VA Health Care: Actions Needed to Improve Oversight of Community-Based Outpatient Clinics

In fiscal year 2016, VHA's 733 CBOCs provided care to more than 3 million veterans at a cost of $5.3 billion. Although most of these clinics are VHA-owned and -operated, 101 are operated through contracts with non-VHA organizations. VHA policy states that CBOCs, whether VHA-operated or contracted, must provide one standard of care that is of high quality.

GAO was asked to review VHA's use of contracts to carry out core functions. This report examines, among other issues, the extent to which VHA oversees CBOC operations.

To conduct this work, GAO reviewed VHA's policies and CBOC Report. GAO also interviewed officials from VHA's central office and from a nongeneralizable sample of eight CBOCs and their four respective VAMCs and VISNs. The CBOCs were selected for variation in factors such as contract status and geographic area.

Community-based outpatient clinics (CBOC) are an important part of the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) health care delivery system. These clinics are geographically separate from VA medical centers (VAMC) and provide outpatient services, including primary care and mental health care. GAO found weaknesses in VHA's oversight of CBOCs:

Incomplete policy implementation. VHA has not implemented certain CBOC oversight requirements as outlined in its policy. Specifically, VHA has not developed guidelines for monitoring the quality and comprehensiveness of care in CBOCs and officials said they have no plans to do so. Officials told GAO they believe the requirement was met as part of their regular oversight of Veterans Integrated Service Networks (VISN)—regional networks responsible for oversight of VAMCs and CBOCs. However, VHA may miss CBOC performance problems that are not identifiable in VISN-level data. Further, although policy requires VHA central office officials to review CBOC performance as part of quarterly VISN performance reviews, officials said they do not specifically do so unless the VISN identifies a problem. Officials from three of the four VISNs in GAO's review said they largely delegate CBOC oversight to VAMCs, and do not separately review clinic performance unless a VAMC identifies a problem.

An inaccurate and incomplete CBOC Report. VHA's CBOC Report is prepared by VHA central office and distributed to VISNs and VAMCs quarterly and at year-end. The CBOC Report could be useful to compare clinical quality of care between VHA-operated and contracted CBOCs, but it is inaccurate and incomplete. Specifically, VHA officials have used their judgment to classify certain sites as CBOCs in the report, rather than use the official classifications in policy. GAO found that 22 percent of sites were incorrectly classified as CBOCs when they were other types of sites, including VAMCs. As a result, the report is of limited usefulness to VHA as an oversight tool.

Lack of guidance or training on the CBOC Report. VHA central office officials do not provide guidance or training specific to understanding the CBOC Report to assist VISNs and VAMCs in their oversight of CBOCs. GAO found that in several places in the report, shorthand text and acronyms were used, but not defined. In addition, several VISN and VAMC officials stated that guidance or training would be helpful.

No requirement to use the CBOC Report. VHA officials told GAO that VAMCs and VISNs are expected to use the CBOC Report as an oversight tool, but GAO found that VHA lacks a requirement that they do so. Officials from three of the four VISNs and three of the four VAMCs in GAO's review were not using the report.

These weaknesses potentially lead to inconsistent oversight and create a risk that VHA is not providing one standard of care that is of high quality to veterans across VHA-operated and contracted CBOCs.

GAO recommends that VHA (1) implement oversight requirements that align with existing policy; (2) establish a process to ensure the CBOC Report is accurate and complete; (3) provide guidance or training to VISNs and VAMCs on how to use the CBOC Report; and (4) require use of the CBOC Report as an oversight tool. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

The Department of Veterans Affairs’ (VA) Veterans Health Administration  (VHA) operates one of the largest health care delivery systems in the  United States. In fiscal year 2016, VHA’s health care system included 168  VA medical centers (VAMC) that offered inpatient, outpatient, and  residential services and 733 community-based outpatient clinics  (CBOC)—stand-alone clinics that are geographically separate from  VAMCs and provide outpatient primary care, mental health care, and, in  some cases, specialty care services. In fiscal year 2016, these clinics  provided care to more than 3 million veterans at a cost of $5.3 billion,  which represented about half of the veterans treated by VHA and nearly  10 percent of total spending for their care. Although most CBOCs (632 of  the 733) are owned and operated by VHA, about 14 percent (101) are  operated by non-VHA health care organizations that contract with VHA to  provide services. According to VHA, as of the end of fiscal year 2016, 29  contractors held CBOC contracts, for which VHA spent nearly $312  million. It is VHA policy that all CBOCs provide one standard of care that  is of high quality, regardless of whether they are VHA-operated or  contracted.

