Detailed Information on the
Veterans Medical Care Assessment

Accelerate the collaborative activities with DoD and other Federal agencies, e.g., interoperable computerized patient health data, improved data on insurance coverage, and enrollment and eligibility information.

Work with Congressional staff to bring about approval for its improved budget structuring. In addition, VA will continue to develop performance-based budgeting.

Develop performance based budgets and clearer resource requests.

Continue the enrollment policy for non-enrolled priority level 8 veterans (higher income, non-disabled), and implement additional programmatic and cost-sharing policies aimed at focusing resources on core veteran populations.

Measure: Clinical Practice Guideline Index

Explanation:The CPGI measures how well VA follows nationally recognized clinical guidelines for care of patients with one or more of the following high-volume diagnoses: ischemic heart disease, hypertension, COPD, diabetes mellitus, major depressive disorder, and tobacco use cessation.

Measure: Percent of Patients Rating VA Health Care Service as Very Good or Excellent (Outpatient)

Explanation:This measure reflects the percentage of outpatients surveyed on the quarterly outpatient surveys who rate their overall quality of care as very good or excellent.

Measure: Increase the Scores on the Prevention Index II

Explanation:The Prevention Index is an average of nationally recognized primary prevention and early detection interventions for nine diseases or health factors that determine patients' health outcomes.

Measure: Percent of Specialty Care Appointments Scheduled Within 30 days of the Desired Date

Explanation:This measure tracks the time between when the specialty care appointment request is made and the date for which the appointment is actually scheduled.

Measure: Percent of Primary Care Appointments Scheduled Within 30 days of the Desired Date

Explanation:This measure tracks the time between when the primary care appointment request is made and the date for which the appointment is actually scheduled.

Measure: Obligations per unique user. (New measure, added February 2008)

Explanation:For VA's Medical Care program, this measure provides critical data that enables management to assess the level of expenditure per patient. Year-to-year changes are analyzed to identify trends; particular attention is paid to cost increases over and above the rate of inflation. The results data are calculated as follows: The numerator is the total medical care expenditures and obligations for the Veterans Health Administration within a given fiscal year. Denominator is the total number of unique users of medical care and services for the same fiscal year.

Is the program purpose clear?

Explanation: The Veterans Health Administration's (VHA) core mission is to serve the health care needs of service-connected veterans, special populations, and low income veterans. The Secretary clearly stated that priority care will be provided to service-connected, special populations, and low income veterans. Priority 1 veterans are moved to the front of the waiting list for care.

Evidence: The core mission is contained in the Secretary's published priorities for providing health care, the new FY 2003-2008 Department of Veteran Affairs (VA) Strategic Plan, the Under Secretary for Health's VHA Vision 2020. Also, the suspension of new Priority 8 enrollment and CARES Policy shows the focus on the core population.

Does the program address a specific and existing problem, interest, or need?

Explanation: The program provides medical care for service-connected, special populations, and lower-income veterans. VA was providing an increasing amount of medical care to non-service-connected disabled, higher-income veterans, many of whom have other health care options. However, the Secretary has directed the program to increase its focus on providing priority care to service-connected and low-income veterans.

Evidence: The specific need and interest is health care to veterans with an increased focus on priorities 1-6.

Is the program designed so that it is not redundant or duplicative of any Federal, state, local or private effort?

Explanation: Federal law allows veterans to receive benefits from various programs, hence VA's program is not unique. Most veterans that VA serves are eligible for other public sources of medical care (e.g., Department of Defense (DoD) and Medicare) or private insurance coverage, especially nonservice-connected, higher-income veterans. The unique part of VA medical care is its service to special populations, such as those with spinal cord injury, mental illness, etc. VA is the leader in many of these areas, and often is the only affordable source of this type of care in many regions. Although much of the care received by veterans is not for service-connected conditions, there is a special component to care given by VHA that addresses the overall impact of military service on health that other agencies are not able to address.

Evidence: As of September 30, 2002 approximately 49% of veteran patients were eligible for Medicare and 700,000 were eligible for the DoD's TRICARE program. In addition, approximately 80% of care is for nonservice-connected conditions. However VA continues to improve collaboration with other agencies, e.g., the development of VA+Choice with HHS to more effectively use federal health care dollars and pursuit of pharmaceutical cost efficiencies with DOD through its TRICARE providers.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: VA has a system of hospitals that is not right sized or in appropriate locations. However, significant progress has been made in the past year in relation to the Capital Asset Realignment for Enhanced Services (CARES) study. VA expects to complete the needed studies and have the Secretary decision finalized by December 2003.

Evidence: A GAO study shows that VA is spending $1 million per day to maintain excess hospital space. Over the past 20 years, veterans have shifted from the northeast to the south without corresponding shift of VA infrastructure.

Is the program effectively targeted, so program resources reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: VA has made a series of decisions more effectively targeting care to its core veterans. It is not clear whether these decisions will hold, given stakeholders desire to expand the benefit.

