VA Long-Term Care
Data Gaps Impede Strategic Planning for and Oversight of State Veterans' Nursing Homes Gao ID: GAO-06-264 March 31, 2006The Department of Veterans Affairs (VA) provides or pays for veterans' nursing home care in three settings: VA-operated nursing homes, privately owned nursing homes in the community from which VA purchases services, and state veterans' nursing homes. VA supports state veterans' nursing homes in a number of ways, including reimbursement for a portion of the cost of providing nursing home services to veterans, issuance of policy guidance, and oversight of their nursing home operations. GAO was asked to determine the extent to which VA collects information on veterans in state veterans' nursing homes and the type of care they receive, to assess whether VA's reimbursement policy has been applied consistently, and to identify revenue sources such homes use.
VA does not compile information on key characteristics of veterans receiving care in state veterans' nursing homes: veterans' length of stay, priority group status for VA hospital and outpatient services, age, and gender. VA needs such information for strategic planning, in order to develop baseline data of characteristics of veterans in state veterans' nursing homes and the care provided to them, which can help VA estimate the proportion of nursing home need it currently meets and the need it may be asked to meet as the number of older veterans changes over time. Based on visits to four states--Florida, Maine, Oklahoma, and Pennsylvania--GAO obtained information on key characteristics of state veterans' nursing home populations, which showed that these populations differed to varying degrees across the states. For example, state veterans' nursing homes in three of the four states generally were providing long-stay care (90 days or more), but 60 percent of stays in state veterans' nursing homes in Maine were short (less than 90 days). GAO also found that certain aspects of VA's per diem reimbursement policy had not been applied consistently. For example, a VA medical center in one of the four states GAO visited approved reimbursement only for care provided to veterans admitted to state veterans' nursing homes who have had wartime military service. VA's policy does not limit reimbursement on this basis. GAO also found that VA headquarters officials have not been consistent in explaining to VA medical centers whether they could approve reimbursement to state veterans' nursing homes for care provided to veterans determined to have lowest priority for VA hospital and outpatient services. In the states that GAO visited, state veterans' nursing homes rely on VA and non-VA revenue sources to varying degrees. In fiscal year 2004, per diem reimbursement from VA accounted for about one-fourth to one-third of revenues used for veterans' care. In addition to revenue from VA, state veterans' nursing homes in two of the four states GAO visited received reimbursement from Medicare and Medicaid for inpatient nursing home care provided to veterans. State veterans' nursing homes in three of the four states received funding directly from their states, ranging from 54 percent to 10 percent of revenues used for veterans' care in fiscal year 2004. In all the states GAO examined, the remainder of revenues comes from veterans' resources, such as Social Security and private pensions.
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
March 2006:
VA Long-Term Care:
Data Gaps Impede Strategic Planning for and Oversight of State
Veterans' Nursing Homes:
GAO-06-264:
GAO Highlights:
Highlights of GAO-06-264, a report to congressional requesters:
Why GAO Did This Study:
The Department of Veterans Affairs (VA) provides or pays for veterans‘
nursing home care in three settings: VA-operated nursing homes,
privately owned nursing homes in the community from which VA purchases
services, and state veterans‘ nursing homes. VA supports state
veterans‘ nursing homes in a number of ways, including reimbursement
for a portion of the cost of providing nursing home services to
veterans, issuance of policy guidance, and oversight of their nursing
home operations.
GAO was asked to determine the extent to which VA collects information
on veterans in state veterans‘ nursing homes and the type of care they
receive, to assess whether VA‘s reimbursement policy has been applied
consistently, and to identify revenue sources such homes use.
What GAO Found:
VA does not compile information on key characteristics of veterans
receiving care in state veterans‘ nursing homes: veterans‘ length of
stay, priority group status for VA hospital and outpatient services,
age, and gender. VA needs such information for strategic planning, in
order to develop baseline data of characteristics of veterans in state
veterans‘ nursing homes and the care provided to them, which can help
VA estimate the proportion of nursing home need it currently meets and
the need it may be asked to meet as the number of older veterans
changes over time. Based on visits to four states”Florida, Maine,
Oklahoma, and Pennsylvania”GAO obtained information on key
characteristics of state veterans‘ nursing home populations, which
showed that these populations differed to varying degrees across the
states. For example, state veterans‘ nursing homes in three of the four
states generally were providing long-stay care (90 days or more), but
60 percent of stays in state veterans‘ nursing homes in Maine were
short (less than 90 days).