In May 2000, VHA published the last in a series of reports in response to  a 1998 request from the Under Secretary for Health to evaluate CBOC  performance. The evaluation found that VHA-operated and contracted  CBOCs performed equally on most performance measures, but  contracted clinics provided fewer primary care visits, had fewer patients  with mental health diagnoses, and did not have adequate cost data  available to compare their costs to those clinics operated by VHA. Since  that time, outpatient care use in VHA has grown substantially. In 2015, an  external assessment of VHA reported that between 2007 and 2014, VHA  outpatient visits increased 41 percent while inpatient bed days declined 9  percent. The 2015 assessment also reported that VHA’s planning  models predicted inpatient bed days would decline by at least another 50  percent over the next 20 years.

We and others have cited longstanding concerns about VHA’s oversight  of its health care system. These concerns contributed to veterans’ health  care being placed on GAO’s High-Risk List beginning in 2015. You  asked us to conduct a management review of VHA that included, among  other issues, its use of contracts to carry out core functions. In this  report, we examine the extent to which:  1.  VHA-operated and contracted CBOCs vary in their provision of health  2.  VHA oversees CBOC operations, including ensuring the same quality  of care at both VHA-operated and contracted CBOCs.

To determine the extent to which VHA-operated and contracted CBOCs  vary in their provision of health care services, we analyzed fiscal years  2014 through 2016 expenditure and encounter data (the three most  recent fiscal years of data available) for the 687 of 733 CBOCs that  provided care as of September 30, 2016, and for which these data were  available. We compared expenditures per encounter and the types of  services provided by VHA-operated clinics to those for contracted clinics.  We also spoke to officials from VHA’s central office about the factors that  influence per-encounter expenditure variation across CBOCs. Given that  our 3-year analysis period was relatively short, we did not adjust the  values for inflation. We assessed the reliability of the encounter and  expenditure data by checking for missing values and obvious errors and  discussing them with VHA officials who were knowledgeable about the  data. We analyzed the data as reported by CBOCs in VHA’s managerial  cost accounting system and we did not independently verify the accuracy  or completeness of the information, or the methodology used by VHA to  calculate total costs for VHA-operated clinics. After taking these steps,  we determined the data were sufficiently reliable for the purposes of this  reporting objective.

In addition, we interviewed officials from eight selected CBOCs and from  the four VAMCs and the four Veterans Integrated Service Networks  (VISN) that oversee them. We also interviewed the four VHA contracting  officers associated with the contracted CBOCs. The eight selected  clinics are a nongeneralizable sample of four pairs of VHA-operated and  contracted CBOCs. (See table 1.) We selected these clinics from a list of  CBOCs that provided services as of March 10, 2017—the most recently  available data at the time of our review—using data from the VHA site  tracking (VAST) system, which lists all facilities and their characteristics.  We selected the clinics for variation in geographic diversity, parent VAMC  complexity level, clinic type (multi-specialty vs. primary care), and clinic  size. We also interviewed officials from the American Legion, a veterans  service organization, to obtain the perspective of veterans on the services  provided at CBOCs. The information from our interviews is not  generalizable to all CBOCs, VAMCs, VISNs, or contracting officers. We  assessed the reliability of the VAST system data on clinic characteristics  by reviewing relevant documentation and speaking to knowledgeable  agency officials. We also performed data reliability checks, such as  examining the data for missing values and obvious errors to test the internal consistency and reliability of the data. After taking these steps,  we determined the data were reliable for the purposes of selecting sites  and determining the complete list of CBOCs.

To evaluate the extent to which VHA oversees CBOC operations,  including ensuring the same quality of care at both VHA-operated and  contracted CBOCs, we reviewed VHA policies, including Directive 1229  that establishes VHA and VISN oversight responsibilities for outpatient  sites of care, including CBOCs. We also reviewed and interviewed  officials about VHA’s CBOC Report that documents clinical quality of care  measures for both VHA-operated and contracted clinics. In addition, we  analyzed the report from the first quarter of 2017—the most recently  available report at the time of our review—and compared CBOCs in the  report against sites in the VAST system as of January 3, 2017. We also  interviewed officials from VHA central office and our selected clinics  (including the contracting officers for our selected contracted clinics), as  well as officials from the selected clinics’ VAMCs and VISNs. We  assessed the oversight activities performed by VHA’s central office and  the VISNs in the context of the federal standards for internal control.

We conducted this performance audit from February 2017 to April 2018 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Over the last decade, VHA has increasingly provided care on an  outpatient basis, including primary care and mental health care services.  VHA Handbook 1006.02, VHA Site Classifications and Definitions,  defines classifications for outpatient sites of care including CBOCs.  VHA’s Directive 1229, Planning and Operating Outpatient Sites of Care,  outlines the process for establishing new CBOCs.

VHA provides outpatient care through CBOCs, health care centers, and  other outpatient services sites, which are defined in VHA’s site  classification policy:

CBOCs are clinics that provide primary care and mental health care  services, and also may provide specialty care services such as  cardiology or neurology, in an outpatient setting. CBOCs can provide  a wide array of services, ranging from a small, mainly telehealth clinic  with one technician and a nurse, to a large clinic with several specialty  care services and providers. Each clinic is overseen by, and  separate from, its VAMC; each VAMC in turn is overseen by one of 18  VISNs.

Health care centers are large multi-specialty outpatient clinics that  provide primary care, mental health care, and on-site surgical  services, in addition to other health care services.

Other outpatient services sites provide nonclinical services, such as  social services, homelessness services, and support services. They  may also provide services that are clinical in nature through telehealth  or other arrangements. (See fig. 1.)

VHA’s Process for Establishing New CBOCs

To establish a new CBOC, VHA’s policy states that the VAMC and VISN  must ensure that one is needed by first exhausting existing VHA  resources (such as changing clinic hours or staffing) and determining that  VHA community care programs cannot meet the identified demand. The  VAMC and VISN follow several steps to assess the need for a new clinic:

Step 1—The VAMC and VISN identify an underserved area using  VHA models that project changes in the veteran population and trends  in veterans’ health care needs.

Step 2—The VAMC develops a detailed proposal for the new clinic— an Access Expansion Plan—that includes information such as  whether the proposed clinic will be VHA-operated or contracted,  projected workload, scope of the services to be provided, and cost. It  also describes, as required by VHA policy, how the VAMC has  exhausted existing VHA resources before proposing a new clinic.

Step 3—The VISN reviews the expansion plan, and if approved  forwards it to an interdisciplinary panel at VHA’s central office, which  reviews it. A list of approved clinics is then sent to the Under  Secretary for Health for endorsement.

Step 4—Endorsed clinics are included in the VISN’s Strategic Capital  Investment Planning process submission for the fiscal year. Final  approval and funding for a new CBOC is dependent on Office of  Management and Budget approval of VA’s budget submission and  VHA’s final appropriations.

In fiscal year 2015, VHA suspended the establishment of new CBOCs  beginning in fiscal year 2018 due to several factors, including budget constraints and an emphasis on the use of VHA community care  programs. However, VISNs can submit requests for exceptions to the  Deputy Under Secretary for Health for Operations and Management for  review. VHA officials told us 11 exceptions had been granted as of  February 2018.

VHA-Operated CBOCs Provided Proportionally More Specialty Care and Had Higher Expenditures than Contracted CBOCs in Fiscal Years 2014 through 2016

VHA-Operated CBOCs Provided Proportionally More Specialty Care and Less Primary Care and Mental Health Care than Contracted CBOCs

We found that VHA-operated CBOCs provided more specialty care and  less primary care and mental health care as a proportion of their total  provided services than contracted CBOCs in fiscal years 2014 through  2016. For example, in fiscal year 2016, specialty care (e.g., cardiology,  gastroenterology, physical therapy) comprised 13 percent of services  provided at VHA-operated clinics and 5 percent of services provided at  contracted clinics. In contrast, VHA-operated clinics provided  proportionally less primary care and mental health services (services  offered at all CBOCs) in fiscal year 2016—these services comprised 66  percent of the services provided at VHA-operated clinics, but 84 percent  of the services provided at contracted clinics. (See fig. 2.)

We found that VHA-operated CBOCs provided several specialty care  services that were not offered in contracted CBOCs. For example, dental  care services and gastrointestinal endoscopy were provided by multiple  VHA-operated clinics, but were not provided by any of the contracted  clinics in fiscal year 2016. In addition, we found that VHA-operated clinics  were generally larger and provided more complex services than  contracted clinics. For example, multi-specialty CBOCs (clinics that  provide two or more on-site specialty care services, and which may offer  procedures requiring local anesthesia or sedation) were more often VHA- operated than contracted. Of the 733 CBOCs in fiscal year 2016, 210  were classified by VHA as multi-specialty, and nearly all of these (206)  were VHA-operated.

Officials from the four VAMCs and VISNs in our review told us decisions  about what types of services CBOCs provide are made on a case-by- case basis according to local needs. For example, officials from one  VAMC told us they decided to add physical therapy specialty care to one  of their VHA-operated clinics based on analysis indicating that veterans’  need for this care in their community would increase. Also, officials said  they wanted to alleviate the travel burden for veterans who needed the  care, as the next closest VHA facility that offered this care was a 2.5-hour  drive away. Officials from another VAMC told us that they approached the  service needs at their clinics from a regional perspective, allowing for  veteran demand for services to be met across multiple clinics in the same  geographic area instead of relying on one clinic to meet the need. As a  result of this approach, VAMC officials were in the process of expanding  services at two of its clinics.

VHA-Operated CBOCs Had Higher Expenditures than Contracted CBOCs

From fiscal years 2014 through 2016, we found that VHA-operated  CBOCs had higher per-encounter expenditures than contracted  CBOCs—a difference ranging from 3 to 5 percent per encounter. (See  table 2.)

We also found that per-encounter expenditures for almost all service  types were higher on average for VHA-operated CBOCs than contracted  CBOCs in fiscal year 2016; the exception was mental health care  services, where VHA-operated clinics’ per-encounter expenditures were 2  percent lower than for contracted clinics. The difference in per-encounter  expenditures was greatest for specialty care services. For example, VHA- operated clinics’ per-encounter expenditures for specialty care services  were 46 percent higher than for contracted clinics. This is in contrast to  primary care, where VHA-operated clinics had 11 percent higher per- encounter expenditures, on average, compared to contracted clinics.  (See fig. 3.)

Officials told us that several factors can influence per-encounter  expenditures, including (1) differences in provider compensation and  types of providers (physicians vs. physician assistants); (2) the number of  patients with complex health conditions that generally require longer visits  and more costly services (as opposed to patients with well-managed  conditions); and (3) geographic differences in the cost of providing care.  One of our selected contracted CBOCs had one of the highest per- encounter expenditures for fiscal year 2016 among all clinics. Officials  from this clinic’s VAMC told us this was due to the contractor being able  to command a very high payment rate at the time of the contract award,  due to temporarily strong local economic conditions, as well as being the  only contractor in the area capable of providing the required services.  Officials said the VAMC is in the process of awarding a new contract for  this clinic.

Although per-encounter expenditures were generally lower for contracted  CBOCs, officials from the VISNs and VAMCs in our review told us they  consider several factors in determining whether a new clinic will be VHA- operated or contracted. Such factors include the ability to directly monitor  performance and implement new standards of care, as well as the ability  to recruit and staff the clinic. For example, officials from two VAMCs in  our review told us that VHA-operated clinics can be easier to manage  because the VAMC has direct control of the clinic. Officials said this  makes it easier to implement changes to VHA standards of care without  the need to enter into contract modification negotiations. On the other  hand, officials from three of the four VISNs and three of the four VAMCs  in our review told us that contractors can be more flexible than VHA in  recruiting staff (such as the ability to offer higher salaries), making a  contracted clinic desirable for geographic areas where VHA has  challenges recruiting or retaining providers.

VHA Has Not Fully Implemented Policy Requirements, and Inaccurate Information Limits Its Oversight of CBOC Quality of Care VHA Has Not Fully Implemented CBOC Oversight Policy Requirements

We found that VHA has implemented certain oversight requirements, but  not others described in Directive 1229—its policy that outlines VHA’s  oversight responsibilities for outpatient sites of care, including CBOCs.  In terms of the oversight requirements that VHA implemented, we found it  has provided reports on patient satisfaction to VISNs and VAMCs on a  monthly basis. Specifically, VHA distributes the results of the VHA Survey  of Healthcare Experiences, a monthly survey of veterans’ satisfaction with  the care they received through VHA health care facilities. In addition, VHA  implemented the requirement to make measures related to evaluating the  progress of outpatient sites of care, such as data on wait times, workload,  and costs, available on an internal VHA website. However, VHA has not  implemented other oversight requirements, which is inconsistent with  federal standards for internal control related to monitoring, which state  that management should establish and operate monitoring activities to  monitor the internal control system and evaluate the results.

We found that VHA has not implemented the following requirements in  Directive 1229:

VHA has not developed guidelines for monitoring the quality and  comprehensiveness of care in CBOCs. Officials from the three VHA  offices with responsibility for collaborating to develop guidelines for  monitoring the quality and comprehensiveness of care in CBOCs, as  required in the policy, told us that they are not currently developing  these guidelines and they have no plans to do so. First, officials from  the office of the Assistant Deputy Under Secretary for Health for  Policy and Planning told us they had not developed these guidelines  because they no longer believed it was their office’s responsibility,  despite the fact that officials from the office had helped to develop the  recently issued policy. Second, officials from the office of the Deputy  Under Secretary for Health for Organizational Excellence told us that  their office was not responsible for addressing the broader issue of  monitoring clinics. Third, officials from the office of the Deputy Under  Secretary for Health for Operations and Management told us that  although they do not have formal guidelines in place, they believe  their office meets the Directive 1229 requirement as part of their  regular VISN oversight. Officials said they collect and review VISN- level performance data, such as patient satisfaction data, which can  be broken down to the level of the CBOC if there is a performance  problem. However, VHA may miss clinic performance problems that  are not identifiable in the VISN-level data. In addition, without  developing such guidelines, VHA has not established standardized  processes for how it monitors CBOCs, which can lead to inconsistent  oversight. This poses the risk that veterans may be subject to different  standards of care depending on the clinic visited.

VISNs do not conduct continuous quality monitoring of CBOCs  to ensure that consistent, quality care is being delivered. We  found that three of the four VISNs in our review largely delegated  oversight of the CBOCs to the VAMCs, rather than conducting  continuous quality monitoring as required in the policy. Specifically,  officials from these VISNs said that they largely focus their oversight  on the VAMCs and do not separately review the performance of every  CBOC unless the VAMC informs them of a quality problem at a  particular clinic. Officials from the remaining VISN in our review said  they do conduct CBOC-specific oversight activities. Specifically, this  VISN had created a performance review survey tool that it sends to  each clinic on an annual basis, and the results are reviewed by a  workgroup made up of VISN staff. The workgroup examines trends  across the CBOCs, including a comparison of VHA-operated and  contracted performance. For example, one question in the tool asks  how an individual CBOC’s performance compares with others  overseen by the VAMC. The delegation of oversight responsibility for  the CBOCs to the VAMCs without consistent VISN-level oversight  creates the potential for inconsistencies in oversight, which does not  align with VHA policy to provide one standard of care for all clinics.  Consequently, veterans may be subject to different standards of care  across clinics.

The Deputy Under Secretary for Health for Operations and  Management has not reviewed CBOC performance with VISNs as  part of the quarterly VISN performance reviews. The Deputy Under  Secretary for Health for Operations and Management is responsible  for conducting reviews of VISN performance with each VISN director.  Specifically, the office of the Deputy Under Secretary for Health for  Operations and Management is required by VHA policy to review  CBOC-level performance data during quarterly VISN performance  reviews. However, officials from this office and two of the VISNs we  contacted told us they do not specifically do this unless the VISN  identifies a performance problem. Of the remaining two VISNs,  officials at one VISN reported only having mid-year and year-end  meetings with VHA central office at which they did not specifically  discuss the CBOCs, and officials from the other VISN said they did  not have any regular quarterly performance reviews with VHA central  office. This lack of consistent oversight poses the risk that VHA is not  providing one, high quality standard of care to veterans across  CBOCs.

VHA’s CBOC Report Lacks Accurate and Complete Information

Directive 1229 requires VHA to provide reports to the VISNs and VAMCs  on CBOC quality of care on a quarterly and year-end basis. We found  that the CBOC Report, which is VHA’s only report that allows for  comparing clinical quality of care data across VHA-operated and  contracted CBOCs, lacks accurate and complete information. These  gaps limit the CBOC Report’s usefulness as a monitoring tool to  determine whether VHA-operated and contracted CBOCs are providing  the same standard of care. This is inconsistent with federal standards for  internal control for information and communication, which state that  management should use quality information to achieve the entity’s  objectives.

Specifically, VHA distributes the CBOC Report to VISNs and VAMCs on a  quarterly and year-end basis, which compiles CBOC quality of care  performance results based on the Healthcare Effectiveness Data and  Information Set (HEDIS)—an industry standard set of quality measures.  VISNs and VAMCs have access to other types of CBOC performance  data, such as patient satisfaction data and wait time data, but these data  are not used to assess clinical quality of care and they cannot be used to  examine performance across all CBOCs or stratified by VHA-operated  versus contracted CBOCs. In contrast, the CBOC Report allows for the  comparison of clinical quality of care data across all CBOCs, which can  be stratified according to whether the clinic is VHA-operated or  contracted.

However, we found the following issues with the CBOC Report:  Incorrect classification of CBOCs. We compared CBOCs from the  most recent CBOC Report at the time of our review (the first quarter of  fiscal year 2017) against sites in the VAST system as of January 3,  2017, which is VHA’s listing of all VHA sites of care and their  characteristics. We found that 22 percent of sites were incorrectly  classified as CBOCs, based on the site classifications in VAST.  Several of these sites were much more complex, such as health care  centers and VAMCs. For example, a VAMC was included in the  report as a CBOC, but this VAMC has three specialized intensive care  units and serves as a regional referral center for intensive inpatient  surgery, including open heart surgery. In addition, we also identified  sites included in the report that provided less complex services than  those that are provided in CBOCs, such as other outpatient services  sites.

VHA officials who produce the CBOC Report told us that, prior to the  establishment of the VAST site classifications in 2014, they used their  judgment to classify existing sites of care as CBOCs and they have  not updated their classifications since then. For sites established  since 2014, officials told us they use the VAST site classifications, but  may also use their judgment in certain situations. For example, if a  site’s classification changed in VAST from a non-CBOC to a CBOC,  they would make a decision about whether to classify it as a CBOC in  the report by examining various aspects of the facility, such as the  services provided and encounters. This procedure differs from what is  documented in the methodology section of the CBOC Report, which  states that site classifications are based on VAST. Further, VHA  officials said they did not have a document available that outlined how  they make these decisions. Because the site classifications in the  CBOC Report are based, in part, on officials’ judgment in addition to  the classifications in VAST, the report does not present accurate  information on CBOCs across VHA and is of limited usefulness to  VHA as a tool to ensure that VHA-operated and contracted CBOCs  are providing the same standard of care that is of high quality.

Missing CBOCs. We found that 53 CBOCs (7 percent of all CBOCs)  were missing from the CBOC Report from the first quarter of fiscal  year 2017, rendering the data incomplete. VHA officials provided  examples of why a CBOC might not be included in the report. For  example, a newer CBOC might not be included because it did not  have quality of care data available at the time the report was  developed. However, we identified several other sites that were listed  in the report, despite unavailable data.

Inaccurate summary calculations. Due to the incorrect site  classifications and missing CBOCs, the national- and VISN-level  summary calculations of performance in the CBOC Report were also  inaccurate. Specifically, the report includes national- and VISN-level  averages for each HEDIS measure, which VHA officials can use as  benchmarks for clinic performance. These averages were over- inclusive—incorporating performance results from additional sites that  were not CBOCs, and under-inclusive—omitting performance results  from CBOCs that were missing from the report. These inaccuracies  may lead VHA officials to draw incorrect conclusions about the quality  of care provided in CBOCs. For example, officials from one VAMC  told us that they use the national averages as benchmarks against  which they compare the performance of their CBOCs. Because this  VAMC requires CBOCs with lower-than-average HEDIS performance  results to develop a formal action plan to improve performance,  officials may not be identifying clinics that are in need of an action  plan due to the inaccuracy of the averages. In addition, VHA central  office officials who develop the CBOC Report said that the results  from recent reports have shown that VHA-operated and contracted  clinics in general provided the same standard of care, but this  conclusion may not be correct as it is based on unreliable data.

No guidance or training for use of the CBOC Report. VHA central  office officials do not provide guidance or training specific to the  CBOC Report to assist VISNs and VAMCs in using it to oversee  CBOCs. This is inconsistent with federal standards for internal control  related to the control environment, which state that management  should, among other things, develop personnel to achieve the entity’s  objectives. Such development may include training to enable  individuals to develop competencies appropriate for key roles. In our  review of the CBOC Report from the first quarter of fiscal year 2017,  we found that in several places in the report, shorthand text and  acronyms were used, but not defined. In addition, although there is a  methodology section, it is not clear that the measures described in the  report are HEDIS measures, for which VHA makes training available.  Several VAMC and VISN officials stated that guidance or training that  is specific to understanding the CBOC Report would be helpful. If  VISNs and VAMCs are not trained on how to use the report, they may  not know how to use it to oversee CBOCs and ensure they are  providing one standard of care that is of high quality.

No requirement for VISNs or VAMCs to use the CBOC Report.

VHA does not require that the CBOC Report be used as a tool to  oversee CBOCs. As a result, we found that the report was not widely  used. Specifically, an official from the office of the Deputy Under  Secretary for Health for Organizational Excellence—which produces  the CBOC Report—told us that the office’s role is to compile the  reports and distribute them, but not to monitor performance. Officials  from the office of the Deputy Under Secretary for Health for  Operations and Management said that VISNs and VAMCs are  expected to use the report as part of their CBOC oversight; however,  we found there is no requirement that they do so. We found that  officials from three of the four VISNs and three of the four VAMCs in  our review were not regularly using the CBOC Report. Officials from  one of the four VAMCs and one of the four VISNs in our review were  using it as part of CBOC oversight activities at the time of our review.  Officials from another VISN said that they planned to start using the  CBOC Report after we made them aware of it during our interview. If  VISN and VAMC officials do not use the report as a part of their  oversight, they may be missing opportunities to compare VHA- operated and contracted CBOCs and ensure they are providing one  standard of care that is of high quality.

CBOCs are an integral part of VHA’s health care delivery system, and  VHA requires that such clinics, whether VHA-operated or contracted,  provide the same standard of care to veterans that is of high quality.  Although VHA has implemented certain policy requirements for CBOC  oversight, we found several weaknesses in its oversight that make it  difficult to determine whether it is ensuring this consistent standard of  care across the clinics.

Specifically, VHA has not fully implemented oversight requirements that  align with its established policies, including a requirement to establish  guidelines for overseeing CBOC quality of care. The CBOC Report, as  VHA’s only report comparing clinical quality of care across both VHA- operated and contracted clinics, could be an important part of those  guidelines. However, as it currently stands, the report is inaccurate and  incomplete and VISNs and VAMCs are not trained on or required to use  it; thus, it is of limited use to VHA, including the VISNs and VAMCs that  have responsibility for CBOC oversight. As a result, VHA lacks assurance  that both VHA-operated and contracted CBOCs are providing one  standard of care that is of high quality.

We are making the following four recommendations to the VHA  Undersecretary for Health:  Implement oversight requirements that align with VHA’s existing policy,  including developing guidelines for monitoring quality of care in CBOCs.  (Recommendation 1)

Establish a process for regularly updating the CBOC Report to ensure it  contains an accurate and complete list of CBOCs that is consistent with  VHA’s established site classifications. (Recommendation 2)

Ensure that VISNs and VAMCs receive guidance or training on how to  use the CBOC Report. (Recommendation 3)

Require the use of the CBOC Report as an oversight tool for ensuring  one standard of care that is of high quality across VHA-operated and  contracted CBOCs. (Recommendation 4)

We provided VA with a draft of this report for its review and comment. VA  provided written comments, which are reprinted in appendix I. In its  written comments, VA concurred with all four of the report’s  recommendations, and identified actions it is taking to implement them.

We are sending copies of this report to the appropriate congressional  committees, the Acting Secretary of Veterans Affairs, the Under Secretary  for Health, and other interested parties. In addition, the report is available  at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contact and Staff Acknowledgments

Debra A. Draper, (202) 512-7114 or draperd@gao.gov.

In addition to the contact named above, Janina Austin, Assistant Director;  Malissa G. Winograd, Analyst-in-Charge; Jennie F. Apter; Zhi Boon; Keith  Haddock; and Sarah-Lynn McGrath made key contributions to this report.  Also contributing were Jacquelyn Hamilton and Vikki Porter.

Community-based outpatient clinics are an increasingly important part of the Department of Veterans Affairs’ health care system, providing millions of veterans with services like primary and mental health care. Most of them are operated by VA, but others are operated by contractors.

We found weaknesses in VA's oversight of community-based outpatient clinics, leading us to make four recommendations to help ensure veterans receive the same standard of care regardless of whether a clinic is operated by VA or by a contractor.