VA Health Care
Spending for Mental Health Strategic Plan Initiatives Was Substantially Less Than Planned Gao ID: GAO-07-66 November 21, 2006The Department of Veterans Affairs (VA) provides mental health services to veterans with conditions such as post-traumatic stress disorder (PTSD) and substance abuse disorders. To address gaps in services needed by veterans, VA approved a mental health strategic plan in 2004. VA planned to increase its fiscal year 2005 allocations for plan initiatives by $100 million above fiscal year 2004 levels and its fiscal year 2006 allocations for plan initiatives by $200 million above fiscal year 2004 levels. GAO was asked to provide information on VA's allocation and use of funding for mental health strategic plan initiatives in fiscal years 2005 and 2006, and to examine the adequacy of how VA tracked spending and the extent of spending for plan initiatives. GAO reviewed VA reports and documents on plan initiatives and conducted interviews with VA officials at headquarters, 4 of 21 health care networks, and seven medical centers. VA networks provide oversight of medical center operations and most medical center resources.
In fiscal year 2005, VA headquarters allocated about $88 million of the $100 million above fiscal year 2004 levels that VA officials intended for mental health strategic plan initiatives. VA allocated about $53 million directly to medical centers and certain offices based on proposals submitted for funding and other approaches targeted to specific initiatives. VA solicited proposals from networks for initiatives to be carried out at medical centers through requests for proposals (RFP). In addition, VA headquarters officials said that VA allocated $35 million for plan initiatives through VA's general resource allocation system to its 21 health care networks on a retrospective basis, several months after resources had been provided to the networks though the general resource allocation system. VA did not notify network and medical center officials that these funds were to be used for plan initiatives. Network and medical center officials interviewed told GAO that they were not aware these allocations had been made. As a result, it is likely that some of these funds were not used for plan initiatives. VA did not allocate the approximately $12 million remaining of the $100 million for fiscal year 2005 because, according to VA officials, there was not enough time during the fiscal year to do so. Medical center officials said they used funds allocated for plan initiatives for new services and for enhancement of existing services. For example, two medical centers increased the number of mental health providers at community-based outpatient clinics. However, some medical center officials reported they did not use all funds allocated by the end of the fiscal year, due in part to the time it took to hire staff. In fiscal year 2006, VA headquarters allocated about $158 million of the $200 million above fiscal year 2004 levels intended for mental health strategic plan initiatives directly to medical centers and certain offices. VA allocated about $92 million of these funds to support new initiatives, using RFPs and other targeted funding approaches. VA also allocated about $66 million to support recurring costs of continuing initiatives from the prior fiscal year. About $42 million of the $200 million for fiscal year 2006 was not allocated. Officials from seven medical centers GAO interviewed reported they had used funds for plan initiatives, such as the creation of a new case management program. Officials at some medical centers reported they did not anticipate problems using all of the funds allocated within the fiscal year; however, officials at other medical centers were less certain they would be able to do so. VA tracking of spending for plan initiatives was inadequate. In fiscal year 2005, VA did not track such spending. In fiscal year 2006, VA tracked aspects of plan initiatives but not dollars spent. However, available information indicates that VA spending for plan initiatives was substantially less than planned. In fiscal year 2006, VA medical centers returned to headquarters about $46 million of about $158 million allocated for plan initiatives because they could not spend the funds that year. However, VA cannot determine to what extent the approximately $112 million remaining was spent on plan initiatives because it did not track specifically how these funds were spent.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-66, VA Health Care: Spending for Mental Health Strategic Plan Initiatives Was Substantially Less Than Planned
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
November 2006:
VA Health Care:
Spending for Mental Health Strategic Plan Initiatives Was Substantially
Less Than Planned:
VA Mental Health Services:
GAO-07-66:
GAO Highlights:
Highlights of GAO-07-66, a report to congressional requesters
Why GAO Did This Study:
The Department of Veterans Affairs (VA) provides mental health services
to veterans with conditions such as post-traumatic stress disorder
(PTSD) and substance abuse disorders. To address gaps in services
needed by veterans, VA approved a mental health strategic plan in 2004.
VA planned to increase its fiscal year 2005 allocations for plan
initiatives by $100 million above fiscal year 2004 levels and its
fiscal year 2006 allocations for plan initiatives by $200 million above
fiscal year 2004 levels.
GAO was asked to provide information on VA‘s allocation and use of
funding for mental health strategic plan initiatives in fiscal years
2005 and 2006, and to examine the adequacy of how VA tracked spending
and the extent of spending for plan initiatives.
GAO reviewed VA reports and documents on plan initiatives and conducted
interviews with VA officials at headquarters, 4 of 21 health care
networks, and seven medical centers. VA networks provide oversight of
medical center operations and most medical center resources.
What GAO Found:
In fiscal year 2005, VA headquarters allocated about $88 million of the
$100 million above fiscal year 2004 levels that VA officials intended
for mental health strategic plan initiatives. VA allocated about $53
million directly to medical centers and certain offices based on
proposals submitted for funding and other approaches targeted to
specific initiatives. VA solicited proposals from networks for
initiatives to be carried out at medical centers through requests for
proposals (RFP). In addition, VA headquarters officials said that VA
allocated $35 million for plan initiatives through VA‘s general
resource allocation system to its 21 health care networks on a
retrospective basis, several months after resources had been provided
to the networks though the general resource allocation system. VA did
not notify network and medical center officials that these funds were
to be used for plan initiatives. Network and medical center officials
interviewed told GAO that they were not aware these allocations had
been made. As a result, it is likely that some of these funds were not
used for plan initiatives. VA did not allocate the approximately $12
million remaining of the $100 million for fiscal year 2005 because,
according to VA officials, there was not enough time during the fiscal
year to do so. Medical center officials said they used funds allocated
for plan initiatives for new services and for enhancement of existing
services. For example, two medical centers increased the number of
mental health providers at community-based outpatient clinics. However,
some medical center officials reported they did not use all funds
allocated by the end of the fiscal year, due in part to the time it
took to hire staff.
In fiscal year 2006, VA headquarters allocated about $158 million of
the $200 million above fiscal year 2004 levels intended for mental
health strategic plan initiatives directly to medical centers and
certain offices. VA allocated about $92 million of these funds to
support new initiatives, using RFPs and other targeted funding
approaches. VA also allocated about $66 million to support recurring
costs of continuing initiatives from the prior fiscal year. About $42
million of the $200 million for fiscal year 2006 was not allocated.
Officials from seven medical centers GAO interviewed reported they had
used funds for plan initiatives, such as the creation of a new case
management program. Officials at some medical centers reported they did
not anticipate problems using all of the funds allocated within the
fiscal year; however, officials at other medical centers were less
certain they would be able to do so.
VA tracking of spending for plan initiatives was inadequate. In fiscal
year 2005, VA did not track such spending. In fiscal year 2006, VA
tracked aspects of plan initiatives but not dollars spent. However,
available information indicates that VA spending for plan initiatives
was substantially less than planned. In fiscal year 2006, VA medical
centers returned to headquarters about $46 million of about $158
million allocated for plan initiatives because they could not spend the
funds that year. However, VA cannot determine to what extent the
approximately $112 million remaining was spent on plan initiatives
because it did not track specifically how these funds were spent.
What GAO Recommends:
GAO recommends that VA track the extent to which the resources
allocated for strategic plan initiatives are spent for these
initiatives. VA did not comment on the content of this report.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-66].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Laurie E. Ekstrand at
(202) 512-7101 or ekstrandl@gao.gov.
[End of Section]
Contents:
Letter:
Results In Brief:
Background:
VA Allocated about $88 Million of the $100 Million Planned for Mental
Health Strategic Plan Initiatives in Fiscal Year 2005, but Officials
Reported That Not All Allocated Funds Were Used for Plan Initiatives:
VA Allocated about $158 Million of the $200 Million Planned for Mental
Health Strategic Plan Initiatives in Fiscal Year 2006, but Some
Officials Were Uncertain If All Funds Would Be Used for Plan
Initiatives:
VA Tracking of Funds Spent for Mental Health Strategic Plan Initiatives
Was Inadequate, but Available Information Indicates That Spending for
These Initiatives Was Substantially Less Than Planned:
Conclusion:
Recommendation for Executive Action:
Agency Comments:
Appendix I: Department of Veterans Affairs (VA) Health Care Networks,
Medical Centers, and Other Facilities GAO Selected for Review:
Appendix II: Description of Selected Department of Veterans Affairs
(VA) Mental Health Services:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2005:
Table 2: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health
Service, Fiscal Year 2005:
Table 3: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2006:
Table 4: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health
Service, Fiscal Year 2006:
Abbreviations:
CBOC: community-based outpatient clinic:
CWT: Compensated Work Therapy:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
OMHS: Office of Mental Health Services:
PTSD: post-traumatic stress disorder:
RFP: request for proposal:
VA: Department of Veterans Affairs:
VERA: Veterans Equitable Resource Allocation system:
United States Government Accountability Office:
Washington, DC 20548:
November 21, 2006:
The Honorable Lane Evans:
Ranking Minority Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Michael Michaud:
Ranking Minority Member:
Subcommittee on Health:
Committee on Veterans' Affairs:
House of Representatives:
The Department of Veterans Affairs (VA) provides a range of inpatient
and outpatient mental health services to veterans with conditions such
as depression, post-traumatic stress disorder (PTSD), and substance
abuse disorders. In November 2004, the Secretary of VA approved a
mental health strategic plan that identified additional services that
VA planned to add to the baseline of mental health services that it
already offered to meet veterans' mental health needs.[Footnote 1] This
mental health strategic plan was based on previous VA efforts that
identified gaps in the availability and adequacy of VA mental health
services, including services for the treatment of substance abuse
disorders. VA's mental health strategic plan was intended to help VA's
leadership identify the actions and resources needed to begin
eliminating the gaps between mental health services VA provided at the
time of the plan's formulation and those additional services VA
anticipated that would be required to meet future needs.