GAO also found that certain aspects of VA‘s per diem reimbursement
policy had not been applied consistently. For example, a VA medical
center in one of the four states GAO visited approved reimbursement
only for care provided to veterans admitted to state veterans‘ nursing
homes who have had wartime military service. VA‘s policy does not limit
reimbursement on this basis. GAO also found that VA headquarters
officials have not been consistent in explaining to VA medical centers
whether they could approve reimbursement to state veterans‘ nursing
homes for care provided to veterans determined to have lowest priority
for VA hospital and outpatient services.
In the states that GAO visited, state veterans‘ nursing homes rely on
VA and non-VA revenue sources to varying degrees. In fiscal year 2004,
per diem reimbursement from VA accounted for about one-fourth to one-
third of revenues used for veterans‘ care. In addition to revenue from
VA, state veterans‘ nursing homes in two of the four states GAO visited
received reimbursement from Medicare and Medicaid for inpatient nursing
home care provided to veterans. State veterans‘ nursing homes in three
of the four states received funding directly from their states, ranging
from 54 percent to 10 percent of revenues used for veterans‘ care in
fiscal year 2004. In all the states GAO examined, the remainder of
revenues comes from veterans‘ resources, such as Social Security and
private pensions.
What GAO Recommends:
To promote adequate strategic planning and stronger oversight, GAO
recommends that VA compile and report data on state veterans‘ nursing
home populations and clarify certain aspects of its reimbursement
policy. VA stated that it agreed with GAO‘s overall findings and
generally concurred with GAO‘s recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-06-264.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Laurie E. Ekstrand (202)
512-7101 or ekstrandl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Selected States Have Admission Criteria That Differ in Two Key
Respects:
State Veterans' Nursing Homes in Selected States Vary in the Extent to
Which They Rely on Revenue from VA and Other Sources:
VA Does Not Compile Information on State Veterans' Nursing Home
Populations Needed for Strategic Planning:
VA's Per Diem Reimbursement Policy Has Not Been Applied Consistently:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Veteran and Nonveteran Workload (Average Daily Census) in
State Veterans' Nursing Homes, Fiscal Year 2004:
Table 2: Sources and Percentage of State Veterans' Nursing Home
Revenues Used for Veterans' Care, Fiscal Year 2004:
Figures:
Figure 1: State Veterans' Nursing Home Locations, Fiscal Year 2005:
Figure 2: Number of State Veterans' Nursing Home Beds, Fiscal Year
2005:
Figure 3: Projected Veteran Population Age 65 and Older, Fiscal Year
2005 through Fiscal Year 2030:
Figure 4: Percentage of Veterans' Nursing Home Stays That Were Long
Stay (90 Days or More) and Short Stay (Less Than 90 days), Fiscal Year
2004:
Figure 5: States with State Veterans' Nursing Homes Certified for
Medicare Reimbursement, Fiscal Year 2005:
Figure 6: Age Distribution of Veterans in State Veterans' Nursing
Homes, Fiscal Year 2004:
Abbreviations:
CARES: Capital Asset Realignment for Enhanced Services:
CMS: Centers for Medicare & Medicaid Services:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
March 31, 2006:
The Honorable Larry E. Craig:
Chairman:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Christopher H. Smith:
House of Representatives:
The Department of Veterans Affairs (VA) operates a nursing home program
that provides or pays for veterans' care in three different settings:
VA nursing homes operated directly by VA, privately owned nursing homes
in the community from which VA purchases services, and state veterans'
nursing homes. State veterans' nursing homes, which numbered 116 by the
close of fiscal year 2005, are joint federal-state partnerships in
which VA pays a portion of the cost of providing nursing home care for
eligible veterans in these homes,[Footnote 1] provides grants to cover
part of the cost of construction, acquisition, or renovation of these
homes, and has oversight responsibilities for certain aspects of costs
and services. By fiscal year 2003, state veterans' nursing homes had
become responsible for the largest share of VA's nursing home
workload[Footnote 2] among the three settings of VA's nursing home
program. In fiscal year 2005, state veterans' nursing homes accounted
for almost 52 percent of VA's nursing home workload. In contrast, about
35 percent of the workload was provided in VA-operated nursing homes
and about 13 percent was provided in privately owned nursing homes from
which VA purchases services. That same year, VA spent about $382
million to support the delivery of care to veterans in state veterans'
nursing homes and over $123 million to support capital construction and
renovation in 23 states.
