VA Health Care
Spending for and Provision of Prosthetic Items Gao ID: GAO-10-935 September 30, 2010In fiscal year 2009, the Department of Veterans Affairs (VA) provided more than 59 million prosthetic items to more than 2 million veterans. After VA physicians and other clinicians prescribe prosthetic items, VA's Prosthetic and Sensory Aids Service (PSAS) is responsible for processing prescriptions and providing prosthetic items to veterans. PSAS is also responsible for managing VA's spending for prosthetic items--more than $1.6 billion in fiscal year 2009. In fiscal year 2008, this spending exceeded VA's budget estimates. Each year, VA makes an initial funding allocation for prosthetic items, and may reallocate by increasing or decreasing the funding available for prosthetic items during the fiscal year. GAO was asked to examine (1) how, for fiscal years 2005 through 2009, VA's spending for prosthetic items compared to budget estimates, and the extent to which VA reallocated funding for prosthetic items; (2) how PSAS monitors its performance in processing and providing prosthetic items to veterans; and (3) the efforts VA has undertaken to improve PSAS's performance. GAO reviewed VA's spending and funding allocation data for fiscal years 2005 through 2009. GAO also reviewed documents and interviewed VA officials at headquarters, 5 of VA's 21 regional health care networks, called VISNs, and 13 VA medical centers (VAMC).
VA spending for prosthetic items for each of fiscal years 2005 through 2009 differed from budget estimates, varying in amounts--both under and over budget estimates--ranging from 6 to 12 percent of VA's overall spending for prosthetic items during the 5 fiscal years. In fiscal years 2005, 2008, and 2009, VA spent about $91 million, $83 million, and $183 million more, respectively, than VA originally estimated for its congressional budget justification. Conversely, in fiscal years 2006 and 2007, VA spent about $82 million and about $150 million less, respectively, for prosthetic items than estimated. VA officials reported that they did not perform analysis to determine the specific causes of these differences, but that new trends are taken into account when allocating funding to be used for prosthetic items. In an effort to more closely match funds available for prosthetic items to actual spending needs, VA reallocated the funding available to PSAS and relied on VISNs and VAMCs to address the need for additional funding for prosthetic items at specific VA locations. For example, in fiscal year 2008, when an additional $83 million in funding was required for prosthetic items, VA reallocated $56 million to PSAS and VISNs and VAMCs covered $27 million in spending for prosthetic items. PSAS has performance measures that monitor the timeliness of its processing of prosthetic prescriptions and a number of veteran feedback mechanisms to identify problems in how it provides prosthetic items to veterans. In fiscal year 2009, PSAS's performance measures showed that nearly all of its prescriptions for prosthetic items met its performance goals. While in many cases, PSAS's performance measures serve as a reasonable proxy for monitoring the timeliness of veterans' receipt of their prosthetic items, they may miss some instances in which veterans experience long wait times. Recognizing this shortcoming, PSAS officials rely on a number of other mechanisms--such as telephone calls from veterans and receipt of veteran evaluation cards--to obtain information on veteran satisfaction that may alert them to timeliness or other problems not reflected in their performance measures. VA is making a number of efforts at various levels to improve its performance in providing prosthetic items to veterans. For example, in 7 of VA's 21 VISNs, PSAS personnel at the VISN level centrally manage the provision of prosthetic items at all of the VAMCs in their region. According to VA officials in several VISNs that have adopted this centralized management structure, giving VISN-level PSAS personnel more authority has allowed local PSAS personnel at the VAMCs to devote more time to meeting veterans' needs, and in some cases, has enhanced management effectiveness and efficiency. At the national level, in fiscal year 2009, PSAS had 49 national contracts for prosthetic items, which, according to PSAS officials, help ensure that the quality of prosthetic items provided to veterans is consistent across the country. VA provided technical comments that GAO incorporated as appropriate.
GAO-10-935, VA Health Care: Spending for and Provision of Prosthetic Items
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
September 2010:
VA Health Care:
Spending for and Provision of Prosthetic Items:
GAO-10-935:
GAO Highlights:
Highlights of GAO-10-935, a report to congressional requesters.
Why GAO Did This Study:
In fiscal year 2009, the Department of Veterans Affairs (VA) provided
more than 59 million prosthetic items to more than 2 million veterans.
After VA physicians and other clinicians prescribe prosthetic items,
VA‘s Prosthetic and Sensory Aids Service (PSAS) is responsible for
processing prescriptions and providing prosthetic items to veterans.
PSAS is also responsible for managing VA‘s spending for prosthetic
items”more than $1.6 billion in fiscal year 2009. In fiscal year 2008,
this spending exceeded VA‘s budget estimates. Each year, VA makes an
initial funding allocation for prosthetic items, and may reallocate by
increasing or decreasing the funding available for prosthetic items
during the fiscal year.
GAO was asked to examine (1) how, for fiscal years 2005 through 2009,
VA‘s spending for prosthetic items compared to budget estimates, and
the extent to which VA reallocated funding for prosthetic items; (2)
how PSAS monitors its performance in processing and providing
prosthetic items to veterans; and (3) the efforts VA has undertaken to
improve PSAS‘s performance. GAO reviewed VA‘s spending and funding
allocation data for fiscal years 2005 through 2009. GAO also reviewed
documents and interviewed VA officials at headquarters, 5 of VA‘s 21
regional health care networks, called VISNs, and 13 VA medical centers
(VAMC).
What GAO Found:
VA spending for prosthetic items for each of fiscal years 2005 through
2009 differed from budget estimates, varying in amounts”both under and
over budget estimates”ranging from 6 to 12 percent of VA‘s overall
spending for prosthetic items during the 5 fiscal years. In fiscal
years 2005, 2008, and 2009, VA spent about $91 million, $83 million,
and $183 million more, respectively, than VA originally estimated for
its congressional budget justification. Conversely, in fiscal years
2006 and 2007, VA spent about $82 million and about $150 million less,
respectively, for prosthetic items than estimated. VA officials
reported that they did not perform analysis to determine the specific
causes of these differences, but that new trends are taken into
account when allocating funding to be used for prosthetic items. In an
effort to more closely match funds available for prosthetic items to
actual spending needs, VA reallocated the funding available to PSAS
and relied on VISNs and VAMCs to address the need for additional
funding for prosthetic items at specific VA locations. For example, in
fiscal year 2008, when an additional $83 million in funding was
required for prosthetic items, VA reallocated $56 million to PSAS and
VISNs and VAMCs covered $27 million in spending for prosthetic items.
PSAS has performance measures that monitor the timeliness of its
processing of prosthetic prescriptions and a number of veteran
feedback mechanisms to identify problems in how it provides prosthetic
items to veterans. In fiscal year 2009, PSAS‘s performance measures
showed that nearly all of its prescriptions for prosthetic items met
its performance goals. While in many cases, PSAS‘s performance
measures serve as a reasonable proxy for monitoring the timeliness of
veterans‘ receipt of their prosthetic items, they may miss some
instances in which veterans experience long wait times. Recognizing
this shortcoming, PSAS officials rely on a number of other mechanisms”
such as telephone calls from veterans and receipt of veteran
evaluation cards”to obtain information on veteran satisfaction that
may alert them to timeliness or other problems not reflected in their
performance measures.
VA is making a number of efforts at various levels to improve its
performance in providing prosthetic items to veterans. For example, in
7 of VA‘s 21 VISNs, PSAS personnel at the VISN level centrally manage
the provision of prosthetic items at all of the VAMCs in their region.
According to VA officials in several VISNs that have adopted this
centralized management structure, giving VISN-level PSAS personnel
more authority has allowed local PSAS personnel at the VAMCs to devote
more time to meeting veterans‘ needs, and in some cases, has enhanced
management effectiveness and efficiency. At the national level, in
fiscal year 2009, PSAS had 49 national contracts for prosthetic items,
which, according to PSAS officials, help ensure that the quality of
prosthetic items provided to veterans is consistent across the country.
VA provided technical comments that GAO incorporated as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-10-935] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
In Fiscal Years 2005 through 2009, Actual Spending Needs for
Prosthetic Items Differed from Estimates, Resulting in the
Reallocation of Funding Available for Prosthetic Items:
PSAS Uses Administrative Data and Veteran Feedback Mechanisms to
Monitor Its Performance in Processing and Providing Prosthetic Items
to Veterans:
VA Is Making Local, Regional, and National Efforts to Improve PSAS's
Performance:
Agency Comments:
Appendix I: The Total Costs and Number of Prosthetic Items VA Provided
to Veterans in Fiscal Years 2005 through 2009:
Appendix II: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Examples of VA Prosthetic Items, by Type:
Table 2: Initial Specific Purpose Funding for Prosthetic and Sensory
Aids Service (PSAS), Reallocation Amounts, and Final Specific Purpose
Funding, Fiscal Years 2005 through 2009:
Table 3: Total Costs and Number of Prosthetic Items VA Provided to
Veterans by Type of Prosthetic Item, Fiscal Years 2005 through 2009:
Table 4: Total Costs and Number of Prosthetic Items Provided to
Veterans by Veterans Integrated Service Network (VISN), Fiscal Years
2005 through 2009:
Table 5: Total Costs and the Number of Prosthetic Items Provided to
Veterans by VA Station, Fiscal Years 2005 through 2009:
Figures:
Figure 1: VA Spending for Prosthetic Items, by Type, Fiscal Year 2009:
Figure 2: Estimated and Actual VA Spending for Prosthetic Items,
Fiscal Years 2005 through 2009:
Figure 3: Actual VA Spending for Prosthetic Items by Type of Funding,
Fiscal Years 2005 through 2009:
Abbreviations:
NPPD: National Prosthetics Patient Database:
PSAS: Prosthetic and Sensory Aids Service:
VA: Department of Veterans Affairs:
VAMC: Veterans Affairs medical center:
VHA: Veterans Health Administration:
VISN: Veterans Integrated Service Network:
VPR: VISN prosthetic representative:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 30, 2010:
The Honorable Daniel K. Akaka:
Chairman:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Bob Filner:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
The Department of Veterans Affairs (VA), through its Prosthetic and
Sensory Aids Service (PSAS), provides prosthetic items to those
veterans who have experienced the loss or permanent impairment of a
body part or function. During fiscal year 2009, PSAS procured and
delivered more than 59 million prosthetic items[Footnote 1] to more
than 2 million veterans, or nearly 40 percent of the veterans who
received health care services from VA during the year.[Footnote 2] The
prosthetic items provided by VA include a variety of medical devices
and equipment ranging from artificial limbs and surgical implants--
such as pacemakers and hip replacements--to eyeglasses and hearing aid
batteries. In recent years, the annual number of veterans who have
received prosthetic items through PSAS and the annual amount that VA
has spent on those items have increased significantly. Between fiscal
years 2005 and 2009, the number of veterans to whom PSAS furnished
prosthetic items grew 50 percent, from about 1.5 million to almost 2.2
million. During the same period, VA spending for prosthetic items
increased about 60 percent, from about $1 billion to more than $1.6
billion.
As PSAS provides more prosthetic items to more veterans, it is
increasingly important that PSAS effectively manage the funding VA
allocates to PSAS for prosthetic items and that it ensure prosthetic
items are provided to veterans in an economical and timely manner.
[Footnote 3] Each year, VA develops annual spending estimates for
prosthetic items, which are included in VA's annual congressional
budget justification as part of its estimate for health care services.
VA does not, however, receive a specific appropriation for prosthetic
items; rather, VA receives an appropriation for all of its health care
services, including prosthetic items--the Medical Services
appropriation. As a result, VA has considerable discretion in how it
allocates its appropriated funding among its health care services,
including the reallocation of funding throughout a fiscal year as
required to meet actual spending needs. In 2009, veterans service
organizations reported that actual spending for prosthetic items
significantly exceeded estimates for fiscal year 2008. In light of
this information, these organizations recommended that Congress ensure
VA's appropriations are sufficient to meet the prosthetic needs of all
veterans so that any requests for additional funding for prosthetic
items do not compromise other programs.[Footnote 4]
You expressed interest in obtaining information in order to better
understand the operation of PSAS, including its management of VA
funding allocated for prosthetic items and its performance in
providing prosthetic items in a timely manner. This report discusses
(1) how, for fiscal years 2005 through 2009, VA's spending for
prosthetic items compared to budget estimates, and the extent to which
VA reallocated the funding available for prosthetic items; (2) how
PSAS monitors its performance in processing and providing prosthetic
items to veterans; and (3) the efforts VA has undertaken to improve
PSAS's performance in providing prosthetic items to veterans.
To determine how VA's spending for prosthetic items compared to budget
estimates, we obtained information from VA on its annual spending for
prosthetic items for each of fiscal years 2005 through 2009.[Footnote
5] We also reviewed VA's estimates for prosthetic items that the
department included in its annual congressional budget justifications
for the same fiscal years. We compared actual spending for prosthetic
items with the estimates reported in the budget justifications. To
determine the extent to which VA reallocated funding for prosthetic
items, we obtained information for each of fiscal years 2005 through
2009 on the funding VA initially allocated and subsequently
reallocated for prosthetic items. We interviewed VA officials from
PSAS's central office and the Veterans Health Administration's (VHA)
[Footnote 6] Office of Finance on differences between spending and
estimates for prosthetic items as well as about VA's reallocation of
funding. We also interviewed officials from a judgmental sample of 13
VA medical centers (VAMC); these VAMCs were located in Phoenix and
Tucson, Arizona; Bay Pines, Gainesville, and Tampa, Florida; Atlanta
and Augusta, Georgia; Albuquerque, New Mexico; Buffalo and Syracuse,
New York; Portland, Oregon; Columbia, South Carolina; and Seattle,
Washington. We conducted site visits to 12 of the 13 VAMCs.[Footnote
7] To select the 13 VAMCs, we obtained data from VA's National
Prosthetic Patient Database[Footnote 8] on the prosthetic items that
VA provided veterans during fiscal years 2005 through 2009 and
identified the number of prosthetic items provided to veterans at each
VAMC and their reported costs. We used these data and input from VA
officials to select the VAMCs based on factors such as spending for
prosthetic items, the number of prosthetic items provided, PSAS
management structure, geographic location, whether VAMCs operated
special units that use a large number prosthetic items,[Footnote 9]
and recent performance in meeting PSAS performance goals.
To identify how PSAS monitors its performance in processing and
providing prosthetic items to veterans and to describe the efforts VA
has undertaken to improve PSAS's performance, we interviewed VA
officials from PSAS's central office; 5 of VA's 21 regional health
care networks, called Veterans Integrated Service Networks
(VISN);[Footnote 10] and the 13 VAMCs in our sample. We also obtained
and reviewed VA's quarterly performance measure reports used to
monitor the timeliness of VA's processing of prosthetic items to
veterans.
We assessed the reliability of data on VA's spending and allocation of
funding, data from the National Prosthetic Patient Database, and data
on PSAS's performance measures for monitoring the timeliness of VA's
processing of prosthetic items in several ways. These included
electronic and manual data testing and interviews of VA officials
knowledgeable about the data. We determined that the data that we used
in our analyses were sufficiently reliable for the purposes of this
report.
We conducted this performance audit from June 2009 through August 2010
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
As part of a uniform set of benefits provided to all veterans who
enroll in its health care system, VA, through PSAS, provides
prosthetic items to veterans. PSAS has budget and management
responsibilities for VA's provision of prosthetic items, including
allocating funding for prosthetic items to VISNs and VAMCs and
ensuring veterans receive prescribed prosthetic items in a timely
manner. According to PSAS officials, several factors--including
expansions in the types of items VA defines as prosthetic items--
contributed to an increased demand for prosthetic items between fiscal
years 2005 and 2009.
Prosthetic Items Provided to Veterans:
VA, through VHA, operates one of the nation's largest health care
systems.[Footnote 11] VA provides a range of services to veterans who
are enrolled in its health care system, such as preventive and primary
health care, a full range of outpatient and inpatient services, and
prescription drugs.[Footnote 12] VA's outpatient care includes
providing prosthetic items to those veterans disabled as a result of
amputation or permanent impairment of a body part or function.
[Footnote 13] VA classifies a variety of medical devices and equipment
as prosthetic items, including artificial arms and legs, eyeglasses,
hearing aids, hearing aid batteries, home dialysis equipment and
supplies, home respiratory aids, hospital beds, orthoses (orthotic
braces, supports, and footwear),[Footnote 14] pacemakers, telehealth
equipment,[Footnote 15] and wheelchairs. These items range in price,
including a cane tip that costs about $2 as well as a microprocessor-
controlled knee which can cost more than $100,000. In addition, while
the vast majority of prosthetic items are purchased from outside
vendors, VA fabricated nearly 4 percent of the artificial limbs and
orthoses provided to veterans in fiscal year 2009.
Table 1 shows the types of prosthetic items VA provides and specific
examples of each type.
Table 1: Examples of VA Prosthetic Items, by Type:
Type of prosthetic item: Accessibility items[A];
Examples of items:
* scooters and accessories;
* standard, motorized, and custom-built wheelchairs and accessories.
Type of prosthetic item: Artificial limbs[A];
Examples of items:
* artificial arms and legs.
Type of prosthetic item: Medical equipment[A];
Examples of items:
* computer equipment;
* diabetic socks;
* hearing aid batteries;
* hospital beds and accessories;
* patient lifts;
* recreational equipment[B];
* telehealth equipment[C];
* walking aids (e.g., walkers).
Type of prosthetic item: Orthoses[A];
Examples of items:
* ankle, knee, leg, spinal, and other braces;
* arch supports, shoe inserts, and shoes.
Type of prosthetic item: Other[A];
Examples of items:
* home dialysis equipment and supplies;
* Home Improvement and Structural Alterations grants[D];
* home oxygen equipment and supplies;
* restorations (e.g., breast, eye, and facial).
Type of prosthetic item: Sensori-neuro aids[A];
Examples of items:
* blind aids;
* eyeglasses and contact lenses;
* hearing aids;
* speech devices.
Type of prosthetic item: Surgical implants;
Examples of items:
* anchors, plates, and screws;
* biological implants (e.g., bone and tissue grafts);
* dental implants;
* implantable cardioverter defibrillators and leads;
* pacemakers;
* stents.
Source: GAO analysis of VA data.
Note: This table presents data from VA's National Prosthetic Patient
Database--an internal system used by VA to administer the department's
provision of prosthetic items--on the types of prosthetic items VA
provided to veterans in fiscal year 2009.
[A] Accessibility items, artificial limbs, medical equipment,
orthoses, other, and sensori-neuro aids also include components used
for fabrication and repair of those items.
[B] Recreational equipment includes artificial legs used for swimming,
artificial arms used for archery, hand-powered cycles, and Braille
dominos.
[C] Telehealth is the use of telecommunications technology including
video, digital pictures, and messaging devices to exchange health care
information to provide health care services to rural and remote areas.
[D] Home Improvement and Structural Alterations grants provide for the
improvements and structural alterations veterans need to access their
home and essential bathroom facilities.
[End of table]
In fiscal year 2009, the type of prosthetic items for which VA spent
the largest amount was surgical implants, which accounted for 27
percent of the more than $1.6 billion VA spent for prosthetic items
that year. (See figure 1.) See appendix I for information on the total
costs of and number of prosthetic items provided to veterans in fiscal
years 2005 through 2009.
Figure 1: VA Spending for Prosthetic Items, by Type, Fiscal Year 2009:
[Refer to PDF for image: pie-chart]
Surgical implants: 27%;
Sensori-neuro aids: 17%;
Medical equipment: 14%;
Accessibility items: 11%;
Orthoses: 6%;
Artificial limbs: 6%;
Other[A]: 19%.
Source: GAO analysis of VA data.
Note: This figure presents data from VA‘s National Prosthetic Patient
Database”an internal system used by VA to administer the department‘s
provision of prosthetic items.
[A] Other includes home dialysis equipment and supplies, Home
Improvement and Structural Alterations grants, home oxygen equipment
and supplies, restorations, and other miscellaneous items.
[End of figure]
VA's Process for Estimating and Allocating Funding for Prosthetic
Items:
The funding VA uses to procure prosthetic items for veterans is made
available as part of the appropriations process for VA's health care
services.[Footnote 16] Each year, VA formulates its annual health care
budget by developing estimates of its likely spending for all of its
health care services, including prosthetic items.[Footnote 17] We have
previously noted that the formulation of VA's budget is challenging,
as it is based on assumptions and imperfect information on the health
services VA expects to provide.[Footnote 18] For example, VA is
responsible for anticipating the service needs of very different
veteran populations--including an aging veteran population and a
growing number of veterans returning from military operations in
Afghanistan and Iraq--and for calculating future costs associated with
providing health care services to these populations. VA uses an
actuarial model to develop its budget estimates for most of its health
care services, including estimates for prosthetic items, and
incorporates these estimates in the department's annual congressional
budget justification to the appropriations subcommittees.[Footnote 19]
Rather than receiving an appropriation for each individual health care
service it provides, VA receives an appropriation for all its health
care services--the Medical Services appropriation.[Footnote 20] As a
result, VA has considerable discretion in how it allocates
appropriated funding among its various health care services.
VA allocates the Medical Services appropriation either as specific
purpose funding or general purpose funding. Where specific purpose
funding is restricted to the purposes of individual health care
services, such as organ transplant services or readjustment
counseling, general purpose funding may be used to cover costs related
to any health care service, including services for which specific
purpose funding may be insufficient. While most of the funding from
the Medical Services appropriation is distributed among the VISNs and
ultimately to the VAMCs, according to VA officials, VA also maintains
a national reserve to provide additional funding, when needed, to
VISNs and VAMCs, as well as for those health care services for which
VA allocates specific purpose funds. In addition, during the course of
a fiscal year, VA may reallocate funding--that is, adjust how the
department allocates its funding--to match spending needs, including
redesignating specific purpose funds as general purpose funds or vice
versa.
Citing significant decreases in the level of care and timely delivery
of prosthetic items, VA designated funding for prosthetic items as
specific purpose funding in 2001.[Footnote 21] In general, VA
allocates specific purpose funds to PSAS, which in turn allocates them
to VISNs; VISNs then allocate funds to VAMCs. These specific purpose
funds are for the procurement of prosthetic items as well as the
procurement of various components for VA-fabricated or VA-repaired
prostheses and orthoses. According to VA officials, these funds do not
cover administrative and clinical costs, such as the salaries and
benefits of PSAS personnel or labor costs associated with VA
fabrication of prosthetic items. Typically, these administrative and
clinical costs are covered by a VISN's or VAMC's general purpose
funds. In addition, VISNs and VAMCs may use their general purpose
funds for prosthetic items if spending needs exceed the amount
available in specific purpose funds.
PSAS Roles and Responsibilities:
After physicians and other clinicians at VA medical facilities
determine the prosthetic needs of veterans and prescribe specific
prosthetic items to meet those needs, PSAS is responsible for
processing the prescriptions and providing the prescribed prosthetic
items to individual veterans.[Footnote 22] According to PSAS
officials, purchasing agents, generally located at VAMCs, perform
administrative actions to process prescriptions for prosthetic items.
These administrative actions include activities such as requesting and
obtaining additional information from a prescribing clinician,
obtaining a price quote from a contractor, and creating a purchase
order to authorize the procurement and shipment of an over-the-counter
item or the fabrication of a custom-ordered item. PSAS officials
stated that the processing of the prescription is considered complete
when a prosthetic item has been issued to the veteran from PSAS's
inventory or a purchase order is created for the item.[Footnote 23]
PSAS also has some clinical staff--prosthetists and orthotists--who
provide clinical services related to the provision of artificial limbs
and orthoses, including participating in the evaluations of prosthetic
needs for amputees and, subsequently, designing, fabricating, fitting,
and adjusting artificial limbs and custom orthoses. PSAS officials
reported that they provide varying levels of services related to the
design, fabrication, fitting, and delivery of artificial limbs and
orthoses at 77 locations.
PSAS officials are also responsible for the overall administration of
VA's provision of prosthetic items. Specifically, PSAS officials in
VA's central office establish national policies and procedures on VA's
provision of prosthetic items; allocate VA specific purpose funding
for prosthetic items among the 21 VISNs; monitor the spending of this
specific purpose funding and, if appropriate, facilitate the
reallocation of funding among the VISNs; and establish and monitor
mechanisms, such as performance measures and goals, to evaluate VA's
performance in providing prosthetic items. VISN prosthetic
representatives (VPR), located within each of VA's 21 VISNs, further
allocate specific purpose funding among their VAMCs and, with the
assistance of local prosthetics chiefs,[Footnote 24] support central
office efforts to monitor VA's spending for prosthetic items and VA's
performance in providing prosthetic items.
Factors Contributing to the Increased Demand for Prosthetic Items:
Between fiscal years 2005 and 2009, the annual number of veterans who
received prosthetic items through PSAS increased about 50 percent and
the total amount VA spent on those items grew by about 60 percent.
According to VA officials, a number of factors have contributed to
this growth and may contribute to expected increases in the future.
These factors include the following:
* VA has expanded the medical devices and equipment it classifies as
prosthetic items. For example, during fiscal year 2008, VA classified
biological implants, such as bone and tissue grafts, as prosthetic
items.[Footnote 25] In fiscal year 2009, VA spent about $21 million on
biological implants.
* New technologies in prosthetic items available to veterans may
increase costs. For example, in the fall of 2010, PSAS plans to begin
providing the X2 microprocessor knee--the latest generation of
components for prosthetic legs--to some veterans.[Footnote 26]
According to PSAS officials, this component is expected to add about
$40,000 to the cost of each prosthesis using this technology.
* VA guidance clarifying veteran eligibility for certain prosthetic
items expanded the number of veterans receiving prosthetic items. For
example, in October 2008, VA released a directive restating the
department's policy on veteran eligibility for eyeglasses. As result,
the number of eyeglasses VA provided to veterans increased by nearly
22 percent, from about 830,000 pairs in fiscal year 2008 to more than
1 million pairs in fiscal year 2009.[Footnote 27]
In addition, VA expanded eligibility for enrollment in its health care
system. In 2009, VA raised the income thresholds that define certain
veterans' eligibility for VA health care services, resulting in
approximately 260,000 additional veterans gaining
eligibility.[Footnote 28] This may also have increased the number of
prosthetic items provided.
In Fiscal Years 2005 through 2009, Actual Spending Needs for
Prosthetic Items Differed from Estimates, Resulting in the
Reallocation of Funding Available for Prosthetic Items:
In each of fiscal years 2005 through 2009, VA's actual spending needs
for prosthetic items differed from the estimates VA reported in its
congressional budget justifications for those years, on which the
initial allocation to PSAS for prosthetic items was based. As shown in
figure 2, VA spent less for prosthetic items than it had estimated in
its justifications for fiscal years 2006 and 2007. These differences--
about $82 million in fiscal year 2006 and about $150 million in fiscal
year 2007--represented 7 and 12 percent, respectively, of VA's actual
spending for prosthetic items during those fiscal years. In fiscal
years 2005, 2008, and 2009, VA spent about $91 million, $83 million,
and $183 million more, respectively, than originally estimated (9, 6,
and 11 percent, respectively, of VA's spending for prosthetic items in
those fiscal years).[Footnote 29]
Figure 2: Estimated and Actual VA Spending for Prosthetic Items,
Fiscal Years 2005 through 2009:
[Refer to PDF for image: vertical bar graph]
Fiscal year: 2005;
Estimated spending: $947 million;
Actual spending: $1.04 billion.
Fiscal year: 2006;
Estimated spending: $1.200 billion;
Actual spending: $1.12 billion.
Fiscal year: 2007;
Estimated spending: $1.39 billion;
Actual spending: $1.24 billion.
Fiscal year: 2008;
Estimated spending: $1.34 billion;
Actual spending: $1.42 billion.
Fiscal year: 2009;
Estimated spending: $1.46 billion;
Actual spending: $1.64 billion.
Source: GAO analysis of VA data.
Notes: Estimated spending represents amounts originally reported in
VA's annual congressional budget justifications. Actual VA spending
represents total obligations for prosthetic items reported by VA.
[End of figure]
VA officials from the VHA Office of Finance and PSAS central office
said that they did not perform analysis to determine the specific
reasons for the differences between VA's budget estimates and its
actual spending for prosthetic items in a given fiscal year. PSAS
officials reported that they do perform some analysis to identify new
trends in VA's spending for prosthetic items, which are taken into
account when allocating specific purpose funding for prosthetic items.
According to officials, to develop the budget estimates, VHA's Office
of Finance uses the most recently available spending and utilization
data in its actuarial model. They noted, however, that these data are
3 years old at the time VA begins to develop budget estimates for a
new fiscal year--for example, the actuarial model in VA's 2010 budget
estimate used spending and utilization data from fiscal year 2007.
This, coupled with the increased demand for prosthetic items, makes it
more difficult to accurately estimate year-to-year PSAS funding needs,
according to VA officials.
PSAS central office officials reported that they depend upon staff at
the VISNs and VAMCs to identify local factors, such as a new surgical
service, that could increase demand for prosthetic items, in order to
develop more up-to-date estimates for the purpose of allocating
specific purpose funding for prosthetic items to VISNs and VAMCs. PSAS
officials at each of the 13 VAMCs in our sample identified numerous
local factors that can affect spending for prosthetic items during a
particular fiscal year. For example, at one VAMC, the prosthetics
chief said that the hiring of a new surgeon was expected to increase
local spending for certain surgical implants, such as pacemakers, by
more than $300,000. This same prosthetics chief also noted that recent
increases in the diagnosis and treatment of sleep apnea resulted in an
increase of nearly $380,000 in local spending for prosthetic items.
In 4 of the 5 fiscal years we reviewed, VA reallocated the funding
available for prosthetic items--that is, adjusted the amount of the
specific purpose funding for these items--in an effort to better match
specific purpose funds for prosthetic items with actual spending
needs. Specifically, in fiscal years 2006, 2007, and 2009, VA reduced
the amount of specific purpose funding for prosthetic items.[Footnote
30] During fiscal year 2008, VA allocated an additional $56 million in
specific purpose funds from the department's national reserve in order
to meet a request from PSAS for additional funding. (See table 2.) VA
based these reallocations on projections of annual spending for
prosthetic items developed throughout each fiscal year using year-to-
date information on spending. Each year during the third quarter of
the fiscal year, for example, VA uses the amount spent on prosthetic
items through the first two quarters of the fiscal year to project
spending for the rest of the fiscal year and reallocates funding to
adjust the amount of specific purpose funding available for prosthetic
items accordingly.
Table 2: Initial Specific Purpose Funding for Prosthetic and Sensory
Aids Service (PSAS), Reallocation Amounts, and Final Specific Purpose
Funding, Fiscal Years 2005 through 2009:
Fiscal year: 2005;
Initial specific purpose funding allocation: $947 million;
Reallocation amounts: $0;
Final specific purpose funding allocation: $947 million;
Percentage that reallocations increased (decreased) funding: 0%.
Fiscal year: 2006;
Initial specific purpose funding allocation: $1.20 billion;
Reallocation amounts: ($72 million);
Final specific purpose funding allocation: $1.13 billion;
Percentage that reallocations increased (decreased) funding: (6%).
Fiscal year: 2007;
Initial specific purpose funding allocation: $1.39 billion;
Reallocation amounts: ($158 million);
Final specific purpose funding allocation: $1.23 billion;
Percentage that reallocations increased (decreased) funding: (11%).
Fiscal year: 2008;
Initial specific purpose funding allocation: $1.34 billion;
Reallocation amounts: $56 million;
Final specific purpose funding allocation: $1.40 billion;
Percentage that reallocations increased (decreased) funding: 4%.
Fiscal year: 2009;
Initial specific purpose funding allocation: $1.73 billion;
Reallocation amounts: ($35 million);
Final specific purpose funding allocation: $1.69 billion;
Percentage that reallocations increased (decreased) funding: (2%).
Source: GAO analysis of VA data.
Notes: Initial specific purpose funding allocations represent the
funding VA allocated to PSAS for prosthetic items at the beginning of
the fiscal year. Final specific purpose funding allocations represent
the actual amount of funding VA allocated for prosthetic items at the
end of the fiscal year. Reallocation amounts represent increases or
decreases in the amount of funding VA allocated as specific purpose
funds for prosthetic items.
[End of table]
In addition to the efforts VA made at the national level to reallocate
funds to better match specific purpose funding for prosthetic items
with actual spending needs, for 3 of the 5 fiscal years we reviewed,
some VISNs and VAMCs used general purpose funds for prosthetic items.
VA policy requires that VISNs provide additional funding to PSAS, when
necessary, from general purpose funding to ensure the provision of
prosthetic items is not delayed for lack of funding. In fiscal years
2005, 2007, and 2008, VISNs and VAMCs provided $91 million, $5
million, and $27 million, respectively, from their general purpose
funds to address the difference between allocated specific purpose
funding and actual spending needs for prosthetic items. (See figure
3.) While VHA and PSAS officials acknowledge the use of general
purpose funds for prosthetic items reduced the funding available for
other purposes, they emphasized that this use did not compromise any
veteran's medical care.
Figure 3: Actual VA Spending for Prosthetic Items by Type of Funding,
Fiscal Years 2005 through 2009:
[Refer to PDF for image: stacked vertical bar graph]
Fiscal year: 2005;
Specific purpose funding: $947 million;
General purpose funding: $91 million.
Fiscal year: 2006;
Specific purpose funding: $1.12 billion;
General purpose funding: 0.
Fiscal year: 2007;
Specific purpose funding: $1.23 billion;
General purpose funding: $5 million.
Fiscal year: 2008;
Specific purpose funding: $1.40 billion;
General purpose funding: $27 million.
Fiscal year: 2009;
Specific purpose funding: $1.634 billion;
General purpose funding: 0.
Source: GAO analysis of VA data.
Notes: Actual VA spending represents total obligations for prosthetic
items reported by VA. In this figure, specific purpose funding
represents VA funding specifically allocated for prosthetic items.
General purpose funding represents VA funding that can be used for any
health care service, including covering the costs of services for
which specific purpose funding is insufficient.
[End of figure]
PSAS Uses Administrative Data and Veteran Feedback Mechanisms to
Monitor Its Performance in Processing and Providing Prosthetic Items
to Veterans:
PSAS has performance measures that monitor the timeliness of its
processing of prosthetic prescriptions and a number of veteran
feedback mechanisms to identify problems in how it provides prosthetic
items to veterans. In fiscal year 2009, PSAS's performance measures
showed that nearly all of its prescriptions for prosthetic items met
its performance goals. While in many cases, PSAS's performance
measures serve as a reasonable proxy for monitoring the timeliness of
veterans' receipt of their prosthetic items, they may miss some
instances in which veterans experience long wait times. Recognizing
this shortcoming, PSAS officials rely on a number of other mechanisms--
such as feedback submitted through telephone calls from veterans and
receipt of veteran evaluation cards--to obtain information on veteran
satisfaction that may alert them of timeliness or other problems not
reflected in its performance measures.
Performance Measures Assess Timeliness of Administrative Actions, but
Do Not Always Reflect Veterans' Actual Receipt of Prosthetic Items:
During fiscal years 2005 through 2009, PSAS had in place and monitored
two performance measures that assessed the timeliness of
administrative actions related to processing prosthetic prescriptions.
* The first measure, called "delayed orders," assessed the percentage
of prosthetic prescriptions for which the first administrative action
related to the prescription, such as researching the cost of the
prosthetic item from different commercial vendors, occurred more than
5 business days after the clinical provider submitted it. PSAS's
performance goal related to this measure was to have no more than 2
percent of orders categorized as delayed orders.
* The second measure, called "consults pending,"[Footnote 31] assessed
the percentage of prosthetic prescriptions that took more than 45
business days to complete the administrative process associated with
ordering the prosthetic item; that is, from the time the first
administrative action was taken to the time PSAS determined that the
order was complete.[Footnote 32] PSAS's related performance goal was
to have no consults pending; that is, to administratively process all
prescriptions within 45 business days.
For fiscal year 2009, PSAS basically met both of its goals related to
the delayed orders and consults pending performance measures. PSAS
calculated its performance relative to these performance measures for
processing all prosthetic prescriptions submitted at each of its VAMCs
and VISNs during the year.[Footnote 33] Based on its calculations,
PSAS met its delayed order goal of no more than 2 percent delayed
orders, and slightly missed its goal of having no consults pending by
about 0.3 percent.
According to VA, the delayed order and consults pending measures in
many cases accurately reflected the timeliness of processing of
prosthetic items. However, because of a weakness in PSAS's consults
pending measure, some prescriptions that took longer than 45 business
days to process were not detected by the measure. Specifically, PSAS
officials found that prescriptions could be canceled and reentered,
effectively resetting the clock on their processing time. In one VAMC
we visited, for example, the prosthetics chief noted that the VAMC was
receiving a number of complaints from veterans on the timely receipt
of their prosthetic items. Upon further investigation, she identified
more than 3,000 unprocessed prosthetic prescriptions that were not
reflected in the VAMC's consults pending measure because the computer
system used to process prescriptions allowed purchasing agents to
cancel and reenter the prescriptions that were not meeting the 45
business day goal. According to PSAS officials, there are a number of
legitimate reasons why processing the prescription for prosthetic
items can take longer than 45 days to complete.[Footnote 34] However,
this prosthetics chief told us that, due to high purchasing agent
workloads, some of the delays she identified most likely represented
orders for prosthetic items that fell through the cracks, and veterans
may not have received their prosthetic items until 5 or 6 months after
their prescriptions were submitted.
Recognizing the limitation in its consults pending measure, PSAS
started--at the beginning of fiscal year 2010--to use a new measure,
called the "timeliness monitor," which according to PSAS officials was
designed to better assess the timeliness of the complete
administrative process of providing a prosthetic item to a veteran and
provide better assurance that a prosthetic item was provided in a
timely manner. Specifically, PSAS officials said that the timeliness
monitor assesses whether both the goals for the delayed order and
consults pending measures were met,[Footnote 35] and whether the
prescription was completed by either issuing a prosthetic item
directly to the veteran from PSAS's inventory, or generating a
purchase order for the item. PSAS's goal related to the new timeliness
monitor is to have 95 percent of prosthetic prescriptions meet the
timeliness monitor performance measure, according to PSAS officials.
In the first quarter of fiscal year 2010, PSAS's timeliness monitor
showed that less than 83 percent of prescriptions for prosthetic items
met the time frames in the timeliness monitor performance measure.
According to PSAS officials at two VISNs, one factor that played a
significant role in PSAS not meeting its goal for the timeliness
monitor was that the new measure may recognize some prescriptions as
incomplete when actually they have been completely processed by PSAS
staff. For example, if a veteran does not return to the VAMC to pick
up a custom-fit item, such as a pair of orthopedic shoes, the item
would not be recorded on the veteran's prosthetic record even though
PSAS staff had completed the administrative process related to the
item and it was available for pick up. PSAS officials told us that
they are updating their system to allow purchasing agents to close
prescriptions that were processed by PSAS but not recorded in a
veteran's record for legitimate reasons, effectively excluding these
prescriptions from being considered in the timeliness monitor.
According to PSAS officials, once the system is updated, PSAS's
timeliness monitor scores should improve considerably.
An additional weakness of VA's performance measures--both with the new
"timeliness monitor" and the former "consults pending" measure--is
that these measures do not always identify cases in which a veteran
waits a long time to receive an item. In many cases, the
administrative actions related to prosthetic prescriptions do serve as
a reasonable proxy for monitoring the timeliness of when veterans
received their prosthetic items. For example, when a veteran receives
an item out of inventory at a VAMC, the time the prescription is
recorded as complete reflects the time that the veteran received their
prosthetic item. However, the completion of processing of a
prescription does not always correspond with the time at which the
veteran receives the item. In particular, delays that occur for items
that must be fabricated for the veteran or are back-ordered by a
vendor are not reflected in VA's performance measures. For example,
according to the prosthetics chief at one VAMC we visited, veterans
routinely waited 10 to 12 weeks to receive eyeglasses because of
manufacturing delays at the facility that produced the eyeglasses--
even though PSAS processed the eyeglass prescriptions in a timely
manner. That is, once the purchase order was sent to the facility to
manufacture the eyeglasses, VA's system considered the processing of
the prescription to be complete. Officials reported that the VA
optical laboratory could not meet the unexpected increase in demand
that followed guidance that VA issued in October 2008. This guidance
restated the department's policy that veterans whose vision impairment
interferes with their participation in their own medical treatment are
eligible to receive eyeglasses. The prosthetics chief at the VAMC
explained that through feedback from veterans, they became aware of
these delays. The VA optical laboratory has since taken steps to
improve wait times, including authorizing overtime and using
commercial vendors. Further, officials told us that they are planning
a renovation of the optical laboratory to improve its operations.
[Footnote 36]
PSAS officials stated that they recognize their performance measures
have limitations and that they rely on a number of feedback
mechanisms--described below--to alert them of timeliness or other
problems not reflected in PSAS's performance measures.
PSAS Obtains Information on Veteran Satisfaction from a Number of
Feedback Mechanisms:
At a national level, PSAS uses additional mechanisms to identify
timeliness or other problems which are not captured by its performance
measures. These include the following:
* Comments or complaints on VA's Web site. When VA receives comments,
complaints, or other inquiries related to prosthetics through its Web
site,[Footnote 37] the department directs the information to PSAS's
central office, according to PSAS officials. PSAS's central office
either handles the inquiry directly, or routes it to the relevant
location or service, such as a VISN or VAMC, to resolve. As of July
2010, PSAS central office officials reported that they have responded
to and closed more than 2,085 inquiries received through VA's Web site.
* Direct contact with PSAS staff. PSAS central office, VISNs, and
VAMCs receive letters, in-person visits, and telephone calls from
veterans about complaints or problems with prosthetic items, according
to VA officials we spoke with. If these complaints come in through
contacts with PSAS staff at the central office, VISN, or VAMC
leadership, the complaints or problems are generally passed on to PSAS
staff at the VAMC level for direct action. PSAS officials told us that
it is PSAS's policy to handle complaints and problems in the most
direct manner. For example, in one VAMC we visited, officials said
that when they receive a complaint, they pass it on to the PSAS
purchasing agent responsible for ordering the prosthetic item. The
purchasing agent is then responsible for contacting the patient to
resolve the complaint or problem. PSAS central office officials
reported that while individual VISNs and VAMCs may, to varying
degrees, track patient complaints made in person or by letter or
telephone, PSAS central office does not systematically track these
complaints.
In addition to efforts initiated nationally, some VISNs and VAMCs we
visited reported that they have developed local mechanisms to further
monitor veteran satisfaction with VA's processing and providing
prosthetic items:
* VISN-sponsored surveys. One VISN we visited conducts patient
satisfaction surveys of veterans who receive prosthetic items from the
VAMCs in the VISN. On a quarterly basis, PSAS personnel at the VISN
send these surveys directly to a sample of veterans who have received
prosthetic items requesting veterans to rate aspects of PSAS's
performance such as the quality of the prosthetic items they received,
the instructions they received, the courtesy and knowledge of the
prosthetic staff that they came in contact with, and the time it took
to deliver the prosthetic items. The patients return the surveys to
the VISN, where PSAS staff summarize the results of the surveys and
provide quarterly reports to the prosthetics chiefs and leadership in
each of the VAMCs. The VISN requires prosthetics chiefs at VAMCs with
a patient satisfaction score below the VISN's established goal to
develop improvement plans. VISN PSAS staff told us that the surveys
have enabled them to identify problems and make improvements in how
PSAS staff at the VAMCs interact with veterans, how PSAS staff process
prosthetic prescriptions, and in the timeliness and quality of the
services provided by vendors, such as home oxygen suppliers.
* Vendor evaluation cards. PSAS officials at one VISN reported that
their VISN required some of their vendors--such as vendors for home
oxygen and durable medical equipment--to include a patient comment
card with the delivery of the prosthetic items. Veterans return these
comment cards to the VISN where VISN PSAS officials review the
comments and forward relevant information to VAMC prosthetics offices
on at least a quarterly basis.
* VAMC comment cards. Several VAMCs in our sample provided their own
comment cards. Typically, these cards are or will be made available at
the PSAS counter and waiting area. PSAS officials at these VAMCs told
us that they collect and review the comment cards they receive and
address the comments veterans make concerning VA's processing and
providing of prosthetic items on a case-by-case basis.[Footnote 38]
* Letters informing veterans to expect delivery of prosthetic items.
Officials at two of the five VISNs we visited told us that they use a
feature in PSAS's system for processing prescriptions to generate and
send a letter to a veteran each time a prescription is processed.
These letters provide information such as the date the prosthetic item
was ordered from a vendor, the date the veteran can expect to receive
the prosthetic item, and contact information for the PSAS staff
responsible for monitoring the order.
PSAS officials expressed confidence that, together, the mechanisms
they have in place would alert them of serious timeliness and veteran
satisfaction issues.
VA Is Making Local, Regional, and National Efforts to Improve PSAS's
Performance:
Officials at PSAS's central office, the VISNs, and the VAMCs in our
sample told us about a number of local, regional, and national efforts
to enhance management effectiveness and efficiency and improve
prosthetic services for veterans.
PSAS Staff at Some VA Medical Facilities Have Made Local Improvements
to Enhance Performance:
PSAS staff at the 13 VAMCs in our sample reported that they had
undertaken local efforts to improve performance. For example, PSAS
personnel at one VAMC were working to obtain funding from VA's Office
of Rural Health to place orthotic fitters--technicians who fit
orthoses--at community-based outpatient clinics. By placing fitters in
these clinics, PSAS officials hope to improve access for veterans--for
example, to eliminate the need for veterans to travel for several
hours to a VAMC to be fitted for and obtain their orthotic shoes--as
well as to relieve the workload of prosthetists and orthotists at the
VAMCs in this VISN. In addition, 6 of the 13 VAMCs in our sample had
recently completed renovations, were in the process of renovating, or
were planning renovations of their laboratories and clinical space.
PSAS officials explained that the purpose of these renovations was to
provide greater patient privacy or increase their capacity to
fabricate artificial limbs within the VAMCs. Some officials further
explained that increasing the capacity of their prosthetic
laboratories would allow more veterans to receive their prosthetic
limbs directly from the VA rather than from outside vendors, which
could increase convenience for veterans and reduce costs for VA.
Some VISNs Have Centralized Management of PSAS at the VISN Level:
At the regional level, according to PSAS central officials, 7 of VA's
21 VISNs have chosen to centralize the management of PSAS within the
VISN. Under a centralized PSAS management structure, the VPR is in
charge of managing all aspects of the provision of prosthetic items in
the VAMCs within their VISN, including the hiring and firing of PSAS
personnel such as prosthetics chiefs and purchasing agents, and
resolving veterans' complaints.[Footnote 39] PSAS's central office has
recommended that VISNs adopt this management structure for PSAS for
more than a decade, but as part of VA's overall decentralized
management structure, each VISN's leadership has the authority to
determine how PSAS is managed in its region.
Although PSAS's central office has not collected performance data
conclusively showing the benefits of centralized management, officials
we spoke with identified several potential benefits. PSAS central
office officials stated that a centralized management structure allows
for resource sharing within the VISN--for example, PSAS purchasing
agents at one VAMC performing duties for other VAMCs within the VISN--
and helps ensure greater uniformity of supervision and services. PSAS
and VISN officials at three VISNs we visited that had centralized
management noted that because centralization shifts costs and
decisions related to PSAS personnel from the VAMCs to the VISN, PSAS
avoids competing with other health care services within VAMCs for
staff resources. Officials in two of these VISNs also stressed that
centralization not only improved efficiency by facilitating the
development and implementation of standardized procedures for
processing prosthetic prescriptions across the VISN, but also enhanced
veteran care by moving some of the day-to-day administrative tasks up
to the VISN, thus freeing PSAS staff at the VAMCs to devote more time
to meeting veterans' needs.
While in general, the officials we spoke with--both at PSAS's central
office and at VISNs that had adopted a centralized approach to
managing PSAS--supported centralization, a few VAMC officials in some
centralized VISNs expressed some concerns. For example, VAMC officials
at two VAMCs we visited said that although PSAS was currently meeting
the needs of veterans at their facilities, they were concerned that
under a centralized management structure local leadership might not
have the authority to take appropriate action if the performance of
local PSAS staff was not satisfactory. In addition, one of these
officials noted that under a prior director, centralization had
contributed to a lack of communication between PSAS personnel and VAMC
leadership. Specifically, it was their understanding that, since PSAS
staff reported directly to the VISN rather than the leadership at that
VAMC, the previous VAMC leadership had at times not included PSAS
staff in management meetings and decisions that affected PSAS.
National Efforts Undertaken by PSAS Have Focused on Improving
Consistency of Prosthetic Services across VA:
PSAS has a number of national efforts to improve the delivery of
prosthetic items across VA. These efforts include developing national
contracts, conducting site visits to poorly performing VAMCs,
providing clinical practice recommendations for physicians who
prescribe prosthetic items, obtaining accreditation and certification
for prosthetic laboratories and staff, and training new management
staff.
* National contracts. PSAS uses national contracts that, according to
PSAS officials, provide prosthetic items to veterans across the
country in a more consistent, timely, and cost-efficient manner. PSAS
first used national contracts to purchase prosthetic items in fiscal
year 2002, and in fiscal year 2009, PSAS had 49 national contracts for
prosthetic items ranging from orthopedic shoes and diabetic socks to
implantable joints and cardiac pacemakers. According to PSAS
officials, national contracts can improve efficiency and timeliness
because the specifications, price, and shipping requirements for
prosthetic items are determined by the contract rather than by
individual purchasing agents. These contracts also help ensure that
the quality of the prosthetic items provided to veterans is consistent
across the country. According to PSAS officials, PSAS's use of
national contracts has resulted in substantial cost savings since
fiscal year 2002.
* Site visits. Officials from PSAS central office told us that they
have begun to conduct site visits to review PSAS operations in a
number of VAMCs. Specifically, PSAS officials told us that they are
conducting site visits to identify staffing or other problems that
lead to poor performance and to make recommendations that should lead
to faster and more consistent prosthetic services for veterans at
these facilities. For the initial visits, PSAS selected VAMCs and
VISNs that performed poorly on PSAS's performance measures, such as
its consults pending measure. As of June 2010, PSAS staff had
conducted 42 site visits, and PSAS officials said they plan to conduct
reviews in all 153 VAMCs.
* Clinical practice recommendations. PSAS has developed 40 clinical
practice recommendations, which are guidance documents to help VA
clinical staff make appropriate decisions about prosthetic
prescriptions. These include prescribing recommendations for orthotic
devices, home oxygen equipment, pacemakers, and hip and knee joint
replacements. According to PSAS officials, these recommendations help
ensure that prosthetic items are provided to veterans in a more
consistent manner across the country.[Footnote 40]
* Accreditation and certification. PSAS has implemented an initiative
to provide additional assurance that VA is providing high-quality
prosthetic services and to develop the technical and management skills
of PSAS staff. In fiscal year 2007, PSAS established a policy to
obtain accreditation for its orthotic and prosthetic laboratories, and
certification for all clinical personnel. According to PSAS officials,
as of September 2010, PSAS had obtained accreditation, or the
accreditation was pending, for nearly all of its 77 orthotic and
prosthetic service locations, and certification for 165 of its 172
orthotists, prosthetists, and fitters.
* Management training. PSAS created a technical intern program to
train prospective managers on the operations of PSAS at the VAMC
level. According to VA officials, this program is important because a
large number of the prosthetics chiefs are nearing retirement and in
many cases there are few experienced staff who could replace them.
Agency Comments:
We provided a draft of this report to VA for review. We received
technical comments from VA, which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Veterans
Affairs, appropriate congressional committees, and other interested
parties. In addition, the report will be available at no charge on
GAO's Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or williamsonr@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 II.
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
Appendix I: The Total Costs and Number of Prosthetic Items VA Provided
to Veterans in Fiscal Years 2005 through 2009:
This appendix provides the results of our analysis of data from the
National Prosthetic Patient Database (NPPD)--an internal database used
by the Department of Veterans Affairs (VA) to administer its provision
of prosthetic items that contains information on prosthetic items
furnished to veterans.[Footnote 41] This appendix presents the total
costs and number of prosthetic items provided to veterans in fiscal
years 2005 through 2009.[Footnote 42]
* Table 3 shows the total costs and number of prosthetic items
provided to veterans by type of prosthetic item. For fiscal year 2009,
the total cost for various types of prosthetic items ranged from about
$93 million for orthoses to about $439 million for surgical implants.
* Table 4 shows the total costs and number of prosthetic items
provided to veterans by Veterans Integrated Service Network (VISN).
[Footnote 43] For fiscal year 2009, the total costs for prosthetic
items for VISNs ranged from about $34 million in VISN 5 (Capitol
Health Care Network) to about $164 million in VISN 8 (VA Sunshine
Healthcare Network).
* Table 5 shows the total costs and number of prosthetic items
provided to veterans by VA station.[Footnote 44] For fiscal year 2009,
the total costs of prosthetic items at individual stations that
provided any prosthetic items ranged from less than $1 million at
Pittsburgh HCS-Highland Dr., Chattanooga, and several other stations
to about $39 million at the San Antonio VAMC.
Table 3: Total Costs and Number of Prosthetic Items VA Provided to
Veterans by Type of Prosthetic Item, Fiscal Years 2005 through 2009:
Dollars in millions and items in thousands:
Prosthetic item type: Accessibility items--scooters and accessories,
standard, motorized, and custom-built wheelchairs and accessories;
Dollars spent (number of items provided):
2005[A]: $125 (311);
2006[A]: $130 (364);
2007[A]: $140 (407);
2008: $163 (482);
2009: $180 (519);
Total[B]: $738 (2,083).
Prosthetic item type: Artificial limbs--artificial arms and legs;
Dollars spent (number of items provided):
2005[A]: $67 (161);
2006[A]: $73 (92);
2007[A]: $81 (93);
2008: $96 (100);
2009: $98 (102);
Total[B]: $414 (548).
Prosthetic item type: Medical equipment--computer equipment, hospital
beds and accessories, patient lifts, recreational equipment, (e.g.,
hand cycles), telehealth equipment, and walking aids;
Dollars spent (number of items provided):
2005[A]: $97 (1,148);
2006[A]: $117 (1,269);
2007[A]: $148 (1,542);
2008: $186 (1,852);
2009: $233 (2,209);
Total[B]: $781 (8,020).
Prosthetic item type: Other--home dialysis equipment and supplies,
Home Improvement and Structural Alteration grants, home oxygen
equipment and supplies, restorations (e.g., breast, eye, and facial);
Dollars spent (number of items provided):
2005[A]: $194 (12,492);
2006[A]: $205 (12,404);
2007[A]: $230 (13,000);
2008: $274 (46,569);
2009: $302 (51,826);
Total[B]: $1,205 136,292).
Prosthetic item type: Orthoses--ankle, knee, leg, spinal, and other
braces; arch supports; shoe inserts; and shoes;
Dollars spent (number of items provided):
2005[A]: $58 (1,059);
2006[A]: $60 (1,052);
2007[A]: $66 (1,155);
2008: $79 (1,320);
2009: $93 (1,470);
Total[B]: $355 (6,055).
Prosthetic item type: Sensori-neuro aids--blind aids, eyeglasses,
contact lenses, hearing aids, and speech devices;
Dollars spent (number of items provided):
2005[A]: $54 (953);
2006[A]: $56 (1,122);
2007[A]: $62 (1,050);
2008: $219 (2,003);
2009: $278 (2,664);
Total[B]: $669 (7,792).
Prosthetic item type: Surgical implants--anchors, plates, and screws;
biological implants (e.g., bone and tissue grafts); dental implants;
implantable cardioverter defibrillators and leads; pacemakers; and
stents;
Dollars spent (number of items provided):
2005[A]: $312 (247);
2006[A]: $341 (229);
2007[A]: $355 (242);
2008: $387 (270);
2009: $439 (313);
Total[B]: $1,834 (1,300).
Prosthetic item type: Total[B];
Dollars spent (number of items provided):
2005[A]: $907 (16,371);
2006[A]: $980 (16,531);
2007[A]: $1,082 (17,490);
2008: $1,404 (52,596);
2009: $1,623 (59,103);
Total[B]: $5,996 162,090).
Source: GAO analysis of VA data.
Notes: Data for this table were obtained from VA's National Prosthetic
Patient Database (NPPD)--an internal system used by VA to administer
the department's provision of prosthetic items. Data on total
obligations for prosthetic items from NPPD are different from the
obligation data we used to report VA's annual spending for prosthetic
items in the body of our report. The data on spending represent
obligations for the procurement of prosthetic items during the course
of a fiscal year, while NPPD data represent obligations that VA has
incurred for prosthetic items actually provided to veterans during a
fiscal year. In some instances, there may be a delay between when VA
procures a prosthetic item and when the item is provided to the
veteran. For example, VA may incur an obligation for the procurement
of prosthetic items for PSAS inventory in one fiscal year, and
distribute the inventoried prosthetic items to veterans in the next
fiscal year.
[A] Prior to fiscal year 2008, VA's NPPD did not contain data related
to hearing aids, hearing aid batteries, and several other prosthetic
devices included in the "other" and "sensori-neuro aids" categories.
As a result, these items are not included for fiscal years 2005
through 2007. According to a VA official, VA spent $145 million, $140
million, and $140 million for these items during fiscal years 2005,
2006, and 2007, respectively.
[B] Amounts for fiscal years and types may not sum to totals due to
rounding.
[End of table]
Table 4: Total Costs and Number of Prosthetic Items Provided to
Veterans by Veterans Integrated Service Network (VISN), Fiscal Years
2005 through 2009:
Dollars in millions and items in thousands.
VISN[A]: 1;
VISN name: New England Healthcare System;
Dollars spent (number of items provided:
2005[B]: $39 (2,083);
2006[B]: $41 (2,028);
2007[B]: $47 (2,033);
2008: $58 (3,599);
2009: $66 (3,857);
Total [B]: $251 (13,600).
VISN[A]: 2;
VISN name: VA Healthcare Network Upstate New York;
Dollars spent (number of items provided:
2005[B]: $23 (240);
2006[B]: $24 (239);
2007[B]: $26 (254);
2008: $32 (978);
2009: $38 (1,110);
Total [B]: $142 (2,821).
VISN[A]: 3;
VISN name: VA New York/New Jersey Veterans Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $28 (410);
2006[B]: $31 (548);
2007[B]: $34 (555);
2008: $43 (1,742);
2009: $50 (1,946);
Total [B]: $186 (5,201).
VISN[A]: 4;
VISN name: Stars and Stripes Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $44 (1,563);
2006[B]: $48 (1,687);
2007[B]: $50 (1,709);
2008: $69 (4,129);
2009: $76 (4,490);
Total [B]: $287 (13,578).
VISN[A]: 5;
VISN name: Capitol Health Care Network;
Dollars spent (number of items provided:
2005[B]: $20 (633);
2006[B]: $24 (540);
2007[B]: $24 (493);
2008: $29 (1,081);
2009: $34 (1,182);
Total [B]: $133 (3,929).
VISN[A]: 6;
VISN name: The Mid-Atlantic Network;
Dollars spent (number of items provided:
2005[B]: $55 (550);
2006[B]: $52 (555);
2007[B]: $63 (688);
2008: $85 (2,126);
2009: $102 (2,508);
Total [B]: $357 (6,426).
VISN[A]: 7;
VISN name: The Atlanta Network;
Dollars spent (number of items provided:
2005[B]: $59 (811);
2006[B]: $62 (756);
2007[B]: $72 (922);
2008: $97 (2,663);
2009: $108 (2,931);
Total [B]: $399 (8,082).
VISN[A]: 8;
VISN name: VA Sunshine Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $90 (1,855);
2006[B]: $100 (1,910);
2007[B]: $109 (1,784);
2008: $143 (5,862);
2009: $164 (6,430);
Total [B]: $607 (17,840).
VISN[A]: 9;
VISN name: Mid South Veterans Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $48 (668);
2006[B]: $54 (645);
2007[B]: $59 (673);
2008: $74 (2,390);
2009: $83 (2,694);
Total [B]: $317 (7,071).
VISN[A]: 10;
VISN name: VA Healthcare System of Ohio;
Dollars spent (number of items provided:
2005[B]: $24 (341);
2006[B]: $29 (386);
2007[B]: $34 (404);
2008: $47 (1,813);
2009: $60 (2,237);
Total [B]: $194 (5,180).
VISN[A]: 11;
VISN name: Veterans Integrated Service Network;
Dollars spent (number of items provided:
2005[B]: $34 (507);
2006[B]: $38 (452);
2007[B]: $43 (469);
2008: $56 (1,823);
2009: $67 (2,218);
Total [B]: $239 (5,471).
VISN[A]: 12;
VISN name: The Great Lakes Health Care System;
Dollars spent (number of items provided:
2005[B]: $36 (893);
2006[B]: $38 (826);
2007[B]: $42 (830);
2008: $52 (1,859);
2009: $58 (1,998);
Total [B]: $226 (6,407).
VISN[A]: 15;
VISN name: VA Heartland Network;
Dollars spent (number of items provided:
2005[B]: $37 (504);
2006[B]: $42 (465);
2007[B]: $48 (487);
2008: $60 (1,760);
2009: $70 (1,952);
Total [B]: $257 (5,168).
VISN[A]: 16;
VISN name: South Central Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $77 (772);
2006[B]: $80 (773);
2007[B]: $88 (848);
2008: $115 (3,788);
2009: $131 (4,276);
Total [B]: $491 (10,457).
VISN[A]: 17;
VISN name: VA Heart of Texas Health Care Network;
Dollars spent (number of items provided:
2005[B]: $50 (725);
2006[B]: $58 (763);
2007[B]: $61 (795);
2008: $80 (2,036);
2009: $90 (2,049);
Total [B]: $339 (6,368).
VISN[A]: 18;
VISN name: VA Southwest Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $39 (1,654);
2006[B]: $45 (1,765);
2007[B]: $46 (1,912);
2008: $59 (2,925);
2009: $70 (3,267);
Total [B]: $258 (11,523).
VISN[A]: 19;
VISN name: Rocky Mountain Network;
Dollars spent (number of items provided:
2005[B]: $40 (285);
2006[B]: $43 (314);
2007[B]: $47 (348);
2008: $59 (2,739);
2009: $67 (3,416);
Total [B]: $257 (7,102).
VISN[A]: 20;
VISN name: Northwest Network;
Dollars spent (number of items provided:
2005[B]: $38 (343);
2006[B]: $41 (338);
2007[B]: $46 (367);
2008: $59 (2,189);
2009: $66 (2,372);
Total [B]: $250 (5,609).
VISN[A]: 21;
VISN name: Sierra Pacific Network;
Dollars spent (number of items provided:
2005[B]: $38 (232);
2006[B]: $40 (283);
2007[B]: $45 (300);
2008: $58 (1,520);
2009: $71 (1,751);
Total [B]: $253 (4,085).
VISN[A]: 22;
VISN name: Desert Pacific Healthcare Network;
Dollars spent (number of items provided:
2005[B]: $47 (275);
2006[B]: $47 (280);
2007[B]: $50 (648);
2008: $64 (2,329);
2009: $71 (2,771);
Total [B]: $279 (6,303).
VISN[A]: 23;
VISN name: Minneapolis & Lincoln Offices;
Dollars spent (number of items provided:
2005[B]: $40 (1,027);
2006[B]: $44 (976);
2007[B]: $48 (971);
2008: $66 (3,245);
2009: $77 (3,649);
Total [B]: $276 (9,868).
VISN name: : Total[C];
Dollars spent (number of items provided:
2005[B]: $907 (16,371);
2006[B]: $980 (16,531);
2007[B]: $1,082 (17,490);
2008: $1,404 (52,596);
2009: $1,623 (59,103);
Total [B]: $5,996 162,090).
Source: GAO analysis of VA data.
Note: Data for this table were obtained from VA's National Prosthetic
Patient Database (NPPD)--an internal system used by VA to administer
the department's provision of prosthetic items. Data on total
obligations for prosthetic items from NPPD are different from the
obligation data we used to report VA's annual spending for prosthetic
items in the body of our report. The data on spending represent
obligations for the procurement of prosthetic items during the course
of a fiscal year, while NPPD data represent obligations that VA has
incurred for prosthetic items actually provided to veterans during a
fiscal year. In some instances, there may be a delay between when VA
procures a prosthetic item and when the item is provided to the
veteran. For example, VA may incur an obligation for the procurement
of prosthetic items for PSAS inventory in one fiscal year, and
distribute the inventoried prosthetic items to veterans in the next
fiscal year.
[A] VISNs 13 and 14 were consolidated and designated as VISN 23 in
January 2002.
[B] Prior to fiscal year 2008, VA's NPPD did not contain data related
to hearing aids, hearing aid batteries, and several other prosthetic
devices. As a result, these items are not included for fiscal years
2005 through 2007. According to a VA official, VA spent $145 million,
$140 million, and $140 million for these items during fiscal years
2005, 2006, and 2007, respectively.
[C] Amounts for fiscal years and VISNs may not sum to totals due to
rounding:
[End of table]
Table 5: Total Costs and the Number of Prosthetic Items Provided to
Veterans by VA Station, Fiscal Years 2005 through 2009:
Dollars in millions and items in thousands:
VISN: 1;
Station[A]: Bedford;
Dollars spent (number of items provided):
2005[B]: $1 (90);
2006[B]: $1 (112);
2007[B]: $1 (103);
2008: $1 (127);
2009: $1 (134);
Total[C]: $5 (565).
VISN: 1;
Station[A]: Manchester;
Dollars spent (number of items provided):
2005[B]: $2 (88);
2006[B]: $2 (143);
2007[B]: $3 (165);
2008: $3 (312);
2009: $5 (359);
Total[C]: $15 (1,067).
VISN: 1;
Station[A]: Newington Campus;
Dollars spent (number of items provided):
2005[B]: $1 (14);
2006[B]: $2 (16);
2007[B]: $2 (17);
2008: $2 (15);
2009: $2 (15);
Total[C]: $9 (77).
VISN: 1;
Station[A]: Northampton;
Dollars spent (number of items provided):
2005[B]: $1 (119);
2006[B]: $1 (114);
2007[B]: $1 (110);
2008: $2 (155);
2009: $3 (193);
Total[C]: $9 (691).
VISN: 1;
Station[A]: Providence;
Dollars spent (number of items provided):
2005[B]: $3 (177);
2006[B]: $3 (177);
2007[B]: $4 (180);
2008: $5 (205);
2009: $7 (278);
Total[C]: $23 (1,018).
VISN: 1;
Station[A]: Togus;
Dollars spent (number of items provided):
2005[B]: $6 (203);
2006[B]: $6 (271);
2007[B]: $7 (295);
2008: $9 (596);
2009: $10 (625);
Total[C]: $38 (1,991).
VISN: 1;
Station[A]: VA Boston HCS-Boston Div.;
Dollars spent (number of items provided):
2005[B]: $6 (968);
2006[B]: $6 (674);
2007[B]: $7 (662);
2008: $10 (1,139);
2009: $10 (1,052);
Total[C]: $40 (4,495).
VISN: 1;
Station[A]: VA Boston HCS-West Roxbury Div.;
Dollars spent (number of items provided):
2005[B]: $8 (8);
2006[B]: $8 (9);
2007[B]: $9 (11);
2008: $8 (13);
2009: 8 (21);
Total[C]: $41 (62).
VISN: 1;
Station[A]: West Haven Campus;
Dollars spent (number of items provided):
2005[B]: $7 (371);
2006[B]: $9 (468);
2007[B]: $10 (439);
2008: $11 (813);
2009: $13 (893);
Total[C]: $50 (2,984).
VISN: 1;
Station[A]: White River Jct.;
Dollars spent (number of items provided):
2005[B]: $3 (44);
2006[B]: $3 (44);
2007[B]: $3 (50);
2008: $5 (224);
2009: $6 (287);
Total[C]: $20 (650).
VISN: 2;
Station[A]: Albany;
Dollars spent (number of items provided):
2005[B]: $4 (49);
2006[B]: $4 (43);
2007[B]: $4 (44);
2008: $5 (46);
2009: $6 (53);
Total[C]: $23 (235).
VISN: 2;
Station[A]: Bath;
Dollars spent (number of items provided):
2005[B]: $1 (19);
2006[B]: $1 (19);
2007[B]: $1 (21);
2008: $2 (25);
2009: $2 (30);
Total[C]: $8 (115).
VISN: 2;
Station[A]: Canandaigua;
Dollars spent (number of items provided):
2005[B]: $1 (11);
2006[B]: $1 (11);
2007[B]: $1 (13);
2008: $1 (13);
2009: $1 (15);
Total[C]: $5 (63).
VISN: 2;
Station[A]: Rochester;
Dollars spent (number of items provided):
2005[B]: $1 (13);
2006[B]: $1 (13);
2007[B]: $1 (15);
2008: $2 (15);
2009: $2 (18);
Total[C]: $7 (75).
VISN: 2;
Station[A]: Syracuse;
Dollars spent (number of items provided):
2005[B]: $7 (79);
2006[B]: $8 (83);
2007[B]: $10 (90);
2008: $11 (97);
2009: $12 (113);
Total[C]: $47 (462).
VISN: 2;
Station[A]: Upstate New York HCS;
Dollars spent (number of items provided):
2005[B]: $9 (68);
2006[B]: $9 (70);
2007[B]: $8 (71);
2008: $13 (781);
2009: $15 (881);
Total[C]: $54 (1,871).
VISN: 3;
Station[A]: Bronx;
Dollars spent (number of items provided):
2005[B]: $4 (34);
2006[B]: $5 (156);
2007[B]: $5 (52);
2008: $6 (59);
2009: $7 (66);
Total[C]: $27 (367).
VISN: 3;
Station[A]: Castle Point Division-Hudson Valley HCS-;
Dollars spent (number of items provided):
2005[B]: $2 (37);
2006[B]: $2 (42);
2007[B]: $2 (41);
2008: $2 (41);
2009: $2 (52);
Total[C]: $10 (214).
VISN: 3;
Station[A]: Hudson Valley HCS;
Dollars spent (number of items provided):
2005[B]: Less than $1 (6);
2006[B]: Less than $1 (7);
2007[B]: $1 (12);
2008: $1 (12);
2009: $1 (12);
Total[C]: $3 (48).
VISN: 3;
Station[A]: Lyons;
Dollars spent (number of items provided):
2005[B]: Less than $1 (7);
2006[B]: Less than $1 (5);
2007[B]: Less than $1 (10);
2008: Less than $1 (7);
2009: $0 (0);
Total[C]: $1 (29).
VISN: 3;
Station[A]: New Jersey HCS;
Dollars spent (number of items provided):
2005[B]: $5 (78);
2006[B]: $5 (105);
2007[B]: $6 (155);
2008: $7 (186);
2009: $8 (217);
Total[C]: $30 (743).
VISN: 3;
Station[A]: New York Harbor HCS-NY Div.;
Dollars spent (number of items provided):
2005[B]: $9 (63);
2006[B]: $9 (67);
2007[B]: $10 (71);
2008: $15 (1,218);
2009: $17 (1,348);
Total[C]: $59 (2,767).
VISN: 3;
Station[A]: New York Harbor HCS-Brooklyn-Poly Pl. Campus;
Dollars spent (number of items provided):
2005[B]: $4 (67);
2006[B]: $4 (78);
2007[B]: $4 (107);
2008: $6 (117);
2009: $7 (126);
Total[C]: $26 (496).
VISN: 3;
Station[A]: Northport;
Dollars spent (number of items provided):
2005[B]: $5 (117);
2006[B]: $5 (88);
2007[B]: $6 (105);
2008: $6 (102);
2009: $8 (126);
Total[C]: $30 (538).
VISN: 4;
Station[A]: Butler;
Dollars spent (number of items provided):
2005[B]: $1 (15);
2006[B]: $2 (16);
2007[B]: $2 (18);
2008: $3 (205);
2009: $3 (212);
Total[C]: $11 (466).
VISN: 4;
Station[A]: Clarksburg;
Dollars spent (number of items provided):
2005[B]: $2 (23);
2006[B]: $3 (59);
2007[B]: $3 (75);
2008: $4 (244);
2009: $5 (249);
Total[C]: $18 (650).
VISN: 4;
Station[A]: Coatesville;
Dollars spent (number of items provided):
2005[B]: $1 (12);
2006[B]: $1 (53);
2007[B]: $1 (58);
2008: $3 (322);
2009: $3 (316);
Total[C]: $9 (760).
VISN: 4;
Station[A]: Erie;
Dollars spent (number of items provided):
2005[B]: $2 (34);
2006[B]: $2 (42);
2007[B]: $3 (55);
2008: $4 (274);
2009: $4 (303);
Total[C]: $16 (708).
VISN: 4;
Station[A]: James E. Van Zandt VA (Altoona);
Dollars spent (number of items provided):
2005[B]: $2 (223);
2006[B]: $2 (221);
2007[B]: $2 (189);
2008: $3 (353);
2009: $4 (377);
Total[C]: $12 (1,364).
VISN: 4;
Station[A]: Lebanon;
Dollars spent (number of items provided):
2005[B]: $4 (453);
2006[B]: $5 (463);
2007[B]: $5 (414);
2008: $7 (868);
2009: $9 (909);
Total[C]: $30 (3,108).
VISN: 4;
Station[A]: Philadelphia;
Dollars spent (number of items provided):
2005[B]: $10 (42);
2006[B]: $10 (47);
2007[B]: $10 (107);
2008: $12 (349);
2009: $13 (400);
Total[C]: $55 (946).
VISN: 4;
Station[A]: Pittsburgh HCS-Highland Dr.;
Dollars spent (number of items provided):
2005[B]: $0 (0);
2006[B]: Less than $1 (2);
2007[B]: Less than $1 (1);
2008: $0 (0);
2009: Less than $1 (1);
Total[C]: $1 (4).
VISN: 4;
Station[A]: Pittsburgh HCS-University Dr.;
Dollars spent (number of items provided):
2005[B]: $15 (702);
2006[B]: $15 (721);
2007[B]: $16 (727);
2008: $21 (1,121);
2009: $23 (1,313);
Total[C]: $88 (4,584).
VISN: 4;
Station[A]: Wilkes Barre;
Dollars spent (number of items provided):
2005[B]: $5 (37);
2006[B]: $5 (41);
2007[B]: $5 (42);
2008: $7 (278);
2009: $8 (279);
Total[C]: $29 (677).
VISN: 4;
Station[A]: Wilmington;
Dollars spent (number of items provided):
2005[B]: $2 (21);
2006[B]: $3 (21);
2007[B]: $3 (22);
2008: $4 (115);
2009: $5 (131);
Total[C]: $16 (310).
VISN: 5;
Station[A]: Baltimore;
Dollars spent (number of items provided):
2005[B]: $7 (377);
2006[B]: $7 (259);
2007[B]: $7 (225);
2008: $8 (348);
2009: $11 (418);
Total[C]: $40 (1,626).
VISN: 5;
Station[A]: Fort Howard;
Dollars spent (number of items provided):
2005[B]: Less than $1 (6);
2006[B]: Less than $1 (6);
2007[B]: Less than $1 (6);
2008: Less than $1 (5);
2009: $1 (12);
Total[C]: $3 (34).
VISN: 5;
Station[A]: Martinsburg;
Dollars spent (number of items provided):
2005[B]: $4 (104);
2006[B]: $5 (105);
2007[B]: $5 (111);
2008: $6 (332);
2009: $7 (338);
Total[C]: $26 (990).
VISN: 5;
Station[A]: Perry Point;
Dollars spent (number of items provided):
2005[B]: $1 (5);
2006[B]: $1 (6);
2007[B]: $2 (9);
2008: $3 (12);
2009: $2 (14);
Total[C]: $8 (46).
VISN: 5;
Station[A]: Washington;
Dollars spent (number of items provided):
2005[B]: $8 (141);
2006[B]: $11 (165);
2007[B]: $9 (143);
2008: $13 (384);
2009: $14 (399);
Total[C]: $56 (1,232).
VISN: 6;
Station[A]: Asheville-Oteen;
Dollars spent (number of items provided):
2005[B]: $5 (83);
2006[B]: $6 (95);
2007[B]: $8 (109);
2008: $11 (278);
2009: $14 (300);
Total[C]: $45 (865).
VISN: 6;
Station[A]: Beckley;
Dollars spent (number of items provided):
2005[B]: $2 (53);
2006[B]: $3 (49);
2007[B]: $3 (58);
2008: $5 (251);
2009: $5 (262);
Total[C]: $17 (673).
VISN: 6;
Station[A]: Durham;
Dollars spent (number of items provided):
2005[B]: $17 (83);
2006[B]: $13 (63);
2007[B]: $15 (91);
2008: $20 (276);
2009: $25 (359);
Total[C]: $90 (872).
VISN: 6;
Station[A]: Fayetteville NC;
Dollars spent (number of items provided):
2005[B]: $3 (66);
2006[B]: $3 (66);
2007[B]: $4 (74);
2008: $7 (233);
2009: $8 (272);
Total[C]: $26 (712).
VISN: 6;
Station[A]: Hampton;
Dollars spent (number of items provided):
2005[B]: $4 (51);
2006[B]: $4 (60);
2007[B]: $5 (79);
2008: $5 (181);
2009: $7 (214);
Total[C]: $24 (585).
VISN: 6;
Station[A]: Richmond;
Dollars spent (number of items provided):
2005[B]: $13 (88);
2006[B]: $12 (78);
2007[B]: $14 (81);
2008: $17 (254);
2009: $19 (296);
Total[C]: $74 (796).
VISN: 6;
Station[A]: Salem;
Dollars spent (number of items provided):
2005[B]: $5 (61);
2006[B]: $5 (63);
2007[B]: $7 (86);
2008: $9 (197);
2009: $10 (240);
Total[C]: $35 (648).
VISN: 6;
Station[A]: W.G. (Bill) Hefner Salisbury VAMC;
Dollars spent (number of items provided):
2005[B]: $6 (66);
2006[B]: $6 (80);
2007[B]: $8 (109);
2008: $11 (456);
2009: $14 (565);
Total[C]: $44 (1,276).
VISN: 7;
Station[A]: Augusta;
Dollars spent (number of items provided):
2005[B]: $10 (82);
2006[B]: $11 (97);
2007[B]: $13 (122);
2008: $18 (409);
2009: $19 (444);
Total[C]: $71 (1,153).
VISN: 7;
Station[A]: Birmingham;
Dollars spent (number of items provided):
2005[B]: $11 (161);
2006[B]: $11 (108);
2007[B]: $12 (181);
2008: $16 (475);
2009: $18 (537);
Total[C]: $69 (1,462).
VISN: 7;
Station[A]: Charleston;
Dollars spent (number of items provided):
2005[B]: $7 (55);
2006[B]: $8 (61);
2007[B]: $9 (69);
2008: $12 (177);
2009: $13 (193);
Total[C]: $49 (555).
VISN: 7;
Station[A]: Columbia;
Dollars spent (number of items provided):
2005[B]: $8 (98);
2006[B]: $8 (92);
2007[B]: $11 (108);
2008: $14 (314);
2009: $17 (361);
Total[C]: $59 (972).
VISN: 7;
Station[A]: Decatur;
Dollars spent (number of items provided):
2005[B]: $13 (253);
2006[B]: $13 (235);
2007[B]: $15 (288);
2008: $22 (738);
2009: $23 (793);
Total[C]: $86 (2,307).
VISN: 7;
Station[A]: Dublin;
Dollars spent (number of items provided):
2005[B]: $3 (39);
2006[B]: $3 (47);
2007[B]: $5 (56);
2008: $6 (62);
2009: $7 (77);
Total[C]: $24 (281).
VISN: 7;
Station[A]: Montgomery;
Dollars spent (number of items provided):
2005[B]: $5 (86);
2006[B]: $5 (79);
2007[B]: $5 (59);
2008: $7 (343);
2009: $7 (376);
Total[C]: $28 (942).
VISN: 7;
Station[A]: Tuscaloosa;
Dollars spent (number of items provided):
2005[B]: $2 (37);
2006[B]: $2 (37);
2007[B]: $2 (40);
2008: $3 (146);
2009: $4 (150);
Total[C]: $13 (411).
VISN: 8;
Station[A]: Bay Pines;
Dollars spent (number of items provided):
2005[B]: $9 (155);
2006[B]: $11 (163);
2007[B]: $12 (177);
2008: $16 (902);
2009: $19 (973);
Total[C]: $67 (2,370).
VISN: 8;
Station[A]: Broward County;
Dollars spent (number of items provided):
2005[B]: $0 (0);
2006[B]: $0 (0);
2007[B]: $0 (0);
2008: $1 (18);
2009: $1 (12);
Total[C]: $2 (30).
VISN: 8;
Station[A]: Daytona Beach;
Dollars spent (number of items provided):
2005[B]: $1 (10);
2006[B]: $1 (51);
2007[B]: $1 (71);
2008: $1 (68);
2009: $1 (84);
Total[C]: $5 (284).
VISN: 8;
Station[A]: Ft. Myers;
Dollars spent (number of items provided):
2005[B]: $2 (14);
2006[B]: $1 (12);
2007[B]: $2 (14);
2008: $2 (16);
2009: $2 (21);
Total[C]: $8 (78).
VISN: 8;
Station[A]: Jacksonville;
Dollars spent (number of items provided):
2005[B]: $1 (11);
2006[B]: $1 (16);
2007[B]: $2 (17);
2008: $2 (19);
2009: $3 (24);
Total[C]: $9 (88).
VISN: 8;
Station[A]: Leesburg (Lake County);
Dollars spent (number of items provided):
2005[B]: $0 (0);
2006[B]: Less than $1 (1);
2007[B]: Less than $1 (1);
2008: Less than $1 (1);
2009: Less than $1 (1);
Total[C]: Less than $1 (3).
VISN: 8;
Station[A]: Mayaguez;
Dollars spent (number of items provided):
2005[B]: $0 (0);
2006[B]: $0 (0);
2007[B]: $0 (0);
2008: Less than $1 (7);
2009: Less than $1 (8);
Total[C]: Less than $1 (15).
VISN: 8;
Station[A]: Miami;
Dollars spent (number of items provided):
2005[B]: $10 (179);
2006[B]: $11 (216);
2007[B]: $11 (182);
2008: $14 (685);
2009: $16 (743);
Total[C]: $63 (2,006).
VISN: 8;
Station[A]: North Florida/South Georgia HCS-Gainesville;
Dollars spent (number of items provided):
2005[B]: $17 (525);
2006[B]: $20 (503);
2007[B]: $22 (427);
2008: $27 (1,150);
2009: $31 (1,316);
Total[C]: $117 (3,921).
VISN: 8;
Station[A]: North Florida/South Georgia HCS-Lake City;
Dollars spent (number of items provided):
2005[B]: $4 (183);
2006[B]: $4 (158);
2007[B]: $4 (158);
2008: $6 (210);
2009: $6 (274);
Total[C]: $24 (982).
VISN: 8;
Station[A]: Oakland Park;
Dollars spent (number of items provided):
2005[B]: $1 (18);
2006[B]: $1 (14);
2007[B]: $1 (16);
2008: $0 (0);
2009: $0 (0);
Total[C]: $3 (48).
VISN: 8;
Station[A]: Orlando;
Dollars spent (number of items provided):
2005[B]: $4 (109);
2006[B]: $4 (99);
2007[B]: $5 (79);
2008: $5 (115);
2009: $6 (133);
Total[C]: $25 (534).
VISN: 8;
Station[A]: Ponce;
Dollars spent (number of items provided):
2005[B]: $0 (0);
2006[B]: $0 (0);
2007[B]: $0 (0);
2008: Less than $1 (11);
2009: Less than $1 (13);
Total[C]: $1 (24).
VISN: 8;
Station[A]: San Juan;
Dollars spent (number of items provided):
2005[B]: $11 (145);
2006[B]: $12 (147);
2007[B]: $13 (172);
2008: $17 (418);
2009: $18 (464);
Total[C]: $71 (1,345).
VISN: 8;
Station[A]: Tallahassee;
Dollars spent (number of items provided):
2005[B]: Less than $1 (7);
2006[B]: Less than $1 (9);
2007[B]: Less than $1 (10);
2008: $1 (17);
2009: $1 (16);
Total[C]: $3 (58).
VISN: 8;
Station[A]: Tampa;
Dollars spent (number of items provided):
2005[B]: $20 (244);
2006[B]: $22 (260);
2007[B]: $23 (192);
2008: $33 (1,353);
2009: $38 (1,416);
Total[C]: $138 (3,465).
VISN: 8;
Station[A]: Viera;
Dollars spent (number of items provided):
2005[B]: $1 (45);
2006[B]: $2 (38);
2007[B]: $2 (29);
2008: $2 (30);
2009: $2 (31);
Total[C]: $10 (173).
VISN: 8;
Station[A]: W Palm Beach;
Dollars spent (number of items provided):
2005[B]: $8 (198);
2006[B]: $9 (213);
2007[B]: $10 (229);
2008: $15 (830);
2009: $18 (890);
Total[C]: $60 (2,360).
VISN: 8;
Station[A]: Zephyrhills;
Dollars spent (number of items provided):
2005[B]: $1 (10);
2006[B]: $1 (10);
2007[B]: $1 (11);
2008: $1 (13);
2009: $1 (12);
Total[C]: $4 (55).
VISN: 9;
Station[A]: Chattanooga;
Dollars spent (number of items provided):
2005[B]: Less than $1 (3);
2006[B]: Less than $1 (4);
2007[B]: Less than $1 (4);
2008: Less than $1 (3);
2009: Less than $1 (4);
Total[C]: $1 (19).
VISN: 9;
Station[A]: Huntington;
Dollars spent (number of items provided):
2005[B]: $4 (85);
2006[B]: $5 (52);
2007[B]: $6 (60);
2008: $8 (227);
2009: $9 (265);
Total[C]: $32 (689).
VISN: 9;
Station[A]: Knoxville;
Dollars spent (number of items provided):
2005[B]: $1 (10);
2006[B]: $2 (9);
2007[B]: $2 (10);
2008: Less than $1 (5);
2009: Less than $1 (9);
Total[C]: $6 (42).
VISN: 9;
Station[A]: Lexington-Cooper Dr.;
Dollars spent (number of items provided):
2005[B]: $0 (0);
2006[B]: $0 (0);
2007[B]: $0 (0);
2008: $0 (0);
2009: $11 (74);
Total[C]: $11 (74).
VISN: 9;
Station[A]: Lexington-Leestown;
Dollars spent (number of items provided):
2005[B]: $8 (50);
2006[B]: $8 (48);
2007[B]: $9 (59);
2008: $12 (280);
2009: $2 (248);
Total[C]: $39 (684).
VISN: 9;
Station[A]: Louisville;
Dollars spent (number of items provided):
2005[B]: $7 (72);
2006[B]: $8 (59);
2007[B]: $9 (53);
2008: $12 (389);
2009: $12 (410);
Total[C]: $48 (983).
VISN: 9;
Station[A]: Memphis;
Dollars spent (number of items provided):
2005[B]: $8 (87);
2006[B]: $9 (96);
2007[B]: $10 (89);
2008: $12 (343);
2009: $13 (375);
Total[C]: $52 (991).
VISN: 9;
Station[A]: Middle Tennessee HCS;
Dollars spent (number of items provided):
2005[B]: $14 (198);
2006[B]: $16 (196);
2007[B]: $16 (205);
2008: $21 (662);
2009: $25 (743);
Total[C]: $91 (2,005).
VISN: 9;
Station[A]: Mountain Home;
Dollars spent (number of items provided):
2005[B]: $5 (163);
2006[B]: $6 (182);
2007[B]: $7 (193);
2008: $9 (481);
2009: $11 (566);
Total[C]: $38 (1,584).
VISN: 10;
Station[A]: Chillicothe;
Dollars spent (number of items provided):
2005[B]: $1 (30);
2006[B]: $1 (31);
2007[B]: $2 (33);
2008: $3 (150);
2009: $3 (183);
Total[C]: $10 (427).
VISN: 10;
Station[A]: Cincinnati;
Dollars spent (number of items provided):
2005[B]: $5 (80);
2006[B]: $6 (132);
2007[B]: $6 (129);
2008: $10 (333);
2009: $13 (397);
Total[C]: $41 (1,071).
VISN: 10;
Station[A]: Cleveland-Wade Park;
Dollars spent (number of items provided):
2005[B]: $11 (119);
2006[B]: $14 (134);
2007[B]: $17 (149);
2008: $21 (725);
2009: $26 (953);
Total[C]: $90 (2,079).
VISN: 10;
Station[A]: Columbus;
Dollars spent (number of items provided):
2005[B]: $2 (35);
2006[B]: $2 (38);
2007[B]: $3 (48);
2008: $5 (231);
2009: $7 (275);
Total[C]: $20 (626).
VISN: 10;
Station[A]: Dayton;
Dollars spent (number of items provided):
2005[B]: $4 (78);
2006[B]: $5 (50);
2007[B]: $5 (45);
2008: $8 (375);
2009: $11 (430);
Total[C]: $32 (977).
VISN: 11;
Station[A]: Ann Arbor HCS;
Dollars spent (number of items provided):
2005[B]: $7 (48);
2006[B]: $9 (51);
2007[B]: $10 (60);
2008: $12 (309);
2009: $16 (369);
Total[C]: $53 (837).
VISN: 11;
Station[A]: Battle Creek;
Dollars spent (number of items provided):
2005[B]: $2 (37);
2006[B]: $2 (40);
2007[B]: $3 (45);
2008: $4 (201);
2009: $6 (235);
Total[C]: $17 (559).
VISN: 11;
Station[A]: Detroit (John D. Dingell);
Dollars spent (number of items provided):
2005[B]: $5 (68);
2006[B]: $6 (65);
2007[B]: $6 (78);
2008: $6 (248);
2009: $7 (287);
Total[C]: $30 (745).
VISN: 11;
Station[A]: Illiana HCS (Danville);
Dollars spent (number of items provided):
2005[B]: $3 (150);
2006[B]: $3 (108);
2007[B]: $4 (67);
2008: $5 (212);
2009: $6 (234);
Total[C]: $22 (771).
VISN: 11;
Station[A]: Indianapolis;
Dollars spent (number of items provided):
2005[B]: $11 (103);
2006[B]: $13 (98);
2007[B]: $14 (117);
2008: $17 (331);
2009: $18 (387);
Total[C]: $73 (1,036).
VISN: 11;
Station[A]: N. Indiana HCS-Ft. Wayne;
Dollars spent (number of items provided):
2005[B]: $2 (39);
2006[B]: $2 (32);
2007[B]: $3 (37);
2008: $4 (52);
2009: $4 (60);
Total[C]: $15 (220).
VISN: 11;
Station[A]: N. Indiana HCS-Marion;
Dollars spent (number of items provided):
2005[B]: $1 (14);
2006[B]: $1 (14);
2007[B]: $1 (16);
2008: $3 (338);
2009: $4 (445);
Total[C]: $10 (827).
VISN: 11;
Station[A]: Saginaw;
Dollars spent (number of items provided):
2005[B]: $2 (42);
2006[B]: $2 (43);
2007[B]: $3 (49);
2008: $5 (131);
2009: $7 (201);
Total[C]: $18 (466).
VISN: 11;
Station[A]: Toledo;
Dollars spent (number of items provided):
2005[B]: $1 (7);
2006[B]: $Less than $1 (2);
2007[B]: $0 (0);
2008: $0 (0);
2009: $0 (0);
Total[C]: $1 (9).
VISN: 12;
Station[A]: Adams Benjamin Jr. (Crown Point IN);
Dollars spent (number of items provided):
2005[B]: $Less than $1 (6);
2006[B]: $1 (6);
2007[B]: $1 (8);
2008: $1 (8);
2009: $1 (9);
Total[C]: $4 (36).
VISN: 12;
Station[A]: Hines;
Dollars spent (number of items provided):
2005[B]: $10 (289);
2006[B]: $9 (348);
2007[B]: $10 (383);
2008: $12 (583);
2009: $13 (541);
Total[C]: $54 (2,144).
VISN: 12;
Station[A]: Iron Mountain MI;
Dollars spent (number of items provided):
2005[B]: $1 (29);
2006[B]: $1 (28);
2007[B]: $1 (29);
2008: $2 (102);
2009: $2 (137);
Total[C]: $7 (326).
VISN: 12;
Station[A]: Jesse Brown VAMC-Chicago HCS;
Dollars spent (number of items provided):
2005[B]: $6 (302);
2006[B]: $5 (220);
2007[B]: $6 (185);
2008: $8 (326);
2009: $10 (325);
Total[C]: $35 (1,359).
VISN: 12;
Station[A]: Madison WI;
Dollars spent (number of items provided):
2005[B]: $6 (126);
2006[B]: $6 (91);
2007[B]: $6 (81);
2008: $7 (175);
2009: $8 (182);
Total[C]: $33 (656).
VISN: 12;
Station[A]: Milwaukee WI;
Dollars spent (number of items provided):
2005[B]: $11 (63);
2006[B]: $12 (57);
2007[B]: $13 (63);
2008: $15 (221);
2009: $16 (258);
Total[C]: $67 (661).
VISN: 12;
Station[A]: North Chicago IL;
Dollars spent (number of items provided):
2005[B]: $2 (44);
2006[B]: $2 (40);
2007[B]: $2 (46);
2008: $4 (271);
2009: $5 (318);
Total[C]: $14 (719).
VISN: 12;
Station[A]: Tomah;
Dollars spent (number of items provided):
2005[B]: $1 (33);
2006[B]: $2 (35);
2007[B]: $2 (34);
2008: $3 (173);
2009: $3 (229);
Total[C]: $11 (504).
VISN: 15;
Station[A]: Columbia MO;
Dollars spent (number of items provided):
2005[B]: $6 (61);
2006[B]: $6 (68);
2007[B]: $7 (80);
2008: $8 (79);
2009: $9 (88);
Total[C]: $37 (375).
VISN: 15;
Station[A]: Kansas City;
Dollars spent (number of items provided):
2005[B]: $8 (71);
2006[B]: $9 (78);
2007[B]: $10 (76);
2008: $16 (830);
2009: $19 (923);
Total[C]: $61 (1,979).
VISN: 15;
Station[A]: Leavenworth;
Dollars spent (number of items provided):
2005[B]: $2 (30);
2006[B]: $1 (24);
2007[B]: $2 (26);
2008: $2 (29);
2009: $2 (31);
Total[C]: $10 (141).
VISN: 15;
Station[A]: Marion IL;
Dollars spent (number of items provided):
2005[B]: $4 (58);
2006[B]: $6 (52);
2007[B]: $7 (58);
2008: $6 (65);
2009: $7 (73);
Total[C]: $31 (306).
VISN: 15;
Station[A]: Poplar Bluff;
Dollars spent (number of items provided):
2005[B]: $1 (14);
2006[B]: $1 (17);
2007[B]: $1 (19);
2008: $1 (23);
2009: $2 (37);
Total[C]: $6 (110).
VISN: 15;
Station[A]: Robert J. Dole VAM&ROC (Wichita);
Dollars spent (number of items provided):
2005[B]: $4 (47);
2006[B]: $3 (41);
2007[B]: $4 (45);
2008: $5 (51);
2009: $6 (56);
Total[C]: $23 (239).
VISN: 15;
Station[A]: St Louis-Jeff Bks.;
Dollars spent (number of items provided):
2005[B]: $5 (150);
2006[B]: $6 (127);
2007[B]: $7 (123);
2008: $8 (126);
2009: $10 (133);
Total[C]: $37 (659).
VISN: 15;
Station[A]: St Louis-John Cochran;
Dollars spent (number of items provided):
2005[B]: $6 (27);
2006[B]: $6 (25);
2007[B]: $6 (26);
2008: $10 (519);
2009: $12 (574);
Total[C]: $40 (1,171).
VISN: 15;
Station[A]: Topeka - Colmery-O'Neil;
Dollars spent (number of items provided):
2005[B]: $2 (46);
2006[B]: $2 (32);
2007[B]: $2 (34);
2008: $3 (38);
2009: $3 (38);
Total[C]: $11 (189).
VISN: 16;
Station[A]: Alexandria;
Dollars spent (number of items provided):
2005[B]: $2 (35);
2006[B]: $2 (39);
2007[B]: $2 (45);
2008: $3 (224);
2009: $4 (246);
Total[C]: $14 (588).
VISN: 16;
Station[A]: Baton Rouge;
Dollars spent (number of items provided):
2005[B]: Less than $1 (2);
2006[B]: Less than $1 (4);
2007[B]: Less than $1 (8);
2008: $1 (10);
2009: Less than $1 (6);
Total[C]: $2 (29).
VISN: 16;
Station[A]: Central AR Veterans HCS LR;
Dollars spent (number of items provided):
2005[B]: $15 (116);
2006[B]: $17 (127);
2007[B]: $17 (121);
2008: $20 (616);
2009: $22 (656);
Total[C]: $91 (1,635).
VISN: 16;
Station[A]: Fayetteville AR;
Dollars spent (number of items provided):
2005[B]: $3 (70);
2006[B]: $4 (81);
2007[B]: $4 (87);
2008: $7 (395);
2009: $10 (501);
Total[C]: $28 (1,134).
VISN: 16;
Station[A]: G. V. (Sonny) Montgomery VAMC;
Dollars spent (number of items provided):
2005[B]: $6 (55);
2006[B]: $6 (49);
2007[B]: $7 (59);
2008: $10 (303);
2009: $11 (307);
Total[C]: $41 (772).
VISN: 16;
Station[A]: Gulf Coast HCS;
Dollars spent (number of items provided):
2005[B]: $6 (78);
2006[B]: $6 (70);
2007[B]: $6 (85);
2008: $10 (649);
2009: $11 (699);
Total[C]: $39 (1,581).
VISN: 16;
Station[A]: Houston;
Dollars spent (number of items provided):
2005[B]: $17 (138);
2006[B]: $20 (138);
2007[B]: $23 (157);
2008: $27 (394);
2009: $33 (518);
Total[C]: $119 (1,345).
VISN: 16;
Station[A]: Muskogee;
Dollars spent (number of items provided):
2005[B]: $2 (55);
2006[B]: $2 (58);
2007[B]: $3 (79);
2008: $5 (322);
2009: $5 (353);
Total[C]: $17 (868).
VISN: 16;
Station[A]: New Orleans;
Dollars spent (number of items provided):
2005[B]: $6 (45);
2006[B]: $2 (36);
2007[B]: $3 (42);
2008: $5 (155);
2009: $5 (206);
Total[C]: $22 (484).
VISN: 16;
Station[A]: Oklahoma City;
Dollars spent (number of items provided):
2005[B]: $12 (97);
2006[B]: $12 (89);
2007[B]: $15 (111);
2008: $18 (483);
2009: $18 (518);
Total[C]: $76 (1,298).
VISN: 16;
Station[A]: Overton Brooks VAMC;
Dollars spent (number of items provided):
2005[B]: $6 (43);
2006[B]: $7 (49);
2007[B]: $6 (45);
2008: $7 (230);
2009: $8 (258);
Total[C]: $33 (625).
VISN: 16;
Station[A]: Tulsa;
Dollars spent (number of items provided):
2005[B]: $2 (39);
2006[B]: $1 (35);
2007[B]: $1 (9);
2008: $2 (8);
2009: $2 (8);
Total[C]: $8 (98).
VISN: 17;
Station[A]: Austin Satellite;
Dollars spent (number of items provided):
2005[B]: $Less than $1 (3);
2006[B]: $1 (7);
2007[B]: $1 (8);
2008: $1 (12);
2009: $1 (13);
Total[C]: $4 (43).
VISN: 17;
Station[A]: Bonham VAMC;
Dollars spent (number of items provided):
2005[B]: $1 (27);
2006[B]: $7 (31);
2007[B]: $Less than $1 (8);
2008: $0 (0);
2009: $0 (0);
Total[C]: $8 (66).
VISN: 17;
Station[A]: Dallas VAMC;
Dollars spent (number of items provided):
2005[B]: $21 (447);
2006[B]: $20 (471);
2007[B]: $25 (491);
2008: $29 (839);
2009: $33 (684);
Total[C]: $128 (2,932).
VISN: 17;
Station[A]: Kerrville VAMC;
Dollars spent (number of items provided):
2005[B]: $Less than $1 (10);
2006[B]: $Less than $1 (9);
2007[B]: $Less than $1 (10);
2008: $1 (12);
2009: Less than $1 (7);
Total[C]: $2 (48).
VISN: 17;
Station[A]: San Antonio VAMC;
Dollars spent (number of items provided):
2005[B]: $19 (146);
2006[B]: $22 (149);
2007[B]: $25 (172);
2008: $36 (659);
2009: $39 (758);
Total[C]: $140 (1,884).
VISN: 17;
Station[A]: Temple VAMC;
Dollars spent (number of items provided):
2005[B]: $7 (72);
2006[B]: $6 (76);
2007[B]: $7 (81);
2008: $11 (483);
2009: $15 (567);
Total[C]: $46 (1,278).
VISN: 17;
Station[A]: Waco VAMC;
Dollars spent (number of items provided):
2005[B]: $2 (20);
2006[B]: $2 (22);
2007[B]: $2 (25);
2008: $3 (31);
2009: $2 (20);
Total[C]: $11 (117).
VISN: 18;
Station[A]: Amarillo HCS;
Dollars spent (number of items provided):
2005[B]: $3 (79);
2006[B]: $4 (80);
2007[B]: $4 (87);
2008: $5 (174);
2009: $6 (192);
Total[C]: $22 (613).
VISN: 18;
Station[A]: El Paso HCS;
Dollars spent (number of items provided):
2005[B]: $2 (185);
2006[B]: $3 (249);
2007[B]: $3 (250);
2008: $4 (422);
2009: $5 (475);
Total[C]: $17 (1,582).
VISN: 18;
Station[A]: New Mexico HCS;
Dollars spent (number of items provided):
2005[B]: $9 (514);
2006[B]: $11 (549);
2007[B]: $12 (674);
2008: $15 (896);
2009: $18 (1,027);
Total[C]: $65 (3,660).
VISN: 18;
Station[A]: Northern Arizona HCS;
Dollars spent (number of items provided):
2005[B]: $2 (166);
2006[B]: $2 (146);
2007[B]: $2 (98);
2008: $4 (157);
2009: $4 (186);
Total[C]: $15 (753).
VISN: 18;
Station[A]: Phoenix;
Dollars spent (number of items provided):
2005[B]: $7 (447);
2006[B]: $9 (455);
2007[B]: $10 (561);
2008: $12 (746);
2009: $15 (777);
Total[C]: $54 (2,985).
VISN: 18;
Station[A]: S. Arizona HCS;
Dollars spent (number of items provided):
2005[B]: $13 (227);
2006[B]: $13 (255);
2007[B]: $12 (210);
2008: $15 (418);
2009: $19 (467);
Total[C]: $72 (1,577).
VISN: 18;
Station[A]: West Texas HCS;
Dollars spent (number of items provided):
2005[B]: $2 (35);
2006[B]: $2 (32);
2007[B]: $2 (32);
2008: $3 (111);
2009: $4 (143);
Total[C]: $13 (352).
VISN: 19;
Station[A]: Cheyenne;
Dollars spent (number of items provided):
2005[B]: $3 (33);
2006[B]: $3 (32);
2007[B]: $4 (33);
2008: $5 (385);
2009: $6 (472);
Total[C]: $21 (956).
VISN: 19;
Station[A]: Eastern Colorado HCS;
Dollars spent (number of items provided):
2005[B]: $11 (76);
2006[B]: $13 (79);
2007[B]: $14 (84);
2008: $19 (1,191);
2009: $21 (1,426);
Total[C]: $77 (2,858).
VISN: 19;
Station[A]: Grand Junction;
Dollars spent (number of items provided):
2005[B]: $2 (16);
2006[B]: $2 (16);
2007[B]: $2 (20);
2008: $3 (251);
2009: $4 (367);
Total[C]: $13 (670).
VISN: 19;
Station[A]: Montana HCS;
Dollars spent (number of items provided):
2005[B]: $6 (55);
2006[B]: $7 (56);
2007[B]: $6 (62);
2008: $8 (307);
2009: $11 (384);
Total[C]: $38 (864).
VISN: 19;
Station[A]: Pueblo;
Dollars spent (number of items provided):
2005[B]: $Less than $1 (9);
2006[B]: $1 (12);
2007[B]: $1 (15);
2008: $1 (14);
2009: $1 (16);
Total[C]: $3 (66).
VISN: 19;
Station[A]: Salt Lake City HCS - George E. Wahlen VAMC;
Dollars spent (number of items provided):
2005[B]: $16 (80);
2006[B]: $17 (101);
2007[B]: $18 (111);
2008: $21 (516);
2009: $22 (658);
Total[C]: $95 (1,466).
VISN: 19;
Station[A]: Sheridan;
Dollars spent (number of items provided):
2005[B]: $2 (16);
2006[B]: $2 (17);
2007[B]: $2 (21);
2008: $2 (75);
2009: $2 (93);
Total[C]: $10 (223).
VISN: 20;
Station[A]: Alaska HCS;
Dollars spent (number of items provided):
2005[B]: $1 (13);
2006[B]: $1 (14);
2007[B]: $2 (17);
2008: $2 (99);
2009: $3 (113);
Total[C]: $10 (256).
VISN: 20;
Station[A]: American Lake;
Dollars spent (number of items provided):
2005[B]: $4 (54);
2006[B]: $5 (60);
2007[B]: $6 (70);
2008: $5 (502);
2009: $5 (440);
Total[C]: $26 (1,126).
VISN: 20;
Station[A]: Boise;
Dollars spent (number of items provided):
2005[B]: $4 (29);
2006[B]: $4 (28);
2007[B]: $4 (29);
2008: $6 (147);
2009: $7 (185);
Total[C]: $25 (419).
VISN: 20;
Station[A]: Portland;
Dollars spent (number of items provided):
2005[B]: $12 (82);
2006[B]: $13 (71);
2007[B]: $14 (89);
2008: $17 (392);
2009: $20 (442);
Total[C]: $75 (1,075).
VISN: 20;
Station[A]: Roseburg HCS;
Dollars spent (number of items provided):
2005[B]: $3 (29);
2006[B]: $3 (28);
2007[B]: $3 (30);
2008: $4 (198);
2009: $5 (255);
Total[C]: $18 (540).
VISN: 20;
Station[A]: Seattle;
Dollars spent (number of items provided):
2005[B]: $10 (46);
2006[B]: $10 (44);
2007[B]: $11 (51);
2008: $15 (378);
2009: $16 (412);
Total[C]: $63 (931).
VISN: 20;
Station[A]: Southern Oregon Rehabilitation Ctr & Clinics;
Dollars spent (number of items provided):
2005[B]: $1 (9);
2006[B]: $1 (11);
2007[B]: $1 (12);
2008: $2 (87);
2009: $2 (100);
Total[C]: $8 (220).
VISN: 20;
Station[A]: Spokane;
Dollars spent (number of items provided):
2005[B]: $2 (23);
2006[B]: $2 (24);
2007[B]: $3 (27);
2008: $4 (235);
2009: $4 (247);
Total[C]: $16 (557).
VISN: 20;
Station[A]: Walla Walla;
Dollars spent (number of items provided):
2005[B]: $1 (57);
2006[B]: $1 (58);
2007[B]: $2 (42);
2008: $3 (151);
2009: $4 (178);
Total[C]: $10 (486).
VISN: 21;
Station[A]: Fresno;
Dollars spent (number of items provided):
2005[B]: $3 (25);
2006[B]: $3 (24);
2007[B]: $3 (28);
2008: $4 (164);
2009: $5 (186);
Total[C]: $18 (428).
VISN: 21;
Station[A]: Livermore;
Dollars spent (number of items provided):
2005[B]: $1 (8);
2006[B]: $1 (8);
2007[B]: $1 (7);
2008: $2 (9);
2009: $2 (11);
Total[C]: $6 (43).
VISN:
21;
Station[A]: Manila;
Dollars spent (number of items provided):
2005[B]: Less than $1 (5);
2006[B]: Less than $1 (4);
2007[B]: Less than $1 (6);
2008: Less than $1 (4);
2009: Less than $1 (4);
Total[C]: $1 (22).
VISN: 21;
Station[A]: N. California HCS-Martinez;
Dollars spent (number of items provided):
2005[B]: $5 (39);
2006[B]: $6 (48);
2007[B]: $7 (56);
2008: $11 (496);
2009: $14 (566);
Total[C]: $44 (1,204).
VISN: 21;
Station[A]: N. California HCS-Sacramento;
Dollars spent (number of items provided):
2005[B]: $Less than $1 (4);
2006[B]: $0 (0);
2007[B]: $0 (0);
2008: $0 (0);
2009: $0 (0);
Total[C]: $Less than $1 (4).
VISN: 21;
Station[A]: Pacific Islands HCS (Honolulu);
Dollars spent (number of items provided):
2005[B]: $3 (30);
2006[B]: $3 (40);
2007[B]: $3 (55);
2008: $4 (123);
2009: $5 (132);
Total[C]: $19 (379).
VISN: 21;
Station[A]: Palo Alto;
Dollars spent (number of items provided):
2005[B]: $9 (42);
2006[B]: $10 (80);
2007[B]: $13 (65);
2008: $15 (329);
2009: $17 (389);
Total[C]: $65 (906).
VISN: 21;
Station[A]: San Francisco;
Dollars spent (number of items provided):
2005[B]: $11 (39);
2006[B]: $11 (41);
2007[B]: $12 (44);
2008: $15 (270);
2009: $18 (328);
Total[C]: $66 (723).
VISN: 21;
Station[A]: San Jose;
Dollars spent (number of items provided):
2005[B]: Less than $1 (4);
2006[B]: $1 (4);
2007[B]: Less than $1 (3);
2008: Less than $1 (4);
2009: $1 (5);
Total[C]: $3 (21).
VISN: 21;
Station[A]: Sierra Nevada HCS;
Dollars spent (number of items provided):
2005[B]: $5 (35);
2006[B]: $5 (34);
2007[B]: $5 (36);
2008: $7 (121);
2009: $8 (129);
Total[C]: $30 (355).
VISN: 22;
Station[A]: Greater Los Angeles HCS;
Dollars spent (number of items provided):
2005[B]: $11 (53);
2006[B]: $11 (53);
2007[B]: $11 (371);
2008: $14 (639);
2009: $13 (822);
Total[C]: $60 (1,938).
VISN: 22;
Station[A]: Loma Linda VAMC;
Dollars spent (number of items provided):
2005[B]: $10 (66);
2006[B]: $10 (62);
2007[B]: $12 (74);
2008: $16 (553);
2009: $19 (686);
Total[C]: $65 (1,441).
VISN: 22;
Station[A]: Long Beach HCS;
Dollars spent (number of items provided):
2005[B]: $6 (32);
2006[B]: $7 (33);
2007[B]: $7 (40);
2008: $9 (304);
2009: $10 (366);
Total[C]: $39 (776).
VISN: 22;
Station[A]: San Diego HCS;
Dollars spent (number of items provided):
2005[B]: $13 (59);
2006[B]: $13 (66);
2007[B]: $14 (89);
2008: $17 (494);
2009: $18 (502);
Total[C]: $75 (1,210).
VISN: 22;
Station[A]: Sepulveda;
Dollars spent (number of items provided):
2005[B]: $2 (18);
2006[B]: $2 (20);
2007[B]: $2 (25);
2008: $2 (30);
2009: $3 (39);
Total[C]: $10 (132).
VISN: 22;
Station[A]: Southern Nevada HCS;
Dollars spent (number of items provided):
2005[B]: $5 (46);
2006[B]: $5 (45);
2007[B]: $5 (49);
2008: $6 (310);
2009: $8 (356);
Total[C]: $28 (807).
VISN: 23;
Station[A]: Des Moines;
Dollars spent (number of items provided):
2005[B]: $3 (59);
2006[B]: $3 (59);
2007[B]: $4 (63);
2008: $5 (81);
2009: $5 (83);
Total[C]: $19 (346).
VISN: 23;
Station[A]: Fargo;
Dollars spent (number of items provided):
2005[B]: $2 (71);
2006[B]: $2 (100);
2007[B]: $2 (116);
2008: $3 (317);
2009: $4 (354);
Total[C]: $14 (958).
VISN: 23;
Station[A]: Fort Meade;
Dollars spent (number of items provided):
2005[B]: $2 (36);
2006[B]: $2 (36);
2007[B]: $2 (40);
2008: $2 (136);
2009: $3 (149);
Total[C]: $10 (397).
VISN: 23;
Station[A]: Grand Island;
Dollars spent (number of items provided):
2005[B]: $1 (30);
2006[B]: $1 (32);
2007[B]: $1 (32);
2008: $2 (30);
2009: $2 (35);
Total[C]: $7 (159).
VISN: 23;
Station[A]: Hot Springs;
Dollars spent (number of items provided):
2005[B]: $1 (22);
2006[B]: $1 (25);
2007[B]: $1 (28);
2008: $1 (29);
2009: $1 (29);
Total[C]: $7 (133).
VISN: 23;
Station[A]: Iowa City;
Dollars spent (number of items provided):
2005[B]: $5 (50);
2006[B]: $6 (51);
2007[B]: $6 (58);
2008: $7 (57);
2009: $8 (64);
Total[C]: $32 (280).
VISN: 23;
Station[A]: Knoxville;
Dollars spent (number of items provided):
2005[B]: $1 (5);
2006[B]: $1 (4);
2007[B]: Less than $1 (2);
2008: Less than $1 (1);
2009: Less than $1 (1);
Total[C]: $2 (13).
VISN: 23;
Station[A]: Lincoln;
Dollars spent (number of items provided):
2005[B]: $1 (48);
2006[B]: $1 (19);
2007[B]: $1 (19);
2008: $1 (22);
2009: $1 (22);
Total[C]: $5 (131).
VISN: 23;
Station[A]: Minneapolis;
Dollars spent (number of items provided):
2005[B]: $16 (445);
2006[B]: $17 (378);
2007[B]: $18 (347);
2008: $21 (912);
2009: $25 (972);
Total[C]: $97 (3,054).
VISN: 23;
Station[A]: Omaha;
Dollars spent (number of items provided):
2005[B]: $6 (58);
2006[B]: $7 (50);
2007[B]: $7 (56);
2008: $14 (997);
2009: $17 (1,168);
Total[C]: $51 (2,328).
VISN: 23;
Station[A]: Sioux Falls;
Dollars spent (number of items provided):
2005[B]: $2 (69);
2006[B]: $3 (74);
2007[B]: $3 (73);
2008: $5 (223);
2009: $6 (250);
Total[C]: $20 (690).
VISN: 23;
Station[A]: St. Cloud;
Dollars spent (number of items provided):
2005[B]: $1 (133);
2006[B]: $1 (149);
2007[B]: $2 (137);
2008: $4 (440);
2009: $5 (522);
Total[C]: $13 (1,380).
Station[A]: Total[C];
Dollars spent (number of items provided):
2005[B]: $907 (16,371);
2006[B]: $980 (16,531);
2007[B]: $1,082 (17,490);
2008: $1,404 (52,596);
2009: $1,623 (59,103);
Total[C]: $5,996 (162,090).
Source: GAO analysis of VA data.
Note: Data for this table were obtained from VA's National Prosthetic
Patient Database (NPPD)--an internal system used by VA to administer
the department's provision of prosthetic items. Data on total costs
for prosthetic items from NPPD are different from the obligation data
we used to report VA's annual spending for prosthetic items in the
body of the report. The data on spending represent obligations for the
procurement of prosthetic items during the course of a fiscal year,
while NPPD data represent obligations that VA has incurred for
prosthetic items actually provided to veterans during a fiscal year.
In some instances, there may be a delay between when VA procures a
prosthetic item and when the item is provided to the veteran. For
example, VA may incur an obligation for the procurement of prosthetic
items for PSAS inventory in one fiscal year, and distribute the
inventoried prosthetic items to veterans in the next fiscal year.
[A] A station is a medical facility or group of medical facilities
under a single director. A station may include more than one VA
medical center.
[B] Prior to fiscal year 2008, VA's NPPD did not contain data related
to hearing aids, hearing aid batteries, and several other prosthetic
devices. As a result, these items are not included for fiscal years
2005 through 2007. According to a VA official, VA spent $145 million,
$140 million, and $140 million for these items during fiscal years
2005, 2006, and 2007, respectively.
[C] Amounts for fiscal years and stations may not sum to totals due to
rounding.
[End of table]
[End of section]
Appendix II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Acknowledgments:
In addition to the contact named above, Kim Yamane, Assistant
Director; Susannah Bloch; Matthew Byer; Aaron Holling; Lisa Motley;
Daniel Ries; and Said Sariolghalam made key contributions to this
report.
[End of section]
Footnotes:
[1] The more than 59 million prosthetic items provided to veterans
include about 35 million batteries and more than 15 million components
related to the repair of prosthetic items, such as parts to repair
wheelchairs and artificial limbs.
[2] According to VA, the vast majority (96 percent) of veterans
receiving prosthetic items from the department did not serve in the
current conflicts in Afghanistan and Iraq. In fiscal year 2009, the
prosthetic items provided to the veterans from these current conflicts
accounted for about $38.4 million (2 percent) of the $1.6 billion VA
spent for prosthetic items.
[3] In general, the funding VA allocates to PSAS for prosthetic items
covers the procurement of prosthetic items and components necessary to
fabricate prosthetic items. According to VA officials, these funds do
not cover administrative and clinical costs, such as the salaries and
benefits of PSAS personnel or labor costs associated with VA
fabrication of prosthetic items.
[4] Veterans for Veterans, Independent Budget for the Department of
Veterans Affairs, Fiscal Year 2010, [hyperlink,
http://www.independentbudget.org/] (accessed Jul 10, 2010), p. 92.
[5] For purposes of this report, we used data on VA's obligations for
prosthetic items to report its annual spending for prosthetic items.
Obligations refer to a definite commitment creating a legal liability
to make payments immediately or in the future. An obligation is
incurred, for example, when an agency awards a contract to a private
entity.
[6] VHA is the organization within VA that administers the
department's health care system.
[7] We interviewed VAMC and PSAS officials from the VAMC in Portland,
Oregon, by telephone.
[8] The National Prosthetic Patient Database is an internal system
used by VA to administer the department's provision of prosthetic
items.
[9] For example, VA polytrauma rehabilitation centers provide
intensive rehabilitative care to veterans and servicemembers who have
experienced severe injuries to more than one organ system.
[10] VISNs oversee the operations of the various medical facilities
within their assigned geographic areas. In general, each of the 21
VISNs has budget and management responsibilities, such as allocating
funding for health care services to facilities, clinics, and programs
within their region and ensuring access to appropriate health care
services.
[11] According to VA, in fiscal year 2009, this system treated 5.7
million patients with appropriations of about $41.2 billion. In that
same fiscal year, VA operated more than 1,300 sites of care, including
153 VAMCs and 783 ambulatory care and community-based outpatient
clinics.
[12] In general, veterans must enroll in VA's health care system in
order to receive VA's medical benefits package, which covers most of
VA's medical services. VA's enrollment system includes eight
categories for enrollment, with priority generally based on service-
connected disability, low income, and other recognized statuses such
as former prisoners of war. 38 U.S.C. § 1705; 38 C.F.R. § 17.36 (2010).
[13] Certain veterans, such as veterans needing prosthetic items for a
service-connected condition, are eligible for prosthetic items even if
they are not enrolled in VA's health care system. 38 C.F.R. § 17.37
(2010).
[14] An orthosis is a device, such as a brace, that supports and
strengthens an impaired limb.
[15] Telehealth is the use of telecommunications technology including
video, digital pictures, and messaging devices to exchange health care
information in order to provide health care services to rural and
remote areas.
[16] The Veterans Health Care Reform and Transparency Act of 2009
provided for VA to receive advance appropriations for its Medical
Services, Medical Support and Compliance, and Medical Facilities
appropriation accounts beginning with fiscal year 2011. Pub. L. No.
111-81, § 3, 123 Stat. 2137, 3137-38 (codified at 38 U.S.C. § 117).
The Military Construction and Veterans Affairs and Related Agencies
Appropriations Act, 2010 provided appropriations for fiscal year 2010
and advance appropriations for fiscal year 2011 for those accounts.
Pub. L. No. 111-117, div. E, tit. II, 123 Stat. 3034, 3298-3300
(2009). Advance appropriations represent budget authority that becomes
available one or more fiscal years after the fiscal year covered by
the appropriations act in which they are made.
[17] VA begins to formulate its budget approximately 18 months before
the start of the fiscal year to which the request relates and about 10
months before the transmission of the President's budget request to
Congress, which usually occurs in early February. Due to the timing of
budget preparation, VA's spending estimates for one fiscal year are
not based on VA's actual spending from the prior year since these data
are not yet available when VA prepares its estimates.
[18] See GAO, VA Health Care: Challenges in Budget Formulation and
Issues Surrounding the Proposals for Advance Appropriations,
[hyperlink, http://www.gao.gov/products/GAO-09-664T] (Washington,
D.C.: Apr. 29, 2009).
[19] This model estimates future VA health care costs by using
projections of veterans' demand for VA's health care services as well
as cost estimates associated with particular health care services.
[20] For fiscal year 2009, VA's Medical Services appropriation totaled
about $31.0 billion plus reimbursements.
[21] This reversed a 1998 decision that had designated funding for
prosthetic items as general purpose funding. According to officials,
delays in the procurement of prosthetic items were common between
fiscal years 1998 and 2000. Prior to 1998, funding for prosthetic
items had been designated as specific purpose funding.
[22] PSAS also processes benefits for several programs funded under
the Veterans Benefits Administration--the organization within VA
responsible for administering the department's programs that provide
financial and other forms of assistance to veterans, their dependents,
and their survivors. Specifically, PSAS processes clothing allowance
benefits and furnishes automobile adaptive equipment to eligible
veterans. These programs are not considered part of the PSAS budget.
[23] At the 12 VAMCs we visited, PSAS maintained an inventory of
certain over-the-counter items, such as raised toilet seats,
compression socks, knee braces, manual wheelchairs, and walkers.
According to PSAS officials, most VAMCs maintain similar inventory.
[24] According to PSAS officials, prosthetics chiefs are officials who
are responsible for managing the day-to-day operations of PSAS, such
as overseeing the procurement of prosthetic items, at individual VAMCs.
[25] Biological implants include all nonsynthetic material, such as
human bone and tissue, surgically inserted into the body.
[26] As part of the medical evaluation of a veteran's prosthetic
needs, VA clinicians assess whether new technology may be appropriate.
[27] In the previous 4 fiscal years, the annual increase in the number
of eyeglasses VA provided ranged from 2 percent to 7 percent.
[28] See 38 C.F.R. § 17.36 (2010); 74 Fed. Reg. 22,832 (May 15, 2009).
[29] VA received a $1.5 billion supplemental Medical Services
appropriation in fiscal year 2005. Department of the Interior,
Environment, and Related Agencies Appropriation Act, 2006, Pub. L. No.
109-54, 119 Stat. 499, 563-64 (2005). For fiscal years 2008 and 2009,
VA received appropriations for its Medical Services account that
exceeded the amounts requested by about $1.9 billion and about $1.2
billion, respectively.
[30] The amount by which VA reduced the specific purpose funding was
reallocated to general purpose funds available for other health care
services, according to VA officials.
[31] A consult is VA's term for a prescription for a prosthetic item
entered into VA's medical record system by a physician.
[32] PSAS considers the processing of the prescription complete when a
prosthetic item has been issued to the veteran from PSAS's inventory
or a purchase order is created for the item.
[33] PSAS summarizes this information in a quarterly report it calls
the Prosthetic and Sensory Aids Budget and Management Scorecard.
[34] For example, the item may require another visit to the VAMC by
the veteran (for example, for fitting or pick up) before the
prescription for the prosthetic item can be completed.
[35] PSAS also changed how the goals for delayed orders and pending
consults are measured. Through fiscal year 2009, these performance
measures used 5 business days and 45 business days respectively.
Beginning in fiscal year 2010, VA assesses these measures using 8
calendar days and 60 calendar days.
[36] According to the supervisor of this optical laboratory, wait
times have been reduced to 3 or 4 weeks using overtime and commercial
vendors. In addition, he said the renovations and improvements should
be complete by the end of fiscal year 2011 and at that time, the
optical laboratory should be able to better meet the increased demand.
[37] See VA's Inquiry Routing & Information System, [hyperlink,
https://iris.va.gov/scripts/iris.cfg/php.exe/enduser/home.php]
(accessed Aug. 9, 2010).
[38] PSAS at one VAMC recently began using comment cards, and
according to the prosthetics chief, she had not yet received the
initial results at the time of our visit.
[39] VISNs with centralized management for PSAS generally use VISN-
level general purpose funds for PSAS staff, whereas in noncentralized
VISNs, each VAMC usually funds PSAS staff using VAMC-level general
purpose funds.
[40] See [hyperlink, http://www.prosthetics.va.gov/cpr.asp] (accessed
on Aug. 8, 2010) for PSAS's clinical practice recommendations.
[41] Prior to fiscal year 2008, NPPD did not contain data related to
hearing aids, batteries, and several other prosthetic items. As a
result, these items are not included in the tables in this appendix
for fiscal years 2005 through 2007. According to a VA official, VA
spent about $145 million, $140 million, and $140 million for these
items during fiscal years 2005, 2006, and 2007, respectively.
[42] Data on total obligations for prosthetic items from NPPD are
different from the obligation data we used to report VA's annual
spending for prosthetic items in the body of our report. The data on
spending represent obligations for the procurement of prosthetic items
during the course of a fiscal year, while NPPD data represent
obligations that VA has incurred for prosthetic items actually
provided to veterans during a fiscal year. In some instances, there
may be a delay between when VA procures a prosthetic item and when the
item is provided to the veteran. For example, VA may incur an
obligation for the procurement of prosthetic items for PSAS inventory
in one fiscal year, and distribute the inventoried prosthetic items to
veterans in the next fiscal year.
[43] VA has organized its health care system under 21 VISNs, which
oversee the operations of the various medical facilities within their
assigned geographic areas. Each of the 21 VISNs has budget and
management responsibilities, such as allocating resources, including
funding, for health care services to facilities, clinics, and programs
within their network and ensuring access to appropriate health care
services.
[44] A station is a medical facility or group of medical facilities
under a single director. A station may include more than one VA
medical center.
[End of section]
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Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