VA indicated at a 2005 congressional hearing[Footnote 2] that it would
provide $100 million above fiscal year 2004 levels for mental health
strategic plan initiatives in fiscal year 2005 from available
resources. In addition, in a 2005 executive decision memo, VA indicated
its intent to increase its fiscal year 2006 funding levels to $200
million above fiscal year 2004 levels for mental health strategic plan
initiatives. This $200 million in funds for fiscal year 2006 was to be
composed of $100 million for a continuation of fiscal year 2005
initiatives plus an additional $100 million included in the President's
budget request for fiscal year 2006, according to the executive
decision memo. These additional funds represented only a portion of the
overall funds available to support VA mental health services in those 2
fiscal years. VA's appropriation for fiscal year 2006, for example,
included more than $31.5 billion for its medical programs,[Footnote 3]
of which VA expected to spend more than $2 billion on mental health
services. VA headquarters allocates most of these resources to VA's 21
regional health care networks[Footnote 4] through a general resource
allocation system and the networks in turn allocate resources to their
medical centers.
VA officials have stated that funds for mental health strategic plan
initiatives are to be used to address priorities such as the expansion
of PTSD services, postdeployment mental health services for veterans
returning from combat in Iraq and Afghanistan and other geographic
areas--Operation Iraqi Freedom (OIF) and Operation Enduring Freedom
(OEF), respectively, and the expansion of programs for the treatment of
substance abuse disorders. In recent years, VA's mental health services
and budget have come under increased scrutiny due to the potential for
increased demand for mental health services from veterans returning
from combat in Iraq and Afghanistan. In particular, concerns have been
expressed by members of Congress and others regarding the adequacy of
resources that VA is devoting to provide mental health care for these
veterans while also continuing to provide services for veterans who are
currently receiving mental health care.
You requested that we provide information on VA's allocation and
spending for mental health strategic plan initiatives in fiscal years
2005 and 2006, and the extent to which VA tracks the use of funding for
plan initiatives. In this report, we provide information on (1) how
much of the $100 million for mental health strategic plan initiatives
in fiscal year 2005 was allocated and how those funds were used by
selected medical centers, (2) how much of the $200 million for mental
health strategic plan initiatives in fiscal year 2006 was allocated and
how those funds were used by selected medical centers, and (3) the
adequacy of how VA tracked funds spent for mental health strategic plan
initiatives in fiscal years 2005 and 2006 and the extent to which
allocated funds were spent for these initiatives.
To provide information on how much of the $100 million for fiscal year
2005 and $200 million for fiscal year 2006 for mental health strategic
plan initiatives was allocated to networks, medical centers, and
certain offices, we reviewed the plan itself as well as reports and
other documents related to the development, implementation, and funding
of the mental health strategic plan. We also conducted interviews with
VA headquarters officials with responsibilities related to mental
health services, budgeting, and the allocation of financial resources.
We took steps to ensure that the data VA provided to us on the funding
allocated in fiscal years 2005 and 2006 were sufficiently reliable for
our purposes. We reviewed the data for internal consistency and
compared the data to other VA information as well as information we
obtained through interviews with VA officials. We did not independently
verify the accuracy of the data. Nor did we independently determine the
extent to which legislation regarding VA health care expressly requires
spending or authorizes various types of mental health services but
relied on VA's determination regarding these services. To describe how
funds were used by selected medical centers, in May and June 2006, we
conducted site visits to 2 of VA's 21 health care networks and three
medical centers located in those networks, and we also conducted phone
interviews with officials in 2 other networks and four medical centers
located in those networks.[Footnote 5] We selected these 4 networks
because VA had identified them as having gaps in substance abuse and/or
mental health services prior to the implementation of the mental health
strategic plan, and because they received varying levels of funding--
from relatively high to relatively low--in fiscal year 2005 for mental
health strategic plan initiatives. We interviewed clinical and
administrative officials at these networks and medical centers and at
three community-based outpatient clinics (CBOC)[Footnote 6] associated
with these medical centers and at five Vet Centers.[Footnote 7] We
conducted these interviews in May and June 2006. The findings from our
site visits and phone interviews with network and medical center
officials cannot be generalized to other medical centers or networks.
For a list of VA health care networks and medical centers included in
our review, see appendix I. For a list of selected VA mental health
services discussed in this report, see appendix II. This work expands
upon the preliminary findings that we reported in September
2006.[Footnote 8]
To discuss how VA tracked funds spent for mental health strategic plan
initiatives in fiscal years 2005 and 2006 and the extent to which these
funds were spent for mental health strategic plan initiatives, we
reviewed documents related to VA's tracking efforts and interviewed VA
headquarters officials responsible for those efforts. We also requested
from VA headquarters information on the amount of funds returned by
medical centers to headquarters when medical centers were unable to
spend all the funds in a fiscal year. In addition, we requested
information from VA headquarters on the amount of funds medical centers
spent on plan initiatives. To gain further insights and perspectives on
veterans' mental health services generally, we reviewed our previous
work on VA health care, including those related to mental health and
strategic planning (see Related GAO Products at the end of this
report), and interviewed officials from selected veterans' service
organizations and professional and advocacy organizations. We focused
on the allocation and use of funds related to mental health strategic
plan initiatives, and did not evaluate the appropriateness of the
mental health strategic plan, VA's efforts to implement the initiatives
outlined in the plan, or VA's allocation and use of funding for mental
health services generally. We performed our work from January 2006
through November 2006 in accordance with generally accepted government
auditing standards.
Results In Brief:
VA headquarters allocated about $88 million of the $100 million VA
officials said would be used for VA mental health strategic plan
initiatives in fiscal year 2005 by using several approaches. VA
allocated about $53 million directly to medical centers and certain
offices based on proposals submitted for funding and other approaches
targeted to specific initiatives. VA headquarters solicited submissions
from networks through requests for proposals (RFP) for specific
initiatives to be carried out at networks' medical centers. In
addition, VA headquarters officials said that VA allocated $35 million
for mental health strategic plan initiatives through VA's general
resource allocation system to its 21 health care networks, which, in
turn, could allocate these resources to individual medical centers.
VA's decision that $35 million of the funds allocated through its
general resource allocation system was for mental health strategic plan
initiatives was a retroactive decision, made several months after these
resources had been provided to networks through the general resource
allocation system. Moreover, VA did not notify networks and medical
centers that these funds were to be used for plan initiatives. Network
and medical center officials we interviewed in 4 networks told us that
they were unaware that any portion of their general allocation was to
be used specifically for mental health strategic plan initiatives. The
approximately $12 million remaining of the $100 million was not
allocated because, according to headquarters officials, there was not
enough time during the fiscal year to allocate the funds. Officials we
interviewed from seven medical centers in four networks reported using
resources allocated directly to their medical centers for plan
initiatives for new mental health services and more of the services
they were already providing. For example, one medical center used
funding to develop a program to help veterans with mental health
diagnoses develop job skills and find employment. Some medical center
officials told us they had not been able to use all of the funds
provided for plan initiatives during the fiscal year in part because of
the length of time it took to hire new staff.
VA headquarters allocated about $158 million of the $200 million VA
planned for its mental health strategic plan initiatives in fiscal year
2006 directly to medical centers and certain offices by using several
approaches. VA allocated about $92 million of these funds to support
new mental health strategic plan initiatives, using RFPs and other
approaches targeted to specific initiatives. VA also allocated about
$66 million to support the recurring costs of continuing mental health
strategic plan initiatives that were funded in fiscal year 2005 through
RFPs and other targeted approaches. About $42 million of the $200
million for fiscal year 2006 was not allocated. A portion of the
approximately $42 million not allocated was a result of partial-year
allocations made for projects that were funded later in fiscal year
2006 and that are expected to receive 12-month allocations for fiscal
year 2007, according to VA officials. Officials we interviewed at seven
medical centers said they had used funds to implement plan initiatives.
Such initiatives included a new mental health intensive case management
program at one medical center. However, officials at some medical
centers told us they were uncertain that they would be able to use all
of the funds for plan initiatives by the end of the fiscal year.
VA tracking of spending for plan initiatives in fiscal years 2005 and
2006 was inadequate. In fiscal year 2005, VA headquarters did not track
the spending of allocated funds for mental health strategic plan
initiatives. In fiscal year 2006, VA began tracking information on
mental health strategic plan initiatives by developing a quarterly
reporting system that focused primarily on staffing but did not track
dollars spent. In fiscal year 2006, VA compiled information on
allocated funds returned to headquarters by medical centers that they
could not spend in the fiscal year. However, VA does not have
information on whether the funds medical centers retained were spent
for plan initiatives. Available information indicates that spending of
allocations for plan initiatives was substantially less than planned in
both fiscal years 2005 and 2006. In fiscal year 2005, about $12 million
of the planned $100 million for plan initiatives was not allocated for
them and thus was not spent for them. Thirty-five million dollars was
allocated through VA's general resource allocation system, but because
VA headquarters did not specify that these funds were for plan
initiatives, it is likely that portions of this money were not spent on
them and VA officials said that they do not have information on these
funds being spent for plan initiatives. VA officials also told us that
they did not have information on the extent to which the approximately
$53 million allocated directly to medical centers and certain offices
was actually spent on plan initiatives. Officials at medical centers we
interviewed told us that they used some of these funds on mental health
activities other than the planned initiatives or carried over funds
until the next fiscal year. In fiscal year 2006, available information
indicates that the maximum amount of allocated funds that could have
been spent for plan initiatives also fell substantially below what was
planned. About $42 million of the $200 million that was planned for
allocation to plan initiatives was never allocated for these
initiatives, and thus, never spent for them. Also, about $46 million of
the approximately $158 million that was allocated was returned by
medical centers to headquarters because it had not been spent on plan
initiatives by the end of the fiscal year. However, all of the
approximately $112 million in allocations that medical centers and
offices retained was not necessarily spent on plan initiatives as
originally planned. VA instructed medical centers in August 2006 to
spend funds for other mental health activities if they could not spend
the funds for the plan initiatives for which they were allocated by the
end of the fiscal year. Moreover, VA did not track specifically how
these funds were spent.
To help provide information on how funds are spent for VA's mental
health strategic plan initiatives, we are recommending that VA track
the extent to which the resources allocated for plan initiatives are
spent for those initiatives.
VA did not provide agency comments on the contents of this report. We
offered VA the opportunity to review but not retain copies of this
report as part of a process to help safeguard the draft contents from
unauthorized disclosure. However, VA chose not to review the draft
report in this manner. VA had previously seen portions of this report
that had been included in a statement for the record prepared for a
hearing of the House Veterans' Affairs Committee, Subcommittee on
Health, on September 28, 2006. We discussed the information in that
statement with VA officials who have responsibilities related to mental
health services, budgeting, and the allocation of financial resources,
and they agreed that the data in the statement were accurate. Further,
we briefed VA staff on the new material in this report on November 14,
2006.
Background:
VA operates a national health care system that provides health care
services to over 5 million patients annually. As part of that system,
VA provides mental health services to veterans in inpatient and
outpatient settings in a variety of VA health care facilities,
including medical centers, CBOCs, and Vet Centers. Veterans receiving
these services include homeless veterans, veterans with serious mental
illness, and veterans returning from combat who are dealing with
postdeployment readjustment issues. Mental health services are provided
for a range of conditions such as depression, PTSD, and substance abuse
disorders.
Organizational Structure and Funding of VA's Mental Health Services:
VA's Under Secretary for Health heads VA health care programs and is
responsible for oversight of operations in VA's 21 health care
networks, which are structured to manage and allocate resources to more
than 150 VA medical centers. Mental health services are provided on an
inpatient and outpatient basis in medical centers and may also be
provided on an outpatient basis in CBOCs, which are associated with
medical centers. Within VA, the lead mental health expert is the Deputy
Chief Patient Care Services Officer for Mental Health. This position
does not have direct authority for operations, but instead serves as an
advisor to VA networks and medical centers on mental health services.
In addition, the official in this position is responsible for oversight
of the Office of Mental Health Services (OMHS) located at VA
headquarters. OMHS includes various clinical experts who provide
consultation on mental health services, including PTSD and substance
abuse, to VA program officials in the networks and medical centers.
VA headquarters allocates most of its medical program services budget
each year through a general resource allocation system to its 21 health
care networks. This system, the Veterans Equitable Resource Allocation
(VERA) system, uses a case-mix[Footnote 9] formula to allocate funding
to the networks, which in turn allocate funding to their medical
centers. Although the VERA system is used to allocate funds, it does
not designate funds for specific purposes or prescribe how those funds
are to be used.[Footnote 10] Medical centers also receive funding for
specific purposes, such as prosthetics, from VA headquarters that is
not allocated through the VERA system. In addition, VA medical center
resources include collections from insurance reimbursements,
copayments, and deductibles for the care of some veterans.[Footnote 11]
VA's Mental Health Strategic Plan:
In April 2002, President Bush established the President's New Freedom
Commission on Mental Health and directed the Commission to identify
policies that could be implemented by federal, state, and local
governments to improve the delivery of mental health care across the
country.[Footnote 12] In July 2003, the Commission released its final
report and recommendations for improving the American mental health
care system. After release of the report, VA's Under Secretary for
Health formed a work group of mental health and health care
professionals charged with reviewing the Commission's recommendations
to determine if those recommendations were relevant to VA's mental
health program.
Following that effort, in July 2004, VA completed its mental health
strategic plan for improving the delivery of mental health services
within its health care system. This plan was formally approved by the
Secretary of VA in November 2004. The mental health strategic plan
contained recommended initiatives for improving VA mental health
services by addressing a range of issues, including, for example,
improving awareness about mental illness and improving access to mental
health services. According to VA officials, the mental health strategic
plan was designed to address gaps in mental health services provided to
veterans across the country. Some of the service gaps identified by the
VA were in treating veterans with serious mental illness,[Footnote 13]
female veterans, and veterans returning from combat in Iraq and
Afghanistan. The implementation of the mental health strategic plan
sought to ensure, for example, that mental health services are provided
in community-based outpatient settings; that veterans have consistent
access to mental health services across the country; and that acute
inpatient mental health services are coordinated with other inpatient
services provided to veterans.
Within VA, OMHS is responsible for coordinating with the networks and
medical centers on the overall implementation of the mental health
strategic plan. This includes formulating strategies for allocating
funds committed for the plan's implementation. Such strategies include,
for example, the use of RFPs solicited from networks for specific
initiatives to be carried out at their individual medical centers. In
addition to making these funding decisions, OMHS is also responsible
for tracking the use of funds allocated for implementing the mental
health strategic plan.
While VA initially attempted to develop an estimate of the cost to
fully implement the mental health strategic plan, VA has since decided
that a comprehensive cost estimate is inappropriate. According to VA, a
full-implementation cost estimate is inappropriate because the plan is
a "living document" that will continue to change over time as it is
implemented, and thus, the costs will change as well. VA, working with
an actuarial firm that used certain assumptions provided by VA,
developed both a long-term and a shorter-term "unofficial" estimate of
implementation costs for the initiatives included in the plan because
VA wished to have a "rough estimate" of what might be entailed in
providing all services that might be needed if capacity were not a
constraint, according to VA officials. VA and the actuary it used
concluded, however, that the methodology used to develop these
estimates was problematic. For example, the estimates used incorrect
projections for utilization of mental health services, in part, because
VA's population and mental health services are different from those in
the private sector. VA officials said that more current and accurate
data are becoming available for use in projecting the number of OIF and
OEF veterans who would be entering the system and need such services,
and that such data and improvements in projecting demand were used in
development of the President's budget request for fiscal years 2006 and
2007.
VA Allocated about $88 Million of the $100 Million Planned for Mental
Health Strategic Plan Initiatives in Fiscal Year 2005, but Officials
Reported That Not All Allocated Funds Were Used for Plan Initiatives:
VA headquarters allocated about $88 million of the $100 million that VA
officials said would be allocated for VA mental health strategic plan
initiatives in fiscal year 2005 by using several approaches. About $53
million was allocated directly to medical centers and certain offices
and $35 million was allocated through VA's general resource allocation
system to its health care networks, according to VA officials. The
approximately $12 million remaining of the $100 million was not
allocated by any approach, headquarters officials said, because there
was not enough time during the fiscal year to allocate the funds.
Officials we interviewed at seven medical centers in four networks
reported using allocated funds to provide new mental health services
and to provide more of existing services. However, some medical center
officials reported that they did not use all allocated funds for plan
initiatives by the end of fiscal year, due in part to the length of
time it took to hire new staff.
VA Allocated Approximately $53 Million Directly to Medical Centers and
Certain Offices:
VA headquarters allocated about $53 million directly to medical centers
and certain offices based on proposals submitted for funding and other
approaches targeted to specific initiatives related to the mental
health strategic plan in fiscal year 2005. (See table 1.) VA
headquarters developed RFPs and solicited submissions from networks for
specific initiatives to be carried out at their individual medical
centers through these RFPs. VA allocated resources through this and
other targeted approaches to support a range of mental health services,
based, in part, on the priorities of VA leadership and legislation for
programs related to PTSD, substance abuse, and other mental health
areas,[Footnote 14] according to VA headquarters officials. VA
headquarters officials told us that the Secretary of VA had identified
several areas of the mental health strategic plan that were to be
priorities for implementation, including those related to substance
abuse, PTSD, services for veterans of OIF/OEF, mental health in CBOCs,
and homelessness. Nearly $20 million of the approximately $53 million
allocated by using RFPs and other targeted approaches was for mental
health services related to legislation that expressly required spending
or authorized such services, according to VA officials. In addition,
nearly $33 million was allocated for mental health services not
directly related to such legislation.
Table 1: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2005:
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: Domiciliary
expansion[A];
Amount allocated (dollars): $5,999,971.
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: Compensated work
therapy/supported employment mentoring sites[B];
Amount allocated (dollars): 4,535,738.
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: PTSD[B];
Amount allocated (dollars): 2,726,840.
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: Operation Iraqi
Freedom (OIF) and Operation Enduring Freedom (OEF)[B];
Amount allocated (dollars): 2,445,554.
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: Substance abuse[B];
Amount allocated (dollars): 2,175,367.
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: Psychosocial
rehabilitation for veterans with serious mental illness[B];
Amount allocated (dollars): 1,786,414.
Type of mental health service: Allocations related to legislation that
expressly required spending or authorized services: Subtotal;
Amount allocated (dollars): $19,669,884.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
PTSD and OEF/OIF;
Amount allocated (dollars): 12,899,611.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Compensated work therapy enhancement and expansion;
Amount allocated (dollars): 4,972,784.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Grant and per diem liaisons;
Amount allocated (dollars): 4,500,000.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Mental health services in nursing homes;
Amount allocated (dollars): 4,000,000[D].
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Community-based outpatient clinic mental health;
Amount allocated (dollars): 1,997,653.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Substance abuse;
Amount allocated (dollars): 2,998,911.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Mental health intensive case management teams;
Amount allocated (dollars): 999,824.
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Development of educational programs;
Amount allocated (dollars): 600,000[E].
Type of mental health service: Allocations not directly related to
legislation that expressly required spending or authorized services[C]:
Subtotal;
Amount allocated (dollars): $32,968,783.
Type of mental health service: Total;
Amount allocated (dollars): $52,638,667.
Source: GAO summary of VA information.
Notes: A total of $48 million was allocated to medical centers to use
for their mental health services. In addition, $4 million was allocated
to VA's Office of Geriatrics and Extended Care and $600,000 was
allocated to the Employee Education System. GAO did not independently
determine the extent to which legislation regarding VA health care
expressly requires spending or authorizes these services but relied on
VA's determination regarding these services.
[A] Related to the Homeless Veterans Comprehensive Assistance Act of
2001, which authorized VA to establish up to 10 new domiciliary
programs for homeless veterans, and authorized appropriations of $5
million in fiscal years 2003 and 2004 for any such domiciliaries. See
Pub. L. No. 107-95, § 2043, 115 Stat. 903, 913.
[B] Related to the Veterans Health Care, Capital Asset, and Business
Improvement Act of 2003, in which Congress required VA to allocate a
minimum of $25 million in each of fiscal years 2004, 2005, and 2006 to
carry out a program to expand and improve the provision of specialized
mental health services for veterans, including PTSD and substance abuse
services. Congress also required VA to ensure that after these
allocations, total expenditures related to treatment of substance abuse
and PTSD were not less than $25 million above the total expenditures on
such programs in fiscal year 2003, adjusted for increases in the costs
of delivering those services. See Pub. L. No 108-170 § 108, 117 Stat.
2042, 2046-47.
[C] For some mental health services, such as substance abuse, VA
planned to allocate some funds that were related to legislation
expressly requiring spending or authorizing those services as well as
other funds that were not.
[D] This amount was allocated to VA's Office of Geriatrics and Extended
Care.
[E] This amount was allocated to VA's Employee Education System.
[End of table]
Most of the approximately $53 million allocated--about $48 million--
went to VA medical centers. PTSD services and OEF/OIF veterans' mental
health care received combined allocations of about $18 million. In
addition, combined allocations for Compensated Work Therapy (CWT)
totaled nearly $10 million. Other initiatives receiving funding
included substance abuse services, domiciliary expansion, and
psychosocial rehabilitation for veterans with serious mental illness.
In addition, VA allocated $4 million that was initially planned for CWT
programs to VA's Office of Geriatrics and Extended Care to support
development of a new nursing home care model. This shift occurred
toward the end of the fiscal year, when it appeared that not all mental
health strategic plan funding would be allocated that year. VA
officials noted that the nursing home model was aligned with
initiatives in the mental health strategic plan related to the needs of
veterans in long-term care settings. The remaining funds--$600,000--
were allocated to VA's Employee Education System to develop educational
programs.
VA headquarters officials issued five RFPs from October 2004 to January
2005 that described the specific types of services for which mental
health strategic plan funding was available. The RFPs related to PTSD,
veterans of OIF and OEF, substance abuse, and psychosocial
rehabilitation services were issued in October 2004; the domiciliary
RFP was issued in January 2005. All of the RFPs noted that funding
would be provided to address unmet needs or gaps in services. Review
panels headed by mental health experts within VA reviewed the proposals
submitted by networks, ranked them, and provided their rankings to VA's
leadership who made the allocation decisions.[Footnote 15] VA then
allocated funding directly to medical centers for the mental health
strategic plan initiatives beginning in February 2005 and continuing
throughout fiscal year 2005.
In addition to RFPs, VA also used other approaches targeted to specific
initiatives based on identified needs. For example, VA headquarters
officials used a targeted approach to allocate funding to medical
centers to expand mental health services at CBOCs that had fewer mental
health visits than a standard that VA identified for this
purpose.[Footnote 16] In addition, VA headquarters allocated funds to
support the creation of CWT-supported employment mentor sites in each
network. The medical centers selected at those sites were expected to
provide training and support for existing and future CWT programs aimed
at helping veterans with serious mental illness find and maintain
employment. VA headquarters also used targeted funding approaches to
allocate funds to medical centers to enhance existing CWT programs
through the addition of new staff and to establish CWT programs at
medical centers without such programs. VA headquarters used targeted
approaches to allocate funding for new and expanded mental health
intensive case management teams; grant and per diem liaisons for
homeless veterans; and PTSD, OIF and OEF veterans', and substance abuse
services.
VA headquarters officials said that allocations made for initiatives in
fiscal year 2005 through RFPs and other approaches targeted to specific
initiatives would be made for a total of 2 to 3 fiscal years. These
officials said they anticipated that medical centers would hire
permanent staff whose positions would need to be funded for more than 1
year. The expectation of VA leadership was that after funds allocated
through these approaches were no longer available, medical centers
would continue to support these programs using their general operating
funds received through VA's general resource allocation system.
VA Allocated $35 Million through Its General Resource Allocation System
to Its Health Care Networks on a Retrospective Basis:
VA allocated $35 million for mental health strategic plan initiatives
in fiscal year 2005 through its general resource allocation
system[Footnote 17] to its health care networks, according to VA
headquarters officials. The decision to allocate these resources to
VA's networks for mental health strategic plan initiatives was
retrospective and VA did not notify networks and medical centers of
this decision. Although VA headquarters made fiscal year 2005 general
resource allocations to the networks in December 2004,[Footnote 18] the
decision that $35 million in funds allocated at that time was for
mental health strategic plan initiatives was not finalized until April
2005, several months after the general allocation had been made. VA
headquarters officials said that they made the decision to allocate $35
million from the general resource allocation system because these
resources would be more rapidly allocated than if they had been
allocated through RFPs. However, other VA headquarters officials told
us that the decision was also made, in part, because VA did not have
sufficient unallocated funds remaining after the December 2004 general
allocation to fund $100 million for the mental health strategic plan
through RFPs and other targeted approaches.
VA headquarters officials, as well as network and medical center
officials, indicated that there was no guidance to the networks and
medical centers instructing them to use specific amounts from their
general fiscal year allocation for mental health strategic plan
initiatives. Network and medical center officials we spoke with in four
networks were unaware that any specific portion of their general
allocation was intended by headquarters officials to be used for mental
health strategic plan initiatives. Several VA medical center officials
noted, however, that some of the funds in their general allocation were
used to support mental health programs generally, as part of their
routine operations. However, because network and medical center
officials we interviewed did not know that funds had been allocated for
mental health strategic plan initiatives through VA's general resource
allocation system, nor did VA headquarters notify networks and medical
centers throughout VA of this retrospective allocation, it is likely
that some of these funds were not used for plan initiatives.
VA Did Not Allocate about $12 Million Planned for Mental Health
Strategic Plan Initiatives:
VA did not allocate approximately $12 million remaining of the $100
million planned for mental health strategic plan initiatives in fiscal
year 2005 because, according to VA headquarters officials, there was
not enough time during the fiscal year to allocate the funds through
the RFP process or other approaches targeted to specific initiatives.
In addition, officials said that when resources were allocated later in
the fiscal year through an RFP, rather than at the beginning of the
year, the amount allocated was only a portion of the annualized cost.
For example, if funds for a project with an annual cost of $4 million
were allocated midway through the fiscal year, only half the annual
cost was allocated at that time--$2 million. The expectation was that
the full $4 million would be made available for the project over the 12
months in the next fiscal year. The approximately $12 million in
unallocated funds in fiscal year 2005 was intended for mental health
strategic plan initiatives based on an allocation plan developed by VA.
(See table 2.) About $11 million of the resources not allocated was for
services related to legislation that expressly required spending or
authorized such services, according to VA officials. VA headquarters
officials said that the funds not allocated for mental health strategic
plan initiatives were allocated for other health care services.
Table 2: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health
Service, Fiscal Year 2005:
Type of mental health service: Related to legislation that expressly
required spending or authorized services: Substance abuse[A];
Planned amount not allocated (dollars): $2,824,633.
Type of mental health service: Related to legislation that expressly
required spending or authorized services: Operation Iraqi Freedom (OIF)
and Operation Enduring Freedom (OEF)[A];
Planned amount not allocated (dollars): 2,554,446.
Type of mental health service: Related to legislation that expressly
required spending or authorized services: PTSD[A];
Planned amount not allocated (dollars): 2,273,160.
Type of mental health service: Related to legislation that expressly
required spending or authorized services: Psychosocial rehabilitation
for veterans with serious mental illness[A];
Planned amount not allocated (dollars): 2,213,586.
Type of mental health service: Related to legislation that expressly
required spending or authorized services: Compensated work
therapy/supported employment mentoring sites[A];
Planned amount not allocated (dollars): 1,464,262.
Type of mental health service: Related to legislation that expressly
required spending or authorized services: Subtotal;
Planned amount not allocated (dollars): $11,330,116[B].
Type of mental health service: Not directly related to legislation that
expressly required spending or authorized services[C]: Compensated work
therapy enhancement and expansion;
Planned amount not allocated (dollars): 1,027,216.
Type of mental health service: Not directly related to legislation that
expressly required spending or authorized services[C]: Subtotal;
Planned amount not allocated (dollars): $1,031,217[D].
Type of mental health service: Total;
Planned amount not allocated (dollars): $12,361,333.
Source: GAO summary of VA information.
Notes: GAO did not independently determine the extent to which
legislation regarding VA health care expressly requires spending or
authorizes these services but relied on VA's determination regarding
these services.
[A] Related to the Veterans Health Care, Capital Asset, and Business
Improvement Act of 2003, in which Congress required VA to allocate a
minimum of $25 million in each of fiscal years 2004, 2005, and 2006 to
carry out a program to expand and improve the provision of specialized
mental health services for veterans, including PTSD and substance abuse
services. Congress also required VA to ensure that after these
allocations, total expenditures related to treatment of substance abuse
and PTSD were not less than $25 million above the total expenditures on
such programs in fiscal year 2003, adjusted for increases in the costs
of delivering those services. See Pub. L. No 108-170 § 108, 117 Stat.
2042, 2046-47.
[B] Included in this subtotal is less than $100 that was not allocated
for domiciliary expansion. The Homeless Veterans Comprehensive
Assistance Act of 2001 authorized VA to establish up to 10 new
domiciliary programs for homeless veterans. See Pub. L. No.107-95, §
2043, 115 Stat. 903, 913.
[C] For some mental health services, such as substance abuse, VA
planned to allocate some funds that related to legislation expressly
requiring spending or authorizing those services as well as other funds
that were not.
[D] Included in this subtotal is approximately $4,000 that was not
allocated for community-based outpatient clinic mental health,
substance abuse, PTSD, and OIF/OEF services, as well as for mental
health intensive case management teams.
[End of table]
Medical Center Officials Reported Using Allocated Funds for Mental
Health Strategic Plan Initiatives, but Not Using All Funds Allocated
for Plan Initiatives:
Officials we interviewed from seven medical centers in four networks
reported using the funds allocated to them for mental health strategic
plan initiatives through RFPs and other targeted approaches, but some
officials said that some of these funds were not used for plan
initiatives in fiscal year 2005. Officials said they used funds
allocated to provide new mental health services and to provide more of
existing mental health services included in plan initiatives. For
example, officials at medical centers in Bay Pines and the Tennessee
Valley Healthcare System reported using funds to increase the number of
mental health providers at CBOCs, some of which previously had no
mental health providers available to see veterans. The Albuquerque
medical center used funds to develop a CWT-supported employment program
to help veterans with mental health diagnoses develop job skills and
find employment. The Tennessee Valley Healthcare System also
implemented a new 6-week PTSD day treatment program in which veterans
live in the community but come to the medical center during the day for
counseling, group therapy, and other services. The Tampa medical center
funded new mental health staff to work with veterans being treated in
its Polytrauma Rehabilitation Center. The Tuscaloosa medical center
opened a new domiciliary for homeless veterans and the Phoenix medical
center hired a new grant and per diem liaison for its homeless program.
The medical centers in our review used the mental health strategic plan
funds for recurring uses, such as hiring staff, and for nonrecurring
uses. Nonrecurring uses included acquisition of furniture and equipment
as well as building renovation.
Officials at four medical centers reported that they were not able to
use all of their fiscal year 2005 funding by the end of the fiscal year
as planned and cited several factors that contributed to this
situation. The length of time it takes to recruit new staff in general
and the special problems of hiring specialized staff such as
psychiatrists were cited. Officials at two medical centers noted that
they received funding for multiple new positions, but that it was
difficult for the medical center to recruit and hire for so many
positions in a relatively short period of time. In addition, in some
cases the need to locate or renovate space for mental health programs
contributed to delays in using funds. For example, officials at the
Albuquerque medical center reported that although it received funding
for staff for a new residential program, it took some time to renovate
the space needed for that program, which limited the amount of funding
for staff they were actually able to spend in fiscal year 2005.
Medical centers varied in how they treated fiscal year 2005 funds that
were allocated by VA for mental health strategic plan initiatives but
not used for those initiatives. Officials at three medical centers
reported that they carried over the funds for use in the next fiscal
year.[Footnote 19] For example, officials at the Phoenix medical center
reported carrying over unused funding for a substance abuse residential
rehabilitation program. Officials at two medical centers reported that
they used these funds for other health care purposes. For example,
officials at the Albuquerque medical center said that funding that was
not used for staffing due to difficulties with hiring was made
available to meet other needs in the medical center for that fiscal
year. Officials at another medical center, the Tennessee Valley Health
Care System, reported having unused fiscal year 2005 funding due to
difficulties with hiring, and using this funding to support other
mental health programs, in particular to hire mental health staff for
its CBOCs. VA headquarters officials advised participants from networks
and medical centers in a weekly conference call in August 2005 that if
they were unable to hire staff for initiatives in fiscal year 2005,
they should use the funds allocated only for mental health services.
VA Allocated about $158 Million of the $200 Million Planned for Mental
Health Strategic Plan Initiatives in Fiscal Year 2006, but Some
Officials Were Uncertain If All Funds Would Be Used for Plan
Initiatives:
VA headquarters allocated about $158 million of the $200 million to be
used for VA mental health strategic plan initiatives in fiscal year
2006 directly to medical centers and certain offices by using several
approaches. About $92 million of these funds was allocated to support
new mental health strategic plan initiatives for fiscal year 2006. VA
also allocated about $66 million to support the recurring costs of the
continuing mental health strategic plan initiatives that were funded in
fiscal year 2005. The remaining approximately $42 million was not
allocated. Officials at some medical centers expected to use all the
allocations they received during fiscal year 2006. However, officials
at other medical centers were uncertain that they would use all their
allocated funds for plan initiatives during the fiscal year.
VA Allocated about $158 Million Directly to Medical Centers and Certain
Offices:
VA headquarters allocated about $158 million directly to medical
centers and certain offices through RFPs and other approaches targeted
to specific initiatives related to the mental health strategic plan in
fiscal year 2006. (See table 3.) About $92 million was for new mental
health strategic plan activities, and about $66 million was to support
the recurring costs of continuing mental health strategic plan
initiatives that were first funded in fiscal year 2005. As in fiscal
year 2005, the new resources went to support a range of mental health
services in line with priorities of VA's leadership and legislation,
according to VA officials. Funding for services for PTSD, OIF and OEF
veterans, substance abuse, and CBOC mental health services accounted
for nearly three-fifths of the funds allocated for new initiatives. VA
did not allocate resources in fiscal year 2006 for mental health
strategic plan initiatives through its general resource allocation
system, according to VA officials.
Table 3: Summary of VA Information on Mental Health Strategic Plan
Allocations to Medical Centers and Certain Offices by Type of Mental
Health Service, Fiscal Year 2006:
Type of mental health service: New fiscal year 2006 initiatives:
Allocations related to legislation that expressly required spending or
authorized services: Domiciliary expansion[A];
Amount allocated (dollars): $7,437,593.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: PTSD and OEF/OIF;
Amount allocated (dollars): 18,772,089.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Substance abuse;
Amount allocated (dollars): 16,887,550.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Community-based outpatient clinic
mental health;
Amount allocated (dollars): 16,782,344.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Psychosocial and recovery-oriented
services;
Amount allocated (dollars): 6,249,025.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Telemental health programs to provide
mental health services through videoconferencing;
Amount allocated (dollars): 5,063,987.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Web-based support tools for veterans
with mental health concerns;
Amount allocated (dollars): 5,000,000.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Grant and per diem liaisons;
Amount allocated (dollars): 4,700,000.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Mental health intensive case
management teams;
Amount allocated (dollars): 3,749,029.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Suicide prevention and residential
rehabilitation treatment program infrastructure improvements;
Amount allocated (dollars): 1,803,853.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Inpatient mental health services at
two VA facilities in Tennessee;
Amount allocated (dollars): 1,629,657.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Support for Gulf Coast mental health
programs affected by Hurricane Katrina;
Amount allocated (dollars): 1,610,643.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Educational programs;
Amount allocated (dollars): 1,391,208.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Stand Down events for homeless
veterans;
Amount allocated (dollars): 467,665.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Pilot program for incarcerated
veterans with mental illness;
Amount allocated (dollars): 233,334.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Peer housing assistance pilot program
for homeless veterans;
Amount allocated (dollars): 168,980.
Type of mental health service: New Fiscal year 2006 initiatives:
Allocations not directly related to legislation that expressly required
spending or authorized services: Initiative for mentally ill
chemically- addicted veterans;
Amount allocated (dollars): 69,517.
Type of mental health service: Subtotal--new fiscal year 2006
initiatives;
Amount allocated (dollars): $92,016,474.
Type of mental health service: Initiatives initially funded in fiscal
year 2005;
Amount allocated (dollars): 65,675,513.
Type of mental health service: Total;
Amount allocated (dollars): $157,691,987.
Source: GAO summary of VA information.
Notes: GAO did not independently determine the extent to which
legislation regarding VA health care expressly requires spending or
authorizes these services but relied on VA's determination regarding
these services.
[A] Related to the Homeless Veterans Comprehensive Assistance Act of
2001, which authorized VA to establish up to 10 new domiciliary
programs for homeless veterans. See Pub. L. No. 107-95, § 2043, 115
Stat. 903, 913.
[End of table]
VA headquarters officials used RFPs and other approaches targeted to
specific initiatives to determine which medical centers would receive
funding for new mental health strategic plan initiatives in fiscal year
2006. In November 2005, for example, VA issued an RFP that covered six
mental health areas: PTSD services, including residential services;
health promotion and preventive care services for veterans returning
from OEF and OIF; specialized substance abuse treatment programs; new
mental health residential rehabilitation and treatment
programs;[Footnote 20] enhanced or new CBOC mental health services; and
new telemental health programs to provide mental health services
through videoconferencing. VA also used other approaches to target
funds to medical centers for grant and per diem program liaisons, new
or expanded mental health intensive case management teams, and expanded
inpatient services at the Tennessee Valley Healthcare System medical
center. Further, VA allocated funding for medical supplies, equipment,
and office furniture for Gulf Coast mental health programs affected by
Hurricane Katrina. As in fiscal year 2005, VA allocated funding to the
Employee Education System to support educational programs. VA also
allocated funding to support additional mental health initiatives such
as the development of web-based support tools for veterans with mental
health concerns, infrastructure improvements at residential
rehabilitation treatment facilities, suicide prevention efforts, and
Stand Down events to provide services such as counseling and health
screenings for homeless veterans.
VA Did Not Allocate about $42 Million for Mental Health Strategic Plan
Initiatives:
VA did not allocate about $42 million of the $200 million planned for
mental health strategic plan initiatives in fiscal year 2006 by any
approach. The approximately $42 million in unallocated funds were
intended for certain mental health strategic plan initiatives based on
an allocation plan developed by VA. According to VA officials, VA was
unable to allocate all the $200 million, in part, because of the
delayed implementation of three new Centers of Excellence, focusing on
veterans' mental health issues, including PTSD, for which VA planned
allocations totaling $4.5 million.[Footnote 21] VA officials also cited
the unanticipated length of time required to refine the processes for
implementation of initiatives related to the provision of mental health
services in primary care settings. VA had solicited proposals related
to primary care mental health services through a May 2006 RFP[Footnote
22] and had anticipated allocating about $11 million for such services
from funds reserved for emerging needs related to the mental health
strategic plan. In addition, VA officials reported that a portion of
the funds were unallocated for reasons related to the timing of
allocations that were made for plan initiatives through RFPs and other
funds targeted to medical centers. Specifically, some of these
allocations were made well into the fiscal year. VA allocated only the
amount of funds through these approaches for fiscal year 2006 that
would fund the projects through the end of the fiscal year, and not the
full 12-month costs, which VA expects to fund in fiscal year 2007. VA
officials said they anticipated that the full 12-month allocation would
be available for these projects in fiscal year 2007. Most of the
unallocated funds had been planned for initiatives to provide services
that VA identified as not directly in response to legislation that
expressly required spending or authorized such services. (See table 4.)
Table 4: Summary of VA Information on Planned Funding for Mental Health
Strategic Plan Initiatives Not Allocated by Type of Mental Health
Service, Fiscal Year 2006:
Type of Mental Health Service: Related to legislation that expressly
required spending or authorized services: Centers of Excellence[A];
Planned Amount Not Allocated (dollars): $4,500,000.
Type of Mental Health Service: Related to legislation that expressly
required spending or authorized services: Domiciliary expansion[B];
Planned Amount Not Allocated (dollars): 8,804.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: PTSD and OEF/OIF;
Planned Amount Not Allocated (dollars): 10,690,920.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Psychosocial and
recovery-oriented services;
Planned Amount Not Allocated (dollars): 5,652,638.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Telemental health
programs to provide mental health services through videoconferencing;
Planned Amount Not Allocated (dollars): 3,936,013.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Substance abuse;
Planned Amount Not Allocated (dollars): 3,112,450.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Mental health
program review;
Planned Amount Not Allocated (dollars): 1,000,000.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Inpatient mental
health services at two VA facilities in Tennessee;
Planned Amount Not Allocated (dollars): 773,503.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Mental health
intensive case management teams;
Planned Amount Not Allocated (dollars): 539,419.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Community-based
outpatient clinic mental health;
Planned Amount Not Allocated (dollars): 194,266.
Type of Mental Health Service: Not directly related to legislation that
expressly required spending or authorized services: Reserved for
emerging needs;
Planned Amount Not Allocated (dollars): 11,900,000.
Type of Mental Health Service: Total;
Planned Amount Not Allocated (dollars): $42,308,013.
Source: GAO summary of VA information.
Notes: GAO did not independently determine the extent to which
legislation regarding VA health care expressly requires spending or
authorizes these services but relied on VA's determination regarding
these services.
[A] In the Conference Report accompanying the Military Quality of Life
and Veterans Affairs Appropriations Act of 2006, the Conference
Committee stated that VA should consider designating specialized
medical treatment facilities for mental health and PTSD as Centers of
Excellence, and directed VA to establish three specific centers. See
H.R. Conf. Rep. No. 109-305, at 39 (2005).
[B] Related to the Homeless Veterans Comprehensive Assistance Act of
2001, which authorized VA to establish up to 10 new domiciliary
programs for homeless veterans. See Pub. L. No. 107-95, § 2043, 115
Stat. 903, 913.
[End of table]
Medical Center Officials Reported Using Allocated Funds for Mental
Health Strategic Plan Initiatives, but Were Uncertain Whether All Funds
Allocated Would Be Used for Plan Initiatives:
Officials at seven medical centers we interviewed in May and June of
2006 reported using funds allocated to them through RFPs and other
approaches to support new 2006 initiatives and to continue to support
initiatives funded in fiscal year 2005. Officials at four of these
medical centers told us that they were using these funds to support
expanded mental health services. For example, officials at several
medical centers, including Bay Pines, Decatur, and the Tennessee Valley
Healthcare System, reported using fiscal year 2006 funding to expand
mental health services in their CBOCs by adding clinical staff. As part
of this expansion of services, the Tampa medical center used funding
for a new mental health intensive case management program. Five medical
centers had received funding for expanded mental health services, but
had not yet used all of the allocated funds. The Albuquerque medical
center, for example, had received funding for a new substance abuse
program for geriatric patients and a new case management program for
veterans with PTSD. As of May 2006, both programs were still being
developed and positions had been advertised but had not yet been
filled.
Officials at two medical centers reported that they did not anticipate
problems using all of the funds they had received in fiscal year 2006.
However, officials at four other medical centers were less certain they
would be able to use all of the funds. Officials at two of these
medical centers were not sure whether they would be able to hire all of
their new staff by the end of the fiscal year. In addition, officials
at the Bay Pines and Phoenix medical centers noted that they had not
yet learned whether proposals they submitted in response to fiscal year
2006 RFPs would be funded; as a result, officials at those medical
centers were uncertain whether they would be able to use all of their
fiscal year 2006 funds for plan initiatives by the end of the fiscal
year.
VA Tracking of Funds Spent for Mental Health Strategic Plan Initiatives
Was Inadequate, but Available Information Indicates That Spending for
These Initiatives Was Substantially Less Than Planned:
VA tracking of spending for mental health strategic plan initiatives
was inadequate for fiscal years 2005 and 2006. In fiscal year 2005, VA
headquarters did not track spending on mental health strategic plan
initiatives. In fiscal year 2006, VA began to track some information on
medical centers' mental health strategic plan initiatives, but did not
track the amount of allocated funds that was spent for them.[Footnote
23] VA headquarters officials used this newly instituted tracking
system to gather implementation information reported by networks and
medical centers on a quarterly basis. The tracked information was
primarily related to positions to be filled, the schedule for filling
them, and when they were filled. Headquarters officials said that this
tracking was intended, in part, to measure medical centers' progress in
implementing plan initiatives. Officials told us that they believe that
tracking of hiring provides information on how funds were spent because
most costs of initiatives are personnel costs. However, the data on
hiring did not include information on the individual salaries of staff,
associated benefits, the portion of the fiscal year for which staff are
employed, equipment, supplies, rent, or renovation of facilities. As a
result the quarterly reports do not allow VA to determine how much was
spent on plan initiatives. In fiscal year 2006, VA headquarters
officials compiled information on the amount of funds returned to
headquarters that medical centers could not spend during the fiscal
year. However, VA does not have information on whether the funds
medical centers retained were spent for plan initiatives.
Available information indicates that spending of allocations for mental
health strategic plan initiatives was substantially less than planned
in both fiscal years 2005 and 2006. In fiscal year 2005, approximately
$12 million of the planned $100 million for plan initiatives was not
allocated for plan initiatives and thus was not spent on them. Thirty-
five million dollars was allocated through VA's general resource
allocation system, but because VA headquarters did not specify that
these funds were for mental health strategic plan initiatives, it is
likely that portions of this money were not spent on them, and VA
officials said they do not have information on these funds being spent
for plan initiatives. In addition, VA officials told us that they did
not have information on the extent to which the approximately $53
million in funds that were allocated directly to medical centers and
certain offices was actually spent on plan initiatives. Officials at
medical centers we interviewed told us that they used some of these
funds on mental health activities other than the planned initiatives or
carried over funds until the next fiscal year.
In fiscal year 2006, available information indicates that the maximum
amount of allocated funds that could have been spent for plan
initiatives in fiscal year 2006 also fell substantially below what was
planned. About $42 million of the $200 million that was planned for
allocation to mental health strategic plan initiatives was never
allocated for them, and thus, never spent for plan initiatives.
Additionally, about $46 million of the approximately $158 million that
was allocated was returned by medical centers to headquarters because
it had not been spent for plan initiatives before the end of the fiscal
year.[Footnote 24] However, all of the remaining approximately $112
million of funds allocated to and retained by medical centers and
offices was not necessarily spent on plan initiatives as originally
planned. VA officials provided written guidance to medical centers in
August 2006 instructing them to spend funds for other mental health
activities if they could not spend them for the planned initiatives
before the end of the fiscal year. VA officials told us that because
they had provided instructions to spend the funds on mental health
activities that such activities would constitute spending on mental
health strategic plan activities. VA's guidance, however, did not
specify that funds be used for the plan initiatives or alternative
initiatives. Moreover, VA did not track specifically how these funds
were spent. As a consequence, VA cannot determine how much of the
approximately $112 million that was allocated for plan initiatives and
not returned to headquarters was spent on plan initiatives.
Conclusion:
VA allocated additional resources for mental health strategic plan
initiatives in fiscal years 2005 and 2006 to help address identified
gaps in VA's mental health services for veterans. The allocations that
were made resulted in some new and expanded mental health services for
plan initiatives according to officials at selected medical centers.
However, in fiscal year 2005, lack of adequate time for headquarters to
allocate funds for plan initiatives to medical centers, late-in-the-
year allocations that hampered medical center efforts to bring staff on
board during the fiscal year, and a lack of guidance concerning
allocations for plan initiatives made through VA's general resource
allocation system resulted in spending on initiatives falling short of
what was planned. In fiscal year 2006, a larger amount, approximately
$158 million of the planned $200 million for plan initiatives, was
allocated to medical centers and other offices than in fiscal year
2005. However, at the end of the fiscal year about $46 million was
returned to VA headquarters that had not been spent on mental health
strategic plan initiatives, and some funds that remained with medical
centers and other offices may have been directed towards mental health
activities other than plan initiatives.
Although available information shows that a substantial portion of the
resources intended for plan initiatives in fiscal years 2005 and 2006
was not spent on these initiatives, VA does not know the amount of
allocated funds actually spent on them. The extent of spending is
unknown because VA did not track spending of these funds. Although some
tracking of mental health strategic plan initiatives was started in
fiscal year 2006, data were not collected that would allow an
assessment of spending. Tracking the extent to which allocations for
plan initiatives are spent for these initiatives is important as VA
continues to allocate resources for future plan initiatives. This would
help to ensure that the money is being spent as planned, and that VA is
in fact addressing gaps that it has identified in mental health
services for veterans.
Recommendation for Executive Action:
To provide information for improved management and oversight of how
funds VA allocates are spent to fill identified gaps in mental health
services for veterans, we recommend that the Secretary of Veterans
Affairs direct the Under Secretary for Health to take the following
action:
Track the extent to which the resources allocated for mental health
strategic plan initiatives are spent for plan initiatives.
Agency Comments:
VA did not provide agency comments on the contents of this report. We
offered VA the opportunity to review and comment on the report, but not
retain copies of the draft as part of a process to help safeguard the
contents from unauthorized disclosure. VA in a written response
(reproduced in app. III) said that it was unable to provide comments on
the draft report because VA was not provided a copy of the report for
appropriate staffing to include review and analysis. VA further stated
that while it respected our desire to maintain the integrity of GAO
draft reports by preventing improper disclosure of draft contents, that
this did not outweigh the need for VA staff to have a copy of the draft
report for review and analysis. We have provided similar report review
opportunities to other agencies for other reports, and have received
agency comments in those circumstances.
We met with VA officials on November 14, 2006, and provided them with
an oral briefing covering the contents of the draft report. Further, a
portion of the contents of this report had previously been released as
a statement for the record at a hearing held by the House Veterans'
Affairs Committee, Subcommittee on Health, on September 28, 2006. We
discussed the information in that statement with VA officials who have
responsibilities related to mental health services, budgeting, and the
allocation of financial resources, and they agreed that the data in the
statement were accurate. As a result, VA is aware of the report's
contents.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days from the date of this report. At that time, we will send copies to
the Secretary of Veterans Affairs, appropriate congressional
committees, and other interested parties. We will also make copies
available to others upon request. In addition, the report will also be
available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov]. If you or your staff have any questions about this
report, please contact me at (202) 512-7101 or ekstrandl@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 major contributions to this report are listed in appendix IV.
Signed by:
Laurie E. Ekstrand:
Director, Health Care:
[End of section]
Appendix I: Department of Veterans Affairs (VA) Health Care Networks,
Medical Centers, and Other Facilities GAO Selected for Review:
VA health care network: Network 7 (Atlanta, Ga.)--Southeast Network;
Site visits or phone interviews: Phone interviews;
Medical centers and other facilities:
* Decatur, Ga., medical center;
* Tuscaloosa, Ala., medical center;
* Birmingham, Ala., Vet Center.
VA health care network: Network 8 (Bay Pines, Fla.)--Sunshine
Healthcare Network;
Site visits or phone interviews: Site visits;
Medical centers and other facilities:
* Bay Pines, Fla., medical center;
* Tampa, Fla., medical center;
* Dunedin, Fla., community-based outpatient clinic (CBOC);
* Lakeland, Fla., CBOC;
* St. Petersburg, Fla., Vet Center;
* Tampa, Fla., Vet Center.
VA health care network: Network 9 (Nashville, Tenn.)--Mid South
Healthcare Network;
Site visits or phone interviews: Site visits;
Medical centers and other facilities:
* Tennessee Valley Healthcare System[A] (Nashville, Tenn., and
Murfreesboro, Tenn., campuses) medical center;
* Clarksville, Tenn., CBOC;
* Chattanooga, Tenn., Vet Center.
VA health care network: Network 18 (Phoenix, Ariz.)--Southwest Health
Care Network;
Site visits or phone interviews: Phone interviews;
Medical centers and other facilities:
* Albuquerque, N.M., medical center;
* Phoenix, Ariz., medical center;
* Albuquerque, N.M., Vet Center.
Source: GAO.
[A] The Tennessee Valley Healthcare System is a medical center that has
two locations.
[End of table]
[End of section]
Appendix II: Description of Selected Department of Veterans Affairs
(VA) Mental Health Services:
Table 6: :
VA Mental Health Service: Community-based outpatient clinics (CBOC);
Description: CBOCs provide medical services, which can include mental
health, on an outpatient basis in a community setting. CBOCs are
affiliated with a VA medical center.
VA Mental Health Service: Compensated Work Therapy (CWT);
Description: CWT is a therapeutic work-for-pay program that (1) uses
remunerative work to maximize a veteran's level of functioning, (2)
prepares veterans for successful reentry into the community, and (3)
provides a structured daily activity to those veterans with severe and
chronic disabling physical and/or mental conditions.
VA Mental Health Service: Domiciliary program;
Description: Domiciliary residential rehabilitation and treatment
programs for homeless veterans, providing coordinated, integrated
rehabilitative and restorative clinical care in a bed-based program,
with the goal of helping eligible veterans achieve and maintain the
highest level of functioning and independence possible.
VA Mental Health Service: Grant and Per Diem program;
Description: VA offers grants to non-VA organizations in the community
to provide supportive housing programs and supportive service centers
for homeless veterans. Once programs are established, VA provides per
diem payments to help offset operational expenses of the program. Grant
and per diem liaisons oversee services provided by these organizations.
VA Mental Health Service: Mental health intensive case management;
Description: Mental health intensive case management teams are designed
to deliver high-quality services that: (1) provide intensive, flexible
community support; (2) improve health status (reduce psychiatric
symptoms and substance abuse); (3) reduce psychiatric inpatient
hospital use and dependency; (4) improve community adjustment,
functioning, and quality of life; (5) enhance satisfaction with
services; and (6) reduce treatment costs.
VA Mental Health Service: Mentally ill chemically-addicted veterans
initiative;
Description: The Mentally Ill Chemically Addicted program, intended to
assist underserved veterans with serious and persistent mental
illnesses, involves recovery-and rehabilitation-oriented services in
Network 17 as well as training on the recovery model and psychosocial
rehabilitation concepts and skills.
VA Mental Health Service: Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF);
Description: Assessment, preventative, and early intervention mental
health services for veterans returning from combat in Iraq,
Afghanistan, and other areas. These services involve outreach and
education efforts, as well as a range of psychosocial support services.
VA Mental Health Service: Peer housing assistance pilot program for
homeless veterans;
Description: The Peer Housing Location Assistance Group pilot program
is a recovery-oriented program that encourages and enables each veteran
to take responsibility and initiative to choose and apply for as many
housing opportunities as his or her eligibility characteristics,
preferences, and motivation permit. The program aims to help
participants manage the process and frustrations of finding and
maintaining safe and secure housing through a combination of
information, problem-solving, encouragement, professional assistance,
and peer support.
VA Mental Health Service: Pilot program for incarcerated veterans with
mental illness;
Description: A collaborative venture between the North Texas Health
Care System and the Texas Correctional Office on Offenders with Medical
and Mental Impairments that provides active outreach and case
management services to veterans with diagnosed mental illness being
released from the Texas prisons and involves work with the Texas
diversion courts for mentally ill offenders to provide outreach and
case management services for veterans convicted of minor offences who
have been diagnosed with mental illness.
VA Mental Health Service: Polytrauma Rehabilitation Centers;
Description: Polytrauma Rehabilitation Centers provide comprehensive
interdisciplinary rehabilitation and coordinated complex medical,
surgical, and mental health care, as well as long-term follow-up, to
veterans of OIF and OEF who have sustained severe injuries and have
complex rehabilitation needs.
VA Mental Health Service: Post-traumatic stress disorder (PTSD);
Description: Specialized services for veterans returning from Iraq and
Afghanistan, as well as veterans from past service eras, including the
Vietnam War. As part of VA's overall coordination of postdeployment
programs, PTSD services are focused on veterans who are survivors of
traumatic events and require comprehensive treatment.
VA Mental Health Service: Psychosocial rehabilitation for veterans with
serious mental illness;
Description: A comprehensive approach to restoring a veteran's full
potential following the onset of serious mental illness. This approach
involves assisting the veteran in all aspects of normal life to attain
the highest level of functioning in the community; it includes such
components as patient and family education; enhancement of residential,
social, and work skills; cognitive behavioral therapy; motivational
interviewing, integrated dual diagnosis treatment, and provision of
intensive case management when needed.
VA Mental Health Service: Residential rehabilitation treatment program
infrastructure improvements;
Description: Safety, security, privacy, access, and infrastructure
improvements to domiciliary and residential rehabilitation treatment
programs, including repairs, renovations, furnishings, appliances,
equipments, household goods, and program supplies and materials. A
special emphasis for a component of these funds was improving access to
these mental health residential programs for women veterans.
VA Mental Health Service: Stand Downs;
Description: Stand Downs are typically 1 to 3 day events that provide
services to homeless veterans such as food, clothing, health
screenings, VA and Social Security benefits counseling, and referrals
to a variety of other supportive services such as housing, employment,
and substance abuse treatment. Stand Downs are collaborative events
that are coordinated between local VA facilities, other government
agencies, and community agencies that serve the homeless.
VA Mental Health Service: Substance abuse;
Description: Specialized services for veterans with substance abuse
disorders such as alcoholism and drug addictions. These services, for
example, are provided in residential rehabilitation treatment programs.
VA Mental Health Service: Suicide prevention initiative;
Description: Initiative designed to obtain causes of death for veterans
who have died in recent years, to identify those who have died from
suicide and related causes, to identify risk factors, and to evaluate
regional and local variability in rates and risk factors. The goal is
to obtain information that can guide evidence-based efforts at suicide
prevention, nationally and at other levels.
VA Mental Health Service: Support for Gulf Coast mental health programs
affected by Hurricane Katrina;
Description: Special needs funding for medical supplies, equipment,
office furniture, and modular buildings for Gulf Coast VA mental health
programs that sustained damage due to Hurricane Katrina.
VA Mental Health Service: Telemental health;
Description: Telemental health uses electronic communications and
information technology to provide and support mental health care where
geographic distance separates the clinicians and patients. These
services are often used in rural areas where the availability of mental
health providers is limited.
VA Mental Health Service: Web-based support tools for veterans with
mental health concerns;
Description: Initiative to develop an interactive set of web-based
tools to allow veterans who have behavioral or mental health concerns
to track important aspects of their self-care and professional care.
Source: GAO summary of VA information.
[End of table]
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
November 14, 2006:
Ms. Laurie Ekstrand:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Ekstrand,
This responds to your request that the Department of Veterans Affairs
(VA) review and comment on your draft report on VA's spending
implementing the Department's mental health strategic plan (GAO
Engagement Code 290522.)
VA was not provided a copy of the report for appropriate staffing, to
include review and analysis. This is an unusual departure from what has
been the usual GAO practice. Under this constraint, VA is unable to
provide comments on your draft report.
I do appreciate your providing an exit briefing and oral summary of the
report's findings and recommendation to my staff today.
I respect your desire to maintain the integrity of GAO draft reports
and that leaks outside official channels be controlled. Yet, that does
not outweigh the need for VA staff to have a copy of GAO's draft report
to fact-check, review and analyze in order that we might develop cogent
comments (including possible technical corrections).
I hope that in the future GAO will appreciate that this is a critical
step in the audit process and will provide the Department with a copy
of draft reports when requesting VA's comments.
Sincerely, Yours,
Signed by:
R. James Nicholson:
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Laurie E. Ekstrand, (202) 512-7101 or ekstrandl@gao.gov:
Acknowledgments:
In addition to the contact named above, Debra Draper, Assistant
Director; James Musselwhite, Assistant Director; Jennie Apter; Robin
Burke; and Steven Gregory made key contributions to this report.
[End of section]
Related GAO Products:
VA Health Care: Preliminary Information on Resources Allocated for
Mental Health Strategic Plan Initiatives. GAO-06-1119T. Washington,
D.C.: September 28, 2006.
VA Health Care: Budget Formulation and Reporting on Budget Execution
Need Improvement. GAO-06-958. Washington, D.C.: September 20, 2006.
VA Long-Term Care: Data Gaps Impede Strategic Planning for and
Oversight of State Veterans' Nursing Homes. GAO-06-264. Washington,
D.C.: March 31, 2006.
VA Long-Term Care: Trends and Planning Challenges in Providing Nursing
Home Care to Veterans. GAO-06-333T. Washington, D.C.: January 9, 2006.
VA Health Care: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services. GAO-05-287. Washington, D.C.: February 14, 2005.
VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data
Gaps. GAO-05-65. Washington, D.C.: November 10, 2004.
VA and Defense Health Care: More Information Needed to Determine If VA
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder
Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
VA Health Care: Resource Allocations to Medical Centers in the Mid
South Healthcare Network. GAO-04-444. Washington, D.C.: April 21, 2004.
Department of Veterans Affairs: Key Management Challenges in Health and
Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.
VA Health Care: Allocation Changes Would Better Align Resources with
Workload. GAO-02-338. February 28, 2002.
Agencies' Annual Performance Plans Under the Results Act: An Assessment
Guide to Facilitate Congressional Decisionmaking, Version 1. GAO/GGD/
AIMD-10.1.18. Washington, D.C.: February 1998.
Managing for Results: Critical Issues for Improving Federal Agencies'
Strategic Plans. GAO/GGD-97-180. Washington, D.C.: September 16, 1997.
Business Process Reengineering Assessment Guide, Version 3. GAO/AIMD-
10.1.15. Washington, D.C.: May 1997.
Agencies' Strategic Plans Under GPRA: Key Questions to Facilitate
Congressional Review, Version 1. GAO/GGD-10.1.16. Washington, D.C.: May
1997.
FOOTNOTES
[1] The plan is known formally as A Comprehensive Veterans Health
Administration Strategic Plan for Mental Health Services. In this
report, we will refer to it as the mental health strategic plan.
[2] Full Committee Hearing on the Continuum of Care for Post Traumatic
Stress Disorder Before the House Comm. on Veterans' Affairs, 109th
Cong. (July 27, 2005).
[3] Total includes medical care collections, but does not include
certain other amounts, such as appropriations for construction.
[4] VA headquarters delegates decision making regarding financing and
service delivery for health care services to its 21 health care
networks, including most budget and management responsibilities
concerning medical center operations. Medical centers typically include
one or more hospitals as well as other types of health care facilities
such as outpatient clinics and nursing homes.
[5] Throughout this report, the phrase "how funds were used by medical
centers" refers to information provided by medical center officials
regarding the hiring of staff, purchase of certain equipment, and other
purposes. These activities would be expected to result in obligations
and expenditures of funds either immediately or in the future.
[6] CBOCs provide medical services, which may include mental health
services, on an outpatient basis in local communities. As of December
2005, VA operated over 700 freestanding CBOCs, in addition to other
CBOCs that are located in VA medical centers.
[7] Vet Centers provide mental health services, including readjustment
counseling and outreach services, to all veterans who served in any
combat zone. There are 207 such centers that operate in all 50 states,
the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin
Islands.
[8] See GAO, VA Health Care: Preliminary Information on Resources
Allocated for Mental Health Strategic Plan Initiatives, GAO-06-1119T
(Washington, D.C.: Sept. 28, 2006).
[9] Case mix is a classification of patients into categories based on
their health care needs and related costs.
[10] For a discussion of how VERA allocates resources to networks, see
GAO, VA Health Care: Allocation Changes Would Better Align Resources
with Workload, GAO-02-338 (Washington, D.C.: Feb. 28, 2002).
[11] For a discussion of resource allocations to medical centers, see
GAO, VA Health Care: Resource Allocations to Medical Centers in the Mid
South Healthcare Network, GAO-04-444 (Washington, D.C.: Apr. 21, 2004).
[12] For more information about the President's New Freedom Commission
on Mental Health, see, for example, [Hyperlink,
http://http://www.mentalhealthcommission.gov].
[13] For the purposes of the mental health strategic plan, VA defined
veterans with serious mental illness to be "those who currently or at
any time during the past year: 1) have a diagnosed mental, behavioral
or emotional disorder of sufficient duration to meet the Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition) criteria, that
2) results in a disability (i.e. functional impairment that
substantially interferes with or limits one or more major life
activities)." This definition included adults who would meet these
criteria during the year without the benefit of treatment or support
services.
[14] The Veterans Health Care, Capital Asset, and Business Improvement
Act of 2003, Pub. L. No. 108-170, § 108, 117 Stat. 2042, 2046-47,
required VA to allocate a minimum of $25 million in each of fiscal
years 2004, 2005, and 2006 to carry out a program to expand and improve
the provision of specialty mental health services for veterans,
including PTSD and substance abuse services. Congress also required VA
to ensure that after these allocations, total expenditures related to
treatment of substance abuse and PTSD were not less than $25 million
above the total expenditures on such programs in fiscal year 2003,
adjusted for increases in the costs of delivering those services. The
Homeless Veterans Comprehensive Assistance Act of 2001, Pub. L. No. 107-
95, § 2043, 115 Stat. 903, 913, authorized VA to establish up to 10 new
domiciliary programs for homeless veterans.
[15] According to the network and medical center staff we spoke with,
even though the proposals were formally submitted by the networks,
medical center staff had a significant amount of input into the
proposals.
[16] VA's performance measure was that for each network, in at least 85
percent of all CBOCs with 1,500 or more patients, mental health visits
would account for at least 10 percent of all visits. VA targeted funds
to CBOCs that had no mental health providers or that needed additional
providers to meet the performance measure of 10 percent.
[17] This allocation system is known as the Veterans Equitable Resource
Allocation (VERA) system. In fiscal year 2005, VA headquarters used
VERA to allocate about 85 percent of its medical care appropriations to
its 21 health care networks, which in turn allocated resources to their
medical centers. VERA allocates resources primarily on the basis of
patient workload and case mix where workload is the number of veterans
treated and case mix is a classification of patients into categories
based on their health care needs and related costs. See GAO-02-338 and
GAO-04-444.
[18] Fiscal year 2005 covered the period of October 1, 2004, through
September 30, 2005.
[19] VA may carry over from one fiscal year to the next unobligated
balances of funds made available without fiscal year limitation and
other funds appropriated for multiple fiscal years.
[20] These could include homeless domiciliary programs, psychosocial
programs, substance abuse programs, PTSD programs, or other general
programs.
[21] In the Conference Report accompanying the Military Quality of Life
and Veterans Affairs Appropriations Act of 2006, Pub. L. No. 109-114,
the Conference Committee stated that VA should consider designating
specialized medical treatment facilities for mental health and PTSD as
Centers of Excellence, and directed VA to establish three specific
centers. These centers are to be located at VA facilities in
Canandaigua, New York; Waco, Texas; and San Diego, California. See H.R.
Conf. Rep. No. 109-305, at 39 (2005).
[22] Through the RFP, funds were available for programs that promote
effective treatment of common mental health conditions in primary care
settings, in order to integrate care for veterans' physical and mental
health and allow mental health specialists to focus on veterans with
more severe illnesses. Funds were also available for related education
and training.
[23] Although VA headquarters' tracking system did not track spending
for plan initiatives in fiscal year 2005, some network and medical
center staff we spoke with reported on separate efforts to track
medical centers' use of funds for mental health strategic plan
initiatives. Some network staff told us that they developed their own
tracking processes because they anticipated that they would eventually
have to account for the use of funds allocated for mental health
strategic plan initiatives.
[24] Officials told us that unspent fiscal year 2006 funds returned to
headquarters were placed in a reserve fund for use in fiscal year 2007
and would be used for plan initiatives in that fiscal year. These
officials said that the reserve fund is composed of appropriations that
do not have to be obligated within a single fiscal year.
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To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S.
Government Accountability Office, 441 G Street NW, Room 7125
Washington, D.C. 20548:
Public Affairs:
Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548:
