veterans Benefits Administration: Progress and Challenges in
Implementing the Results Act (GAO/T-HEHS-98-125, Mar. 26, 1998).
Vocational Rehabilitation: Opportunities to Improve Program
Effectiveness (GAO/T-HEHS-98-87, Feb. 4, 1998).
VA Disability Compensation: Disability Ratings May Not Reflect
Veterans' Economic Losses (GAO/HEHS-97-9, July 7, 1997).
Disabled Veterans Programs: U.S. Eligibility and Benefit Types
Compared With Five Other Countries (GAO/HRD-94-6, Nov. 24, 1993).
VA Benefits: Law Allows Compensation for Disabilities Unrelated to
Military Service (GAO/HRD-89-60, July 31, 1989).
VA INFORMATION SYSTEMS
Year 2000 Computing Crisis: Leadership Needed to Collect and
Disseminate Critical Biomedical Equipment Information
(GAO/T-AIMD-98-310, Sept. 24, 1998).
Information Systems: VA Computer Control Weaknesses Increase Risk of
Fraud, Misuse, and Improper Disclosure (GAO/AIMD-98-175, Sept. 23,
1998).
Year 2000 Computing Crisis: Progress Made in Compliance of VA
Systems, But Concerns Remain (GAO/AIMD-98-237, Aug. 21, 1998).
VA Information Technology: Improvements Needed to Implement
Legislative Reforms (GAO/AIMD-98-154, July 7, 1998).
PERFORMANCE AND ACCOUNTABILITY
SERIES
=========================================================== Appendix 3
Major Management Challenges and Program Risks: A Governmentwide
Perspective (GAO/OCG-99-1)
Major Management Challenges and Program Risks: Department of
Agriculture (GAO/OCG-99-2)
Major Management Challenges and Program Risks: Department of
Commerce (GAO/OCG-99-3)
Major Management Challenges and Program Risks: Department of Defense
(GAO/OCG-99-4)
Major Management Challenges and Program Risks: Department of
Education (GAO/OCG-99-5)
Major Management Challenges and Program Risks: Department of Energy
(GAO/OCG-99-6)
Major Management Challenges and Program Risks: Department of Health
and Human Services (GAO/OCG-99-7)
Major Management Challenges and Program Risks: Department of Housing
and Urban Development (GAO/OCG-99-8)
Major Management Challenges and Program Risks: Department of the
Interior (GAO/OCG-99-9)
Major Management Challenges and Program Risks: Department of Justice
(GAO/OCG-99-10)
Major Management Challenges and Program Risks: Department of Labor
(GAO/OCG-99-11)
Major Management Challenges and Program Risks: Department of State
(GAO/OCG-99-12)
Major Management Challenges and Program Risks: Department of
Transportation (GAO/OCG-99-13)
Major Management Challenges and Program Risks: Department of the
Treasury (GAO/OCG-99-14)
Major Management Challenges and Program Risks: Department of
Veterans Affairs (GAO/OCG-99-15)
Major Management Challenges and Program Risks: Agency for
International Development (GAO/OCG-99-16)
Major Management Challenges and Program Risks: Environmental
Protection Agency (GAO/OCG-99-17)
Major Management Challenges and Program Risks: National Aeronautics
and Space Administration (GAO/OCG-99-18)
Major Management Challenges and Program Risks: Nuclear Regulatory
Commission (GAO/OCG-99-19)
Major Management Challenges and Program Risks: Social Security
Administration (GAO/OCG-99-20)
Major Management Challenges and Program Risks: U.S. Postal Service
(GAO/OCG-99-21)
High-Risk Series: An Update (GAO/HR-99-1)
The entire series of 21 performance and accountability reports and
the high-risk series update can be ordered by using the order number
GAO/OCG-99-22SET.
*** End of document. ***