In 2004, we reported, in part, that VA lacked key information on
veterans in state veterans' nursing homes, as well as on the type of
nursing home care delivered in this setting.[Footnote 3] We found that
VA did not collect data on the proportion of veterans in state
veterans' nursing homes for whom VA is required to provide nursing home
care in accordance with the Veterans Millennium Health Care and
Benefits Act[Footnote 4] (Millennium Act veterans), as well as other
veterans for whom VA provides such care on a discretionary basis. We
also found that VA did not collect data on the extent to which veterans
in state veterans' nursing homes received long-stay, chronic nursing
home care that typically lasts 90 days or more, nor did VA collect data
on short-stay, postacute nursing home care that typically lasts less
than 90 days. In contrast, we found that VA collects such data from VA-
operated nursing homes, both on the number of Millennium Act veterans
and other veterans in these homes and on the extent to which veterans
in this setting receive long and short-stay nursing home care. We
concluded that VA's lack of uniform, comparable data across the three
settings of its nursing home program impeded VA's strategic planning
for nursing home care. As a result, we recommended that VA collect data
on the number of Millennium Act veterans and other veterans receiving
care in state veterans' nursing homes and the type of care they
receive. VA concurred in principle with our recommendations.
In commenting on our 2004 report, the Secretary of the Department of
Veterans Affairs indicated that patient populations served in state
veterans' nursing homes are relatively similar nationwide and that
patients receive predominantly long-stay nursing home care.[Footnote 5]
Comprehensive information on state veterans' nursing home populations
would enable VA to develop a baseline for tracking changes in the
veteran populations and care provided in this setting. Such
information--along with comparable information from VA nursing homes
and for veterans for whom VA purchases services in privately owned
nursing homes--would allow VA to strategically plan how to best use the
three settings of its nursing home program to meet the needs of
veterans. Moreover, when used in conjunction with forecasts of the
likely demand for VA's nursing home care in the future, such data could
allow VA to make informed policy decisions about which groups of
veterans VA will serve in the future and therefore the extent to which
VA will need to provide long and short-stay nursing home care. Such
decisions are important because most veterans who need nursing home
care do not receive it from VA, but instead receive it from non-VA
providers primarily funded by Medicare and Medicaid. Although VA is in
the process of developing its strategic plan for nursing home care, it
has not finalized its strategic plan for its long-term care services,
which includes nursing home care.[Footnote 6]
Comprehensive data on the veterans served in state veterans' nursing
homes could also help VA assess the impact of proposed changes to its
per diem reimbursements for state veterans' nursing homes. The
President's 2006 budget request for VA contained a proposal to change
per diem reimbursement to take into account veterans' VA priority group
status[Footnote 7] and the type of nursing home care veterans need. You
have expressed concern over the potential impact of these changes on
the veterans receiving care in state veterans' nursing homes.
Comprehensive information on the veteran populations served in state
veterans' nursing homes--including the number of veterans in this
setting in each of VA's priority groups--could help VA and the Congress
by providing better information to assess the impact of such proposed
policy changes.
You requested that we provide information on state veterans' nursing
homes and the extent to which VA collects information on veterans and
the type of care they receive in this setting. During the course of our
work, we also found inconsistencies in certain practices related to
VA's per diem reimbursements to state veterans' nursing homes. In this
report, we (1) describe the extent to which key admission criteria for
state veterans' nursing homes in selected states differ, (2) describe
the extent to which state veterans' nursing homes in the selected
states rely on VA and non-VA sources of revenue, (3) examine whether VA
compiles information on state veterans' nursing home populations needed
for VA's strategic planning of its nursing home care, and (4) assess
whether VA's per diem reimbursement policy has been applied
consistently.