Evidence: The Secretary made a decision to stop enrollment of new Priority Level 8 veterans (those without disabilities and higher incomes) and give priority to service-connected veterans on the waitlist. Furthermore, the allocation of the medical care budgets to hospitals only targets core veterans.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: Medical care has numerous key measures, some related to quality, cost, access. Although the key measures focus mainly on output, medical care does include critical quality of care measures recognized throughout the health care community.

Evidence: The measures are : Clinical Practice Guidelines Index and Improve Performance on the Prevention Index. These goals pertain to all priority levels, but are based on its core population.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: All Medical Care performance measures have strategic targets that are designed to meet the highest standards of the area being measured. Specific timeframes are established for achieving each strategic target.

Evidence: The measures are : Clinical Practice Guidelines Index and Improve Performance on the Prevention Index. These goals pertain to all priority levels, but are based on its core population.

Does the program have a limited number of specific annual performance measures that demonstrate progress toward achieving the program's long-term measures?

Explanation: Medical Care has a comprehensive list of annual performance measures that demonstrate incremental progress towards reaching the long-term goals.

Evidence: Annual performance plans list VA performance measures with annual and long-term goals. Goals: Improve Waiting Times and Improve Customer Satisfaction.

Does the program have baselines and ambitious targets and timeframes for its annual measures?

Explanation: Baselines are established during the development of every new measure. Long-term stretch goals are established that are designed to meet the highest standards of the area being measured. Annual incremental targets are then established based on various factors including available funding.

Evidence: Annual performance plans list VA performance measures with annual and long-term goals. Goals: Improve Waiting Times and Improve Customer Satisfaction.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, etc.) commit to and work toward the annual and/or long-term goals of the program?

Explanation: VA's long-term care performance goals only include in-house care at this time, not State and community nursing homes. In addition, performance data from DoD, provider contract services, and outpatient clinics are not shared with VA. VA needs to expand the performance measures to account for care VA pays for in non-VA facilities.

Evidence: VA does not collect data at this time from non-VA facilities. Changes to standard contracting language are pending that will make contractors accountable for performance information.

Are independent and quality evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: There are many independent evaluations or studies conducted. These include regular reviews by such organizations as GAO, IG, JCAHO, NCQA, American Customer Satisfaction Index, and the External Peer Review Program. Although, these are not directly linked to VHA's long-term goals, they do provide information needed to evaluate performance.

Evidence: VA has contracts with some outside contractors to perform limited evaluations (e.g. prosthetics and cardiology). In addition, GAO, VA IG, and external organizations conduct studies.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: However, VA is working toward this level of performance-based budgeting. VA has proposed a new account structure that more accurately aligns funding with respective programs. VA's current cost accounting system, the Financial Management System (FMS), does capture unit costs and is used for formation of cost, efficiency, and effectiveness measures. However, until VA is able to capture unit costs or Core FLS (new financial management system) is in place, complete cost accounting will not be possible.

Evidence: VA will begin operational testing and migration of Core FLS as the new budget accounting structure is coordinated with the existing FMS accounting system. See FY 2004 President's Budget Submission, VA Account Restructure Directive, and GAO Report-03-10 citing improvement in aligning budget to program goals.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: VHA has taken steps to improve strategic planning efforts by creating the Strategic Planning Committee (SPC), a subcommittee to the National Leadership Board, to address proactively strategic issues. The SPC has completed a full revision of the VHA strategic objectives, developed new strategies, and has begun to incorporate the CARES process into the full planning process. The CARES process will strategically look at veterans' future needs and how to provide for those needs.

Evidence: VHA established the SPC Charter, continues its work on the CARES study, and proposed a restructured budget account structure for FY 2004.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: VA collects performance data from each facility (except certain non-VA long-term care sites and contract care) and uses the data to improve performance and measurement of its medical care system. VA should begin including program partners (e.g., State and community nursing homes) in its performance data.

Evidence: Each facility is required to collect data on an index of 10-15 key preventive and chronic disease measures, which VA uses to track the clinical management of patients at each facility and system-wide.

Are Federal managers and program partners (grantees, subgrantees, contractors, cost-sharing partners, etc.) held accountable for cost, schedule and performance results?

Explanation: Network directors have performance criteria in contracts, they do not capture all of the key cost, schedule, and performance results. However, progress has been made in this areas. Performance evaluations are linked to critical issue areas, and program partners are held to performance standards. The External Peer Review Program (EPRP) performs reviews of medical records at contract CBOCs using the same criteria as used for reviews of internal VHA patient care.

Evidence: VISN Director's performance evaluations do not capture all of the key cost, schedule, and performance results. In addition VA has created the Business Oversight Board (BOB) to review all major business policy and operations issues. Also, the Deputy Secretary holds Monthly Performance Review meetings which focus on discussions about cost, schedule and scope for each Program and Staff Office in VA.

Are all funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: VA does obligate funds in a timely manner.

Evidence: Financial statements and apportionments show how VA obligates funds in a timely manner.

Does the program have procedures (e.g., competitive sourcing/cost comparisons, IT improvements, approporaite incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: Significant progress has been made in the areas of efficiency and cost effectiveness in acquisition of pharmacy, prosthetics, medical/surgical supplies, and increased collection of revenue. Improvements in IT accountability have also been made. All IT projects now have progress measures with specific milestones. VA has developed a comprehensive competitive sourcing plan to study over 52,000 FTE in VHA with associated cost savings.

Evidence: VA will begin operational testing and migration of its cost accounting system as the new budget accounting structure is coordinated with the existing accounting system. IT progress is shown through submission of the business plans for each project.

Does the program collaborate and coordinate effectively with related programs?

Explanation: DoD and VA have made progress on several high-level management collaboration issues and expand the traditional resource sharing at the local level. However, most of these initiatives are in the initial stages of implementation and have not yet demonstrated significant implementation or specific resource savings. Through the DoD/VA Executive Council, the Departments recently completed a joint strategic plan to increase their partnership efforts. The joint plan calls for the development of an interoperable clinical data repository to enable both departments access to shared clinical data. The departments plan to develop a data repository to allow VA access to DoD personnel data to verify veterans military service records. They established a limited pilot for DoD to use the VA Consolidated Mail Order Pharmacy and are in the process of assessing the results of the study. In addition, the Departments expect to use the Executive Council to identify and implement the DoD/VA resource sharing pilots required by FY2003 NDAA.

Evidence: The DoD/VA Joint Sharing Strategic Plan identifies goals to increase future sharing, such as a clinical data repository. However, most of these initiatives are still in the planning phase and have not achieved sustained or quantifiable results. Major challenges still exist with the implementation of the interoperable VA and DoD information systems for enrollment and two-way shared patient information. While the two Department's health care systems expend nearly $30 billion annually each, VA's FY 2004 performance target for sharing agreements is only $150 million. The Departments have not yet identified the 3 pilot sharing sites required in the 2003 NDAA. The North Chicago VA-Navy project is still awaiting implementation after years of planning. Other sharing initiatives, which appear to have promise, like DoD's use of VA's consolidated mail order pharmacy, are still in the early pilot and evaluation stage.

Does the program use strong financial management practices?

Explanation: VA is free of any material internal control weaknesses in this area.

Evidence:  

Has the program taken meaningful steps to address its management deficiencies?

Explanation: VHA has established permanent and ad hoc committees to address management deficiencies, and monitor corrective actions. VHA tracks status of each IG and GAO audit until recommendations are resolved and closed out by the auditing agency. An important need is for a cost-accounting system throughout the medical care system, which has fallen behind by two years.

Evidence: VHA has established the National Leadership Board Charter and monitors VHA status reports on IG audits.

Has the program demonstrated adequate progress in achieving its long-term outcome performance goals?

Explanation: VA has made progress in meeting most of its long-term goals, especially those related to quality. Although these goals are output goals, they relate to important outcome goals. Improved long term planning is needed in areas such as infrastructure, long term care, DoD coordination, and providing care to the most needy veterans.

Evidence: VA's quality initiatives and performance have been highlighted in its Performance Plan, and VA has received recognition and awards from the Institute of Medicine and Harvard University.

Does the program (including program partners) achieve its annual performance goals?

Explanation: VA achieves most of its annual goals. Performance data is collected on program partner performance, but is not yet fully integrated into the system-wide performance data.

Evidence: The performance reports shows VA achieving most of these goals.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program performance goals each year?

Explanation: Due to the lack of a cost accounting system, VA is unable to accurately measure its efficiencies and cost effectiveness. Some progress has been made in areas such as the improved ratio of collections to billing.

Evidence: VA lacks a cost accounting system and is currently working on establish one.

Does the performance of this program compare favorably to other programs, including government, private, etc., that have similar purpose and goals?

Explanation: VA compares its health care with indices and data from the Centers for Disease Control (CDC), Medicare managed care plans, National Committee for Quality Assurance (NCQA), and the Behavioral Risk Factor Surveillance System. These comparison show VA to be performing well. We are awaiting data from the common measures exercise to evaluate VA against other Federal programs, no comparative performance evaluations of these programs have been done.

Evidence: Medicare program data, CDC and NCQA data indicate that VA's patient care quality is very high. No reliable data currently exists for comparisons with other Federal health care delivery programs.

Do independent and quality evaluations of this program indicate that the program is effective and achieving results?

Explanation: Evaluations are done on system components (e.g., specific conditions). They have been compared to other systems by many independent entities (e.g., Institute of Medicine and Harvard University).

Evidence: One evaluation showed VA is effective in delivering prosthetic treatment to veterans, while a second showed VA is not as effective as the private sector in treating some cardiac problems. Studies have shown VA to be a leader in many quality of care indicators and has been cited for patient safety innovations such as a leader in use of bar coding drugs to reduce errors. While these are significant areas for study, not enough studies have been done yet to provide a system-wide evaluation of program effectiveness or results.