To perform our work, we collected information on state veterans'
nursing homes primarily from four states--Florida, Maine, Oklahoma, and
Pennsylvania--and supplemented this information with data from national
sources. We selected these four states based on geographic region,
population density, plans to expand the number of state veterans'
nursing homes, and whether the state veterans' nursing homes in these
states receive Medicare and Medicaid reimbursements. We used a data
collection instrument to obtain data from each of the four states on
all of their state veterans' nursing homes and reviewed VA and state
veterans' nursing home documents. In the four states we conducted site
visits to a total of nine state veterans' nursing homes: two of
Florida's five state veterans' nursing homes, two of Maine's five
homes, three of Oklahoma's seven homes, and two of Pennsylvania's six
homes. We interviewed state veterans' nursing home program officials,
the administrators of the nine state veterans' nursing homes we
visited, officials at VA headquarters, and staff at six VA medical
centers of jurisdiction. Staff from VA medical centers of jurisdiction
oversee the state veterans' nursing homes in their geographic areas
through annual on-site inspections and through reviewing and approving
requests from these homes for per diem reimbursements. To identify the
characteristics of veteran nursing home populations needed for VA's
strategic planning, we identified several of the key characteristics of
nursing home populations that are useful for long-term care planning
and collected data on these characteristics from state veterans'
nursing home patient populations in the selected states. During the
course of our work--in interviews with staff of VA medical centers of
jurisdiction, state veterans nursing home officials, and VA
headquarters staff--we found inconsistencies in certain practices
related to VA's per diem reimbursements. These practices involved
determining which veterans can be counted for per diem reimbursements.
To examine these issues further, we reviewed VA's policy and guidance
for overseeing state veterans' nursing home operations. To identify
states that have state veterans' nursing homes certified for Medicare
or Medicaid reimbursement we also used data from the Centers for
Medicare & Medicaid Services (CMS) Nursing Home Compare national
database. For additional information on VA's national per diem and
construction grant programs, we interviewed VA headquarters staff who
administer these programs. We also reviewed our previous reports on VA
long-term care as well as those related to strategic planning (see
Related GAO Products at the end of this report). We took steps to
ensure that data we obtained from selected state veterans' nursing
homes were sufficiently reliable for our purposes. For example, we
verified the accuracy of state veterans' nursing home programs' data
for internal consistency and compared this information with available
VA national data as well as information we obtained through interviews
with officials and visits to the selected states. Because we limited
our review to four states, the results are not generalizable to other
states with state veterans' nursing homes. We performed our work from
December 2004 through March 2006 in accordance with generally accepted
government auditing standards. For additional details of our scope and
methodology, see appendix I.
Results in Brief:
Criteria for granting admission to state veterans' nursing homes differ
in two key respects, because states have the flexibility to establish
their own admission criteria. Florida, Maine, and Pennsylvania admit
both wartime and peacetime veterans. In contrast, Oklahoma admits
wartime veterans only. Maine and Pennsylvania admit both veterans and
certain nonveterans, such as widows of veterans or parents of veterans
who died in the line of military duty. In contrast, Florida and
Oklahoma admit veterans only. The selected states also have some key
admission criteria in common. Each state requires veterans to have been
discharged from the military under honorable conditions and requires
all patients to be certified by a physician as having a medical basis
for admission to a nursing home.
State veterans' nursing homes in the four selected states rely on VA
and non-VA sources of revenue to varying degrees. In each of these
states, VA's per diem reimbursements accounted for about one-fourth to
one-third of state veterans' nursing home revenues used for veterans'
care in fiscal year 2004. VA reimburses state veterans' nursing homes
for services provided to eligible veterans--in general, those who were
discharged from military service under conditions other than
dishonorable and who have been determined by a physician as requiring
nursing home care. In addition to revenues from VA, state veterans'
nursing homes in two of the four selected states--Florida and Maine--
receive reimbursement from Medicare and Medicaid for the inpatient
nursing home care they provided to veterans. Additionally, state
veterans' nursing homes in three of the four selected states--
Pennsylvania, Oklahoma, and Florida--receive funds directly from their
states for veterans' care. In fiscal year 2004, this source accounted
for 54 percent of the revenues used to provide care to veterans in
Pennsylvania, 32 percent in Oklahoma, and 10 percent in Florida.
VA does not compile the information it needs for strategic planning on
several key characteristics of the veteran populations receiving care
in state veterans' nursing homes: veterans' length of stay, VA priority
group status, age, and gender. VA does not have information, for
example, on the extent to which veterans in state veterans' nursing
homes receive long and short-stay care. Patients' length of stay is a
predictor of the amount and type of medical resources devoted to their
care. VA officials have assumed that state veterans' nursing homes
predominantly provide long-stay care, but our review of selected states
and national data suggests that this may not always be the case. VA
concurred in principle with our 2004 recommendation to collect data on
veterans' lengths of stay in state veterans' nursing homes nationwide,
and the agency informed us in 2005 that it will report these data to
its policymakers and planners in fiscal year 2007. In our visits to
selected states, we found that state veterans' nursing homes in
Pennsylvania, Oklahoma, and Florida generally provide long-stay care.
In contrast, we found that 60 percent of the stays in Maine state
veterans' nursing homes are short. VA also does not compile information
it needs on the VA priority group status of veterans admitted to state
veterans' nursing homes. The availability of priority group status
information may differ among the states. Veterans in state veterans'
nursing homes who have previously enrolled for VA hospital and
outpatient medical services will have been assigned to a priority
group. However, veterans in state veterans' nursing homes who have not
enrolled will not have been assigned a priority group. The extent to
which veterans without a priority group designation enroll with VA upon
admission to state veterans' nursing homes may vary because not all
states require veterans to enroll for VA hospital and outpatient
medical services.
During the course of our work, we found that certain aspects of VA's
per diem reimbursement policy had not been applied consistently. For
example, staff from a VA medical center of jurisdiction told us that
they approved reimbursements to state veterans' nursing homes only for
care provided to veterans whose military service occurred during VA-
designated periods of military conflict (wartime veterans). However,
VA's policy does not limit per diem reimbursements to such veterans. We
also found that VA headquarters officials have provided inconsistent
instructions on VA's reimbursement policy. Specifically, staff at a VA
medical center of jurisdiction were told by a VA headquarters official
that they could not approve per diem reimbursements to state veterans'
nursing homes for care provided to new Priority Group 8 veterans, but
were told by a different headquarters official that they could approve
such care. Lacking clear guidance on whether they should approve
reimbursement for services provided to new Priority Group 8 veterans
admitted to state veterans' nursing homes, the medical center staff
decided to approve such reimbursements.
To help ensure that VA can conduct adequate strategic planning for its
nursing home care and strengthen its administration and oversight, we
are recommending that VA compile and report data on the age and gender
of veterans admitted to state veterans' nursing homes, compile
available data on the priority group status of veterans in state
veterans' nursing homes, and explore with these nursing homes options
for estimating the number of unenrolled veterans in each priority
group, clarify that VA policy allows state veterans' nursing homes to
receive reimbursement for both wartime and peacetime veterans, and
clarify whether VA policy allows reimbursement for new Priority Group 8
veterans.
VA stated that it agreed with our overall findings and generally
concurred with our recommendations. VA stated that it plans to collect
demographic information on state veterans' nursing home patients on a
more structured, routine basis. VA indicated that the collection of
state veterans' nursing home demographic information on a more
structured, routine basis requires the development of new software,
which VA anticipates might be completed by the end of fiscal year 2007.
VA agreed with our recommendations to clarify reimbursement policy on
the state veterans' nursing homes and stated that it plans to do so by
issuing a national information letter to VA medical centers of
jurisdiction by the end of fiscal year 2006.
Background:
VA provides or pays for nursing home care for veterans in three
settings. VA reports that it operates 134 nursing homes of its own,
which in fiscal year 2005 accounted for about 35 percent of VA's
nursing home care workload. Almost all of these nursing homes are
attached or in close proximity to a VA medical center. VA also
contracts for care of veterans in over 2,000 VA-approved, privately
owned nursing homes located in communities across the country. In
fiscal year 2005, these homes provided services to nearly 13 percent of
VA's nursing home workload. In fiscal year 2005, about 52 percent of
VA's nursing home workload was provided in a third setting--state
veterans' nursing homes located in 44 states and Puerto Rico (see fig.
1).[Footnote 8]
Figure 1: State Veterans' Nursing Home Locations, Fiscal Year 2005:
[See PDF for image]
[End of figure]
Across the country, there is wide variation in the capacity of state
veterans' nursing home programs, as determined by the number of beds in
state veterans' nursing homes. For example, in the 44 states and Puerto
Rico that operate state veterans' nursing homes, the number of state
veterans' nursing home beds ranged from 38 in North Dakota to 1,439 in
Oklahoma in fiscal year 2005 (see fig. 2).
Figure 2: Number of State Veterans' Nursing Home Beds, Fiscal Year
2005:
[See PDF for image]
[End of figure]
State veterans' nursing homes provide long and short-stay care.
Generally, long-stay care involves care of 90 days or more needed by
veterans who cannot be cared for at home because of severe, chronic
physical or mental limitations. Such care includes assistance with
activities of daily living.[Footnote 9] Short-stay care typically
involves care of less than 90 days and includes skilled nursing
services for rehabilitative care following hospitalization or serious
illness.
VA funds state veterans' nursing homes through per diem reimbursements
that cover a portion of the costs of the nursing home care provided to
veterans. In fiscal year 2005, VA paid $382 million in per diem
payments for patient care. VA annually adjusts its per diem
reimbursement rate for all state veterans' nursing homes, which in
fiscal year 2005 was $59.36 per veteran. As part of VA's support and
oversight of state veterans' nursing homes, VA medical centers of
jurisdiction process and approve per diem reimbursements for the state
veterans' nursing homes located in their geographic areas.[Footnote 10]
In addition to paying for a portion of the cost of providing nursing
home care to veterans, VA supports state veterans' nursing homes
through grants for construction, acquisition,[Footnote 11] or
renovation of existing structures. VA provides grants to states for
nursing home construction, acquisition, or renovation following its
review and approval of proposals submitted by state officials.[Footnote
12] In fiscal year 2005, VA spent over $123 million for construction or
renovation projects.[Footnote 13] VA requires states with state
veterans' nursing homes that were constructed, acquired, or renovated
with VA construction grants to operate these homes as state veterans'
nursing homes for a period of 20 years.
In addition to per diem payments and construction grants from VA, state
veterans' nursing homes may receive payments from a number of different
sources, including Medicare and Medicaid. CMS, an agency within the
U.S. Department of Health and Human Services, certifies that nursing
homes--including state veterans' nursing homes--are qualified to
receive Medicare and Medicaid reimbursement.[Footnote 14] For state
veterans' nursing homes that are certified to receive Medicaid
reimbursement, the state's Medicaid funding may be one source of a
state's support for its state veterans' nursing homes.[Footnote 15]
Medicare and Medicaid typically reimburse state veterans' nursing homes
for different types of nursing home care provided to veterans. Medicare
primarily covers costs for acute health care services, and, therefore,
limits its nursing home coverage to short stays requiring skilled
nursing care following hospitalization. In contrast, Medicaid programs
provide coverage for long-stay nursing home care for patients who
require assistance with activities of daily living, such as eating and
bathing. Although VA is not authorized in most cases to bill and
collect payments from Medicare and Medicaid, state veterans' nursing
homes are not prohibited from doing so. As a result, in addition to per
diem reimbursement from VA, state veterans' nursing homes may receive
reimbursement from other sources such as Medicare or Medicaid for care
provided to an individual veteran.
The number of veterans aged 65 and older is expected to decrease after
2013 through 2030 (see fig. 3). From 2005 to 2013, the number of these
veterans first declines then increases until 2013, in part, because of
the aging of Vietnam-era veterans. In contrast, the number of persons
aged 65 and older in the general population is expected to increase
steadily from 2005 through 2030.
Figure 3: Projected Veteran Population Age 65 and Older, Fiscal Year
2005 through Fiscal Year 2030:
[See PDF for image]
[End of figure]
VA has recognized the importance of accounting for demographic changes
in the veteran population and strategically planning the future
delivery of nursing home care to veterans. In May 2004, in an
announcement of realignment decisions resulting from VA's Capital Asset
Realignment for Enhanced Services (CARES) process,[Footnote 16] the
Secretary of Veterans Affairs identified the need for VA to plan to
meet the needs of an aging veteran population. In his CARES
announcement, the Secretary noted that VA was in the process of
developing a strategic plan for long-term care, including nursing home
services. A strategic plan for long-term care would, for instance,
incorporate forecasts of the likely demand for VA's nursing home care,
help determine which veterans VA will serve--as a matter of policy--
among those seeking nursing home care from VA, and help determine the
extent to which VA should provide long and short-stay nursing home care
to the veterans it has chosen to serve.
Selected States Have Admission Criteria That Differ in Two Key
Respects:
The selected states we reviewed have criteria for granting admission to
their state veterans' nursing homes that differ in two key respects.
States have the flexibility to establish their own admission criteria
because VA does not control the admission process or specify the
admission criteria that states should use. The selected states differ
in whether their state veterans' nursing homes admit peacetime
veterans. Florida, Maine, and Pennsylvania admit both wartime and
peacetime veterans. In contrast, Oklahoma admits wartime veterans only.
The selected states also differ in that some admit certain nonveterans.
Maine and Pennsylvania admit certain nonveterans--such as widows of
veterans or parents of veterans who died in the line of military duty.
In contrast, Florida and Oklahoma admit veterans only (see table 1).
Table 1: Veteran and Nonveteran Workload (Average Daily Census) in
State Veterans' Nursing Homes, Fiscal Year 2004:
Veterans;
Florida[A]: 327;
Maine: 320;
Oklahoma: 1140;
Pennsylvania: 947.
Nonveterans;
Florida[A]: 0[B];
Maine: 108;
Oklahoma: 0[B];
Pennsylvania: 87.
Total workload;
Florida[A]: 327;
Maine: 428;
Oklahoma: 1140;
Pennsylvania: 1034.
Source: GAO analysis of Florida, Maine, Oklahoma, and Pennsylvania
data.
[A] In fiscal year 2004, Florida was in the process of opening two new
state veterans' nursing homes; workload at these two homes is not
included in this table.
[B] Florida and Oklahoma do not admit nonveteran patients.
[End of table]
The four states we visited all share two other key admission criteria.
Each state requires veterans to have been discharged from the military
under honorable conditions and requires all patients to be certified by
a physician as having a medical basis for admission to a nursing home.
In the selected states, this latter requirement is met if a physician
certifies that the patient either requires some form of skilled nursing
care or needs assistance with activities of daily living. For example,
patients in Maine's state veterans' nursing homes must be certified by
a physician as requiring skilled nursing care or assistance with at
least three such activities of daily living. Similarly, Pennsylvania
admits patients to its state veterans' nursing homes if they have been
certified as needing skilled nursing care or assistance with activities
of daily living. In Florida, admission to a state veterans' nursing
home requires that a VA physician certify that the patient requires
nursing home care. In Oklahoma, a physician from a state veterans'
nursing home must conduct a physical exam and certify that any veteran
admitted to a state veterans' nursing home is disabled or diseased to a
degree that requires nursing home care.
State Veterans' Nursing Homes in Selected States Vary in the Extent to
Which They Rely on Revenue from VA and Other Sources:
State veterans' nursing homes in the four states we visited rely, to
varying degrees, on VA and non-VA sources of revenue. (See table 2 for
a summary of the sources of revenue used for veterans' care in state
veterans' nursing homes in the four selected states.) In fiscal year
2004 about one-fourth to one-third of the revenue used by these nursing
homes for veterans' care[Footnote 17] came from VA per diem
reimbursements. This source accounted for 34 percent of revenues used
to provide care to veterans in Oklahoma, 29 percent in Florida, 24
percent in Maine, and 22 percent in Pennsylvania. VA reimburses state
veterans' nursing homes for services provided to eligible veterans--
those who were discharged from military service under conditions other
than dishonorable and who have been determined by a physician as
requiring nursing home care. VA, however, does not provide per diem
reimbursement for services provided to nonveterans admitted to a state
veterans' nursing home--such as a veteran's spouse or parent of a
veteran killed in the line of military duty.
Table 2: Sources and Percentage of State Veterans' Nursing Home
Revenues Used for Veterans' Care, Fiscal Year 2004:
Sources of revenue for veterans' care: VA per diem;
Oklahoma: 34%;
Florida: 29%;
Maine: 24%;
Pennsylvania: 22%.
Sources of revenue for veterans' care: Self-payment and other
sources[A];
Oklahoma: 33%;
Florida: 30%;
Maine: 25%;
Pennsylvania: 23%.
Sources of revenue for veterans' care: State funds;
Oklahoma: 32%;
Florida: 10%;
Maine: 0;
Pennsylvania: 54%.
Sources of revenue for veterans' care: Medicaid[B];
Oklahoma: 0[C];
Florida: 22%;
Maine: 37%;
Pennsylvania: 0[C].
Sources of revenue for veterans' care: Medicare, Parts A & B;
Oklahoma: 0[C];
Florida: 9%[D];
Maine: 15%[E];
Pennsylvania:
